Health literacy, knowledge of HIV/AIDS, and public stigma among general citizens of Japan: an online cross-sectional survey

Health literacy, knowledge of HIV/AIDS, and public stigma among general citizens of Japan: an online cross-sectional survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health literacy, knowledge of HIV/AIDS, and public stigma among general citizens of Japan: an online cross-sectional survey Taisuke Togari, Sakurako Abe, Yoji Inoue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3266371/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to clarify the relationship between health literacy, knowledge of human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS), and public stigma toward people living with HIV/AIDS (PLWH) in the general Japanese population. Methods We conducted an online cross-sectional survey targeting adults (age range: 20 s to 60 s) from among the 2.2 million registrants in Rakuten Insight from September 20 to 25, 2019. Stratified randomized sampling was performed by region, sex, and age. The study participants were 2,500 heterosexual HIV-negative adults with no acquaintances who were PLWH. Among these participants, 232 who provided incomplete responses were excluded, leaving 2,268 eligible for analysis (effective response rate: 90.7%). Results Models were compared using structural equation modeling for the relationship between health literacy (16-item version of the European Health Literacy Survey), basic knowledge about HIV/AIDS, public stigma toward HIV/AIDS, and social distance. The results indicated that health literacy scores mediated public stigma and were associated with social distance (standardized coefficient of indirect effect: –.157, p < .001). Knowledge of HIV/AIDS also affected social distance through public stigma (standardized coefficient of indirect effect: –.082, p < .001). The model fit was as follows: Tucker–Lewis index = 0.90, comparative fit index = 0.91, and root mean square error of approximation = 0.058. Conclusions These findings indicate that health literacy not only maintains and promotes individual health but also has the potential to reduce stigma toward HIV/AIDS and is more closely associated with less public stigma toward HIV/AIDS than knowledge of HIV/AIDS. HIV/AIDS social stigma social discrimination health literacy structural equation modeling Figures Figure 1 Figure 2 Introduction Since surveillance was started in 1985, the number of new reports of people living with human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) in Japan has continued to increase, exceeding 1500 in 2007. However, since 2013, the number of new reports has decreased, reaching 1057 in 2021[ 1 ]. Sexual contact is the main route of HIV transmission in Japan [ 1 ], and a survey by the Japanese government reported that 85.3% of Japanese citizens were aware of this fact [ 2 ]. On the other hand, stigma toward people with HIV has been reported in many countries. Goffman defined stigma as “an attribute that is significantly discrediting” [ 3 ], and Link and Phelan defined the presence of stigma as when “elements of labeling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them”[ 4 ]. In the HIV/AIDS research field, stigma is viewed on multiple levels [ 5 ], and has been argued to involve both social and personal dimensions [ 6 ]. The personal dimension has been proposed to be divided into nonstigmatized people (those who stigmatize) and stigmatized people (those who are the target of stigma) [ 7 ]. In the context of research on stigma toward people living with mental disorders, stigma at the individual level can be divided into public stigma and self-stigma. Public stigma is defined as a “negative belief about a group, agreement with belief and/or negative emotional reaction, and behavior response to prejudice” [ 8 ]. Self-stigma is defined as a “negative belief about the self, agreement with belief, negative emotional reaction, and behavior response to prejudice” [ 8 ]. Based on these definitions, stigma as a negative belief on the “stigmatized” side can be interpreted as self-stigma, whereas that on the “nonstigmatized” side can be interpreted as public stigma. A great deal of research has been conducted on self-stigma in people living with HIV/AIDS (PLWH), including in terms of “internalized stigma” and “cognition of stigma”. These types of stigmata have been shown to place a burden on the physical and mental health of PLWH [ 7 , 9 – 11 ]. Additionally, UNAIDS made “Zero discrimination” one of its “visions of the global HIV response” for 2020 [ 12 ]. This target was raised in light of evidence that stigma and discrimination hinder HIV testing and access to HIV health care services [ 12 ]. In a survey of PLWH in Japan, 85.2% of the respondents thought that it was dangerous to tell someone they were HIV-positive, and 65.9% said they were trying to keep others from knowing that they were HIV-positive [ 13 ]. Therefore, stigma toward HIV/AIDS and its impact on PLWH continues to be significant. On the other hand, studies of public stigma toward HIV/AIDS are extremely limited, and hardly any have been conducted in Japan. Prior research on the factors underlying the public stigma toward HIV/AIDS has revealed the following associations: male gender [ 14 ], older age [ 15 ], less education [ 15 , 16 ], lower income [ 15 ], homophobia [ 16 ], and conformity to social norms [ 16 ]. In addition, public stigma is strengthened by a sense of shame of infection and a strong attitude of self-responsibility for acquiring the illness [ 17 ], as well as a low state of empathy [ 18 ]. Although improving attitudes toward PLWH [ 19 ] and reading positive online news against stigmatization [ 18 ] have been found to be important for reducing public stigma toward HIV/AIDS, these studies were conducted in the United States, Malaysia, Hong Kong, and China. To the best of our knowledge, no sufficient studies have been conducted in Japan. In addition, the accumulation of research on this topic is not sufficient at present. Many studies on the factors related to the formation of public stigma have been conducted on people living with mental illness; this is referred to as the common-sense model of stigma[ 20 , 21 ], and has been found to include the following social and personal evaluations: disease temporal constancy (stability) and disease controllability [ 22 ], time lines (considering whether the disease is acute or chronic), outcomes (assessment of disease severity), and disease coherence (overall understanding of the disease) [ 21 ]. In recent years, increasing attention has been given to the fact that individual mental health literacy (MHL) reduces public stigma. Based on the Australian government’s definition of health literacy as a health goal in the 1990s (“the ability of individuals to gain access to, understand, and use information to promote and maintain good health” [ 23 ]), MHL is conceptualized as follows: “(a) knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others who are developing a mental disorder or are in a mental health crisis” [ 24 , 25 ]. Although there are various measures of MHL [ 26 ], many intervention studies have been conducted with the aim of reducing public stigma through improving MHL. In particular, intervention effects through improving MHL have been shown in Latinos [ 27 ], adolescents [ 28 ], workplaces [ 29 ], and schools [ 30 ]. However, MHL and health literacy have progressed in separate ways [ 25 ]. In the 2000s, health literacy was associated with the concept of empowerment and regarded as an asset for improving people’s empowerment within the domains of health care, disease prevention, and health promotion [ 31 ]. It was then defined as follows: “Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and make decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course” [ 31 ]. Based on this definition, indicators were developed for the European Health Literacy Survey (HLS-EU) [ 32 ], and these have been adopted in many countries, especially in Europe, as an outcome of health policy [ 33 ]. Therefore, while MHL focuses on knowledge and skills, health literacy in the recent HLS-EU is a concept associated with comprehensive empowerment. Based on the common-sense model of stigma [ 21 ], not only knowledge, but also health literacy, i.e., motivation and competence related to obtaining, understanding, utilizing and evaluating health information, may be related to reducing stigma. However, this relationship has not yet been fully investigated. Given this background, the present study aimed to clarify the relationship between health literacy based on the HLS-EU, knowledge of HIV/AIDS, and public stigma toward PLWH in the general Japanese population. Methods Sampling An online cross-sectional survey following a stratified allocation by sex, age, and region that targeted adults in their 20 s to 60 s from among the 2.2 million registrants in Rakuten Insight was conducted from September 20 to 25, 2019. To avoid response bias, we included the following screening items at the beginning of the survey: “Do you have an acquaintance living with HIV?”, “Are you currently living with HIV?”, and “Which of the following is your sexual orientation?”