Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers.

BACKGROUND: HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. METHODS: Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. RESULTS: The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. CONCLUSIONS: This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. TRIAL REGISTRATION: South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Emotional well-being and work engagement of nurses who moonlight (dual employment) in private hospitals.

BACKGROUND AND AIM: Given the myriad occupational stressors of nursing itself, plus the challenges of moonlighting, we aimed to investigate the emotional well-being of moonlighting nurses and their work engagement. Well-being was defined by levels of general health, mental health, emotional exhaustion, personal accomplishment, compassion satisfaction and compassion fatigue. DESIGN: A cross-sectional descriptive survey (December 2017 to March 2018) at private health care facilities in a Metropolitan Municipality, South Africa. METHODS: Two hundred and fifty-one nurses completed self-administered questionnaires, which comprised of validated scales. RESULTS: Nurses were at low risk for emotional exhaustion (M=12.8; SD=11.23) and scored high on compassion satisfaction (M=42.34; SD=7.22) and work engagement (M=4.87, SD=1.18). Personal accomplishment (t= 2.535; P<.05) compassion satisfaction (t= 6.790; P=.000) and mental health (t=3.206; P<.05) made a statistically significant unique contribution to the prediction of work engagement. Nurses who had considered leaving the profession scored significantly higher on emotional exhaustion and compassion fatigue. CONCLUSION: Nurses who moonlighted in private health care facilities reported low risk for burnout and high levels of compassion satisfaction and work engagement. Further research is needed to explore the reasons for these findings. Attention must be given to ensuring the occupational well-being of nurses in order to retain them in the profession.

Waiting to inhale: factors associated with healthcare workers' fears of occupationally-acquired tuberculosis (TB).

BACKGROUND: Fear of TB infection is rooted in historical and social memories of the disease, marked by stigma, segregation and exclusion. Healthcare workers (HCWs) face these same fears today, and even seek to hide their TB status when infected. This study sought to investigate factors associated with HCWs fears of acquiring TB while at work, including selected biographic characteristics, TB knowledge, infection control and perceptions that their colleagues stigmatise co-workers with TB/ presumed to have TB. METHODS: In the Free State Province, South Africa, a representative sample of 882 HCWs from eight hospitals completed self-administered questionnaires on issues related to fear of occupationally acquired TB, infection control, TB knowledge and workplace TB stigma. The data were analysed using descriptive statistics as well as binomial logistic regression. RESULTS: Most of the HCWs (67.2%) were concerned about contracting TB at work. Support staff were less likely to worry about acquiring TB than clinical staff (OR = 0.657, P = 0.041). Respondents who indicated that there were inadequate numbers of disposable respirators at work, were 1.6 times more likely to be afraid of contracting TB at work (P = 0.040). With every unit increase on the TB stigma scale, respondents were 1.1 times more likely to fear acquiring TB at work (P = 0.000). CONCLUSIONS: Being a professional clinical HCW, not having adequate disposable respirators available and seeing/perceiving co-workers stigmatise colleagues with (presumptive) TB were all significantly associated with the fear of occupationally-acquired TB. It is recommended that campaigns to destigmatise TB, as well as appropriate TB infection control education and measures, are necessary to alleviate HCWs fears of acquiring the disease in the workplace. Ultimately this should create a health-enabling working environment, where HCWs are not afraid to function and are free to seek treatment and support when necessary.

Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa.

Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the "HIV and TB Stigma among Health Care Workers Study" (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma - and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma - resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa.

BACKGROUND: The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting. METHODS: The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa. RESULTS: Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity. CONCLUSIONS: The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

How the 'HIV/TB co-epidemic-HIV stigma-TB stigma' syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT).

INTRODUCTION: Tuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing a syndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV-TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment. DESIGN: A cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study). SETTING: Six hospitals in the Free State province of South Africa. PARTICIPANTS: 820 HCWs of the six selected hospitals. RESULTS: The study results demonstrate that the co-epidemic (ß=0.399 (screening model) and ß=0.345 (treatment model)) combined (interaction effect: ß=0.133 (screening) and ß=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (ß=0.345 (screening) and ß=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB-illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (ß=0.421 (screening) and ß=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=-0.216) and treatment (probit coefficient=-0.160). Confidentiality consistently emerged as a contextual correlate of OHU use. CONCLUSIONS: Theoretically, our results confirm HIV as a 'syndemic generator' which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services. TRIAL REGISTRATION NUMBER: Pre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204.

Changing Cultural Practices: A Case Study of Male Circumcision in South Africa.

