Re-validation and cultural adaptation of the brief, standardized assessment tool for measuring HIV-related stigma in healthcare settings in Almaty, Kazakhstan

PLOS ONE RESEARCH ARTICLE Re-validation and cultural adaptation of the brief, standardized assessment tool for measuring HIV-related stigma in healthcare settings in Almaty, Kazakhstan Balnur Iskakova ID1*, Zhamilya Nugmanova1, Recai Murat Yucel2, Kristi E. Gamarel3, Elizabeth J. King3 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Epidemiology, School of Public Health, Kazakh National Medical University Named After S. D. Asfendiyarov, Almaty, Kazakhstan, 2 Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, Pennsylvania, United States of America, 3 Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America * Abstract OPEN ACCESS Citation: Iskakova B, Nugmanova Z, Murat Yucel R, Gamarel KE, King EJ (2022) Re-validation and cultural adaptation of the brief, standardized assessment tool for measuring HIV-related stigma in healthcare settings in Almaty, Kazakhstan. PLoS ONE 17(11): e0276770. https://doi.org/10.1371/ journal.pone.0276770 Editor: Alpamys Issanov, Nazarbayev University School of Medicine, KAZAKHSTAN Received: May 25, 2022 Accepted: October 13, 2022 Published: November 2, 2022 Copyright: © 2022 Iskakova et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. The HIV epidemic continues to grow in Kazakhstan and HIV stigma remains a major barrier to HIV prevention and treatment in the country. HIV stigma in healthcare setting may also discourage people living with HIV (PLHIV) from getting the care needed. Therefore, studying the attitudes of healthcare workers towards PLHIV is important and requires well-constructed measurement tools adapted to the specific cultural context. In our study, we aimed to adapt and re-validate a brief questionnaire on HIV stigma among healthcare workers in Almaty, Kazakhstan. We held focus group discussions to obtain input on an existing questionnaire and surveyed 448 primary healthcare providers to psychometrically evaluate the scale. The final HIV-stigma scale consisted of 15 items, 6 of them measuring negative opinions about PLHIV and the rest assessing stigmatizing health facility policies towards PLHIV. Both HIV-stigma subscales demons6trated adequate psychometric properties (with Cronbach’s alpha α = 0.57 for the first and α = 0.86 for the second subscale, and with factor loadings >0.35 within each subscale). High numbers of respondents holding negative attitudes towards PLHIV, detected in this sample (87%; n = 380), may suggest the need for immediate actions addressing HIV stigma in healthcare in Kazakhstan. Introduction Human immunodeficiency virus (HIV)- related stigma continues to be a barrier to addressing the HIV epidemic, restricting access to prevention, testing and treatment services for those who need the services the most [1]. Discriminatory behaviors towards people living with HIV (PLHIV), as a manifestation of stigma, has been linked to poorer psychological wellbeing among individuals affected by HIV, which can result in social isolation and decreased PLOS ONE | https://doi.org/10.1371/journal.pone.0276770 November 2, 2022 1 / 12 PLOS ONE Re-validation and cultural adaptation of HIV-related stigma assessment tool retention in HIV care [2–5]. HIV stigma in healthcare settings can serve as an extra burden for PLHIV in getting necessary medical care [3]. Kazakhstan, a country in the Eastern European and Central Asian (EECA) region, is gradually meeting the goals set by the Joint United Nations Program on HIV/AIDS on ending AIDS by 2030 (95-95-95). According to the latest estimates, around 77% of PLHIV in Kazakhstan (among men and women aged 15 years and older) were aware of their status, 57% were on antiretroviral therapy and only 48% had suppressed viral loads by 2020 [6]. HIV stigma has been posited to be one of the main contributing factors to low levels of HIV care coverage in the country [7–10]. A survey conducted among PLHIV in several regions in Kazakhstan showed healthcare facilities to be the most commonly reported setting of experienced HIV stigma and discrimination: 17.6% of the respondents reported receiving some levels discrimination and 6% of them suggested strong discriminative behaviors from healthcare staff [5]. Despite the significance of HIV stigma in each step of the HIV care continuum, there are numerous limitations in addressing this issue scientifically. The measurement of HIV stigma has been largely restricted to the perspectives of PLHIV [11], which neglects to account for the role of those who enact stigma. In other words, a focus on PLHIV has the potential to place the responsibility on those being stigmatized to cope with discrimination without attending to the structures and systems that perpetuate these conditions. Studying HIV-related stigma from the perspective of those who enact is also important in attempting organization-level interventions on addressing this issue [12]. The validity of HIV stigma scales being developed presents an additional challenge. Systematic reviews suggest numerous scales are being used, many of which are not validated or adapted to different languages and cultures [13, 14]. Translating a measuring instrument into the language of the study population alone has shown to be not adequate for its further use [15, 16]. This is particularly true if the phenomenon is an attitude that cannot be measured and compared across cultures directly [15]. In addition, country specific characteristics of the phenomenon under investigation need to be considered within the adaptation of survey tools. For example, PLHIV are generally known to face multiple stigmas interlinked between HIVrelated stigma and other forms of marginalization such as gender identity, sexual orientation, occupation and drug abuse history. This issue is particularly relevant to countries where traditional values and norms are confronted with such phenomena [16, 17]. There is no study that addresses the challenges of measuring HIV-related stigma in a Kazakhstani context in our understanding. Therefore, this exploratory study is aimed to re-validate the brief HIV stigma assessment tool [18] in Kazakh and Russian languages and adapt it to country-specific characteristics of the HIV epidemic. Methods Adaptation process The brief HIV stigma assessment tool used in this study was designed and validated in multiple diverse country settings (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christoph (...truncated)