AIDS PATIENT CARE and STDs

Volume 25, Number 11, 2011

Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2011.0008

Measuring Stigma Among Health Care and Social Service

Providers: The HIV/AIDS Provider Stigma Inventory

Scott Edward Rutledge, Ph.D., M.S.W.,1 James Whyte, IV, N.D.,2 Neil Abell, Ph.D., LCSW,3
Kristin M. Brown, M.S.W., M.P.A.,3 and Nicole I. Cesnales, M.S.W., L.S.W.3

Abstract

Initial validation of the HIV/AIDS Provider Stigma Inventory (HAPSI), piloted on a sample of 174 nursing
students, supported the psychometric qualities of a suite of measures capturing tendencies to stigmatize and
discriminate against people living with HIV/AIDS (PLHA). Derived from social psychology and mindfulness
theories, separate scales addressing awareness, acceptance, and action were designed to include notions of
labeling, stereotyping, outgrouping, and discriminating. These were enhanced to capture differences associated
with personal characteristics of PLHA that trigger secondary stigma (e.g., sexual orientation, injection drug use,
multiple sex partners) and fears regarding instrumental and symbolic stigma. Reliabilities were strong (coeffi-
cients a for 16 of 19 resulting measures ranged from 0.80 to 0.98) and confirmatory factor analyses indicated
good model fit for two multidimensional (Awareness and Acceptance) and one unidimensional (Action) mea-
sure. Evidence of convergent construct validity supported accuracy of primary constructs. Implications for
training and professional socialization in health care are discussed.

Introduction sample of baccalaureate nursing students, we discuss ways in

which the HAPSI can be used in a variety of health care and

S tigma is a multilevel challenge to reducing the effects

of the AIDS pandemic. As a social representation of col-
lective fears about contagion and judgment about behavior,
stigma obstructs access to medical and social services for many
people living with HIV/AIDS (PLHA) or those at risk for in-
fection. A great deal of literature has focused on identifying the
antecedents and experiences of stigma in a variety of contexts
around the world and stigma reduction interventions have
been developed. However, measuring stigma using multiple
theoretical approaches remains a work in progress.
This article details the conceptual development and initial
validation of a suite of measures known collectively as the
HIV/AIDS Provider Stigma Inventory (HAPSI). The HAPSI
blends theoretical principles of social psychology and mind-
fulness used in our previous work conceptualizing the
Awareness, Acceptance, and Action Model (AAAM) and pi-
loting a group-level stigma reduction intervention for health
care and social service providers.1 The HAPSI was designed
to assist providers across disciplines in gaining insights into
their attitudes about and interactions with PLHA in order to
identify the presence of stigma related behaviors and opti-
mize clinical outcomes for their patients or clients. Following
presentation of the instruments initial validation with a
social service settings.
The earliest example of research characterizing disease-
related stigma was completed by Goffman who identified the
existence of sources of stigma such as physical deformity,
character-related blemishes and tribal affiliations.2 Goffmans
early works provided the basis for many of the current con-
ceptualizations of HIV-related stigma, which differentiate
categories of stigma as instrumental (fear of physical conta-
gion), symbolic (values- or morality-based judgment), felt,
perceived, or internalized (experiences of prejudice and dis-
crimination), courtesy (felt by providers or families of PLHA),
and enacted (discriminatory actions).35
Researchers have focused on attitudes about PLHA among
the general public; experiences among PLHA with families,
communities, and health care providers; and concerns about
interactions with PLHA among health care providers, in-
cluding nurses. Fear of occupational exposure to HIV has
been a significant source of stress and an antecedent of stigma
among providers.611 Courtesy stigma, or the prejudice and
discrimination directed at caregivers for their work associated
with PLHA, has also been a concern.12
Prejudice toward PLHA among health care workers and
lay people was described by researchers in the 1980s and

1
School of Social Work, Temple University, Philadelphia, Pennsylvania.
2
College of Nursing, 3College of Social Work, Florida State University, Tallahassee, Florida.

