Fuzzy Modeling of the Enactment of Stigma by Healthcare Personnel Toward People Living with HIV in the Frame of Counterfactual Thinking: A Mixed-Method Approach

Abstract

Existing research on HIV stigma has not thoroughly studied the healthcare providers' (HCP) judgment toward people living with HIV (PLHIV). The goal of this article is to conceptualize formation of stigma within attitudes of HCP through their judgmental process by using the Fairness Theory. The study is also aimed to develop a model for cognitive patterns of HCPs' stigmatizing judgments toward PLHIV by applying fuzzy logic. We applied a mixed method in two phases, including qualitative method and fuzzy analytical modeling. A sample of 17 physicians and 9 nurses from 6 hospitals in Tehran were recruited and saturation was achieved after 21 in-depth interviews. Then, the answers of six HCPs were selected for defining the fuzzy sets and membership functions' curve. Six patterns of HCPs' judgments emerged that were used for the fuzzy analysis. These patterns are outcomes of assessment on various aspects of fairness of stigmatization that is impacted by HCPs' counterfactual prototypes. Moral codes, hospital and medical rules, and also constraints imposed from the workplace environment are the references of counterfactual prototypes that affected the HCPs' judgment. Health policy makers can design more effective HIV stigma reduction interventions based on the six patterns of HCPs' judgment.

Introduction

HIV studies often note that optimal effectiveness of HIV treatment programs requires a greater attention of healthcare providers (HCPs) as important sources of stigma toward people living with HIV (PLHIV).^1
–3 Limited research has been conducted on the HCP–patient relationship as a crucial parameter affecting discrimination, and how stigma forms within the HCPs' judgment processes. Such biases are important given that in several studies, PLHIV noted that they worry about receiving negative moral judgments from their physicians.⁴

Bias is created by individuals' perception of deviation from social norms, resulting in cognitive affirmations of unworthiness.⁵ Because HIV is associated with “deviant” behavior that is perceived as an individual's responsibility and viewed as contagious and a threat to the community, people with HIV are stigmatized.⁶ The discriminatory intention of an HCP toward PLHIV can be associated with behavioral memories involved in his/her judgment process to elicit the judgment categories/prototypes used in judgment formulation.⁷ Discrimination is affected by the justice perception, related in turn to the biases of those interacting with PLHIV. HCPs do not make the same judgment about the stigma toward the PLHIV when they experience a similar situation regarding PLHIV. Based on a counterfactual thinking theory, when an HCP visits an HIV-positive patient, she or he has behavioral expectations or standards about interacting with PLHIV (Alipour unpublished observations). In this situation, there are several factors that impose limitations such that the HCP's expectations are not actually accrued. Thus, HCPs experience a judgmental process about the fairness of their behavior toward PLHIV, affected by their cognitive maps that alter the real condition to expected condition by using the counterfactual scenarios/prototypes.^8,9 Applications of Fairness Theory to these counterfactual prototypes include the following¹⁰:

Would prototype: This prototype addresses some negative state of affairs that would have been better in a different situation.

Could prototype: Under powerful constraints on behavior, people or organizations sometimes do unpleasant things because they have no other choices. When extenuating circumstances exist, a person or a firm can be forgiven for inflicting harm.

Should prototype: Individuals and organizations are expected to behave ethically. We are interested in what they should do when faced with a possibly hurtful decision.

The judgmental process leading to development of discriminatory intentions is a complex phenomenon, understanding of which requires novel research methods and diverse measures of stigma.¹¹ Thus, we intend to shed new light on the HCPs' judgment process by using Fairness Theory and by modeling HCPs' discrimination-enacting processes via applying fuzzy logic—never previously used in HIV stigma research—to determine how to translate this underlying cognitive mechanism into fuzzy membership functions to model and measure stigma more accurately and identify diverse patterns of stigmatizing judgments toward PLHIV.

Methods

In this article, we used a two-phase mixed method: (1) qualitative data collection and (2) fuzzy analytical modeling.

