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Nyi Nyi Zayar,1 Rassamee Chotipanvithayakul,1 Espen Bjertness,2 Aung Soe Htet,2 Alan Frederick Geater,1 Virasakdi Chongsuvivatwong1 1Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand; 2Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, NorwayCorrespondence: Rassamee Chotipanvithayakul, Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, 6th Floor of Administrative Building, 15 Kanjanavanich Road, Hat Yai, Songkhla, 90110, Thailand, Tel +66-074-451165, Email rassamee.s@psu.ac.thPurpose: We investigated the association of TB patients and their household contacts with diabetes mellitus (DM) and hypertension compared to the general population, and the mediating effects of risk behaviors including current smoking, alcohol drinking, and poor diet quality.Patients and Methods: A cross-sectional study on screening for DM, hypertension, and risk behaviors among newly diagnosed TB patients (n = 221) and their household contacts (n = 257) aged 25– 74 years in Yangon in 2018. Health data of the general population (n = 755) were obtained from an NCD risk factor survey in Yangon. A directed acyclic graph is used to identify possible pathways of association between variables. Associations are presented as adjusted odds ratios (aOR).Results: Compared to the general population, both TB patients and their household contacts were associated with current smoking and drinking, and TB patients were more likely to be underweight. Without considering mediating effects, TB patients had higher odds of DM (aOR = 6.3, 95% CI: 3.8– 10.6), but both TB patients and household contacts had lower odds of hypertension (aOR = 0.54; 95% CI: 0.33– 0.87) and (aOR = 0.68; 95% CI: 0.47– 0.98), respectively. The body mass index-mediated pathway reduced the odds of DM and hypertension among TB patients (aOR = 3.4; 95% CI: 2.2– 5.3) and (aOR = 0.3; 95% CI: 0.2– 0.5), respectively.Conclusion: The shared risk behaviors among TB patients and household contacts with high burden of DM in TB patients endorse screening of risk behaviors and strengthening the integration of NCD services among TB patients and household contacts in this dual-burden country.Keywords: TB, diabetes mellitus, hypertension, non-communicable diseases, screening, mediator

Yingwu Guo,1,2,* Jun Liu,1,* Yingrong Du,1,* Virasakdi Chongsuvivatwong2,* 1Department of Infectious Diseases, Third People’s Hospital of Kunming City, Kunming, People’s Republic of China; 2Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand*These authors contributed equally to this workCorrespondence: Virasakdi Chongsuvivatwong, Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla, 90110, Thailand, Tel +66897350098, Email cvirasak@medicine.psu.ac.thBackground: Fertility decision-making plays a negligible role in completing fertility goals among couples living with HIV (CLWH). Being commonly matched concerning fertility motivation seems essential for fertility desire/intention. Few studies report on intra-couple congruences or incongruences in fertility motivation on desire/intention. This study aims to assess the effects of (in)congruency in fertility motivation on fertility desire and intention among couples living with HIV.Methods: This study uses the actor-partner interdependence model (APIM) to assess the independent direct and indirect effect of fertility motivation on intention, and dyadic response surface analysis with congruency/incongruent effect (DRSA) of fertility motivation on intention using fertility desire as mediator variable among CLWH. CLWH were selected from a clinic in Kunming, China, between October and December 2020. Cross-sectional research included 314 CLWH.Results: APIM revealed that the wife’s fertility motivation had an indirect influence on fertility intention of couples mediated by her fertility desire (R2 = 0.42). There was a significant effect on fertility intention by interaction of (in)congruency in fertility motivation among couples. DRSA shows that linear congruency in fertility motivation of both husband and wife increased fertility desire and intention of couples. However, if there was an incongruent in fertility motivation among husband and wife, husband’s domination in fertility motivation was common and negatively affect the wife’s fertility desire to have a child. Overall, couples who were matched on fertility motivation reported a significant greater relationship with fertility intention than couples who were mismatched.Conclusion: Counseling could help both the husband and wife achieve a greater positive fertility intention by addressing comparable fertility goals.Keywords: (in)congruency, dyadic data analysis, Traits-Desires-Intentions-Behavior model, couples living with HIV