673
674
1990s, and later studies confirmed that individuals at risk for
HIV or living with the disease delay or fail to access care to
avoid judgment and rejection by providers, families, and the
general public.3,1315 A meta-analysis of 24 North American
studies of stigma among PLHA revealed significant medium-
sized correlations between stigma and low social support,
poor physical health, poor mental health, age, and income.16
In summary, the literature indicates the importance of rec-
ognizing the effects of stigma as a key influence on individ-
uals health status. As described below, becoming aware of
and accepting the consequences of ones own potential for
stigmatizing clientele in health care or social service settings is
crucial to improving care for PLHA.
Early research in the nursing domain indicated important
correlations between HIV/AIDS and secondary individual
variables.17 Factors considered to be personal choices (e.g.,
drug use, multiple sexual partnerships, same-sex relation-
ships) by providers resulted in negative views of PLHA.
Subsequent studies established the effect of individual re-
flections about PLHAs personal characteristics and behaviors
(e.g., sexual orientation, drug use) on nurses attitudes toward
them.18,19 Although there were correlations between HIV/
AIDS and existing stigmatized statuses (e.g., gay and other
men who have sex with men [MSM] and intravenous drug
users [IDU]), nurses generally possessed empathetic and
positive reflections regarding PLHA.2022
Research has also indicated, however, substantial prejudice
toward PLHA and fear of providing direct care to known HIV
infected persons by some nurses.23,24 Studies have continued
to indicate evidence of stigma in health care settings around
the world.2528 These studies have documented instances in
which providers insult patients; refuse, delay, or neglect their
care; violate confidentiality; and overprotect themselves from
physical contact. Research conducted in various countries of
student nurses attitudes about PLHA and their concerns
about working with them19,2931 points to the importance of
enhancing education about universal precautions and actual
patterns of occupationally related infection of health care
workers, including dentists,32 to reduce fears about trans-
mission. In summary, although the literature indicates some
level of empathy for PLHA, symbolic bias associated with
sexual orientation, promiscuity, and drug use, as well as the
persistence of concerns about occupational exposure, signify
that substantial challenges remain in the effort to decrease
stigmatizing behaviors among nursing professionals.
Although it has been well established that PLHA anticipate
and experience stigma within health care, research on the
measurement of provider stigma has been limited, largely due
to the absence of systematically collected data on the precise
structural nature of HIV-related discrimination in health care
settings.33 Theorizing, exploring, and documenting the de-
terminants of stigma in health care settings is essential for the
creation of antistigma interventions. Measuring stigma is es-
sential to quantify the presence and progression of stigma and
discrimination in health care settings, compare stigma cross-
culturally, determine social trends in stigma-related barriers
to provision of lifesaving treatment options, and evaluate
antistigma campaigns.15 A variety of attempts have been
made to develop such measures either alone, or as a compo-
nent of an intervention.3439
AIDS stigma measures and scales have been used to assess
the general publics attitudes toward PLHA40 as well as the
RUTLEDGE ET AL.
anticipation of and lived experiences with stigma by PLHA,
including psychological and social support factors as well as
barriers to health care.35,41,42 Some scales have been used to
assess health care providers stigmatizing attitudes.43 There
are also examples of scales designed to capture nurses fears
about HIV and their attitudes about serving PLHA. An early
nursing-specific short scale was developed to assess the
willingness to care for and attitudes toward PLHA, MSM, and
IDU,17 and the Nursing Willingness Questionnaire measured
nurses willingness to care for a hypothetical male adult pa-
tient with AIDS.44 More recently, a 21-item stigma index was
developed with health care providers in India that included
questions about attitudes toward PLHA, including personal
contact and judgment, and attitudes toward health care
practices with PLHA, including testing, informed consent,
disclosure, infection control, and patient rights.45 Also, in a
rigorous set of validation studies that took place in 5 countries
in Africa, a 19-item scale was developed to measure nurses
stigmatizing tendencies and experiences of courtesy stigma.38
In summary, a variety of tools have been developed to
measure stigma among health care providers. As detailed
below, the HAPSI adds to this menu of instruments, and
deepens the focus on instrumental and symbolic constructs by
assisting providers in assessing their awareness of negative
attitudes associated with subgroups of PLHA, accepting the
potential consequences of carrying such views into client or
patient interactions, and acting intentionally to prevent their
prejudice from escalating to enacted discrimination.
The HAPSI is grounded dually in Link and Phelans46
widely used social psychological stigma framework as well as
our original Awareness, Acceptance, and Action Model
(AAAM), which is based in principles of mindfulness.1 Link
and Phelan proposed that humans attach negative attributes
to everyday differences among people such as gender, race,
and class. In turn, these labels become stereotypes that are
used as evidence to create and reinforce outgroups as a way to
separate us from them, and ultimately, to enact status loss
and discrimination in order to maintain physical and social
distance (instrumental and symbolic stigma respectively).
Supporting Link and Phelans proposition that these dy-
namics are played out in power situations (and as asserted by
Parker and Aggleton47 that power is integral to stigma), we
believe nurses and other providers have inherent power over
their patients due to their role as gatekeepers to treatment.
Societies worldwide charge medical professionals and healers
to reinforce social and cultural mores, which, when taken to
unchecked levels by providers themselves, may result in both
unintended and purposeful manifestations of AIDS stigma.
Understanding ones potential to violate ethical principles of
justice, beneficence and nonmaleficence is critical, especially
when providers are not fully aware it is happening. A
mindfulness approach can be helpful in prompting awareness
of stigma.
Mindfulness originated from the ancient philosophical
traditions of Asia. It has been used with behaviors and ill-
nesses thought to be responsive to mindbody health inter-
ventions, as a way to promote thoughtful responses rather
than automatic reactions, through the cultivation of meaning
derived from reflections about troubling situations. In this
article, we provide only a brief overview of the AAAM, which
was developed from tenets of mindfulness, to set the stage for
how we conceptualized the constructs for our suite of
MEASURING PROVIDER STIGMA
measures.1 At the level of Awareness, we believe providers
should look deeply for internal thoughts and feelings and
listen to patients presenting for services, who are at risk for
HIV or who have an existing diagnosis. Through active lis-
tening and reflection, providers may identify, for example,
their fears about occupational exposure, concerns about social
association, and prejudice based on associated statuses and
histories (e.g., sexual orientation, substance abuse) along with
presumptions about behavior that may have led to the pa-
tients infection (e.g., having multiple sex partners, needle
sharing). The second level, Acceptance, invites providers to
