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MEASURING FACILITY/
PROVIDER INDEX OF STIGMA
AND DISCRIMINATION IN
KENYA
1
The Presentation Outline
1.
2.
3.
4.
5.
Introduction
Objectives
Methodology
Results
Conclusion
2
Introduction


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In many countries, S&D associated with
HIV/AIDS is widespread
S&D a barrier to the maximization of the
benefits of interventions targeted at fighting
HIV/AIDS pandemic.
The negative effects call for measures to
combat S&D
However, no standardized method is available
for capturing and measuring all the aspects of
S&D.
3
Introduction…

Against this background, the USAID
Interagency Working Group on S&D
Indicators developed specific tools to
measure S&D in the communities,
facilities/providers, and, among the
PLHIV
4
Objectives



The main goal - field-test the USAID IWG
indicators measuring HIV/AIDS-related S&D
and determine its validity and reliability in the
Kenyan context, focusing on facilities and
providers of health services.
The specific objectives were:
•
•
Estimate indicators of HIV/AIDS-related S&D for
facility/ provider indicators.
Use the derived indicators to determine HIV/AIDS
related S&D sub-index for Kenya
5
Methodology
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A non-probability multistage sampling method was adopted
5 provinces out of the total of 8 provinces in Kenya selected
including two provinces with the highest prevalence rates of
HIV
A similar procedure was adopted to select the districts for the
study
out of which a sample of facilities and providers was selected
for interviews
The facilities and providers stratified by
•
•
•
ownership (public, private, FBO/NGO)
level of HIV and AIDS care (comprehensive care centers (CCC), semiCCC, voluntary counseling and testing centers and clinics)
Occupation (doctors, nurses etc) for providers only
6
Methodology…
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A total of 118 facilities were sampled in the 5 provinces
Public sector6 (17 CCC, 37 semi-CCC and 12 VCT/clinics
Private-for-profit health sector (4 CCC, 49 semi-CCC and
8 VCT/ clinics)
FBO/NGO facilities (15 CCC, 28 semi-CCC and 18
VCT/clinics
A total of 671 providers were interviewed
•
•
•
270 were from public facilities
207 from private facilities
194 from FBO/ NGO facilities.
7
Methodology…
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
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The instrument was based on the indicators and questions
recommended by the USAID Interagency Working Group on
S&D Indicators
Tailored to the local conditions
The questions covered the following indicators:
•
•
•
•
•
•
•
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1) health facilities with policies protecting PLHIV against
discrimination;
2) facilities enforcing policies protecting PLHIV against discrimination;
3) providers aware of policies protecting PLHIV against
discrimination;
4) providers with nondiscriminatory attitudes;
5) providers reporting nondiscriminatory care;
6) providers reporting blame;
7) providers reporting shame;
8) providers reporting fear of casual contact
8
Level of Care
Type of Ownership
Public
Private
FBO/NGO
Total Sample
Province
CCC[1]
Semi-CCC
VCT/ Clinic
Total
Central
5
8
2
15
Coast
8
5
4
17
Nairobi
1
1
2
4
Nyanza
1
11
2
14
Rift Valley
2
12
2
16
Sub-total
17
37
12
66
Central
1
13
4
18
Coast
2
10
1
13
Nairobi
0
1
0
1
Nyanza
1
9
0
10
Rift Valley
0
16
3
19
Sub-total
4
49
8
61
Central
7
3
5
15
Coast
3
4
2
9
Nairobi
1
1
1
3
Nyanza
2
7
5
14
Rift Valley
2
13
5
20
Sub-total
15
28
18
61
36
114
38
188
9
Findings
 Existence of policies:
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
All public facilities have policy guidelines from
the Ministry of Health
28 out of 55 facilities with policies in private
for profit
22 out of 56 facilities with policies FBO/NGO
sector
Based on the data, an indicator of 35% of
facilities without polices was computed
10
Using the same methodology, the indicator for discriminatory care by type
of ownership was estimated. The indicators were 30.35% in the public
sector, 31.04% at private facilities, and 30.29% at FBO/NGO facilities,
implying that it did not vary a great deal among the different ownership
types (see Figure 3.1).
35%
30%
25%
20%
Level
30.35%
31.04%
30.29%
15%
10%
5%
0%
Public
Private
FBO/ NGO
11
Findings…
 Implementation of policies:


A few facilities (27%) were reported as implementing
policies to protect PLHIV
and therefore the indicator for the proportion of facilities not
implementing policies protecting HIV positive clients against
discrimination was computed at 73%
 Providers’ awareness of policies:


Majority (75%) of the providers were aware of the policies
The indicator of the percentage of providers not aware of
the policies protecting HIV positive clients against
discrimination was therefore calculated to be 25%.
12
Findings…
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
Discriminatory attitude:
•
A number of questions that were posed in order to compute
an indicator for discriminatory attitudes towards people
living with HIV/AIDS gave an average index of 30.43% for
this indicator.
Discriminatory care:
•
The questions which were used to examine whether or not
the health delivered to HIV patients was discriminatory in
nature produced overall results showing an average of
25.76% for reporting use of discriminatory care.
Blame:
•
The responses to the questions were averaged to obtain an
indicator of blame of 19.8%.
13
Indicator of discriminatory
attitudes by level of care
40%
35%
Level of indicator
30%
25%
20%
36.56%
38.44%
31.93%
15%
10%
5%
0%
CCC
Semi-CCC
VCT/ Clinic
14
Indicator of discriminatory
attitudes by type of personnel
35%
33.54%
32.18%
31.77%
29.73%
30%
31.30%
26.82%
23.82%
Level of indicator
25%
20%
15%
10%
5%
0%
Medical Officer Clinical Officer
Nurse
Counselor
Administrator
Other prov iders
Lab
Technologist
15
Levels of discriminatory care by
type of personnel
45%
38.39%
40%
33.40%
33.31%
35%
34.32%
31.26%
27.96%
30%
26.41%
25%
20%
15%
10%
5%
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0%
16
Levels of “blame” by type of
facility ownership
FBO
17.83%
Private
20.03%
Public
16%
20.94%
17%
18%
19%
20%
21%
22%
Indicator le v e l
17
Levels of “blame” by type of
health personnel
27.68%
Lab Technologist
40.00%
Other provider
25.64%
Administrator
18.40%
Counselor
29.43%
Nurse
30.10%
Clinical Officer
20.85%
Doctor
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Indicator level
18
Levels of “shame” by type of
facility ownership
9.69%
FBO
Private
15.42%
10.79%
Public
0%
5%
10%
15%
20%
Level of indicator
19
Level of “shame” by type of
personnel
15.63%
Lab Technologist
Other providers
6.67%
Administrator
6.84%
Counselor
11.11%
Nurse
11.00%
Clinical Officer
12.81%
Doctor
12.12%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Level of indicator
20
Level of “fear” by level of care
VCT/ Clinic
19.38%
Semi-CCC
16.90%
CCC
16%
18.42%
16%
17%
17%
18%
18%
19%
19%
20%
20%
21
Level of “fear” by type of
personnel
30%
25%
25%
21%
20%
19%
18%
18%
16%
14%
15%
10%
5%
0%
Doctor
Clinical officer
Nurse
Counselor
Administrator
Other
providers
Lab
Technologist
22
Findings…

Shame:
•
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The method followed to measure indicator for the
“Shame” domain was similar to that used the “Blame”
domain, and it produced 11.90%.
Fear of casual contact:
•
The responses on twelve different questions used to
capture providers’ fear of casual contact with PLHIV
due to a worry of contagion of the virus were
analyzed, and gave overall value equal to 17.5% for
this indicator.
23
Overall Index

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The values of the 8 indicators were used for constructing
indices for S&D in Kenya for the facility/providers
The domains on policies were considered very crucial in
fighting stigma and discrimination, and were allocated 50% of
the total of the weights
•
•
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existence of policies taking 20%
implementation of the policies taking 30%.
The remaining 6 domains assigned equal weights of 8.3%
towards the index
With these assumptions, the score for the overall estimated
index was 40%.
This index is positively related to stigma and discrimination, that
is, the higher the level of this index, the higher the level of S&D
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Conclusion
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The tool faces several limitations:
One:
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the questions tend to guide the providers on what is being sought (that is
measuring S&D)
Since the informants are relatively more knowledgeable, they are inclined to
provide favorable responses to suggest the absence of, non-existence or limited
S&D
The actual level of S&D may therefore be much higher than calculated.
Two,
•
there is no mechanism to cross - check the responses by the providers
Three
•
the weights allocated to the various indicators in constructing the overall index
subjective and could easily influence the magnitude of the final result
These limitations, notwithstanding, the tool is valid and reliable in
measuring S&D in the Kenyan context.
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Conclusion, cont’d

HIV/AIDS related stigmatization and
discrimination (S&D) provides a major
constraint to effective and sustained
response to prevention, treatment and care
at the individual, family and community
levels. Arguably, the increasing incidence of
S&D poses great potential to wipeout the
gains already realized in the fight against
HIV/AIDS including scale-up efforts.
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The results of the analysis are:
•
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Existence of policies
Implementation of policies
Providers’ awareness of policies
Discriminatory attitude
Discriminatory care
Blame
Shame
Fear of casual contact
27
Thank You
28