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\title{How do Key-Populations Cope with their Behavior-Related Stigma? A Qualitative Study in a Province in Sri Lanka}
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             \author[1]{Mekala  Fernando}

             \author[2]{  H.M.J.P.Vidanapathirana}

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\date{\small \em Received: 9 April 2021 Accepted: 2 May 2021 Published: 15 May 2021}

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\begin{abstract}
        


Key populations are at the highest risk of acquiring and transmitting the Human Immuno-deficiency Virus (HIV). Due to the stigma vested upon them, they have become least accessible for preventive and curative services for HIV. Therefore, coping strategies are essential to minimize stigma to end AIDS by 2025, five years ahead of the global target of ending AIDS in 2030.The objective was to describe the coping strategies adopted by key-populations to overcome behavior-related stigma. Data from thirty-two in-depth interviews were analyzed using the thematic analysis method.

\end{abstract}


\keywords{coping strategies, key populations, stigma.}

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{{\textit{CrossRef DOI of original article:}} \underline{10.34257/GJMRKVOL21IS7PG11}}
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\section[{Introduction}]{Introduction}\par
nternationally, intravenous drug users (IDU), female sex workers (FSW), men who have sex with men(MSM), and transgender (TG) are known as Key populations (KP) (United Nations Programme on HIV/AIDS (UNAIDS, 2017). They are at the highest risk of acquiring and transmitting HIV due to their behavior. In the Sri Lankan context, the four key population groups identified at the time of developing this study were drug users (DU), FSW, MSM, and TG (National STD/AIDS Control Programme, Sri Lanka (NSACP), 2015). They are well known as a hidden population. Thus, they face a high level of self, perceived and enacted stigma because they belong to a KP group. In this study self, and perceived stigma are collectively called behaviorrelated stigma.\par
Stigma and discrimination are major obstacles to universal access to HIV prevention, treatment, and care. The initial reaction to stigma is silence. Then it further develops to denial and finally can lead to violence. Therefore, it is evident that strengthening coping strategies among KP to reduce stigma is of utmost importance \hyperref[b5]{(Rosenbloom \& Volkow, 2007)}.\par
Coping is defined as the process by which individuals regulate stressors that they face. Coping strategies are two general types: 1) those that are "active/ problem-focused strategies" versus 2) those that are "passive/avoidant" strategies (Health Policy project, 2013). They can be either interpersonal or intrapersonal \hyperref[b7]{(Zhang et al., 2014)}.\par
Reducing stigma and discrimination is identified as one of the four critical enablers that help to overcome critical barriers to service uptake, including social exclusion and marginalization, criminalization, stigma, and inequity among KP (UNAIDS, 2014).\par
Improvements to interventions that minimize stigma in KP groups can be done with the help of the identified coping strategies. These will help them to overcome the stigma and make them highly accessible to health care facilities.\par
The objective of the study was to describe the coping strategies adopted by Key populations to overcome behavior-related stigma. 
\section[{II.}]{II.} 
\section[{Methods}]{Methods}\par
A qualitative study was conducted to identify the coping strategies adopted by the KP to over comestigma. In-depth interviews were selected over focus group discussions because participants would not voice their views and experiences in a forum where their peers were present. The study included 32 participants, eight from each group in the Western province in Sri Lanka. The participants who were more than 18 years of age, resided in either Colombo, Kalutara or, Gampaha districts for more than six months, and who were not diagnosed with any psychiatric illness were included in this study were selected. The level of stigma was not considered during the recruitment of participants. The ideas reached saturation with the sample size mentioned above.\par
Investigators developed an in-depth interview guide to collect data. A thorough literature review, discussions with experts, and representatives from the KP groups were conducted to develop the guide. A panel of experts assessed the content validity of the guide.\par
The qualitative data were analyzed using the thematic analysis approach. Transcribing was done by the principal investigator.\par
Ethical clearance was obtained from the ethics review committee, faculty of Medicine, University of Kelaniya, Sri Lanka, before the commencement of the study. Administrative clearance was obtained from the provincial director of health services of Western province. 