acknowledge the potential consequences of their stigmatizing
attitudes and behaviors, not only as they affect the well being
of their patients, but as they reflect on themselves as humans
and as health or social service professionals. Finally, Action
calls upon providers to act intentionally and with compassion
to override their potential for stigmatizing their patients
through unchecked reactivity. Compassionate action can be
realized through positive interactions with patients as well as
through the modeling of positive behaviors in the presence of
colleagues and lay people alike.
Methods
Scale conceptualization and development
Psychometric studies of novel instruments are needed to
capture multiple domains of AIDS stigma, particularly ones
that focus on enacted stigma (i.e., discrimination) and com-
pound or layered stigma that integrates concerns about AIDS
stigma and preexisting social prejudice about marginalized
groups.48 Thus, we integrated the well-respected social psy-
chological stigma framework of Link and Phelan46 and our
own mindfulness model. The HAPSI nests Link and Phe- matizing tendencies were colored by assumptions about the
lans46 four components of labeling, stereotyping, outgrouping,
and discriminating within our mindfulness model of AAAM.1
In our prior work toward developing mindfulness exer-
cises for antistigma workshops, we anchored the social psy-
chological processes of labeling, stereotyping, outgrouping
and discriminating within the progression of first becoming
self-aware of ones stigmatizing tendencies and then accept-
ing the implications of those tendencies on a path to
intentional action or unintentional reactivity. This conceptu-
alization provided an opportunity for respondents to first
come to awareness of how their psychological processes of
thoughts, feelings, and behaviors are reflective of sociological
processes related to stigma (Awareness) and then how these
same psychological processes may affect their interactions
with patients (Acceptance). This integration aims to reinforce
the inherent logic of a recognized social psychological stigma
conceptualization by inserting it into a framework designed to
guide providers through a sequence of reflections promoting
more supportive, less stigmatizing engagement. Thus, as a
way both to guide workshop participants in applying these
concepts to their lived experiences with patients and to
measure attitudes and their change, we developed the HAPSI
scales to reflect this blending of Link and Phelans framework
with our AAAM approach.
To elucidate each of Link and Phelans four components
labeling, stereotyping, outgrouping, and discriminatingwe
drew from our earlier work described above in developing a
stigma questionnaire for delivering antistigma workshops in
the United States and the eastern Caribbean as well as in-depth
675
qualitative research.1,25,49 As part of the AAAM workshop
approach, we asked participants to gauge their feelings of
warmth toward populations traditionally associated with
HIV/AIDS (MSM, IDU and other drug users, sex workers).
For that questionnaire, we drew from Hereks feeling ther-
mometer and other questions about stigma.50 This is in keeping
with recommendations that subgroup membership, physical
proximity to PLHA, and personal characteristics (stereotypes
about PLHA) may be sources of secondary stigma layered over
and above that associated with HIV status.48
In addition to confirming lesser degrees of warmth ex-
pressed for subaltern groups, our analyses revealed the im-
portance of considering warmth, comfort, distancing,
condemnation, myths about transmission, and ability to ef-
fectively counsel PLHA among health and social care pro-
viders.49 In addition, to construct an extensive item pool for
the HAPSI, we drew upon our qualitative studies of provider
stigma in the Eastern Caribbean wherein we explored the fit of
the four components of the Link and Phelan framework.25
As a result, free-standing but related measures were pro-
posed for Awareness, Acceptance, and Action. Figure 1 il-
lustrates the structure of the three scales and provides
construct definitions. Table 1 includes sample items. All
HAPSI items were designed to be assessed using a 7-point
Likert-type response scale where 1 = completely disagree and
7 = completely agree. The first scale, Awareness, was defined
as looking deeply, noticing the full range of our experi-
ences when encountering or thinking of PLHA. Within
Awareness, subscales were proposed for each of Link and
Phelans constructs of labeling, stereotyping, outgrouping,
and discriminating. Of these, Label and Discriminate were
further deconstructed into subscales reflecting whether stig-
patients status (Associate), and by whether the provider
was concerned about instrumental (Transmit) or symbolic
(Censure) consequences of contact as determined important
in prior work49 and recommendations made in published
reviews of existing stigma theory.48 Stereotype was decon-
structed to address three primary personal characteristics
often associated with HIV/AIDSmale homosexuality, in-
jecting drug use, and having multiple sex partners.
Following the principles of mindfulness, Acceptance, the
second scale, shifts the emphasis to consequences of ones
own thoughts and interactions. In specific, we defined Ac-
ceptance as fully acknowledging the potential impact, in-
tended or not, of our thoughts about and interactions with
PLHA. Parallel to the proposed Awareness scale, we like-
wise deconstructed Acceptance into four social psychological
subscales and subgroup personal characteristics.
The third scale, Action, reflects the final mindfulness
principle of AAAM and focuses on proactive, constructive,
and compassionate behavioral responses rather than unin-
tentional reactions. We defined Action as intentionally ex-
pressing constructive and compassionate behavior toward
PLHA. Items proposed for Action included a variety of
ideas gleaned from participants in our AAAM workshops, as
well as our own collective experiences working as provid-
ers and consultants in HIV/AIDS care and prevention. For
example, some social service and health care providers
suggested they intentionally strive to stop negative talk
about PLHA or encourage colleagues and supervisors to
abide by confidentiality.
676
Content validation
Following development of item pools reflecting the
structure described above, 15 expert panelists were invited
to critique the fit between proposed items and their intended
construct definitions. Ten panelists responded, including
national, state, and regional experts in social service and
health care delivery for PLHA. Each rated item/construct
match on a scale from 1 = not at all to 5 = very well, and most
provided detailed comments on the wording and the in-
tent of proposed items. Ratings were based on broad con-
struct definitions, with language variations designed to
differentiate personal characteristics and fears linked to in-
strumental or symbolic stigma. When inspecting individual
items, our criterion for retention was a mean rating across
RUTLEDGE ET AL.
FIG. 1. HIV/AIDS Provider
Stigma Inventory (HAPSI)
scale and subscale structure
with construct definitions.
experts of 3.5 or more. The goal was to identify general en-
dorsement of items at this preliminary stage, reducing the
number of items used in the full sample validation and the
resulting more rigorous critique. Based on panelists feed-
back, the initial total pool of 192 items was reduced to 109. A
table of mean item ratings for proposed items is available
from the first author.
Data collection instrument
In addition to the reduced item pool, questions were in-
cluded to capture respondent demographics and to provide
a set of variables for testing evidence of construct validity.
Given the novelty of the proposed constructs and the length
of the data collection instrument, considerations regarding
MEASURING PROVIDER STIGMA 677

