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The Moderating Role of Social Support on the Relationship Between Anxiety, Stigma, and Intention to Use Illicit Drugs Among HIV-Positive Men Who Have Sex with Men. AIDS Behav 2020; 24:55-64. [PMID: 31754966 DOI: 10.1007/s10461-019-02719-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The present study examined the association between anxiety, stigma, social support and intention to use illicit drugs, and the moderating role of social support on the association between anxiety/stigma and intention to use illicit drugs among 450 Chinese HIV-positive MSM. Findings show that controlling for significant background variables, self-stigma and anxiety were positively associated with intention to use illicit drugs, while social support was negatively associated with intention to use illicit drugs. A significant moderation effect of social support was also observed, that the negative association between self-stigma/anxiety and intention to use illicit drugs was only significant among participants with lower levels of social support. Findings highlight the importance of reducing self-stigma and anxiety, and promoting social support in drug use prevention for HIV-positive MSM.
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Ma PHX, Chan ZCY, Loke AY. Self-Stigma Reduction Interventions for People Living with HIV/AIDS and Their Families: A Systematic Review. AIDS Behav 2019; 23:707-741. [PMID: 30298241 DOI: 10.1007/s10461-018-2304-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Stigma is a primary concern for people living with human immunodeficiency virus (HIV)/AIDS (PLWHA), and has great impact on their and their family members' health. While previous reviews have largely focused on the public stigma, this systematic review aims to evaluate the impact of HIV/acquired immunodeficiency syndrome (AIDS)-related self-stigma reduction interventions among PLWHA and their families. A literature search using eight databases found 23 studies meeting the inclusion criteria. Five types of intervention approaches were identified: (1) psycho-educational intervention, (2) supportive intervention for treatment adherence (antiretroviral therapy), (3) psychotherapy intervention, (4) narrative intervention, and (5) community participation intervention. Overall, the reviewed articles suggested a general trend of promising effectiveness of these interventions for PLWHA and their family members. Psycho-educational interventions were the main approach. The results highlighted the need for more interventions targeting family members of PLWHA, and mixed-methods intervention studies.
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Affiliation(s)
- Polly H X Ma
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China
| | - Zenobia C Y Chan
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China
| | - Alice Yuen Loke
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, GH 525, Kowloon, Hong Kong, China.
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Nyssen OP, Taylor SJC, Wong G, Steed E, Bourke L, Lord J, Ross CA, Hayman S, Field V, Higgins A, Greenhalgh T, Meads C. Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations. Health Technol Assess 2017; 20:vii-xxxvii, 1-367. [PMID: 27071807 DOI: 10.3310/hta20270] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched. DATA SOURCES Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015). REVIEW METHODS Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines. OBJECTIVES To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom. RESULTS From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW. LIMITATION Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure. CONCLUSIONS Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative. STUDY REGISTRATION This study is registered as PROSPERO CRD42012003343. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Olga P Nyssen
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación, Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Stephanie J C Taylor
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Steed
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Liam Bourke
- Centre for Sport and Exercise Science, Sheffield Hallam University, Sheffield, UK
| | - Joanne Lord
- Southampton Health Technology Assessment Centre, University of Southampton, Southampton, UK
| | - Carol A Ross
- Cumbria Partnership NHS Foundation Trust, Penrith, UK
| | - Sheila Hayman
- Medical Foundation for the Care of Victims of Torture, London, UK
| | - Victoria Field
- Freelance experienced therapeutic writing practitioner, International Federation for Biblio/Poetry Therapy, Steamboat Springs, CO, USA
| | - Ailish Higgins
- Health Economics Research Group, Brunel University, London, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Russell S, Namukwaya S, Zalwango F, Seeley J. The Framing and Fashioning of Therapeutic Citizenship Among People Living With HIV Taking Antiretroviral Therapy in Uganda. QUALITATIVE HEALTH RESEARCH 2016; 26:1447-1458. [PMID: 26246523 PMCID: PMC4974486 DOI: 10.1177/1049732315597654] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this article, we examine how people living with HIV (PLWH) were able to reconceptualize or "reframe" their understanding of HIV and enhance their capacity to self-manage the condition. Two in-depth interviews were held with 38 PLWH (20 women, 18 men) selected from three government and nongovernment antiretroviral therapy (ART) delivery sites in Wakiso District, and the narratives analyzed. ART providers played an important role in shaping participants' HIV self-management processes. Health workers helped PLWH realize that they could control their condition, provided useful concepts and language for emotional coping, and gave advice about practical self-management tasks, although this could not always be put into practice. ART providers in this setting were spaces for the development of a collective identity and a particular form of therapeutic citizenship that encouraged self-management, including adherence to ART. Positive framing institutions are important for many PLWH in resource-limited settings and the success of ART programs.