Phase 1—qualitative method: in-depth interview with concerned subjects

Stigma is a complicated, socially defined, and contextual phenomenon.¹²

To study HCPs' attitudes and bias toward PLHIV, we took Grounded Theory as the basis of our analysis and used field notes and in-depth interviews for the data collection process. Coding and data categorization processes were developed based on a generic analytic cycle.¹³ Themes were identified using reference framework theory,^14,15 which was complemented by categorization and conceptualization based on Fairness Theory (Table 1).

Table 1.

Extracting Themes and Categories and Conceptualizing with Theory

Theme	Theory
Theme 1: HCPs judge PLHIV—even unconsciously. This affects physicians' decisions and behaviors. HCPs' judgment leads to their perception of fairness of the situation.	Fairness Theory
Theme 2: The fairness of the situation is an outcome of a comparison. HCPs compared the real condition with the expected condition.	Comparative thinking of the Fairness Theory
Theme 2—Category 1: The perception of fairness (unfairness) of the condition sometimes is targeted toward PLHIV.	Counterfactual thinking
Theme 2—Category 2: The perception of fairness (unfairness) of the condition is sometimes targeted toward HCPs themselves, other patients, or some other members of society. Majority of HCPs expressed the sense of victimization if they got stuck by a needle.	Counterfactual thinking
Theme 3: Expected condition is formed based on HCPs' reference point. They have several reference points/sources that can be divided into three categories:	Counterfactual thinking
Theme 3—Category 1: Moral codes, including religious or nonreligious norms.	Should prototype
Theme 3—Category 2: Hospital protocols and medical scientific rules	Would prototype
Theme 3—Category 3: Constraints and status quo that come from external environment	Could prototype

HCP, healthcare provider; PLHIV, people living with HIV.

Data collection

Selection of the HCPs was based on (1) experience in providing medical care to PLHIV at least once during the past 2 years, and (2) willingness to participate in interview sessions. A total of 26 participants—17 physicians and 9 nurses from 2 private and 4 public hospitals in Tehran—participated in the study. In-depth interviews were conducted in Persian in HCPs' offices. Interviews were not audio recorded, since no consent for recording was obtained, but field notes were taken during each interview by the principal investigator and an assistant. Each interview consisted of a 45- to 60-min semistructured interview using open-ended and discovery-oriented questions and a structured interview of ≤45 min using appropriate inquiries regarding personal perceptions and lived experiences of HIV-related stigma. Participants were asked to identify their positions in reference to fuzzy membership function diagrams. Responses and identities of respondents were coded for confidentiality.

Basic meaning units were identified and coded; similar codes were categorized under Judgment, Expectations, Comparative Thinking, Expectation Sources, and Victimization.

Mode of transmission and HCPs' judgments and decision-making

Participants were asked about their thought processes while visiting PLHIV to learn about bias elements that could affect HCPs' medical decisions. Many respondents explained that they tried to accept PLHIV without judgment, but admitted bias. Two respondents described PLHIV as “licentious” and stated that they would either treat such patients as low priority or pass them to other providers. Four other respondents clearly mentioned that their biases affected their medical decisions, especially about drug addicts and sex workers. Several respondents also expressed being unconsciously or indirectly influenced by their biases (Table 2).

Table 2.

Judgment and Decision-Making About Patients

Respondents	Judgment about patient
Female	…I was getting curious for what reason s/he becomes positive; it did not affect my decision but consequently I became conservative… in which way transmission happen is important to me; surely drug addiction and sexual transmission is different from blood transmission…
Supervisor
Master of nursing
Male	…, It's very important and risky for a surgical operation [on an HIV-positive patient], during surgery we become very careful and do invasive jobs with fear and trembling. One time our professor assigned an invasive procedure [on an PLHIV] to me and so I tried to pass it to other junior students.
Surgery resident
Male	I am trying not to be judgmental. But they are considered as licentious in traditional thinking; as a surgeon I have a right to choose among patients by my priority, in this case I will give the last chance for the HIV positive to be saved, surly I have him to die because I prefer to save other patients…
Surgeon
Male	…,I won't think they are licentious, we had a patient with several tattoo on his body who had a recent travel to Thailand, we guessed that he might be HIV Positive and he did not have any test, our personnel were not eager to do medical services, however we have finished his therapy.
Supervisor
BS in nursing/MS in management
Female	I think they are licentious, I assume they have done something wrong, it affects my decisions… we assumed that he might be a drug addict, our professor pass him to me so I tried to pass him to other students.
Surgery resident
Male	…, it becomes important how the transmission does happen; surely drug addiction and sexual transmission are different from blood transmission. I have to see the patient in the special situation, I think it affects my decision unconsciously.
Specialist doctor
Female	…, It's a taboo in my mind if HIV occurs because sex or drug addiction, it's not affecting my therapy process, but once … I could not communicate very well with him specifically when I understood the transmission happened through sex.
Medical doctor
Male	… I do not judge them; it's possible it happened through other ways; they are the victims of social condition.
Specialist doctor
Male	… If the transmission has happened through sex, I think he is a victim of our social conditions but I don't feel compassion with drug addicts.
Medical doctor