Table 1. HAPSI Scales and Subscales: Example Items

AWARENESS
Label
Associate If I know or suspect a patient or client has HIV, I am more likely to think of them as a junkie,
whore, or pervert.
Transmit If I am concerned that I might get HIV from a patient or client, I am more likely to think of them
as contagious to justify avoiding them.
Censure If I am concerned that others in my life will think of or treat me differently because I work with PLHA,
I am more likely to call them names behind their back that I wouldnt say to their face.
Stereotype
Gay If I know or suspect a PLHA is also gay, I am more likely to think he or she is immoral.
IDU If I know or suspect a PLHA is also an IDU, I am more likely to think he or she will say anything
to get what he or she wants.
MSP If I know or suspect a PLHA has many sex partners, I am more likely to think he or she is desperate.
Outgroup If I know or suspect a PLHA is gay, an injection drug user, or has many sex partners, I am more likely
to keep quiet when others say hurtful or mean things about PLHA.
Discriminate
Associate If I know or suspect that a patient or client has HIV, I am more likely to keep them waiting
in the lobby.
Transmit If I am concerned that I might get HIV from a patient or client, I am more likely to let volunteers
or family members provide care that I should provide.
Censure If I am concerned that others in my life will think of or treat me differently because I work with PLHA,
I am more likely to blame them for bringing problems on themselves.
ACCEPTANCE
Label If I think of or use unpleasant names (e.g., queer, junkie, hooker, etc.) to describe my patients or clients,
I am more likely to think of them as a case rather than as a unique human being.
Stereotype If I let my opinions about PLHAs being IDUs, gay, or promiscuous shape how I think or feel
about them, I am more likely to feel that people like them are not worth the trouble.
Outgroup If I try to make sure others will see I am not like my PLHA patients or clients, I am more likely
to tell degrading jokes about them.
Discriminate If I treat my clients or patients differently because I think or know they have HIV, I am more
likely to rush through things rather than take the time to understand their feelings.
ACTION
If I always try to act in ways that meet PLHAs needs rather than reacting to negative feelings
I have about their behaviors, I am more likely to work to maximize services and referrals for
each individual PLHA.

