www.aids2014.org
Poverty, Intersectional Stigma,
and Health Outcomes Among
HIV-Positive African Caribbean
Black Women in O...
www.aids2014.org
Background
www.aids2014.org
Background
• African Caribbean Black (ACB) women are 7-
fold overrepresented in new HIV infections in
com...
www.aids2014.org
Background
• Qualitative research with ACB women in Canada
highlight intersecting stigma and discriminati...
www.aids2014.org
Stigma Processes
• Link and Phelan (2001) reconceptualized stigma
as processes of:
– Labeling, stereotypi...
www.aids2014.org
Poverty and HIV-related Stigma
• HIV-related stigma associated with:
– poverty, stress, deleterious menta...
www.aids2014.org
Poverty and HIV
• Poverty is a powerful structural driver of HIV
infection—as are racial and gender inequ...
www.aids2014.org
Gaps in the Literature
• HIV-related stigma, sexism and racism have
each been examined as stressors with
...
www.aids2014.org
Gaps in Literature
• Scant research has examined poverty, stigma
and:
• multiple forms of stigma (i.e. ra...
www.aids2014.org
Theoretical Approach
www.aids2014.org
Intersectionality
• Interdependent and mutually constitutive
relationship between social identities and s...
www.aids2014.org
Fundamental Cause Theory
• Social contexts and factors are associated with
persistent health inequities (...
www.aids2014.org
Objectives
1. Examine associations between perceived poverty and:
– intrapersonal (resilient coping)
– in...
www.aids2014.org
Methods
www.aids2014.org
Methods
• A community-based, multi-method approach
• Qualitative Phase 1: 15 focus groups with
diverse wo...
www.aids2014.org
Methods
• Quantitative Phase 2: Cross-sectional survey
with HIV-positive African Caribbean Black
women in...
www.aids2014.org
Measures
• HIV-related Stigma Scale Revised (Wright et al., 2007)
• Everyday Discrimination Scale: Race (...
www.aids2014.org
Data Analysis
• 1. Multiple logistic regression analyses to assess
associations between:
– Perceiving one...
www.aids2014.org
Results
www.aids2014.org
Table 1. Socio-demographic Characteristics
of participants (n=173)
Characteristic Mean (SD)
Age, yrs 40.7...
www.aids2014.org
Table 2. Indicators of Economic Insecurity
Is there enough income per month to: No Yes
Pay for your rent/...
www.aids2014.org
Table 4. Univariate and multivariate logistic
modeling of factors associated with
perceived poverty
Varia...
www.aids2014.org
Variables Unadjusted logistic
regression analyses,
OR (95% CI)
p value Adjusted logistic
regression
analy...
www.aids2014.org
Stigma as mediators of associations
between poverty and depression
• Total effect of perceived poverty on...
www.aids2014.org
Stigma as mediators of associations
between poverty and QOL
• Total effect of perceived poverty on QOL: t...
www.aids2014.org
Stigma as mediators of associations
between poverty and SRH
• Total effect of perceived poverty on
depres...
www.aids2014.org
Stigma as mediators of the effect of
perceived poverty on depression and self-
rated health
Gender discri...
www.aids2014.org
Stigma as mediators of the effect of
perceived poverty on depression and self-
rated health
Gender discri...
www.aids2014.org
Discussion
Perceived
poverty
associated
with:
Health (QOL, SRH, depression)
Economic insecurity linked wi...
www.aids2014.org
Discussion
Structural
contexts of
health
Corroborates prior research on health impacts of poverty,
HIV re...
www.aids2014.org
Implications for Interventions
Structural: macro
Poverty reduction
Strategies to reduce
intersectional st...
www.aids2014.org
Research Implications
Methodological
• Longitudinal
design
• Quantitative
approaches to
intersectional
re...
www.aids2014.org
Acknowledgments
• Co-authors and colleagues, Wangari Tharao and Mona
Loutfy
• Peer research assistants an...
