Background: The Human Immunodeficiency Virus (HIV) has been a stigmatized illness as well as a medical condition. Attitudes toward HIV/AIDS testing have been shown to suggest an individual’s predisposition to test for HIV. The objectives of this study were to develop an instrument examining the attitudes towards HIV/AIDS by adapting and validating the HIV Antibody Testing Attitude Scale for use in HIV self-testing among young people in Nigeria.

Methods: The adapted HIV self-testing instrument was evaluated by subject matter experts to make a judgment on the instrument items for the essential, useful, or not necessary measurements of the instrument.

Results: Items on the instrument were modified to reflect the testing type, the adapted items were then analyzed by themes, and the amalgamated instrument incorporated key aspects that were to effectively examine the attitudes towards HIV self-testing among young people in Nigeria.

Conclusion: Developing an instrument that examines the attitudes towards HIV self-testing among young people in Nigeria, helps to reveal a true sense of perspectives, barriers, and concerns and ultimately identify ways to overcome presenting concerns.

• Attitudes

• HIV

• Self-testing

• Population

• Nigeria

Uzoaru F, Collins L, Ross L, Nwaozuru U (2023) The Adaptation and Content Validity of an Instrument to Examine the Attitudes and Percep tions of HIV Self-Testing Among the Young Population in Nigeria. Ann Public Health Res 10(2): 1123.

The Human Immunodeficiency Virus (HIV) has been a stigmatized illness as well as a medical condition [1,2]. Despite the progress in the fight against HIV/AIDS, including the development of rapid test benefits for HIV/AIDS status awareness, stigmatization against HIV, and those who may have it still exist [3]. Attitudes toward HIV/AIDS testing have been shown to suggest an individual’s predisposition to test for HIV [4]. Consequently, HIV prevention efforts need, and have, focused on examining the attitude that influences perceptions about HIV and sexual behavior in general [4]. In Nigeria, as with most sub Saharan African countries, young people are among the groups most vulnerable to HIV infection. They are also the population group with the highest incidence of HIV cases [5,6]. A number of social factors influence young people’s perception of HIV, including the pressure of friends and classmates, social norms, and self-efficacy [7].

As the World Health Organization (WHO) pushes for the adoption of HIV Self-Testing (HIVST), there are no psychometrically valid tests to measure attitudes toward HIV self-testing, a gap this study seeks to fill. Over the years, many instruments have been developed and validated for measuring attitudes towards HIV/AIDS, including AIDS Impact Scale [8], AIDS Knowledge Scale (AKS) [9], AIDS Attitude Scale (AAS) [10 12], Bougardus Social Distance Scale [13], Clinical Attitude Scale (CAS) [9,14], Fear of AIDS Scale [15,16], HIV Prevention Attitude Scale [17], the Q-Sort instrument [18], and the HIV Antibody Testing Attitude Scale (HTAS). Previous HIV attitude scales have measured a variety of constructs [4,19-23].

The seven most common scales are: 

1) Attitude towards HIV behavior,

2) Subjective norms of HIV behavior;

3) Perceived self-efficacy;

4)  Perceived knowledge about HIV;

5) Perceived susceptibility to HIV;

6) Social support and;

7) Sexual sensation seeking.

Since the HIV-Antibody Testing Attitude Scale (HTAS) has previously been validated among young people in Nigeria who are within the age bracket this study targets [23,24], we selected the instrument to adapt for use to test young people’s attitudes and perception of HIV self-testing. To adapt the scale, we measured two constructs, accepting attitude towards HIV testing and intention to use an HIV self-testing kit. These constructs are supported by the Theory of Planned Behavior [25].

