Review articleMeta-analysis and systematic review of studies on the effectiveness of HIV stigma reduction programs
Introduction
Public stigma refers to the negative reactions that the general population has towards individuals with a condition or attribute that is socially discredited (Corrigan and Watson, 2002, Goffman, 1963). It is a multidimensional construct that is defined as the general public identifying and labeling differences between themselves and a specific group; conferring these differences with negative attributes; separating themselves and this group into “us” versus “them” division; and the conferment of status loss and discrimination to the discredited group in a situation with a power differential between the public and the discredited group (Link and Phelan, 2001). Despite tremendous strides in biomedical interventions in containing the human immunodeficiency virus (HIV) in the past two decades, HIV stigma remains a significant impediment to public health across the globe and a key obstacle to HIV treatment, prevention, care and support (Mahajan et al., 2008, Valdiserri, 2002).
Research has documented high levels of stigmatizing attitudes and behaviors towards people living with HIV (PLHIV; Cao et al., 2006, Herek et al., 2002, Lau and Wong, 2001, Mak et al., 2006, Preston et al., 2002, Sullivan et al., 2009). Such stigma leads to poorer access to health services and lower levels of medical adherence (Dlamini et al., 2009, Li et al., 2011, Mo and Mak, 2009, Sayles et al., 2009), as well as poorer mental health (Dowshen et al., 2009, Li et al., 2011), physical health (Logie and Gadalla, 2009, Wolitski et al., 2009), and quality of life (Derlega et al., 2002, Liu et al., 2006). Denial of medical care services, loss of employment, and violence have also been reported among PLHIV (People Living with HIV) (Gielen et al., 1997, Sayles et al., 2009). HIV stigma also deters HIV prevention efforts due to resistance to HIV testing (Ford et al., 2004, Herek et al., 2003) and non-disclosure of HIV status to sexual partners (Smith et al., 2008, Wolitski et al., 2009). It poses adverse effects on resource allocation in public health policy for HIV care (Mak et al., 2006, Sayles et al., 2007, Sengupta et al., 2010). The profound negative effects of HIV stigma on society have called for a global need to design effective interventions to reduce HIV stigma among the general public. In particular, the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommends that every national HIV response should include key programs to reduce stigma and to increase access to proper treatment (Joint United Nations Programme on HIV/AIDS, 2012).
An increasing number of HIV stigma reduction programs targeting different populations and using various approaches have been identified (Brown et al., 2003). Most of them aim to reduce public stigma by improving participants' knowledge about HIV because it is believed that stigma is a result of misconceptions about the condition concerned (Bos et al., 2008, Herek and Capitanio, 1999, Liu et al., 2006). Critics argue that knowledge alone does not necessarily lead to a decrease in the levels of stigma (Joint United Nations Programme on HIV/AIDS, 2012). Earnshaw and Chaudoir, 2009 HIV stigma framework specified that mechanisms of stigma against PLHIV are manifested in three main ways: stereotyping (cognitive), prejudice (affective), and discrimination (behavioral) towards PLHIV. Thus, besides increasing HIV-related knowledge, stigma reduction programs should also aim at improving participants' multidimensional attitudes towards PLHIV.
To improve attitudes towards PLHIV, researchers have advocated for promotion of perspective-taking and empathy of the participants towards PLHIV. The promotion of perspective-taking and empathy have been shown to decrease stereotyping and improve intergroup attitudes (Todd and Galinsky, 2014) and more positive attitudes towards PLHIV in experimental settings (Batson et al., 1997, Larson-Presswalla et al., 1995, Tarrant and Hadert, 2010). One of the most common methods to enhance perspective-taking and empathy was through contact, which refers to all interactions (e.g., in-vivo, video-based) between the participants and the stigmatized individuals, with the specific objective to reduce stigmatizing attitudes (Heijnders and Van der Meij, 2006). Contact can also enhance the awareness of the presence of discrimination in social life (Bos et al., 2008, Couture and Penn, 2003) and in healthcare settings (Yiu et al., 2010) and the negative impact of discrimination on PLHIV. A meta-analysis found that the effect of contact in reducing prejudice was significant across different settings, age groups, ethnicities, and countries (Pettigrew and Tropp, 2006).
In addition to contact, interactive components such as role-plays, games, and other experiential activities have been found to be effective in enhancing perspective-taking and empathy. These interactive approaches simulate imaginary behavioral exposure, where participants were instructed to imagine issues and stressors that PLHIV might face in daily situations or the workplace (Britton et al., 1999, Mak et al., 2015). Use of interactive components have shown to be associated with increased willingness to treat PLHIV (Burgess et al., 2001), decreased stigma towards PLHIV (Mak et al., 2015), and increased awareness of confidentiality (Wu et al., 2010) among healthcare professionals.
