Using a Multi-level Framework to Test Empirical Relationships Among HIV/AIDS-Related Stigma, Health Service Barriers, and HIV Outcomes in KwaZulu-Natal, South Africa
- 178 Downloads
HIV/AIDS-related (HAR) stigma is an ongoing problem in Sub-Saharan Africa that is thought to impede HIV preventive and treatment interventions. This paper uses a systematic sample of households (Level 1) nested within near-neighbor clusters (Level 2) and communities (Level 3) to examine multilevel relationships of HAR stigma to health service barriers (HSBs) and HIV outcomes in KwaZulu-Natal, South Africa, thereby addressing methodological and conceptual gaps in the literature from this context. Findings suggest differential patterns of prediction at Level 1 when examining two different dimensions of stigma: more highly stigmatizing attitudes predicted more household health service barriers; and perceptions of greater levels of community normative HAR stigma predicted higher household HIV ratios. Level 2 findings were similarly dimension-differentiated. Cross-level analyses found that near-neighbor cluster-level (setting level) consensus about (standard deviation) and level of (mean) community normative HAR stigma significantly predicted household-level HSBs and HIV ratio, controlling for household-level community normative HAR stigma. These differential patterns of prediction suggest that HAR stigma is a multi-level construct with multiple dimensions that relate to important outcomes differently within and across multiple ecological levels. This has important implications for future research, and for developing interventions that address setting-level variation in stigma.
KeywordsHIV-related stigma Health service barriers HIV prevalence Ecological measurement Multilevel analysis South Africa Setting-level measurement
This research was funded by a graduate training grant from the National Institute of Mental Health (F31MH097666; PI Dr. Leslie D. Williams). Its parent project, SIZE, was funded by a 2008 grant from the National Institute of Child Health and Human Development (R01HD055137; PI Dr. J. Lawrence Aber) titled “Well-being of South African Children: Household, Community, and Policy Influences,” as well as by financial contributions from the Rockefeller Foundation and from the Center for World Health at the UCLA David Geffen School of Medicine. The authors acknowledge the support and guidance of their collaborators at UNICEF and the South African Department of Social Development. They extend their appreciation to all involved local municipal counselors, traditional leaders, school principals, and community-based organizations working in the area. Finally, and most importantly, they would like to thank the Human Sciences Research Council research staff (including data collectors and community outreach staff), the communities in which the study was conducted, and the children and families who participated in the study.
This study was funded by the National Institute of Mental Health (F31MH097666; PI Dr. Leslie D. Williams); and by the National Institute of Child Health and Human Development (R01HD055137; PI Dr. J. Lawrence Aber).
Compliance with Ethical Standards
Conflict of interest
All authors declared that they have no conflict of interest.
Research Involving Human Participants
Institutional review boards at both New York University in New York, NY; and Human Sciences Research Council in Durban, South Africa approved all study procedures.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained for all study participants. For child participants, informed consent was obtained from their primary caregivers. After this caregiver consent was obtained, children were informed about the study using child-appropriate language, and asked whether they wanted to give assent to participate. All consent and assent forms were reviewed and approved by institutional review boards at both New York University in New York, NY and Human Sciences Research Council in Durban, South Africa.
