Mechanisms of Action and Preliminary Impact of a Stigma-Mitigation Training to Enable Healthcare Discussions About Anal Pleasure and Health in China: A Sequential Explanatory Mixed Methods Pilot Study

Stigma toward anal sex impedes engagement in health services that are vital to Ending the HIV Epidemic. We evaluated a stigma-reduction training to build HIV worker capacity to address anal pleasure and health during HIV service encounters in China. In a sequential explanatory mixed-methods design, we assessed the training’s preliminary impact on anal health promotion activities and, based on the Theoretical Domains Framework, mechanisms of action among 51 health workers. We conducted descriptive statistics, bivariate comparisons, and thematic analyses based on pre/post-training online surveys and post-training in-depth interviews. The frequency of anal health promotion activities among the 38 participants who completed pre/post-training surveys increased by 7–8% of the scale range, but not significantly (p-values between 0.06 and 0.08). Mechanisms for discussing anal sex (knowledge, skills, role responsibility, self-efficacy, organizational acceptability, and positive emotions) shifted from baseline (5%-36% range), primarily due to boosts in knowledge and skills (28% and 36%, all p <.05). Additional mechanisms of comfort addressing sexual orientation, anal health, and sex-related concerns also increased (4–14% range, all p <.05). Qualitative analysis revealed mechanistic themes of heightened empathy, weakened stereotypes, and a shift toward accepting role responsibility to discuss anal sex. Gay and bisexual workers reported notable personal growth to optimize their own anal health. Although knowledge and communication skills increased provider confidence, some participants remained hesitant to initiate discussion during HIV service encounters. For most participants the theoretically-informed training activities operated as hypothesized, to enhance mechanisms that could increase provider-initiated discussion of anal pleasure and health.