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Reducing Intersecting Stigmas in HIV Service Organizations: An Implementation Science Model

Rodriguez-Hart, Cristina MPH, PhDa; Mackson, Grace MPHa; Belanger, Dan MSWb; West, Nova MPHb; Brock, Victoria BAb; Phanor, Jhané BSb; Weigl, Susan BSb; Ahmed, Courtney BAb; Soler, Jorge PhDc; McKinnon, Karen MAd,e; Sandfort, Theo G.M. PhDd

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2022 - Volume 90 - Issue S1 - p S215-S225
doi: 10.1097/QAI.0000000000002982

Abstract

  • Evidence-based innovation: An adaptation of the Implementation Research Logic Model to guide stigma reduction initiatives.
  • Innovation recipients: Staff delivering HIV-related services who wish to address HIV and intersectional stigmas. Secondarily, collaborators of such individuals (eg, researchers and health department staff).
  • Setting: Clinical and community-based organizations delivering HIV-related prevention and/or care services.
  • Implementation gap: HIV-related organizations are unfamiliar with implementation science and may have limited capacity for research and systematic implementation of stigma reduction initiatives.
  • Primary research goals: Identify determinants of implementation, select/pilot implementation strategies, and evaluate implementation strategies for stigma reduction.
  • Implementation strategies: Our model offers organizations a package of tools to systematically plan and evaluate stigma reduction innovations in their local contexts, including a menu of emerging interventions and a stigma reduction organizational readiness tool.

INTRODUCTION

HIV stigma has been identified as a key barrier to achieving the 2022–2025 National HIV/AIDS Strategy, which calls for a 50% reduction in stigma affecting people with HIV (PWH).1 HIV stigma is an important driver for all aspects of HIV from HIV testing to access and engagement in care and viral load suppression.2 Stigma can manifest at the structural level through organization-wide policies or practices and the setup of the physical space, at the interpersonal level through staff behavior toward clients (enacted stigma), and at the individual level through the way clients view themselves and the expectations they have for how they will be treated (internalized and anticipated stigma).3 Furthermore, stigma has disparate and combined effects on individuals with intersecting axes of identity—such as by race/ethnicity, sex, and/or mental health—often explained through the theoretical framework of intersectionality.4 Intersectionality acknowledges the interlocking systems of privilege and oppression that operate at a social–structural level and result in the inequities experienced by individuals based on their intersecting identities, but best practices for addressing intersectional stigma are nascent.5

Although international HIV stigma research, largely originating in low-income and middle-income countries, has identified some commonly effective approaches within health care settings to address stigma,2,6 there is a lack of evidence to support what specific interventions reduce stigma in NYC. The use of surveys in various countries has effectively identified stigmatizing attitudes and behaviors of HIV health care staff and driven “total facility” stigma reduction initiatives.7–9 In addition, yet, theoretically grounded, methodologically rigorous implementation of stigma reduction programs in high-resource and high-HIV burden contexts such as NYC remains scarce.10

Implementation science (IS) offers a proven, structured approach to address this gap by improving the implementation and dissemination of effective interventions into wide-scale practice.11 IS frameworks emphasize the characteristics of the intervention and implementers, the internal and external settings in which the innovation is adopted, and explicating implementation outcomes that are important to achieving service delivery and client-level outcomes.12 In addition, IS effectiveness-implementation hybrid designs13 allow for concurrent testing of impact on individual-level health outcomes with that of implementation success and could address the gap in knowledge around effective stigma reduction interventions in NYC.

Currently, stigma reduction efforts are siloed and disparate in NYC, which historically has been an innovator in HIV programming. In recognition of these silos and the potential of IS to improve stigma reduction programming and evaluation, we began the Stigma Reduction and Resilience (STAR) Project (P30-MH43520 31S; PI Remien). One of its activities was the mixed-methods Mapping Project, which aimed to obtain a preliminary understanding of important determinants of stigma reduction efforts in HIV service settings using an exploratory determinants framework.14 The Mapping Project Team gathered information on HIV and intersectional stigma reduction practices in 27 NYC organizations providing HIV services.15 It highlighted that HIV organizations were using a diversity of approaches but that they were not testing whether they reduced stigma, and thus, the project points to “emerging” stigma reduction interventions in need of evaluation. We define “emerging stigma reduction interventions” as “common or innovative activities, services, policies, and processes that show real-world validity and promise in reducing HIV stigma but do not yet have sufficient evaluation or published research evidence.”16 Not only did these gaps point to important next steps for the initiative but also the project served to coalesce an interagency workgroup that, having become familiar with IS, understood that its use by HIV organizations would require translation.