Poverty, Intersectional Stigma, and Health Outcomes Among HIV-Positive African Caribbean Black Women in Ontario, Canada
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Poverty, Intersectional Stigma, and Health Outcomes Among HIV-Positive African Caribbean Black Women in Ontario, Canada

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Presentation given by Carmen Logie at the Under the Baobab African Diaspora Networking Zone at the International AIDS Conference, AIDS 2014.

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Poverty, Intersectional Stigma, and Health Outcomes Among HIV-Positive African Caribbean Black Women in Ontario, Canada

  1. 1. www.aids2014.org Poverty, Intersectional Stigma, and Health Outcomes Among HIV-Positive African Caribbean Black Women in Ontario, Canada Carmen Logie1,2, PhD; Wangari Tharao3 PhD (c); Mona Loutfy2, M.D. 1: Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada; 2: Women’s College Research Institute, University of Toronto: 3: Women’s Health in Women’s Hands Community Health Centre, Toronto, Canada
  2. 2. www.aids2014.org Background
  3. 3. www.aids2014.org Background • African Caribbean Black (ACB) women are 7- fold overrepresented in new HIV infections in comparison with their white counterparts in Canada (PHAC, HIV and AIDS in Canada. Surveillance Report to December 31, 2008. 2009, Public Health Agency of Canada: Ottawa.)
  4. 4. www.aids2014.org Background • Qualitative research with ACB women in Canada highlight intersecting stigma and discrimination: • Increase vulnerability to HIV infection • Reduce access to care • Negatively impact mental health (Logie, James, Tharao & Loutfy, 2011; Newman et al., 2008; Tharoa & Massaquoi, 2001; Williams et al., 2009)
  5. 5. www.aids2014.org Stigma Processes • Link and Phelan (2001) reconceptualized stigma as processes of: – Labeling, stereotyping, separation, status loss, and discrimination in contexts of power inequity • Occur across multiple statuses (e.g. HIV, ethnoracial identity, gender) and levels (individual, structural, social conditions)
  6. 6. www.aids2014.org Poverty and HIV-related Stigma • HIV-related stigma associated with: – poverty, stress, deleterious mental and physical health and AIDS-related mortality (Logie & Gadalla, 2009; Tsai, 2013) • Associations between HIV-related stigma and poverty contribute to social exclusion: – symbolic exclusion: HIV representative of illness and death (Pryor, 1989; Tsai, 2013) – Instrumental: PLHIV not seen as equal contributors of material resources (Pryor, 1989; Tsai, 2013) – institutional: workplace discrimination, medical coverage linked with disability insurance (Logie et al. 2011)
  7. 7. www.aids2014.org Poverty and HIV • Poverty is a powerful structural driver of HIV infection—as are racial and gender inequity (Gupta et al., 2008) • Less is known how poverty continues to influence the lives and health of ACB women living with HIV in Canada
  8. 8. www.aids2014.org Gaps in the Literature • HIV-related stigma, sexism and racism have each been examined as stressors with negative health impacts—largely have been looked at separately (e.g. Hatzenbuehler, Phelan & Link, 2013; Logie & Gadalla, 2009; Paradies, 2006; Szymanski & Stewart, 2010) • Associations between poverty, stigma and health are complex and unclear (Fuller-Rowell et al. 2012; Simons et al., 2013; Schulz et al. 2012) – Do certain types of stigma mediate the relationship between poverty and health? – If so, what types of stigma, what health outcomes, and for who?