. The study participants were 2,500 heterosexual HIV-negative adults with no acquaintances who were PLWH. Among these participants, 232 who provided incomplete responses were excluded, leaving 2,268 eligible for analysis (effective response rate: 90.7%). With 44 observed variables, four latent variables, a power of 0.8, and α of 0.05, the required sample size was 2,200 [ 34 , 35 ]. Variables Public stigma We used a 21-item, 6-point scale developed by Mak et al. [ 21 ]. This scale measures the degree of public stigma perceptions and attitudes. It consists of two subscales. The Public Stigma (PS) subscale consists of 12 items, such as “People with HIV/AIDS are a burden to society” and “People with HIV/AIDS often cause troubles to others”. The Personal Advocacy (PA) subscale consists of nine items, such as “If I were an employer, I would provide job opportunities to people with HIV/AIDS” and “I am willing to participate in volunteer services for people with HIV/AIDS”. With the permission of the original author, the English version was forward-translated into Japanese and then back-translated, and the final version was confirmed by the original author. The α coefficients of the Japanese version were 0.93 for 21 items, 0.94 for PS, and 0.86 for PA. Social distance to PLWH Social distance is used as a behavioral response to prejudice among people living with mental illness [ 36 ]. This study was based on the questionnaire [ 37 , 38 ] created in “The Stigma in Global Context Mental Health Study” and translated into Japanese by Yamazaki et al. After reading the presented vignette (the case of Mr. A), in this study, there were nine items, including “Mr. A will live in the neighborhood”, “Mr. A will be a colleague at work”, and “Mr. A will marry your relative”. The items were scored on a 4-point Likert scale: “acceptable”, “probably acceptable”, “probably unacceptable”, and “unacceptable”. The α coefficient was 0.93. In addition, when applied to PLWH, the content of the vignette was revised as follows based on the opinions of experts in PLWH research. Mr. A (35 years old, male, single), who works for a major trading company, was found to be HIV-positive and is receiving treatment at a hospital. Mr. A told his coworkers that he was HIV-positive, and with their understanding, he achieved a lot of results. However, Mr. A’s current job makes it difficult for him to take time off and he is overworked, so he decided to change to a less burdensome job. His doctor thought the same. Mr. A contacted several companies on the condition that they understood he was a PLWH and would hire him, but none did. Mr. A currently has to take oral medicine every day. He has to take time off from his job once every few months for medical examinations and tests at a specialized hospital. In the past, he was hospitalized for several weeks because of side effects when switching from oral medication to a new type. However, Mr. A currently has no symptoms and can commute to work every day without any problems. In addition, Mr. A has an honest personality. He can perform his work just like any other person. Mr. A suspected that he would not be able to change jobs because he was a PLWH, and he felt deep regret. Health literacy In the present study, we decided to focus on the comprehensive health literacy of the general public in Japan. We used the Japanese version [ 39 ] of the HLS-EU short version (16-item version; HLS-EU-Q16) [ 40 ] created by the Consortium Health Literacy Project European [ 31 ], which was examined from this perspective. The HLS-EU-Q16 is composed of four subscales: access (four items), understand (six items), appraise (three items), and apply/use (three items). It was measured on a 4-point Likert scale from “very easy” to “very difficult” [ 40 ]. Based on previous studies [ 41 , 42 ], the score was converted to a range of 0–50 points and analyzed accordingly. Knowledge of HIV/AIDS We provided the participants with eight statements to gauge their basic scientific knowledge about HIV, including “HIV is the name of a virus (human immunodeficiency virus) and AIDS is the name of a disease (acquired immunodeficiency syndrome)”, “If you are infected with HIV, but receive treatment, it is extremely difficult to develop AIDS”, and “If the level of HIV in the blood remains undetectable for more than 6 months as a result of treatment, HIV cannot be transmitted through sexual intercourse”. The responses were given on a 3-point scale: 1, “I just learned about it for the first time”, 2, “I have heard of it”, and 3, “I know it well”. The contents were set after consultation with experts in HIV/AIDS. The α coefficient was 0.86. Attribute variables Gender, age, and marital status were used as attribute variables. Statistical methods Statistical analysis was performed using structural equation modeling, and a hypothetical model was constructed in line with the research objectives (Fig. 1). Four latent variables were included in this model. Two latent variables, HLS-EU-Q16 scores and knowledge of HIV/AIDS, were included as independent variables. It was assumed that the two latent variables were correlated. On the dependent variable side, we included both public stigma and social distance as latent variables. Based on previous research [ 21 ], we established a causal relationship between the degree of perception of public stigma and social distance. Figure 1 Hypothesis model for health literacy, knowledge and public stigma Note HLS-EU-Q16; 16-item version of European Health Literacy Survey Questionnaire PLWH; people living with HIV/AIDS First, the factor structure was confirmed by confirmatory factor analysis. Next, we compared the following four models: Model 1 (M1), a model that made all path coefficients free parameter; Model 2 (M2), a model that fixed the path coefficient between “knowledge” and “social distance” (w1) to zero; Model 3 (M3): M2 + a model that fixed the path coefficient between “health literacy” and “social distance” (w2) to zero; and Model 4 (M4): M3 + a model that fixed the path coefficient between “knowledge” and “public stigma” (w3) to zero. M1 was the least constrained and M4 was the most constrained model. Next, we compared the Tucker–Lewis index (TLI), comparative fit index (CFI), root mean square error of approximation (RMSEA), and Akaike information criterion (AIC). The χ 2 test was used to compare M1 with the other models. Missing values were estimated using the full information maximum likelihood method. The indirect effect was tested by the Sobel test [ 43 ]. The statistical package IBM SPSS 29 and Amos 29 (Chicago, IL) was used for the analysis. Results Table 1 shows the socio-demographic characteristics of the study participants (mean age Table 1 Socio-demographic details (N = 2268) n (%) Gender Male 1093 (48.2) Female 1175 (51.8) Age group 20–29 443 (19.5) 30–39 452 (19.9) 40–49 448 (19.8) 50–59 469 (20.7) 60–69 456 (20.1) Marital status Married 1446 (63.8) Unmarried 655 (28.9) Divorced/ bereaved 167 (7.4) Table 2 Psychometric properties of each subscale in HLS-EU-Q16 Subscale name Number of items Range Mean (SD) Cronbach's alpha Obtain/Access information relevant to health 4 0–50 23.58 (10.30) 0.74 Understand Information relevant to health 6 0–50 31.88 (9.68) 0.83 Evaluate/Appraise information relevant to health 3 0–50 24.23 (10.70) 0.68 Apply/use information relevant to health 3 0–50 27.91 (10.00) 0.67 HLS-EU-Q16: European Health Literacy Survey Questionnaire 16 Table 3 Model fit indices for associations between health literacy and PLWH social distancing Model comparison under the assumption that M1 is correct χ 2 df TLI CFI RMSEA AIC Δdf Δχ 2 p M1 7004.6 806 0.90 0.91 0.058 7282.6 - - - M2 7004.7 807 0.90 0.91 0.058 7280.7 1 0.037 0.848 M3 7011.1 808 0.90 0.91 0.058 7285.1 2 5.133 0.077 M4 7026.4 809 0.90 0.91 0.058 7298.4 3 15.422 0.001 M1: the model to make all pathes free parameter M2: the model that fixes the path between "knowledge" and "social distance" (w1) to zero M3: M2་the model that fixes the path between "health literacy" and "social distance" (w2) to zero M4: M3་the model that fixes the path between "knowledge" and "public stigma" (w3) to zero [standard deviation]: 44.8 [13.6] years). Table 2 shows the distribution of the four HLS-EU-Q16 subscale scores. Confirmatory factor analysis revealed that χ 2 = 7004.6, degrees of freedom = 806, TLI = 0.90, CFI = 0.91, RMSEA = 0.058, and error covariance correction was required at five locations. Table 3 shows the results of the comparisons of the four models. As a result, we were able to adopt M2 because the null hypothesis (M1 is not correct) could not be rejected and the AIC was the lowest. Figure 2 shows the path model between the latent variables of M2. HLS-EU-Q16 scores mediated public stigma and were associated with social distance. The standardized coefficient for the indirect effect was –.157 (p < .001). Knowledge of HIV/AIDS was also found to affect social distance through public stigma. The standardized coefficient for the indirect effect was –.082 (p < .001). Figure 2 Final model for health literacy, knowledge and public stigma Note Dashed line path coefficient fixed at zero HLS-EU-Q16: 16-item version of the European Health Literacy Survey Questionnaire PLWH: people living with HIV/AIDS Table 4 shows the standardized loadings in the structural and measurement equations of the final model. The standardized estimates ranged from 0.39 to 0.94, and all estimates were statistically significant (p < .001). Discussion The results of this study revealed that health literacy affects social distance through public stigma. In particular, public stigma and social distance were found to be strongly related. This finding was similar to previous studies on psychiatric disorders [ 21 , 44 , 45 ]. In the present study, public stigma focused on the negative aspects of cognition and attitudes [ 21 ], and the relationship between public stigma and social distance, which is a behavioral outcome, was assumed as a hypothesis. In addition, this result suggests the value of focusing on and improving health literacy. In other words, health literacy has repeatedly been examined as the ability to live for one’s own health. Systematic reviews have shown that health literacy affects mortality [ 46 ], quality of life [ 47 ], self-management [ 48 ], and health behavior [ 49 ]. Table 4 Final model for associations between health literacy and PLWH social distancing: unstandardized and standardized loadings by structural equation modeling Outline of item content B * (SE) β † p Public stigma of HIV/AIDS →Personal advocacy 1.00 - 0.80 - →Public stigma (narrow) 4.63 (0.52) 0.85 < .001 Personal advocacy →reach out to PLWH 1.00 - 0.20 - →provide job opportunities to PLWH 3.98 (0.44) 0.68 < .001 →participate in volunteer services for PLWH 2.31 (0.27) 0.45 < .001 →PLWH deserve our care 2.10 (0.25) 0.39 < .001 →PLWH should be treated fairly 4.21 (0.46) 0.69 < .001 →making friends with PLWH 5.20 (0.56) 0.85 < .001 →accept PLWH 5.09 (0.55) 0.89 < .001 →PLWH can reintegrate into society 4.13 (0.45) 0.76 < .001 →fight for the rights of PLWH 2.82 (0.32) 0.55 < .001 Public stigma (narrow) →keep my distance with PLWH 1.00 - 0.66 - →PLWH are a burden 0.92 (0.03) 0.70 < .001 →PLWH cause troubles 0.95 (0.03) 0.74 < .001 →PLWH harm others 0.93 (0.03) 0.69 < .001 →estrange PLWH 1.15 (0.03) 0.87 < .001 →PLWH are repulsive 1.21 (0.03) 0.88 < .001 →PLWH are dislikeable 1.11 (0.03) 0.84 < .001 →PLWH should be segregated 1.07 (0.03) 0.84 < .001 →avoid PLWH 1.14 (0.03) 0.87 < .001 →PLWH make people angry 0.78 (0.03) 0.69 < .001 →PLWH are normally discriminated 0.78 (0.03) 0.61 < .001 →afraid of being alone with PLWH 1.03 (0.03) 0.76 < .001 Knowledge of HIV/AIDS →with continuing effective treatment, HIV is not transmittable 1.00 - 0.62 - →most HIV infections are due to homosexual contact 1.39 (0.06) 0.66 < .001 →HIV transmission is common through sexual contact 1.38 (0.06) 0.64 < .001 →the number of new HIV infections goes sideways. 