\section[{III.}]{III.} 
\section[{RESULTS}]{RESULTS}\par
The age range of drug users (DU) participants was 26 -48 years, 29 -51 years in men who have sex with men (MSM), 20 -55 years in female sex workers (FSW), and 24 -45 years in transgender (TG). The educational level of these groups varied from nonattendance to school to a diploma holder among DU, schooling up to grade 10 to degree holder among MSM, grade five at school to G.C.E. Advance level among FSW and G.C.E.O/L to degree holder among TG.\par
The active (problem focus) coping strategies identified in this study are being open regarding the key behavior, being financially stable, winning the confidence of family members, and engaging in activities that improve physical \& mental health. The passive coping strategies identified in this study are being obedient to the stigmatizers/nonconfrontation, keeping the behavior a secret, avoid family members, relatives, close friends, being away from home/ residence, looking at the issue from a non-KP's angle.\par
The above themes were further classified as intrapersonal and interpersonal.\par
IV. 
\section[{Active Coping Strategies}]{Active Coping Strategies} 
\section[{Intrapersonal}]{Intrapersonal}\par
? Being financially stable (Intrapersonal)\par
Being financially stable has been a positive factor for all four KP groups to cope with their behaviorrelated stigma. They believed that if a person is financially stable and could help others financially, they will not be stigmatized.\par
One FSW stated: "I earn more than what I need for my expenses at the moment. I know that I can't do this job for a long time, especially when I get old. Therefore, I save the same money for my future needs."\par
? Engaging in activities that improve physical and mental health Some of them have been engaged in other activities like religious activities, watching a film, or listening to music to overcome the stigma when an incident that provoked stigmatizing attitudes on them occurred. There were few FSW who mentioned that they would engage in some other activity to forget the stigma. Some stated that they would engage in religious activities. One transman expressed that he would read a novel when a stigmatizing attitude arises in his mind. 
\section[{Interpersonal ? Being open and talk regarding the Key behavior}]{Interpersonal ? Being open and talk regarding the Key behavior}\par
Explaining to others regarding their Key behavior was a coping strategy adopted by all four KPs. One DU stated, "People always scold me for using abusive drugs. When they scold, I tell them: Yes, I do so. I can't stop using it."\par
That was one of the coping strategies adopted by many MSM participants as well. One stated, "When I was penalized by society due to my homosexual behavior, I didn't keep silent. I explained to them the situation. After that, they didn't harass me." Another MSM participant stated that the "General population doesn't accept homosexuality. But I think we should explain about this and tell them that MSM also has a right to live."\par
They have been assertive and explaining the stigmatizers that homosexuality is a normal phenomenon and there is a right for homosexual people to live in society. This was one of the main adaptive strategies adopted by the FSW participants to overcome stigma. They had confronted and opposed the negative perceptions on FSW raised by society. 
\section[{a) Winning confidence of the family}]{a) Winning confidence of the family}\par
Building confidence is a positive factor through which the KP could overcome their behavior-related stigma. They believed that they could live with a minimal level of stigma despite their key behavior if they could build confidence among the family as a needy person.\par
One transman stated: "Although I changed by gender identity, I don't do wrong things. I studied well and became an accountant. Now my parents don't stigmatize me. I have heard my mother explaining about me to one of her friends in the village. I was proud to hear that."\par
V. 