- 1.UNAIDS. AIDS Epidemic Update: December 2009. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS and World Health Organization; 2009.Google Scholar
- 2.UNAIDS. (2006). 2006 Report on the Global AIDS Epidemic. Joint United Nations Programme on HIV/AIDS.Google Scholar
- 3.Rankin WW, Brennan S, Schell E, Laviwa J, Rankin SH. The stigma of being HIV-positive in Africa. Public Library of Science Medicine. 2005;2(8):0702–4.Google Scholar
- 6.Chan BT, Tsai AC. HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003–2013. J Acquir Immune Defic Syndr (1999). 2016;72(5):558–64.Google Scholar
- 8.Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary counseling and testing in a black township in Cape Town, South Africa. Sex Trans Inf. 2003;79:442–7.Google Scholar
- 17.Ahmed S, Lutalo T, Wawer M, Serwadda D, Sewankambo NK, Nalugoda F, Makumbi F, Wabwire-Mangen F, Kiwanuka N, Kigozi G, Kiddugavu M, Gray R. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS. 2001;15:2171–9.PubMedGoogle Scholar
- 19.Ngugi EN, Simonsen JN, Bosire M, Ronald AR, Plummer FA, Cameron DW, Waiyaki P, Ndinya-Achola JO. Prevention of transmission of human immunodeficiency virus in Africa: effectiveness of condom promotion and health education among prostitutes. Lancet. 1988;332:887–90.Google Scholar
- 28.Nelson LE, Wilton L, Agyarko-Poku T, et al. The association of HIV stigma and HIV/STD knowledge with sexual risk behaviors among adolescent and adult men who have sex with men in Ghana, West Africa. Res Nursing Health. 2015;38(3):194–206.Google Scholar
- 29.Kelly J, Ryan AM, Altman BE, Stelzner SP. Understanding and changing social systems: an ecological view. In: Rappaport J, Seidman E, editors. Handbook of Community Psychology. Julian Kluwer Academic/Plenum Publishers, New York; 2000.Google Scholar
- 30.Williams LD. Understanding the relationships among HIV/AIDS-related stigma, health service utilization, and HIV prevalence and incidence in Sub-Saharan Africa: a multi-level theoretical perspective. Am J Commun Psychol. 2014;53:146–58.Google Scholar
- 33.Chan D. Functional relations among constructs in the same content domain at different levels of analysis: a typology of composition models. J Appl Psychol. 1998;83(2):234–46.Google Scholar
- 35.Bronfenbrenner U, Morris PA. The bioecological model of human development. In: Handbook of Child Psychology. 6th ed. Volume 1, Wiley, Hoboken; 2006. pp. 793–828Google Scholar
- 36.Von Korff M, Koepsell T, Curry S, Diehl P. Multilevel analysis in epidemiologic research on health behaviors and outcomes. Am J Epidemiol. 1992;135(10):1077–82.Google Scholar
- 37.Shisana, O., Simbayi, L., & Human Sciences Research Council. Nelson Mandela/HSRC Study of HIV/AIDS: South African National HIV Prevalence, Behavioural Risks and Mass Media. Cape Town, South Africa: Human Sciences Research Council Publishers; 2002.Google Scholar
- 38.Bond V, Chase E, Aggleton P. Stigma, HIV/AIDS and prevention of mother-to-child transmission in Zambia. Eval Prog Plan. 2002;25:347–56.Google Scholar
- 39.Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, Labadarios D, Onoya D. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town, South Africa: HSRC Press; 2014.Google Scholar
- 40.McBurney P. On transferring statistical techniques across cultures: the Kish grid. Curr Anthropol. 1988;29(2):323–5.Google Scholar
- 41.Genburg BL, Hlavka Z, Konda KA, Maman S, Chariyalertsak S, Chingono A, Mbwambo J, Modiba P, Van Rooyen H, Celentano DD. A comparison of HIV/AIDS-related stigma in four countries: negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS. Soc Sci Med. 2009;68:2279–87.Google Scholar
- 42.Westbrook L, Bauman L. Perceived stigma of HIV/AIDS: public view. Bronx: Albert Einstein College of Medicine; 1996.Google Scholar
- 43.Academy for Educational Development (AED) (2002). Speak for the Child Data Collection Protocols. USAID and the Academy for Educational Development.Google Scholar
- 44.Garson GD. Introductory Guide to HLM with HLM 7 Software. Hierarchical linear modeling: guide and applications. North Carolina State University, Raleigh; 2013.Google Scholar
- 45.Shinn M. Mixing and matching: levels of conceptualization, measurement, and statistical analysis in community research. In: Tolan P, Keys C, Chertok F, Jason LA, editors. Researching community psychology: issues of theory and methods, 1990. 111-126.Google Scholar
- 46.Latkin CA, Vlahov D. Socially desirable response tendency as a correlate of accuracy of self-reported HIV serostatus for HIV seropositive injection drug users. Addiction. 2002;93(8):1191–7.Google Scholar
- 48.Skinner D, Mfecane S. Stigma, discrimination and the implications for people living with HIV/AIDS in South Africa. J des Aspects Soc du VIH/SIDA. 2004;1(3):157–64.Google Scholar