Development of internalized and personal stigma among patients with and without HIV infection and occupational stigma among health care providers in Southern China

Figures & data

Figure 1 Conceptual framework of the study.

Table 1 Summary of stigma items among HIV-positive and non-HIV patients in development and validation sample

Items for HIV and non-HIV patients	Development sample (mean, SD)			Validation sample (mean, SD)			P-value**
	HIV	non-HIV	P-value*	HIV	non-HIV	P-value*
1. PLWH should be ashamed of themselves	2.62 (0.9)	2.00 (0.6)	<0.001	2.71 (0.9)	2.18 (0.6)	<0.001	<0.001
2. PLWH must have done something wrong to deserve it	2.27 (0.9)	2.00 (0.6)	<0.001	2.40 (0.9)	2.11 (0.7)	<0.001	<0.001
3. It is the fault of PLWH that they got HIV	2.43 (0.9)	2.08 (0.6)	<0.001	2.49 (0.9)	2.19 (0.7)	<0.001	0.006
4. Be uncomfortable around people with HIV	2.87 (0.8)	2.49 (0.6)	<0.001	3.00 (0.8)	2.43 (0.7)	<0.001	0.166
5. Getting HIV is a punishment for bad behavior	2.13 (0.9)	2.14 (0.6)	0.872	2.29 (0.9)	2.20 (0.8)	0.058	<0.001
6. Be afraid to be around people with HIV	2.56 (0.9)	2.53 (0.6)	0.533	2.54 (0.9)	2.56 (0.7)	0.597	0.796
7. Not like to be friends with someone with HIV	2.67 (0.9)	2.59 (0.7)	0.048	2.59 (0.9)	2.49 (0.7)	0.022	0.003
8. Do not like someone with HIV to be living next door	2.58 (0.8)	2.55 (0.7)	0.402	2.55 (0.9)	2.50 (0.7)	0.196	0.15
9. Do not like to sit next to someone with HIV	2.68 (0.9)	2.46 (0.6)	<0.001	2.68 (0.9)	2.28 (0.7)	<0.001	0.003
10. Do not eat together with PLWH	2.56 (0.8)	2.73 (0.6)	<0.001	2.52 (0.8)	2.48 (0.7)	0.428	<0.001
11. Less of PLWH because of their HIV status	2.45 (0.8)	2.53 (0.6)	0.048	2.51 (0.9)	2.25 (0.7)	<0.001	0.166
12. Most employers would not employ me because I am HIV-positive	2.81 (0.8)	2.75 (0.6)	<0.001	2.81 (0.8)	2.71 (0.7)	0.011	0.542
13. Getting HIV was just a matter of bad luck	2.46 (0.9)	2.13 (0.7)	<0.001	2.53 (0.9)	1.98 (0.7)	<0.001	0.156
14. It is safe for me to handle other people’s children (R)	2.84 (0.8)	2.04 (0.6)	<0.001	2.80 (0.8)	2.14 (0.6)	<0.001	0.172
15. Have a lot to teach people about life through having HIV (R)	2.66 (0.8)	2.64 (0.6)	0.699	2.64 (0.8)	2.46 (0.7)	<0.001	<0.001
16. Do not like to date with PLWH	2.66 (0.8)	2.57 (0.6)	0.022	2.58 (0.8)	2.59 (0.7)	<0.001	0.227
17. PLWH deserves as much respect as anyone else	3.36 (0.6)	3.14 (0.5)	<0.001	3.40 (0.7)	3.09 (0.6)	<0.001	0.795

Notes:

* Student’s t-test for HIV/non-HIV effect;

** Student’s t-test for sample effect.

Abbreviations: PLWH, people living with HIV; R, reversed items; SD, standard deviation.

Table 2 Summary of stigma items among health care providers in development and validation sample