HCPs' judgments about fairness of the conditions, their expectations, and comparative thinking

A specific question was posed as to whether it was acceptable to house PLHIV with other patients. Responses show how HCPs' expectations, which form their perception about the fairness with respect to PLHIV, derive from sources justifying their evaluation of enacted stigma toward PLHIV and their perceptions about fairness, including (but not limited to) ethical codes and hospital rules. The HCPs' disparate experience and knowledge about HIV transmission gave them different interpretations about the risk of transmission. While 20 respondents felt PLHIV should be kept isolated from others, 6 respondents had conditional disagreement with isolation (Table 3).

Table 3.

Healthcare Providers' Expectations and Expectation Sources

Respondents	Expectations	Categorizing the source of expectations
Female	I feel pity for them, they should not be isolated, they are also human beings	Human right
Medical student
Intern
Male	They should not be hospitalized in the same rooms with the other patients. It's against the hospital hygienic procedures as much as the other patient's right is concerned.	Hospital procedures
Specialist doctor		Hospital procedures
Female	We mix them in the same rooms with the	Moral codes
Surgery resident	other patients; it is the routine of our hospital, although it is not consistent with moral codes.	Moral codes
Female	They may bother other patients; the other patients may react to their presence. It is not a good norm for both of them.	Norms
Supervisor
BS of nursing
Male	I disagree with placing them in the same rooms with the other patients; hospital is not a location of trial and error.	Hospital rules
Medical doctor		Hospital rules
Female	Isolation makes them depressed, they also have some rights.	Human right
Supervisor
MS of nursing
Female	As soon as I will understand that someone is HIV positive I will inform other colleagues/classmates for caution. Moral codes require me for sharing my information.	Moral codes
Surgery resident		Moral codes
Female	They should have exclusive room because the other patient may humiliate them or insult them.	Moral codes
Resident of pediatrician		Moral codes
Female	I am a specialist in infectious disease, from scientific point of view there is no reason to receive them in the rooms with the other patients, but it may become problematic.	Scientific codes
Specialized in infectious disease		Scientific codes
Male	There is no scientific fact to isolate them but based on my medical experiences it is better not to allow HIV-positive patient to move freely.	Condition
Specialist doctor		Condition
Male	Because of the other patients' rights, I agree with isolation but based on Islamic ethics we should help them equally like the other patients.	Islamic ethical codes
Supervisor
BS in nursing
Male	I agree with isolation…We have to consider things in a legal way not moral way, the moral forces are not measurable but legal forces are measureable.	legal codes
Specialist doctor		legal codes
Male	Based on the protocol, we have to consider all the patients as HIV positive unless otherwise proven.	Protocol
Surgery resident		Protocol
Female	Sometimes it's not medical concern; the majority of HIV-positive people are from lower class of the society. They bring some problems to the hospital. One time there was someone who deliberately touched the other patients, personal properties, or urinating on the other patient's stuff.	Condition
Nurse infectious disease control		Condition
Male	Sometimes there is a contrast between morality and rules. Sometimes the first priority is me as a doctor, patient or protocols. Sometimes the medical moral will be breached, in some condition medical ethics should be violated because of our families.	Relativism/condition
Surgeon		Relativism/condition

Victimization

HCPs' sense of victimization due to interactions with PLHIV, particularly related to needle stick risk, was expressed by 22 respondents; 18 respondents would decline to inform their family if a needle stick occurred. Both can be sources of justification for avoiding PLHIV (Table 4).

