Layered Stigma Among Health Facility & Social Services Staff Toward Most-at-Risk Populations in Jamaica

"The pervasive norm of stigma and discrimination toward MARPs within Jamaica creates and reinforces a hostile environment where MSM and SW are unable to safely identify their sexuality and experiences..."

This paper describes a study conducted in Jamaica (Kingston, Montego Bay, and Ocho Rios) in 2011 on stigma and discrimination (S&D) within health and social services settings toward persons living with HIV (PLHIV), men who have sex with men (MSM), and sex workers (SWs). It was motivated by the observation that "S&D norms within health services often mirror and mutually reinforce wider social norms. Within health care settings, S&D is particularly of concern given its impact on the ability of those stigmatized to receive appropriate and quality prevention services, treatment, and care." With the goal of informing social and behaviour change communication (SBCC) interventions for vulnerable sectors, the study was carried out by FHI 360's Communication for Change (C-Change) project, with funding from United States Agency for International Development (USAID) and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

In short, the study findings support past research indicating widespread stigma toward PLHIV, MSM, and SWs in health services in general and specific to Jamaica. The majority of respondents were not trained in HIV or working with most-at-risk populations (MARPs). Fear of casual contact or desire to avoid contact with PLHIV and MARPs occurred in both clinical and non-clinical settings: Almost half of clinical health providers reported fear of HIV transmission while performing basic clinical procedures. Measures of shame, blame, and judgment, particularly as they related to views on immorality toward PLHIV and MARPs, appeared to be the norm. While with less frequency, enacted stigma (unlawful discrimination as well as a wider set of stigmatising actions) was reported. The study also found high levels of layered stigma (HIV-related stigma combined with stigma toward marginalised groups) by health staff toward clients who are SWs or MSM, and who are also HIV-positive. Male SWs were significantly more likely to report having experienced S&D in health settings than female SWs.

Excerpts from the report follow:
"Conclusions

..."[W]hile stigmatizing attitudes and beliefs have a critical impact on accessing quality services in Jamaica, these attitudes may not translate into overt discrimination in the health and social services sector. Instead, what exists may be a perception and probable reality that PLHIV, SW, and MSM experience covert discrimination when they access services....Reduced access results as PLHIV and MARPs opt out of services. When services are accessed, they may be of lower quality due to the provider’s stigmatizing attitudes or because MARPs are fearful of disclosing their sexual orientation or their engagement in sex work, resulting in inappropriate care or interventions.

A critical finding of this study was that PLHIV were the clients most likely to be discriminated against, particularly based upon reports of fear of HIV transmission. A significant proportion of health facility and social services staff feared touching and conducting important clinical procedures on this population. This must urgently and comprehensively be addressed through training and other stigma-reduction initiatives. In turn, SW and MSM may secondarily be assumed to be HIV infected and therefore experience layered stigma arising from providers stereotyping these individuals as the ones who spread HIV in addition to stigma they face as a result of being MSM or SW alone. MSM experienced the highest measures of S&D based upon reported shame, blame, and judgment construct responses, followed by SW.

Recommendations

• Both clinical and nonclinical staff need training...in HIV prevention and interpersonal communication with emphasis on S&D in the health care settings. This training needs to be ongoing....[and] increased training of all health care and social services staff in psycho-social support for MARPs is needed.
• ...[T]he amount of MARP–friendly providers needs to be increased....In response to these improvements MARPs are actively encouraged and motivated to seek these services through health promotion campaigns.
• MARP–friendly provider criteria should be established so that each provider offers a minimum package of care, including standard medical protocol, to MARPs and is committed to similar philosophies and ongoing internal anti-S&D efforts.
• Further qualitative work should be undertaken to deepen the understanding of some of the findings in relation to MARP–friendly providers and social services organizations. The goal of the work is to prepare organizations for improvements in professionalism, attitudes, and capabilities to effectively reach and support MARPs based on a positive deviance approach.
• Fear of HIV transmission needs to be addressed through dialogue, training, and monitoring related to the conduct of clinical procedures on PLHIV in health care settings.
• As the National Health Program moves away from vertical delivery of HIV/STI [sexually transmitted infection] programs, health services strengthening must be given priority...
• A MARP provider needs assessment should be conducted to address capacity and gaps in knowledge, attitudes, and practices as it relates to MARP and PLHIV service provision...
• The supportive environment for social and behavior change must be addressed. Policies regarding homosexuality and SW must be addressed directly and comprehensively to facilitate nondiscriminatory attitudes and ultimately to increase access. Policies and the legislative framework must support the sanctioning of health care providers in cases where confidentiality is proven to be breached and when discrimination occurs to encourage compliance with ethical guidelines and standards of care and the protection of the rights of clients.
• Targeted and interactive communication campaigns addressing S&D toward PLHIV and MARPs broadly in communities and specifically within health and social services need to be developed in an ongoing effort to encourage dialogue and community solutions to this critical issue. Such campaigns can also reinforce in-service, interpersonal communication, and anti-S&D training.
• This survey should be considered as a baseline of S&D within the health and social services sectors, and efforts to reduce S&D should be measured against its findings in subsequent years..."