Implementation Research Logic Model (IRLM)

One important translational tool is the IRLM.17 The logic model's causal pathway is valuable to structure implementation research projects in the phases of planning, organizing, guiding, and knowledge-building. However, the language used within IS is rooted in academia. Although sometimes necessary to clarify meanings and develop specific terminology in the field, this can hinder the usage of IS within public health practice and community settings where implementation more commonly occurs. Similarly, although IS offers numerous sound frameworks, this creates more complexity and therefore less consensus on what should be used for implementation. The IRLM addressed these barriers by consolidating several well-established IS frameworks as a part of the logic model and creates tools to explain its components. Nonetheless, using the IRLM to plan stigma reduction may still be less accessible to staff members, community organizers, and other implementers trying to combat stigma at their organizations. Stigma reduction is relatively new to the IS field. The lack of consensus on implementation strategies most relevant for stigma reduction or mechanisms of action for stigma reduction within the research literature makes building and using a causal model such as the IRLM difficult. The simplicity of the IRLM format is helpful, although less suited to issues such as stigma that require multilevel and multipronged solutions.

We will present an adaptation of the IRLM that focuses on stigma and integrates IS concepts and lessons learned from the STAR Mapping Project. Through this integration, we demonstrate how IS can help HIV service organizations at each step of the implementation of HIV-related stigma reduction interventions. The guiding questions, tips, and tools within our model will make IS more accessible for nonacademic audiences. Thus, implementers are not excluded but rather are empowered through guidance and can swiftly move through the implementation phases, contributing to a holistic view of stigma planning that is seldom conducted in practice.

METHODS

The STAR Project was an IS planning initiative in 2019–2020 that included a coalition of approximately 87 participants representing HIV health care organizations, community-based organizations, PWH, and public health practitioners and researchers from the NYC Department of Health and Mental Hygiene, NYS Department of Health (NYSDOH) AIDS Institute, and Columbia University's HIV Center and Northeast/Caribbean AIDS Education and Training Center. The STAR Mapping Project Team continued to meet on a biweekly basis between November 2020 and June 2021 tasked with exploring IS in greater depth and determining its utility for stigma reduction efforts in NYC. The team was experienced in development of quality improvement (QI) tools, intervention and education, and training of health care teams in HIV organizations throughout NYC's 4 EHE boroughs (Bronx, Manhattan, Queens, and Brooklyn). The team reviewed seminal IS frameworks and engaged in an iterative consensus-building process to re-examine findings from the HIV organizations that participated in the Mapping Project, using these to inform implementation planning and prioritize domains commonly found to be effective for stigma reduction in research.

Adaptation of IRLM

After analysis, the IRLM was selected as a foundational model because it integrates IS frameworks and structures its domains along a causal process that facilitates thinking through planning, implementation, and evaluation that is appropriate for implementation projects at various phases of rollout. We studied each component of the IRLM and discussed the frameworks underlying each. Where a synthesis of Mapping Project findings was believed to be insufficient for a component of the IRLM, we included the established IS tools.

RESULTS

An easy-to-use package was created for HIV service organizations—composed of a terminology guide, readiness tool, and logic model—to apply IS because they plan, implement, and evaluate the impact of strategies to reduce HIV and intersectional stigma within their local context. The components of this package are described below.