1.44 (0.05) 0.76 < .001 →low out-of-pocket medical costs due to public subsidies 1.37 (0.05) 0.70 < .001 →need for regular hospital visits 1.38 (0.06) 0.64 < .001 →less likely to develop with treatment 1.34 (0.06) 0.62 < .001 →"HIV" is the name of the virus 1.19 (0.06) 0.56 < .001 Social distance to PLWH →the same hospital 1.00 - 0.77 - →have a meal together 1.14 (0.03) 0.87 < .001 →marry your family 0.59 (0.03) 0.44 < .001 →work next seat 1.20 (0.02) 0.93 < .001 →the same workplace 1.14 (0.02) 0.94 < .001 →become freiends 1.15 (0.02) 0.91 < .001 →ask to take care of child 0.81 (0.03) 0.58 < .001 →greet and talk 0.84 (0.02) 0.77 < .001 →live next door 0.99 (0.02) 0.83 < .001 HLS-EU-Q16 →Obtain/Access information 0.87 (0.02) 0.83 < .001 →Understand information 0.89 (0.02) 0.82 < .001 →Appraise information 1.00 - 0.83 - →Apply/use information 1.01 (0.02) 0.90 < .001 PLWH: people living with HIV HLS-EU-Q16: 16-item version for European health literacy survey questionnaire *nonstandardized coefficient †standardized coefficient However, the results of the present study suggest the possibility that health literacy impacts the recognition and behavior of building healthy relationships that reduce discrimination and prejudice against minorities. However, these findings are still in the early stage, so more evidence regarding the relationship between health literacy and prejudice/discrimination, not only in PLWH, but also in patients with other diseases and minorities, needs to be accumulated. The present findings indicate that knowledge influences social distance through public stigma. However, the impact of knowledge on public stigma was smaller than that of health literacy, and no direct relationship was observed with social distance. Some previous studies on mental illness have reported a negative association between knowledge and public stigma [ 50 ], while others have reported no such association [ 51 , 52 ]. The impact of knowledge about HIV/AIDS was found to be limited rather than irrelevant, unlike mental illness. However, the present study found a correlation between knowledge and health literacy. Health literacy based on the HLS-EU-Q16 is the ability to obtain, understand, evaluate, and utilize information rather than knowledge itself [ 31 ] and includes the ability to make decisions and act based on knowledge. In the data–information–knowledge–wisdom hierarchy [ 53 ], a classic model in informatics, health literacy based on the HLS-EU is close to a level of wisdom. The results of this study could promote the development and implementation of programs to reduce public stigma based on health behavioral theories, including health literacy. Several studies have reported public stigma countermeasure programs for HIV/AIDS, and systematic reviews have shown modest effectiveness but tend to be of poor methodological quality [ 19 ]. Therefore, further studies are needed in the future. Regarding intervention studies on health literacy targeting the general population, there has not yet been sufficient research, especially on health literacy centered on skills [ 54 , 55 ]. On the other hand, in recent years, national policies to promote health literacy have been developed in EU countries (Austria, Ireland, Italy, Portugal, Spain and the UK), and the following policies have been implemented: providing tailored health information, educating professionals and developing health education programs or materials for people with lower levels of health literacy [ 33 ]. In Finland, health literacy is positioned within school education programs, and curricula are officially organized in primary and secondary education [ 56 ]. Based on our research results, we can expect a reduction in public stigma such as HIV/AIDS by placing health literacy as one of the school education and policy outcomes. As a countermeasure against public stigma toward HIV/AIDS, a campaign based on extremely well-executed research evidence with the slogan “U = U (Undetectable = Untransmittable)” was recently launched [ 57 ]. That campaign may reduce the level of public stigma [ 58 ] and improve the mental health of PLWH [ 59 ]. However, it is important for HIV-negative people to not only acquire knowledge about “U = U”, but also make use of that knowledge in their decision-making and actions. Therefore, to reduce public stigma toward HIV/AIDS, it is not enough to carry out correct knowledge campaigns. It is necessary to carry out efforts aimed at maintaining and improving health literacy for HIV-negative people in conjunction with knowledge campaigns. The concept of public stigma used in this study involves the perceptions of those who stigmatize others at the individual level. On the other hand, it has been suggested that public stigma at not only the individual but also the collective level, may influence the internalization of stigma, such as perceived stigma and self-stigma. In other words, a multilevel approach that includes social-level stigma is needed when examining stigma [ 5 ]. To the best of our knowledge, this study is one of the few that have attempted to clarify the relationship between health literacy and public stigma toward PLWH, and the results are of theoretical and practical significance. However, the following limitations should be noted. First, this was an online survey, and the sample was drawn from a panel administered by a survey agency. Although the scale of the agent panel used in this study is one of the largest in Japan, the reproducibility of other sampling methods, such as the Basic Resident Register, needs to be examined. Second, because this was a cross-sectional study, no causal relationships could be established. In the future, a detailed examination of the causal relationships needs to be examined in a study using a longitudinal design. Abbreviations HIV/AIDS Human immunodeficiency virus infection and acquired immunodeficiency syndrome PLWH People living with HIV/AIDS MHL Mental health literacy TLI Tucker–Lewis index CFI Comparative fit index RMSEA Root mean square error of approximation AIC Akaike information criterion HLS-EU European Health Literacy Survey Declarations Ethics approval and consent to participate The authors declare that all methods were carried out in accordance with relevant guidelines and regulations. They also declare that all procedures contributing to this work have been performed in accordance with the ethical standards of the relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was obtained from the Open University of Japan Institutional Review Board committee (2019-30). Informed consent was obtained from all subjects. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed in this study are not publicly available to protect the privacy of the participants but are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by JSPS KAKENHI Grant No. 19H03928. Authors’ contributions TT and YI conceptualized the project; TT provided guidance in the analyses; TT and SA conducted the data analyses; TT drafted the manuscript; all authors participated in writing the manuscript and approved the final version for submission. Acknowledgements We would like to thank all the people who cooperated in conducting this survey. References JapanNationalInstituteofInfectiousDisease. The topic of HIV/AIDS in Japan. Infectious Agent Surveillance Report (IASR). 2022;43:221-30. Office JC. Overview of the Public Opinion Survey on HIV/AIDS. 2018. https://survey.gov-online.go.jp/hutai/h29/h29-hiv.pdf. 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The Long-Term Effectiveness of Interventions Addressing Mental Health Literacy and Stigma of Mental Illness in Children and Adolescents: Systematic Review and Meta-Analysis. Int J Public Health. 2021;66:1604072. https://doi.org/10.3389/ijph.2021.1604072. Hanisch SE, Twomey CD, Szeto AC, Birner UW, Nowak D, Sabariego C. The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review. BMC Psychiatry. 2016;16:1. https://doi.org/10.1186/s12888-015-0706-4. Ma KKY, Anderson JK, Burn A-M. Review: School-based interventions to improve mental health literacy and reduce mental health stigma - a systematic review. Child and adolescent mental health. 2023;28:230-40. https://doi.org/10.1111/camh.12543. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. https://doi.org/10.1186/1471-2458-12-80. Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13:948. https://doi.org/10.1186/1471-2458-13-948. van der Heide I, Heijmans M, Rademakers J. Health literacy policies: European perspectives. In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sørensen K, editors. International handbook of health literacy: research, practice and policy across the lifespan. Bristol: Policy Press; 2019. Christopher Westland J. Lower bounds on sample size in structural equation modeling. Electronic Commerce Research and Applications. 2010;9:476-87. https://doi.org/10.1016/j.elerap.2010.07.003. Soper D. A-priori Sample Size Calculator for Structural Equation Models [Software]. 2023. https://www.danielsoper.com/statcalc. Accessed 07/17 2023. Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health. 1999;89:1328-33. https://doi.org/10.2105/ajph.89.9.1328. Yamazaki Y, Matoba T, Kikuzawa S, Sakano J Eyes and stigma towards mental illness: national survey research. Tokyo: Akashi Shoten; 2012. Kikuzawa S, Pescosolido B, Kasahara-Kiritani M, Matoba T, Yamaki C, Sugiyama K. Mental health care and the cultural toolboxes of the present-day Japanese population: Examining suggested patterns of care and their correlates. Soc Sci Med. 2019;228:252-61. https://doi.org/10.1016/j.socscimed.2019.03.004. Nakayama K, Osaka W, Togari T, Ishikawa H, Yonekura Y, Sekido A, et al. Comprehensive health literacy in Japan is lower than in Europe: a validated Japanese-language assessment of health literacy. BMC Public Health. 2015;15:505. https://doi.org/10.1186/s12889-015-1835-x. Pelikan JM, Röthlin F, Ganahl K. Measuring comprehensive health literacy in general populations: validation of instrument, indices and scales of the HLS-EU study: 6th Annual Health Literacy Research Conference November 3-4, 2014 Bethesda, Maryland, Hyatt Regency Bethesda 2014. https://www.bumc.bu.edu/healthliteracyconference/files/2014/06/Pelikan-et-al-HARC-2014-fin.pdf. Accessed 07/17 2023. Dsouza JP, Van den Broucke S, Pattanshetty S. Validity and Reliability of the Indian Version of the HLS-EU-Q16 Questionnaire. Int J Environ Res Public Health. 