Items for health care providers	Sample 1	Sample 2	P-value#
	Mean (SD)	Mean (SD)
1. PLWH through sex and drug use got what they deserved	2.08 (0.8)	2.33 (1.0)	0.018
2. People infected through commercial sex deserve sympathy	2.11 (0.8)	2.34 (1.0)	0.026
3. People infected through drug use deserve sympathy	1.98 (0.8)	2.32 (1.0)	0.001
4. People who behave promiscuously should be blamed for AIDS	2.09 (0.9)	2.25 (1.0)	0.126
5. Deserve good care – blood donation (R)	2.10 (1.0)	2.27 (1.0)	0.132
6. Deserve good care – commercial sex (R)	1.75 (1.0)	1.94 (1.1)	0.113
7. Deserve good care – drug use (R)	1.73 (0.9)	2.08 (1.2)	0.003
8. If I worked with HIV-positive patients, I would want to change my job	1.82 (0.7)	1.96 (0.9)	0.138
9. I feel ashamed if I know someone with AIDS	2.15 (0.7)	2.25 (0.9)	0.251
10. I feel ashamed if a relative got HIV/AIDS	2.13 (0.7)	2.17 (1.0)	0.683
11. I am afraid of PLWH	2.04 (0.8)	2.30 (1.1)	0.017
12. I would not buy from a vendor who has HIV/AIDS	1.97 (0.9)	1.94 (1.0)	0.756
13. I would not share utensils with PLWH	1.96 (0.9)	2.02 (0.9)	0.530
14. I am willing to work with HIV-positive patients (R)	1.68 (0.8)	1.76 (1.0)	0.443
15. I am willing to provide same care to all patients (R)	1.62 (0.9)	1.86 (1.0)	0.029
16. I am willing to perform a physical examination of HIV-positive patient (R)	1.49 (0.8)	1.72 (1.0)	0.022
17. I am willing to interact with HIV-positive patients in the same way as other patients (R)	1.60 (0.9)	1.81 (1.0)	0.053

Note:

# Student’s t-test for sample effect.

Abbreviations: PLWH, people living with HIV/AIDS; R, reversed items; SD, standard deviation.

Table 3 Distribution of characteristics among HIV and non-HIV patients

Variables	Development sample (n =1,395)						Validation sample (n =1,334)
	Total		HIV		non-HIV		Total		HIV		non-HIV
	n	%	n	%	n	%	n	%	n	%	n	%
Age (mean, SD)	38.8 (12.0)		38.1 (11.0)		39.5 (13.0)		38.8 (14.0)		38.9 (12.1)		39.7 (15.6)
Gender
Female	516	37.9	270	38.8	590	84.4	493	37.0	246	36.9	505	75.7
Male	847	62.1	426	61.2	109	15.6	841	63.0	421	63.1	162	24.3
Ethnic group
Han	984	72.2	504	72.4	590	84.4	985	73.8	480	72.0	505	75.7
Other	379	27.8	192	27.6	109	15.6	349	26.2	187	28.0	162	24.3
Religious belief
No	1,027	75.3	522	75.0	627	89.7	1,068	80.1	505	75.7	563	84.4
Yes	336	24.7	174	25.0	72	10.3	266	19.9	162	24.3	104	15.6
Place of residence
Rural	960	70.4	490	70.4	268	38.3	725	54.3	470	70.5	255	38.2
Urban	403	29.6	206	29.6	431	61.7	609	45.7	197	29.5	412	61.8
Marital status
Single	334	24.5	159	22.8	123	17.6	336	25.2	175	26.2	161	24.1
Married/cohabiting	741	54.4	383	55.0	552	79	817	61.2	358	53.7	459	68.8
Separated/divorced/widowed	288	21.1	154	22.1	24	3.4	181	13.6	134	20.1	47	7.0
Size of family
1	88	6.5	52	7.5	6	0.9	42	3.1	36	5.4	6	0.9
2–4	1,042	76.4	535	76.9	495	70.8	990	74.2	507	76.0	483	72.4
≥5	233	17.1	109	15.7	198	28.3	302	22.6	124	18.6	178	26.7
Education
Primary school or less	283	20.8	144	20.7	162	23.2	298	22.3	139	20.8	159	23.8
Junior high school	635	46.6	296	42.5	372	53.2	627	47.0	339	50.8	288	43.2
Senior high school	335	24.6	158	22.7	153	21.9	364	27.3	177	26.5	187	28.0
University or equivalent	110	8.1	98	14.1	12	1.7	45	3.4	12	1.8	33	4.9
Occupational status
Government-employed	126	9.2	62	8.9	67	9.6	167	12.5	64	9.6	103	15.4
Enterprise-employed	503	36.9	256	36.8	243	34.8	437	32.8	247	37.0	190	28.5
Self-employed	195	14.3	172	24.7	37	5.3	40	3.0	23	3.4	17	2.5
Unemployed	539	39.5	206	29.6	352	50.4	690	51.7	333	49.9	357	53.5
Household income (CNY)
<800	294	21.6	163	23.4	81	11.6	196	14.7	131	19.6	65	9.7
801–2,000	340	24.9	177	25.4	145	20.7	258	19.3	163	24.4	95	14.2
2,001–5,000	409	30	184	26.4	233	33.3	447	33.5	225	33.7	222	33.3
5,001–8,000	165	12.1	88	12.6	151	21.6	234	17.5	77	11.5	157	23.5
≥8,001	155	11.4	84	12.1	89	12.7	199	14.9	71	10.6	128	19.2
HIV/AIDS stigma score (mean, SD)
Internalized stigma			44.6 (8.0)						45.0 (7.9)
Personal stigma					41.3 (5.8)						40.7 (6.1)