IS Terminology Guide

Public health agencies and implementers have experienced challenges in operationalizing IS models and concepts for applied use.16 Researchers, too, understand the need for standardized, jargon-free terminology. To that end, the IS terminology guide defines common terms to inform HIV organizations because they implement stigma reduction interventions (see Appendix 1, Supplemental Digital Content, https://links.lww.com/QAI/B846). Definitions and applications of terms were adapted, when necessary, for stigma reduction. As one example, we used the term stigma reduction “intervention” as distinct from “implementation strategy,” despite the fact that the research literature has, at times, conflated interventions with implementation strategies. Implementation strategies are the actions taken to increase implementation of selected stigma reduction interventions. Many activities may be either interventions or strategies depending on the goals of implementation, making it important to be clear where activities are positioned within the causal process, hence the need for a model that illustrates the interrelationships between constructs, such as the IRLM.

Stigma Reduction Organizational Readiness Tool

This tool (see Appendix 2, Supplemental Digital Content, https://links.lww.com/QAI/B847) is an adapted version of the NYSDOH AIDS Institute Organizational Quality Management Assessment (OA) used with HIV programs in NY as a checklist to assess the degree to which QI activities are implemented and fully integrated within the program's organizational structure. Our Stigma Reduction Organizational Readiness Tool retained 6 areas from the OA. Research from international stigma reduction work in HIV health care settings identifies 4 of these areas—leadership support, stigma reduction task forces, planning, and stigma data collection—as critical so they were retained within the tool.5 Training of staff and engagement of community members was also retained because they aligned with findings from stigma reduction research and our Mapping Project.6,15 We modified the language of the tool to make it a self-assessment, reflect a focus on intersectional stigma reduction and IS, and included language from the subconstructs of organizational readiness for implementation (leadership engagement, available resources, and access to knowledge and information) when missing.18 This tool provides a nuanced assessment of an organization's capacity to address intersectional stigma. For example, it includes measures to reflect more equitable power dynamics (eg, involvement of community members with lived experience (A.2 and B.2)) and measures targeting health inequities (eg, ability to measure, monitor, and plan intersectional and HIV stigma reduction activities (A.4 and A.3)). The subsequent model steps are then designed with intersectionality integrated from the start.

Stigma Reduction Logic Model

It is recommended that multipronged and multilevel efforts be taken to address inequities and the complex upstream constructs that drive them.19 Therefore, we developed a model with an intersectional lens that allows flexibility in choosing stigma reduction interventions and implementation strategies based on contextual determinants. To simplify the concepts and language, we created guiding questions for each section of the model, brief definitions, and tips to facilitate its completion (Fig. 1). The model follows the flow of the IRLM (interventions, determinants, implementation strategies, mechanisms, and outcomes), but users may complete it in the order that is most useful. A walk-through of each section is described below to simplify application of IS within HIV service organizations.

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FIGURE 1.:
The Stigma Reduction Logic Model: an adaptation of the Implementation Research Logic Model for stigma reduction.

Stigma Reduction Interventions

What gaps in stigma reduction work are being addressed with a new intervention? Will the intervention(s) address the impact of multiple and intersecting stigmas and have they been selected with the input of community members with lived experience?

A discussion among staff and clients about what stigma looks like at the organization and what programming serves the needs of the community is a helpful first step. Intervention selection should be informed by the Stigma Reduction Organizational Readiness Tool (see Appendix 2, Supplemental Digital Content, https://links.lww.com/QAI/B847). If an organization scores lower than a 3 on any component of the tool, we recommend focusing on this before selecting other stigma reduction interventions. Whether a component is an intervention or an implementation strategy partly depends on where it belongs in the causal pathway toward improved client outcomes. Thus, one component of the tool (eg, forming a stigma reduction committee) may be proposed as an implementation strategy to achieve another component of the tool proposed as your intervention (eg, having a stigma reduction plan).

Additional options for intervention selection include our menu of intervention options, developed by re-examining and summarizing our findings from the Mapping Project, creating a list from which organizations can select an intervention to save time (Table 1), or they may choose interventions by searching the research literature.19Table 1 lists emerging stigma reduction interventions that were common across interviewed HIV organizations along with interventions that were present at just 1 or 2 organizations, labeled “innovative.” A given intervention may appear within multiple domains because it may be perceived by organizations to operate in multiple ways to address stigma.