\section[{Passive Coping Strategies}]{Passive Coping Strategies} 
\section[{Intrapersonal}]{Intrapersonal}\par
? Being obedient to stigmatizers/nonconfrontation Being obedient to the stigmatizers and nonconfrontation have been adopted by some KP who participated in this study. The majority of the drug users claimed that there is no benefit in being assertive towards drug use when they get harassed by society. They believed that if they kept calm and obedient to what the stigmatizers tell them, they could overcome that situation.\par
However, non -confrontation with the stigmatizers has not been adopted by any MSM who participated in the in-depth interviews.\par
? Keeping the behavior a secret\par
The majority of the KPs who participated in the in-depth interviews had kept their Key behavior a secret. Most of the MSM participants believed that it is not necessary to reveal their sexual orientation to others. They also thought that keeping the status of homosexuality a secret would help them spend life without problems. One MSM participant stated: "I have no problem regarding my homo-sexual behavior because my spouse doesn't know about it. I have my homo-sexual relationship very secret, and I ensure it is nondisclosed to anybody other than my homo-sexual partner."\par
This coping strategy was adopted by almost all the FSW participants as well. They have adopted different strategies to keep sex work a secret. Some of them directly stated that they would keep their engagement in sex work a secret while some described how they kept this principal fact a secret by taking safety measures to hide sex work. Some of them are engaged in another job while doing sex work, not staying in brothel houses or streets were commonly raided by police, finding clients through telephone calls/ internet or at night clubs, engage in sex work only with few known clients, and Engage in sex work only at night. One transman stated, "Since nobody can't identify me as a transman just by a glance, I don't want to go and tell everyone that I'm transgender. I don't think it as a necessity as well." 
\section[{? Being away from home}]{? Being away from home}\par
Being away from home has been adopted as a coping strategy by the majority of the KP. This was a leading strategy among the DU participants, and they believed that to overcome the stigma and discrimination due to drug use, they need to have an environment that does not induce such behavior. Few of them thought that the rehabilitation centers did not work for them. Once they come home (to the usual setting where they have been using drugs) they are put to the same behavior again. Therefore, they suggested that it would have been effective if the authorities could provide a new place where they could live for about one or two years. They believed they could live there without using drugs because there is no conducive environment for such behavior. Thus, if a person is determined to stop using drugs, he or she may continue to do so. Some MSM participants also believed that it would have been better if they could live away from their parents or siblings while some have decided to do so. 
\section[{Interpersonal}]{Interpersonal}\par
? Looking at the issue from a non-KP's angle Few who participated in this study believed that they should look at the issue from a person who does not belong to their community. They pointed that others discriminate against them mainly because they think the key behaviors are against our cultural norms and values.\par
They believed that it is easier to be ignorant rather than trying to open the eyes of people whose conception of Key populations cannot be changed. 
\section[{VI. Conclusions and Recommendations}]{VI. Conclusions and Recommendations}\par
We identified both active and passive coping strategies adopted by KP groups to overcome behaviorrelated stigma. The main active coping strategies are being open regarding the Key behavior, being financially stable, winning the confidence of others, engaging in activities that improve physical and mental health while being obedient to stigmatizers, keeping the Key behavior a secret, avoid family members, relatives, friends and being away from the residence were the passive coping strategies.\par
New interventions to reduce stigma among KP can be developed and the existing interventions can be improved using the coping strategies identified in this study. Since these coping strategies are merely the ideas of KP, these findings should be forwarded to Consultant Psychiatrists and higher officials in the mental health directorate to assess their suitability to be incorporated into stigma reduction interventions. 
