Stigma Reduction Training Improves Healthcare Provider Attitudes toward, and Experiences of, Young Marginalized People in Bangladesh

"Results indicate that health provider attitudes toward young people living with HIV and marginalized, or 'key,' populations can be improved with focused stigma reduction interventions in Bangladesh."

Stigma and discrimination can inhibit the uptake of HIV and sexual and reproductive health and rights (SRHR) services, particularly among adolescents and young people. In some settings, for example, young people may avoid seeking services due to cultural or societal norms against sexual activity outside of marriage. When they do access services, young people often experience stigma from healthcare providers when they are perceived to be engaging in "prohibited" behaviours. In Bangladesh, studies have documented avoidance of services by people living with HIV (PLHIV) due to fear of potential discrimination, as well as high levels of discriminatory behaviour by health workers. This study evaluated a stigma reduction training programme for health providers in Bangladesh.

The training programme took place within the context of the "Link Up" project, which took place in five countries, including Bangladesh (see Related Summaries, below), from 2014 to 2016. In 2014 and 2015, Marie Stopes Bangladesh (MSB), in partnership with Link Up, trained over 1,000 of their healthcare providers on youth-focused SRHR. An example of a training activity includes: Using coloured cards and markers, participants discuss and write forms of stigma faced by key populations at risk of HIV. The cards are posted on a wall, with causes of stigma representing "roots" of a tree at the bottom, actual forms of stigma as the "trunk" of the tree in the middle, and effects of stigma as the tree's leaves and branches.

From July 2014 to January 2015, all MSB providers who were scheduled to receive Link Up training were invited to participate in the study. After completing a self-administered questionnaire measuring stigmatising attitudes toward young populations, the service providers received the initial 2-day HIV and SRHR training, including a 90-minute session on issues related to stigma and gender. The same providers repeated the survey a second time before participating in a 1-day supplemental training to highlight messages on social stigma (based on deep-seated cultural or moral beliefs about the behaviour and practices of the patient) and to encourage reflection on personal values around key populations and youth sexuality. A third survey was repeated 5-6 months after the second stigma training.

Of the 400 providers recruited, 300 providers participated in all study activities (all three surveys and both trainings) and were included in the analysis. These 300 MSB service providers were mostly female (90.7%), with 15.7% reporting they were doctors, 52.3% other healthcare practitioners, and 32.0% counselors.

Table 4 in the paper shows changes from baseline to midterm to endline surveys in key stigma-related indicators. For example, agreement that PLHIV should feel ashamed of themselves decreased significantly after the initial training (35.3%-19.7%; p < .001) and remained stable after the supplemental stigma training (19.7%-16.3%; p = .245). Provider agreement that PLHIV have engaged in irresponsible behaviours decreased minimally after the first training (58.0%-55.0%; p = .456), but more substantially after the second training (55.0%-45.7%; p = .006). Agreement that key populations engaged in "immoral behaviour" decreased after both trainings with regard to: sexually active young people (50.3%-36.0%-21.7%; p < .001), sex workers (51.0%-37.3%-25.3%; p = .001), men who have sex with men, or MSM (49.3%-38.0%-24.0%; p < .001), hijra, or transgender people (39.3%-29.3%-20.3%; p < .001), and young unmarried pregnant women (38.0%-28.3%-18.0%; p < .001).

The researchers also conducted a client exit interview survey: 266 clients participated in the first round, and 371 participated in the second round. Clients overall were more likely to report discussing with service providers that they were a member of a population at risk of health provider stigma after the second provider training, especially among the MSM subgroup (67.6%-86.7%; p < .05). The percentage of clients who reported being dissatisfied with services decreased from 3.4% after first training to .0% after second training, and dissatisfaction with the quality/professionalism of the service declined from 2.3% to .8%. In addition, there were substantial increases in clients who were "very satisfied" with overall services (15.0% after first training to 23.5% after second training) and quality and professionalism of services (9.0%-31.0%). These improvements in both client satisfaction measures were statistically significant (p < .001), as well as significant within all age, sex, and Link Up outreach population subgroups.

Reflecting on the findings, the researchers note that "[s]ome providers were unwilling to provide HIV- and SRHR-related services to these young subgroups at baseline and feared being put at risk of disease due to their exposure to these young people. Value-based stigma reflected through judgmental or negative attitudes was also high among the providers at baseline. Both the fear-based and value-based stigma were significantly reduced after both training interventions - some more so after the second training. Moral judgment of the young marginalized subgroups (as measured through provider 'agreement' that they engaged in immoral behavior) improved positively but remained high at endline..."

In conclusion: "...it is hoped that future MSB refresher trainings and expansion of the approach to other service providers in Bangladesh will influence further reductions in stigmatizing attitudes. This training approach, which is currently used more widely in sub-Saharan Africa, may have potential for future south-south collaborations to train service providers in Asia. Reaching young people at risk of being denied the health services they need and deserve due to provider stigma is essential."