Tessa Oraro - Academia.edu (original) (raw)
Papers by Tessa Oraro
Journal of the International Association of Providers of AIDS Care, May 17, 2022
The study focused on the representations, processes and effects of HIV stigma for healthcare work... more The study focused on the representations, processes and effects of HIV stigma for healthcare workers living with HIV within health facilities in Zambia. A descriptive study design was deployed. A total of 56 health workers and four service user participants responded to a structured questionnaire (n = 50) or took part in key informant interviews (n = 10) in five high HIV-prevalence provinces. Most participants did not disclose if they were living with HIV, except for four participants who responded to the questionnaire and were selected for being open about living with HIV. Semi-structured interviews were carried out with health workers in key government health facility positions. The questions were standardized and used a Likert scale. Descriptive statistical and thematic analyses were applied to the data. Results show that antiretroviral treatment (ART) has an impact on stigma reduction. Almost half the participants agreed that treatment is reducing levels of HIV stigma. However, fears of exposure of HIV status and labelling and judgemental attitudes persist. No comprehensive stigma reduction policies and guidelines in healthcare facilities were mentioned. Informal flexible systems to deliver HIV services were in place for health workers living with HIV, illustrating how stigma can be quietly navigated. Lack of confidentiality in healthcare facilities plays a role in fuelling disclosure issues and hampering access to testing and treatment. Stigma reduction training needs standardization. Further, codes of conduct for 'stigma-free healthcare settings' should be developed.
Journal of the International AIDS Society
Introduction: There is strong global commitment to eliminate HIV-related stigma, and work in this... more Introduction: There is strong global commitment to eliminate HIV-related stigma, and work in this area continues to evolve. Wide variation exists in frameworks and measures used. Methods: Building on the existing knowledge syntheses, we carried out a systematic review to identify frameworks and measures aiming to understand or assess internalized stigma, stigma and discrimination in healthcare, and in law and policy. The review addressed two questions: Which conceptual frameworks have been proposed to assess internalized stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? Which measures of these different types of stigma and discrimination have been proposed and what are their descriptive properties? Searches, completed on 6 May 2021, cover publications from 2008 onwards. The review is registered in PROSPERO (CRD42021249348), the protocol incorporated stakeholder input, and the data are available in the Systematic Review Data Repository. Results and discussion: Sixty-nine frameworks and 50 measures met the inclusion criteria. Critical appraisal figures and detailed evidence tables summarize these resources. We established a compendium of frameworks and a catalogue of measures of HIV-related stigma and discrimination. Seventeen frameworks and 10 measures addressed at least two of our focus domains, with least attention to stigma and discrimination in law and policy. The lack of common definitions and variability in scope and structure of HIV-related frameworks and measures creates challenges in understanding what is being addressed and measured, both in relation to stigma and efforts to mitigate or reduce its harmful effects. Having comparable data is essential for tracking change over time within and between interventions. Conclusions: This systematic review provides an evidence base of current understandings of HIV-related stigma and discrimination and how further conceptual clarification and increased adaptation of existing tools might help overcome challenges across the HIV care continuum. With people living with HIV at the centre, experts from different stakeholder groups could usefully collaborate to guide a more streamlined approach for the field. This can help to achieve global targets and understand, measure and help mitigate the impact of different types of HIV-related stigma on people’s health and quality of life. Keywords: human rights; key and vulnerable populations; law and policy; quality of life; stigma; structural drivers
Existing literature has largely prioritised an empirical approach towards health financing resear... more Existing literature has largely prioritised an empirical approach towards health financing research, neglecting the contextual considerations that shape the way in which decisions are made. This thesis sought to expand our insight into decision-making at institutional and household level in order to improve the applicability of health financing research to the real-world setting. Using an interpretivist approach, the thesis investigated the influence of priority-setting by key health financing actors on universal health coverage (UHC) strategy. It further analysed the empirical determinants of voluntary health insurance demand amongst different informal sector groups in Kenya and Cameroon. Finally, it sought to apply social analysis to understand the contextual conditions that shape decision-making at household and institutional level. This thesis identified a link between the perceived lack of a systematic and inclusive process for UHC in Kenya and divergence amongst key stakeholde...
