Myanmar version of the HIV stigma scale

1. Abstract

The Myanmar version of the HIV stigma scale (HIVSS-M-3) is a culturally adapted, psychometrically validated patient-reported outcome measure designed to evaluate the multi-faceted manifestations of human immunodeficiency virus (HIV)-related stigma among individuals living with HIV in Myanmar. HIV-related stigma represents a pervasive global health obstacle that impedes voluntary counseling and testing, compromises adherence to antiretroviral therapy (ART), and exacerbates psychological morbidity. Because stigma manifests through culture-bound idioms of distress and local cosmological beliefs, Western measurement instruments frequently fail to capture contextualized experiences within Southeast Asian populations. Developed through a collaborative synthesis of the seminal Berger HIV Stigma Scale and adaptations tailored for South Asian populations, the HIVSS-M-3 addresses this gap by capturing both canonical stigma domains and indigenous socio-religious constructs, specifically Buddhist understandings of karmic retribution.

The instrument comprises 35 self-report items distributed across six empirically substantiated dimensions: Personalized Stigma, Concerns with Public Attitudes, Negative Self-Image, Healthcare Provider Stigma, Disclosure Concerns, and Religious Concerns. Psychometric evaluation in a sample of adults living with HIV demonstrated robust internal consistency across all subscales, with Cronbach’s alpha coefficients ranging from 0.72 to 0.95. Modern measurement evaluation utilizing Rasch model analysis verified adequate item fit, with infit and outfit mean square statistics falling within the acceptable parameter bounds of 0.68 to 1.40, and established an absence of differential item functioning across biological sex and educational attainment. Factor analytic procedures confirmed that the multidimensional construct accounted for 68.23% of total variance. Convergent validity was established via strong correlations with depressive symptomatology and social support. The HIVSS-M-3 represents an empirically rigorous, culturally grounded psychometric instrument vital for behavioral medicine, epidemiologic investigations, and health systems research in resource-limited Southeast Asian settings.

2. Keywords

HIV stigma, Psychometrics, Myanmar, Cross-cultural adaptation, Rasch analysis, Health psychology, Internalized stigma, Enacted stigma, Antiretroviral adherence, Medical sociology

3. Authors

The adaptation and psychometric validation of the Myanmar version of the HIV stigma scale was executed through an international, interdisciplinary partnership involving public health institutions, academic medical centers, and community-led civil society organizations:

• Feifei Huang, PhD, RN — School of Nursing, Fujian Medical University, Fuzhou, Fujian, China.
• Wei-Ti Chen, PhD, RN, FAAN — School of Nursing, University of California, Los Angeles (UCLA), Los Angeles, California, United States. Corresponding Author: [email protected].
• Cheng-Shi Shiu, PhD — Department of Social Work, National Taiwan University, Taipei, Taiwan.
• Sai Htun Lin — Advocacy, Human Rights & Technical Services Department, Secretariat Office, Myanmar Positive Group (MPG), Yangon, Myanmar.
• Min San Tun — Advocacy, Human Rights & Technical Services Department, Secretariat Office, Myanmar Positive Group (MPG), Yangon, Myanmar.
• Thet Wai Nwe, MD — National AIDS Program, Department of Public Health, Ministry of Health and Sports, Naypyitaw, Myanmar.
• Yin Thet Nu Oo, MD, PhD — Health Systems Research Division, Department of Medical Research, Yangon, Myanmar.
• Htun Nyunt Oo, MD — National AIDS Program, Department of Public Health, Ministry of Health and Sports, Naypyitaw, Myanmar. Corresponding Author: [email protected].

4. Purpose

The primary clinical and epidemiologic objective of the Myanmar version of the HIV stigma scale is to provide a standardized, culturally calibrated diagnostic instrument for identifying the severity, configuration, and downstream psychosocial impacts of stigma among people living with HIV (PLWH) in Myanmar. While international public health targets established by UNAIDS (such as the 95-95-95 cascade targets) aim to diagnose 95% of all HIV-positive individuals, provide sustained antiretroviral therapy for 95% of those diagnosed, and achieve viral suppression for 95% of those treated, pervasive social discrimination remains an intractable obstacle. In low- and middle-income countries, the persistence of health-related stigma directly undermines the care cascade by discouraging testing, delaying post-diagnosis linkage to clinical services, inducing treatment non-adherence, and generating severe psychological distress.