Table 4.

Sense of Victimization and Family Concerns

	Sense of victimization
Male	I feel I am a victim.
Surgery resident	I feel I am a victim.
Female	I feel I am a victim and I won't disclose even to my family.
Nurse infectious disease control
Male	I do not feel I am a victim, it was my own fault; my wife is a doctor and she understands me.
Surgeon
Male	I feel that I am a victim… Our professor told us that the spouse of an HIV-positive person should not know the real status because they won't have any sex life together. They may start having sex with the other people rather than their spouse so the HIV may be spread.
Specialist doctor
Female	I feel I am a victim. A medical student who got stuck by a needle became extremely desperate. She was crying a lot and lost her mental balance, it affected her a lot.
Surgery resident
Male	I don't feel that I am a victim; it's a possible issue in our job.
Medical doctor
Female	I am not disclosing it to my family, it brings many worries to them, I feel that I am a victim.
Supervisor
MS of nursing
Female	If I got stuck by a needle, it's so painful to be transmitted without nothing, I won't disclose it to my family.
Medical doctor

Phase 2—fuzzy analytical study

The concept of fuzzy membership function enables us to model the complex world of the cognitional judgments.^9,16 For modeling the biases of HCPs, we extrapolated cognitive patterns corresponding to judgments about behaviors encountered in relation to PLHIV in the hospital. These behaviors are “real” conditions (x) that given HCPs compare with a “standard or expected” condition (y). Questions were posed in relation to both the degree of real conditions (x or RC) in how they actually behave with their patient and to the expectation (y or EC) of behavior or thinking toward their patient. Given the geometrical distance d(x,y) between the rating (x) and the rating (y), the reference point or prototype plays a main role in formulating the judgment transform d(x,y) to the perceived distance. If a given HCP responds in a five-point Likert scale, we have three main alternative conditions, as shown in Table 5.

Table 5.

Comparing Real and Expected Condition

Condition	Discrimination perception
Real C < expected C If X < Y so d(x,y) < 0	The HCP perceives that there is some discrimination toward PLHIV
Real C > expected C If X > Y so d(x,y) > 0	The HCP perceives that there is some discrimination toward PLHIV and there is some discrimination toward himself/herself, other HCPs, or other patients
Real C = expected C If X = Y so d(x,y) = 0	The HCP perceives that there is no discrimination toward PLHIV nor toward others

Given two HCPs at the same hospital with equal d(x,y), their biases and behavioral intentions toward a given PLHIV can still be unequal. Perceived distance between the RC and the EC is represented by the membership grade μEC (RC) of RC in the fuzzy set EC, which can be interpreted as the grade to which the RC is similar to the EC.^9,17 Thus, in our case, the three fuzzy sets of EC discrimination perception and their membership functions are conceptualized based on the counterfactual prototypes of Would, Could, and Should (Table 6). Several methods for constructing membership functions are described in the literature, which can be calculated based on the experts' judgment or on data.¹⁷ Considering this article's methodological approach, we collected data from 6 physicians from 26 first-phase participants based on (1) those who scored the same for both real and expected conditions, (2) diverse counterfactual prototypes, and (3) willingness to stay in the study's next phase.

Table 6.

Universal Sets and Fuzzy Membership Functions

Counterfactual's prototype	Universal sets: axis x	Membership functions: axis y
Should	Us = {x \| x [−4,0]}, Us = {x \| x [+4,0]}	S: d(x,m) → μS: [0,1]
Could	Uc = {x \| x [−4,0]}, Uc = {x \| x [+4,0]}	C: d(x,Y) → μC: [0,1]
Would	Uw = {x\| x [−4, 0], Uw = {x \| x [+4,0]}	W: d(x,y) → μw: [0,1]

Results

Results are shown in Table 4 where two patterns of behavior for each of the three prototypes were identified.

