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
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

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Background

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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.)

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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)

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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)

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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)

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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

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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?

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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)

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Theoretical Approach

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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

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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)

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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

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Methods

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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

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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

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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)

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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)

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Results

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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

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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%)

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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*

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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**

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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)

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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)

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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)

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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

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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

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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

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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

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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

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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

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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