Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes

BMC Public Health

Paula Holland²  Morten Skovdal⁴  David Bitira¹  Godfrey Siu⁵  Mala Ram³  Gitau Mburu² 

[1] Community Health Alliance Uganda, Kampala, Uganda;Division of Health Research, Lancaster University, Lancaster LA1 4YG, UK;International HIV/AIDS Alliance, 91-101 Davigdor Road, Hove BN3 1RE, UK;Department of Public Health, University of Copenhagen, Copenhagen, Denmark;Child Health and Development Centre, Makerere University, Kampala, Uganda

关键词: Africa;    Uganda;    Peer-support;    Disclosure;    Gender;    Men;    Masculinity;    Stigma;    HIV;    Intersectionality;   

Others  :  1126222
DOI  :  10.1186/1471-2458-14-1061

 received in 2014-04-02, accepted in 2014-10-03,  发布年份 2014

【 摘 要 】

Background

Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men’s health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men’s participation in and utilisation of HIV services in Uganda.

Methods

Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.

Results

Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men’s participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men’s risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a ‘sick role’; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men’s involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.

Conclusion

To improve men’s involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

【 授权许可】

   
2014 Mburu et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Earnshaw VA, Chaudoir SR: From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav 2009, 13(6):1160-1177.
• [2]Brown P: Naming and framing: the social construction of diagnosis and illness. J Health Soc Behav 1995, 36:34-52.
• [3]Parker R, Aggleton P: HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003, 57(1):13-24.
• [4]Diderichsen F, Evans T, Whitehead M: The Social Basis of Disparities in Health. New York: Oxford University Press; 2001.
• [5]Oxman-Martinez J, Hanley J: Health and Social Services for Canada's Multicultural Population: Challenges for equity. Ottawa: Heritage Canada; 2005.
• [6]Parker R: Stigma, prejudice and discrimination in global public health. Cad de Saude Publica 2012, 28(1):164-169.
• [7]Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S: A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? J Int AIDS Soc 2013, 16(3 Suppl 2):18734. doi: 10.7448/IAS.16.3.18734
• [8]Turan JM, Nyblade L: HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence. AIDS Behav 2013, 17(7):2528-2539.
• [9]Hankivsky A, Christoffersen A: Intersectionality and the determinants of health: a Canadian perspective. Crit Publ Health 2008, 18(3):271-283.
• [10]Hancock A: When multiplication doesn't equal quick addition: examining intersectionality as a research paradigm. Perspect Polit 2007, 5(1):63-79.
• [11]Monteiro SS, Villela WV, Soares PS: The interaction between axes of inequality in studies on discrimination, stigma and HIV/AIDS: contributions to the recent international literature. Glob Public Health 2013, 8(5):519-533.
• [12]Coburn D, Denny K, Mykhalouskiy E, McDonough P, Robertson A, Love R: Population health in Canada: a brief critique. Am J Public Health 2003, 93(3):392-396.
• [13]Hedwig TH: Living communities, health disparities and the everyday health experiences of Inupiaq migrants to Anchorage, Alaska. In Proceedings of the Fifth IPSSAS seminar on Living Communities, New Perspectives on Inuit Urban Life May 21-31 May, 2007; Copenhagen. Edited by Thuesen ST. Copenhagen: IPSSAS; 2007.
• [14]Wyrod R: Masculinity and the persistence of AIDS stigma. Cul Health Sex 2011, 13(4):443-456.
• [15]Watzlawik M: When a man thinks he has female traits–constructing femininity and masculinity: methodological potentials and limitations. Integr Psychol Behav Sc 2009, 43(2):126-137.
• [16]Levant RF, Wimer DJ: Masculinity constructs as protective buffers and risk factors for men's health. Am J Mens Health 2014, 8(2):110-120.
• [17]Addis ME, Mahalik JR: Men, masculinity, and the context of help seeking. Am Psychologist 2003, 58(1):5-14.
• [18]Clark JP: How to peer review a qualitative manuscript. In Peer Review in Health Sciences. 2nd edition. Edited by Godlee F, Jefferson T. London: BMJ Books; 2003:219-235.
• [19]Ministry of Health [Uganda], ICF International, Centers for Disease Control and Prevention, U.S. Agency for International Development, WHO: Uganda AIDS Indicator Survey 2011. Kamplala: Ministry of Health; 2012.
• [20]Uganda Bureau of Statistics: The State of Uganda Population Report. Kampala: Uganda Bureau of Statistics; 2012.
• [21]Wyrod R: Bwaise Town: masculinity in urban Uganda in the age of AIDS. PhD thesis. University of Chicago: Department of Sociology; 2007.