Yingwu Guo,1,2 Yingrong Du,1 Sanguan Lerkiatbundit,3 Jun Liu,1 Jingsong Bai,1 Yongrui Yang,1 Yin Yang,1 Aihui Wu,1 Virasakdi Chongsuvivatwong2 1Department of Infectious Diseases, Third People’s Hospital of Kunming City, Kunming, People’s Republic of China; 2Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; 3Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, ThailandCorrespondence: Virasakdi Chongsuvivatwong, Email cvirasak@medicine.psu.ac.thBackground: Survival and quality of life of people living with HIV (PLWH) have been improving. Understanding fertility intention among PLWH is critical in helping them accomplish their pregnancy goals while significantly lowering the risk of HIV transmission. The purpose of this study was to identify factors based on the theory of planned behavior (TPB) that may explain fertility intention among PLWH.Methods: A survey was conducted in face-to-face interviews based on TPB, and the latent variables were devised and tested for their potential influences on fertility intentions in 487 reproductive-aged PLWH at antiretroviral treatment clinics in Kunming, China. Analysis was mainly based on the structural equation model.Results: About 38.4% of the respondents answered that they were likely to have a/another child in the next three years. Our hypothesized factors could explain 53.7% of the total variance of fertility intention. The 20- to 35-year-old group had a higher fertility intention. Perceived partner expectations toward fertility were the strongest predictors of fertility intention followed by beliefs in the support of the two-child policy. In contrast, the three components of attitudes, subjective norm, and perceived behavioral control did not influence fertility intention.Conclusion: In this HIV endemic area of China, fertility intended by PLWH is a matter of the couple that is also influenced by the national population fertility policy.Keywords: people living with HIV, fertility intention, theory of planned behavior

Jingyi Dai,1,2,* Jun Zhao,3,* Yingrong Du,1 Lin Zhuang,1 Edward B McNeil,2 Virasakdi Chongsuvivatwong2 1Department of Liver Diseases, The Third People’s Hospital of Kunming City, Kunming, Yunnan, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; 3Department of Preventive Medicine, School of Public Health and Management, Hubei University of Medicine, Shiyan, Hubei, People’s Republic of China*These authors contributed equally to this workCorrespondence: Virasakdi Chongsuvivatwong Email cvirasak@medicine.psu.ac.thBackground: Data concerning adherence to hepatocellular carcinoma (HCC) surveillance among chronic liver disease (CLD) patients at high risk of developing HCC in China are limited. We aimed to examine the relationship between HCC-related knowledge dimensions and adherence to HCC surveillance procedures among chronic liver disease patients at high risk of developing HCC and to identify potential barriers.Methods: A total of 380 patients with chronic liver disease at high risk of developing HCC were recruited between May and August 2018 to complete a survey during the first week of their first hospitalization at the Third People’s Hospital of Kunming in China. We followed up each patient up to 7 months by telephone to confirm whether the patient returned to complete investigations for HCC surveillance. Patient’s socio-demographic characteristics, HCC-related knowledge, and perceived barriers to HCC surveillance were measured using a structured questionnaire during their hospitalization. Factor analysis was performed on the knowledge questions to reduce the dimensions. Univariate and multivariate analyses were performed to examine the association between dimensions of HCC-related knowledge and patients’ adherence to HCC surveillance.Results: A total of 327 eligible patients had been successfully contacted in the follow-up phase. Only a