NIMH Satellite on Stigma Reduction Washington, DC July 22, 2012

NIMH Satellite on Stigma Reduction

Washington, DCJuly 22, 2012James Blanchard, MD, MPH, PhDCentre for Global Public HealthUniversity of Manitoba

Closing the gap between research and programs for scaling up strategies to

reduce stigma and discrimination

Research and Programs – the “Perspective Gap”

• Research paradigm– Relies heavily on

theory to build knowledge and develop interventions

– Focuses on internal validity for building knowledge and testing interventions

– Prioritizes “getting research into practice”

• Program paradigm– Relies on

experience and community perspectives to develop interventions

– Focuses on local context and community responses to assess interventions

– Emphasizes “getting research out of practice”

Research and Programs – the “Implementation Gap”

• Research paradigm– Emphasizes

adherence and fidelity to “proven” interventions.

– Requires clear, measurable indicators to assess progress and effectiveness.

– Is often constrained by lack of robust program contexts within which to conduct research.

• Program paradigm– Emphasizes

adaptation to local situations and flexibility in design.

– Often gives priority to experiential evidence and key informant feedback to measure success.

– Often is constrained by resources and expertise to engage in research

“…the systematic application of theoretical and empirical scientific knowledge to improve the design, implementation and evaluation of public health programmes.”

An example – Addressing stigma and discrimination in female sex work in

India

Stigma and Discrimination – Issues for FSWs in India

• Poverty and low social standing:– Economic dependency and lack of power over resources– Lack of access to health services and other social

entitlements– Lack of education and skills to negotiate with

government and other power structures• Moral and legal aspects:

– Promotes / sanctions harassment, exploitation and violence by police, power brokers and members of their own families and communities

– Internalization of stigma resulting in feelings of unworthiness and lack of entitlement to human rights

• HIV:– Seen as a threat to the community, accentuating social

exclusion and stigma and discrimination

Program Response – Structural Interventions

Structural Interventions

Public attitudes and stigma

Media advocacySupport local organizations

Social and economic issues

Promote access to social entitlementsStrengthen CBOs

Violence and exploitation

Police sensitizationCrisis response

systemLegal

empowerment

Police Officers Trained in Each District (as of October 2008)

Districts Total No. of Police Officers to be

trained

Total No. of Police officers trained

% of coverage

Bangalore (R ) 1929 206 11%Bangalore (U) 3338 1226 37%

Bellary 1630 1412 87%Chitradurga 1333 1184 88%Davangere 728 880 121%Gadag 521 428 82%Gulbarga 1311 1461 111%Haveri 577 315 54%Kolar 1566 1626 104%Shimoga 1189 222 19%Uttar Kannada 1658 221 13%Belgaum 995 802 80%Bijapur 1491 378 20%Bagalkot 795 246 31%Raichur 1409 527 37%Dharwad 1652 340 20%

Total 22,122 10,979 52.8%

Knowledge and Attitudes of Police Officers Before and After Training

40.8

52.1

42.8

20.9

31.7 30.424.9

32.2

14.0

31.7

23.4

13.218.4 15.8

39.0

49.9

0

20

40

60

sex workersare criminals

sex workerscause thespread of

AIDS

sex workerscorruptsociety

violence isthe ony wayto deal with

sex workers;that is all

theyunderstand

societyneeds to becleansed ofsex workers

HIV andAIDS are the

same

sex work is aprofession

sex workersdeserverespect

Attitudes / knowledge statement

Perc

enta

ge o

f pol

ice

offic

ers

who

agr

ee pre-sensitisation training post-sensitisation training

FSWs Reporting Being Beaten or Raped in Past Year: Polling Booth Surveys (13

Districts) and IBBA (5 Districts)

Program Response – Community Mobilization

• Enhance the dignity and self-esteem of FSWs

• Support FSWs to develop a strong “shared voice”

• Build the capacity of collective organizations to effectively advocate for their rights and address stigma and discriminition

Progress in the Development of FSW Collectives

Indicators March 2007

March 2008

Jan 2009

Amount Deposited in SHGs (INR) - 5,102,500 15,419,203

# of collectives registered 9 19 20

Total membership in the collectives

12,118 29,289 35,983

Total annual budget of the collectives

5,210,000 24,385,115

28,565,456

Total corpus fund (cumulative) 1,051,000 2,143,286 2,563,209

Number of CBOs with FCRA numbers

0 0 2

Number of peers promoted to higher role

- 158 203

Constraints with Program Performance Measurement

• Lack of theoretical of conceptual framework:– Difficult to translate across contexts

• Lack of explicit empowerment objectives at the individual level:– Difficult to measure diverse community needs

and empowerment progress

Power Within

Power with

Others

Power over

Resources

Socio-demographic characteristics

CommunityMobilization

Program and structural interventions Empowerment

Dimensions

Power imbalances Social exclusion

Vulnerability

Disempowering social context

Power to Address

“Program Science”Framework

FSW Empowerment Domains

– “Power within” – self-esteem, and confidence to participate in meetings with other sex workers or health/social workers.

– “Power with” – confidence in the ability to work together and support each other, and the benefits of collectivization.

– “Power over resources” – represented by the possession of social entitlements, including a bank account, voter ID and ration cards.

Levels of Empowerment, By District

Power Within Power With others

Power With-1.5

-1

-0.5

0

0.5

1

1.5

BelgaumGulbargaGadagDharwadSolapur

Mea

n Po

wer

Dom

ain

Scor

e

‡

‡

‡

‡‡

‡ ‡

‡ ‡

‡‡

‡

Key Findings

• Younger women scored lower in all empowerment domains.

• There was considerable variation between districts in power domains, but generally, in districts with weaker CBO programs, scores were lower.

• Duration of time exposed to the program and number of program contacts was positively associated with “power within” and “power with” in most districts.

Key Findings (2)

• “Power within” was associated with greater self-efficacy for condom use with regular partners, and with higher service utilization, in all districts.

• “Power with” was associated with greater autonomy, reduced reported violence, and increased self-efficacy for service utilization in three districts, and with self-efficacy for condom use in all districts.

Scaling up Strategies to reduce Stigma – Program Science

approaches• Develop “program-science” platforms

through innovative funding models:– Diverse program contexts– “Embedded” research and researchers– Coordinated funding models – programs and

research funding• Further develop practical conceptual

frameworks for research and program development:– Address the complexity of relationships and

pathways.– Develop analytic approaches and

measurement tools

Final thoughts

• Put the community at the centre of “program science” platforms:– Systematically engaged to define the issues

and research questions– Participating in all aspects of research design

and conduct

Acknowledgements

• Karnataka FSW community and CBOs• Karnataka Health Promotion Trust

– HL Mohan, V Gurnani, P Bhattacharjee, S Isac, R Prakash

• University of Manitoba– S Moses, BM Ramesh, A Blanchard

– M Shahmanesh (Univ. College London)