Reducing HIV-related stigma among young people attending school in Northern Uganda: study protocol for a participatory arts-based population health intervention and stepped-wedge cluster-randomized trial.

BACKGROUND: HIV-related stigma negatively impacts HIV prevention, treatment, and care, particularly among children and adolescents in sub-Saharan Africa. Interventions that are culturally grounded and relevant for addressing root causes may reduce the stigma experienced by HIV-positive and HIV-affected young people. This study, to be conducted in a post-conflict, rural setting in Omoro District, Uganda, will develop and evaluate a transformative  arts-based HIV-related stigma intervention rooted in local cultural knowledge to reduce stigma and improve HIV prevention and care for young people living with HIV. The intervention will be delivered to young people attending school by community Elders, with the support of teachers, through the transfer of local cultural knowledge and practices with the aim of re-establishing the important cultural and social role of Elders within a community that has suffered the loss of intergenerational transfer of cultural knowledge throughout a 25-year civil war. METHODS: A formative research phase consisting of interviews with students, teachers, and Elders will inform the intervention and provide data for study objectives. Workshops will be delivered to Elders and teachers in participating schools to build capacity for arts-based, educational workshops to be conducted with students in the classroom. The intervention will be evaluated using a stepped-wedge cluster-randomized trial. Government-funded schools in Omoro District will be randomized into three blocks, each comprised of two primary and two secondary schools (n=1800 students). Schools will be randomly assigned to a crossover sequence from control to intervention condition in 8-week intervals. A process evaluation will be implemented throughout the study to evaluate pathways between intervention development, implementation, and effects. DISCUSSION: This study will generate comprehensive, in-depth participatory research and evaluation data to inform an effective and sustainable protocol for implementing arts-based HIV stigma interventions for young people in school settings. Findings will have widespread implications in post-conflict settings for HIV prevention, treatment, and care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04946071 . Registered on 30 June 2021.

"I die silently inside". Qualitative findings from a study of people living with HIV who migrate to and settle in Canada.

We report on qualitative findings from a mixed methods study, examining enacted and internalized stigma during mandatory HIV screening among immigration applicants living with HIV in Canada. Qualitative findings show alignment with characteristics of internalized HIV stigma. We conducted 34 semi-structured interviews, and analyzed the data through thematic analysis, using Intersectionality and the Internalized HIV Stigma Scale as our theoretical and analytical frameworks. Participants described experiences of enacted and internalized HIV stigma in ways that were consistent with the four main domains of stereotypes, disclosure concerns, social relationships, and self-acceptance, but also extended the description of HIV stigma beyond these domains. Experiences of internalized HIV stigma and enacted stigma during the Canadian Immigration Medical Examination could potentially influence individuals' long-term engagement in the HIV care cascade during the process of migration to, and settlement in, Canada. We present recommendations for the broader migrant health research agenda, health and social care providers, and public health policies.

Mandatory HIV screening, migration and HIV stigma in Canada: exploring the experiences of sub-Saharan African immigrants living with HIV in western Canada. / Dépistage obligatoire du VIH, migration et stigmatisation liée au VIH au Canada : analyse de l'expérience d'immigrants d'Afrique subsaharienne vivant avec le VIH dans l'Ouest canadien.

INTRODUCTION: In this mixed-methods pilot study, we examined the intersections of the current Canadian immigration policy, mandatory HIV screening during the Immigration Medical Exam (IME) and enacted and internalized stigma for HIV-positive immigrants from sub-Saharan Africa (SSA) in a western Canadian province. We focus on qualitative findings from this study. METHODS: Using the Internalized HIV Stigma Scale (IHSS), we collected data from eight immigrants from SSA living with HIV in a western Canadian province. We then conducted semistructured interviews with seven of the eight participants. Due to the small sample size, survey data were summarized using descriptive analysis. Qualitative data were analyzed through constant comparative analysis. RESULTS: The following key themes emerged from analysis of qualitative data: experiences of HIV-related emotional distress during the IME; varied experiences of HIV testing during the IME; and inconsistent patterns of linkage to medical care, psychosocial supports and engagement in the HIV care cascade. CONCLUSION: Findings from this pilot study cannot be generalized to the broader population of immigrants living with HIV in Canada. However, we found that the experiences of internalized HIV stigma and enacted stigma during the IME potentially influence the long-term engagement in the HIV care cascade during the process of migration and settlement in Canada. Further study in this population is recommended to examine the intersections of current mandatory HIV screening process during the Canadian immigration process, migration, settlement, culture, stigma and engagement in the HIV care cascade.

African and Caribbean Nurses' Decisions about HIV Testing: A Mixed Methods Study.

Nurses in Jamaica, Kenya, South Africa, and Uganda are at risk for occupational exposure to HIV. Little is known about the experiences and policy supports related to nurses having themselves tested for the virus. This article reports a mixed-methods study about contextual influences on nurses' decision-making about HIV testing. Individual and focus group interviews, as well as a questionnaire on workplace polices and quality assurance and a human resource management assessment tool provided data. Fear of a positive diagnosis and stigma and lack of confidentiality along with gaps in the policy environment contributed to indecision about testing. There were significant differences in policy supports among countries. Institutional support must be addressed if improvements in HIV testing for health care workers are going to be effectively implemented. Future work is required to better understand how HRM policies intersect to create conditions of perceived vulnerability for HIV positive staff.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa.

