Steinhardt School of Culture, Education, and Human Development, New York University, 246 Greene Street, 8th Floor, New York, NY, 10003, USA.
National Development and Research Institutes, New York, NY, USA.
AIDS Behav. 2020 Jan;24(1):81-94. doi: 10.1007/s10461-019-02439-2.
HIV/AIDS-related (HAR) stigma is an ongoing problem in Sub-Saharan Africa that is thought to impede HIV preventive and treatment interventions. This paper uses a systematic sample of households (Level 1) nested within near-neighbor clusters (Level 2) and communities (Level 3) to examine multilevel relationships of HAR stigma to health service barriers (HSBs) and HIV outcomes in KwaZulu-Natal, South Africa, thereby addressing methodological and conceptual gaps in the literature from this context. Findings suggest differential patterns of prediction at Level 1 when examining two different dimensions of stigma: more highly stigmatizing attitudes predicted more household health service barriers; and perceptions of greater levels of community normative HAR stigma predicted higher household HIV ratios. Level 2 findings were similarly dimension-differentiated. Cross-level analyses found that near-neighbor cluster-level (setting level) consensus about (standard deviation) and level of (mean) community normative HAR stigma significantly predicted household-level HSBs and HIV ratio, controlling for household-level community normative HAR stigma. These differential patterns of prediction suggest that HAR stigma is a multi-level construct with multiple dimensions that relate to important outcomes differently within and across multiple ecological levels. This has important implications for future research, and for developing interventions that address setting-level variation in stigma.
艾滋病毒/艾滋病相关（HAR）耻辱感是撒哈拉以南非洲地区持续存在的问题，据认为这会阻碍艾滋病毒预防和治疗干预措施的开展。本文使用系统抽样方法，以家庭（一级）为单位，嵌套在近邻集群（二级）和社区（三级）中，研究了HAR 耻辱感与南非夸祖鲁-纳塔尔省健康服务障碍（HSB）和艾滋病毒结果之间的多层次关系，从而解决了该背景下文献中存在的方法和概念上的差距。研究结果表明，在检查耻辱感的两个不同维度时，一级存在不同的预测模式：更具歧视性的态度预测了更多的家庭健康服务障碍；社区规范 HAR 耻辱感水平的感知预测了更高的家庭艾滋病毒比率。二级结果也存在类似的维度差异。跨层次分析发现，近邻集群层面（环境层面）对社区规范 HAR 耻辱感的共识（标准差）和水平（均值）显著预测了家庭层面的 HSB 和 HIV 比值，同时控制了家庭层面的社区规范 HAR 耻辱感。这些不同的预测模式表明，HAR 耻辱感是一个多层次的结构，具有多个维度，在多个生态层次内和跨层次上与重要结果的关系不同。这对未来的研究以及开发针对耻辱感的环境层面变化的干预措施具有重要意义。
