Date of Graduation

5-2024

Document Type

Dissertation

Degree Name

Doctor of Philosophy in Health, Sport and Exercise Science (PhD)

Degree Level

Graduate

Department

Health, Human Performance and Recreation

Advisor/Mentor

Davis, Robert E.

Committee Member

Buttram, Mance E.

Second Committee Member

Dobbs, Page D.

Third Committee Member

Hirshfield, Sabina

Keywords

Heterosexism; HIV; HIV stigma; Medical education; Medical students; Racism

Abstract

Background: Intersecting and related forms of stigma, including HIV-related stigma, racism, and heterosexism, disproportionately impact both communities vulnerable to acquiring HIV and people living with HIV (PLHIV), ultimately impacting more distal outcomes related to HIV prevention, treatment, and epidemiological patterns in the United States (US). The Southern US is the region most impacted by new HIV diagnoses, mainly among Black men who have sex with men (MSM). However, there is a paucity of research on medical students, specifically those in the Southern US, regarding stigmatizing attitudes they may hold towards PLHIV, and how these associate with racism and heterosexism. This research has conceptualized medical students as both future physicians and as representing the institutional level. It aimed to measure stigmatizing attitudes, racism, heterosexism, HIV-related knowledge, and feelings towards people with intersectional identities most impacted by HIV, such as Black MSM. Methods: A cross-sectional, non-probability sampling approach was utilized for two online survey-based studies between January and March 2024. In study 1, a newly created 21-item HIV Knowledge measure, rated for content validity by experts (n = 3), was tested with a sample of 128 medical students from Arkansas, Florida, and South Carolina. Sociodemographic information, measures of HIV stigma, racism and heterosexism were collected. Study 2 focused on the construction and validation of the 14-item Intersectional Identities Feeling Thermometer Scale (IIFTS) using an exploratory principal components analysis. Results: Study 1 found that the HIV Knowledge measure displayed high content and construct validity, based on raters’ scores; higher scores associated positively with factors such as medical school grade. HIV knowledge scores displayed an expected negative significant association with HIV stigma. Heterosexism displayed the strongest relationship with HIV stigma, followed by racism. Factors such as high religiosity and Republican affiliation associated with both heterosexism and HIV stigma; factors such as gender, sexuality and race did not impact HIV stigma scores. HIV knowledge did not moderate the effects of either heterosexism or racism on HIV stigma. Study 2 found strong evidence for the presence of an Intersectionality subscale, containing 12 items, and weaker evidence for a Race subscale containing 2 items. Based on associations with other measures, the Intersectionality subscale captured a novel theoretical dimension: intersectional feeling bias, a form of generalized bias directed towards people with intersectional identities by medical students. Conclusion: The implications of these studies are multifold: medical students in the Southern US require exposure to updated HIV prevention, treatment, and epidemiologic knowledge; however, this alone is insufficient. They also require cultural competence training aimed at understanding and reducing the impacts of HIV stigma, heterosexism, and racism. In addition to attitudes, feelings comprised a core component of bias. Measures such as the IIFTS can be used to create awareness and clarify these feelings and can be used to track progress as students are exposed to stigma reduction interventions. Taken together, these findings provide compelling evidence for a need for institutional-level improvement to reduce HIV stigma, racism, and heterosexism among medical students in the Southern US.

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