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Differential item functioning for items in Berger's HIV Stigma Scale: an analysis of cohorts from the Indian, Swedish, and US contexts | mijn-bsl Skip to main content
Open Access 24-03-2018
Differential item functioning for items in Berger's HIV Stigma Scale: an analysis of cohorts from the Indian, Swedish, and US contexts
Auteurs: Maria Reinius, Deepa Rao, Lisa E. Manhart, Maria Wiklander, Veronica Svedhem, John Pryor, Randall Mayer, Bambi Gaddist, Shuba Kumar, Rani Mohanraj, Lakshmanan Jeyaseelan, Lena Wettergren, Lars E. Eriksson
The HIV Stigma Scale
Unidimensionality
DIF detection
Magnitude of detected DIF
Demographic characteristics
Fit of the graded response models
DIF within cohorts—the US cohort
DIF between cohorts
DIF across cohorts—gender
DIF between cohorts—cumulative DIF impact on individual scores
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To examine whether items in Berger's HIV Stigma Scale function differently with persons of different age, gender, and cultural backgrounds.
Secondary data from cohorts, collected in South India (n = 250), Sweden (n = 193), and the US (n = 603) were reanalyzed to evaluate DIF within, between, and across these cohorts. All participants had answered the revised version of the HIV stigma scale consisting of 32 items forming the subscales Personalized stigma, Disclosure concerns, Concerns about public attitudes, and Negative self-image. Differential Item Functioning (DIF) for these items was assessed using hybrid ordinal regression-IRT technique. When DIF was detected, the cumulative impact of DIF on individual subscale scores was evaluated.
DIF was detected for 9 items within, between, or across cohorts, but the DIF was negligible in general. Detected DIF between the Swedish and Indian cohorts had a cumulative salient impact on individual scores for the subscale Disclosure Concerns; Disclosure concerns were overestimated in the Swedish cohort and both over- and underestimated in the Indian cohort.
The items in the 32-item version of the HIV stigma scale did not seem to be particularly prone to present DIF. The DIF between the Indian and Swedish cohort for items in the subscale Disclosure Concerns could, however, result in both type I and type II errors if scores should be compared between the Indian and Swedish cohort.
Supplementary material 1 Item-level Monte Carlo thresholds for changes in pseudo R2 (100 replications) regarding DIF within cohorts. The data points are connected with lines to show a fluctuation across items, not implying a series. Numbers on the x-axis correspond to the order that items appear in the subscale, not the number that the item have in the instrument. These graphs show thresholds for three different pseudo R2 measures. The measure used in the article was Nagelkerke (EPS 2386 KB)
Supplementary material 2 Item-level Monte Carlo thresholds for changes in pseudo R2 (100 replications) regarding DIF between cohorts. The data points are connected with lines to show a fluctuation across items, not implying a series. Numbers on the x-axis correspond to the order that items appear in the subscale, not the number that the item have in the instrument. These graphs show thresholds for three different pseudo R2 measures. The measure used in the article was Nagelkerke (EPS 2401 KB)
Supplementary material 3 Item-level Monte Carlo thresholds for changes in pseudo R2 (100 replications) regarding DIF across cohorts. The data points are connected with lines to show a fluctuation across items, not implying a series. Numbers on the x-axis correspond to the order that items appear in the subscale, not the number that the item have in the instrument. These graphs show thresholds for three different pseudo R2 measures. The measure used in the article was Nagelkerke (EPS 2409 KB)
Electronic supplementary material
The online version of this article (https://doi.org/10.1007/s11136-018-1841-4) contains supplementary material, which is available to authorized users.
Since the beginning of the pandemic, people with HIV have been stigmatized. Mahajan [ 1 ] defines HIV-related stigma as when people living with HIV are labeled, stereotyped, experience separation and status loss, and become discriminated both on an individual and structural level. Across different contexts perceived HIV-related stigma is associated to poor mental and physical health for persons living with HIV [ 2 ‐ 5 ]. Even in the current era of efficient treatment, making HIV a chronic illness with normal life expectancy where treatment is generally available, people living with HIV are exposed to and relate to HIV-related stigma [ 6 , 7 ] and stigma has been found to be a common barrier to treatment and prevention [ 8 , 9 ].
Stigma has sometimes been understood as an individual process, where stigma is constituted of what some individuals do to others [ 10 ], whereas other scholars have argued that an individual perspective of stigma only may be relevant in highly individualized countries (as the US or some parts of Europe) [ 11 ]. Parker and Aggleton [ 11 ] argue that stigma, where it appears, is strongly related to the specific context of culture and power, and that the social and cultural phenomenon of stigma may be linked to actions of whole groups of people. Some known aspects of HIV-related stigma are also clearly cultural specific, as they, for example, relate to specific religious beliefs [ 12 ].
The efforts to reduce HIV-related stigma have yet not matched the magnitude of the problem [ 13 ]. Parker and Aggleton suggest that the diversity and complexity of HIV-related stigma makes it difficult to grasp in a programmatically useful way [ 11 ]. Ogden and Nyblade, on the other hand, argue that differences in HIV-related stigma across cultures are largely superficial and that stigma is expressed remarkably consistent across contexts [ 13 ]. Valid and reliable instruments for measuring HIV-related stigma are essential for stigma research, for evaluation of stigma-reducing interventions, and for monitoring and understanding experiences of HIV-related stigma [ 10 , 14 , 15 ]. Based on findings that suggest consistencies in HIV-related stigma across cultures [ 13 ], it would be valuable to have measures of HIV-related stigma that are valid across cultures, thus enabling measurement of changing trends in HIV-related stigma over time and across contexts.
