Translation, adaption and validation of HIVAIDS stigma and discrimination scale for university students in China.

This study successfully translated, culturally adapted, and validated the HIV/AIDS Stigma and Discrimination Scale for Chinese university students, demonstrating that the resulting 14-item instrument possesses strong reliability and validity for assessing stigma levels among undergraduates.

The Gist

The Big Picture: Why This Study Matters

Imagine HIV/AIDS as a heavy, invisible backpack that people carry. The virus itself is bad, but the stigma (the shame, fear, and judgment from others) is like a second, even heavier backpack that makes walking much harder.

In China, researchers noticed that while they knew a lot about the virus, they didn't have a good way to measure how much "judgment backpack" regular people (specifically university students) were carrying. They needed a ruler to measure this invisible weight.

This paper is the story of how a team of researchers took a ruler designed in Iran, translated it into Chinese, and tested it to make sure it was accurate, reliable, and culturally appropriate for Chinese students.

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The Journey: From "Rough Draft" to "Gold Standard"

Think of this process like cooking a foreign recipe for a local Chinese banquet. You can't just translate the ingredients word-for-word; you have to adjust the spices so they taste right to the local palate.

1. The Translation (The "Double-Check" Kitchen)

The team didn't just use Google Translate. They used a rigorous method called Brislin's Model:

• Forward Translation: Two English experts translated the original Iranian questions into Chinese.
• Back-Translation: Two different people (who didn't know the original questions) translated the Chinese version back into English.
• The Comparison: The team compared the new English version with the original. If they matched, the meaning was preserved. If not, they tweaked the Chinese until the "flavor" was the same.

2. The Cultural Taste-Test (The Expert Panel)

This is where the "cooking" got serious. The team asked experts to review the questions.

• The Problem: One question asked if families feel "humiliated" to have a family member with HIV.
• The Cultural Fix: In China, family bonds and "filial piety" (respect for parents/elders) are sacred. The experts said, "Chinese families might not feel humiliated in the same way; they might feel sad or worried, but they rarely abandon their loved ones."
• The Result: They removed that specific question and tweaked others to fit Chinese social norms. It's like swapping a spicy pepper for a milder chili because the local guests prefer it.

3. The Pilot Test (The "Dry Run")

Before the big event, they tested the survey on 117 students.

• The Result: The survey worked well, but the structure was a bit messy. It was like a puzzle where some pieces didn't quite fit the picture they were trying to make. They realized they needed to remove a few "puzzle pieces" (questions) to make the picture clear.

4. The Big Survey (The Main Event)

From April to July 2022, they handed out the survey to 1,604 university students across 179 colleges in China.

• The Goal: To see if the survey could consistently measure stigma and if the questions actually grouped together logically.

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The Results: Did the Ruler Work?

After crunching the numbers, the researchers found that their new "Chinese Ruler" (called the CV-HPSDS) was excellent.

• It's Consistent: If you ask the same person the same question twice (two weeks apart), they give a similar answer. It's like a reliable scale that doesn't jump around.
• It's Clear: The survey naturally sorted itself into 3 main categories (dimensions):
  1. Social Disease Perspective: How people view HIV as a scary disease.
  2. Social Support: How willing people are to help or stand by someone with HIV.
  3. Patient Social Discrimination: How people treat or exclude those with HIV.
• It's Accurate: The math showed that these three categories are distinct and real. They aren't just random questions; they measure specific types of feelings.

The Final Product: They ended up with a 14-question survey (down from the original 18). It's shorter, sharper, and perfectly tuned for Chinese university students.

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Why This is a Big Deal

Before this study, if you wanted to measure HIV stigma in China, you might have had to use a ruler made for doctors, or a ruler made for people in the US or Iran. Those rulers didn't fit perfectly.

Now, researchers have a custom-made tool.

• For Schools: They can use it to see if their anti-stigma campaigns are working.
• For Policy Makers: They can identify exactly where the "judgment backpack" is heaviest and target those areas.
• For the Future: It helps build a world where people with HIV are treated with understanding rather than fear.

The "Fine Print" (Limitations)

The authors are honest about the cracks in their foundation:

• The Sample: They only asked university students. This is like testing a new car only on a smooth highway; we don't know how it handles off-road (older people, rural areas, or different education levels).
• The Method: It was an online survey. Sometimes people click answers quickly without reading, like skimming a menu.
• Missing Ingredients: The survey didn't ask enough about fear of catching the virus, which is a huge part of stigma.

The Bottom Line

This paper is a success story of cultural adaptation. The researchers didn't just copy-paste a foreign tool; they rebuilt it, piece by piece, to fit the Chinese context. They created a reliable, valid, and culturally sensitive way to measure the invisible weight of stigma, paving the way for a more compassionate future.

Technical Summary

1. Problem Statement

• Context: HIV/AIDS remains a significant global health burden, with stigma and discrimination (SAD) identified as major barriers to effective prevention, treatment, and the achievement of the "95-95-95" targets.
• Gap: While numerous scales exist to measure HIV-related stigma, most are designed for specific populations (e.g., healthcare workers) or specific cultural contexts (e.g., Iran). There is a lack of comprehensive, psychometrically validated instruments to assess public stigma and discrimination specifically among the general population in China, particularly university students.
• Objective: To translate, culturally adapt, and validate the HIV/AIDS Public Stigma and Discrimination Scale (HPSDS) for use with Chinese university students, creating a reliable tool (CV-HPSDS) to measure SAD levels in this demographic.

