Efficacy of a Multi-Level Pilot Intervention (“Harmony”) to Reduce Discrimination Faced by Men Who Have Sex with Men and Transgender Women in Public Hospitals in India: Findings from a Pre- and Post-Test Quasi-Experimental Trial among Healthcare Workers
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting and Design
2.2. Intervention Development
Qualitative Formative Research
2.3. Conceptual Framework
2.4. Intervention Description
Intervention Components | Evidence-Based Approaches | Activities |
---|---|---|
Workshop (Group-level intervention) | Provision of education through lectures and interactive sessions | Conducted half-day training for facility HCWs (8 modules): Information on same-sex and bisexuality and gender identity; Talks by MSM and TGW (telling their stories); stigma and discrimination in healthcare settings; healthcare needs (including mental health and gender transition care); relevance of sexual orientation and gender identity questions in clinical history taking; inclusive language, communication and practice; discussion on sexual/gender minority-friendly and non-discriminatory hospital policies; developing action steps to improve quality of services for MSM and TGW. |
Involvement of popular opinion leaders (HCW Champions) [28,30] | Identified local hospital champions among HCWs (based on community agencies’ inputs) who shared their perspectives and experiences on how to provide non-discriminatory care to MSM and TGW. | |
Involvement of MSM/TGW community champions—Intergroup contact (Contact hypothesis) [29,32] | Community champions as co-trainers. Interactions of the HCWs with MSM/TGW community leaders and representatives, and hearing their testimonials regarding the issues faced by them in healthcare settings. | |
Awareness of prejudice (Consciousness raising) [40] | Participants were made self-aware of their prejudice by a description of scenarios during the lectures, good practices and the testimonials of MSM/TGW community representatives. | |
Peer interactions | HCWs discussed their beliefs and feelings with peers in a safe, non-judgmental environment. | |
Entertainment | A break in between the workshop sessions during which MSM/TGW community representatives provided a dance performance. This also showcased the artistic and creative talent among MSM/TGW communities. | |
Short videos (Individual level intervention) | Collective action [27] (Creation of short videos) | Short videos were created based on the inputs from the MSM/TGW communities in the qualitative formative research. MSM/TGW community representatives acted in the short videos that highlighted the issues faced by MSM/TGW in healthcare settings. Inputs on the scripts of the videos were obtained from community and policy stakeholders. |
Entertainment/Infotainment (Sharing of short videos) | Four short videos (in local languages) were shared with HCWs (one video per week for 4 weeks) over WhatsApp over a period of two months after the workshop. These videos were intended to raise awareness about the issues faced by MSM and TGW in healthcare settings. |
2.5. Participants and Recruitment
3. Measures
3.1. Data Analysis
3.2. Ethical Considerations
4. Results
4.1. Characteristics of HCWs
4.1.1. Characteristics of MSM/TGW Participants of the Client Surveys
4.1.2. Outcomes among HCWs to Assess the Intervention Efficacy
4.2. Intervention Feasibility and Acceptability
5. Discussion
6. Limitations and Strengths
7. Lessons Learnt and Implications
8. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Measures | Number of Items | Items or Content | Range of Responses and Scores or % for Binary Items | PCA Findings (Components Extracted) |
---|---|---|---|---|
Primary Outcome Measures | ||||
Positive attitudes (score) | 5 |
| 1 for “strongly disagree” to 5 for “strongly agree” Score range: 5–25) | Single component identified (Eigen value = 2.04) |
Comfort level in providing care to MSM/TGW, % | 2 |
| % of those who endorsed “agree” or “strongly agree” | |
| % of those who endorsed “disagree” or “strongly disagree” | |||
Understanding healthcare challenges faced by MSM/TGW people, % | 2 |
| % of those who endorsed “agree” or “strongly agree” | |
| % of those who endorsed “agree” or “strongly agree” | |||
Secondary Outcome Measures | ||||
Support for non-discriminatory policies (score) | 3 |
| 1 for “strongly disagree” to 5 for “strongly agree” (Score range: 3–15) | Single component identified (Eigen value = 1.53) |
Perceived clinical efficacy (score) | 3 |
| 1 for “strongly disagree” to 5 for “strongly agree” (Score range: 3–15) | Single component extracted (Eigenvalue = 1.76) |
Understanding the importance of sexual orientation and gender identity (SOGI) questions in clinical history taking (score) | 3 |
| 1 for “strongly disagree” to 5 for “strongly agree” (Score range: 3–15) | Single component extracted (Eigenvalue = 2.11) |
Outcome Measures | Number of Items | Items or Content | Range of Responses and Scores or % for Binary Items | PCA Findings (Components Extracted) |
---|---|---|---|---|
Overall satisfaction with hospital services | 1 | When you used the services of [public hospital] as a day patient or inpatient, in general, were you satisfied that your needs as a man who has sex with men or as a transgender person were met? | % of those reported “Yes” | |
Discrimination experiences related to sexual orientation and gender identity (score) | 6 [47,48] | In general, when getting medical care from [public hospitals], how often has the following occurred because the doctor or other hospital staff knew or suspected you are a man who has sex with men or a transgender woman?