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Affiliation(s)
| | - Stella Namukwaya
- Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Flavia Zalwango
- Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Systematic review of stigma reducing interventions for African/Black diasporic women. J Int AIDS Soc 2015; 18:19835. [PMID: 25862565 PMCID: PMC4393416 DOI: 10.7448/ias.18.1.19835] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 02/12/2015] [Accepted: 02/13/2015] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Literature indicates that racism, sexism, homophobia and HIV-related stigma have adverse impacts on health, well-being, and quality of life among HIV-positive women of African descent (African/Black diaspora). However, limited evidence exists on the effectiveness of interventions aimed at reducing stigma tailored for these women. This study systematically reviewed randomized controlled trials (RCTs), non-randomized observational and quasi-experimental studies evaluating the effectiveness of interventions aimed at reducing stigma experienced by this population. METHODS The Cochrane methodology was used to develop a search strategy in consultation with a librarian scientist. Databases searched included the Cochrane Library, Ovid EMBASE, PsycInfo, and 10 others. Two reviewers independently assessed the studies for potential relevance and conducted the Cochrane grading of RCTs to assess risk of bias and the Newcastle-Ottawa scale to assess the quality of non-randomized studies. Eligible papers were selected if they employed an intervention design with African/Black diasporic women living with HIV as the target population and had a primary outcome of stigma reduction. RESULTS Of the five studies that met all of the eligibility criteria, four demonstrated the effectiveness of interventions in reducing HIV-related stigma. Only two of the five studies were designed specifically for HIV-positive African/Black diasporic women. Limitations included the absence of interventions addressing other forms of stigma and discrimination (e.g. gender discrimination, racism, heterosexism). CONCLUSIONS Our findings suggest that there are limited interventions designed to address multiple forms of stigma, including gender and racial discrimination, experienced by HIV-positive African/Black diasporic women.
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Rao D, Desmond M, Andrasik M, Rasberry T, Lambert N, Cohn SE, Simoni J. Feasibility, acceptability, and preliminary efficacy of the unity workshop: an internalized stigma reduction intervention for African American women living with HIV. AIDS Patient Care STDS 2012; 26:614-20. [PMID: 22984780 PMCID: PMC3462391 DOI: 10.1089/apc.2012.0106] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Observational studies have examined the prevalence and impact of internalized stigma among African American women living with HIV, but there are no intervention studies investigating stigma reduction strategies in this population. Based on qualitative data previously collected, we adapted the International Center for Research on Women's HIV Stigma Toolkit for a domestic population of African American women to be consistent with Corrigan's principles of strategic stigma change. We implemented the intervention, led by an African American woman living with HIV, as a workshop across two afternoons. The participants discussed issues "triggered" by videos produced specifically for this purpose, learned coping mechanisms from each other, and practiced them in role plays with each other. We pilot tested the intervention with two groups of women (total N=24), measuring change in internalized stigma with the Stigma Scale for Chronic Illness before and after workshop participation. Sixty-two percent of the participants self-reported acquiring HIV through heterosexual sexual contact, 17% through intravenous drug use, 4% in utero, and 13% did not know the route of transmission. The intervention was feasible, enthusiastically accepted by the women, and led to decreased stigma from the start of the workshop to the end (p=0.05) and 1 week after (p=0.07) the last session of workshop. Findings suggest the intervention warrants further investigation.
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Affiliation(s)
- Deepa Rao
- Department of Global Health, International Training and Education Center for Health, University of Washington, Seattle, USA.