One of the many instruments designed to measure HIV-related stigma perceived by persons living with HIV is the HIV Stigma Scale by Berger et al. [ 16 ]. Although developed and originally found valid and reliable in a US context [ 16 ], the instrument has been translated and found to be relevant and valid across various countries and cultures [ 17 , 18 ]. These findings suggest that HIV-related stigma as assessed by the Berger's scale is, to some extent, universal. For example, the HIV Stigma Scale has been used to compare levels of perceived HIV-related stigma among persons living with HIV in Kenyan, Puerto Rican, and the United States contexts [ 3 ], where Hispanics reported significantly higher levels of stigma than persons from the African continent. When used in Kenya, Puerto Rico, and the United States, the HIV Stigma Scale showed good internal consistency measured by Cronbach's α for the combined data. The authors, however, did not explore differential item functioning for items in the HIV Stigma Scale, and it is possible that participants from different countries interpreted the items differently, resulting in bias.
Participants' interpretation of scales can be assessed with methods based on Item Response Theory (IRT) and analysis of Differential Item Functioning (DIF). As items in the HIV Stigma Scale are statements that participants are requested to agree or disagree with on a four-point Likert scale, the probability that an individual will agree with the statement on a certain item can, according to IRT, be seen as a mathematical function of how stigmatized the person is and how severe the stigma is that the item captures. Items in the HIV Stigma Scale would be considered to have DIF if participants with different sociodemographic backgrounds have unequal probabilities of agreeing with statements in the items, while experiencing the same level of stigma [ 19 ]. For example, an analysis of DIF in an American sample, showed that black, non-Hispanic persons and white, non-Hispanic persons with the same level of stigma, had different probabilities of agreeing with items in the HIV Stigma Scale, indicating that persons with different backgrounds may experience HIV-related stigma differently [ 20 ].
In addition to its use in several studies in the United States [ 21 ‐ 23 ], the HIV Stigma Scale has been used, for example, in Sweden [ 18 ] and South India [ 17 ], providing an ideal opportunity to evaluate whether DIF occurs. The HIV Stigma Scale has been translated into the respective native languages, back translated into English, and checked for comparability with the original English questionnaire [ 17 , 18 ]. The English, Tamil, and Swedish versions of the instrument could therefore be considered consistent regarding content and all items were found relevant for both a Swedish and a South Indian context by both experts and people living with HIV in each country [ 17 , 18 ]. There are, however, results from the psychometric validation from both the Swedish and the Indian contexts that may indicate that at least parts of the concept of HIV-related stigma are culturally embedded. For the Swedish version, a high rate of missing responses were found for an item regarding the risk of losing employment if one's HIV status is disclosed, where written comments in the margin of the questionnaire ("Does this happen in Sweden?") indicated that some Swedish respondents found this item irrelevant [ 18 ]. In validation of the Indian version of the HIV Stigma Scale, respondents had difficulties understanding the four-point Likert scale and the word "unclean" in the item "Having HIV makes me feel unclean" was often misinterpreted to mean "personal hygiene" [ 17 ].
Although the HIV Stigma Scale has been used for measuring stigma in a wide range of different contexts, it is not clear whether items in the HIV Stigma Scale are interpreted differently by persons with different backgrounds. The aim of the present study was, therefore, to examine whether items in the HIV Stigma Scale function differently with regard to gender and cultural background.
The present work builds on secondary analysis of data collected using the HIV Stigma Scale in India [ 17 ], Sweden [ 18 ], and three areas in the US, South Carolina [ 24 ], Iowa [ 24 ], and the city of Chicago [ 20 ]. Item-level data from these studies were used to evaluate items for DIF between, within, and across the cohorts. A hybrid ordinal logistic regression—IRT approach [ 25 ] was used for DIF detection, using the lordif-package [ 26 ] with R statistics [ 27 ]. When DIF was detected, we evaluated the cumulative impact that the detected DIF had on individual IRT scores [ 28 ].
Data from the Swedish cohort were collected at the Karolinska University hospital in Stockholm in 2013 from 193 persons living with HIV [ 18 ]. Data for the South Indian cohort were collected from 2007 to 2008 through networks caring for men and women living with HIV in the state of Tamil Nadu. Participants were residing in and around the cities Chennai (n = 150), which is an urban area and Vellore (n = 100), a semirural area [ 17 ]. Data from the United States were collected at two different time points in three different states. Between 2005 and 2010, data were collected through Ryan White II/III clinics and a community-based organization providing medical case management in South Carolina (n = 210) [ 20 ], from Iowa Department of Public Health Title II case-managed clients in Iowa (n = 331) [ 20 ], and a private University Hospital HIV Clinic in Chicago (n = 62) [ 24 ].
Available data on sociodemographic information differed across location. Information about gender and age was available for all participants from Sweden, India, and Chicago (US). Gender was categorized as male, female, or transgender in data collected in Chicago, with one participant categorized as transgender. For all other data, gender was categorized as male or female. Differences between cohorts were assessed with χ2-test for gender and ANOVA with Tukey post hoc analysis for age.
The HIV Stigma Scale is designed to measure four dimensions of perceived HIV-related stigma among persons living with HIV: Personalized stigma, Disclosure concerns, Concerns about public attitudes, and Negative self-image. Personalized stigma is proposed to capture perceived consequences of other people knowing about one's HIV infection. Disclosure concerns captures concerns that one can have over disclosing one's HIV status to others. Concerns about public attitudes includes concerns that one can have over what other people think about people with HIV. Negative self-image includes negative feelings that one can have about oneself related to one's HIV, (e.g., feeling unclean or not as good as others because of HIV) [ 16 ]. In scale construction of the original HIV Stigma Scale, items were assigned to dimensions following an exploratory factor analysis where a majority of items cross-loaded. Seventeen items were therefore assigned to more than one dimension. Subscales were subsequently refined to consist of unique items in a revised 32-item version [ 29 ]. Since DIF analyses with the lordif-package assume unidimensionality in the latent trait, where all items measure a single concept [ 19 ], the items that compose the revised 32-item version of the HIV Stigma Scale were used in the present work. The instrument includes 32 statements related to HIV stigma that are completed on a four-point Likert scale, ranging from 1 ("completely disagree") to 4 ("completely agree"), and item scores for each subscale are summed into subscale scores [ 16 ]. Higher scores indicate higher levels of perceived stigma for all four subscales.
