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

www.aids2014.org

Background

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.)

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)

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)

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)

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

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?

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)

www.aids2014.org

Theoretical Approach

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

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)

www.aids2014.org

Objectives1. 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

www.aids2014.org

Methods

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

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

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)

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)

www.aids2014.org

Results

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

www.aids2014.org

Table 2. Indicators of Economic InsecurityIs 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%)

www.aids2014.org

Table 4. Univariate and multivariate logistic modeling of factors associated with

perceived povertyVariables 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*

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**

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)

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)

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)

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

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

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

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

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

www.aids2014.org

Research ImplicationsMethodological

• 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

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