Application of the Chinese version of Zelaya’s HIV-related stigma scale to undergraduates in mainland China

For nearly 40 years since the first case was identified in 1980s, stigma against people living with HIV (PLWH) has been documented as a major barrier to HIV- related prevention, diagnosis, care and treatment [1], which not only inhibits high-risk individuals from reducing their risk behaviors, getting tested for the virus and disclosing their positive status, but also causes delays in their care-seeking behavior, diagnosis and treatment initiation [2, 3]. Elimination of the stigma is critical to achieve the “90–90-90” targets by 2020 and finally to end the AIDS epidemic by 2030 [4].

Recently, college students in China have been chosen as a key target population for anti-stigma and anti-discrimination intervention, because they are among the most vulnerable to HIV infection due to their earlier initiation of sexual activity and subsequent unsafe sexual behaviors such as having multiple sex partners, having sex with casual or commercial sex partners, and inconsistent condom use [5‐8]. For example, a cross -sectional study based on a national large sample of 18,000 Chinese college students [5] and our most recently published study [6] have demonstrated that nearly one-third of sexually active college students started their sexual activity earlier than 18 years of age. Furthermore, early sexual initiators, whether male [7] or female [8], were found to have a higher likelihood than late initiators to have sex with multiple sexual partners or non-regular partners, and fail to use condom consistently.

Various paradigms, approaches and techniques have been attempted to define, conceptualize, measure and provide solutions to HIV-related stigma, and has also yielded valuable results [9‐16], including the design and development of a great number of scales and accompanying questions to measure and compare different dimensions of stigma in a variety of cultural contexts and with the three most commonly-mentioned groups (i..e, healthcare workers, HIV-infected individuals and the general population). However, the lack of a standardized instrument makes it difficult to measure stigma consistently and thus poses a challenge to compare and contrast evaluated interventions [4, 17, 18]. Furthermore, although scales were adapted to different linguistic and sociocultural contexts, their reliability and validity were rarely tested [12]. Therefore, there is a need for developing a standardized, reliable and valid measurement tool to assess the current level and predictors of HIV-related stigma, and subsequently develop, implement and evaluate anti-stigma interventions.

A review of the existing literature indicated that there existed a multitude of candidate HIV-related scale items that can be used or adapted for use in the undergraduate student population in China [19‐29]. However, only a few scales were provided with the evidence of validity and reliability [21‐23, 26, 27], and none of these scales had been assessed in a large, nationally diverse sample of undergraduates. For instance, the discrimination related HIV/AIDS scale [22], which was developed by Cao and her colleagues in 2013 and consisted of 19 items with four dimensions (Fear, avoidance, disclosure and moral judgment), had ever been tested by using only exploratory factor analysis in a sample of 449 medical and nursing students from Nantong University. Similarly, the 15-item scale designed by Yang, Wang and Yuan [26] to measure three dimensions of stigma (Fear, moral judgment, personal stigma) and the 29-item scale covering the three dimensions of stigma (social distance, moral judgment, and personal stigma) designed by Qian and Wang [27] were also verified in a small sample of college students, although further evidence of construct validity was provided by both exploratory and confirmatory factor analyses. In comparison, the Chinese version of Zelaya’s HIV-related Stigma Scale (CVZHSS), which was translated by Xing and colleagues in 2012 [23] and yielded a four-factor structure and successfully measured the four dimensions of stigma [including fear of casual transmission, moral judgment such as shame and blame, personal stigma (i.e., personal beliefs and feelings related to fair treatment of PLWH in a society), and perceived community stigma (i.e., the respondents’ perceptions of how people in a community feel and respond towards PLWH)] as expected from the original scale by using traditional exploratory factor analysis, seems to be a promising measurement tool because it has some advantages over the above-mentioned three scales in several important ways. First, it assessed stigma more comprehensively, because it measured “perceived community stigma” reported by HIV-uninfected individuals, besides highlighting the three most commonly included dimensions (Fear, moral judgment and personal stigma) [30]. Second, the CVZHSS has been employed globally to assess HIV stigma among individuals who do not know their HIV status {including but not limited to college students [21, 23, 24] and rural-urban migrants in China [31], correctional staff in prisons and jails [32] and adults and adolescents [33] in the United States, male bar patrons [30] and nursing students [34] in India} for more than 10 years due to its flexibility to adapt to varying linguistic and sociocultural contexts and also because of its diversity in the measurement of its four dimensions. Third, it has been well-validated in a relatively large sample of medical college students in Zhejiang province of China [23] and used fairly extensively in Chinese college students majoring in nursing [21], medicine [23, 24] and education [24].