In Myanmar, social, economic, and political shifts have complicated public health infrastructure, placing heavy burdens on vulnerable populations. Clinicians and community-based health workers historically lacked an empirical assessment instrument adapted to the specific Burmese sociocultural landscape. Conventional Western instruments often assume secularized or individualized paradigms of disease causality, neglecting the powerful role of communal collectivism and local religious frameworks. By addressing these conceptual omissions, the HIVSS-M-3 facilitates targeted, evidence-based intervention planning across hospital, ambulatory, and community settings.

From an applied behavioral perspective, the tool enables clinical investigators to disaggregate generic distress into distinct psychopathological dimensions. For instance, distinguishing between internalized self-blame and external institutional mistreatment allows clinicians to tailor psychological support versus administrative advocacy. Furthermore, the scale functions as an evaluative endpoint for non-governmental organizations, peer support networks, and state-sponsored healthcare initiatives seeking to quantify the efficacy of community de-stigmatization campaigns, institutional sensitivity training, and peer-to-peer psychological counseling models.

5. Psychological Construct

The overarching construct evaluated by the HIVSS-M-3 is health-related stigma, conceptualized as a multidimensional, socially situated process wherein an individual possesses an attribute that marks them as devalued, deviant, or socially discredited within a particular cultural matrix. Building upon established sociological and health psychology frameworks, the HIVSS-M-3 delineates stigma into six distinct latent dimensions:

Personalized Stigma (Enacted Stigma)

Personalized stigma reflects concrete, overt experiences of social rejection, interpersonal hostility, social exclusion, and relational estrangement directly attributable to an individual’s serostatus. Rather than anticipating harm, respondents reporting high personalized stigma have encountered explicit forms of discrimination, such as being abandoned by friends, subjected to verbal harassment, or excluded from communal meals. This dimension captures the tangible disruption of social bonds and loss of interpersonal status in everyday life.

Concerns with Public Attitudes

This subscale assesses an individual’s perception of macro-level societal hostility, cultural stereotypes, and community prejudices targeting people living with HIV. Even in the absence of direct personal confrontation, a person’s cognitive awareness that society views HIV-positive individuals as dangerous, morally contaminated, or deserving of social expulsion creates profound vulnerability. High scores denote heightened vigilance regarding widespread public antipathy and community intolerance.

Negative Self-Image (Internalized Stigma)

Negative self-image operationalizes the psychological process of internalized stigma, occurring when an individual absorbs external prejudices, moral condemnations, and social stereotypes into their own self-concept. Clinically manifesting as chronic guilt, unworthiness, disgust, and self-directed revulsion, this facet directly erodes self-esteem and self-efficacy. Individuals endorse feelings that their diagnosis makes them fundamentally tainted, inferior, or personally ruined, which frequently precipitates clinical depression and suicidal ideation.

Healthcare Provider Stigma

Medical setting discrimination represents an institutional form of enacted and anticipated stigma occurring where safety and care are explicitly expected. This dimension quantifies patient encounters with discriminatory attitudes, clinical neglect, breach of medical confidentiality, excessive isolation protocols, or outright refusal of service by nurses, physicians, and paramedical personnel. Because healthcare provider stigma directly interrupts access to life-saving antiretroviral therapy, it constitutes one of the most clinically harmful sub-constructs.

Disclosure Concerns

This factor evaluates cognitive preoccupation, behavioral hypervigilance, and emotional distress centered on keeping one’s HIV diagnosis confidential. In socio-cultural environments where HIV is intensely stigmatized, the management of personal information becomes a primary coping mechanism. High disclosure anxiety reflects profound fear that involuntary revelation of serostatus will lead to social ostracization, job loss, physical abandonment, or familial disgrace, driving individuals to expend substantial cognitive and logistical energy concealing medications and clinic visits.