Unidimensionality for scales was assessed through confirmatory factor analysis (CFA), where all items in each scale were specified to load onto one single factor, respectively. Since responses to the HIV stigma scale are ordinal, the CFA models were fitted using weighted least squares means and variance (WLSMV) [ 30 ]. Measures of model fit used were as follows: Chi-square (expected to be non-significant if the model showed acceptable fit to the data), the Comparative Fit Index and the Tucker–Lewis Index (CFI and TLI, cut-off > 0.95), and the root mean square error of approximation (RMSEA, cut-off < 0.08) [ 31 , 32 ]. Since Chi-squares were significant in all CFA's but three and RMSEA exceeded the cut-off for two subscales regarding the Swedish cohort, we also assessed the dimensionality of the models exploratory with parallel analysis and the Empirical Kaiser Criterion [ 33 ].
A combined ordinal logistic regression—IRT approach for DIF detection and analysis of DIF impact [ 25 ]—was employed, as implemented in the lordif-package [ 26 ]. First, IRT item parameter estimates were obtained, using the mirt package [ 34 ], according to the graded response model [ 35 ]. The graded response model was chosen over the partial credit model since all items had the same number of response categories (four). Missing values were not imputed; participants were excluded listwise in each separate analysis if missing values were present. The minimum cell count for not collapsing response categories was set to five. Three ordinal regression models were examined for each item:
$${\text{Model 1 }}\left( {{\text{no DIF}}} \right):logitP({u_{\text{i}}} \ge k)={\alpha _{\text{k}}}+{\beta _1} \times \theta$$
$${\text{Model 2 }}\left( {{\text{uniform DIF}}} \right):logitP({u_{\text{i}}} \ge k)={\alpha _{\text{k}}}+{\beta _1} \times \theta +{\beta _2} \times group$$
$${\text{Model 3 }}\left( {{\text{non}} - {\text{uniform}}} \right){\text{ DIF}}:logitP({u_{\text{i}}} \ge k)={\alpha _{\text{k}}}+{\beta _1} \times \theta +{\beta _2} \times group+{\beta _2} \times \theta \times group,$$
where P(ui ≥ k) represented probabilities that item response ui is k or higher [ 26 ], θ was the latent trait in the present work, four dimensions of perceived HIV-related stigma (Personalized stigma, Disclosure Concerns, Concerns of public attitudes and Negative Self-image). Group was a variable indicating group (country or gender) and (θ × group) represented the interaction between the latent trait and group. Pseudo R2 changes (Nagelkerke) were used as a criterion for DIF detection. When pseudo R2 changes for an item exceeded the empirical threshold, that item was flagged for DIF. Pseudo R2 changes between Model 1 and Model 2 indicate a uniform DIF, with a constant effect for different levels of stigma while pseudo R2 changes between Model 2 and 3 indicate a non-uniform DIF, with an effect that varied conditional on levels of stigma. The procedure was extended for multiple groups in analysis of DIF between cohorts [ 26 ]. Empirical thresholds for DIF detection were generated through Monte Carlo simulations of DIF-free samples [ 26 ]. The empirical thresholds were set to be above the highest value identified in the Monte Carlo simulation, identical for all items in each separate analysis, but varying between analyses [ 26 ]. The Monte Carlo-simulated item-level thresholds are presented in Online Resource 1.
An iterative process was used to prevent false-positive and false-negative results that may occur when many items with DIF are included in analysis [ 25 ]. Trait estimates were updated using the items that were not flagged for DIF and used as a new threshold for DIF detection. The logistic regression was then repeated and if different items were flagged for DIF than in the initial calculation, trait estimates were updated again based on the DIF-free samples in the most previous round. This procedure was repeated until the same items were flagged for DIF in two successive rounds [ 26 ].
Based on the knowledge that HIV-related stigma can be experienced differently by persons living with HIV from different backgrounds [ 20 ], a series of DIF analyses was performed between and within each cohort, comparing groups with different backgrounds. For the US cohort, DIF was examined between Black, non-Hispanic persons and White, non-Hispanic persons (data collected in Chicago excluded), as earlier examined by Rao et al. [ 20 ]. The US cohort was then combined with the Swedish and South Indian cohort and DIF was assessed between persons living in Sweden, the US, and South India. Since respondents in the different cohorts differed with respect to gender, we also examined whether the HIV Stigma Scale had DIF between men and women. Transgender was in analysis coded as missing since this category only included one respondent. DIF related to gender was assessed for the three cohorts combined and are referred to as DIF across cohorts.
There are no minimal clinically important score differences specified for the HIV Stigma Scale to define a salient DIF. We therefore evaluated the individual-level cumulative impact of detected DIF through comparing unadjusted IRT scores (with DIF) with adjusted IRT scores (accounted for DIF). Unadjusted IRT scores were subtracted from adjusted IRT scores and if individual IRT scores were unaffected by DIF, this difference would be zero [ 28 ]. Differences that were equal to or exceeded a small effect size (i.e., 0.20) were considered to be salient [ 36 ].