This article presents a case study of Simon, a 25-year old Black South African male. According to his Pedi customs, Simon underwent traditional male circumcision (TMC) as a 12-year-old adolescent. He tells of his fears relative to this experience and how, over time, he transitioned from a belief in TMC to a strong preference for medical male circumcision (MMC). Using a single-case study design, the aim of the research was to explore the value of the exercise of choice in TMC, which may influence cultural perceptions of gender and masculinity. The study unpacks the way in which the meaning and experience of TMC is shaped by the social and cultural contexts of South Africa. This qualitative exploration complements conventional medical accounts of circumcision, which are often focused on the medical procedure while ignoring cultural and social factors. Issues of gender, particularly the construction of hegemonic masculinity and how it positions men, women, and young boys in relation to each other and their communities, are discussed. Simon's case study provides new insights and perspectives on personally and culturally sensitive issues which are not easily accessed nor commonly understood. Data collected via in-depth interviews were transcribed and analyzed thematically. Analysis applied information from the literature and key concepts from the theoretical standpoint of social constructivism. Case study analysis allowed space for unexpected, emergent themes to arise from the data. Four main themes were identified, notably language, silence, patriarchy, and masculinity.

Reducing HIV- and TB-Stigma among healthcare co-workers in South Africa: Results of a cluster randomised trial.

RATIONALE: The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism. OBJECTIVE: This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign. METHODS: Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention. RESULTS: The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.

Factors Associated With HIV-Related Stigma Toward Colleagues in the Health Care Workforce in South Africa.

South Africa has the highest number of people living with HIV in the world, and health care workers (HCWs) are as likely to be infected as the general population. Stigma in health care settings has severe implications for HCWs and health facilities when HCWs with HIV delay or avoid seeking care, causing increased morbidity and mortality. We explored factors associated with HIV stigma toward colleagues. A representative sample of 882 HCWs from 8 hospitals was surveyed in the Free State, South Africa. We applied multigroup structural equation modeling to compare effects between 3 professional categories. In all 3 groups, there was a significant negative relationship between stigmatizing attitudes against other co-workers and knowing a colleague living with HIV, having a colleague who worked to reduce stigma in the workplace, and having basic HIV knowledge. Our results have implications for understanding and crafting interventions to reduce HIV stigma among HCWs.

Towards a health-enabling working environment - developing and testing interventions to decrease HIV and TB stigma among healthcare workers in the Free State, South Africa: study protocol for a randomised controlled trial.

BACKGROUND: Occupational exposure to tuberculosis (TB) constitutes a major health risk for healthcare workers (HCWs). The HIV epidemic equally affects the workforce because of the mutually reinforcing epidemiology of HIV and TB. Stigmas associated with HIV and TB have become so intricately entangled that they stop some HCWs from seeking care in a context where serious shortages in human resources for health besiege public health facilities. It is thus imperative to research, as well as attempt to tackle, HIV and TB stigma among HCWs. But little has been done internationally-and nationally, only our own exploratory studies. Our project aims to address this by (1) scientifically assessing the extent and sources of HIV and TB-related stigma among HCWs and (2) developing and testing evidence-based, stigma-reduction interventions in public hospitals in the Free State Province of South Africa. METHODS/DESIGN: The research follows a stratified cluster randomised controlled trial (RCT) design. Pre intervention, a self-administered questionnaire with the pilot study's validated stigma scales is used to measure stigma and other key variables among randomly selected HCWs in eight hospitals-stratified by size and district and then randomly allocated to four intervention and four control sites. Interventions comprise HIV- and TB-stigma reduction activities-mainly Social and Behavioural Change Communication (SBCC) interventions-at three social-ecology levels (individual, community, and socio-structural). An outside assessor will appraise the trial mid-way through implementation. Post intervention, all baseline respondents will be followed up to complete the baseline questionnaire with additional items on interventions. Qualitative data will be collected to better understand HIV and TB stigma and explore if, and how, interventions impact stigma levels in the workplace. DISCUSSION: The study regards as HCWs all staff, working in all different types of jobs, at all levels in the hospitals. Thus, the research addresses HIV and TB stigma across the whole workforce and the entire workplace. In doing so it will (1) generate essential information on stigma among HCWs and (2) implement stigma-reduction interventions that are innovative yet replicable, and potentially beneficial in addressing a pernicious human-rights-based issue. TRIAL REGISTRATION: South African National Clinical Trials Register, registration ID: DOH-27-1115-5204 . Prospectively registered on 26 August 2015.

Power and Integrated Health Care: Shifting from Governance to Governmentality.