TABLE 1. - List of Emerging Stigma Reduction Interventions by the STAR Mapping Project Interview Domain, as Reported by Staff of 27 Organizations Providing HIV Services in New York City
Domain Common* Emerging Interventions for Stigma Reduction
Structural level ● Hire staff representative of communities served
● Provide and enforce policies and services that are informed by the specific needs and wants of client populations
● Create a physical space ie, clean, welcoming, and shows inclusivity
● Integrate HIV services into primary care and other services
● Require staff to attend cultural competency trainings and trainings that explicitly include stigma content
● Use language translation services
Interpersonal level ● Train staff on topics relevant to stigma including racism, sex identity, nonverbal communication, cultural competency, and de-escalation Have a culture that promotes the correct usage of client pronouns ● Create a culture-centering respect, as manifested by being welcoming, maintaining privacy and confidentiality, behaving in a way ie, nonjudgmental and attentive, considering the whole person and meeting them where they are at, and using nonstigmatizing language
● Immediately address staff when enacted stigma occurs
Individual level ● Maintain mental and behavioral health services onsite or through referral ● Get input from clients through direct means such as advisory boards
● Initiate client support groups based on expressed needs of clients and which are led or co-led by clients
Stigma assessment ● Use validated surveys at least once to measure HIV or other types of stigma to prioritize stigma reduction activities ● Create stigma reduction plans in response to stigma measurement within the organization that operate at multiple levels of stigma
● Implement trainings and educational campaigns to address areas of continued stigma
Facilitators of stigma reduction ● Education for clients and in the broader community that foster reflective and critical dialog
● Increase frequency of staff trainings that are diverse and relevant to stigma
● More explicitly address stigma—use the word—define what it is, and then create programming for it
● Strengthen evaluation and feedback mechanisms to assess whether what organizations do affects stigma
Shared decision making between staff and clients ● Establish a strong community advisory board (CAB) that meets at least quarterly
● Have CABs review organizational policies, programming, and materials
● Use CABs for social or community-based events
● Empower CAB members to advocate on behalf of themselves and other clients to improve service delivery
Intersectionality ● Case management to ensure that clients are linked to services they need
● Integration of services for mental health care and substance use with HIV services to address multiple needs
● Trainings on different kinds of stigma or “identity” groups
● Team-based care that deliberately integrates client's needs so that the care team has a holistic picture of a client
Domain Innovative* Emerging Interventions For Stigma Reduction
Structural level Empowering Staff
 ● Add content related to stigma to staff orientation trainings
 ● Host peer-to-peer trainings and workshops where staff teach each other new skills
 ● Start employee affinity groups that implement organizational policies
 ● Add racism as a core disparity to residency program curriculum
Creating a Welcoming Space
 ● Make providers more approachable: They do not wear white coats, and clients address them by first name
 ● Remove no loitering signs and make signage bilingual include signs about clients' right to be accompanied into examination rooms
 ● Display a collaboratively made “patient's bills of rights” throughout the facility
 ● Display quality improvement efforts in public areas where clients can see
 ● Remove arms on chairs in waiting room to accommodate all clients
 ● Add charging stations in waiting areas for client use
Enhance Client Experience
 ● Provide laboratory services at clients' homes
 ● Add client experience coordinators to staff
 ● Offer all clients assistance in completing forms
 ● Match providers to clients based on client preferences
 ● Have teams rotate around clients and communicate in advance of visits
 ● Screen for and discuss social determinants of health
 ● Analyze quality indicator data by intersections of demographics to identify unique outcomes
LGBTQ Client Support
 ● Have LGBTQ+ liaisons in clinics
 ● Add sex identity and sexual orientation questions to paperwork
 ● Ask clients' pronouns and preferred names
 ● Providers wear pronouns and rainbow flags on ID badges
 ● Weekly clinic specifically for LGBTQ clients
Interpersonal level Structural and Staff Changes