According to the Theory of Planned Behavior (TPB), behavioral intention is a function of three things: attitude, subjective norm, and perceived self-efficacy [26,27]. Attitude is measured as the extent to which a person finds a behavior favorable or unfavorable [28]. Subjective norm measures social pressure on an individual to perform a behavior, and perceived self-efficacy measures how easy or difficult a person believes performing the behavior would be or is [29]. The theory has been used in measuring intention to test for HIV in the past. In the 2014 article by Meadowbrooke, et al., the indication of attitude towards testing was based on respondents’ agreement with the 5-point Likert-type scale statement, “Getting an HIV test is the responsible thing to do”, where strongly disagree received the lowest score [30]. The construct was also measured by a single item, “I intend to test for HIV in the next 6 months” using a 5-point probability scale, where ‘very likely’ received the highest score of 5 [24].

In order to maintain the content validity of a new HIVST instrument to the existing HTAS, conceptually speaking, this study will not restrict the number of items that could measure the intention to test [31]. The objectives of this study were to develop an instrument examining the attitudes towards HIV/AIDS by adapting and validating the HTAS for use in HIV Self-Testing (HIVST) among young people in Nigeria. Prior to utilizing the instrument, it was essential to evaluate its validity with Subject Matter Experts (SMEs) [32]. To inform this effort, we surveyed and interviewed Subject Matter Experts (SMEs).

Adapting HTAS for HIVST

The 22-item HTAS was used for this study, instead of the initially developed 32-item instrument (see Appendix 1). The 22 item instrument was rearranged by Peltzer, et al. (2004) in their psychometric study which was carried out in multiple countries including Nigeria. 

Content Validity 

To test the validity of the adapted HTAS, a qualitative approach was employed. Subject Matter Experts (SMEs) were recruited by convenience sampling, to include individuals who had worked with at least one member of the study team in various capacities during the course of their career. A draft questionnaire of the adapted HTAS was emailed to ten academics and program specialists in sexual health, behavioral science, and HIV areas, soliciting their participation as SMEs in the study. SMEs that consented to participate in the survey were emailed the questionnaire, with the instruction to review the questionnaire and check grammar, wording, and scaling. The instruction included a request for the SMEs to make a judgment on each item for example in their estimation, would they consider the item ‘essential’, ‘useful’, or ‘not necessary to measure the constructs of interest: (a) attitude towards HIV self-testing (b) intention to use an HIV self-testing kit. Further instructions included an explanation that the adapted scale was intended to examine attitudes toward HIV self-testing in young Nigerians, aged 14 to 24, and that they were free to comment on the wording of the items or suggest additional items that might better measure the constructs. Their feedback was requested within two weeks.

Data Analysis

To adapt the HTAS, all 22 items were analyzed in accordance with its use of plain language, active voice, and applicability to self-testing. Items that were assessed to have been worded inappropriately to self-testing were edited to reflect the functioning of HIVST. In place of the 5-point Likert scale used for HTAS, feedback from the SMEs was measured by whether they considered an item “Essential” (the item is vital to measuring young people’s perception and attitude towards HIV self-testing), “Useful” (the item would provide important information about young people’s perception and attitude towards HIV self-testing) or “Not necessary” (even without this item, the instrument could still measure young people’s perception and attitude towards HIV self-testing). Items needed to receive a rating of ‘Essential’ or ‘Useful’ to be retained in the adapted scale. To reduce the length of the final instrument and make it more concise and manageable for respondents, variance in the feedback from the SMEs determined which item to retain in the adapted HIVSTS and which items would be removed. If there were disagreements with the SMEs on whether an item was essential, useful, or not necessary, a decision was made about retaining or removing the item based on which rating it received most from the SMEs. For instance, if an item was assessed as ‘Essential’ by three SMEs, ‘Useful’ by two SMEs, and ‘Not necessary’ by one SME, the item was retained. If an item received ‘Not necessary’ by most of the SMEs (≥ 50%), that item was removed. Survey responses were summarized through descriptive statistics of the SMEs’ feedback.

Ethical Considerations

The study falls under the National Institute of Health (NIH) Exemption for Human Subject Research, as the adaptation of HTAS was sourced from publicly available information, and the consultation of subject experts is not considered human subject research by the US Department of Health and Human Services [33,34]. Protocol for an Institutional Review Board was therefore not sought.