• [22]Wyrod R: Between women's rights and men's authority: masculinity and shifting discourses of gender difference in urban Uganda. Gend Soc 2008, 22(6):799-823.
• [23]Siu GE, Seeley J, Wight D: Dividuality, masculine respectability and reputation: how masculinity affects men's uptake of HIV treatment in rural eastern Uganda. Soc Sci Med 2013, 89:45-52.
• [24]Uganda Bureau of Statistics: The 2002 Uganda Population and Housing Census. Kampala: Uganda Bureau of Statistics; 2006.
• [25]Kim YM, Kalibala S, Neema S, Lukwago J, Weiss DC: Meaningful involvement of people living with HIV/AIDS in Uganda through linkages between network groups and health facilities: an evaluation study. Psychol Health Med 2012, 17(2):213-222.
• [26]Hodgson I, Nakiyemba A, Seeley J, Bitira D, Gitau-Mburu D: Only connect–the role of PLHIV group networks in increasing the effectiveness of Ugandan HIV services. AIDS care 2012, 24(11):1368-1374.
• [27]Mburu G, Ram M, Skovdal M, Bitira D, Hodgson I, Mwai GW, Stegling C, Seeley J: Resisting and challenging stigma in Uganda: the role of support groups of people living with HIV. J Int AIDS Soc 2013, 16(3 Suppl 2):18636.
• [28]Mburu G, Oxenham D, Hodgson I, Nakiyemba A, Seeley J, Bermejo A: Community systems strengthening for HIV care: experiences from Uganda. J Soc Work End Life Palliat Care 2013, 9(4):343-368.
• [29]Silverman D: Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction. 2nd edition. London: Sage Publications; 2001.
• [30]Courtenay WH: Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med 2000, 50(10):1385-1401.
• [31]Lee C, Owens RG: Issues for a psychology of men's health. J Health Psychol 2002, 7(3):209-217.
• [32]Harrison A, O'Sullivan LF, Hoffman S, Dolezal C, Morrell R: Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. J Urban Health 2006, 83(4):709-722.
• [33]Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson S: Masculinity as a barrier to men's use of HIV services in Zimbabwe. Global Health 2011, 7(1):13. BioMed Central Full Text
• [34]Siu GE, Wight D, Seeley J: How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda. J Int AIDS Soc 2012, 15(Suppl 1):1-9.
• [35]Byamugisha R, Tumwine JK, Semiyaga N, Tylleskär T: Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey. Reprod Health 2010, 7:12. BioMed Central Full Text
• [36]Lynam J, Cowley S: Understanding marginalization as a social determinant of health. Crit Publ Health 2007, 17(2):137-149.
• [37]O'Sullivan LF, Harrison A, Morrell R, Monroe-Wise A, Kubeka M: Gender dynamics in the primary sexual relationships of young rural South African women and men. Cult Health Sex 2006, 8(2):99-113.
• [38]Hoffman S, O'Sullivan LF, Harrison A, Dolezal C, Monroe-Wise A: HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa. Sex Transm Dis 2006, 33(1):52-58.
• [39]Skovdal M, Campbell C, Nyamukapa C, Gregson S: When masculinity interferes with women's treatment of HIV infection: a qualitative study about adherence to antiretroviral therapy in Zimbabwe. J Int AIDS Soc 2011, 14:29. BioMed Central Full Text
• [40]Mankowski ES, Maton KI: A community psychology of men and masculinity: historical and conceptual review. Am J Community Psychol 2010, 45(1–2):73-86.
• [41]Campbell C, Nhamo M, Scott K, Madanhire C, Nyamukapa C, Skovdal M, Gregson S: The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe. BMC Public Health 2013, 13:354. BioMed Central Full Text
• [42]Dworkin SL, Treves-Kagan S, Lippman SA: Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: a review of the global evidence. AIDS Behav 2013, 17(9):2845-2863.
• [43]Dageid W, Govender K, Gordon SF: Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention. Cult Health Sex 2012, 14(8):925-940.
• [44]Mfecane S: Narratives of HIV disclosure and masculinity in a South African village. Cult Health Sex 2012, 14(Suppl 1):S109-S121.
• [45]Earnshaw VA, Lang SM, Lippitt M, Jin H, Chaudoir SR: HIV Stigma and Physical Health Symptoms: Do Social Support, Adaptive Coping, and/or Identity Centrality Act as Resilience Resources? AIDS Behav 2014. doi:10.1007/s10461-014-0758-3
• [46]Takada S, Weiser SD, Kumbakumba E, Muzoora C, Martin JN, Hunt PW, Haberer JE, Kawuma A, Bangsberg DR, Tsai AC: The Dynamic Relationship Between Social Support and HIV-Related Stigma in Rural Uganda. Ann Behav Med 2014, 48(1):26-37.
• [47]Lynch I, Brouard PW, Visser MJ: Constructions of masculinity among a group of South African men living with HIV/AIDS: reflections on resistance and change. Cult Health Sex 2010, 12(1):15-27.
• [48]Verloo M: Multiple inequalities, intersectionality and the European Union. Eur J Wom Stud 2006, 13(3):211-228.