Abbreviations: SD, standard deviation; CNY, Chinese Yuan.

Table 4 Distribution of characteristics among health care providers

Variables	Development		Validation
	sample (n= 157)		sample (n= 155)
	n	%	n	%
Age (mean, SD)	34.5 (10.6)		32.5 (10.1)
Gender
Female	141	50.7	137	88.4
Male	16	10.2	18	11.6
Ethnic group
Han	133	84.7	131	84.5
Other	24	15.3	24	15.5
Religious belief
No	129	82.2	130	83.9
Yes	28	17.8	25	16.1
Marital status
Single	48	30.6	69	44.5
Married/cohabiting	103	65.6	81	52.3
Separated/divorced/widowed	6	3.8	5	3.2
Size of family
1	3	1.9	3	1.9
2–4	123	78.3	125	80.6
≥5	31	19.7	27	17.4
Employment level
Elementary	89	56.7	101	65.2
Intermediate	37	23.6	41	26.5
Advanced	31	19.7	13	8.4
Years of professional experience (mean, SD)	13.7 (10.8)		10.3 (9.7)
Job title
Doctor	55	35.0	43	27.7
Nurse	88	56.1	101	65.2
Other	14	8.9	11	7.1
Education
High school or less	27	17.2	39	25.2
University or equivalent	130	82.8	116	74.8
Household income (CNY)
<2,000	11	7.0	13	8.4
2,001–5,000	34	21.7	55	35.5
5,001–8,000	66	42.0	62	40.0
8,001–13,000	32	20.4	14	9.0
≥13,001	14	8.9	11	7.1
HIV/AIDS stigma score (mean, SD)	32.3 (8.8)		35.3 (9.6)

Abbreviations: SD, standard deviation; CNY, Chinese Yuan.

Figure 2 Scree plots for the three scales of internalized stigma, personal stigma, and occupational stigma.

Notes: (A) Internalized stigma among HIV-positive patients. (B) Personal stigma among non-HIV patients. (C) Occupational stigma among health care providers.
Abbreviations: FA, exploratory factor analysis; PC, principal component analysis.

Table 5 Factor loadings among HIV and non-HIV patients and health care providers in development and validation samples

Items	Factor loadings
	Development sample			Validation sample
	Factor 1	Factor 2	Factor 3
1) Items of internalized stigma among HIV patients (α=0.869)
Being refused (α=0.880)
7. I would understand if people rejected my friendship because I am HIV-positive	0.82			0.67
8. My neighbors would not like me living next door if they knew I had HIV	0.81			0.58
16. Because of my HIV, people would not date me	0.81			0.58
12. Most employers would not employ me because I am HIV-positive	0.73			0.56
13. If I was on public or private transport and someone knew I had HIV, they would not sit next to me	0.70			0.54
14. If I eat around a restaurant and people knew I had HIV, they would not eat in the same place	0.69			0.61
4. When people know I have HIV, I feel uncomfortable around them	0.66			0.44
Guilt (α=0.709)
3. I feel that it is my fault that I got HIV		0.84		0.63
5. Getting HIV is a punishment for bad behavior		0.78		0.53
2. I must have done something wrong to deserve getting HIV		0.68		0.63
2) Items of personal stigma among non-HIV patients (α=0.853)
Refusing (α=0.810)
7. I would not like to be friends with someone with HIV	0.88			0.54
8. I would not like someone with HIV to be living next door	0.80			0.49
9. If I was in public or private transport, I would not like to sit next to someone with HIV	0.76			0.42
16. I would not date with a person if I know that he/she has HIV	0.76			0.41
6. I feel afraid to be around people with HIV	0.74			0.45
4. I feel uncomfortable around people with HIV	0.69			0.45
11. I think less of someone because they have HIV	0.67			*
Blaming (α=0.852)
2. If you have HIV, you must have done something wrong to deserve it		0.85		0.51
1. People with HIV should be ashamed of themselves		0.81		0.45
3. People with HIV/AIDS have only themselves to blame		0.79		0.43
5. I think getting HIV is a punishment for bad behavior		0.61		0.42
3) Items of stigma from health care providers (α=0.839)
Blaming (α=0.872)
1. People who got HIV/AIDS through sex and drug use, got what they deserved	0.89			0.79
4. People who behave promiscuously should be blamed for AIDS	0.86			0.79
3. Infected through drug use deserve sympathy	0.86			0.84
2. Infected through commercial sex deserve sympathy	0.82			0.80
Professionalism* (α=0.893)
15. Willing to provide same care (R)		0.92		0.94
16. Willing to do physical examination of HIV-positive patients (R)		0.88		0.85
17. Willing to interact same as other patients (R)		0.83		0.89
14. Willing to work with HIV-positive patients (R)		0.70		0.60
Egalitarianism* (α=0.780)
6. Deserve good care – commercial sex (R)			0.90	1.04
7. Deserve good care – drug use (R)			0.88	0.95
5. Deserve good care – blood donation (R)			0.68	0.50