quarter of patients completed HCC surveillance within 7 months after their first admission to hospital. High costs and perceived poor test efficacy were the two major barriers for HCC surveillance. Three common factors were derived from the factor analysis of HCC-related knowledge, namely, “Surveillance”, “Lifestyle”, and ‘Prognosis’. Knowledge of HCC surveillance and lifestyle but not prognosis had an influence on adherence to HCC surveillance. Patients with better surveillance and lifestyle knowledge domain had better adherence to HCC surveillance.Conclusion: Adherence to HCC surveillance procedures is low in the study area. Closing the gap in HCC-related knowledge, particularly regarding surveillance and lifestyle, may help to increase adherence rates.Keywords: HCC surveillance, adherence, knowledge, barriers

Yijing Xie,1,2 Edward McNeil,2 Yancun Fan,1 Virasakdi Chongsuvivatwong,2 Xingsheng Zhao,3 Hutcha Sriplung2 1Health Management Faculty and Research Institute for Health Policy of Inner Mongolia, Inner Mongolia Medical University, Hohhot, Inner Mongolia, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand; 3Inner Mongolia People’s Hospital, Hohhot, Inner Mongolia, People’s Republic of ChinaCorrespondence: Hutcha SriplungEpidemiology Unit, Faculty of Medicine, Prince of Songkla University, 15 Kanchanawanit Road, Hat Yai, Songkhla 90110, ThailandTel +66 7 445 1165Fax +66 7 442 9754Email hutcha.s@psu.ac.thPurpose: Measures to prevent respiratory infection diseases (RIDs) in hospitals are important to protect both patients and physicians. In 2003, an outbreak of severe acute respiratory syndrome occurred in Inner Mongolia Autonomous Region (IMAR) of China. We aimed to evaluate competency in RID prevention procedures in terms of hospital performance and physician behavior.Patients and Methods: We conducted a cross-sectional study in 10 tertiary general public hospitals in 3 cities of IMAR. In each hospital, we chose the respiratory and ear–nose–throat outpatient departments (OPDs) and the emergency department (ED) to invite patients with symptoms of cough to join the study before they consulted a physician. After their consultation, we asked the patients to complete a checklist to score the performance of the departments and the behavior of their physicians in terms of RID prevention practices according to international professional guidelines.Results: From 711 respondents, in the domain of hospital performance, display of posters on directive to wash hands after coughing/sneezing had an average score of 0.452 (range 0– 1), while other cough etiquette items had scores averaging between 0.33 and 0.39. The average score for air ventilation was 0.66. For physicians’ performance, informing patients the location of handwashing facilities scored the highest (0.62), while low scores were seen for offering a mask to coughing patients (0.14) and encouraging coughing patients to distance themselves from others (0.17). Most RID prevention procedures received low scores in EDs in both hospital performance and physician behavior domains.Conclusion: Hospitals in IMAR should improve their performance in RID prevention procedures, especially in giving information to RID patients through the display of posters. The practice of physicians in preventing respiratory infection spread was suboptimum. ED staff and hospital administrators should improve their procedures to prevent the spread of respiratory infections, especially given the increasing occurrences of global pandemics such as COVID-19.Keywords: hospital performance, physician behavior, spread of respiratory infections, real patients survey

Yun Wang,1,2 Huijuan Chen,3 Zhongfeng Huang,4 Edward B McNeil,2 Xiaolong Lu,1 Virasakdi Chongsuvivatwong2 1School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; 3Department of Tuberculosis Prevention and Control, Guizhou Center for Disease Prevention and Control, Guiyang, Guizhou, People’s Republic of China; 4Department of Tuberculosis, Guiyang Public Health Clinical Center, Guiyang, Guizhou, People’s Republic of ChinaCorrespondence: Virasakdi ChongsuvivatwongEpidemiology Unit, Faculty of Medicine, Prince of Songkla University, 15 Kanchanawanit Road, Hat Yai, Songkhla, ThailandTel +66 74 429 754Fax +66 74 212 900Email cvirasak@medicine.psu.ac.thPurpose: Treatment