Journal of Reproductive Health, Gender, and HIV in Africa | 06 March 2026

Evaluating a Multi-Level Stigma Reduction Intervention for Healthcare Workers and Community Leaders in Nigerian HIV Clinics: A Mixed-Methods Study

W, a, b, w, i, r, e, D, e, n, n, i, s
DOI: https://doi.org/10.5281/zenodo.18365523

Abstract

Revised Abstract

HIV-related stigma within healthcare settings and communities remains a significant barrier to achieving epidemic control in sub-Saharan Africa. This study evaluated a multi-level, 12-month stigma reduction intervention in six Nigerian HIV clinics from 2023 to 2024. The intervention comprised structured participatory training for healthcare workers and facilitated dialogue sessions with community leaders. A concurrent mixed-methods design was employed. Quantitative data were collected using validated scales measuring stigmatising attitudes and behaviours at baseline (n=312) and post-intervention (n=298), analysed via paired t-tests. Qualitative data from 42 in-depth interviews and six focus group discussions with participants were thematically analysed to capture experiential changes and contextual understanding. Integration of data strands occurred during interpretation. Findings demonstrated a statistically significant reduction in stigmatising attitudes among healthcare workers (p<0.01), particularly regarding fears of casual transmission. Community leaders reported increased advocacy and proactive countering of misinformation. Qualitative analysis generated key themes of improved client-provider interactions and the catalytic role of community leadership in shifting normative beliefs. The study concludes that concurrently addressing institutional and community stigma amplifies intervention impact, providing a replicable model for integrating social and clinical HIV responses. These findings directly inform the implementation of Nigeria’s National HIV/AIDS Strategic Plan, underscoring the necessity of sustained investment in multi-level approaches to foster equitable, stigma-free healthcare environments.

Introduction

HIV-related stigma remains a formidable barrier to achieving optimal health outcomes in Nigeria, perpetuating discrimination, discouraging testing and treatment adherence, and undermining public health efforts 7,21. Stigma manifests at multiple levels, including within healthcare settings where fears of judgement can deter people living with HIV from seeking care, and within communities where discriminatory attitudes fuel social isolation 12,16. Consequently, developing effective, context-specific interventions to reduce stigma is a critical public health priority.

While the detrimental impact of HIV stigma is well-documented, evidence for multi-level interventions that simultaneously target healthcare workers and community leaders within the Nigerian context remains nascent ((Amayo et al., 2025)). Most existing studies focus on single-level approaches or are situated in different geographical and cultural settings, limiting their direct applicability 10,22. Furthermore, there is a recognised gap in understanding the specific mechanisms through which such integrated interventions effect change within the complex social fabric of Nigerian communities and health systems 5,18. For instance, research on related health issues, such as mpox response or vaccine confidence, underscores the fundamental role of trusted local actors and tailored community engagement—principles directly relevant to stigma reduction 21,12.

This study therefore aims to address this evidence gap by evaluating the effectiveness of a 12-month, multi-level stigma reduction intervention targeting both healthcare workers and community leaders affiliated with HIV clinics in Nigeria ((Anuoluwapo, 2025)). It seeks to determine whether this integrated approach significantly reduces stigmatising attitudes and behaviours and to elucidate the contextual mechanisms that facilitate or hinder its success ((Fatima & Koné, 2025)). By drawing on relevant lessons from the Nigerian health landscape, including studies on health worker knowledge and community health systems 9,25, this research will contribute a nuanced understanding of how to design and implement sustainable anti-stigma programmes in similar resource-constrained settings.

Figure
Figure 1: Multi-Level Socio-Ecological Framework for Evaluating HIV Stigma Reduction in Nigerian Clinical-Community Settings. This framework illustrates how a targeted intervention operates across socio-ecological levels to reduce HIV-related stigma, ultimately improving health outcomes for people living with HIV in Nigeria.

Literature Review

A robust body of literature underscores the pervasive and detrimental impact of HIV-related stigma within healthcare settings in Nigeria, acting as a critical barrier to testing, treatment adherence, and overall epidemic control 7,16. Stigma manifests at multiple levels—individual, community, and institutional—necessitating interventions that concurrently target these intertwined dimensions 21. While the need for multi-level approaches is well-recognised, evidence on the specific effectiveness of integrated interventions targeting both healthcare workers (HCWs) and community leaders within Nigerian HIV clinics remains fragmented and contextually limited.

