Division of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis, MN, USA.
Health Sciences Libraries, University of Minnesota Twin Cities, Minneapolis, MN, USA.
J Int AIDS Soc. 2020 Aug;23(8):e25553. doi: 10.1002/jia2.25553.
Nearly 40 years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low- and middle-income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research.
We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews.
Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings.
Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self-reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.
在艾滋病流行的近 40 年里，艾滋病毒耻辱感的持续存在是一个极其紧迫的问题。医疗保健环境中的歧视（即实施的耻辱感）尤其成问题，因为它剥夺了人们获得关键医疗服务的机会，同时也通过证实对预期耻辱的恐惧，阻碍了预防性保健的寻求。我们回顾了在中低收入国家（LMIC）医疗保健环境中针对耻辱感干预措施的现有研究，在这些国家，由于艾滋病毒负担沉重、医疗保健系统欠发达以及艾滋病毒耻辱感与对其他边缘化身份的歧视交织在一起，因此控制耻辱感的努力往往更加复杂。本综述描述了迄今为止该领域的进展，并确定了研究差距，以指导未来的研究方向。
我们使用 Embase、Ovid MEDLINE、PsycINFO 和 Scopus（截至 2020 年 3 月 5 日）对中低收入国家医疗保健环境中的艾滋病毒减少干预措施进行了范围界定审查。提取了关于研究设计、耻辱感测量技术、干预措施特征和研究结果的信息。我们还使用 Joanna Briggs 研究所的系统评价清单评估了方法学严谨性。
我们的搜索确定了 8766 项研究，其中 19 项被纳入最终分析。干预后，除一项研究外，所有研究均报告耻辱感降低。这些研究显示出在中低收入国家的广泛区域分布，并且许多研究采用了利用对照条件的设计。然而，这些优势掩盖了关键的缺点，包括缺乏来自中低收入国家中最低收入类别的研究，以及缺乏解决耻辱感的体制或结构性决定因素的干预措施。最后，尽管大多数耻辱感测量是基于现有工具，但只有三项研究描述了为使耻辱感测量适应当地环境而采取的步骤。
在中低收入国家消除医疗保健耻辱感需要能够同时解决资源限制、高艾滋病毒负担和更严重耻辱感的干预措施。我们的研究结果表明，这将需要更客观、可靠和文化上适应的耻辱感测量方法，以促进有意义的方案评估和研究之间的比较。除一项研究外，所有研究都得出结论，他们的干预措施有效地减少了医疗保健方面的耻辱感。尽管令人鼓舞，但大多数研究使用自我报告的测量方法来衡量影响的事实表明，社会期望可能会使结果向上偏倚。研究结果的同质性也阻碍了我们得出关于指导未来耻辱感减少方案设计的潜在最佳实践的实质性结论。
