Discriminatory attitudes towards people from key populations among health facility staff
Export Indicator
This indicator is divided into four subindicators:
A. Discriminatory attitudes towards sex workers.
B. Discriminatory attitudes towards gay men and other men who have sex with men.
C. Discriminatory attitudes towards people who inject drugs.
D. Discriminatory attitudes towards transgender people.
What it measures
Progress towards reducing negative attitudes towards people from key populations among health facility staff.
Attitudes and opinions of health-care staff towards people from key populations are a driver of HIV stigma and discrimination in health-care settings. Globally, many people from key populations, including gay men and other men who have sex with men, sex workers, transgender people and people who inject drugs, experience negative attitudes and harmful actions in health-care settings, which undermines their health and ability to lead a productive life.
Administrators and health facility staff worldwide have shown that stigma and discrimination can be addressed successfully. Stigma-reduction efforts in Brazil, China, Ghana, India, Thailand, the United Republic of Tanzania and Viet Nam have resulted in significant changes in attitudes and practices of health facility staff, and improved care for people from key populations. Asking about provider preferences related to service provision can help to understand discriminatory attitudes towards people from key populations.
Number of respondents who agreed with the stigmatizing statement.
Total number of respondents.
Numerator/denominator.
Any type of facility-based survey, such as the Service Provision Assessment, quality assurance surveys, or the Health Policy Project Measuring HIV Stigma and Discrimination Among Workers in Health. Facilities Questionnaire. The indicator is constructed from responses to the following question:
Please tell us if you strongly agree, agree, disagree or strongly disagree with the following statement:
A. If I had a choice, I would prefer not to provide services to sex workers.
B. If I had a choice, I would prefer not to provide services to men who have sex with men.
C. If I had a choice, I would prefer not to provide services to people who inject drugs.
D. If I had a choice, I would prefer not to provide services to transgender people.
The numerator includes respondents who agree or strongly agree with the statement.
The questions recommended for the construction of this indicator were selected from a 25-item tool validated in health facility settings in several countries. (Measuring HIV stigma and discrimination among health facility staff. Washington, DC: Futures Group, Health Policy Project; 2013 (http://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubID&p...).
Every 3–5 years.
None
None.
This indicator directly assesses discriminatory attitudes towards people from key populations among health facility staff, which has been linked with poorer engagement in care and reduced adherence to treatment. The questions used to construct these indicators are included in the Health Policy Project Measuring HIV Stigma and Discrimination Among Workers in Health. Facilities Questionnaire, which is typically implemented as part of an intervention to achieve stigma-free health facilities and HIV services. The tool has been validated in six countries.
This indicator may be subject to social desirability bias if respondents provide what they perceive to be the “correct” or “acceptable” response rather than what they actually believe, leading to underreporting of stigma. This suggests the observed stigma levels would be higher in the absence of response bias. The use of self-administered rather than interviewer-administered questionnaires may reduce social desirability bias by providing a greater sense of anonymity.
Carr D, Kidd R, Fitzgerald M, Nyblade L. Achieving a stigma-free health facility and HIV services: resources for administrators. Washington, DC: Futures Group, Health Policy Project; 2015 (https://www.healthpolicyproject.com/pubs/281_SDAdministratorsGuide.pdf, accessed 7 November 2023).
Krishnaratne S, Bond V, Stangl A, Pliakas T, Mathema H, Lilleston P, et al. Stigma and judgment towards people living with HIV and key population groups among three cadres of health workers in South Africa and Zambia: analysis of data from the HPTN 071 (PopART) Trial. AIDS Patient Care STDs. 2020;34(1):38–50.
Sampling manual for facility surveys for population, maternal health, child health and STD programs in developing countries. Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill; 2001 (https://www.measureevaluation.org/resources/publications/ms-01-03.html, accessed 7 November 2023).
Nyblade L, Stockton M, Giger K, Bond V, Ekstrand ML, Lean RM, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2020;17(25):25.
Nyblade L, Jain A, Benkirane M, Li L, Lohiniva AL, McLean R, et al. A brief, standardized tool for measuring HIV-related stigma among health facility staff: results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis. J Int AIDS Soc. 2013;16(Suppl 2):18718.
Stangl A, Lilleston P, Mathema H, Pliakas T, Krishnaratne S, Sievwright K, et al. Development of parallel measures among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc. 2019;22(12):e25421.