HTAS Adaptation

The 22-item HTAS was categorized into two sub-scales: facilitators of testing, and barriers to testing. These categories were retained in the adaptation. However, items in both sub scales were modified to reflect the testing type the instrument was being adapted for. Six out of the eight items measuring facilitators of HIV testing were modified, while 10 out of 14 items measuring barriers to testing were modified (see Table 1).

Table 1: Comparison between the validated HTAS and the adapted HIVSTS.

Much of the modification involved changing “HIV antibody testing” to “HIV self-testing”, so test takers are not confused about which approach of HIV testing their opinion was being sought on. The item “I would be afraid to get an HIV test because people who test positive cannot get health insurance” was amended to be read, “I would be afraid to use an HIV self-testing kit because people who test positive cannot get medical treatment” because healthcare financing in Nigeria remains largely out of pocket [35-37]. The item “HIV test information is kept very confidential by the medical staff who do the testing” was not applicable to self-testing as is and was thus modified to “HIV self-testing information is kept very confidential by medical staff I share the result of the test with.” The adapted items were then analyzed by themes. The item “I do not have time to get an HIV test” was removed from the adapted instrument since getting HIVST is at a person’s convenience [38-40].

The draft adapted HIVST Attitude Scale (HIVSTS) consisted of a 21 Likert-type items scale. Same is with the HTAS, the 8 items on the adapted scale would measure degrees of positive attitude towards HIVST (i.e., facilitators of HIV self-testing) included statements like “my family would support me if I decided to self-test for HIV”. A Likert score of 1 to 5 is assigned to the five response options: Strongly disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, and Strongly Agree = 5. Similarly, 13 items would measure degrees of negative attitude towards HIVST (i.e., barriers to HIV self-testing) included statements like “people assume that everyone who is tested for HIV is infected with HIV”. These items are reverse scored: Strongly disagree = 5, Disagree = 4, Neutral = 3, Agree = 2, Strongly Agree = 1. In the adapted scale, these items are to be reverse scored to have a high total score that reflects a higher degree of favorable attitude towards HIVST.

Four themes were identified from analyzing the items: confidentiality, social support, social acceptance, and interaction with healthcare professionals or healthcare system (Table 2).

Table 2: Themes identified from narrative analysis of the 21-item HIVSTS.

Among facilitators of HIV self-testing, 4 items fell under the theme “social support”, including “my family would support me if I decided to self-test for HIV. One item each was identified under the themes “confidentiality” and “social acceptance”: “HIV self testing information is kept very confidential by medical staff I share the result of the test with” and “I would not want anyone to know if I got an HIV self-test” respectively. Among barriers of HIV self-testing, 3 items were categorized under the social support theme, while 7 items were under the social acceptance theme. 2 items were categorized under the confidentiality theme.

Content Validity

We reached out to ten SMEs to participate in the study, six of them consented, while four declined, citing unavailability. The adapted HIVSTS questionnaire was subsequently emailed to the six SMEs. All six SMEs responded to the adapted questionnaire by the deadline. The names and credentials of the SMEs are detailed in (Table 3). As shown in (Table 4),

Table 3: Subject Matter Expert (SME) participants.

Table 4: Subject Matter Expert (SME) participants.

i:One SME believed the two items were measuring the same thing.

ii: The same SME as above believed these two items were measuring the same thing.

six items received the highest number of votes from the SMEs are essential, including “HIV self-testing is not really confidential” (5 SMEs) and “results from HIV self-test are accurate (4 SMEs). One item, “it would be embarrassing to get an HIV self-testing kit” was voted as essential by all 6 SMEs. One SME believed the questions “my friends would not look down on me if I were to use an HIV self-testing kit” and “my friends would support my decision to get an HIV self-testing kit” measured the same thing. Likewise, “I am afraid that if I used an HIV self-testing kit, the result would go into my hospital file where anyone can see” was measuring the same thing as “anyone who gets an HIV self-testing kit is dirty”. However, all four items were retained in the final draft of HIVSTS (Table 5)