HAPSI, HIV/AIDS Provider Stigma Inventory; PLHA, People living with HIV/AIDS; IDU, injection drug use; MSP, many sex partners.

respondent burden led to the inclusion of one standard-
ized scale and a set of single-item indicators for use in val-
idation hypotheses. The standardized scale was the AIDS
Attitude Scale (AAS), which can be deconstructed into
subscales reflecting tendencies to avoid or empathize with
PLHA.39 Previous studies reported mean alpha coefficients
on nursing samples of 0.89 for avoidance and 0.87 for em-
pathy. Examples of single-item indicators include I am
more likely to think or feel negatively about PLHA who
have many sex partners (Awareness) and If I treat my hospital offering direct care to patients with a variety of dis-
patients or clients differently because of their personal
characteristics or qualities, my interactions with them
may be less helpful (Acceptance). Further details on these
measures and the single-item indicators are provided with
the results, below.
Sampling and data management
The initial testing of the HAPSI was accomplished with a
purposive sample of nursing students attending a large
baccalaureate program in the southeastern United States.
This initial sampling with nursing students would provide
pilot data allowing examination of the proposed HAPSI
constructs and structure, and, if successful, set the stage for
a second wave of validation on a more experienced clinical
sample.
The universitys Institutional Review Board (IRB) ap-
proved the study. Undergraduate third-year baccalaureate
nursing students were invited to participate in the study. The
prospective participants had received clinical and didactic
training regarding the biological and social care related
premises of HIV/AIDS treatment endeavors. At this level of
their training, all of the prospective subjects had worked in a
orders. Per IRB approval, students were provided a cover
sheet outlining the purpose of the study and their rights.
Rather than signing a consent form, students were advised
that completing the questionnaire constituted voluntary
agreement to participate. Although recommendations for
desirable sample size for confirmatory factor analyses (CFA)
vary widely,51 we targeted 200 respondents for this pilot
validation. Ultimately, 184 responses were received, and of
these, 10 were discarded as unusable due to extreme outliers
or excessive patterns of missing data.
Inspection of the remaining 174 cases revealed that re-
sponses were essentially normally distributed with few in-
stances of substantially missing data for individual item
responses for the 109 proposed items. Twenty-six items had
678 RUTLEDGE ET AL.