The universal set of Should

Use of the prototype Should assumes a reference point based on the moral codes and ethical norms that is a concept of absolute extreme.

Pattern 1: Physician #1 rated RC = 2 and EC = 4, so d(x,y) = −2, x < y (Table 7 and right side of Fig. 1). Here, −2 means that she or he perceives some discrimination toward PLHIV in her or his hospital. She or he identified a 0.3 nondiscrimination (fairness) and so 0.7 discrimination toward PLHIV in the hospital. Framed under the prototype “Should,” her or his expectation is defined by moral principles. In addition, she or he perceives a high level of discrimination toward PLHIV at the hospital (0.7). Therefore, the probability of her or his contribution to nondiscrimination programs toward PLHIV is high because she or he believed in moral codes and perceived that the hospital broke with ethical frameworks.

FIG. 1.

Patterns 1 and 2 for Should membership function.

Table 7.

Patterns of Physicians' Fuzzy Membership Functions of Six Prototypes

Perceived distance d(x,y) by x < y	−4	−3.5	−3	−2.5	−2	−1.5	−1	−0.5	0
Pattern 1: Membership grades in the fuzzy set of Should	0.05	0.05	0.10	0.15	0.30	0.5	0.7	0.9	1
Pattern 3: Membership grades in the fuzzy set of Would	0.15	0.3	0.4	0.55	0.7	0.8	0.9	0.95	1
Pattern 5: Membership grades in the fuzzy set of Could	0.95	1	0.4	0.6	0.85	0.9	0.95	0.95	1
Perceived distance d(x,y) by x > y	0	+0.5	+1	+1.5	+2	+2.5	+3	+3.5	+4
Pattern 2: Membership grades in the fuzzy set of Should	1	0.95	0.9	0.7	0.55	0.3	0.2	0.1	0.1
Pattern 4: Membership grades in the fuzzy set of Would	1	0.95	0.9	0.85	0.8	0.6	0.5	0.35	0.2
Pattern 6: Membership grades in the fuzzy set of Could	0.5	0.4	1	0.95	0.95	0.9	0.6	0.5	0.4

Pattern 2: Physician #2 rated RC = 4, EC = 2 so d(x,y) = 2, x > y (Table 7 and left side of Fig. 1). Here, +2 condition means that she or he perceives a 0.55 nondiscrimination (fairness); thus, 0.45 discrimination is applied. She or he believed mixing PLHIV with other patients may cause harm to others in the hospital and described separating PLHIV as protecting both other patients and hospital personnel from the risk of transmission as well as protecting HIV patients from stigma and discrimination by others, stating, “Actually, we respect PLHIV by isolating them.” Framed under the prototype “Should,” her or his ethical principles and moral codes focus on protecting herself or himself and society. Her or his discriminatory perception toward PLHIV was not high; she or he may not contribute to reducing discrimination toward PLHIV, but rather than viewing this condition as discrimination, she or he interpreted it as means of protecting social interests and healthcare benefits (Fig. 1).

The universal set of Would

Use of the prototype Would assumes a reference point, e.g., hospital rules, medical protocols, and social realities.

Pattern 3: Physician #3 rated RC = 2, EC = 4, so d(x,y) = −2, x < y (Table 7 and right side of Fig. 2). Here, −2 produces a 0.70 nondiscrimination (fairness) and 0.3 discrimination applied toward PLHIV. Under prototype W, she or he believed that patient mixing was not allowed in her or his hospital and interpreted this as a social reality stemming from the decision-making authority of the hospital, stating, “The reality is not always in line with our expectance, and if we allow PLHIV to mix freely with other patients, it will cause some disturbance.” Therefore, her or his discrimination perception is reduced to 0.3. Although she or he has no objection to mixing, she or he may not actively contribute to reduce discrimination because she or he obeys the rule of the hospital.

FIG. 2.

Patterns 3 and 4 for Would membership function.

