Reducing Provider-Held Stigma and Improving Young Client Satisfaction in Bangladesh: Findings from a Link Up Evaluation

"The Link Up training package had a positive impact on providers' beliefs and attitudes, and on the quality of care provided to young people living with - or at increased risk of contracting - HIV, including young key populations."

Citing research indicating that stigma can inhibit uptake of critical HIV and sexual and reproductive health and rights (SRHR) services, the Population Council designed and evaluated a training programme for service providers in Bangladesh as part of Link Up, a global project led by the International HIV/AIDS Alliance designed to improve the SRHR of young people in Bangladesh, Burundi, Ethiopia, Myanmar, and Uganda (see Related Summaries, below). The intervention consisted of facility- and community-based integrated HIV and SRH activities designed for young people (ages 15 to 24) at higher risk of stigmatisation because they are living with HIV, have had premarital sex, and/or are sex workers (SWs), men who have sex with men (MSM), hijras (transgender people), or "pavement-dwelling" persons who are typically migrant and live on streets or in improvised dwellings.

Specifically, over 1,000 healthcare providers (doctors, paramedics/nurses/family welfare visitors, and counselors) participated in various training activities held by local Link Up partner Marie Stopes International Bangladesh (MSIB) at 270 health facilities in 38 target districts in Bangladesh. As detailed in Box 1 of the report, the initial 2-day "integration training" featured participatory activities such as: naming stigma through pictures, sharing personal stories of stigma, creation of a key population stigma problem tree, values clarification, discussion of questions about sex, brainstorming about how language can stigmatise subgroups, use of cards to understand gender and sexuality terminologies, MSM and transgender case studies, role plays, and writing of a charter for a stigma-free service. Such activities were crafted to address providers' potential concerns about the risk of HIV transmission from clients, related stigma toward people living with HIV due to fear of transmission, and measures to minimise transmission risk. The training typically also included a 1-day session on HIV stigma, sexuality, gender, and key populations. A 1-day supplemental training highlighted messages on social stigma and encouraged reflection on personal values around key populations and youth sexuality.

All service providers receiving the initial integration training were invited to participate in the study. At baseline, 300 providers were recruited and given a self-administered questionnaire measuring stigmatising attitudes toward young populations. The questionnaire was given to the same 300 providers again at midterm, 6 months after the initial integration training and before participating in the 1-day supplemental stigma training, and finally at endline, 5-6 months after the supplemental stigma training. A subset of 25 doctors, nurses/paramedics, and counselors also participated in in-depth interviews after completing the endline survey. To assess the impact of provider training on client satisfaction, cross-sectional surveys of MSIB clients aged 15-24 were implemented before and after the supplemental stigma training. The client exit survey was completed by 264 clients in the first round and 367 in the second round.

In brief, the results indicate:

• There was a shift in provider attitudes about people who live with HIV. For example, the percentage of providers who reported that people living with HIV should feel ashamed dropped from 35% at baseline to 20% after the initial integration training, yet after the supplemental stigma training, the change was less pronounced (from 20% to 16%). Similarly, after the integration training, the percentage of providers who agreed with the statement that people living with HIV have had many sexual partners dropped from baseline (57%) to midterm (46%), with a less dramatic reduction after the supplemental stigma training (46% to 43%). And, after the initial integration training, the percentage of providers who said people living with HIV should be allowed to have babies if they choose rose to 53% from 40% at baseline, but only increased slightly (to 56%) after the supplemental stigma training.
• The supplemental stigma training seemed to have had an additional substantial impact on providers' attitudes toward marginalised populations (see Figure 1). Significantly fewer providers reported being unwilling to provide services, fearing disease transmission, or judging clients to be immoral if they were a young sexually active person, including MSM or sex workers. In-depth interviews indicated that the training had helped providers become more self-aware, which they considered to be the first step in overcoming judgmental attitudes, feelings, and beliefs. Many providers said the training helped them shift their mindset to "treating the disease" instead of focusing on clients' "disgraceful" behaviours (premarital sex, homosexual relations, sex work) that are considered contrary to Bangladesh's conservative values and religious beliefs. Many said the training reinforced their duty to treat all clients equally as human beings entitled to services, regardless of background, circumstances, beliefs, or behaviours.
• Overall, clients were more likely to report discussing with service providers that they were a member of a stigmatised population after the supplemental training; this was particularly noticeable among MSM (68% to 87%). Client satisfaction with service delivery increased significantly after the supplemental stigma training, as shown in Figure 2.

The report concludes that the participatory stigma training methods utilised here can be valuable tools to help providers reflect on their own values, attitudes, and practices; these methods can enable them to "be the change". One female doctor explained: "They presented stigma by showing different pictures. For example, an HIV-positive patient went to the hospital and shared his problems. The service providers kept unusual distance wearing gloves unnecessarily while checking up. AIDS is not transmitted through touch; thus treating patients wearing two gloves is stigma. Whenever we take blood, we need to wear [gloves], but using the stuff unnecessarily, getting scared to see them, keeping distance, is stigma." According to the Population Council, "[g]iven the high level of success and acceptability of the training methods used in this study, MSIB has already institutionalized and scaled up the participatory training approach used in the second stigma training for all of their service providers in Bangladesh."

Editor's note: You may also be interested in "Sexual and Reproductive Health and Rights Needs of Young Men Who Live in the Streets in Dhaka City: A Link Up Exploratory Study" [PDF].