While the CVZHSS has been tested and validated successfully for medical college students in Zhejiang province of China and also applied to undergraduates majoring in nursing, medicine and education, its reliability and validity among general college students (including but not limited to college students majoring in medicine, nursing and education) throughout mainland China had not been fully tested prior to the current research. Moreover, eleven factors (See Fig. 1), including five social-demographic characteristics {gender [19], residential areas [19], major [24], age [35], and sexual orientation [35]}, HIV-related knowledge [19], awareness of the national AIDS policy [36], risky sexual behaviors [37], three preventive practices [37] such as having ever being tested for HIV [38], willingness to utilize HIV testing and counselling (HTC) service [37] and perception of HIV risk [36], have previously been studied as correlates of HIV-related stigma. However, these studies usually used bivariate analyses that did not take into account the effects of potential confounders. Thus, independent effects of eleven variables on stigma remain unclear. The present study aims to first validate the Chinese version of Zelaya’s HIV-related Stigma Scale (CVZHSS) among a large undergraduate sample in mainland China, and then apply it to measure the level of different dimensions of stigma and their respective determinants. There are two main goals of this article: (1) to better understand the mechanisms of how stigma is processed, and (2) to better understand the development, implementation and evaluation of anti-stigma interventions to achieve the ambitious goal of “Zero Discrimination” [39].

The primary aim of the study was to validate the CVZHSS among a large undergraduate sample in mainland China. Construct validity was established by conducting both exploratory and confirmatory factor analysis. These two types of results were complementary. This study extends the results by first using the EFA to obtain a modified factor structure for our sample, thus making it possible to make a comparison between the original version and the Chinese version. As expected from the original version, four distinctive dimensions, i.e., fear of casual transmission, moral judgment, personal stigma, and perceived community stigma, were extracted using principal component factor analysis with varimax rotation. One obvious discrepancy is that in our sample, Item20 (“I am willing to make friends with PLWH”) failed to be grouped under the “Perceived community stigma” domain as in the original version. To explain this discrepancy, the wordings of both the original version and the Chinese version were compared. It was found that a translation error was made by changing the subject from “people” (the third person) in the original version to “I” (the first person) in the Chinese version, thus resulting in Item 20 assigned to the “Personal stigma” dimension in our sample.

The following CFA demonstrated that the four-factor model provided a good fit to the data, as evidenced by various model fit indices (CFI = 0.92, GFI = 0.91, RMSEA = 0.07). In addition, the results of reliability analysis also indicated these four factors had acceptable internal consistency (Cronbach’s alpha greater than 0.70). Therefore, the psychometric properties of the Chinese version were found to be largely similar to those of the original version, which showed the construct of HIV- related stigma are consistent across different cultural settings, thereby lending support to a claim that Zelaya’s HIV-related Stigma Scale is a valid, reliable and globally accepted tool [21, 23, 24, 30‐34] for comprehensive measure of stigma among HIV- uninfected individuals, and its four distinct domains should be used separately.

The second aim of this study was to identify possible predictors of stigmatizing attitudes among undergraduates in mainland China. The analysis of associations between the four domains of CVZHSS with the other collected variables potentially affecting stigmatizing attitudes among undergraduates has allowed us to confirm data already available in the literature. The findings indicated that except for non-freshmen, less knowledge about HIV and unsafe sex which were consistently associated with higher levels of stigma in all four dimensions, other eight variables including gender, residential area, major, sexual orientation, having ever being tested, perception of HIV risk, willingness to utilize HTC service and awareness of the national AIDS policy played differential roles in affecting different dimensions of stigma.