interruption and incorrect dosage for measuring drug non-adherence have seldom been studied in multidrug-resistant tuberculosis (MDR-TB) treatment. This study aimed to 1) estimate the overall and drug-specific incidence of short (≤14 days) and serious (>14 days) treatment interruption among MDR-TB patients, 2) identify main reasons and predictors for serious interruption, and 3) document the level of agreement of classification for incorrect drug dosage between self-report and pill count.Patients and methods: A cross-sectional study combining hospital-based interviews and home-based pill count was conducted from January to June 2018. Treatment interruption was determined from patient’s medical records and interviews using a structured questionnaire among 202 patients treated at one designated hospital for MDR-TB treatment. Concordance of pills counted with self-reports for each drug use within one month was assessed for a subgroup of patients at their homes using kappa statistics.Results: Of 202 patients, the incidence of short and serious treatment interruption was 37.6% and 28.7%, respectively. Adverse drug reactions (ADRs) and financial hardship were the top two reasons for serious interruption. Amikacin and cycloserine had the highest rate of specific drug interruption (18.3% and 10.2%, respectively). ADRs (ORadj: 2.82, 95% CI: 1.41–5.61), monthly out-of-pocket expenses exceeding 250 US dollars (ORadj: 2.27, 95% CI: 1.14–4.50), and baseline co-morbidities (ORadj: 2.53, 95% CI: 1.19–5.38) were significantly associated with serious treatment interruption. Of 111 patients assessed for pill count at home, 5.4% had perfect drug adherence, 54.1% had drug under-use, 6.3% had drug over-use, and 34.2% had both problems. The respective number from self-reports was 7.2%, 56.8%, 5.4% and 30.6%. The two methods gave an acceptable level of agreement for most of the drugs (kappa: 0.52–0.95).Conclusion: Close monitoring of ADRs, revision of drug regimens, and financial support for MDR-TB in this study population are needed. Self-report on drug under-use and over-use should be monitored monthly in clinical settings.Keywords: multidrug-resistant tuberculosis, adherence, treatment interruption, Guizhou

Jingyi Dai,1,2,* Jun Zhao,3,* Yingrong Du,1 Edward B McNeil,2 Virasakdi Chongsuvivatwong21Department of Liver Diseases, The Third People’s Hospital of Kunming City, Kunming, Yunnan, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; 3School of Public Health and Management, Hubei University of Medicine, Shiyan, Hubei, People’s Republic of China*These authors contributed equally to this workBackground: Hospital readmissions of patients with cirrhosis is a current problem in China. This study aims to estimate the readmission rate at one year after discharge and to identify associated risk factors of hospital readmission.Methods: Between January 2012 and December 2015, 3,402 patients admitted with cirrhosis were included in the study. The primary outcome was one-year inpatient readmission. Principal components analysis was conducted on the laboratory test indicators to reduce the number of dimensions. Univariate and multivariate analyses were performed using clinical and demographic data to identify independent associated factors of readmission within one year. The odds ratio (OR) and 95% confidence interval were used to assess the strength of association for each factor.Results: Two dimensions, namely “liver function” and “renal function”, were revealed. Patients with a longer length of stay in the index admission (OR: 1.03; 95% CI: 1.03–1.04) and a higher dimension score of liver function (OR: 1.09; 95% CI: 1.05–1.13) were more likely to be readmitted within one-year. Older patients had a significantly higher odds of one-year readmission than younger patients (OR: 1.61; 95% CI: 1.22–2.11), patients who were married had a higher odds than those who were single (OR: 1.62; 95% CI: 1.12–2.36), and patients with hepatitis C virus were more likely to be readmitted within one year than patients with hepatitis B virus (OR: 1.51; 95% CI: 1.19–1.91).Conclusion: Biomarkers and sociodemographic factors can identify patients at high risk for readmission within one year. Our data indicates the need to emphasize proper liver care to older patients who have been hospitalized for a long time.Keywords: cirrhosis, readmission, liver function, renal function