Religious Concerns (Karmic Stigma)

An essential cultural innovation of the HIVSS-M-3 is the formal operationalization of religious concerns, specifically situated within Theravada Buddhist cosmological frameworks. In Myanmar, the philosophical concept of karma (cause and effect spanning lifetimes) can be socially weaponized or internally interpreted as retributive justice. An individual may view HIV infection not merely as a biological event, but as physical and spiritual retribution for transgressions committed in a previous life (kan). This localized facet captures the existential guilt, cosmic blameworthiness, and spiritual isolation that Western psychometric measures fail to assess.

6. Theoretical Framework

The conceptual architecture of the HIVSS-M-3 is rooted in classic sociological theories of stigma, synthesized with contemporary social-cognitive and cross-cultural psychological paradigms. The foundational underpinning is derived from Erving Goffman’s seminal work on stigma, defined as an attribute that is deeply discrediting and reduces the bearer from a whole person to a tainted, discounted one. Goffman classified stigma into three typologies: abominations of the body, blemishes of individual character, and tribal stigma. In the context of HIV in Southeast Asia, all three typologies coalesce: the physical illness is conflated with perceived moral failings (sexual promiscuity, substance use) and cultural transgressions that bring collective shame upon the kinship group.

To operationalize Goffman’s theoretical propositions for clinical research, the instrument incorporates Earnshaw and Chaudoir’s Stigma Mechanisms Framework. This model posits that health-related stigma functions through three interactive mechanisms: enacted stigma (past experiences of discrimination), anticipated stigma (expectations of future mistreatment), and internalized stigma (self-blame and endorsement of negative beliefs). The HIVSS-M-3 adapts these mechanisms into patient-reported subscales that accurately capture the psychological demands of managing a stigmatized identity.

Furthermore, the instrument relies on the theoretical work of Barbara Berger, who developed the original 40-item HIV Stigma Scale in the United States, establishing four core domains: personalized stigma, disclosure concerns, negative self-image, and public attitudes. However, cross-cultural psychometric research by Steward et al. and Jeyaseelan et al. demonstrated that Western frameworks often assume autonomous individualism and secularized attributions of illness. In communal, religious societies, illness is frequently experienced through collective family identity and moral-spiritual causation.

In Myanmar, where the vast majority of the population adheres to Theravada Buddhism, philosophical concepts of suffering (dukkha), moral action, and karmic retribution fundamentally shape health beliefs. When disease etiology is interpreted through the lens of karmic demerit, the diagnosis becomes moralized: the infection is seen as proof of past unrighteous conduct. By integrating this indigenous cosmological belief system into classical social-cognitive models, the HIVSS-M-3 operationalizes an advanced, culturally competent measurement paradigm.

7. Validity

Validation of the HIVSS-M-3 was conducted following the criteria outlined by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) initiative, integrating both Classical Test Theory (CTT) and modern Item Response Theory (IRT) paradigms.

Construct and Structural Validity

Structural validity was assessed via comprehensive exploratory factor analysis (EFA) combined with modern Rasch analysis. The structural integrity of the 35-item scale was verified through Rasch item fit statistics. Item infit and outfit mean-square (MnSq) statistics were calculated to determine how closely the individual survey items aligned with the latent measurement dimension. All 35 items exhibited infit and outfit values spanning from 0.68 to 1.40, falling cleanly within the established psychometric benchmark of 0.60 to 1.40. This confirms that the items measure a coherent psychological construct without introducing excessive noise or item redundancy.

Differential Item Functioning (DIF)

To confirm measurement invariance, Rasch analysis was leveraged to detect potential differential item functioning (DIF) across key demographic variables. The analysis demonstrated that no items exhibited notable DIF across participant biological sex or educational attainment. This confirms that the scale items operate equivalently across demographic strata, enabling meaningful comparative clinical analyses without measurement bias.

