nimh satellite on stigma reduction washington, dc july 22, 2012 james blanchard, md, mph, phd centre...
TRANSCRIPT
NIMH Satellite on Stigma Reduction
Washington, DCJuly 22, 2012
James 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 30.4
24.9
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
Per
cen
tag
e o
f p
oli
ce o
ffic
ers
wh
o a
gre
e
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
Mean
Pow
er
Dom
ain
Score
‡
‡
‡
‡
‡‡ ‡
‡ ‡
‡
‡
‡
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)