Tingting Qiao,1 Yancun Fan,1 Alan F Geater,2 Virasakdi Chongsuvivatwong,2 Edward B McNeil21School of Health Management, Inner Mongolia Medical University, Hohhot 010010, Inner Mongolia, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, ThailandPurpose: The doctor–patient relationship (DPR) in People’s Republic of China is very tense. This study aimed to provide some explanation by exploring factors influencing the DPR from doctors’ and patients’ perspectives.Methods: A cross-sectional study was conducted in one provincial and one city-level general public hospital in Inner Mongolia Autonomous Region of People’s Republic of China. The Difficult Doctor–Patient Relationship Questionnaire (DDPRQ-10) and the Patient–Doctor Relationship Questionnaire (PDRQ-9) were used to assess the quality of the DPR from 226 doctors, and 713 patients’ perspectives, respectively. Multivariate linear regression was used to identify factors significantly associated with the doctors’ and patients’ perceptions of the DPR by assessing coefficients of total effect and their 95% confidence interval.Results: The result revealed that provincial-level doctors had a higher DDPRQ-10 score than city-level doctors. Worse DDPRQ-10 scores were seen for doctors who worked in the Internal Medicine departments were aged between 31 and 40 years, held a master’s degree, were dissatisfied with their income, worked more than 40 hrs per week, felt pressure at work, considered the hospital environment to be bad, often felt affected by negative media reports and had defensive behaviors. Patients visiting the provincial hospital had a lower PDRQ-9 score than those from the city-level hospital. Lower PDRQ-9 scores were also seen for patients who were of Mongolian ethnicity, were dissatisfied with their income, waited longer to see the doctor, had a shorter doctor consultation time, had lower expectations of their treatment result, had a low level of trust in the doctor, regarded the hospital environment as bad and those who were frequently influenced by negative media reports.Conclusion: This study may provide a useful model to raise the quality of the DPR and to supply evidence for health policy makers and administrators to formulate strategies for reducing the problem of tense DPR in Chinese hospitals.Keywords: outpatient, doctor-patient relationship, medical dispute, patient satisfaction, People’s Republic of China, health policy

Labasangzhu,1,2 E Bjertness,3 EB McNeil,2 Deji,1 Y Guo,4 P Songwathana,5 V Chongsuvivatwong2 1Department of Preventive Medicine, Tibet University Medical College, Lhasa, Tibet, China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand; 3Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; 4Department of Health Policies and Management, School of Public Health, Peking University Health and Science Center, Beijing, China; 5Department of Adult and Elderly Nursing, Faculty of Nursing, Prince of Songkla University, Hatyai, Songkhla, Thailand Background: The maternal mortality ratio (MMR) of the Tibet Autonomous Region (hereinafter “Tibet”) is still five times higher than the national average. This study aims to identify the successes and pitfalls of the health system that might be related to the high mortality rate based on the WHO health system building blocks, focusing on human resources for health and health infrastructure and the impact on maternal health and outcomes. Methods: Sources of information include China’s central government and Tibet’s local government policies and regulations, health statistical yearbooks, maternal and child health routine reporting system, and English and Chinese online research articles. Joinpoint analysis was applied for MMR and maternal health service trends, and correlation test was used to test the relationship between maternal health services and outcomes. Results: Between 2000 and 2015, public health spending in Tibet increased 67-fold, the hospital delivery rate increased 70.1%, and the MMR dropped from 466.9 to 100.1 per 100,000 live births. However, the total number of health workers, qualified medical doctors, and registered nurses per 1,000 people were 4.4, 1.4, and 1.0, respectively, much lower than the national average (5.8, 1.8, and 2.4). In Tibet, there were 80 basic and 16 comprehensive emergency obstetric care (EOC) centers. On average, there were 12 basic and 2.5 comprehensive EOC centers per 500,000 of the population. Though it met the WHO’s recommendation, it might remain inadequate in the low population density of the area like Tibet. Conclusion: The shortage of health professionals and EOC centers and health information in predominantly remote rural areas with a scattered population still needs to be rectified. Keywords: health system, human resources for health, emergency obstetric care, Tibet