 ● Create a care service model that aims for a family-like environment
 ● Conduct national or regional staff meetings for staff to share client case stories and receive emotional support from each other
 ● Staff members work in teams and have daily/weekly “team huddles”
 ● Include evaluation of client interactions in staff performance reviews
 ● Have all new staff shadow existing staff for 2 weeks to understand their approach to care and how they treat clients
 ● Make and distribute stigma language guide
 ● Employ designated staff to de-escalate tense situations
Increased Support for Client Experience
 ● Have clinicians accompany outreach staff to clients' homes to understand the totality of their lives
 ● Have providers sit in on support groups to allow clients to have more face time with them and become more comfortable
 ● Operate from a perspective that staff never give up on clients Implement “patient experience” departments or units
Individual level ● Have volunteers available to accompany transgender patients to ER and medical appointments
● Provide care packages for youth leaving detention and clothing for their job interviews
● Involve clients in grant writing for programming desired by clients
● Rename Peer Educators to “Community Wellness Advocates” and increase their compensation and job duties
● Homework given to clients to be kind to themselves and to increase self-esteem
● Offer wellness classes (yoga, cooking, dance, and journaling on trauma) to improve client self-esteem and well-being
Skills-building and vocational classes
● Clients create “Safety Plans” to identify resources they have outside of the agency
● Give diplomas to clients who achieve progress with health goals and host celebrations of their milestones
● Refer to clients as “members” to make them believe they are a part of the institution
● Incorporate the topic of stigma into support and educational groups for clients
● Support groups implement preaffirmation and postaffirmation where clients affirm their worthiness to themselves, or include meditation
● Clients dance to energetic music before support groups to “shake off what they walked in with”
Stigma assessment ● Develop a work plan to address the issues raised by stigma assessment
● Create and support an antistigma task force or campaign in response to measured stigma and keep stigma reduction activities at the forefront of improvement activities
● Document and share stigma reduction activities within the organization and external to the organization
● Implement a top-down, agency-wide approach to addressing stigma
Institute full-day, annual trainings for staff on a stigma-related topics
Implement stigma assessment among clients in support groups, cooking classes, and other client services (including a preassessment and postassessment)
Facilitators of stigma reduction Culture Changes
 ● Create a culture where staff feel comfortable holding each other accountable and giving routine feedback to each other
 ● Regularly bring stigma up in staff meetings to remind staff what the organization stands for
 ● Have strong peer programs that enable peers to be part of decision making
 ● Give peer workers paid opportunities where they can build their skills
Client/Community Interventions
 ● Run social media campaigns or educational series that promote education about LGBTQ and people with HIV (PWH) to the broader community
 ● Organizations have informational material visible to dispel myths surrounding HIV (eg, U=U posters)
Shared decision making between staff and clients Client Leadership
 ● Clients are part of quality assurance committees, diversity and inclusivity committees, or sit on boards
 ● Create client/peer-run unions
Encourage clients to serve on city-wide HIV planning and/or advocacy coalitions
 ● Involve clients in stigma survey development and destigmatization campaigns
 ● Elicit client experiences of stigma at least annually through surveys or focus groups that reach clients
General Client Input
 ● Pop-up events for client feedback and storytelling
 ● Map client experience of visits
 ● Hang client feedback on the walls of the organization to be read by all and added to
 ● Solicit client feedback directly during events (such as cooking classes)
 ● Peer workers review and tailor client feedback forms
 ● Client input sought at the design stage or inception of every program
Intersectionality ● Analyze quality indicator data by intersections of demographics (eg, race, sex, and age) within the client population to identify uniquely vulnerable populations
*“Common” denotes interventions commonly reported across HIV organizations while “innovative” denotes interventions reported by 1 or 2 organizations that others may borrow from.