BMC Health Services Research, Mar 6, 2020
Background: Competing priorities in health systems necessitate difficult choices on which health ... more Background: Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework. Methods: A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour. Results: Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection. Conclusions: This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.
Health Policy and Planning
Within the existing health financing literature, males are typically categorized as the household... more Within the existing health financing literature, males are typically categorized as the household's decision-makers. While this view accurately reflects many local sociocultural realities, approximately a quarter of sub-Saharan African households are now headed by females. In light of various efforts to expand health insurance coverage in the region, it is necessary to examine whether the factors influencing voluntary health insurance enrolment are analogous across male-and female-headed households. This study sought to identify the gendered determinants of voluntary enrolment into a church-run micro health insurance scheme. A cross-sectional survey of 550 households was carried out in Bui and Donga-Mantung Divisions of NorthWest Cameroon in May 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of gender on the associations between health insurance enrolment and the explanatory variables using logistic regression. This study found that voluntary health insurance demand was influenced by involvement in social networks regardless of gender. However, in line with entrenched household roles, men's understanding of potential household health risks ultimately facilitated their enrolment decisions, while economically empowered women prioritised their direct knowledge of household health risks. Men's demand for health insurance was correlated primarily with their education level (OR ¼ 2.238 [CI 1.228-2.552]), as well as with their socioeconomic status (OR ¼ 2.207 [CI 1.173-4.153]), age (OR ¼ 2.238 [CI 1.151-4.352]) and trust of the insurance provider (OR ¼ 4.770 [CI 2.407-9.453]). Conversely, women's enrolment decision was primarily associated with their income levels (OR ¼ 5.842 [CI 1.589-21.484]), as well as by the presence of children (OR ¼ 3.734 [CI 1.228-11.348]). The influence of wealth on health insurance enrolment highlights the need for policymakers to subsidize health insurance schemes for vulnerable population groups. Further, it is imperative to develop sensitization campaigns that are simple and digestible to facilitate understanding of health insurance across all target groups.
International Journal for Equity in Health
Background: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Sahar... more Background: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment. Methods: A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression. Results: The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand. Conclusions: Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factorssuch as time-availability and selfselection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.
Journal of the International Association of Providers of AIDS Care, May 17, 2022
The study focused on the representations, processes and effects of HIV stigma for healthcare work... more The study focused on the representations, processes and effects of HIV stigma for healthcare workers living with HIV within health facilities in Zambia. A descriptive study design was deployed. A total of 56 health workers and four service user participants responded to a structured questionnaire (n = 50) or took part in key informant interviews (n = 10) in five high HIV-prevalence provinces. Most participants did not disclose if they were living with HIV, except for four participants who responded to the questionnaire and were selected for being open about living with HIV. Semi-structured interviews were carried out with health workers in key government health facility positions. The questions were standardized and used a Likert scale. Descriptive statistical and thematic analyses were applied to the data. Results show that antiretroviral treatment (ART) has an impact on stigma reduction. Almost half the participants agreed that treatment is reducing levels of HIV stigma. However, fears of exposure of HIV status and labelling and judgemental attitudes persist. No comprehensive stigma reduction policies and guidelines in healthcare facilities were mentioned. Informal flexible systems to deliver HIV services were in place for health workers living with HIV, illustrating how stigma can be quietly navigated. Lack of confidentiality in healthcare facilities plays a role in fuelling disclosure issues and hampering access to testing and treatment. Stigma reduction training needs standardization. Further, codes of conduct for 'stigma-free healthcare settings' should be developed.
