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Visual representation of the exchange process used in the stigma exercise.
Source publication
Healthcare workers (HCW) face the risk of occupational exposure to infectious diseases, especially in countries with high burdens of tuberculosis (TB) and human immunodeficiency virus (HIV). Disclosure of TB and/or HIV status is needed to ensure prompt action and treatment, and, in the case of TB, prevent transmission to co-workers and patients. Tr...
Context in source publication
Context 1
... stigma exercise focused on showing what it feels like to be stigmatized. Participants were asked to stand in a circle (see Figure 1) and the facilitator instructed the group that every person is to take on the identity of 'John'. The facilitator explained the exercise as follows: […] And so on until the message is back to Person 1. ...
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Citations
... Studies involving TB patients' families provide models for how family-centred counselling could be carried out via home visits [52,53] and educational tools such as videos [54], which our partner advocacy organisation TB Proof has also used to decrease TB stigma [55,56]. At the institutional level, health worker training interventions including participatory workshops and visual messaging may reduce TB stigma amongst health workers [57][58][59]. ...
Background
Anticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.
Methods
Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.
Results
Intervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.
Conclusions
Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.
Supplementary Information
The online version contains supplementary material available at 10.1186/s44263-024-00084-z.
... In a recent systematic review we considered how stigma reduction interventions were implemented at each level of the socio-ecological model. 21 Existing interventions -all in the pilot stage -typically targeted one or possibly two levels; for example, TB support groups or clubs (individual/interpersonal), [40][41][42] home visits (individual/interpersonal), 42,43 education for patients/caregivers (individual/interpersonal), 44 health worker training (institutional), [45][46][47] and community-volunteer led education (community) 48 . This highlights a tension whereby, given limited resources, trade-offs are made between interventions at different levels of the socio-ecological model. ...
Background: Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.
Methods: Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.
Results: Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.
Conclusions: Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.
... The remaining five studies used qualitative data [26][27][28][29][30], four of which did not incorporate any specific analysis approach or framework and focused on the use of quotes. One qualitative study conducted thematic analysis [27]. ...
... Participants discussed the different emotions that they associated with stigma, including feeling 'lonely', 'anxious', 'unwanted' and 'judged' [30]. ...
... This is stigma. This is how a stigmatized person feels' [30]. disclose positive TB results to family members were able to talk publicly about their disease after participating in weekly TB clubs led by a TB leader elected by the group, who also sought additional assistance from community leaders such as priests to provide patient encouragement and support (Box 2). ...
Stigma is a critical barrier for TB care delivery; yet data on stigma reduction interventions is limited. This review maps the available literature on TB stigma reduction interventions, using the Health Stigma and Discrimination framework and an implementation analysis to identify research gaps and inform intervention design. Using search terms for TB and stigma, we systematically searched PubMed, EMBASE and Web of Science. Two independent reviewers screened all abstracts, full-texts, extracted data, conducted a quality assessment, and assessed implementation. Results were categorized by socio-ecological level, then sub-categorized by the stigma driver or manifestation targeted. After screening 1865 articles, we extracted data from nine. Three studies were implemented at the individual and interpersonal level using a combination of TB clubs and interpersonal support to target internal and anticipated stigma among persons with TB. Two studies were implemented at the interpersonal level using counselling or a video based informational tool delivered to households to reduce stigma drivers and manifestations. Three studies were implemented at the organizational level, targeting drivers of stigma among healthcare workers (HW) and enacted stigma among HWs. One study was implemented at the community level using an educational campaign for community members. Stakeholder consultation emphasized the importance of policy level interventions and education on the universality of risk to destigmatize TB. Review findings suggest that internal and anticipated TB stigma may be addressed effectively with interventions targeted towards individuals using counselling or support groups. In contrast, enacted TB stigma may be better addressed with information-based interventions implemented at the organizational or community level. Policy level interventions were absent but identified as critical by stakeholders. Implementation barriers included the lack of high-quality training and integration with mental health services. Three key gaps must be addressed in future research: consistent stigma definitions, standardized stigma measurement, and measurement of implementation outcomes.
... The focus of day 2 was on Module 4. Day 3 was devoted to developing HealthWISE action plans (activities to be carried out by trainees in their health facilities). Throughout, participatory training techniques, including role plays and an interactive exercise on the topic of stigma [10], were demonstrated, which might be useful for participants to help engage workers and disseminate new information in their workplaces. Following the training, participants were expected to create HealthWISE teams and based on the HealthWISE principle of finding simple, low-cost solutions to workplace issues within their local contexts, carry out HealthWISE activities in their hospitals. ...
Ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. The World Health Organization and International Labour Organization designed HealthWISE, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. However, its implementation had never been systematically evaluated. We, therefore, studied the implementation of HealthWISE in seven hospitals in three countries: Mozambique, South Africa, and Zimbabwe. Through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of HealthWISE by applying the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework. Enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. Barriers included lack of clarity about how to use HealthWISE, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. Overall, successful implementation of HealthWISE required dedicated local team members who helped facilitate the process by adapting HealthWISE to the workers’ occupational health and safety (OHS) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-PARiHS framework.