  9. 9. www.aids2014.org Gaps in Literature • Scant research has examined poverty, stigma and: • multiple forms of stigma (i.e. racial discrimination, gender discrimination, HIV related stigma) concomitantly (e.g. Logie & Gadalla, 2009; Mahajan et al., 2008) • more than one health outcome (Hatzenbuehler 2013) • multiple levels of analyses (intra/interpersonal, structural) (Hatzenbuehler 2013)
  10. 10. www.aids2014.org Theoretical Approach
  11. 11. www.aids2014.org Intersectionality • Interdependent and mutually constitutive relationship between social identities and social inequities (Bowleg, 2008; Collins, 2000; Crenshaw, 1989) • Examines multiple, interlocking forms of stigma and inequities across multi-levels of analysis
  12. 12. www.aids2014.org Fundamental Cause Theory • Social contexts and factors are associated with persistent health inequities (Link & Phelan, 1995) • Fundamental social causes: – Influence multiple health outcomes – Involve access to resources (money, knowledge, power, status) that could lower health risks or lessen impacts of illness – Linked to health inequities over time and in different places (Link & Phelan, 1995; Phelan et al., 2010)
  13. 13. www.aids2014.org Objectives 1. Examine associations between perceived poverty and: – intrapersonal (resilient coping) – interpersonal (social support) – structural (racial discrimination, gender discrimination, HIV- related stigma) – health (self-rated health, depression, quality of life) outcomes among ACB women living with HIV in Ontario, Canada 2. Explore intersectional stigma (racial discrimination, gender discrimination, HIV-related stigma) as mediators of the association between perceived poverty and health outcomes
  14. 14. www.aids2014.org Methods
  15. 15. www.aids2014.org Methods • A community-based, multi-method approach • Qualitative Phase 1: 15 focus groups with diverse women living with HIV (n=104) in five cities across Ontario, Canada
  16. 16. www.aids2014.org Methods • Quantitative Phase 2: Cross-sectional survey with HIV-positive African Caribbean Black women in 5 cities in Ontario, Canada • Peer-driven recruitment and purposive sampling
  17. 17. www.aids2014.org Measures • HIV-related Stigma Scale Revised (Wright et al., 2007) • Everyday Discrimination Scale: Race (Clark et al., 2004; Forman et al., 1997), • WHOQOL-HIV BREF (WHO, 2002) • MOS Social Support Scale (Sherborne & Stewart, 1991) • Brief Resilient Coping Scale (Sinclair & Wallston, 2004) • Perceived poverty: “do you consider yourself to be poor?” (5 point Likert scale) • Depression: Beck Depression Inventory Fast- Screen (Beck et al., 1997)
  18. 18. www.aids2014.org Data Analysis • 1. Multiple logistic regression analyses to assess associations between: – Perceiving oneself as poor (dichotomized: agree/strongly agree) and intrapersonal, interpersonal, structural and health factors • 2. Mediation analyses to assess if perceived poverty was associated with significant changes in the mediator variables (HIV-related stigma, racial discrimination, gender discrimination) which would impact health outcomes – Preacher and Hayes bootstrapping method (SPSS macro)
  19. 19. www.aids2014.org Results
  20. 20. www.aids2014.org Table 1. Socio-demographic Characteristics of participants (n=173) Characteristic Mean (SD) Age, yrs 40.7 (8.8) Monthly income (median) $1,400.00 (Range: 0- $7,916.00) n % Education less than high school 45 26.0 high school 60 34.7 college diploma 44 25.4 university degree 24 13.9 Agree/Strongly Agree they perceive themselves as poor 90 52.0 African ethnicity 89 51.4 Caribbean ethnicity 84 48.6