Demographic characteristics by cohort are shown in Table 1. The US sample had a significantly higher proportion of males compared to the Indian sample (66% vs. 50%, χ2 = 60.8, p < 0.001). Further, the one-way ANOVA showed a statistical significance between group effect of age (F(2,495) = 126.7, p < 0.001) (data on participants' age were not available for Iowa and South Carolina). Post hoc comparisons using the Tukey HSD test indicated that the mean age of Indian respondents (mean = 35, SD = ± 6) was significantly lower than the mean age of respondents from the US (mean = 43, SD = ± 11) and Sweden (mean = 49, SD = ± 12), p < 0.001. Mean age for respondents from the US (mean = 43, SD = ± 11) was also significantly lower than the mean age of Swedish respondents (mean = 49, SD = ± 12), p < 0.001.
Demographic characteristics of respondents to the HIV Stigma Scale in South India [ 11 ], Sweden [ 12 ], and the US [ 11 , 14 , 18 ]
%Female
Ageb
Mean, range (SD)
35, 18–49 (6)c,d
49, 19–83 (12)c,e
43, 23–68 (11)d,e,f
41, 18–83 (11)
Respondents with missing values in one or more of the HIV stigma subscales were excluded
aSignificant difference between India and the United States (χ2 = 60.8, p < 0.001)
bOverall significant difference (ANOVA): F(2,495) = 126.7, p < 0.001
cSignificant difference between India and Sweden, Tukey post hoc test, p < 0.001
dSignificant difference between India and Chicago, Tukey post hoc test, p < 0.001
eSignificant difference between Chicago and Sweden, Tukey post hoc test, p < 0.001
fAge only available for respondents from Chicago
The unidimensional models yielded reasonable fit for all data combined and for the South Indian and US cohort separately (Table 2) which suggested suitability for unidimensional IRT analysis. For the Swedish cohort, unidimensionality was not supported in the confirmatory analysis for the scales Disclosure concerns and Concerns with public attitudes. The exploratory analysis using parallel analysis suggested one-factor solution in all analyses. The Empirical Kaiser Criterion, however, suggested two-factor solutions for Disclosure concerns and Negative self-image regarding the South Indian cohort and for Disclosure concerns regarding the Swedish cohort.
Assessment of unidimensionality for all subscales in the 32-item HIV Stigma Scale
Subscale
Fit measures from CFAa
All data combined
Indian cohort
Swedish cohort
US cohort
Personalized stigma
Chi-square(df = 44)
148.37*
75.0544*
67.12*
RMSEA
Disclosure concerns
24.74, ns
Concerns about public attitudes
Chi-square(df = 9)
4.38, ns
< 0.001
Negative self-image
Number of factors proposed to retain by EKCb
Figures in bold indicate that the subscale was not unidimensional according to EKC
*p < 0.001
aConfirmatory factor analysis of unidimensional models, fitted using the weighted least squares mean and variance (WLSMV)
bThe Empirical Kaiser Criterion
The lowest number of endorsements for a category in a group was six. Since the minimum cell count was set to five, none of the response categories were collapsed.
Nine items in the HIV Stigma Scale were flagged for DIF with pseudo R2 change exceeding the thresholds generated through Monte Carlo simulations of DIF-free samples (Table 3). Both uniform (with a constant effect for different levels of stigma) and non-uniform DIF findings (with an effect that varies depending on levels of stigma) were detected.
Differential item functioning findings for items in Berger's HIV Stigma Scale (32-item version) within, between, and across the three cohorts
DIF within cohorts
U.S. cohorta
DIF between cohortsb
DIF across cohorts
DIF related to genderc
Uniform DIF
Non-uniform DIF
Personalized stigmad
Thresholdh
18. Some people who know I have HIV have grown more distant
< 0.0001
24. I have been hurt by how people reacted to learning I have HIV
26. I regret having told some people that I have HIV
28. Some people avoid touching me once they know I have HIV
29. People I care about stopped calling after learning I have HIV
32. People don't want me around their children once they know I have HIV
33. People have physically backed away from me when they learn I have HIV
35. I have stopped socializing with some people because of their reactions to my having HIV
36. I have lost friends by telling them I have HIV
38. People who know I have HIV tend to ignore my good points
0.0115 h
39. People seem afraid of me once they learn I have HIV
Disclosure concernse
1. In many areas of my life, no one knows that I have HIV
0.0293 i
4. Telling someone I have HIV is risky
6. I work hard to keep my HIV a secret
17. I am very careful who I tell that I have HIV
21. I never feel the need to hide the fact that I have HIV (R)
22. I worry that people may judge me when they learn I have HIV
25. I worry that people who know I have HIV will tell others
37. I have told people close to me to keep the fact that I have HIV a secret
Concerns about public attitudesf
5. People with HIV lose their jobs when their employers find out
9. People with HIV are treated like outcasts
10. Most people believe that a person who has HIV is dirty
14. Most people think that a person with HIV is disgusting
16. Most people with HIV are rejected when others find out
20. Most people are uncomfortable around someone with HIV
Negative self-imageg
2. I feel guilty because I have HIV
3. People's attitudes about HIV make me feel worse about myself
7. I feel I am not as good a person as others because I have HIV
8. I never feel ashamed of having HIV (R)
12. Having HIV makes me feel unclean
15. Having HIV makes me feel like I'm a bad person
23. Having HIV in my body is disgusting to me
Empirical thresholds for DIF detection were generated through Monte Carlo simulations of DIF-free samples
aDIF between White non-Hispanics and Black non-Hispanics (data collected in Chicago excluded)
bDIF between persons living in Sweden, US, and South India
cDIF between men and women (transgender coded as missing)
d290 white non-hispanic and 207 Black non-Hispanic participants in within cohort analysis; 559 US, 244 South Indian, and 157 Swedish participants in between cohort analysis; 586 male and 371 female participants in analysis across cohorts
e303 White non-Hispanic and 209 Black non-Hispanic participants in within cohort analysis; 574 US, 250 South Indian, and 168 Swedish participants in between cohort analysis; 599 male and 390 female participants in analysis across cohorts
f296 White non-Hispanic and 206 Black non-Hispanic participants in within cohort analysis; 560 US, 246 South Indian, and 159 Swedish participants in between cohort analysis; 583 male and 379 female participants in analysis across cohorts
g308 White non-Hispanic and 212 Black non-Hispanic participants in within cohort analysis; 582 US, 248 South Indian, and 180 Swedish participants in between cohort analysis; 606 male and 401 female participants in analysis across cohorts
hItalic values indicate pseudo R2 change for items that were flagged for DIF, but where DIF did not have a salient impact on individual scores. The threshold for DIF detection was generated through Monte Carlo simulations of DIF-free items
iBold values indicate items that were flagged for DIF and where DIF had a cumulative salient impact on individual IRT scores
For the US cohort, DIF was examined between Black, non-Hispanic persons and White, non-Hispanic persons. No items were flagged for DIF within the US cohort.