Convergent Validity

Convergent validity was evaluated by assessing theoretical associations with established psychological instruments: the Center for Epidemiological Studies Depression Scale (CES-D) and the Medical Outcomes Study–Social Support Survey (MOS-SSS). In accordance with psychological theory, total and subscale scores on the HIVSS-M-3 demonstrated statistically robust correlations:

• Depressive Symptoms (CES-D): A significant positive correlation of r = 0.60 (p < 0.001) was observed, validating the theoretical expectation that elevated perceived and internalized stigma directly corresponds to heightened psychological distress and depressive symptomatology.
• Perceived Social Support (MOS-SSS): A robust, statistically significant negative correlation of r = -0.77 (p < 0.001) was established, demonstrating that higher levels of experienced stigma are closely tied to social isolation and the breakdown of perceived interpersonal and structural support networks.

8. Reliability

The internal consistency and measurement precision of the HIVSS-M-3 were evaluated through Classical Test Theory and Rasch item response metrics. Reliability statistics confirmed high internal consistency across the instrument’s dimensions:

Classical Internal Consistency

Across the six extracted dimensions, Cronbach’s alpha coefficients met or exceeded conventional benchmarks for psychometric reliability (α ≥ 0.70 for research, α ≥ 0.80 for clinical screening):

• Personalized Stigma: Cronbach’s α = 0.95 (demonstrating excellent measurement precision for overt discrimination experiences).
• Concerns with Public Attitudes: Cronbach’s α = 0.91.
• Negative Self-Image: Cronbach’s α = 0.88.
• Healthcare Provider Stigma: Cronbach’s α = 0.86.
• Disclosure Concerns: Cronbach’s α = 0.82.
• Religious Concerns: Cronbach’s α = 0.72 (acceptable reliability for a concise, three-item culturally specific subscale).

Rasch Reliability and Separation Statistics

Modern measurement indices derived from Rasch calibration provided additional verification of instrument reliability across the latent continuum:

• Person Reliability Index: Values of 3.40 and 1.53 demonstrated that the scale effectively discriminates respondents along varying levels of underlying stigma severity.
• Separation Indices: Separation metrics yielded values of 0.92 and 0.70, confirming that the scale successfully stratifies respondents into distinct performance strata without substantial measurement distortion.

9. Factor Analysis

The dimensional structure of the HIVSS-M-3 was established using Exploratory Factor Analysis (EFA) alongside iterative Rasch calibration, refining an initial pool of 47 candidate items down to 35 finalized items.

Dimensional Extraction and Variance

Prior to factor extraction, data suitability for dimension reduction was evaluated using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity. Parallel analysis and scree plot examination supported a clear six-factor model. The resulting six-factor solution explained an impressive 68.23% of the total cumulative variance in stigma responses, confirming robust structural representation of the construct.

Item Pruning and Factor Loadings

Items were evaluated against strict psychometric retention criteria:

• Retention required a primary factor loading of ≥ 0.40 on the target latent construct.
• Items displaying prominent cross-loadings (≥ 0.35 on multiple secondary dimensions) were eliminated to preserve conceptual distinctiveness.
• Items exhibiting Rasch outfit or infit mean squares outside the 0.68–1.40 range were removed.

This systematic refinement process led to the exclusion of 12 problematic items from the initial 47-item pool, resulting in a streamlined 35-item scale with clear factor differentiation:

• Factor 1: Personalized Stigma (10 items: Items 29, 18, 33, 38, 35, 36, 32, 28, 24, 34 in the analysis pool; standardized loadings ranged from 0.58 to 0.87).
• Factor 2: Concerns with Public Attitudes (7 items: Items 10, 20, 16, 9, 40, 14, 5; standardized loadings ranged from 0.52 to 0.81).
• Factor 3: Negative Self-Image (6 items: Items 23, 12, 7, 15, 2, 3; standardized loadings ranged from 0.55 to 0.84).
• Factor 4: Healthcare Provider Stigma (4 items: Items 46, 45, 44, 47; standardized loadings ranged from 0.61 to 0.89).
• Factor 5: Disclosure Concerns (5 items: Items 17, 37, 6, 25, 19; standardized loadings ranged from 0.48 to 0.79).
• Factor 6: Religious Concerns (3 items: Items 41, 43, 42; standardized loadings ranged from 0.63 to 0.82).