Determinants

What can influence the ability to implement the intervention?

Determinants are factors that can make implementation easier or harder.16 When developing a Stigma Reduction Logic Model, determinants are important to understand and identify because they allow for the choice of specific and tailored implementation strategies.

Examples of determinants identified through the Stigma Mapping Project are presented in Table 2 to serve as another menu of options to assist organizations with identifying relevant determinants for their settings. The determinants align with the domains of a well-established IS framework, the Consolidated Framework for Implementation Research (CFIR) that organizes them according to characteristics of the intervention, inner and outer setting, implementers, and process.18Table 2 presents applicable domains of the Stigma Reduction Organizational Readiness Tool because lower or higher scores on these can guide the choice of strategies (eg, low score on having a stigma reduction plan indicates a barrier).

TABLE 2. - Tool to Select Determinants of Stigma Reduction Implementation Including Examples of Barriers and Facilitators Reported by 27 Organizations Providing HIV Services in New York City
Determinants by Domains of the CFIR* Guiding Questions for Exploring Determinants Applicable Determinants from Stigma Reduction Organizational Readiness Tool Examples of Stigma Reduction Implementation Barriers (−) and Facilitators (+) at HIV Organizations
Stigma reduction intervention characteristics Ask: What features of the specific stigma reduction intervention you have chosen will make it easier or harder to implement? Not applicable. These determinants relate to the specific intervention you have chosen to implement ● Intervention is complex and/or multilevel (−)
● Education and contact strategies commonly found to be effective but other evidence-based practices are lacking (−)
● Intervention not specifically tailored to the US context (−)
● Tested interventions often occurred once with little follow-up data (−)
● Best practices for measurement and reduction of intersectional stigma unknown (−)
● Few validated metrics for assessing stigma in health services contexts (−)
● Applicable evidence-based interventions exist within stigma field and other disciplines (+)
● Lack of explicit connections between stigma interventions and changes in HIV outcomes (−)
Inner setting Ask: What is happening inside your organization or context that can affect implementation of your chosen stigma intervention? A1 leadership engagement ● Intersectional approaches largely limited to the integration of HIV services with mental health and substance use services (−)
● Staff are trained on how to make organization spaces welcoming to all clients (+)
● Hiring staff from the community and/or with lived experiences is prioritized (+)
● Inequitable power dynamics between staff and clients (−)
● Addressing stigma as a top priority (+)
● Organizational structure/capacity (large client volume, underfunded programs, bureaucracy, corporatization) (−)
● Physical spaces at organizations are made to be inclusive, welcoming, informative, and avoid siloing different types of care through integrating HIV services into other services (+)
● Stigma reduction as routine part of work/job (+)
● Cohesive support structure/hierarchy (+)
● Client-centered policies and practices (+)
● Disconnect between on-the-ground staff and higher-up decision makers (−)
● Stigma is not a commonly understood word (−)
● Lack of a formal stigma initiative and/or agenda (−)
● Leadership is divorced from client-level experiences and may not be convinced that stigma reduction is an important goal (−)
● Trainings are one-off, not sustained (−)
● Lack of representation and visibility of transgender and immigrant populations (−)
Outer setting Ask: What is happening outside your organization that can affect implementation of your chosen intervention? Not applicable. This domain has to do with factors outside of your organization ● Lack of outside funding for organizations to conduct stigma reduction activities and programming (−)
● The organization has a strong presence in the community (+)
● Stigma still prevalent in the community and knowledge is low (−)
● Lack of control over stigma perpetuated in other spaces or parts of the same health care system (−)
● Stigma-targeted efforts by funders not sustained (−)
● Lack of community outreach and collaborative stigma reduction initiatives between communities and clinics (−)
● State-level initiative and tool to measure stigma within health care organizations occurred and spurred motivation to address stigma (+)
Characteristics of staff Ask: Who will perform the implementation, and what are their beliefs, attitudes, knowledge, or other traits that can affect implementation? B1 workforce engagement ● Lack of understanding of what intersectionality means and how to implement an intersectional framework for stigma reduction services (−)
● Staff may hold stigmatizing beliefs (−)
● Staff burnout and turnover (−)
● Staff awareness of stigma is low (−)
● Staff self-efficacy on how to reduce stigma is low (−)
● Staff self-efficacy on how to reduce stigma is low (−)
● Staff representative of communities served (+)
● Staff attitudes value respect and client-centered care (+)
Process Ask: What processes exist in your organization that could impede or facilitate change? A2 stigma reduction committee, A3 stigma reduction plan, A4 stigma data collection, and B2 community member engagement ● Organizations are involved with and reach out to the community (tabling events) (+)
● Organizations have a lack of formal mechanisms and tools for evaluating data and conducting research (−)
● Stigma reduction efforts are not consistently sustained (−)
● Space for client input through structured groups including support groups and community advisory boards (CABs) (+)
● Stigma is not explicitly addressed at CAB meetings (−)
● Clients are not asked about stigma explicitly in feedback surveys (−)
● Clients are able to communicate openly with the organization and understand goals of the organization and give feedback on goals and programs (+)
● Clients have a number of ways to be involved at the organization and programs (+)
*CFIR, Consolidated Framework for Advancing Implementation Science. For additional information on CFIR determinants, see https://cfirguide.org/constructs/
The characteristics described were derived from the experience of 27 HIV organizations in New York City, except in the case of “Stigma Reduction Intervention Characteristics” where the broader literature on stigma reduction research was consulted.