\section[{VII.}]{VII.} 
\section[{Discussion}]{Discussion}\par
In-depth interviews were selected over focus group discussions because it was assumed that the participants would not voice their views and experiences in a forum where their peers were present. This assumption was proven to be correct since the participants were quite particular about the maintenance of confidentiality of the information provided by them. This was assured during the interviews and was made sure that only the principal investigator would listen to the audio recordings of the in-depth interviews for transcription. Further, it was decided that in-depth interviews were superior to the focus group discussions because sensitive issues were needed to be discussed at times. A good rapport was built with the participant to obtain accurate information, thus reducing information bias. Conducting the interviews of a particular KP group within a limited number of days prevented contamination bias.\par
Four broader themes of active coping strategies identified from this study were being assertive regarding the key behavior, being financially stable, winning the confidence of the family, and engaging in activities that improve physical and mental health. Most of the participants in all four KP groups have identified that being open about the key behavior, talking about it with family members or with somebody that they can get help to overcome stigma as a coping strategy. According to them, this strategy is dependent on many internal and external factors. There should be a supportive environment for this strategy to be helpful for KP to overcome stigma. No studies described "being K open" as a coping strategy to overcome behaviorrelated stigma. Therefore, it was compared with a qualitative study done among people living with HIV (PLHIV) in China. This Chinese study ensured that seeking support from family, peers, or close friends as a coping strategy has helped them to overcome stigma due to their HIV status  {\ref (Zang et al., 2014)}. In this study, in-depth interviews have been conducted and the same method was used in the current study as well. Although the underlying cause for stigma is different, the two studies have been conducted in the same region.\par
The stigma and the coping strategies used to overcome stigma are similar as China is a country with high socio-cultural values similar to Sri Lanka. Therefore, considering the above positive and negative factors, we compared both these studies with caution.\par
Financial stability has been identified as a key strategy to overcome behavior-related stigma among all four KP groups who are considered in this study. The same strategy has been used by PLHIV in South India (Kumar, Mohanraj, Rao, Murray \& Manhat 2015). It was revealed by a qualitative study which was done in South India through 17 in-depth interviews and four focus group discussions. Regardless of the underlying course, stigma among PLHIV in South India and KP in Sri Lanka seem to be behaving in almost a similar manner when adopting strategies to cope with stigma.\par
Winning the confidence of family members and becoming a wanted person for them was identified as a coping strategy among all four KP groups in this study. However, this was not identified as a coping strategy in any study at international or in Sri Lankan setting.\par
Some participants of all four groups of the qualitative component of the current study were in the opinion that engaging in activities like involving in religious activities, watching films, listening to music has helped them to overcome stigma either by forgetting the problem for a while or understanding the nature of the problem. Zhang et al (2014) have also described that engagement in activities that improve physical and mental wellbeing (Ex: swimming, walking, physical exercises, singing, dancing) as an active coping strategy to overcome HIV stigma among PLHIV. However, there was no study of similar nature to compare the findings of the current study.\par
The broader themes of the passive coping strategies were being obedient to the stigmatizers/ nonconfrontation, keeping the key behavior a secret, avoid family members, relatives, or close friends, and being away from home. Nonconfrontation with the stigmatizers was identified as a key strategy to cope with behavior-related stigma in this study. Nevertheless, this has not been identified as a separate coping strategy in the scientific literature from countries worldwide. Therefore, the results of the current study were not compared with any prior research.\par
Keeping the Key behavior a secret was identified as a coping strategy among the majority of participants of all four KP groups. Participants who wanted to keep it as a secret thoroughly believed that they feel stigmatized merely due to the divulgence of information regarding their key behavior to others. This has been raised as a coping strategy among most of the participants from all KP groups except TG. Although there is hardly any literature that specifically describes this as a coping strategy among KP, a qualitative study done among PLHIV in china clearly describes ma hiding the HIV status as a coping strategy to overcome HIVrelated stigma (Zang et al., 2014). The same strategy has been reported by a group of PLHIV in South India, where they have reported that non-disclosure or selective disclosure of their HIV status has helped them to overcome stigma \hyperref[b3]{(Kumar et al., 2015)}.\par
Being away from home has been adopted as a coping strategy by most of the DU in the study. Nevertheless, only a few participants of other KP groups raised this fact. Since most of the other studies have identified seeking support from family as a coping strategy to combat stigma, being away from home or residence was not identified as such. Nevertheless, this study discussed an issue related to a Key behavior.\par
The current study identified being compassionate as a passive interpersonal coping strategy. Similarly, research among PLHIV in China \hyperref[b7]{(Zhang et al, 2014)} has identified it as a passive interpersonal coping strategy. Most of the participants have coped with the stigma by looking at it from a nonstigmatized person's angle. While the study on HIV stigma looked at the issue from a disease perspective, the current study looked at the problem from a behavioral perspective.			\footnote{© 2021 Global JournalsHow do Key-Populations Cope with their Behavior-Related Stigma? A Qualitative Study in a Province in Sri Lanka} 		 		\backmatter   			 
\subsection[{Acknowledgement}]{Acknowledgement}\par
I Acknowledge the study participants for providing true information and the staff of different organizations for helping me to contact the study participants. 			  			  				\begin{bibitemlist}{1}
\bibitem[Link and Phelan ()]{b4}\label{b4} 	 		‘Conceptualizing stigma’.  		 			B G Link 		,  		 			J C Phelan 		.  	 	 		\textit{Annual. Rev. Sociology}  		2001. 27 p. .  	 