Huijuan Liang,1,2 Yancun Fan,1 Nan Zhang,1 Virasakdi Chongsuvivatwong,2 Qingchun Wang,3 Jing Gong,3 Hutcha Sriplung2 1Research Institute for Health Policy of Inner Mongolia, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand; 3Department of Medical Education, Hohhot First Hospital, Hohhot, Inner Mongolia, China Objective: This study explored women’s preference for cesarean section (CS) and the preference for cesarean sections’ influencing factors, particularly nonmedical factors.Methods: A cross-sectional study was conducted in four tertiary hospitals in Hohhot. We recruited 1,169 pregnant women at ≥28 gestational weeks and classified subjects into three groups by delivery mode preference: vaginal birth (VB), CS, and “no clear preference”. We identified the influencing factors of women’s choices by multinomial logistic regression. The adjusted relative-risk ratios (aRRRs) for the factors affecting the preference for CS and “no clear preference” categories and their 95% CIs were computed, using the preference for VB as the reference group.Results: VB was preferred by 80.3% of the subjects, 8.8% preferred CS, and 10.9% had not decided yet. In the multinomial logistic regression, pregnant women intending to have more than one child were less likely to prefer CS (aRRR: 0.37; 95% CI: 0.22–0.61); choosing a lucky day for baby birth was the strongest factor for CS preference (aRRR: 12.36; 95% CI: 6.62–23.08), and other factors for CS preference were being aged 40 years and above (aRRR: 4.21; 95% CI: 1.43–12.40), being ethnic minority (aRRR: 2.00; 95% CI: 1.17, 3.41), feeling difficulty in getting pregnant (aRRR: 2.23; 95% CI: 1.20, 4.13), and having husband’s preference for CS (aRRR: 7.62; 95% CI: 4.00–14.54). The top reasons for preferring CS were the belief that CS was safer (51.5%), associated with less pain (40.8%), and better for baby’s and woman’s health (24.3% and 22.3%, respectively).Conclusion: Less than one-tenth of the study subjects preferred CS. The cultural beliefs had the strongest influence on the decision of delivery mode. Those intending to have two or more children following the two-child policy were less likely to choose CS. Keywords: mode of delivery, vaginal birth, pregnant women, fertility intention

Jing Li,1 Virasakdi Chongsuvivatwong,2 Sawitri Assanangkornchai,2 Edward B McNeil,2 Le Cai1 1School of Public Health, Kunming Medical University, Kunming, Yunnan Province, China; 2Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: China is in an epidemiologic transition period. Health system responsiveness (HSR) has become an increasing concern in China. With the burden of increasing human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome, responsiveness of HIV care is urgently needed. We aimed at comparing the experience of HSR between HIV-positive and non-HIV patients. Methods: A cross-sectional study was carried out in Yunnan, China, from January to February 2015 among two consecutive groups of HIV and non-HIV patients in two hospitals with the largest HIV admissions. Patients’ experience and expectation of HSR were measured using a self-reported questionnaire containing items of seven domains and 35 vignettes (five per domain). Each of the items and vignettes was ranked from 1 “very good” to 5 “very bad.” For each domain, B-scales were built based on the difference between experience and the vignettes. Ordered probit and censored ordered probit regression models were constructed to compare HSR experience between the two groups adjusted for socioeconomic status (SES) factors. Results: The majority of HIV patients were at clinical stage 1, were infected via unprotected sexual contact, and had a CD4 count