BACKGROUND: The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care. METHODS: A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test. RESULTS: Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps. CONCLUSIONS: Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

Stigma in AIDS nursing care in sub-saharan Africa and the Caribbean.

Some nurses who provide AIDS care, in addition to experiencing stigma themselves, also exhibit negative attitudes and perpetrate stigma and discrimination toward persons living with HIV (PLWHAs). We used a participatory research approach to explore the nature, context, and influence of stigma on the nursing care provided to PLWHAs in four low- and middle-income countries: Jamaica, Kenya, South Africa, and Uganda. Eighty-four registered nurses, enrolled nurses, and midwives participated in interviews and 79 participated in 11 focus groups. Nurses were very aware of the stigma and discrimination that AIDS evoked, and made adjustments to their care to decrease the manifestation of AIDS stigma. Despite the assurance that PLWHAs were treated equally, and that universal precautions were used consistently, we found that in reality, nurses sometimes made decisions about nursing care that were based on the appearance of the patient or knowledge of his or her status.

Compassion practice by Ugandan nurses who provide HIV care.

Compassion is fundamental to ethical nursing practice; it represents a commitment to acknowledge and respond to the suffering of the patient. Many structural, economic, and sociopolitical challenges confront Ugandan nurses in their efforts to incorporate compassion into their care of persons with HIV illness. After reviewing the literature related to compassion fatigue, the author describes nursing in sub-Saharan Africa and presents a qualitative study exploring the impact of education on 24 nurses' lives, including their capacity to avoid or mitigate the development of compassion fatigue. Data were collected through interviews, observation, and focus group discussions. Findings illustrate the barriers participants faced in providing competent care and the liberating effects of new knowledge and skills. Engaging in meaningful relationships, maintaining hopeful attitudes, and advocating for the profession were found to transform and affirm the nurses' approach toward their work and enhance their experiences of compassion satisfaction. The author discusses the unique aspects of the experience of compassion among Ugandan nurses caring for persons with HIV illness.

Pedagogy as influencing nursing students' essentialized understanding of culture.

In this qualitative study, we explored how students understood "culture." Participants defined culture and wrote narratives regarding specific cultural encounters. The sample comprised both nursing (n=14) and non-nursing (n=8) students to allow for comparison groups. Content analysis of the narratives revealed two broad paradigms of cultural understanding: essentialist and constructivist. Essentialist narratives comprised four themes: determinism (culture defied individual resistance); relativism (the possibility of making value judgments disappeared); Othering (culture was equated to exotica, and emphasized difference); and, reductionism (personhood was eclipsed by culture). In contrast, the constructivist narratives were characterized by influence (non-determinism), dynamism (culture was dynamic and evolutionary); and, relationship-building. The unintended negative consequences of essentialist notions of culture were revealed in the nursing students' narratives. Pedagogy is implicated in nursing students' essentialized understanding of culture.

Moral distress among Ugandan nurses providing HIV care: a critical ethnography.

BACKGROUND: The phenomenon of moral distress among nurses has been described in a variety of high-income countries and practice settings. Defined as the biopsychosocial, cognitive, and behavioural effects experienced by clinicians when their values are compromised by internal or external constraints, it results from the inability to provide the desired care to patients. No research has been reported that addresses moral distress in severely resource-challenged regions such as sub-Saharan Africa. AIM: To describe the manifestation and impact of moral distress as it was experienced by Ugandan nurses who provided care to HIV-infected or -affected people. METHOD: A critical ethnography was conducted with 24 acute care and public health nurses at a large referral centre in Uganda. Data were collected through interviews, observation, and focus group discussions. RESULTS: Participants described their passion for nursing and commitment to patients. They experienced moral distress when a lack of resources put patients' wellbeing at risk. The trauma imposed by systemic challenges on the nursing profession was acknowledged, as was the perception that the public blamed nurses for poor patient outcomes. However, participants were determined to serve to the best of their abilities and to take satisfaction from any contributions they were able to make. They cited the importance of education in the development of their capacity to provide care with a positive attitude, and demonstrated a collective resilience as they discussed strategies for addressing issues that affected them and their colleagues. CONCLUSIONS: The experience of moral distress among nurses in Uganda differed somewhat from the experience of nurses in high-income countries. Constraints imposed by the inability to implement skills and knowledge to their fullest extent, as well as a lack of resources and infrastructure may result in the omission of care for patients. Moral distress appears to manifest within a relational and contextual environment and participants focussed on the impact for patients, communities, and the nursing profession as a whole, rather than on their own personal suffering. The opportunity for continuing education led to strategies to transform personal attitudes and practice as well as to enhance the presentation of the profession to the public.

The impact of HIV education on the lives of Ugandan nurses and nurse-midwives.

In this ethnography, I explored the impact of an HIV/AIDS education program on the lives of 24 Ugandan nurses and nurse-midwives. Nurses who previously had viewed themselves simply as providers of advice and sympathy now saw themselves as more holistic, collaborative caregivers. They voiced an increased awareness of their role as leaders and advocates in the community with respect to policy. The education program had positive and synergistic effects on the nurses' professional practice, communication and problem-solving skills, confidence, and engagement in political and social change activities.