October 2017 TOWARDS STIGMA-FREE HEALTH FACILITIES IN GHANA: Guide for Trainers OCTOBER 2017 This guide was prepared by Chipo Chiiya, Mutale Chonta, and Sue Clay (3C Regional Consultants) and Dr. Laura Nyblade and Christin Stewart (RTI International) of Health Policy Plus. Suggested citation: Clay, S., M. Chonta, C. Chiiya, C. Stewart, and L. Nyblade. 2017. Towards Stigma-Free Health Facilities in Ghana: Guide for Trainers. Washington, DC: Palladium, Health Policy Plus. ISBN: 978-1-59560-185-8 Health Policy Plus (HP+) is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-15-00051, beginning August 28, 2015. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). HP+ is implemented by Palladium, in collaboration with Avenir Health, Futures Group Global Outreach, Plan International USA, Population Reference Bureau, RTI International, ThinkWell, and the White Ribbon Alliance for Safe Motherhood. This report was produced for review by the U.S. Agency for International Development. It was prepared by HP+. The information provided in this report is not official U.S. Government information and does not necessarily reflect the views or positions of the U.S. Agency for International Development or the U.S. Government. Towards Stigma-Free Health Facilities in Ghana: Guide for Trainers CONTENTS Acknowledgments ................................................................................................................ ii Abbreviations ....................................................................................................................... iii Introduction .......................................................................................................................... 1 Training Tips ......................................................................................................................... 6 Opening Activities ............................................................................................................... 12 Naming Stigma Through Pictures (Core)............................................................................ 15 Stigma Reflection (Core) .................................................................................................... 18 Confidentiality and Stigma (Core) ...................................................................................... 21 Analyzing Stigma in Health Facilities (Core) ...................................................................... 26 Fears about Nonsexual Transmission/Quantity, Quality, and Route of Entry (QQR) (Core) ......................................................................................................................... 31 Overcoming Fear with Standard Precautions (Core) ......................................................... 35 Breaking the Sex Ice (Core)................................................................................................ 39 Gender and Sexual Diversity (Core) ................................................................................... 44 How Stigma Impacts Human Rights (Core) ........................................................................ 51 Panel Discussion with People Living with HIV (Core) ......................................................... 56 Challenge the Stigma—Be the Change! (Core) ................................................................... 58 Writing a Code of Practice and Action Plan (Core) ............................................................. 61 Appendix 1: Picture Tools ................................................................................................... 63 Appendix 2: Post-Training Debrief...................................................................................... 79 Appendix 3: Non-Core Activities ......................................................................................... 80 Effects of Stigma on the HIV Epidemic (Non-Core) ............................................................ 80 The Blame Game: Things People Say (Non-Core) .............................................................. 84 i Towards Stigma-Free Health Facilities in Ghana: Guide for Trainers ACKNOWLEDGMENTS This guide was produced by the Health Policy Plus (HP+) project—funded by the U.S. Agency for International Development (USAID) and U.S. President’s Emergency Fund for AIDS Relief (PEPFAR)—in collaboration with the Ghana AIDS Commission, the National AIDS Control Programme, and the Educational Assessment Research Center (EARC). The HP+ technical team included Dr. Laura Nyblade and Christin Stewart (RTI International), Andrew Zapfel and Sara Bowsky (Palladium), and Ms. Emma Gyamera and Dr. Nii Addo (EARC). This work was made possible by the generous support of USAID and PEPFAR through HP+ and the Global Fund to Fight AIDS, Tuberculosis and Malaria through the Ghana AIDS Commission. Within these organizations we recognize the leadership and support for this work of Ms. Suzie Jacinthe, Dr. Nabil Alsoufi, and Nadia Tagoe (USAID) and Ms. Sara Faroni and Pryscilla Bolander (Global Fund). We are grateful to the staff at the participating facilities as well as the data collectors who helped gather the baseline assessment data that helped shape this guide. We are especially grateful to all those who gave their time and personal insights as respondents to the survey, including health facility staff and clients living with HIV. Finally, we extend our gratitude to all those who contributed by taking part in the participatory dissemination and curriculum development workshops. This guide adapts and builds on the following key documents: Health Policy Project. 2015. A Facilitator’s Guide for Public Health and HIV Programs: Gender & Sexual Diversity Training. Washington, DC: Futures Group, Health Policy Project. Kidd, R. et al. 2007. Understanding and Challenging HIV Stigma: Toolkit for Action. Academy for Educational Development, International Center for Research on Women, and International HIV/AIDS Alliance. Kidd, R., S. Clay, M. Stockton, and L. Nyblade. 2015. Facilitator’s Training Guide for a Stigma-Free Health Facility. Washington, DC: Futures Group, Health Policy Project. ii Towards Stigma-Free Health Facilities in Ghana: Guide for Trainers ABBREVIATIONS AIDS acquired immune deficiency syndrome ART antiretroviral therapy ARVs antiretroviral drugs HIV human immunodeficiency virus HP+ Health Policy Plus PEP post-exposure prophylaxis STI sexually transmitted infection QQR quantity, quality, route of entry USAID U.S. Agency for International Development iii Towards Stigma-Free Health Facilities in Ghana: Guide for Trainers INTRODUCTION In Ghana, HP+, in partnership with the Ghana AIDS Commission, the National AIDS Control Programme, and the Educational Assessment Research Center, is supporting Ghana’s national HIV response through adapting and testing a comprehensive package for stigma and discrimination reduction in health facilities for high-prevalence countries.1 This process entails conducting baseline assessments of stigma and discrimination in 20 health facilities in five regions to provide the evidence to design tailored stigma and discrimination- reduction interventions that are being piloted in five facilities, one in each of five focal regions. An endline assessment will be carried out to demonstrate the impact of the interventions conducted in the facilities. Participatory training of staff and capacity building of a group of trainers will be a part of the facility interventions. This activity is being funded by USAID and PEPFAR, together with the Global Fund to Fight AIDS, Tuberculosis and Malaria. This guide has been developed for the training component of the intervention and was used as the primary resource at the five-day Training of Trainers Workshop for Stigma Reduction in Health Facilities in September 2017. The trainers then went on to deliver stigma and discrimination-reduction training to health facility staff using a two-day training agenda that they developed. This guide contains all the exercises that may be used in the health facility training as it is rolled out in the five pilot health facilities.Before offering stigma and discrimination-reduction workshops, facilitators should read and understand this guide and use it to prepare teaching materials, including case studies. The contents are intended to provide guidance and do not prevent facilitators from using their own creativity to prepare additional teaching materials as needed. Users of This Guide This guide was prepared for use by health facility staff who, through participation in the training of trainers described above, have the capacity to facilitate stigma and discrimination-reduction workshops for their fellow staff members. Overall Goal The overall goal of this guide is to eradicate stigma and discrimination in health facilities through the provision of participatory capacity development for all levels of facility staff. Steps in Changing Attitudes The training program is focused on action – not just understanding stigma and discrimination and how they negatively impact health services, but concrete action to stop stigma and discrimination. Each exercise is intended to ‘trigger’ participants to change their attitudes, adopt new behaviors, and take action to address stigma and discrimination in their health facilities. Steps for change (1) We realize that WE are stigmatizing: stigma does not just occur, but WE are