| 0 for “never”, 1 for “sometimes” and 2 for “always” (Score range: 0 to 12) | Single component identified (Eigen value = 2.98) |
Positive interactions with HCWs (score) | 4 [49] | Now, we are going to read about a series of statements related to your experiences while accessing healthcare services. You can “agree” or “disagree” with the following statements:
| 0 for “disagree”, 1 for “neither agree nor disagree” and 2 for “agree” (Score range: 0 to 8) | Single component identified (Eigen value = 2.10) |
Variables | Grand Total N = 98 | Chennai & Thane | Chennai | Thane | |||
---|---|---|---|---|---|---|---|
Clinical Staff n = 56 | Non-Clinical Staff n = 42 | Clinical Staff n = 27 | Non-Clinical Staff n = 28 | Clinical Staff n = 29 | Non-Clinical Staff n = 14 | ||
N (%) or Mean (SD) | n (%) or Mean (SD) | n (%) or Mean (SD) | n (%) or Mean (SD) | n (%) or Mean (SD) | n (%) or Mean (SD) | n (%) or Mean (SD) | |
Age (years) | 40.5 (9.1) | 41.1 (10.3) | 39.6 (7.4) | 39.3 (9.7) | 39.5 (7.1) | 42.5 (10.6) | 39.2 (8.4) |
Gender | |||||||
Man | 40 (40.8) | 17 (30.4) | 23 (54.8) | 9 (33.3) | 14 (50.0) | 8 (27.6) | 9 (64.3) |
Woman a | 58 (59.2) | 39 (69.6) | 19 (45.2) | 18 (66.7) | 14 (50.0) | 21 (72.4) | 5 (35.7) |
Years of practice in the healthcare field, Mean (SD) | 13.7 (9.0) | 16.5 (9.4) | 9.83 (7.0) | 16.3 (11.9) | 10.6 (7.4) | 18.0 (9.0) | 8.3 (5.9) |
Number of sexual or gender minority clients personally seen at the clinic/department in the past 3 months, Mean (SD) | 6.4 (16.3) | 7.9 (17.9) | 18.7 (25.0) | 0.66 (1.2) | |||
HCWs having peers, friends or colleagues who identify as gay, bisexual, MSM or transgender person (Yes) | 11 (11.2) | 6 (10.7) | 5 (11.9) | 6 (24.0) | 4 (14.3) | 1 (3.4) | |
Received any focused training on LGBT patient care (Yes) | 5 (5.1) | 0 (0) | 5 (11.9) | 0 (0) | 3 (20.0) | 0 (0) | 2 (14.2) |
Characteristics | Pre-Intervention (N = 200) | Post-Intervention (N = 200) | p Value |
---|---|---|---|
Age (years), Mean (SD) | 28.9 (6.42) | 29.1 (5.87) | 0.77 |
Monthly income, Mean (SD) | 10,778 (6512) | 11,100 (7638) | 0.65 |
Engagement in sex work (past 3 months), n (%) | 116 (58.0) | 89 (44.5) | <0.01 |
Health insurance, n (%) | |||
No insurance | 176 (88.0) | 178 (89.0) | 0.96 |
Government’s health insurance | 20 (10.0) | 18 (9.0) | |
Private health insurance | 4 (2.0) | 4 (2.0) | |
On ART (a proxy for HIV-positive status), n (%) | 18 (9.0) | 13 (6.5) | 0.47 |
Outcomes | Scores or % at 3 Timepoints † (95% CI) | Pairwise Comparisons IRR (95% CI) | ||||
---|---|---|---|---|---|---|
Pre-Intervention (T0) (N = 98) | Post-Intervention (T1) (N = 77) | Follow-Up Assessment (T2) (N = 51) | T0 to T1 | T0 to T2 | T1 to T2 | |
Primary Outcomes | ||||||
Positive attitude towards MSM and TGW, score | 10.25 (9.39, 10.9) | 9.28 (8.30, 10.26) | 12.12 (11.23, 13.01) | 0.92 (0.81, 1.04) | 1.20 (1.07, 1.32) ** | 1.30 (1.13, 1.49) *** |
Comfort level in providing care to MSM and TGW, % | ||||||
| 78.5 (69.2, 87.8) | 96.9 (91.4, 100) | 85.6 (74.7, 96.5) | 1.23 (1.08, 1.41) ** | 1.09 (0.93, 1.26) | 0.88 (0.77, 1.01) |