Nine items in the HIV Stigma Scale were flagged for either uniform, non-uniform, or both uniform and non-uniform DIF between persons living in Sweden, the US, and South India, respectively. One item for Personalized stigma, five items for Disclosure concerns, one item for Concerns about public attitudes, and two items for Negative self-image (Table 3).
One item was found to have non-uniform DIF between men and women (Table 3) (1. In many areas of my life, no one knows that I have HIV, belonging to the subscale Disclosure concerns).
The detected DIF was, in general, negligible, since the cumulative impact of DIF on individual IRT scores was below 0.2. Salient individual-level impacts of DIF (exceeding 0.2) were, however, detected between cohorts for the subscales Disclosure concerns, which are detailed below and shown in Fig. 1.
Cumulative individual-level DIF impact for subscale Disclosure concerns for DIF between persons living in South India (triangles), Sweden (plus signs), and the US (circles). The boxplot to the left shows differences in IRT score between using scores that ignore DIF and scores that account for DIF. In the scatterplot to the right, the difference scores (initial-purified) are plotted against the initial scores ignoring DIF (initial theta)
Regarding DIF between cohorts, changes in individual IRT scores exceeded 0.2 and were therefore thought to be salient for the subscale Disclosure concerns (Fig. 1). Scores for respondents from the US were mainly unaffected by DIF, but DIF had a salient impact on scores for Indian and Swedish respondents, with effects in opposite directions. For Disclosure concerns, the HIV Stigma Scale seemed to overestimate scores for Swedish participants and both overestimate (for persons with low levels of Disclosure concerns) and underestimate (for persons with high levels of Disclosure concerns) scores for Indian participants (Fig. 1). The mean of the differences was close to zero, indicating that this DIF would not affect the mean score if levels of Disclosure concerns would be presented for persons from the Swedish, US, and South Indian cohort together.
The HIV Stigma Scale was developed for quantitative measurement of HIV-related stigma, as perceived by persons living with HIV. Though adapted and used in diverse contexts, this is the first time that the instrument has been assessed for gender-related DIF and DIF across different cultural contexts. The results of the present study indicate that the items in the HIV stigma scale were not especially prone to present culture-related DIF for the subscales Personalized stigma, Concerns about public attitudes, and Negative self-image. These subscales seem to cover aspects of stigma that in general are equally interpreted regarding content across the different groups investigated. These results indicate that levels of Personalized stigma, Concerns about public attitudes, and Negative self-image may be compared between the cohorts without the risk of results being culturally biased. Salient DIF was, however, found between the South Indian and Swedish cohorts for the subscale Disclosure concerns. The subscale Disclosure concerns measures concerns that one can have over disclosing one's HIV status to others. The items that present DIF mainly covers the aspect that one's HIV is a secret and we can only speculate about potential reasons for this DIF. Since India is more densely populated than Sweden, it may be likely that participants in the South Indian cohort live physically closer to family and neighbors than the participants in the Swedish cohort, making it harder for the South Indian participants to keep their HIV a secret. India has been characterized as a 'collectivist' society [ 37 ] and Sweden more of an individualistic society [ 38 ], particularly around interpersonal issues. According to Chadda and Deb [ 37 ] family is far more involved in the care of its members in the Indian society, compared to western societies. This might also make it more difficult for the South Indian participants to keep their HIV a secret from their family, compared to the Swedish participants. If keeping one's HIV a secret is difficult, on the edge of being impossible, in the South Indian context, items like "I work hard to keep my HIV a secret" might have been perceived as irrelevant for South Indian participant, thus generating the detected DIF.
When Rao et al. [ 20 ] examined DIF between Black, non-Hispanic persons and White, non-Hispanic persons, nine items of the scale demonstrated DIF. Our present results did not replicate these findings, as no items were flagged for DIF between Black, non-Hispanic persons and White, non-Hispanic persons. A possible explanation for the differences in results could be that Rao et al. [ 20 ] examined the 40-item version of the HIV Stigma Scale, while the 32-item version was examined in the present study. Seven of the items, from the 40-item full version of the instrument, that demonstrated DIF in the earlier study by Rao et al. were items that cross-loaded in an exploratory factor analysis and therefore were excluded from the 32-item version of the instrument [ 29 ].
A common reason for DIF is a lack of translation equivalence [ 19 ]. The item "Having HIV makes me feel unclean" (Item 12), for example, could not be adequately translated to Tamil, since no words in Tamil captured the intended meaning of "unclean" [ 17 ]. This was adjusted for by letting the questionnaire be administered by professional raters in the South Indian cohort, who assured that item content was understood as intended [ 17 ]. A similar procedure was used for the Swedish cohort where members of the research team also were present to answer questions and assist respondents with explanations of items if needed [ 18 ]. The item "Having HIV makes me feel unclean" (Item 12) did not demonstrate DIF in the present analysis, but if the HIV Stigma Scale is used as a self-administered instrument as originally intended, the detected DIF may possibly be even more pronounced.
