Psychometric validation of a multidimensional health facility HIV stigma instrument among healthcare workers in Taiwan

BACKGROUND: HIV-related stigma within healthcare settings remains a major barrier to HIV prevention, treatment engagement, and equitable care. Existing stigma instruments in Taiwan primarily assess individual-level attitudes and do not adequately capture institutional or structural determinants of stigma. A multidimensional health facility-level stigma instrument is needed to support routine monitoring and stigma-reduction efforts. This study aimed to culturally adapt and psychometrically validate a Traditional Chinese version of the WHO/USAID Health Facility Staff HIV Stigma and Discrimination Questionnaire for use among healthcare workers in Taiwan. METHODS: A cross-sectional psychometric study was conducted using three independent samples. Content validity was evaluated by an expert panel. Item analysis was performed in a pretest sample (n = 157). The main validation sample (N = 619) was randomly divided into Subsample A (n = 310) for exploratory factor analysis and Subsample B (n = 309) for confirmatory factor analysis. Construct validity, convergent and discriminant validity, and reliability were evaluated. External convergent validity was examined using correlations with the Taiwanese version of the Health Care Provider HIV/AIDS Stigma Scale (TW-HPASS). RESULTS: Exploratory factor analysis identified a seven-factor structure consisting of Fear, Extra Infection Precautions, Observed Enacted Stigma, Secondary Stigma, Health Facility Policies and Work Environment, Attitudes toward PWH, and Willingness to Treat Key Populations, explaining 72.98% of total variance. Confirmatory factor analysis demonstrated acceptable model fit (CFI = 0.916, TLI = 0.902, RMSEA = 0.069). Composite reliability values ranged from 0.794 to 0.954, and average variance extracted supported convergent validity. Domains conceptually aligned with HPASS showed moderate-to-strong correlations (r = .362-0.691), whereas structural domains such as observed stigma and institutional policies demonstrated weak or negligible correlations, indicating that the instrument captures distinct facility-level dimensions of stigma beyond individual attitudes. CONCLUSIONS: The Traditional Chinese WHO/USAID Health Facility Staff HIV Stigma and Discrimination Questionnaire demonstrates strong psychometric properties and provides a multidimensional framework for assessing HIV-related stigma in Taiwanese healthcare settings. By capturing individual, interpersonal, and structural dimensions of stigma, the instrument may support facility-level monitoring, cross-institutional benchmarking, and the development of targeted stigma-reduction interventions.