  21. 21. www.aids2014.org Table 2. Indicators of Economic Insecurity Is there enough income per month to: No Yes Pay for your rent/mortgage in full every month on time? 39 (22.5%) 134 (77.5%) Pay for medication costs not covered by other sources? 47 (27.2%) 126 (72.8%) Pay for food each month? 66 (38.2%) 107 (61.8%) Pay for transportation costs every month? 69 (39.9%) 104 (60.1%) Pay for childcare costs that are not covered by other sources? 72 (41.6%) 101 (58.4%) Pay for supplements, or other forms of healthcare? 102 (59.0%) 71 (41.0%) Pay for heating/cooling of your room/apartment/home? 100 (57.8%) 73 (42.2%) Allow for fun activities i.e. movies, go out to dinner? 111 (64.2%) 62 (35.8%)
  22. 22. www.aids2014.org Table 4. Univariate and multivariate logistic modeling of factors associated with perceived poverty Variables Unadjusted logistic regression analyses, OR (95% CI) p value Adjusted logistic regression analyses1, OR (95% CI) p value Socio-demographic Variables Age 1.00 (0.97, 1.04) 0.74 Education 1.11 (0.83, 1.47) 0.49 Income 1.00 (1.00, 1.00) 0.24 Ethnicity (Caribbean vs. African) 0.41 (0.21, 0.81) 0.01* Health Quality of life 0.97 (0.95, 0.99) 0.01* 0.96 (0.93, 0.99) 0.01* Depression 1.09 (1.01, 1.18) 0.03* 1.12 (1.01, 1.25) 0.03* Self-rated health 0.72 (0.51, 1.01) 0.05 0.60 (0.38, 0.94) 0.03** Physical exams in past 5 years 0.48 (0.86, 0.99) 0.04* 0.94 (0.85, 1.0) 0.25 Structural factors: economic insecurity Not enough monthly income to buy food 0.28 (1.46, 5.44) 0.00** 4.02 (1.69, 9.58) 0.00** Not enough monthly income to buy supplements or other forms of healthcare 2.82 (1.44, 5.53) 0.00** 4.20 (1.75, 10.08) 0.00** Not enough monthly income to pay for home’s heating/cooling 3.44 (1.77, 6.69) 0.00** 4.09 (1.74, 9.61) 0.00** Not enough monthly income to allow for fun activities 3.54 (1.72, 7.28) 0.00** 3.07 (1.30, 7.26) 0.01*
  23. 23. www.aids2014.org Variables Unadjusted logistic regression analyses, OR (95% CI) p value Adjusted logistic regression analyses1, OR (95% CI) p value Intrapersonal factors Resilient coping 0.94 (0.86, 1.02) 0.15 0.86 (0.75, 0.97) 0.02* Interpersonal Factors Social support (total score) 0.96 (0.94, 0.98) 0.00** 0.95 (0.92, 0.97) 0.01* Social support: emotional support 0.56 (0.42, 0.75) 0.00** 0.58 (0.40, 0.84) 0.00** Social support: informational support 0.59 (0.43, 0.80) 0.00** 0.55 (0.36, 0.82) 0.00** Social support: tangible support 0.65 (0.49, 0.86) 0.00** 0.62 (0.43, 0.88) 0.01* Social support: affectionate support 0.59 (0.45, 0.79) 0.00** 0.48 (0.32, 0.74) 0.00** Social support: positive social interaction 0.59 (0.44, 0.78) 0.00** 0.49 (0.33, 0.73) 0.00** Structural factors: stigma Racial discrimination 1.11 (1.06, 1.17) 0.00** 1.12 (1.06, 1.19) 0.00** Gender discrimination 1.08 (1.04, 1.12) 0.00** 1.06 (1.01, 1.11) 0.02* HIV-related stigma (total score) 1.13 (1.07, 1.19) 0.00* 1.15 (1.07, 1.23) 0.00** HIV-related stigma: personalized 1.69 (1.28, 2.24) 0.00** 1.86 (1.29, 2.68) 0.00** HIV-related stigma: disclosure 1.80 (1.26, 2.57) 0.00** 1.65 (1.04, 2.62) 0.03* HIV-related stigma: negative self-image 1.25 (0.98, 1.59) 0.07 1.25 (0.92, 1.69) 0.16 HIV-related stigma: public attitudes 2.45 (1.64, 3.67) 0.00** 2.34 (1.46, 3.74) 0.00**
  24. 24. www.aids2014.org Stigma as mediators of associations between poverty and depression • Total effect of perceived poverty on depression: t=2.36, p=0.02* (CI: 0.10, 1.14) • Direct effect was not significant after controlling for: – gender discrimination: t=1.82, p=0.07 (CI: -0.04, 1.01) – racial discrimination: t=1.52, p=0.13 (CI: -0.12, 0.94) – HIV-related stigma: t=0.49, p=0.62 (CI: -0.04, 0.69)