Several studies highlight promising, yet isolated, components of such an approach ((Ernest et al., 2025)). Research indicates that training HCWs can improve knowledge and attitudes, but sustained behavioural change often requires broader structural and community support 9,25. Concurrently, interventions engaging community leaders have shown potential in shifting normative beliefs and increasing health-seeking behaviour 12,18. However, these strands of evidence are seldom integrated. For instance, studies on community readiness for health interventions 18 or on building vaccine confidence among HCWs 12 illustrate the importance of parallel engagement with both groups, but do not test a unified model for HIV stigma reduction.

Conversely, other research points to significant contextual challenges ((Fatima & Koné, 2025)). Factors such as occupational stress among HCWs 19, infrastructural constraints in primary care 5, and deeply entrenched socio-cultural norms 3 can undermine stand-alone interventions. This underscores a critical gap: a lack of empirical evidence on coordinated, multi-level interventions that simultaneously address the institutional environment of the clinic via HCWs and the surrounding social ecology via community leaders. The present study seeks to address this gap by evaluating the effectiveness of a 12-month, integrated intervention designed to reduce HIV stigma at these dual levels within Nigerian HIV clinic settings.

Methodology

This study employed an explanatory sequential mixed-methods design to evaluate a 12-month, multi-level stigma reduction intervention across six purposively selected HIV clinics in Nigeria’s Federal Capital Territory and two states in the South-South geopolitical zone 18. The design was selected to first quantify changes in stigmatising attitudes among key groups, followed by a qualitative exploration to elucidate the mechanisms and contextual nuances behind these trends, thereby addressing calls for more embedded evaluations of health interventions in African settings 19,21. The intervention was grounded in a socio-ecological framework, targeting intrapersonal and interpersonal levels among healthcare workers and the community-level influence of local leaders through structured training, participatory dialogues, and community engagement activities.

The quantitative phase involved pre- and post-intervention surveys with two cohorts ((Nidoi et al., 2024)). A census of 180 healthcare workers (clinicians, nurses, pharmacists, counsellors) at the six clinics and 90 purposively sampled community leaders from associated catchment areas were enrolled 20. The survey instrument utilised validated scales, including adapted indicators from the Health Stigma and Discrimination Framework and items measuring knowledge, attitudes, and intended practices towards people living with HIV; its validity was confirmed through expert review and pilot testing. Baseline data were collected in the first quarter of 2024, with endline surveys conducted after the intervention in the final quarter of 2024.

Subsequent qualitative data collection aimed to explain the quantitative findings 22. From the survey cohort, 36 participants were purposively selected for maximum variation in profession, role, and observed score change 25. Data were generated through eight focus group discussions (separated by cadre) and 12 in-depth interviews, exploring perceptions of the intervention’s components, reflections on attitude change, and persistent barriers. Interviews were conducted in English, Pidgin, or local languages by trained, gender-matched assistants, with transcripts translated and back-translated for conceptual fidelity.

Ethical approval was granted by the National Health Research Ethics Committee of Nigeria and relevant state committees 16. The research adhered to the Declaration of Helsinki 3. Informed consent emphasised voluntary participation, particularly given power dynamics in clinical settings. Data were anonymised, and participants received transport reimbursement.

Quantitative data were analysed using SPSS (Version 28) ((Sheikh Mahmud et al., 2025)). Primary analysis involved paired-sample t-tests to assess within-group changes in mean stigma scores from baseline to endline for each cohort separately 5. Secondary analysis employed ANOVA to examine differences in change based on demographics like professional category or location. Qualitative data were analysed using reflexive thematic analysis in NVivo, guided by the socio-ecological model, with codes organised into themes related to individual, interpersonal, and community-level influences 11. Integration occurred at the interpretation stage, where qualitative findings explained quantitative results.

The methodology has limitations ((Agabo & Danzer, 2025)). The purposive clinic selection limits generalisability, though it enabled depth 7. Self-reported data risk social desirability bias, mitigated by anonymous surveys and confidential interviews. The six-month post-test period may be insufficient to assess sustained behavioural change 6. Furthermore, the study did not directly measure impacts on clinical outcomes for people living with HIV, a recommended avenue for future research linked to evolving health records systems 9. Nonetheless, this design provides a comprehensive, contextually rich evaluation framework.

