Evaluating a Multi-Level Stigma Reduction Intervention for Healthcare Workers and Community Leaders in Nigerian HIV Clinics: A Mixed-Methods Study

Overview

This study evaluated a 12-month multi-level stigma reduction intervention implemented across six HIV clinics in Nigeria between 2023 and 2024. The intervention addressed HIV-related stigma operating at both healthcare institutional and community levels, targeting healthcare workers through structured participatory training and engaging community leaders through facilitated dialogue sessions. HIV-related stigma within healthcare settings and surrounding communities constitutes a persistent barrier to epidemic control efforts in sub-Saharan Africa, necessitating coordinated approaches that address multiple social ecological levels simultaneously. The intervention design reflected recognition that stigma operates through interconnected mechanisms spanning individual attitudes, institutional practices, and community normative beliefs. The study employed a concurrent mixed-methods design to capture both quantitative shifts in stigmatising attitudes and behaviours alongside qualitative understanding of experiential and contextual dimensions of change.

Methods and approach

The research utilized a concurrent mixed-methods design combining quantitative measurement with qualitative exploration. Quantitative data were collected using validated scales measuring stigmatising attitudes and behaviours among healthcare workers and community leaders at baseline (n=312) and post-intervention (n=298). Statistical analysis employed paired t-tests to assess pre-post intervention differences. The qualitative component comprised 42 in-depth interviews and six focus group discussions with intervention participants, generating data on experiential changes and contextual factors influencing intervention reception and impact. Qualitative data underwent thematic analysis to identify patterns and themes related to stigma reduction processes. Integration of quantitative and qualitative data strands occurred during the interpretation phase, enabling triangulation and deeper understanding of intervention mechanisms and outcomes. The multi-level intervention itself consisted of structured participatory training sessions for healthcare workers addressing knowledge gaps and attitudinal barriers, alongside facilitated dialogue sessions with community leaders designed to promote advocacy and counter stigmatising narratives within community contexts.

Key Findings

Quantitative findings demonstrated statistically significant reductions in stigmatising attitudes among healthcare workers following the intervention (p<0.01), with particular improvements observed in attitudes related to fears of casual HIV transmission. Community leaders reported increased engagement in advocacy activities and proactive efforts to counter misinformation regarding HIV transmission and persons living with HIV within their communities. Thematic analysis of qualitative data generated key themes centred on improved client-provider interactions within clinical settings and the catalytic role of community leadership in shifting normative beliefs about HIV and people living with the condition. Qualitative accounts elaborated mechanisms through which the intervention produced change, including increased confidence among healthcare workers in providing non-discriminatory care and enhanced legitimacy of counter-stigma messaging when delivered by respected community figures. The integration of data strands revealed convergence between quantitative measures of attitude change and qualitative narratives of transformed interpersonal dynamics and community discourse, supporting the validity and meaningfulness of observed intervention effects.

Implications

The study concludes that concurrently addressing stigma at both institutional healthcare and community levels amplifies intervention impact beyond what might be achieved through single-level approaches. The intervention model demonstrates replicability potential for integrating social and clinical dimensions of HIV responses across similar contexts. Findings directly inform implementation strategies for Nigeria's National HIV/AIDS Strategic Plan, providing empirical support for prioritizing multi-level stigma reduction within national programming. The research underscores the necessity of sustained investment in comprehensive approaches that address stigma across multiple social ecological levels to achieve equitable, stigma-free healthcare environments conducive to epidemic control objectives. The catalytic role identified for community leaders suggests strategic value in engaging influential community figures as agents of normative change, extending intervention reach beyond clinic walls into broader social contexts where stigma operates. The demonstrated feasibility and effectiveness of this multi-level model offers actionable guidance for HIV programme planners and policymakers seeking evidence-based approaches to dismantling structural and social barriers to HIV care access and retention.