  25. 25. www.aids2014.org Stigma as mediators of associations between poverty and QOL • Total effect of perceived poverty on QOL: t=- 3.78, p=0.00* (CI: -6.06, -1.91) • Direct effect insignificant after controlling for: – HIV-related stigma: t=-1.95, p=0.05 (CI: -4.38, 0.03) • Direct effect significant after controlling for: – gender discrimination: t=-3.08, p=0.00* (CI: -5.25, -1.15) – racial discrimination: t=-2.73, p=0.01* (CI: -4.96, - 0.79)
  26. 26. www.aids2014.org Stigma as mediators of associations between poverty and SRH • Total effect of perceived poverty on depression: t=-2.40, p=0.02* (CI: -0.29, -0.03) • Direct effect insignificant after controlling for: – gender discrimination: t=1.87, p=0.06 (CI: -0.25, 0.01) – racial discrimination: t=-1.95, p=0.05 (CI: -0.27, 0.00) – HIV-related stigma: t=-1.03, p=0.30 (CI: -0.21, 0.07)
  27. 27. www.aids2014.org Stigma as mediators of the effect of perceived poverty on depression and self- rated health Gender discrimination Racial discrimination HIV-related stigma Perceived poverty Depression Self-rated health
  28. 28. www.aids2014.org Stigma as mediators of the effect of perceived poverty on depression and self- rated health Gender discrimination* Racial discrimination* HIV-related stigma Perceived poverty Quality of life * Partial mediator
  29. 29. www.aids2014.org Discussion Perceived poverty associated with: Health (QOL, SRH, depression) Economic insecurity linked with housing, food, healthcare Intersectional stigma Intra (resilient coping) and inter (social support) personal factors
  30. 30. www.aids2014.org Discussion Structural contexts of health Corroborates prior research on health impacts of poverty, HIV related stigma, gender and racial discrimination (e.g. Hatzenbuehler et al. 2013; Krieger et al. 2011; Logie & Gadalla, 2009; Schulz et al. 2012) Highlights high rates of perceived poverty and economic insecurity among HIV-positive ACB women in Ontario Complexity of perceived poverty Perceived poverty associated with economic insecurity indicators—suggests the need to move beyond controlling for income towards exploring economic insecurity Contradictory findings in literature regarding stigma as a mediator in relationship between poverty and health (Fuller-Rowell et al. 2012; Simons et al., 2013; Schulz et al. 2012): this needs more exploration among PLHIV
  31. 31. www.aids2014.org Implications for Interventions Structural: macro Poverty reduction Strategies to reduce intersectional stigma: HIV-related, racism, sexism Community: meso Build social support Address stigmatizing social norms and social exclusion Intra/interpersonal: micro Intra: resilient coping, address depression Inter: disclosure interventions
  32. 32. www.aids2014.org Research Implications Methodological • Longitudinal design • Quantitative approaches to intersectional research • Examine multiple: health outcomes, forms of stigma, levels of analysis Theoretical • Intersectional stigma as fundamental causes of population health inequity—most research has looked at poverty Stigma mechanisms • Need to explore dimensions and types of stigma associated with perceived poverty and various health outcomes • Examine stigma’s role as a mediator
  33. 33. www.aids2014.org Acknowledgments • Co-authors and colleagues, Wangari Tharao and Mona Loutfy • Peer research assistants and participants • Canadian Institutes of Health Research (CIHR) funding • carmen.logie@utoronto.ca

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