2021;18. https://doi.org/10.3390/ijerph18020495. Pedro AR, Raposo B, Luís L, Amaral O, Escoval A, Simões Dias S. Portuguese Version of the HLS-EU-Q6 and HLS-EU-Q16 Questionnaire: Psychometric Properties. Int J Environ Res Public Health. 2023;20. https://doi.org/10.3390/ijerph20042892. Sobel ME. Asymptotic Confidence Intervals for Indirect Effects in Structural Equation Models. Sociological Methodology. 1982;13:290-312. https://doi.org/10.2307/270723. Lem WG, Kawata KHDS, Kobayashi T, Oyama H. Public Stigma Related to People With Mental Health Conditions Among Japanese Company Employees. Journal of clinical medicine research. 2023;15:139-47. https://doi.org/10.14740/jocmr4868. Doll CM, Michel C, Betz LT, Schimmelmann BG, Schultze-Lutter F. The Important Role of Stereotypes in the relation between Mental Health Literacy and Stigmatization of Depression and Psychosis in the Community. Community mental health journal. 2022;58:474-86. https://doi.org/10.1007/s10597-021-00842-5. Fan ZY, Yang Y, Zhang F. Association between health literacy and mortality: a systematic review and meta-analysis. Arch Public Health. 2021;79:119. https://doi.org/10.1186/s13690-021-00648-7. Cabellos-García AC, Martínez-Sabater A, Castro-Sánchez E, Kangasniemi M, Juárez-Vela R, Gea-Caballero V. Relation between health literacy, self-care and adherence to treatment with oral anticoagulants in adults: a narrative systematic review. BMC Public Health. 2018;18:1157. https://doi.org/10.1186/s12889-018-6070-9. van der Gaag M, Heijmans M, Spoiala C, Rademakers J. The importance of health literacy for self-management: A scoping review of reviews. Chronic Illn. 2022;18:234-54. https://doi.org/10.1177/17423953211035472. Ronie W, Stephen JL, Rob P, Tara C, Trish G. Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review. BMC Public Health. 2020;20:1-17. https://doi.org/10.1186/s12889-020-08991-0. Yin H, Wardenaar KJ, Xu G, Tian H, Schoevers RA. Mental health stigma and mental health knowledge in Chinese population: a cross-sectional study. BMC Psychiatry. 2020;20:323. https://doi.org/10.1186/s12888-020-02705-x. Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people with mental illness: a trend analysis based on population surveys in the eastern part of Germany. Eur Psychiatry. 2009;24:225-32. https://doi.org/10.1016/j.eurpsy.2008.06.010. Wang J, Lai D. The relationship between mental health literacy, personal contacts and personal stigma against depression. J Affect Disord. 2008;110:191-6. https://doi.org/10.1016/j.jad.2008.01.005. Jennifer R. The wisdom hierarchy: representations of the DIKW hierarchy. Journal of Information Science. 2007;33:163-80. https://doi.org/10.1177/0165551506070706. Nutbeam D, McGill B. Improving health literacy in clinical and community populations. In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sørensen K, editors. International handbook of health literacy: research, practice and policy across the life span. Bristol: Policy Press; 2019. p. 219-32. Nutbeam D, McGill B, Premkumar P. Improving health literacy in community populations: a review of progress. Health promotion international. 2018;33:901-11. Paakkari O, Paakkari L. Health literacy and the school curriculum: The example of Finland. In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sørensen K, editors. International handbook of health literacy: research, practice and policy across the life span. Bristol: Policy Press; 2019. p. 521-34. The Lancet H. U=U taking off in 2017. Lancet HIV. 2017;4:e475. https://doi.org/10.1016/S2352-3018(17)30183-2. Togari T, Abe S, Inoue Y. [HIV-related public stigma and knowledge regarding the campaign slogan "undetectable=untransmittable" among Japanese people]. [Nihon koshu eisei zasshi] Japanese journal of public health. 2022;69:146-57. https://doi.org/10.11236/jph.21-005. Okoli C, Van de Velde N, Richman B, Allan B, Castellanos E, Young B, et al. Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect. 2021;97:18-26. https://doi.org/10.1136/sextrans-2020-054551. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3266371","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":231676374,"identity":"9df96751-be13-4bd6-98d1-fc4b44b81f5d","order_by":0,"name":"Taisuke Togari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYPACCTkgkQBiMRNUy8MG0WJMshaGxAaiXWQv33z4xc89Fun9EgkPGH7UMLCbE7aFLc2y55lE7swZCQmMPccYmC0J2cfDxmNmwHNAInfDjYQEBt4GBmaDA0RoMfxzQCLdAKiF8S+RWowfA21JAGlhJs6WY2lpzDIHJAxn9jxIOCxzTIKwX9ibDx/++OZAnTw/e07iwzc1NskEQwwI2CSgFiYAnSSRbECEFuYPUAsPgEg7YrSMglEwCkbByAIAPOk42kohxOYAAAAASUVORK5CYII=","orcid":"","institution":"The Open University of Japan","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Taisuke","middleName":"","lastName":"Togari","suffix":""},{"id":231676375,"identity":"b26190d7-a21c-47ce-ba3a-74aa1739ec68","order_by":1,"name":"Sakurako Abe","email":"","orcid":"","institution":"TIS Inc","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sakurako","middleName":"","lastName":"Abe","suffix":""},{"id":231676377,"identity":"c698ede8-ed5a-4171-84e6-c1be9b09be1c","order_by":2,"name":"Yoji Inoue","email":"","orcid":"","institution":"Accelight Inc","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yoji","middleName":"","lastName":"Inoue","suffix":""}],"badges":[],"createdAt":"2023-08-15 15:44:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3266371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3266371/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43010074,"identity":"beec0536-73e7-471b-b9d8-0dce60cfc84b","added_by":"auto","created_at":"2023-09-12 14:27:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102776,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHypothesis model for health literacy, knowledge and public stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHLS-EU-Q16; 16-item version of European Health Literacy Survey Questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLWH; people living with HIV/AIDS\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3266371/v1/b05d7382bf0aacc08c951c65.png"},{"id":43010073,"identity":"0d37e4e1-40d7-45bc-b87f-73e96ff2f7e9","added_by":"auto","created_at":"2023-09-12 14:27:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":118841,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFinal model for health literacy, knowledge and public stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDashed line path coefficient fixed at zero\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHLS-EU-Q16: 16-item version of the European Health Literacy Survey Questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLWH: people living with HIV/AIDS\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3266371/v1/414966b7b617d7257256d900.png"},{"id":48408752,"identity":"d1038db9-4555-42ae-b193-d233e2831d72","added_by":"auto","created_at":"2023-12-18 17:07:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":697738,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3266371/v1/248d33db-4d1f-49d2-a3ff-c3e79ab57e70.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health literacy, knowledge of HIV/AIDS, and public stigma among general citizens of Japan: an online cross-sectional survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince surveillance was started in 1985, the number of new reports of people living with human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) in Japan has continued to increase, exceeding 1500 in 2007. However, since 2013, the number of new reports has decreased, reaching 1057 in 2021[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Sexual contact is the main route of HIV transmission in Japan [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and a survey by the Japanese government reported that 85.3% of Japanese citizens were aware of this fact [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, stigma toward people with HIV has been reported in many countries. Goffman defined stigma as \u0026ldquo;an attribute that is significantly discrediting\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and Link and Phelan defined the presence of stigma as when \u0026ldquo;elements of labeling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them\u0026rdquo;[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the HIV/AIDS research field, stigma is viewed on multiple levels [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and has been argued to involve both social and personal dimensions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The personal dimension has been proposed to be divided into nonstigmatized people (those who stigmatize) and stigmatized people (those who are the target of stigma) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the context of research on stigma toward people living with mental disorders, stigma at the individual level can be divided into public stigma and self-stigma. Public stigma is defined as a \u0026ldquo;negative belief about a group, agreement with belief and/or negative emotional reaction, and behavior response to prejudice\u0026rdquo; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Self-stigma is defined as a \u0026ldquo;negative belief about the self, agreement with belief, negative emotional reaction, and behavior response to prejudice\u0026rdquo; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Based on these definitions, stigma as a negative belief on the \u0026ldquo;stigmatized\u0026rdquo; side can be interpreted as self-stigma, whereas that on the \u0026ldquo;nonstigmatized\u0026rdquo; side can be interpreted as public stigma.\u003c/p\u003e \u003cp\u003eA great deal of research has been conducted on self-stigma in people living with HIV/AIDS (PLWH), including in terms of \u0026ldquo;internalized stigma\u0026rdquo; and \u0026ldquo;cognition of stigma\u0026rdquo;. These types of stigmata have been shown to place a burden on the physical and mental health of PLWH [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, UNAIDS made \u0026ldquo;Zero discrimination\u0026rdquo; one of its \u0026ldquo;visions of the global HIV response\u0026rdquo; for 2020 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This target was raised in light of evidence that stigma and discrimination hinder HIV testing and access to HIV health care services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In a survey of PLWH in Japan, 85.2% of the respondents thought that it was dangerous to tell someone they were HIV-positive, and 65.9% said they were trying to keep others from knowing that they were HIV-positive [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, stigma toward HIV/AIDS and its impact on PLWH continues to be significant.