| 47.3 (35.4, 59.2) | 49.7 (37.2, 62.2) | 38.3 (23.2, 53.3) | 1.05 (0.76, 1.44) | 0.80 (0.54, 1.22) | 0.77 (0.51, 1.15) |
Understanding healthcare challenges faced by MSM and TGW, % | ||||||
| 38.6 (27.7, 49.5) | 51.9 (39.6, 64.1) | 40.6 (24.1, 57.0) | 1.34 (1.004, 1.79) * | 1.05 (0.65, 1.68) | 0.78 (0.51, 1.20) |
| 70.3 (60.2, 80.4) | 71.3 (61.2, 81.4) | 67.6 (52.2, 83.0) | 1.01 (0.87, 1.18) | 0.96 (0.75, 1.23) | 0.95 (0.74, 1.20) |
Secondary outcomes | ||||||
Support for hospital policies for MSM and TGW, score | 6.63 (6.01, 7.25) | 7.13 (6.48, 7.77) | 6.99 (6.32, 7.66) | 1.08 (1.004, 1.15) * | 1.05 (0.98, 1.14) | 0.98 (0.87, 1.00) |
Importance of asking SOGI questions #, score | 8.23 (7.50, 8.95) | 9.62 (9.01, 10.23) | 9.35 (8.62, 10.08) | 1.17 (1.06, 1.29) ** | 1.13 (1.005, 1.29) * | 0.97 (0.88, 1.08) |
Perceived self-efficacy in providing clinical care #, score | 7.57 (6.84, 8.31) | 8.60 (7.95, 9.26) | 6.01 (5.54, 6.48) | 1.13 (1.01, 1.27) * | 0.79 (0.70, 0.90) *** | 0.70 (0.62, 0.78) *** |
Predictors | Overall Satisfaction with the Hospital Services (Yes) | Discrimination Experiences Related to Sexual Orientation or Gender Identity (Score) | Positive Experiences with HCWs (Score) | ||||||
---|---|---|---|---|---|---|---|---|---|
IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | |||||||
MSM/TGW (N = 200) | MSM (n = 100) | TGW (n = 100) | MSM/TGW (N = 200) | MSM (n = 100) | TGW (n = 100) | MSM/TGW (N = 200) | MSM (n = 100) | TGW (n = 100) | |
Post-intervention (Ref. Pre-intervention) | 1.08 (0.98–1.20) | 1.14 * (1.00–1.30) | 0.95 (0.76–1.17) | 1.20 (0.98–1.47) | 0.91 (0.66–1.25) | 1.22 (0.95–1.58) | 1.06 * (1.00–1.13) | 0.93 (0.87–1.00) | 1.15 * (1.03–1.28) |
Discrimination experiences related to sexual orientation or gender identity (score) | 0.93 *** (0.91–0.95) | 0.94 ** (0.91–0.98) | 0.91 *** (0.88–0.93) | 0.97 *** (0.96–0.98) | 0.96 *** (0.94–0.97) | 0.99 (0.97–1.01) | |||
Positive experiences with HCWs (score) | 1.00 (0.98–1.03) | 0.99 (0.96–1.03) | 1.03 (0.99–1.07) | 0.88 *** (0.85–0.92) | 0.81 *** (0.76–0.85) | 0.95 (0.89–1.00) | |||
Insurance (Yes) | 1.06 (0.97–1.17) | 1.02 (0.93–1.12) | 0.74 * (0.59–0.94) | 0.80 (0.63–1.03) | 0.67 (0.33–1.35) | 0.89 * (0.82–0.98) | 0.96 (0.64–1.45) | 0.89 * (0.82–0.98) | |
Age (years/10) | 1.08 * (1.01–1.15) | 1.08 * (1.00–1.15) | 1.11 (0.95–1.31) | 1.12 (0.96–1.31) | 1.18 (0.93–1.51) | 1.20 (0.95–1.52) | 0.99 (0.95–1.04) | 1.01 (0.97–1.06) | 0.97 (0.87–1.07) |
Income (INR/10000) | 1.04 (0.98–1.09) | 1.03 (0.97–1.11) | 1.07 (0.98–1.17) | 0.81 ** (0.70–0.95) | 0.76 * (0.60–0.97) | 0.78 (0.61–1.00) | 1.02 (0.99–1.05) | 0.98 (0.95–1.02) | 1.16 *** (1.07–1.27) |
Engagement in sex work (Yes) | 1.00 (0.92–1.10) | 1.06 (0.94–1.19) | 0.92 (0.80–1.05) | 1.01 (0.81, 1.25) | 1.29 (0.94, 1.78) | 0.75 (0.57, 0.99) * | 0.94 * (0.88–0.99) | 0.97 (0.90–1.03) | 0.93 (0.83–1.05) |
On ART (Yes) [Proxy for HIV-positive status] | 1.14 ** (1.04–1.26) | 1.06 (0.93–1.20) | 1.44 *** (1.18–1.77) | 0.74 (0.53–1.02) | 0.62 (0.38–1.03) | 0.87 (0.54–1.40) | 1.07 (0.98–1.17) | 0.98 (0.89–1.07) | 1.05 (0.83–1.34) |
Theme | Quotes |
---|---|