\bibitem[Zhang et al. ()]{b7}\label{b7} 	 		‘Coping strategies for HIV-related stigma in Liuzhou’.  		 			Y Zhang 		,  		 			C E Golin 		,  		 			J Bu 		,  		 			C B Emrick 		,  		 			N Zhang 		,  		 			M Li 		.  		 \xref{http://dx.doi.org/10.1007/s10461-013-0662-2.15Year2021}{10.1007/s10461-013-0662-2.15Year2021}.  	 	 		\textit{China. AIDS Behaviour}  		2014. 18  (02) .  	 
\bibitem[Rosenbloom and Volkow ()]{b5}\label{b5} 	 		‘Coping with the Stigma of Addiction’.  		 			D L Rosenbloom 		,  		 			N Volkow 		.  	 	 		\textit{Addiction}  		2007. p. 6.  	 
\bibitem[National ()]{b6}\label{b6} 	 		‘Integrated biological and behavioral surveillance survey among key populations at higher risk of HIV in Sri Lanka’.  		 			Std National 		.  	 	 		\textit{Ministry of Health},  				 (Colombo, Sri Lanka)  		2015. 2014.  	 	 (-report) 
\bibitem[Kumar et al. ()]{b3}\label{b3} 	 		‘Positive Coping Strategies and HIV-Related Stigma in South India’.  		 			S Kumar 		,  		 			R Mohanraj 		,  		 			D Rao 		,  		 			K R Murray 		,  		 			L E Manhart 		.  		 \xref{http://dx.doi.org/10.1089/apc.2014.0182}{10.1089/apc.2014.0182}.  	 	 		\textit{AIDS patient care and STDS}  		2015. 29  (3) .  	 
\bibitem[Reduction of HIV-related stigma and discrimination, guidance note Joint United Nations Programme on HIV/AIDS ()]{b1}\label{b1} 	 		‘Reduction of HIV-related stigma and discrimination, guidance note’.  	 	 		\textit{Joint United Nations Programme on HIV/AIDS}  		2014.  	 
\bibitem[UNAIDS data -2017 Joint United Nations Programme on HIV (2017)]{b2}\label{b2} 	 		‘UNAIDS data -2017’.  		 \url{http://www.unaids.org/sites/default/files/media\textunderscore asset/20170720\textunderscore Data\textunderscore book\textunderscore 2017\textunderscore en.pdf}  	 	 		\textit{Joint United Nations Programme on HIV}  		2017. February 23. 2018.  	 
\bibitem[Understanding and challenging HIV and Key population stigma and discrimination, Caribbean Facilitator's Guide Health Policy project ()]{b0}\label{b0} 	 		‘Understanding and challenging HIV and Key population stigma and discrimination, Caribbean Facilitator's Guide’.  	 	 		\textit{Health Policy project}  		2013.  	 	 (Health Policy Project) 
\end{bibitemlist}
 			 		 	 
\end{document}