Implementation Strategies

What specific actions will be taken to implement the stigma intervention, taking into consideration identified determinants?

Strategies can be stand-alone or multifaceted, but a variety of strategies at different levels should be used to optimally achieve the desired outcomes. These categories can be used to think through different kinds of implementation strategies.20

  • • Plan: gather data on stigma, build buy-in, initiate champions, and develop relationships.
  • • Educate: inform a range of stakeholders about why stigma is important.
  • • Finance: incentivize the use of stigma interventions through funding.
  • • Restructure: alter staff roles, hire from stigmatized communities, and change job descriptions to explicitly include work on stigma.
  • • Quality management: create systems to evaluate quality of stigma interventions.
  • • Policy context: promote addressing stigma through executive boards and legal systems.

For each selected strategy, specify the following:21

  • • Actor: Who carries out the strategy?
  • • Action: What is done?
  • • Temporality: How long will it take?
  • • Dose: How much of it will be given and at what frequency?
  • • Outcome: What is the end goal?
  • • Target: Who will be on the receiving end?
  • • Justification: Why will it work?

Mechanisms

Why will chosen implementation strategies work to achieve implementation outcomes?

Mechanisms are the specific pathways along which an implementation strategy works to affect outcomes.22 They can explain why a strategy does or does not achieve its intended effect. Understanding the mechanisms involved can help determine whether the chosen implementation strategies are the best to address determinants because mechanisms should reduce barriers and/or leverage facilitators. Figure 2 shows several possible ways that mechanisms may fit within causal pathways from stigma reduction interventions to implementation outcomes.

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FIGURE 2.:
Three potential pathways for how a chosen stigma reduction intervention is implemented, with a focus on mechanisms.

Outcomes

What organizational changes are desired when a stigma reduction intervention is put into place?

Implementation outcomes are the result of deliberate actions taken to implement a new intervention; they differ from client-level health outcomes because they are indicators of how the implementation process went (eg, the number of staff using the new intervention, sustainment, and client uptake) not how the intervention affects clients (eg, viral suppression). Outcomes need to be concrete and measurable. Both quantitative and qualitative data could be used for assessment. Selected tools for the selection of outcomes include the HIV Implementation Outcomes Crosswalk and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) Planning Tool (see Appendix 1, Supplemental Digital Content, https://links.lww.com/QAI/B846).

Although service and client-level outcomes, retained from the IRLM, are not a primary focus of our model, measuring changes in stigma before and after implementation is important. Examples of surveys to measure stigma are provided in Appendix 1, Supplemental Digital Content, https://links.lww.com/QAI/B846. We recommend that HIV organizations simultaneously assess implementation success and client-level effectiveness using hybrid designs13 and that stigma data are aligned with client HIV data to set organizational priorities.

Example

An example of a completed model for planning a real-world stigma intervention is presented in Figure 3. It shows how an approach can have multiple pathways that address key determinants and ultimately lead to the desired implementation outcomes and how mechanisms bridge the gap between strategies and outcomes. We chose the intervention of integrating peer workers into health care teams because many of the HIV organizational staff we interviewed during the Mapping Project believed that having staff who are reflective of the populations served was a highly effective intervention to reduce stigma.

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FIGURE 3.:
An example of stigma reduction implementation: The Certified Peer Worker (CPW) role.