Table 5: Final draft of the adapted HIVSTS.

since other SMEs did not express the same opinion, most of whom thought the items were either essential or useful. Another SME regarded the item “anyone who gets an HIV self-testing kit is dirty” as essential in the scale, and consequently “anyone who gets an HIV self-testing kit is disgusting” was not necessary since it would reductant to have both in the scale. A different SME suggested additional 2 items, “I do not have issues getting an HIV self-test kit” and “I am confident that I can correctly interpret results from using an HIV self-test kit.” Both items were to be included as facilitators of HIV self-testing.

For the finalized HIVSTS, “I can talk to my friends about making medical decisions” was removed since it was the item to receive the most votes of “Not Necessary” from the SMEs (50%). The revised 22-item HIVSTS instrument, including the additional items suggested by one of the SMEs, was developed for future face validity (Table 5). 

Attitude towards HIVST Instrument

Despite the amalgamated development of the instrument, it was evident that it had key aspects that could effectively examine the attitudes towards HIV self-testing among young people in Nigeria. The adapted tool has the potential to examine the attitude of young people towards HIV self-testing as it relates to four themes: confidentiality of self-testing, the social support from family and friends, social acceptance, and the perception of interacting with healthcare professionals or the healthcare system. The SMEs provided clear insight into what items should be included in the instrument. All SMEs involved in the study agreed that it was essential for an HIVSTS to measure whether young people in Nigeria considered that it would be embarrassing to get an HIV self-test. Although not by mutual consensus among all SMEs, the item measuring the perception of young people of whether they can talk to their friends about making medical decisions was regarded as not necessary to include in an HIVSTS.

SMEs are co-collaborators providing expert knowledge and objective perspectives [41]. Lack of HIV/AIDS knowledge and preventative testing is recognized as having critical implications for public health interventions to control infection and promote treatment and care [42]. Despite the continuous efforts to improve HIV/AIDS understanding and using preventative testing, the stigma remains and discrimination against people with HIV/ AIDS in Sub-Sahara Africa continues to be a challenge [43]. It was evident that there were positive attitudes toward the HIVST instrument which contributed to the collaborative formation of the tool. Wisdom, Chor, et al., also highlight that positive attitudes towards the development of a novel instrument are associated with an increased likelihood of adoption and subsequent use [44]. There is evidence that suggests the successful implementation of an instrument is dependent on attitudes, influencing factors related to the intervention (e.g., content and structure), and the context in which the instrument may be delivered [45]. In this case, developing an instrument that examines the attitudes towards HIV self-testing among young people in Nigeria, helps to reveal a true sense of perspectives, barriers, and concerns and ultimately identify ways to overcome presenting concerns.

Implications for Practice

Depending on the outcome data on attitudes towards HIV self testing among young people in Nigeria, healthcare professionals and educationalists should be prepared to provide additional knowledge and insight on preventative interventions that promote positive health outcomes. Engaging the young people of Nigeria through educational seminars and workshops could promote awareness of perceived thoughts that could hinder or promote positive attitudes.

The HTAS being adapted for HIV self-testing may not be generalizable to other settings. As Peltzer, et al., (2003) found in their study, there are country differences in the results from their scale. Another study limitation is the use of convenience sampling which has a main drawback of lacking generalizability due to the selection bias of the sample [46]. Researchers from other settings who may wish to use this instrument should consider culturally adapting it to make it appropriate to their context [31,47-50].

Developing an instrument that examines the attitudes towards HIV self-testing among young people in Nigeria, helps to reveal a true sense of perspectives, barriers, and concerns and ultimately identify ways to overcome presenting concerns. SMEs are valuable co-collaborators providing expert knowledge and insight into the development of the instrument. Engaging the young people of Nigeria through educational seminars and workshops could promote awareness of perceived thoughts that could hinder or promote positive attitudes.

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