Journal of the International AIDS Society
Introduction: There is strong global commitment to eliminate HIV-related stigma, and work in this... more Introduction: There is strong global commitment to eliminate HIV-related stigma, and work in this area continues to evolve. Wide variation exists in frameworks and measures used. Methods: Building on the existing knowledge syntheses, we carried out a systematic review to identify frameworks and measures aiming to understand or assess internalized stigma, stigma and discrimination in healthcare, and in law and policy. The review addressed two questions: Which conceptual frameworks have been proposed to assess internalized stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? Which measures of these different types of stigma and discrimination have been proposed and what are their descriptive properties? Searches, completed on 6 May 2021, cover publications from 2008 onwards. The review is registered in PROSPERO (CRD42021249348), the protocol incorporated stakeholder input, and the data are available in the Systematic Review Data Repository. Results and discussion: Sixty-nine frameworks and 50 measures met the inclusion criteria. Critical appraisal figures and detailed evidence tables summarize these resources. We established a compendium of frameworks and a catalogue of measures of HIV-related stigma and discrimination. Seventeen frameworks and 10 measures addressed at least two of our focus domains, with least attention to stigma and discrimination in law and policy. The lack of common definitions and variability in scope and structure of HIV-related frameworks and measures creates challenges in understanding what is being addressed and measured, both in relation to stigma and efforts to mitigate or reduce its harmful effects. Having comparable data is essential for tracking change over time within and between interventions. Conclusions: This systematic review provides an evidence base of current understandings of HIV-related stigma and discrimination and how further conceptual clarification and increased adaptation of existing tools might help overcome challenges across the HIV care continuum. With people living with HIV at the centre, experts from different stakeholder groups could usefully collaborate to guide a more streamlined approach for the field. This can help to achieve global targets and understand, measure and help mitigate the impact of different types of HIV-related stigma on people’s health and quality of life. Keywords: human rights; key and vulnerable populations; law and policy; quality of life; stigma; structural drivers
Existing literature has largely prioritised an empirical approach towards health financing resear... more Existing literature has largely prioritised an empirical approach towards health financing research, neglecting the contextual considerations that shape the way in which decisions are made. This thesis sought to expand our insight into decision-making at institutional and household level in order to improve the applicability of health financing research to the real-world setting. Using an interpretivist approach, the thesis investigated the influence of priority-setting by key health financing actors on universal health coverage (UHC) strategy. It further analysed the empirical determinants of voluntary health insurance demand amongst different informal sector groups in Kenya and Cameroon. Finally, it sought to apply social analysis to understand the contextual conditions that shape decision-making at household and institutional level. This thesis identified a link between the perceived lack of a systematic and inclusive process for UHC in Kenya and divergence amongst key stakeholde...
BMC Health Services Research, Mar 6, 2020
Background: Competing priorities in health systems necessitate difficult choices on which health ... more Background: Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework. Methods: A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour. Results: Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection. Conclusions: This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.
Health Policy and Planning
Within the existing health financing literature, males are typically categorized as the household... more Within the existing health financing literature, males are typically categorized as the household's decision-makers. While this view accurately reflects many local sociocultural realities, approximately a quarter of sub-Saharan African households are now headed by females. In light of various efforts to expand health insurance coverage in the region, it is necessary to examine whether the factors influencing voluntary health insurance enrolment are analogous across male-and female-headed households. This study sought to identify the gendered determinants of voluntary enrolment into a church-run micro health insurance scheme. A cross-sectional survey of 550 households was carried out in Bui and Donga-Mantung Divisions of NorthWest Cameroon in May 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of gender on the associations between health insurance enrolment and the explanatory variables using logistic regression. This study found that voluntary health insurance demand was influenced by involvement in social networks regardless of gender. However, in line with entrenched household roles, men's understanding of potential household health risks ultimately facilitated their enrolment decisions, while economically empowered women prioritised their direct knowledge of household health risks. Men's demand for health insurance was correlated primarily with their education level (OR ¼ 2.238 [CI 1.228-2.552]), as well as with their socioeconomic status (OR ¼ 2.207 [CI 1.173-4.153]), age (OR ¼ 2.238 [CI 1.151-4.352]) and trust of the insurance provider (OR ¼ 4.770 [CI 2.407-9.453]). Conversely, women's enrolment decision was primarily associated with their income levels (OR ¼ 5.842 [CI 1.589-21.484]), as well as by the presence of children (OR ¼ 3.734 [CI 1.228-11.348]). The influence of wealth on health insurance enrolment highlights the need for policymakers to subsidize health insurance schemes for vulnerable population groups. Further, it is imperative to develop sensitization campaigns that are simple and digestible to facilitate understanding of health insurance across all target groups.
International Journal for Equity in Health
Background: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Sahar... more Background: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment. Methods: A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression. Results: The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand. Conclusions: Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factorssuch as time-availability and selfselection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.