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Abu-Moghli F, Nabolsi M, Khalaf I, Suliman W. Islamic religious leaders’ knowledge and attitudes towards AIDS and their perception of people living with HIV/AIDS: a qualitative study. Scand J Caring Sci 2010; 24:655-62. [DOI: 10.1111/j.1471-6712.2009.00757.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Uys L, Chirwa M, Kohi T, Greeff M, Naidoo J, Makoae L, Dlamini P, Durrheim K, Cuca Y, Holzemer WL. Evaluation of a health setting-based stigma intervention in five African countries. AIDS Patient Care STDS 2009; 23:1059-66. [PMID: 20025515 DOI: 10.1089/apc.2009.0085] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The study aim is to explore the results of an HIV stigma intervention in five African health care settings. A case study approach was used. The intervention consisted of bringing together a team of approximately 10 nurses and 10 people living with HIV or AIDS (PLHA) in each setting and facilitating a process in which they planned and implemented a stigma reduction intervention, involving both information giving and empowerment. Nurses (n = 134) completed a demographic questionnaire, the HIV/AIDS Stigma Instrument-Nurses (HASI-N), a self-efficacy scale, and a self-esteem scale, both before and after the intervention, and the team completed a similar set of instruments before and after the intervention, with the PLHA completing the HIV/AIDS Stigma Instrument for PLHA (HASI-P). The intervention as implemented in all five countries was inclusive, action-oriented, and well received. It led to understanding and mutual support between nurses and PLHA and created some momentum in all the settings for continued activity. PLHA involved in the intervention teams reported less stigma and increased self-esteem. Nurses in the intervention teams and those in the settings reported no reduction in stigma or increases in self- esteem and self-efficacy, but their HIV testing behavior increased significantly. This pilot study indicates that the stigma experience of PLHA can be decreased, but that the stigma experiences of nurses are less easy to change. Further evaluation research with control groups and larger samples and measuring change over longer periods of time is indicated.
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Affiliation(s)
- Leana Uys
- School of Nursing, University of KwaZulu-Natal, Durban, South Africa
| | - Maureen Chirwa
- College of Medicine, University of Malawi, Lilongwe, Malawi
| | - Thecla Kohi
- College of Health Sciences, Muhimbili University, Dar es Salaam, United Republic of Tanzania
| | - Minrie Greeff
- Department of Nursing, Potchefstroom Campus, North-West University, Potchefstroom, South Africa
| | - Joanne Naidoo
- School of Nursing, University of KwaZulu-Natal, Durban, South Africa
| | - Lucia Makoae
- Department of Nursing, National University of Lesotho, Maseru, Lesotho
| | | | - Kevin Durrheim
- Department of Psychology, University of KwaZulu-Natal, Durban, South Africa
| | - Yvette Cuca
- School of Nursing, University of California, San Francisco, San Francisco, California
| | - William L. Holzemer
- School of Nursing, University of California, San Francisco, San Francisco, California
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Sandelowski M, Barroso J, Voils CI. Gender, Race/Ethnicity, and Social Class in Research Reports on Stigma in HIV-Positive Women. Health Care Women Int 2009; 30:273-88. [DOI: 10.1080/07399330802694880] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sandelowski M, Voils CI, Barroso J, Lee EJ. "Distorted into clarity": a methodological case study illustrating the paradox of systematic review. Res Nurs Health 2008; 31:454-65. [PMID: 18324678 DOI: 10.1002/nur.20278] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systematic review is typically viewed in the health sciences as the most objective--that is, rigorous, transparent, and reproducible--method for summarizing the results of research. Yet, recent scholarship has shown systematic review to involve feats of interpretation producing less certain, albeit valuable, results. We found this to be the case when we tried to overcome the resistance to synthesis of a set of qualitative and quantitative findings on stigma in HIV-positive women. These findings were difficult to combine largely because of fuzzy conceptualizations of stigma and the volume of unique quantitative findings. Our encounter with findings resistant to synthesis heightened our awareness of the extent to which all systematic reviews are accomplished by practices that paradoxically "distort [research findings] into clarity."
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Varas-Díaz N, Marzán-Rodríguez M. The emotional aspect of AIDS stigma among health professionals in Puerto Rico. AIDS Care 2008; 19:1247-57. [PMID: 18071968 DOI: 10.1080/09540120701405403] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
People who live with HIV/AIDS (PLWHA) in Puerto Rico have been a vulnerable group for stigmatization. Emotions have been a widely ignored issue in stigma-related research. Emotions influence the way people establish their relationship with their environment, relate to each other and assign social meanings to who and what surrounds them. Therefore, emotions have a vital role in the stigmatization of PLWHA. The main objective of this study was to explore the role of emotions in the process of stigmatization of PLWHA by health professionals and health profession students. We implemented an exploratory and mixed method design integrating semi-structured interviews and self-administered questionnaires. The sample was composed of 501 health professionals and health profession students. Qualitative results evidenced the role of negative emotions, such as fear, pity, disgust and embarrassment, in the stigmatization of PLWHA. Participants also described emotions as phenomena that should be suppressed in order to provide effective services. Quantitative results evidenced the manifestation of negative emotions for most of the situations presented to them related to HIV/AIDS. Emotions manifested in health scenarios can hinder the productive provision of health-related services and therefore should be addressed as part of stigma reduction interventions.