Usefulness of the workshop | “Learned a lot of terms we did not know. Interacting with them (community members) was useful.” (Doctor) “There is hardly any time to interact because there is so much work. But I understand that we should try to be respectful.” (Doctor) “Thanks for organising this kind of workshop. It shows how our institute is being progressive. However, the medical curriculum doesn’t talk about this yet.” (Doctor) “The sessions with the community were useful. We do think more interactions [with MSM and trans persons] are necessary.” (Counsellor) |
Need for resources | “We always try to be respectful, but there is less time [in the crowded outpatient department].” (Doctor) “There must be separate wards [for transgender people], but there are limited resources.” (Nurse) “Is there a [phone] number we can reach out to in case we want clarifications or help in dealing with a patient.” (Counsellor) |
Need for further learning | “This workshop is ok, but we should know the legalities of all these in more detail. How do we use the [preferred] gender terms when we go by the [names in the] hospital documents?”(Doctor) “We are professionals, so we treat patients and their problems. But more training will help to make the interactions better for them.” (Nurse) “Sometimes we do get cases of them (community members) where we feel we need more training.” (Psychiatrist) “There should be no difficulty during the hospitalisation of such patients. Which ward—male or female, or a separate ward for transgender people? We don’t know the solution. But other female or male [cisgender] patients in the ward feel awkward. What to do?” (Doctor) |
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Chakrapani, V.; Nair, S.; Subramaniam, S.; Ranade, K.; Mohan, B.; Nelson, R.; Sivaraman, S.T.; Shunmugam, M.; Kaur, J.; Rawat, S.; et al. Efficacy of a Multi-Level Pilot Intervention (“Harmony”) to Reduce Discrimination Faced by Men Who Have Sex with Men and Transgender Women in Public Hospitals in India: Findings from a Pre- and Post-Test Quasi-Experimental Trial among Healthcare Workers. Venereology 2023, 2, 86-107. https://doi.org/10.3390/venereology2030009
Chakrapani V, Nair S, Subramaniam S, Ranade K, Mohan B, Nelson R, Sivaraman ST, Shunmugam M, Kaur J, Rawat S, et al. Efficacy of a Multi-Level Pilot Intervention (“Harmony”) to Reduce Discrimination Faced by Men Who Have Sex with Men and Transgender Women in Public Hospitals in India: Findings from a Pre- and Post-Test Quasi-Experimental Trial among Healthcare Workers. Venereology. 2023; 2(3):86-107. https://doi.org/10.3390/venereology2030009
Chicago/Turabian StyleChakrapani, Venkatesan, Smitha Nair, Sudharshini Subramaniam, Ketki Ranade, Biji Mohan, Ruban Nelson, Sajeesh T. Sivaraman, Murali Shunmugam, Jasvir Kaur, Shruta Rawat, and et al. 2023. "Efficacy of a Multi-Level Pilot Intervention (“Harmony”) to Reduce Discrimination Faced by Men Who Have Sex with Men and Transgender Women in Public Hospitals in India: Findings from a Pre- and Post-Test Quasi-Experimental Trial among Healthcare Workers" Venereology 2, no. 3: 86-107. https://doi.org/10.3390/venereology2030009