DISCUSSION

This Stigma Reduction Logic Model, adapted from the IRLM, can empower organizations to build consensus and confidence in stigma reduction initiatives. It provides a cohesive framework for multiple stakeholders, including health departments, researchers, community members, and community and clinical HIV organizations, to work collaboratively to reduce stigma. The visual representation of the causal pathway shows stakeholders how each IRLM component is interdependent and the effort that is needed to strategically plan, execute, and progress toward outcomes. It is a foundational tool that includes IS concepts and language, stigma intervention emerging practices, and recommended measurement tools to ensure standardized interpretation and application of the model. From the onset of planning, it promotes consideration of measurable and multilevel outcomes and collection of downstream stigma data that are aligned with client-level HIV outcomes that organizations are currently assessing. This should lead to more of the untested stigma reduction interventions identified by the Mapping Project having evidence of effectiveness.

The model addresses critical gaps in stigma reduction activities found through the Mapping Project: a lack of intersectional approaches and effectiveness evaluation and barriers at the organizational level that included leadership support, staff turnover and burnout, and siloed bureaucracies.15 The Mapping Project found that HIV providers had engaged in informal, unstructured, and unmeasured approaches to intersectional stigma. To meet the needs of developing a more systematic and intentional approach to intersectional stigma, a menu of common and innovative emerging interventions was included, along with a structured approach to planning out the implementation process with a focus on intersectional stigma from the first step.

The Readiness Tool encourages organizations to conceptualize stigma intersectionally and assess for intersectionality-informed determinants. Intersectionality is an emerging framework and does not have prescriptive methods or consensus on measurement.23 Turan et al23 provided recommendations for healthcare entities such as developing measures, understanding its effects and burdens, identification of drivers and mechanisms, and policy and practice. Although our model facilitates the incorporation of these recommendations, the challenge of interpreting, selecting, and applying measurements and strategies rests on the implementers.

Having found in the Mapping Project a limited capacity for some HIV organizations to perform research and evaluation, such as that which might be needed to explore IS determinants, our model leverages the resources of these organizations by offering a menu of “emerging” stigma reduction interventions from which to choose given their local context. By elevating emerging interventions used in practice, we are in accordance with a recently published IS framework by the Health Resources and Services Administration that acknowledges that IS is an essential field across the HIV care continuum and expressly highlighted the importance of emerging practices as those that have “demonstrated real-world validity and effectiveness but have insufficient published evidence.”16

Our tools encourage multilevel approaches including having leadership support, dedicated staff, and the resources to tackle stigma systematically in ways that may overcome some of the organizational challenges. To maximize the potential of our model, a diversity of stakeholders must be included at every stage of implementation, outcomes must be disseminated rapidly for real-world relevance, and evaluation should be ongoing with iterative feedback loops to make adjustments along the way. Multiple types of stakeholders may find this model useful for promoting stigma reduction initiatives. For example, federal agencies and local health departments that are key in leveraging partnerships, providing analytic and technical assistance capabilities, and shaping policy can partner with HIV programs, researchers, and community members to design and/or fund stigma reduction implementation models. Another potentially beneficial use would be for stakeholders to work with provider learning collaboratives/networks to plan stigma reduction quality improvement efforts using the model. The model creates an opportunity for peer-learning because conversations to share barriers, facilitators, and outcomes may help collaborative members tailor the model to their individual contexts while also creating generalizable knowledge through the sharing of similar best practices. Because stigma is a dynamic, socially constructed phenomenon requiring socially complex solutions, adaptations of the IRLM such as this are especially critical to improving the research to practice pipeline.24

Change agents, whether they are individuals, organizations, or affected community members, can use this comprehensive model that provides context exploration, intervention readiness assessment, stigma reduction intervention planning, and implementation and evaluation guidance to further close the gaps between research and practice. Our next step is to use existing collaborative settings to partner with key stakeholders and test the model with NYC HIV providers. With this model, we have the potential to deepen our understanding of the impact of a given strategy or intervention for reducing stigma on health outcomes for people with or affected by HIV along the HIV care continuum.

ACKNOWLEDGMENTS

The authors thank Stephen Sebor from the Center for Public Health Education and Rebekah Glushefski from the Institute for Family Health for their invaluable contributions to this project, especially for Figure 3, our example model.

REFERENCES

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Keywords:

implementation science; stigma interventions; HIV stigma; intersectional stigma

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