Unidimensionality was assessed with both confirmatory and exploratory methods. Since confirmatory methods indicated that some subscales might not be unidimensional, dimensionality was examined further with both parallel analysis and the Empirical Kaiser Criterion. Parallel analysis [ 39 ] supported unidimensionality for all subscales across all cohorts, while the Empirical Kaiser Criterion suggested two-factor solutions for the South Indian and Swedish cohort. Parallel analysis is an often recommended approach for dimensionality assessment [ 39 ]. The HIV stigma scale is, however, an instrument constituted of oblique, highly correlated factors [ 16 , 18 ], and for this specific case the Empirical Kaiser Criterion has been shown to outperform parallel analysis [ 33 ]. We therefor conclude that the subscales Disclosure concerns and Negative self-image may be, at least, bi-factorial scales when used in the Swedish or South Indian context. These findings may have implications for the interpretation of the detected DIF, as multidimensionality can be mistaken for DIF [ 40 ].
There are several techniques available for DIF detection, and there is a lack of consensus regarding thresholds for detection of DIF [ 28 ]. As we used a hybrid ordinal logistic regression—IRT approach, other techniques may have produced different results. Since statistical significance not necessarily implies practical significance, we used a measure of effect size (changes in pseudo R2) as a criterion for when DIF should be detected [ 19 ]. Different sets of rules have been presented for when pseudo R2 should be considered to represent DIF [ 19 ], where Zumbo [ 41 ] suggested that cut-offs indicating moderate and large DIF should be 0.13 and 0.26, respectively, while the Jodoin and Gierl approach suggests cut-offs of 0.035 and 0.070 [ 42 ]. A cut-off level of 0.02 has also been commonly used and these different cut-offs can, unsurprisingly, produce very different numbers of items flagged for DIF [ 19 ]. In the present work we used Monte Carlo simulations, as implemented in the lordif-package [ 26 ], to generate empirical cut-offs. This rendered cut-offs as low as 0.01 for some analyses, which also resulted in detection of DIF that did not have a salient impact on individual scores. This low threshold for DIF detection was, however, set knowing that cultural DIF probably was adjusted for already in data collection and we sought to find patterns in present DIF that perhaps would have been more pronounced if questionnaires had been exclusively self-administered.
Limitations in the present work are that data were collected at different time points with over 5 years apart and that data from the United States and India were not collected with an intention to be representative for people living with HIV in the respective countries [ 17 , 20 , 24 ]. In those settings, the study populations represented a sub-set of all people living with HIV. The results, therefore, cannot be generalized to represent differences between countries. Furthermore, we do not know if the results would be replicated if data were collected at the same locations today. A recommended minimum sample size for ordinal logistic regression is 200 participants per group [ 19 ]. Thus, a limitation in the present study is the Swedish sample size of 157–180 participants depending on subscale analyzed. In a simulation study, sample sizes as low as 100 per group were sufficient to detect large DIF but not moderate DIF [ 43 ]. It is therefore possible that the present study failed to detect moderate but practically important DIF. Further limitations were that the datasets differed regarding gender and age, and we did not have access to other sociodemographic data. It is generally known that HIV-related stigma is linked to stigma related to other attributes, which can potentiate the power of stigmatization [ 1 ]; groups of people who are already exposed of racism, homophobia, sexism, or poverty are predisposed to greater HIV-related stigma [ 1 ]. As we did not have access to data other than ratings to the HIV stigma scale and gender and, to some extent, age, we were not able to control for potentially confounding variables that may have been a true source of DIF. For the HIV Stigma Scale it would also be interesting to analyze if DIF occurs between groups of different health statuses, e.g., persons who are virally suppressed or not, persons who have been living with HIV for a longer or shorter period of time.
Aside from these limitations, we propose that the results in the present work indicate that the items in the subscales Personalized stigma, Concerns about public attitudes, and Negative self-image in the HIV Stigma Scale are not especially prone to present salient DIF. However, the detected DIF between the Indian and Swedish cohort for the subscale Disclosure concerns did have a cumulative, albeit small, salient effect on individual IRT scores, which could result in both type I and type II errors if levels of Disclosure concerns should be compared between the Swedish and Indian cohorts. The detected DIF in the subscale Disclosure concerns could be a "true" differential item functioning, i.e., that persons from the Swedish and South Indian cohort respond differently to items regarding "keeping one's HIV a secret" and "hiding one's HIV," respectively, even after accounting for their overall level of disclosure concerns. One possible explanation for this could be differences in the actual possibility to keep private things a secret in the Indian society, compared to the Swedish. An additional possible explanation could be that the unidimensional nature that the subscale Disclosure concerns seems to have in the Swedish and South Indian cohort may have caused a DIF due to multidimensionality. Apart from the cause of the detected DIF, we cannot recommend the subscales Disclosure concerns for comparisons between Sweden and South India.
The results in the present study, however, support the use of the subscales Personalized stigma, Concerns about public attitudes, and Negative self-image for comparisons of levels of stigma between the cohorts investigated. As the HIV Stigma Scale is being used to assess stigma in a wide range of different countries, we encourage researchers using the HIV Stigma Scale to cooperate across country borders and examine the cross-cultural validity of the instrument further. This would broaden the understanding of the extent and forms of stigma faced by people living with HIV in different countries.
The work presented here was supported by grants from the Doctoral School in Health Care Sciences, Karolinska Institutet.
All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Procedures for data collection were approved by the Regional Ethical Review Board of Stockholm for data collection in Sweden, by the Institutional Review Boards of the Christian Medical College, Vellore, and the University of Washington for data collection in India, and by Northwestern University and Illinois State University for data collections in the US. Informed consent was obtained from all individual participants included in the study.