Ciren Yangzong,1,2 Sanguan Lerkiatbundit,3 Ouzhu Luobu,4 Chaoying Cui,4 Tippawan Liabsuetrakul,2 Baima Kangzhuo,4 Deji Quzong,4 Luobu Zhandui,5 Pu Zhen,6 Virasakdi Chongsuvivatwong2 1Department of Preventive Medicine, Medical College, Tibet University, Lhasa, Tibet Autonomous Region, People’s Republic of China; 2Epidemiology Unit, Faculty of Medicine, 3Department of Pharmacy Administration, Faculty of Pharmaceutical Science, Prince of Songkla University, Songkhla, Thailand; 4High Altitude Research Centre, 5Experimental Centre, 6Department of Pharmaceutical Science, Medical College, Tibet University, Lhasa, Tibet Autonomous Region, People’s Republic of China Abstract: Parenting style experienced during childhood has profound effects on children’s futures. Scales developed in other countries have never been validated in the Tibetan context. The present study aimed to examine the construct validity and reliability of a Tibetan translation of the 23-item short form of the Egna Minnen Beträffande Uppfostran [One’s Memories of Upbringing] (s-EMBU) and to test the correlation between the parenting styles of fathers and mothers. A cross-sectional study was conducted in a sample of 847 students aged 12–21 years from Lhasa, Tibet, during September and October 2015 with a participation rate of 97.7%. The Tibetan translation of self-completed s-EMBU was administered. Confirmatory factor analysis was employed to test the scale’s validity on the first half of the sample and was then cross-validated with the second half of the sample. The final model consisted of six factors: three (rejection, emotional warmth, and overprotection) for each parent, equality constrained on factor loadings, factor correlations, and error variance between father and mother. Father–mother correlation coefficients ranged from 0.81 to 0.86, and the level of consistency ranged from 0.62 to 0.82. Thus, the slightly modified s-EMBU is suitable for use in the Tibetan culture where both the father and the mother have consistent parenting styles. Keywords: Tibetan, parenting style, s-EMBU, validity, reliability, Egna Minnen Beträffande Uppfostran

Jing Li,1,2,* Sawitri Assanangkornchai,1,* Lin Lu,3 Manhong Jia,3,* Edward B McNeil,1,* Jing You,4,* Virasakdi Chongsuvivatwong1,* 1Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; 2School of Public Health, Kunming Medical University, 3Yunnan Center for Disease Prevention and Control, 4Infectious Diseases Department, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, People’s Republic of China *These authors contributed equally to this work Background: HIV/AIDS-related stigma is a major barrier of access to care for those infected with HIV. The aim of this study was to examine, validate, and adapt measuring scales of internalized, personal, and occupational stigma developed in Africa into a Chinese context. Methods: A cross-sectional study was conducted from January to September 2015 in Kunming, People’s Republic of China. Various scales were constructed on the basis of the previous studies with modifications by experts using exploratory and confirmatory factor analyses (EFA + CFA). Validation of the new scales was done using multiple linear regression models and hypothesis testing of the factorial structure invariance. Results: The numbers of subjects recruited for the development/validation samples were 696/667 HIV-positive patients, 699/667 non-HIV patients, and 157/155 health care providers. EFA revealed a two-factor solution for internalized and personal stigma scales (guilt/blaming and being refused/refusing service), which were confirmed by CFA with reliability coefficients (r) of 0.869 and 0.853, respectively. The occupational stigma scale was found to have a three-factor structure (blaming, professionalism, and egalitarianism) with a reliability coefficient (r) of 0.839. Higher correlations of factors in the HIV patients (r=0.537) and non-HIV patients (r=0.703) were observed in contrast to low-level correlations (r=0.231, 0.286, and 0.266) among factors from health care providers. Conclusion: The new stigma scales are valid and should be used to monitor HIV/AIDS stigma in different groups of Chinese people in health care settings. Keywords: HIV/AIDS-related stigma, exploratory factor analysis, confirmatory factor analysis, guilt, blaming, being refused, refusing service