\u003c/p\u003e \u003cp\u003eOn the other hand, studies of public stigma toward HIV/AIDS are extremely limited, and hardly any have been conducted in Japan. Prior research on the factors underlying the public stigma toward HIV/AIDS has revealed the following associations: male gender [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], older age [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], less education [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], lower income [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], homophobia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and conformity to social norms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, public stigma is strengthened by a sense of shame of infection and a strong attitude of self-responsibility for acquiring the illness [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], as well as a low state of empathy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although improving attitudes toward PLWH [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and reading positive online news against stigmatization [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] have been found to be important for reducing public stigma toward HIV/AIDS, these studies were conducted in the United States, Malaysia, Hong Kong, and China. To the best of our knowledge, no sufficient studies have been conducted in Japan. In addition, the accumulation of research on this topic is not sufficient at present.\u003c/p\u003e \u003cp\u003eMany studies on the factors related to the formation of public stigma have been conducted on people living with mental illness; this is referred to as the common-sense model of stigma[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and has been found to include the following social and personal evaluations: disease temporal constancy (stability) and disease controllability [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], time lines (considering whether the disease is acute or chronic), outcomes (assessment of disease severity), and disease coherence (overall understanding of the disease) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, increasing attention has been given to the fact that individual mental health literacy (MHL) reduces public stigma. Based on the Australian government\u0026rsquo;s definition of health literacy as a health goal in the 1990s (\u0026ldquo;the ability of individuals to gain access to, understand, and use information to promote and maintain good health\u0026rdquo; [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]), MHL is conceptualized as follows: \u0026ldquo;(a) knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others who are developing a mental disorder or are in a mental health crisis\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Although there are various measures of MHL [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], many intervention studies have been conducted with the aim of reducing public stigma through improving MHL. In particular, intervention effects through improving MHL have been shown in Latinos [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], adolescents [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], workplaces [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and schools [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, MHL and health literacy have progressed in separate ways [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the 2000s, health literacy was associated with the concept of empowerment and regarded as an asset for improving people\u0026rsquo;s empowerment within the domains of health care, disease prevention, and health promotion [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It was then defined as follows: \u0026ldquo;Health literacy is linked to literacy and entails people\u0026rsquo;s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and make decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course\u0026rdquo; [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Based on this definition, indicators were developed for the European Health Literacy Survey (HLS-EU) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and these have been adopted in many countries, especially in Europe, as an outcome of health policy [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, while MHL focuses on knowledge and skills, health literacy in the recent HLS-EU is a concept associated with comprehensive empowerment. Based on the common-sense model of stigma [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], not only knowledge, but also health literacy, i.e., motivation and competence related to obtaining, understanding, utilizing and evaluating health information, may be related to reducing stigma. However, this relationship has not yet been fully investigated.\u003c/p\u003e \u003cp\u003eGiven this background, the present study aimed to clarify the relationship between health literacy based on the HLS-EU, knowledge of HIV/AIDS, and public stigma toward PLWH in the general Japanese population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eAn online cross-sectional survey following a stratified allocation by sex, age, and region that targeted adults in their 20 s to 60 s from among the 2.2\u0026nbsp;million registrants in Rakuten Insight was conducted from September 20 to 25, 2019. To avoid response bias, we included the following screening items at the beginning of the survey: \u0026ldquo;Do you have an acquaintance living with HIV?\u0026rdquo;, \u0026ldquo;Are you currently living with HIV?\u0026rdquo;, and \u0026ldquo;Which of the following is your sexual orientation?\u0026rdquo;. The study participants were 2,500 heterosexual HIV-negative adults with no acquaintances who were PLWH. Among these participants, 232 who provided incomplete responses were excluded, leaving 2,268 eligible for analysis (effective response rate: 90.7%). With 44 observed variables, four latent variables, a power of 0.8, and α of 0.05, the required sample size was 2,200 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003ePublic stigma\u003c/h2\u003e \u003cp\u003eWe used a 21-item, 6-point scale developed by Mak et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This scale measures the degree of public stigma perceptions and attitudes. It consists of two subscales. The Public Stigma (PS) subscale consists of 12 items, such as \u0026ldquo;People with HIV/AIDS are a burden to society\u0026rdquo; and \u0026ldquo;People with HIV/AIDS often cause troubles to others\u0026rdquo;. The Personal Advocacy (PA) subscale consists of nine items, such as \u0026ldquo;If I were an employer, I would provide job opportunities to people with HIV/AIDS\u0026rdquo; and \u0026ldquo;I am willing to participate in volunteer services for people with HIV/AIDS\u0026rdquo;. With the permission of the original author, the English version was forward-translated into Japanese and then back-translated, and the final version was confirmed by the original author. The α coefficients of the Japanese version were 0.93 for 21 items, 0.94 for PS, and 0.86 for PA.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSocial distance to PLWH\u003c/h2\u003e \u003cp\u003eSocial distance is used as a behavioral response to prejudice among people living with mental illness [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This study was based on the questionnaire [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] created in \u0026ldquo;The Stigma in Global Context Mental Health Study\u0026rdquo; and translated into Japanese by Yamazaki et al. After reading the presented vignette (the case of Mr. A), in this study, there were nine items, including \u0026ldquo;Mr. A will live in the neighborhood\u0026rdquo;, \u0026ldquo;Mr. A will be a colleague at work\u0026rdquo;, and \u0026ldquo;Mr. A will marry your relative\u0026rdquo;. The items were scored on a 4-point Likert scale: \u0026ldquo;acceptable\u0026rdquo;, \u0026ldquo;probably acceptable\u0026rdquo;, \u0026ldquo;probably unacceptable\u0026rdquo;, and \u0026ldquo;unacceptable\u0026rdquo;. The α coefficient was 0.93. In addition, when applied to PLWH, the content of the vignette was revised as follows based on the opinions of experts in PLWH research.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMr. A (35 years old, male, single), who works for a major trading company, was found to be HIV-positive and is receiving treatment at a hospital. Mr. A told his coworkers that he was HIV-positive, and with their understanding, he achieved a lot of results. However, Mr. A\u0026rsquo;s current job makes it difficult for him to take time off and he is overworked, so he decided to change to a less burdensome job. His doctor thought the same.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMr. A contacted several companies on the condition that they understood he was a PLWH and would hire him, but none did. Mr. A currently has to take oral medicine every day. He has to take time off from his job once every few months for medical examinations and tests at a specialized hospital. In the past, he was hospitalized for several weeks because of side effects when switching from oral medication to a new type.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eHowever, Mr. A currently has no symptoms and can commute to work every day without any problems. In addition, Mr. A has an honest personality. He can perform his work just like any other person. Mr. A suspected that he would not be able to change jobs because he was a PLWH, and he felt deep regret.