Past studies have also indicated that duration of the intervention matters in affecting outcomes. Meta-analyses on the effectiveness of eating disorder prevention programs and drug prevention programs showed larger effect sizes for interventions with multiple sessions (versus single-session) and of longer duration (Stice and Shaw, 2004, Tobler et al., 2000). The present study investigated the possibility of contact experience with PLHIV and interactive components in reducing negative attitudes towards PLHIV; and explored the moderating effects of the number of intervention sessions and the duration of interventions on the effectiveness of HIV stigma reduction programs.
Several systematic reviews have been conducted to synthesize the findings on the effectiveness of HIV stigma reduction interventions among the general population. An earlier review of 22 studies on a variety of interventions to decrease HIV stigma found that the majority (14 out of 22) of the studies aiming to increase tolerance of PLHIV in various populations have achieved mixed success. Findings suggested that some interventions appeared to work on a small scale and in the short term, but many gaps existed with regard to the scale and duration of impact (Brown et al., 2003). Another review reported that provision of factual information about HIV was the key strategy underlying such interventions. Most of these studies used convenience samples with no specific stigma measures (Mahajan et al., 2008). Sengupta et al. (2011) conducted another systematic review of 19 studies of interventions in reducing HIV stigma and concluded that most of the studies (14 out of 19) demonstrated effectiveness in reducing HIV stigma. However, only two of these 14 studies were classified as good quality studies. A recent systematic review of 48 studies that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 2002 and March 2013 also found that although most of the studies were effective at reducing stigma, the outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult (Stangl et al., 2013).
It is important to note that the above findings were all drawn from narrative synthesis of quantitative studies, which precludes this analysis in identifying the studies’ effect sizes and significant moderators that might explain the effects. These limitations underscored the importance of conducting a systematic quantitative review that empirically integrates and consolidates existing findings, summarizes the effects of studies evaluating HIV stigma reduction programs, and identifies possible moderators of the observed effects.
Meta-analysis is preferred over narrative synthesis in several ways. First, it is based on an objective synthesis of findings rather than reviewers’ own stance. Second, any statistical artifacts that may be present in primary research can be corrected before aggregating and making judgments. Third, moderators can be examined to explain the variation between studies and also the inconsistency of results across studies can be quantified and analyzed. These advantages allow evidence-based conclusions to be drawn beyond anecdotal reviews and observations.
The purpose of the present study was to use the meta-analytic approach to empirically review studies that evaluated the effectiveness of stigma reduction programs in improving HIV-related knowledge and reducing negative attitudes towards PLHIV. Potential study-level moderators such as the number of intervention sessions, intervention duration, involvement of contact with PLHIV, and the use of interactive components that may affect the effectiveness of HIV stigma reduction programs were also tested. This study hypothesized that programs showed stronger effects when they contained more than one intervention session, had longer duration, involved contact with PLHIV, and employed interactive components.
Section snippets
Identification of studies
To extract studies evaluating HIV stigma reduction programs, studies of all types, including journal articles, book chapters, and dissertations, were identified in four major online databases: PsycINFO (1967–2016 September), Sociological Abstracts (earliest–2016 September), PubMed (1950–2016 September), and Education Resources Information Center (ERIC) (earliest–2016 September). A broad search strategy was employed which used the following key terms: “HIV”, “stigma”, and “reduction” (see
Included studies
Based on the literature search, 5686 abstracts were identified. Eight hundred thirty-four duplicated abstracts were removed when the abstracts across four databases were combined. A total of 4648 citations did not meet the aforementioned inclusion criteria. Twenty-five citations were further excluded because the abstracts could not be retrieved through interlibrary loans or by attempts to contact the authors. Twenty-six duplicate citations were further removed during the initial abstract
Discussion
The present study conducted a meta-analysis and systematic review on the studies evaluating the effectiveness of HIV stigma reduction programs as indicated by the improvement in HIV-related knowledge and attitudes towards PLHIV. The present study also tested a variety of sample and study characteristics for potential moderators of the intervention effects. The results of the meta-analysis suggest a significant, small effect size both in increasing participant's knowledge and in improving
Conclusion
To conclude, findings of the present review showed that HIV stigma reduction programs in general demonstrated small improvements in HIV-related knowledge and attitudes towards PLHIV. This is at least encouraging as it provides empirical quantitative evidence that HIV stigma may be reduced through various program components and modalities of delivery. Several significant moderators were also identified, namely sample type, number of intervention sessions, and the settings of the interventions.
Acknowledgements
The authors thank (in alphabetical order of their last names): Gladys Chan, Rachael Cheng, Connie Ho, Joyce Ip, Chris Lam, Alison Lee, Philip Or, Ingrid Pang, Cliff Siu, Vinca Tang, Amy Wong, and Samson Wong for their involvement in the initial abstract screening, coding, and coordination of the research tasks of the present study. We would also like to thank Dr. Rita Law for her valuable comments on the earlier draft of the manuscript.
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