10. Instrument / Measurement Tool

• Full Instrument Name: Myanmar version of the HIV stigma scale (HIVSS-M-3)
• Test Type: Patient-Reported Outcome Measure (PROM); psychological self-report questionnaire
• Item Count: 35 items
• Format: 35 items, self-report response format
• Target Population: Adult individuals living with HIV (aged 18 years and older)
• Language: Burmese (Myanmar language)
• Subscale Architecture:
  • Personalized Stigma (Enacted Stigma)
  • Concerns with Public Attitudes
  • Negative Self-Image (Internalized Stigma)
  • Healthcare Provider Stigma
  • Disclosure Concerns
  • Religious Concerns (Karmic Stigma)
• Administration Mode: Self-administered electronically (e.g., via REDCap) or paper-and-pencil clinical administration
• Completion Time: Approximately 15 to 30 minutes when delivered as part of a comprehensive psychosocial assessment battery
• Scoring Instructions: Item scores are summed across corresponding subscale items to generate individual dimension scores, as well as summed overall to yield a total global stigma score. Higher cumulative scores indicate greater perceived, experienced, and internalized stigma.

11. Permissions & Fee and Test Year

The Myanmar version of the HIV stigma scale was formally published in 2021 following cross-cultural adaptation and psychometric validation led by Dr. Feifei Huang, Dr. Wei-Ti Chen, and colleagues, in direct partnership with the National AIDS Program of Myanmar and the Myanmar Positive Group (MPG). The scale validation study was published in BMC Public Health under an open-access Creative Commons Attribution 4.0 International License (CC BY 4.0), permitting educational, clinical, and non-commercial research use provided appropriate scientific citation is maintained.

No licensing fees or commercial royalties are required for academic research or clinical quality improvement use. Clinical investigators, health researchers, and non-governmental entities seeking to utilize the instrument in its authorized Burmese format are encouraged to contact the corresponding authors (Dr. Wei-Ti Chen at UCLA: [email protected], or Dr. Htun Nyunt Oo at the Ministry of Health: [email protected]) to obtain the original language master forms and implementation documentation.

12. References

• Berger, B. E., Ferrans, C. E., & Lashley, F. R. (2001). Measuring stigma in people with HIV: Psychometric assessment of the HIV Stigma Scale. Research in Nursing & Health, 24(6), 518–529. https://doi.org/10.1002/nur.10011
• Earnshaw, V. A., & Chaudoir, S. R. (2009). From conceptualizing to measuring HIV stigma: A review of HIV stigma mechanism measures. AIDS and Behavior, 13(6), 1160–1177. https://doi.org/10.1007/s10461-009-9593-3
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Huang, F., Chen, W. T., Shiu, C. S., Lin, S. H., Tun, M. S., Nwe, T. W., Oo, Y. T. N., & Oo, H. N. (2021). Myanmar version of the HIV stigma scale. BMC Public Health, 21(1), Article 1685. https://doi.org/10.1186/s12889-021-11685-w
• Jeyaseelan, L., Kumar, S., Mohanraj, R., Rebekah, G., Rao, D., & Manhart, L. E. (2013). Assessing HIV/AIDS stigma in south India: Validation and abridgement of the Berger HIV stigma scale. AIDS and Behavior, 17(1), 434–443. https://doi.org/10.1007/s10461-011-0128-3
• Linacre, J. M. (2015). A user’s guide to Winsteps Ministep: Rasch-model computer programs. Winsteps.com.
• Steward, W. T., Herek, G. M., Ramakrishna, J., Bharat, S., Chandy, S., Wrubel, J., & Ekstrand, M. L. (2008). HIV-related stigma: Adapting a theoretical framework for use in India. Social Science & Medicine, 67(8), 1225–1235. https://doi.org/10.1016/j.socscimed.2008.05.032
• Terwee, C. B., Bot, S. D., de Boer, M. R., van der Windt, D. A., Knol, D. L., Dekker, J., Bouter, L. M., & de Vet, H. C. (2007). Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology, 60(1), 34–42. https://doi.org/10.1016/j.jclinepi.2006.03.012

13. Items of the Scale