Integrated care occurs within micro, meso and macro levels of governance structures, which are shaped by complex power dynamics. Yet theoretically-led notions of power, and scrutiny of its meanings and its functioning, are neglected in the literature on integrated care. We explore an alternative approach. Following a discussion on governance, two streams of theorising power are presented: mainstream and second-stream. Mainstream concepts are based on the notion of power-as-capacity, of one agent having the capacity to influence another-so the overall idea is 'power over?'. Studies on integrated care typically employ mainstream ideas, which yield rather limited analyses. Second-stream concepts focus on strategies and relations of power-how it is channelled, negotiated and (re)produced. These notions align well with the contemporary shift away from the idea that power is centralised, towards more fluid ideas of power as dispersed and (re)negotiated throughout a range of societal structures, networks and actors. Accompanying this shift, the notion of governance is slowly being eclipsed by that of governmentality. We propose governmentality as a valuable perspective for analysing and understanding power in integrated care. Our contribution aims to address the need for more finely tuned theoretical frameworks that can be used to guide empirical work.

Workplace interventions to reduce HIV and TB stigma among health care workers - Where do we go from here?

Fear of stigma and discrimination among health care workers (HCWs) in South African hospitals is thought to be a major factor in the high rates of HIV and tuberculosis infection experienced in the health care workforce. The aim of the current study is to inform the development of a stigma reduction intervention in the context of a large multicomponent trial. We analysed relevant results of four feasibility studies conducted in the lead up to the trial. Our findings suggest that a stigma reduction campaign must address community and structural level drivers of stigma, in addition to individual level concerns, through a participatory and iterative approach. Importantly, stigma reduction must not only be embedded in the institutional management of HCWs but also be attentive to the localised needs of HCWs themselves.

Sexual and reproductive health perceptions and practices as revealed in the sexual history narratives of South African men living in a time of HIV/AIDS.

Abstract The frequent positioning of men's sexual risk-taking as driving the HIV/AIDS epidemic in South Africa has triggered interest in men's sexual and reproductive health (SRH) perceptions, attitudes, and practices. Much research, however, presents men as a homogenous group, and focuses on the quantifiable aspects of male sexual behaviors, providing an inadequate basis for understanding men's SRH needs and addressing the gendered aspects of HIV prevention. This study used sexual history narratives to yield more nuanced and contextualized understandings of male sexuality as it relates to SRH. Fifty sexual life history individual interviews and 10 focus-group discussions (FGDs) with men, as well as 25 sexual life history interviews with women, were conducted with participants purposively sampled from three age categories: (18-24, 25-55, and 55+ years), a wide range of cultural and racial backgrounds, and in urban and rural sites across 5 provinces in South Africa. Interviews and FGDs elicited stories of participant's early knowledge of sex and sexual experimentation and then explored sexual relationships and experiences in adulthood-including engagement with HIV risks and SRH management. The data were analyzed using a thematic approach. Many male participants conformed to dominant norms of masculinity associated with a high risk of sexually transmitted infections including HIV, such as having regular unprotected sex, reluctance to test for HIV, and poor SRH-seeking behaviors. Yet, the narrative accounts reveal instances of men taking steps to protect their own SRH and that of their partners, and the complex ways in which hegemonic gender norms influence men and women's SRH. Ultimately, the study points to the value of sexual biographies for gaining a deeper understanding of male sexuality, and the social structures, meanings, and experiences that underlie it. Such insights are critical to more effectively engaging men in HIV prevention efforts.

Reducing the risks to health care workers from blood and body fluid exposure in a small rural hospital in Thabo-Mofutsanyana, South Africa.

Health care workers in sub-Saharan Africa are at high risk of acquiring bloodborne diseases. A training program was launched to build the capacity of occupational health nurses to design and implement workplace-based projects. The study assessed the knowledge, attitudes, and practices of health care workers regarding blood and body fluid exposures in a small district hospital in a rural area of the Free State in South Africa. Under the guidance of two experienced mentors, an occupational health nurse designed a knowledge, attitudes, and practices questionnaire and distributed itto 101 health care workers at risk throughout the hospital; 88% of questionnaires were returned in sealed envelopes.Limited knowledge and ineffective practices were documented. For example, only 54.3% of the respondents reported that needles should never be recapped. A significant correlation (p < .001) was found between limited knowledge and recent blood and body fluid exposure. The study results provided the occupational health nurse with data to address the knowledge, attitudes, and practices deficits by implementing an injury prevention educational intervention. Such training initiatives can decrease the burden of occupational disease among health care workers in rural low-resourced areas.