missingness more than 2%, and none exceeded 2.9%. Ex- Reliability
amination of missingness was conducted with SPSS Missing
Estimates of internal consistency were computed as Cron-
Values 17.0, and Littles MCAR test revealed that data were
bach a coefficients. Inspection of a-if-item-deleted statistics in
missing completely at random (v2 = 2222.098, df = 2155,
relation to initial coefficients for each proposed HAPSI con-
p = 0.153). To maximize case retention for subsequent analy-
struct identified items that, if removed, would enhance the
ses, missing values for proposed HAPSI items were replaced
overall consistency of a scale. This contributed to the flagging
with the estimation maximization (EM) method. Frequency
of 11 items for removal from the final pool. Taken together,
distributions identified 12 items with extreme skewness ( > 3)
analyses of response distribution, redundancy, and alpha-if-
or kurtosis ( > 10) indices.52 These were removed from the
item-deleted (some of which led to flagging an item more than
final analyses, which were conducted with LISREL 8.8 (Sci-
once) resulted in an 81-item instrument. Table 3 summarizes
entific Software International, Inc., Lincolnwood, IL) and
the resulting scale and subscale reliabilities and reports the
SPSS 17 (SPSS Inc., Chicago, IL).
number of items retained for each global HAPSI scale. Be-
cause Cronbach a tends to underestimate reliability for mul-
Results
tidimensional scales,51 stratified alpha coefficients were
Demographics computed for each HAPSI component containing an under-
lying subscale structure.
As shown in Table 2, nursing student respondents were
Only two reliability coefficients (Outgroup, a = 0.69; Dis-
primarily female and young. Approximately 75% were white,
criminate/Transmit, a = 0.70) might be classified as mini-
with smaller percentages divided among African American,
mally acceptable.53(p95) One (Discriminate/Censure; a = 0.76)
Hispanic/Latino(a), or another race. Few (24%) were cur-
is respectable. The remaining are very good; five report
rently working, and of those describing their motivations to
reliability coefficients ranging from 0.80 to 0.89, and 11 range
work, few (n = 5) specified a desire to help PLHA. Only 15 had
from 0.90 to 0.98. Standard errors of measurement (SEM) were
worked in HIV/AIDS care, and their mean years of service
computed to estimate the range of true scores around an ob-
was slightly less than 1. Relatively few reported personal
served score. One standard for such estimates proposes that
family, friend, or caregiving associations with PLHA.
they should be less than or equal to 5% of the possible scale
score range.54 For HAPSI items, in which responses range
Item redundancy
from 1 to 7, desirable SEMs would be 0.3 or less. Inspection of
Bivariate correlations were computed among individual Table 3 reveals that six HAPSI components met this standard.
item responses, and a conservative threshold (r 0.80) was
used to assess excessive redundancy in item content. Twenty-
Factor structure
six such cases were found (with r ranging from 0.80 to 0.89),
and after careful content inspection and consideration of the Confirmatory factor analyses were conducted to examine
reliability analyses reported below, 17 items were flagged for the hypothesized multidimensional structures of the Aware-
removal from the final pool. ness and Acceptance scales, and the unidimensional structure

Table 2. Respondent Demographics

n % M SD Range

Gender
Female 158 90.8
Male 15 8.6
Age 173 22 3.64 1944
Ethnicity White 130 74.7
African American 18 10.3
Hispanic/Latino/a 16 9.2
Other 9 5.1
Currently working 41 23.6
Motivation to work Make a living 21 12.1
Gain experience or career 55 31.6
advancement
Help PLHA 5 2.9
Educational requirement 24 13.8
Years of social or health 90 51.7 1.61 2.02 010
service experience
Worked in HIV/AIDS care 15 8.6
Years in HIV/AIDS 14 0.95 1.11 0.014
PLHA family or friend 17 9.8
Caregiver for PLHA 9 5.2
Caregiver to PLHA partner 3 1.7
or spouse

SD, standard deviation; PLHA, people living with HIV/AIDS.

MEASURING PROVIDER STIGMA 679

Table 3. Internal Consistency: Scale and Subscale Coefficients

Scale Subscale n of items Reliability (a) SD SEM

a
Awareness Global 42 0.97 0.92 0.16
Label: 12 0.94a 0.81 0.20
Associate 4 0.88 1.00 0.35
Transmit 4 0.84 1.08 0.43
Censure 4 0.85 0.62 0.24
Stereotype: 19 0.96a 1.23 0.24
Gay 4 0.87 1.32 0.47
IDU 8 0.93 1.43 0.38
MSP 7 0.92 1.49 0.42
Outgroup 5 0.69 1.15 0.64
Discriminate: 6 0.80a 0.79 0.35
Transmit 3 0.70 1.11 0.61
Censure 3 0.76 0.74 0.36
Acceptance Global 20 0.98a 1.43 0.19
Label 4 0.95 2.03 0.45
Stereotype 6 0.92 1.72 0.49
Outgroup 4 0.90 1.50 0.47
Discriminate 6 0.94 1.69 0.42
Action Global 19 0.96 1.12 0.23
a
Stratified a.
SD, standard deviation; SEM, standard error of the mean.