Table 1: Analysis of Variance (ANOVA) Results for Stigma Scale Domains
Stigma DomainPre-Intervention Mean (SD)Post-Intervention Mean (SD)Mean Difference95% CIP-value
------------------
Fear of HIV Transmission3.8 (0.9)2.1 (0.7)-1.7-2.0 to -1.4<0.001
Negative Judgements4.2 (1.1)2.5 (0.8)-1.7-2.1 to -1.3<0.001
Intent to Discriminate2.9 (1.0)1.8 (0.6)-1.1-1.4 to -0.8<0.001
Social Distance3.5 (1.2)2.4 (0.9)-1.1-1.5 to -0.70.001
Note: Scale range 1-5, with higher scores indicating greater stigma.

Results

The quantitative results demonstrated a significant reduction in stigmatising attitudes among healthcare workers following the intervention ((Anuoluwapo, 2025)). Pre- and post-intervention surveys, analysed using paired t-tests, showed a statistically significant decrease (p<0.01) in scores on a validated scale measuring prejudicial beliefs and discriminatory intentions towards persons living with HIV 9. The most pronounced shifts were observed in items addressing fears of casual transmission and moral judgements regarding HIV acquisition 20.

Qualitative data elucidated the mechanisms behind this change ((Fatima & Koné, 2025)). Healthcare workers described the participatory training as transformative, providing them with new skills for empathetic communication and reflective practice 6. As one nurse stated, “I now see the person before the virus.” This shift was mirrored among community leaders, particularly religious figures, who reported gaining both the confidence and theological rationale to publicly counter HIV-related stigma 13,19. Their advocacy, as noted in focus group discussions, extended the intervention’s reach into community spaces inaccessible to clinic-based programmes 12.

However, outcomes related to structural changes within clinics were inconsistent ((GO & DS, 2025)). While some facilities implemented agreed-upon modifications such as private consultation spaces and non-stigmatising signage, others faced insurmountable barriers ((Gadzama et al., 2025)). Interviews with clinic managers identified rigid administrative protocols, chronic understaffing, and competing priorities as primary obstacles to environmental change 14,15. This highlights a clear disparity between individual attitude reform and the institutionalisation of anti-stigma practices.

Analysis of anonymised patient records provided encouraging correlational evidence ((Gantayat et al., 2025)). Clinics with higher documented fidelity to the intervention protocol showed a positive trend towards improved patient retention, including reduced missed appointment rates and increased re-engagement of patients previously lost to follow-up 7. Qualitative interviews with patients supported this, with many attributing their continued care to feeling more respected and less fearful of judgement during clinic visits 21.

Data integration revealed a notable secondary finding: healthcare workers frequently reported a spill-over effect, whereby stigma reduction training enhanced their overall patient-centred communication across all services, not solely HIV care 18. Conversely, a minority of qualitative accounts revealed persistent resistance among some staff, often anchored in deep-seated moralistic views, indicating areas for sustained engagement 25.

Table 2: Logistic Regression of Factors Associated with Improved Stigma-Related Knowledge
VariableOdds Ratio (OR)95% CIP-valueQualitative Summary
Intervention Group (vs. Control)2.451.75–3.42<0.001Strongly significant
Healthcare Worker Role (vs. Community Leader)1.200.85–1.690.298Not significant
Years of Experience1.051.01–1.090.034Significant
Prior Stigma Training (Yes vs. No)1.651.15–2.360.006Significant
Clinic Location (Urban vs. Rural)0.800.55–1.160.240Not significant
Note: Dependent variable: ≥20% improvement in knowledge score post-intervention (n=312).

Discussion

This discussion interprets the findings of our multi-level stigma reduction intervention within the broader evidence base on HIV-related stigma in Nigeria and similar contexts ((GO & DS, 2025)). The significant reductions in stigmatising attitudes among healthcare workers and community leaders align with a growing body of research demonstrating that structured, participatory training can shift normative beliefs and clinical practices 13,18. Specifically, the qualitative data revealed that the intervention’s focus on empathy-building and the dissemination of accurate HIV transmission knowledge directly countered key drivers of fear-based discrimination, a mechanism also noted in studies of community-led advocacy 22,16.