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go back to reference Scott, N. W., Fayers, P. M., Aaronson, N. K., Bottomley, A., de Graeff, A., Groenvold, M., et al. (2009). A simulation study provided sample size guidance for differential item functioning (DIF) studies using short scales. Journal of Clinical Epidemiology, 62(3), 288–295. https://doi.org/10.1016/j.jclinepi.2008.06.003. CrossRefPubMed Scott, N. W., Fayers, P. M., Aaronson, N. K., Bottomley, A., de Graeff, A., Groenvold, M., et al. (2009). A simulation study provided sample size guidance for differential item functioning (DIF) studies using short scales. Journal of Clinical Epidemiology, 62(3), 288–295. https://doi.org/10.1016/j.jclinepi.2008.06.003. CrossRefPubMed
Maria Reinius
Deepa Rao
Lisa E. Manhart
Maria Wiklander
Veronica Svedhem
John Pryor
Randall Mayer
Bambi Gaddist
Shuba Kumar
Rani Mohanraj
Lakshmanan Jeyaseelan
Lena Wettergren
Lars E. Eriksson
The 'new normal': relativity of quality of life judgments in individuals with bipolar disorder—a qualitative study
Health-related quality of life of survivors of childhood acute lymphoblastic leukemia: a systematic review
Differences in health-related quality of life by academic performance in children of the city of Cordoba-Argentina
Health-related quality of life of Portuguese children and adolescents according to their biological maturation and volume of physical activity
Psychometric properties of the Chinese version of resilience scale specific to cancer: an item response theory analysis
How does age affect the relationship between weight and health utility during the middle years of childhood?


What's new on Simple Life Mom? More soap recipes! I love this peppermint charcoal soap recipe. it was a lot of fun making layers and adding a pretty swirl to the top. Enjoy the recipe.
Thanks for featuring my Keto-Friendly Blueberry Green Smoothie! Have a great day!


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Touchdown! Soyuz Spaceship's Landing Jets Fire in Photo
By Clara Moskowitz
A spectacular shot of a Russian Soyuz spacecraft landing onthe steppes of Kazakhstan shows the bright blaze of the spacecraft's thrustersfiring just before it touched down Wednesday morning (local time).
NASA photographer Bill Ingalls took the photo from arecovery helicopter as the Soyuz TMA-17 capsule safely returned Russiancosmonaut Oleg Kotov, NASA astronaut Timothy "T.J." Creamer, andJapanese spaceflyer Soichi Noguchi backto Earth after six months onboard the International Space Station. The trioserved as members of the Expedition 22 and 23 crews.
Parachutes helped slow the descent of the Soyuz TMA-17spacecraft as it plummeted down from Earth orbit. In the final minutes thethrusters helped further ease off the speed of the capsule to enable a softlanding at 9:25 a.m. Wednesday local time (11:25 p.m. Tuesday EDT).
Gallery - Soyuz Spaceship's Snowy Landing
Images - Space Station's Windows on the World
?Russian Soyuz Spacecraft Lands Safely with Station Crew
Clara Moskowitz
Clara Moskowitz is a science and space writer who joined the Space.com team in 2008 and served as Assistant Managing Editor from 2011 to 2013. Clara has a bachelor's degree in astronomy and physics from Wesleyan University, and a graduate certificate in science writing from the University of California, Santa Cruz. She covers everything from astronomy to human spaceflight and once aced a NASTAR suborbital spaceflight training program for space missions. Clara is currently Associate Editor of Scientific American. To see her latest project is, follow Clara on Twitter.
'Star Wars: Visions' Volume 2 blasts back onto Disney+ this year for Star Wars Day
Tiny NASA moon probe can't reach lunar orbit as planned
Don't panic: Ingenuity helicopter reaches 42 flights on Mars
James Webb Space Telescope pushed past its limits to observe DART asteroid crash
Virgin Orbit's failed debut UK rocket launch traced to '$100 part:' report

redpajama_set_name: RedPajamaCommonCrawl


DETAILS Fabric: Fleece / denim ..
Adaptation's Baja hoodie is composed of black, pink, and purple striped garter-stitched cashmere. Styled with a cropped, relaxed fit, the casual top references the surf culture that inspires the Los Angeles-based label.
Drawstring hood. Kangaroo front pocket. Drop shoulders. Long sleeves.


I Haven't Been Juicing - And I Can Tell!
I've fallen off the juicing bandwagon over the last few months as with the cold weather, I've been craving warm things like oatmeal or just keeping it simple with fruit in the morning.
I've noticed a few things though; which have motivated me to jump back on my juicing routine.
•My teeth are really sensitive!
They hadn't been sensitive for years during my avid juicing and in the last few months the extreme sensitivity to cold, hot and sweet things like honey has really bummed me out! I know that my teeth aren't as healthy when I'm not juicing for long periods of time. And if my teeth suffer- you know my bones are too!
•My skin doesn't look as vibrant or youthful.
Yes indeed, I'll be 35 next month so I'm aware that there should be some changes from my youthful skin at this point but this is ridiculous! I feel like my skin lacks elasticity, tone and even looks dehydrated most of the time. The antioxidant load of daily juicing will help get me back on track.
That's where juicing comes in.
Juicing makes you feel good too- I'm totally enjoying this glass and I'm doing it again tomorrow!


I've had reflux since I was a kid, and been on Prilosec for 7 years or so now. After an endoscopy a few years ago I was diagnosed with a hiatal hernia (http://en.wikipedia.org/wiki/Hiatus_hernia). I've been moving to a Paleo diet over the last couple weeks, and I'd love to get off Prilosec, but I'm not sure if diet will be enough to fix the problem. Has anyone else with a hiatal hernia found their symptoms mostly disappear from switching to a paleo diet?