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Affiliation(s)
- N Varas-Díaz
- Graduate School of Social Work, University of Puerto Rico, San Juan, Puerto Rico.
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12
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The depiction of stigmatization in research about hepatitis C. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2007; 18:364-73. [PMID: 17854724 DOI: 10.1016/j.drugpo.2007.02.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Revised: 11/30/2006] [Accepted: 02/12/2007] [Indexed: 12/13/2022]
Abstract
In the past decade, there has been an increasing emphasis by researchers regarding the stigmatization of people who are hepatitis C positive as they seek health care. Because the vast majority of people with hepatitis C have a history of injection drug use, they are frequently assumed by practitioners to be injection drug users (IDUs), blamed for acquiring the disease, and viewed as irresponsible, immoral, and unworthy. Such stigmatization may cause people who have hepatitis C to avoid testing, treatment and care, as well as to not disclose their hepatitis C or injection drug use to practitioners. The purpose of this paper is to critically examine the representation of stigmatization in 21 published research reports from 1995 to 2006, with a specific focus on how these depictions have shaped the current understanding of interventions to address stigmatization of people with hepatitis C by health care practitioners. We will identify two themes in this literature: (1) hepatitis C-related stigmatization in health care settings arises primarily from practitioners' negative views of injection drug use, and (2) practitioners' negative attitudes toward people with hepatitis C are the result of their lack of awareness and/or information about the disease and/or about injection drug use. We will illustrate that similar themes have informed anti-stigma initiatives in other diseases, notably HIV/AIDS and mental illness, which have had little sustained effect in changing practitioners' behaviour toward the stigmatized population. In conclusion, we will call for research that considers factors beyond the individual practitioner as contributing to the stigmatization of people with hepatitis C, such as social, structural and institutional forces that shape practitioners' interactions with people with hepatitis C in health care settings.
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Abstract
Few studies have examined the personal and social consequences of stigma associated with HIV infection in Russia, a country with one of the most rapidly advancing HIV epidemics globally. By May 2005, Samara Oblast, Russia had 24,022 notified seropositive individuals. Focus-group discussions with randomly sampled seropositive and seronegative individuals, matched by age, gender and education were selected from the general population and used to provide an informal forum for discussion of attitudes to HIV and potentially stigmatizing behavior. The results demonstrated that the perception that HIV was associated with immoral behaviour underpinned stigma. Discriminating attitudes are strongly associated with misperceptions regarding transmission and frequent over-estimation of risks from casual contact. The general population was unforgiving to those who had become infected sexually or through drug use. Infection through a medical procedure or from an assault was perceived as a likely route of infection. Knowledge of population attitudes and perceptions, as well as those who are HIV-positive, is critical for successful interventions and to encourage people to come forward for HIV testing. This research offers insights into the distance that needs to be traveled if stigma is to be addressed in wider efforts to control HIV in Russia.
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Affiliation(s)
- Y Balabanova
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Kittikorn N, Street AF, Blackford J. Managing shame and stigma: case studies of female carers of people with AIDS in southern Thailand. QUALITATIVE HEALTH RESEARCH 2006; 16:1286-301. [PMID: 17038758 DOI: 10.1177/1049732306293992] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The authors of this article discuss the effects of shame and stigma on female caregivers of people living with AIDS in southern Thailand. They conducted a longitudinal ethnographic case study over 8 months and collected data using interviews, observations, field notes, and journaling. The authors performed qualitative content analysis and narrative analysis. Public judgment was created in a moral climate, framed by Buddhist precepts of correct and honorable behavior, with different levels of tolerance and stigmatization between men and women. Women caregivers engaged in concealing practices, deception, and withdrawal from social relationships to manage the effects of shame and stigma.
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Affiliation(s)
- Nilmanat Kittikorn
- Department of Adult Nursing, Faculty of Nursing, Prince of Songkla University, Thailand
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