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eHealth literacy\u003c/h2\u003e \u003cp\u003eIn the present study, we decided to focus on the comprehensive health literacy of the general public in Japan. We used the Japanese version [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] of the HLS-EU short version (16-item version; HLS-EU-Q16) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] created by the Consortium Health Literacy Project European [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], which was examined from this perspective. The HLS-EU-Q16 is composed of four subscales: access (four items), understand (six items), appraise (three items), and apply/use (three items). It was measured on a 4-point Likert scale from \u0026ldquo;very easy\u0026rdquo; to \u0026ldquo;very difficult\u0026rdquo; [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Based on previous studies [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], the score was converted to a range of 0\u0026ndash;50 points and analyzed accordingly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of HIV/AIDS\u003c/h2\u003e \u003cp\u003eWe provided the participants with eight statements to gauge their basic scientific knowledge about HIV, including \u0026ldquo;HIV is the name of a virus (human immunodeficiency virus) and AIDS is the name of a disease (acquired immunodeficiency syndrome)\u0026rdquo;, \u0026ldquo;If you are infected with HIV, but receive treatment, it is extremely difficult to develop AIDS\u0026rdquo;, and \u0026ldquo;If the level of HIV in the blood remains undetectable for more than 6 months as a result of treatment, HIV cannot be transmitted through sexual intercourse\u0026rdquo;. The responses were given on a 3-point scale: 1, \u0026ldquo;I just learned about it for the first time\u0026rdquo;, 2, \u0026ldquo;I have heard of it\u0026rdquo;, and 3, \u0026ldquo;I know it well\u0026rdquo;. The contents were set after consultation with experts in HIV/AIDS. The α coefficient was 0.86.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eAttribute variables\u003c/h2\u003e \u003cp\u003eGender, age, and marital status were used as attribute variables.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using structural equation modeling, and a hypothetical model was constructed in line with the research objectives (Fig.\u0026nbsp;1). Four latent variables were included in this model. Two latent variables, HLS-EU-Q16 scores and knowledge of HIV/AIDS, were included as independent variables. It was assumed that the two latent variables were correlated. On the dependent variable side, we included both public stigma and social distance as latent variables. Based on previous research [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], we established a causal relationship between the degree of perception of public stigma and social distance.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1 Hypothesis model for health literacy, knowledge and public stigma\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e \u003cb\u003eHLS-EU-Q16; 16-item version of European Health Literacy Survey Questionnaire\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003cp\u003ePLWH; people living with HIV/AIDS\u003c/p\u003e \u003cp\u003eFirst, the factor structure was confirmed by confirmatory factor analysis. Next, we compared the following four models: Model 1 (M1), a model that made all path coefficients free parameter; Model 2 (M2), a model that fixed the path coefficient between \u0026ldquo;knowledge\u0026rdquo; and \u0026ldquo;social distance\u0026rdquo; (w1) to zero; Model 3 (M3): M2\u0026thinsp;+\u0026thinsp;a model that fixed the path coefficient between \u0026ldquo;health literacy\u0026rdquo; and \u0026ldquo;social distance\u0026rdquo; (w2) to zero; and Model 4 (M4): M3\u0026thinsp;+\u0026thinsp;a model that fixed the path coefficient between \u0026ldquo;knowledge\u0026rdquo; and \u0026ldquo;public stigma\u0026rdquo; (w3) to zero. M1 was the least constrained and M4 was the most constrained model.\u003c/p\u003e \u003cp\u003eNext, we compared the Tucker\u0026ndash;Lewis index (TLI), comparative fit index (CFI), root mean square error of approximation (RMSEA), and Akaike information criterion (AIC). The χ\u003csup\u003e2\u003c/sup\u003e test was used to compare M1 with the other models. Missing values were estimated using the full information maximum likelihood method. The indirect effect was tested by the Sobel test [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The statistical package IBM SPSS 29 and Amos 29 (Chicago, IL) was used for the analysis.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ctable id=\"Tab1\" border=\"1\" style=\"margin-right: calc(61%); width: 39%;\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eshows the socio-demographic characteristics of the study participants (mean age\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\" style=\"width: 74.8805%;\"\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e Socio-demographic details (N\u0026thinsp;=\u0026thinsp;2268)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 50.7169%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e1093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(48.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e1175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 50.7169%;\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003e60\u0026ndash;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 50.7169%;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e1446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e655\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 2.9209%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47.7961%;\"\u003e\n \u003cp\u003eDivorced/ bereaved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0112%;\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.1524%;\"\u003e\n \u003cp\u003e(7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\" style=\"margin-right: calc(6%); width: 94%;\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"9\" style=\"width: 13.0641%;\"\u003e\n \u003cp\u003eTable\u0026nbsp;2 Psychometric properties of each subscale in HLS-EU-Q16\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\" style=\"width: 8.7598%;\"\u003e\n \u003cp\u003eSubscale name\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.0709%;\"\u003e\n \u003cp\u003eNumber of items\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2082%;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.1076%;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.3844%;\"\u003e\n \u003cp\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1465%;\"\u003e\n \u003cp\u003eCronbach\u0026apos;s alpha\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\" style=\"width: 8.7598%;\"\u003e\n \u003cp\u003eObtain/Access information relevant to health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.0709%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2082%;\"\u003e\n \u003cp\u003e0\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.1076%;\"\u003e\n \u003cp\u003e23.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.3844%;\"\u003e\n \u003cp\u003e(10.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1465%;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\" style=\"width: 8.7598%;\"\u003e\n \u003cp\u003eUnderstand Information relevant to health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.0709%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2082%;\"\u003e\n \u003cp\u003e0\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.1076%;\"\u003e\n \u003cp\u003e31.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.3844%;\"\u003e\n \u003cp\u003e(9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1465%;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\" style=\"width: 8.7598%;\"\u003e\n \u003cp\u003eEvaluate/Appraise information relevant to health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.0709%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2082%;\"\u003e\n \u003cp\u003e0\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.1076%;\"\u003e\n \u003cp\u003e24.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.3844%;\"\u003e\n \u003cp\u003e(10.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1465%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\" style=\"width: 8.7598%;\"\u003e\n \u003cp\u003eApply/use information relevant to health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.0709%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2082%;\"\u003e\n \u003cp\u003e0\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.1076%;\"\u003e\n \u003cp\u003e27.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.3844%;\"\u003e\n \u003cp\u003e(10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1465%;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\" style=\"width: 13.0641%;\"\u003e\n \u003cp\u003eHLS-EU-Q16: European Health Literacy Survey Questionnaire 16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\" style=\"margin-right: calc(4%); width: 96%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\" style=\"width: 15.2454%;\"\u003e\n \u003cp\u003eTable 3 Model fit indices for associations between health literacy and PLWH social distancing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 0.5742%;\"\u003e\n \u003cp\u003eModel comparison under the assumption that M1 is correct\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\n \u003cp\u003eAIC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\n \u003cp\u003e\u0026Delta;df\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\n \u003cp\u003e\u0026Delta;\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\n \u003cp\u003eM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\n \u003cp\u003e7004.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\n \u003cp\u003e806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\n \u003cp\u003e7282.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\n \u003cp\u003eM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\n \u003cp\u003e7004.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\n \u003cp\u003e807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\n \u003cp\u003e7280.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\n \u003cp\u003eM3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\n \u003cp\u003e7011.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\n \u003cp\u003e808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\n \u003cp\u003e7285.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\n \u003cp\u003e5.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 1.3835%;\"\u003e\n \u003cp\u003eM4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5941%;\"\u003e\n \u003cp\u003e7026.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.4988%;\"\u003e\n \u003cp\u003e809\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.7006%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.1994%;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\n \u003cp\u003e7298.