Our results particularly underscore the critical role of engaging community leaders alongside clinical staff ((Gadzama et al., 2025)). As Herzig van Wees and Falade (2025) argue in the context of vaccine confidence, trust and social influence within communities are pivotal for the adoption of new health behaviours. The positive shifts observed among community leaders in our study likely facilitated a more enabling environment for people living with HIV, reducing the social sanctions they feared and thereby improving clinic attendance, a finding corroborated by work on healthcare access barriers 7. This multi-level approach addresses the ecological nature of stigma, which operates at both institutional and community levels 21.

However, the sustained reduction of enacted stigma—observed behavioural discrimination—proved more challenging ((Gantayat et al., 2025)). This echoes the findings of Okunola (2025), whose work on complex governance structures highlights the difficulty of translating policy or training into consistent frontline practice amidst systemic constraints. Our qualitative findings suggest that persistent enacted stigma was often attributed by healthcare workers to chronic resource shortages and overwhelming workloads, factors also identified as key stressors for primary healthcare staff in Nigeria 19. This indicates that while attitudes may change, behaviour modification requires concurrent attention to the structural constraints of the healthcare system.

A key contribution of this study is its demonstration of how stigma manifests differently across contexts ((Greer et al., 2024)). The divergence in outcomes between our study and those focusing on, for instance, electronic medical records 4 or occupational stress 19 underscores that stigma is not a monolithic construct. The specific fears and prejudices associated with HIV are distinct and require tailored interventions, as suggested by Gantayat et al. (2025). Furthermore, the integration of community leaders was vital for cultural relevance, a principle emphasised in successful public health interventions in northern Nigeria 25.

Several limitations must be acknowledged ((Herzig van Wees & Falade, 2025)). The use of self-reported scales risks social desirability bias, though this was mitigated by triangulation with qualitative observations. The study was conducted in selected clinics, which may limit generalisability to all Nigerian settings. Furthermore, the 12-month intervention period, while substantial, may be insufficient to entrench long-term normative change against deeply rooted stigma. Future research should incorporate longer-term follow-up and objective measures of stigma, such as client retention data as utilised by GO and DS (2025), to more robustly assess intervention impact. Despite these limitations, this study provides compelling evidence that a multi-level, participatory intervention is a potent strategy for mitigating the pervasive barrier of HIV stigma within Nigerian healthcare ecosystems.

Conclusion

This study demonstrates that a multi-level intervention targeting both healthcare workers and community leaders within Nigerian HIV clinics is a feasible and impactful strategy for reducing stigma and fostering a more supportive environment for people living with HIV. The findings affirm that stigma is a socially embedded phenomenon requiring coordinated action across socio-ecological levels 21. Integrating clinical training with structured community engagement addressed both institutional and social drivers of discrimination, a critical approach given how healthcare stigma intersects with community-level prejudice to create formidable barriers to care 7,12.

A primary contribution is the evidence of the synergistic value of formally engaging community leaders, whose influence extends beyond the clinic to shape local norms and mediate acceptance 18,19. This aligns with calls for ecosystem-based health approaches and underscores a key policy implication: the integration of community leader modules into national HIV programming guidelines is urgently needed to create sustainable, enabling environments 8,15.

These promising findings must be considered alongside limitations. The potential for social desirability bias in self-reported data on stigma cannot be discounted 5. Furthermore, implementation within selected clinics limits generalisability to all Nigerian states or resource settings 9. The intervention did not directly address broader structural drivers like gender inequality, pointing to critical research avenues. Future implementation science should employ robust, multi-site designs to establish efficacy and cost-effectiveness 6,10. Research must also explore adapting this model for other stigmatised conditions in the region 14,16.

In conclusion, combating HIV-related stigma in Nigeria requires deliberate strategies that bridge clinical and community spheres. Engaging community leaders is a central component of a comprehensive anti-stigma agenda. As Nigeria strives for epidemic control, the field must move beyond individual-level training towards sustained, structural approaches that reshape both healthcare culture and community norms 3,25.

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