Notes: The items are ranked by the value of factor loadings from largest to smallest in the same factor. The numbers represent items in accordance with numbers in Table 1.

* Means that the coefficient for that item is <0.4, so it was omitted from validation sample.

Abbreviation: R, score reversed before loading.

Table 6 Correlation of latent factors in three scales

Stigma types	Internalized stigma	Personal stigma	Occupational stigma of health care providers
	Guilt	Blaming	Professionalism	Egalitarianism
Internalized stigma
Being refused	0.54
Personal stigma
Refusing		0.70
Occupational stigma
Blaming			0.23	0.39
Professionalism				0.27

Table 7 Crude coefficients (95% CI) of HIV/AIDS stigmas and sample characteristics

Variables	Internalized stigma of HIV patients		Personal stigma of non-HIV patients		Occupational stigma
	Being refused	Guilt	Refusing	Blaming	Blaming	Professionalism	Egalitarianism
Age (years): >40 vs ≤40	0.18 (0.05, 0.32)	0.14 (−0.01, 0.28)	0.27 (0.13, 0.40)	0.23 (0.09, 0.37)	−0.18 (−0.54, 0.18)	−0.33 (−0.67, 0.01)	0.02 (−0.30, 0.34)
Gender: male vs female	0.22 (0.08, 0.35)	−0.05 (−0.20, 0.10)	0.01 (−0.13, 0.15)	−0.13 (−0.27, 0.02)	0.06 (−0.42, 0.54)	−0.23 (−0.69, 0.24)	0.75 (0.28, 1.22)
Ethnicity: other vs Han	0.07 (−0.08, 0.21)	0.22 (0.06, 0.38)	0.10 (−0.06, 0.25)	0.11 (−0.06, 0.27)	0.06 (−0.37, 0.48)	0.15 (−0.27, 0.56)	0.29 (−0.13, 0.72)
Religious belief: yes vs no	0.04 (−0.11, 0.19)	0.10 (−0.06, 0.27)	0.23 (0.04, 0.42)	0.14 (−0.05, 0.34)	0.17 (−0.25, 0.59)	0.35 (−0.06, 0.75)	−0.06 (−0.49, 0.36)
Marital status: married vs single	0.13 (0.00, 0.26)	0.26 (0.12, 0.41)	0.21 (0.06, 0.36)	0.29 (0.14, 0.44)	0.13 (−0.18, 0.44)	0.40 (0.11, 0.70)	0.19 (−0.12, 0.5)
Education: ≥ university vs < university	0.37 (−0.12, 0.87)	−0.08 (−0.62, 0.45)	0.04 (−0.28, 0.35)	0.05 (−0.27, 0.38)	−0.71 (−1.05, −0.37)	−0.56 (−0.90, −0.23)	−0.40 (−0.75, −0.05)
Household income: ≥5,000 vs <5,000	−0.14 (−0.30, 0.02)	−0.28 (−0.45, −0.11)	−0.01 (−0.15, 0.13)	0.03 (−0.11, 0.17)	0.16 (−0.15, 0.47)	0.06 (−0.24, 0.36)	0.42 (0.12, 0.73)

Note: Bold values indicate statistical significance.

Abbreviation: CI, confidence interval.