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\n \u003cp\u003e15.422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\" style=\"width: 12.106%;\"\u003e\n \u003cp\u003eM1: the model to make all pathes free parameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.5653%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.5853%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.7094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 2.2483%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\" style=\"width: 21.2143%;\"\u003e\n \u003cp\u003eM2: the model that fixes the path between \u0026quot;knowledge\u0026quot; and \u0026quot;social distance\u0026quot; (w1) to zero\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\" style=\"width: 22.1078%;\"\u003e\n \u003cp\u003eM3: M2་the model that fixes the path between \u0026quot;health literacy\u0026quot; and \u0026quot;social distance\u0026quot; (w2) to zero\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\" style=\"width: 22.1078%;\"\u003e\n \u003cp\u003eM4: M3་the model that fixes the path between \u0026quot;knowledge\u0026quot; and \u0026quot;public stigma\u0026quot; (w3) to zero\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e[standard deviation]: 44.8 [13.6] years). Table 2 shows the distribution of the four HLS-EU-Q16 subscale scores. Confirmatory factor analysis revealed that \u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7004.6, degrees of freedom\u0026thinsp;=\u0026thinsp;806, TLI\u0026thinsp;=\u0026thinsp;0.90, CFI\u0026thinsp;=\u0026thinsp;0.91, RMSEA\u0026thinsp;=\u0026thinsp;0.058, and error covariance correction was required at five locations.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 shows the results of the comparisons of the four models. As a result, we were able to adopt M2 because the null hypothesis (M1 is not correct) could not be rejected and the AIC was the lowest.\u003c/p\u003e\n\u003cp\u003eFigure 2 shows the path model between the latent variables of M2. HLS-EU-Q16 scores mediated public stigma and were associated with social distance. The standardized coefficient for the indirect effect was \u0026ndash;.157 (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Knowledge of HIV/AIDS was also found to affect social distance through public stigma. The standardized coefficient for the indirect effect was \u0026ndash;.082 (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2 Final model for health literacy, knowledge and public stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDashed line path coefficient fixed at zero\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n \u003cdiv class=\"Heading\"\u003eHLS-EU-Q16: 16-item version of the European Health Literacy Survey Questionnaire\u003c/div\u003e\n \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e\n \u003cdiv class=\"Heading\"\u003ePLWH: people living with HIV/AIDS\u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the standardized loadings in the structural and measurement equations of the final model. The standardized estimates ranged from 0.39 to 0.94, and all estimates were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study revealed that health literacy affects social distance through public stigma. In particular, public stigma and social distance were found to be strongly related. This finding was similar to previous studies on psychiatric disorders [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. In the present study, public stigma focused on the negative aspects of cognition and attitudes [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e], and the relationship between public stigma and social distance, which is a behavioral outcome, was assumed as a hypothesis.\u003c/p\u003e\n\u003cp\u003eIn addition, this result suggests the value of focusing on and improving health literacy. In other words, health literacy has repeatedly been examined as the ability to live for one\u0026rsquo;s own health. Systematic reviews have shown that health literacy affects mortality [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e], quality of life [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e], self-management [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e], and health behavior [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFinal model for associations between health literacy and PLWH social distancing: unstandardized and standardized loadings by structural equation modeling\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003eOutline of item content\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003eB\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(SE)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e\u0026beta;\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 42.7504%;\"\u003e\n \u003cp\u003ePublic stigma of HIV/AIDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Personal advocacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Public stigma (narrow)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e4.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 41.6754%;\"\u003e\n \u003cp\u003ePersonal advocacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;reach out to PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;provide job opportunities to PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;participate in volunteer services for PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH deserve our care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH should be treated fairly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;making friends with PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e5.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;accept PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e5.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH can reintegrate into society\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e4.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;fight for the rights of PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 41.6754%;\"\u003e\n \u003cp\u003ePublic stigma (narrow)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;keep my distance with PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH are a burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH cause troubles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH harm others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;estrange PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH are repulsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH are dislikeable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH should be segregated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;avoid PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH make people angry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;PLWH are normally discriminated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;afraid of being alone with PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 42.7504%;\"\u003e\n \u003cp\u003eKnowledge of HIV/AIDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;with continuing effective treatment, HIV is not transmittable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;most HIV infections are due to homosexual contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;HIV transmission is common through sexual contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;the number of new HIV infections goes sideways.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 43.66%;\"\u003e\n \u003cp\u003e\u0026rarr;low out-of-pocket medical costs due to public subsidies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;need for regular hospital visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;less likely to develop with treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;\u0026quot;HIV\u0026quot; is the name of the virus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 42.7504%;\"\u003e\n \u003cp\u003eSocial distance to PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;the same hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;have a meal together\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;marry your family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;work next seat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;the same workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;become freiends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;ask to take care of child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;greet and talk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;live next door\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 42.7504%;\"\u003e\n \u003cp\u003eHLS-EU-Q16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Obtain/Access information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Understand information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Appraise information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 0.9923%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 1.2403%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 40.4351%;\"\u003e\n \u003cp\u003e\u0026rarr;Apply/use information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2094%;\"\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.8864%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.194%;\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" style=\"width: 66.0688%;\"\u003e\n \u003cp\u003ePLWH: people living with HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" style=\"width: 66.0688%;\"\u003e\n \u003cp\u003eHLS-EU-Q16: 16-item version for European health literacy survey questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" style=\"width: 66.0688%;\"\u003e\n \u003cp\u003e*nonstandardized coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" style=\"width: 66.0688%;\"\u003e\n \u003cp\u003e\u0026dagger;standardized coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eHowever, the results of the present study suggest the possibility that health literacy impacts the recognition and behavior of building healthy relationships that reduce discrimination and prejudice against minorities. However, these findings are still in the early stage, so more evidence regarding the relationship between health literacy and prejudice/discrimination, not only in PLWH, but also in patients with other diseases and minorities, needs to be accumulated.