Consistent with a previous research on the relationship between HIV-related stigma, unsafe sexual behaviors and preventive practices [37], stigmatizing attitude towards PLWH were positively associated with unsafe sexual behaviors (including having multiple sexual partners, causal sex, and failing to use condoms consistently) and were negatively associated with willingness to utilize HTC service. One possible explanation for this finding is that those who had ever engaged in unsafe sex [37] and accepted HIV testing [38] are stigmatized because of their association with the gay community [35, 37] and face strong social pressure. Our data also indicated that non- heterosexuals and those who had ever been tested for HIV were more likely to perceive stigma in their community. Such social environments may lead them to try to justify their stigmatized behaviors by blaming or stigmatizing PLWH [37].

Our study indicated that undergraduates who were knowledgeable about the route of HIV transmission and the national AIDS policy and those who perceived themselves to be at risk of contracting HIV were less likely to have stigmatizing attitudes. This finding is not surprising as it fits the knowledge-attitude-belief-practice model, because the increase of knowledge can dispel misconceptions about HIV transmission via casual contact, increase accurate perception of personal risk, and finally contribute to lower levels of HIV-related stigma.

Another interesting finding is that medical education can significantly reduce fear of casual transmission and personal stigma, but has no significant effect on moral judgments and perceived community stigma. One possible explanation for this phenomenon is that the current dominant biomedical model of health places greater emphasis on providing medical students with the knowledge related to the nature of HIV and AIDS, HIV transmission modes, the risk of professional exposure to HIV, while topics regarding professional ethics, human right, and the relationship between health professionals and patients are often ignored [24].

Consistent with a previous study [28, 45], women were less likely to express stigmatizing attitudes towards PLWH. The increased compassion of females was mainly attributable to social gender roles, especially in China where women are economically, culturally, and socially disadvantaged, and they also shared more responsibility for housework and child-care [28]. Furthermore, gender was also found to exert its indirect effects on stigma through the mediating effect of knowledge, with women having higher knowledge and thus lower levels of stigma than men [45].

Contrary to a previous study [25], this study indicates that respondents from urban areas perceived higher levels of community stigma than their rural counterparts. This is because there existed a more traditional family value (e.g., loyalty, respect, obedience and love) in the rural areas, thus contributing to rural respondents’ lower levels of perceived community stigma. In addition, our study also found that non- freshmen consistently reported higher levels of stigma in all the four dimensions. This could be partially explained by the fact that higher-grade (age) undergraduates, despite having a higher level of knowledge [5], had a higher tendency to report having had sexual debut [5] and were more likely to engage in unsafe sexual behaviors such declining condom use [46], because college student are under less control of their parents and also have more opportunity to interact with opposite gender and same-gender peers [47]. Our data also suggested that the prevalence of unsafe sexual behaviors increased significantly from 6.9% among freshmen to 8.5, 9.4 and 14.1% in senior, junior and senior students, respectively (χ2 = 42.94, P < 0.001). Therefore, non-freshmen expressed more negative attitudes toward people living with HIV so as to reduce the resulting discomfort of unsafe sex [37].

The lack of a standardized reliable and valid instrument makes it difficult to measure stigma consistently and thus poses a challenge to compare and contrast evaluated interventions. Therefore, there is a need for developing a valid, reliable and globally accepted scale to assess the current level and predictors of HIV-related stigma, and subsequently develop, implement and evaluate anti-stigma interventions. A review of the existing literature indicated that the Chinese version of Zelaya’s HIV-related Stigma Scale (CVZHSS) seems to be a promising measurement tool, because it has more comprehensively assessed stigma than the other three most commonly used scales and has been validated in a relatively large sample of college students and also because it performs well across the wider geographical, political and cultural contexts. However, previous studies have only performed an exploratory factor analysis to test its construct validity among college students with certain demographic characteristic such as currently pursuing a degree in medicine, nursing and education or/and in one city of a certain province (e.g., Hanzhou city of Zhejiang Province). To the best of our knowledge, the current study is the first to evaluate its construct validity in a large undergraduate sample across the whole country combining exploratory and confirmatory factor analytic approaches as well as to examine their respective determinants of four distinct dimensions in this population. Our results indicated the CVZHSS is a reliable and valid measurement tool and can be used to identify undergraduates with high levels of stigma. However, four dimensions of stigma (i.e., Fear, moral judgement, personal stigma and perceived community stigma) were respectively influenced by different determinants and consequently should be treated independently when designing anti-stigma measures.