2. Methodology

The study followed a rigorous cross-cultural adaptation process based on Brislin's model, involving five key stages:

• Translation & Back-Translation:
  • Forward Translation: Two independent groups translated the original English scale (18 items, 4 dimensions) into Chinese. One group consisted of English teachers with medical knowledge; the other consisted of bilingual individuals without medical backgrounds.
  • Synthesis: A consensus meeting produced a pre-final version (PTL-1).
  • Expert Review: Public health and HIV experts reviewed the PTL-1. They recommended removing items involving illegal behaviors infringing on rights and items culturally inappropriate for China (e.g., regarding family abandonment).
  • Back-Translation: Two bilingual translators with psychology backgrounds but no medical knowledge back-translated the adapted version into English. The original author confirmed semantic and conceptual equivalence.
• Pre-Testing (Pilot Study):
  • Conducted with 117 students to assess intelligibility and clarity.
  • Adjustment: Item 8 (regarding family humiliation) was removed due to cultural incompatibility (Chinese emphasis on family unity/filial piety). The scale was reduced to 17 items.
• Formal Survey:
  • Sample: 2,195 college students from 179 universities in China were recruited via an online platform (Wjx.cn) between April and July 2022.
  • Valid Data: 1,456 valid responses (71.66% response rate).
  • Re-test: 31 students completed the scale again after 2 weeks to assess test-retest reliability.
• Statistical Analysis:
  • Software: SPSS 26.0 and AMOS 23.0.
  • Analyses Performed: Item analysis (Critical Ratio, Item-Total Correlation), Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), Reliability testing (Cronbach's $\alpha$, McDonald's $\omega$, Test-Retest), and Validity testing (Convergent, Discriminant, Known-Groups).

3. Key Contributions

• Cultural Adaptation: Successfully adapted a Western/Iranian scale to the Chinese context by removing culturally insensitive items (specifically regarding family dynamics) and refining language to fit Chinese linguistic norms.
• Scale Optimization: Reduced the original 18-item, 4-dimension scale to a 14-item, 3-dimension structure (CV-HPSDS) that fits the Chinese cultural and statistical landscape better than the original.
• Psychometric Validation: Provided the first comprehensive psychometric validation of an HIV stigma scale specifically for the Chinese general population (university students).
• Open Science: Made the adaptation process and data publicly available via OSF.

4. Key Results

Scale Structure

• Final Version: 14 items organized into 3 dimensions:
  1. Social Disease Perspective (6 items)
  2. Social Support (4 items)
  3. Patient Social Discrimination (7 items)
• Factor Analysis:
  • EFA: KMO = 0.921; Bartlett's test significant ($p < 0.001$). Cumulative variance explained: 76.6%.
  • CFA: Model fit indices were excellent: CFI (0.972), GFI (0.949), TLI (0.965), IFI (0.972), RMSEA < 0.1.

Reliability

• Internal Consistency:
  • Cronbach's $\alpha$: 0.869 (Total scale); Subscale $\alpha$ ranged from 0.875 to 0.927.
  • McDonald's $\omega$: 0.883.
• Test-Retest Reliability: 0.857 (indicating high stability over time).
• Composite Reliability (CR): Ranged from 0.883 to 0.930.

Validity

• Construct Validity:
  • Convergent Validity: Average Variance Extracted (AVE) for all three subscales exceeded 0.5 (0.691, 0.759, 0.658).
  • Discriminant Validity: The square root of AVE for each construct was greater than the correlations between constructs.
• Known-Groups Validity: The scale successfully distinguished between groups as hypothesized. Females, urban residents, medical majors, and those with higher education levels reported significantly lower stigma scores compared to their counterparts.

5. Significance and Limitations

Significance:

• Research Tool: The CV-HPSDS provides a robust, short-form instrument for researchers to measure HIV-related stigma in China, facilitating large-scale studies and intervention planning.
• Policy Impact: By quantifying public attitudes, the scale can help policymakers and health organizations design targeted anti-stigma campaigns to support the "95-95-95" goals.
• Methodological Benchmark: The study sets a standard for cross-cultural adaptation of stigma scales, highlighting the necessity of removing items that conflict with local cultural values (e.g., family cohesion).

Limitations:

• Sampling: The study relied on convenience sampling of university students, which limits the generalizability of findings to the broader Chinese adult population (differences in age, education, and social experience).
• Content Scope: The scale does not include items measuring fear of transmission or specific HIV knowledge, which are components of other stigma scales.
• Ethics: The authors noted a failure to obtain formal ethics approval (likely due to the nature of the online survey and institutional constraints), which restricts publication in certain high-impact journals and limits clinical application.
• Data Collection: Online self-reporting carries risks of inattentive responding or social desirability bias.

Conclusion:
The study successfully developed and validated the CV-HPSDS, a 14-item, 3-dimension scale with strong psychometric properties. It is a reliable and valid tool for assessing HIV/AIDS stigma and discrimination among Chinese university students, offering a foundation for future research and interventions aimed at reducing stigma in China.