\u003c/p\u003e\n\u003cp\u003eThe present findings indicate that knowledge influences social distance through public stigma. However, the impact of knowledge on public stigma was smaller than that of health literacy, and no direct relationship was observed with social distance. Some previous studies on mental illness have reported a negative association between knowledge and public stigma [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e], while others have reported no such association [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. The impact of knowledge about HIV/AIDS was found to be limited rather than irrelevant, unlike mental illness. However, the present study found a correlation between knowledge and health literacy. Health literacy based on the HLS-EU-Q16 is the ability to obtain, understand, evaluate, and utilize information rather than knowledge itself [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] and includes the ability to make decisions and act based on knowledge. In the data\u0026ndash;information\u0026ndash;knowledge\u0026ndash;wisdom hierarchy [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e], a classic model in informatics, health literacy based on the HLS-EU is close to a level of wisdom.\u003c/p\u003e\n\u003cp\u003eThe results of this study could promote the development and implementation of programs to reduce public stigma based on health behavioral theories, including health literacy. Several studies have reported public stigma countermeasure programs for HIV/AIDS, and systematic reviews have shown modest effectiveness but tend to be of poor methodological quality [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, further studies are needed in the future. Regarding intervention studies on health literacy targeting the general population, there has not yet been sufficient research, especially on health literacy centered on skills [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. On the other hand, in recent years, national policies to promote health literacy have been developed in EU countries (Austria, Ireland, Italy, Portugal, Spain and the UK), and the following policies have been implemented: providing tailored health information, educating professionals and developing health education programs or materials for people with lower levels of health literacy [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. In Finland, health literacy is positioned within school education programs, and curricula are officially organized in primary and secondary education [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]. Based on our research results, we can expect a reduction in public stigma such as HIV/AIDS by placing health literacy as one of the school education and policy outcomes.\u003c/p\u003e\n\u003cp\u003eAs a countermeasure against public stigma toward HIV/AIDS, a campaign based on extremely well-executed research evidence with the slogan \u0026ldquo;U\u0026thinsp;=\u0026thinsp;U (Undetectable\u0026thinsp;=\u0026thinsp;Untransmittable)\u0026rdquo; was recently launched [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e]. That campaign may reduce the level of public stigma [\u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e] and improve the mental health of PLWH [\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e]. However, it is important for HIV-negative people to not only acquire knowledge about \u0026ldquo;U\u0026thinsp;=\u0026thinsp;U\u0026rdquo;, but also make use of that knowledge in their decision-making and actions. Therefore, to reduce public stigma toward HIV/AIDS, it is not enough to carry out correct knowledge campaigns. It is necessary to carry out efforts aimed at maintaining and improving health literacy for HIV-negative people in conjunction with knowledge campaigns.\u003c/p\u003e\n\u003cp\u003eThe concept of public stigma used in this study involves the perceptions of those who stigmatize others at the individual level. On the other hand, it has been suggested that public stigma at not only the individual but also the collective level, may influence the internalization of stigma, such as perceived stigma and self-stigma. In other words, a multilevel approach that includes social-level stigma is needed when examining stigma [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, this study is one of the few that have attempted to clarify the relationship between health literacy and public stigma toward PLWH, and the results are of theoretical and practical significance. However, the following limitations should be noted. First, this was an online survey, and the sample was drawn from a panel administered by a survey agency. Although the scale of the agent panel used in this study is one of the largest in Japan, the reproducibility of other sampling methods, such as the Basic Resident Register, needs to be examined. Second, because this was a cross-sectional study, no causal relationships could be established. In the future, a detailed examination of the causal relationships needs to be examined in a study using a longitudinal design.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV/AIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus infection and acquired immunodeficiency syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLWH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople living with HIV/AIDS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental health literacy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTLI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTucker\u0026ndash;Lewis index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComparative fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMSEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot mean square error of approximation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAkaike information criterion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHLS-EU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Health Literacy Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that all methods were carried out in accordance with relevant guidelines and regulations. They also declare that all procedures contributing to this work have been performed in accordance with the ethical standards of the relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was obtained from the Open University of Japan Institutional Review Board committee (2019-30). Informed consent was obtained from all subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed in this study are not publicly available to protect the privacy of the participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by JSPS KAKENHI Grant No. 19H03928.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTT and YI conceptualized the project; TT provided guidance in the analyses; TT and SA conducted the data analyses; TT drafted the manuscript; all authors participated in writing the manuscript and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the people who cooperated in conducting this survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJapanNationalInstituteofInfectiousDisease. 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U=U taking off in 2017. Lancet HIV. 2017;4:e475. https://doi.org/10.1016/S2352-3018(17)30183-2.\u003c/li\u003e\n\u003cli\u003eTogari T, Abe S, Inoue Y. [HIV-related public stigma and knowledge regarding the campaign slogan \u0026quot;undetectable=untransmittable\u0026quot; among Japanese people]. [Nihon koshu eisei zasshi] Japanese journal of public health. 2022;69:146-57. https://doi.org/10.11236/jph.21-005.\u003c/li\u003e\n\u003cli\u003eOkoli C, Van de Velde N, Richman B, Allan B, Castellanos E, Young B, et al. Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect. 2021;97:18-26. https://doi.org/10.1136/sextrans-2020-054551.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV/AIDS, social stigma, social discrimination, health literacy, structural equation modeling","lastPublishedDoi":"10.21203/rs.3.rs-3266371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3266371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to clarify the relationship between health literacy, knowledge of human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS), and public stigma toward people living with HIV/AIDS (PLWH) in the general Japanese population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted an online cross-sectional survey targeting adults (age range: 20 s to 60 s) from among the 2.2\u0026nbsp;million registrants in Rakuten Insight from September 20 to 25, 2019. Stratified randomized sampling was performed by region, sex, and age. The study participants were 2,500 heterosexual HIV-negative adults with no acquaintances who were PLWH. Among these participants, 232 who provided incomplete responses were excluded, leaving 2,268 eligible for analysis (effective response rate: 90.7%).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eModels were compared using structural equation modeling for the relationship between health literacy (16-item version of the European Health Literacy Survey), basic knowledge about HIV/AIDS, public stigma toward HIV/AIDS, and social distance. The results indicated that health literacy scores mediated public stigma and were associated with social distance (standardized coefficient of indirect effect: \u0026ndash;.157, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Knowledge of HIV/AIDS also affected social distance through public stigma (standardized coefficient of indirect effect: \u0026ndash;.082, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The model fit was as follows: Tucker\u0026ndash;Lewis index\u0026thinsp;=\u0026thinsp;0.90, comparative fit index\u0026thinsp;=\u0026thinsp;0.91, and root mean square error of approximation\u0026thinsp;=\u0026thinsp;0.058.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese findings indicate that health literacy not only maintains and promotes individual health but also has the potential to reduce stigma toward HIV/AIDS and is more closely associated with less public stigma toward HIV/AIDS than knowledge of HIV/AIDS.\u003c/p\u003e","manuscriptTitle":"Health literacy, knowledge of HIV/AIDS, and public stigma among general citizens of Japan: an online cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-12 14:26:58","doi":"10.21203/rs.3.rs-3266371/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31a26361-48e0-444c-bc7f-f3c01108fa4d","owner":[],"postedDate":"September 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-18T16:59:34+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-12 14:26:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3266371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3266371","identity":"rs-3266371","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}