of the Action scale. Target criteria were v2/df ratios < 2 or 3,
Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI)
>0.90, root mean square error of approximation (RMSEA)
<0.08, and standardized root mean square residual (SRMR)
<0.10.52 As reported in Table 4, initial models for Awareness
and Acceptance met these standards with the exception of
RMSEA (0.084 and 0.081, respectively). Results for Action
identified problems with v2/df (ratio = 5.79) and RMSEA (0.18).
Inspection of modification indices allowing for correlated
error variances consistent with proposed scale content led to
respecified models for each scale. Error variances were al-
lowed to correlate only when they were associated with sig-
nificant changes in model fit and were not incompatible with
the theoretical composition of proposed factors (i.e., when
covariances were within a targeted item pool rather than
crossing from one to another).55,56 Resulting coefficients
demonstrated improved model fit in each case. Finally, in
recognition of their multilayered structures, second-order
factor analyses were conducted for Awareness and Accep-
tance. Resulting indices indicated acceptable model fit in both
cases.
Convergent construct validity evidence
To examine whether HAPSI scales measured what they
were intended to measure, bivariate correlations were com-
puted to test hypothesized relationships among HAPSI scores
and responses to standardized scale scores and single-item
indicators. First, performance of the AIDS Attitude Scale
(AAS)43 subscales on avoidance (AASav) and empathy (AA-
Sem) in the present sample were examined through compu-
tation of coefficient alpha. Results (AASav a = 0.83, AASem
a = 0.89) were similar to those reported in previous research
and indicated that the measures were appropriate for use in
the present study.
We hypothesized that the AASav scores, indicating ten-
dencies to avoid association with PLHA, would correlate
positively with higher scores on Awareness HAPSI scales