Pattern 4: Physician #4 rated RC = 4, EC = 2, so d(x,y) = +2, x > y (Table 7 and left side of Fig. 2). Here, +2 means a 0.8 nondiscrimination (fairness) factor, and so 0.20 discrimination is applied toward himself or herself. Under prototype W, he or she considered hospital rules allowing patient mixing to have a negative impact on personnel yet viewed them as a reality to be accepted, stating, “In order to observe hospital rules and protocols, we are forced to allow PLHIV to mix freely with other patients. We don't have any authority to change the circumstance” (Fig. 2).

The universal set of Could

Under prototype “Could,” the powerful constraints of social and contextual limitations are imposed such that people sometimes do unpleasant things because they have no other choices. Therefore, the rate of the “expected condition” in perception of the respondent is less than the expected y that she or he expresses in the questionnaire, and the geometric distance decreases; accordingly, we assume Y = y – 1 and d(x, Y) = [−3,3], UC = {x | x [−3,3]}.

Pattern 5: Physician #5 rated real condition = 2, expected condition = 4, so d(x,y) = −2, x < y (Table 7 and right side of Fig. 3). Here, −2 means she or he thinks 0.85 nondiscrimination (fairness) toward PLHIV and so 0.15 discrimination toward PLHIV. She or he described an incident in which an HIV-positive infant was housed with other infants: “[the mothers] protested and made chaos in the hospital … and complained to hospital managers. To avoid disturbance, it is better to isolate [PLHIV], even if I believe they should not be isolated.” For this reason, her or his discrimination perception reduced to 0.15; although she or he agrees with mixing, the probability of her or his contribution to reduce discrimination is very low.

FIG. 3.

Patterns 5 and 6 for Could membership function.

Pattern 6: Physician #6 rated RC = 4, EC = 2 so d(x,y) = +2, x > y (Table 7 and left side of Fig. 3). Here, +2 means he or she thinks 0.6 nondiscrimination (fairness) toward himself or herself and so 0.40 discrimination toward himself or herself. Under the prototype “Could,” with powerful limitations imposed by public health policies, he or she thinks that people must adapt to their environment and often have no choice but to behave in unpleasant ways. He or she stated, “I am relatively tolerant … because I work in a public hospital that hosts a big segment of HIV population in Iran… [but] if we allow PLHIV to mix freely with other patients, it may make me a victim of hospital decisions that ignore the rights of other patients and hospitals' personnel.” Accordingly, the probability of his or her contribution to HIV stigma reduction programs is not relatively high (Fig. 3).

Discussion

In this study, we analyzed HCPs' judgments using fuzzy logic principles after conducting in-depth interviews within the framework of Fairness Theory. In the first, qualitative phase, we categorized different HCPs' biases toward PLHIV based on judgment sources, stereotypes, and feelings, some of which were identified in previous studies.^18
–20 Moral codes, religious attitudes, and social norms identified as contributing to stigma^21
–23 were reviewed and classified under the Should prototype based on Fairness Theory. We used concept of attribution model of stigma that includes “justifications” as a reason for prejudices²² as well as System Justification²⁴ in our classification of the Could prototype to identify HCPs' sources of judgments. For the Would prototype, we did not find an appropriate model serving to our case. However, studies find that a lack of specific policies or guidelines about PLHIV care can increase discriminatory attitudes of HCPs.²⁵ To get to zero discrimination, we need to design effective interventions not only to learn about the prevalence of different cognitive prototypes among HCPs but also to assess the strength of counterfactuals among HCPs²⁶ to enable cluster analysis of different types of HCP stigma.

Conclusions

As the first users of fuzzy logic as an exploratory methodology in this context, we found it to be a solid framework for unfolding the complex issue of discrimination toward PLHIV through more in-depth understanding of HCPs' judgments. Using this methodology in future surveys can provide more accurate predictions about HCPs' discriminatory behavior toward PLHIV. Although the purpose of this qualitative study was not to seek generalizability of the findings, the self-selected, convenient sampling method limits our ability to generalize these results; nevertheless, we believe our findings can be representative of similar situations.

Footnotes

Acknowledgment

The work is dedicated to the memory of Dr. Mathilde Krim and her tireless scientific and advocacy efforts to halt the HIV/AIDS epidemic.

Author Disclosure Statement

No competing financial interests exist.

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