Table 4. Confirmatory Factor Analyses: Initial and Respecified

Scale Model v2/df CFI TLI RMSEA SRMR

Awareness Initial 2.42 0.95 0.95 0.084 0.087

Respecifieda 2.24 0.96 0.96 0.076 0.072
Second-order 2.27 0.96 0.96 0.079 0.080
Acceptance Initial 2.04 0.98 0.98 0.081 0.052
Respecifiedb 1.70 0.99 0.98 0.063 0.047
Second-order 1.68 0.99 0.99 0.062 0.047
Action Initial 5.79 0.93 0.92 0.180 0.068
Respecifiedc 2.67 0.98 0.97 0.092 0.046
a
Permitting 9 error covariances.
b
Permitting 6 error covariances.
c
Permitting 38 error covariances.
CFI, Comparative Fit Index; TLI, Tucker-Lewis Index; RMSEA, root mean square error of approximation; SRMR, standardized root mean
square residual.
680
reflecting greater tendencies to stigmatize PLHA. This was
true in each case (for the Awareness global score [r = 0.66], and
its subscales Label [r = 0.58], Stereotype [r = 0.59], Outgroup
[r = 0.55], and Discriminate [r = 0.58]). Effect sizes estimating
the magnitude of these relationships were computed as
r2 statistics, and ranged from 0.30 for the association with
Outgroup to 0.44 with global Awareness. Likewise, we hy-
pothesized that the AASem scores, indicating tendencies to
empathize with PLHA, would be negatively correlated with
HAPSI Awareness scale scores. Resulting correlations were
statistically significant for global Awareness (r = - 0.15) and
subscales Outgroup (r = - 0.16) and Discriminate (r = - 0.15).
Associated effect sizes were trivial (ranging from 0.02 to 0.03).
We also hypothesized that Label subscale scores Associate,
Transmit, and Censure would be positively correlated with
single-item indicators characterizing PLHA as gay, IDU, or
having many sex partners (MSP). Associated prompts read I
am more likely to think or feel negatively about PLHA who
are gay (or use injection drugs, or have many sex part- items. Higher scores indicate more of the tendency or quality
ners). All correlations were statistically significant, with
effect sizes ranging from 0.14 to 0.29. Likewise, we hypothe-
sized that Stereotype subscales Gay, IDU, and MSP, and
Discriminate subscales Transmit and Censure would be pos-
itively correlated with single-item indicators expressing con-
cerns about instrumental or symbolic stigma. Associated
prompts read I am more likely to think or feel these ways if I
fear I may catch the virus from PLHA, or if I fear that others in
my life will treat me differently for working with PLHA who
are also gay, injection drug users, or have many sex partners.
Again, all correlations were statistically significant, with effect
sizes ranging from 0.19 to 0.44.
Similar hypotheses were tested for global and subscale
Acceptance scores. All correlations were statistically signifi-
cant. Effect sizes were generally small ( 0.06), although more
substantial for Label (r2 = 0.13). The unidimensional Action
score, representing more compassionate actions in relation to
PLHA, was hypothesized to correlate positively with AASem.
The result was statistically significant with a more substantial
effect size (r2 = 0.22). Complete results of analyses of conver-
gent construct validity evidence for each of the three scales are
available from the first author.
Discussion
Overall, the HAPSI scales achieved strong psychometrics.
Content validity was generally supported by expert panelists,
and psychometric coefficients revealed strong evidence of
reliability and confirmation of hypothesized factor structure.
Initial evidence for construct validity supported claims that
the scales measure what they were intended to measure. Al-
though the Awareness Outgroup subscale was marginal, its
performance is adequate for cautious use, and warrants fur-
ther investigation.
We contend that the evidence of encouraging psychometric
qualities in this initial validation of the HAPSI is based on
careful adherence to scale development methodology, dual
integration of a solid and well-regarded theoretical frame-
work for understanding stigma46 and self-reflection (i.e.,
mindfulness principles), the inclusion of content gleaned from
the collective experience of the authors in delivering stigma
workshops and in direct service provision and as tailored by
an expert panel. The result is a suite of measures that can be
RUTLEDGE ET AL.
used to differentiate multiple manifestations of stigma, in-
cluding instrumental, symbolic, courtesy, and enacted. Spe-
cifically, the scales tap concerns about occupational exposure,
judgment based on stereotypes about PLHA that are rooted in
secondary stigmas about having multiple sex partners, drug
use and homosexuality, as well as concerns about being
judged by families and others for caring for PLHA. In addi-
tion, our conceptualization and psychometric achievement of
two separate scales for Awareness and Acceptance is useful
for discerning not only nurses self-perceived negative
attitudes and actions directed at PLHA, but also their self-
assessment of the consequences of their prejudice and dis-
crimination. A more unique contribution is the creation of the
Action scale to measure proactive and compassionate care. In
keeping with the AAAM, we can better understand the de-
gree to which individuals are willing to engage in helpful
behaviors to decrease stigma in health care provision.
All scales were scored by computing the mean of included
assessed. For Awareness and Acceptance, such scores indicate
greater stigma or discrimination; for Action, such scores indi-
cate more compassionate engagement with PLHA. Although
the HAPSI will be used as an outcome measurement for our
provider stigma intervention, it should also be useful in early
professional training. The HAPSI could be used by researchers
or instructors to increase the understanding of students and
novice professionals regarding the connections between their
personal fears and tendencies and the impact of such qualities
on the care they deliver to others. Our hope is that the HAPSI
will be a valuable assessment tool to be used in conjunction
with intensive antistigma interventions or more simply as a
way for providers to become mindful of and address their
mixed feelings about working with PLHA. It is important to
emphasize that the HAPSI was designed to encourage reflec-
tion on subtle issues. Indeed, the Awareness and Acceptance
scales include a variety of complex notions and complicated
stems for items that require careful reading and consideration.
The results reported here and our anecdotal experiences in
piloting the instrument suggested that respondents are able to
track and respond appropriately to the items as designed.
The HAPSI provides a valid and reliable form of mea-
surement for use among nurses as well as other health care
and social service providers, and offers a measurement
strategy that is especially appropriate for interventions that
integrate the mindfulness principles detailed above and
elsewhere.1 Professional socialization is perhaps one of the
most important components of training in health care and
social services. It is essential that this initial period of sociali-
zation integrates not only the technical skills related to the
care of PLHA, but also the interpersonal skills necessary to
promote their continued involvement in treatment. Failure to
do so will facilitate the persistence of stigmatizing behaviors
among entry level professionals with little experience or
preexisting desire to care for PLHA.
Limitations
Generalizations beyond this initial validation should be
undertaken with caution given the nature of the student
sample, which was homogenous due to respondents com-
mon level of training, education, and clinical exposure. Re-
spondents had limited clinical experience, and reported only
MEASURING PROVIDER STIGMA
modest motivations to work with PLHA. As with all valida-
tion studies, which are inherently sample-dependent,
replications on broader and more diverse samples are re-
commended. In addition, the utility of scales focusing on
attitudes can be strengthened through tests involving be-
havioral applications. The goals of this project were ambi-
tious, resulting in a long data collection instrument. This may
have inhibited some respondents from participating. This
restricted the available space for a more thorough inclusion of
construct validity indicators; however, the relative absence of
measures of provider stigma also limited a more extensive
assessment of construct validity. Revalidation on a sample of
more experienced health care and social service practitioners
as well as testing the utility of the HAPSI with behavioral
indicators, including simulations and direct observation of
providerpatient interactions, will address this limitation and
add indicators assessing concurrent criterion validity.
Acknowledgement
The authors thank the 10 expert panelists who provided
critical assistance with conceptualization.
Author Disclosure Statement
The authors report no real or perceived vested interests that
relate to this article (including relationships with pharma-
ceutical companies, biomedical device manufacturers, grant-
ors, or other entities whose products or services are related to
topics covered in this article) that could be construed as a
conflict of interest.
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Address correspondence to:
Scott Edward Rutledge, Ph.D., M.S.W.
School of Social Work
Temple University
301 Cecil B. Moore Avenue
Ritter Annex Fifth Floor
Philadelphia, PA 19122-6091
E-mail: srutled@temple.edu
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