Just writing for my own reference. If anyone does happen upon this comment i was interested in the remark about fat, especially coconut oil, being bad for the lower esophageal sphincter. I realise FODMAPS may be bad for reflux etc but i was under the impression coconut oil may actually good for reflux, GERD etc, due to the anti-bacterial properties and whatnot. Does anyone have any information on why fat and especially coconut fat, would cause the lower esophageal sphincter to loosen please?
Nance - you are a Master! Took the words out of my mouth, was okayish till about 5pm and had a bit of acid, especially after years of having maybe 10 or more snacks a day to one is a bit hard, so cheated had some bread (yeah I know, not good) and yoghurt!
Just remember--you should feel free to eat 2 or 3 times per day if you're physically hungry (vs. cravings.) You don't limit yourself to one meal until/unless your body is okay with that; it might take a week or two if it's going to happen.
Nance - welldone on your weightloss! We are told to eat small meal so that the acid in the stomach has something to munch on apart from it's own walls, but maybe the stomach gets the message and starts producing less as it reakises only one meal a day so no need to produce any more. If this works for me then you are a genius if it doesn't then you still are as it works for you. Will start today one meal at lunch and maybe water if I feel hungry later in the day, wow if I could reduce my losec in 2 weeks to half that would be great.
@Gerald: for me, the more frequently I eat the more I need/want to eat but thankfully, the opposite is also true. I am currently about 30 pounds down with 40 or so to go.
Thanks Nance, I've been on Prilosec for 15yrs as well, will try and follow example, may I ask did the diet help you lose weight, I am overweight at 34 BMI 109kg and should be 73kg, been joggin on the spot and will keep it up as long as my ancles can take it. Wow ONE large meal?? I thought many small meals would be better to shrink the stomach but if it works for you then great.
Oops! I forget to say I put oil & vinegar on the salad.
I'm sure the hernia is alive and well, but obviously the food I eat goes happily through my stomach and doesn't get bottled up which is apparently the underlying cause of GERD in many people. I eat one large 3-course meal per day; if I get hungry, I feel free to have a second but I rarely need it. My menu is very simple and I enjoy it so much I rarely use spices other than salt, pepper and tumeric. Typical menu: leaf lettuce salad, fatty meat and veggies in a 1-skillet meal and a piece of whole fruit for dessert. Once in a blue moon I'll have a can of sardines or about 5 pecan halves later.
Wow Nance that sounds great, can you tell me what you eat, maybe small meals and you avoid wheat and sugary foods, what foods do you eat? Any exercises or other things you do for the Hernia or which may have contributed to your success, thankyou Nance.
Kate that's great news about your father, did he lose surplus weight whilst changing dietary habits? This may help to alleviate pressure on the LES as well, once I can taper off the anti-depressants I will give the Melatonin a go, I did read somewhere that one man did experience auto immune problems after a year of Melatonin supplementation - something t possibly look out for. Also I think Folic acid could be substituted for Folate or a more benign version of Folic Acid?
Possibly. The b vitamins were just add ins. The Melatonin was supposed to be the main agent.
That Brazilian cocktail which contains the melatonin also contains a high dose of folic acid, which can cause cancer.
I'm in the same boat, been on Omeprazole 20mg for 15yrs, about a year decided to listen to the alternative health guys on the net that say it's too little acid that is the cause for GERD and started changing the environment of my stomach from alkaline to acid and took apple cider vinegar and HCI Hydrochloric acid and stopped Omeprazole for a few days then BANG!!! Massive relfux and pain in my throat that didn't go away, went to hospital and was diagnosed via endoscopy of sliding hiatus hernia and inflammation of the esophagus (actually looked grey instead of pink) so was put on Nexium for a month to reduce acid and also Talcid which kind of soothes the esophagus, stops damage. So the pains went away.
My theory till now, is that if you have GERD but no Hiatus Hernia then it's easier to heal via low carbing or paleo or increasing acid etc, BUT a hernia is a bulge in the stomach that migrates to the sternum and open the LES, the opening of the stomach, the door as it were and so, what happens when you stop taking meds is that the normal amount or more acids are produced, right? That door is wide open, right? Acid is free to rise up and burn the esophagus and cause pain and if not stopped can lead to cancer.
But can low carb or paleo heal a Hiatus Hernia? I suppose by not eating refined carbs and sugars less gas may be produced and so less pressure moving upwards.
The Melatonin study I think dealt with normal GERD and didn't specify Hiatal Hernia. Taking Melatonin can give palpitations as well and should be used cautiously if you are taking anti-deressants which Iam and so took some for a short time only.
I found so far Paleo or low carb gives me palpitations in the evening, must be potassium/magnesium issue?
I would add, pressing down on the solar plexus area to push the Hernia down, abdominal breathing, hanging by a door frame to stretch the belly area, good posture, these are what I am trying now.
I had an upper GI and have a photo of my very own hiatal hernia!
3 weeks into primal, I realized I didn't need my Prilosec any more after 15 years of steady use.
Months later, I can tell you I never need it if I stay primal; one or 2 days of wheat- and/or sugary foods and I need it.
I would be surprised if a hiatal hernia could be easily fixed through dietary measures. But, you can eat in a manner that reduces reflux. There are a few things that seem to work but I think the best is to pay attention to, and to significantly limit, consumption of FODMAPs (google it). Particularly troublesome FODMAPs (for me) include onions and lactose.
Other things that help reduce reflux include eating in a way that strains the lower esophageal sphincter as little as possible, resulting in a tighter squeeze. To that end, note that the following loosen the LES: fat (especially coconut fat), dense/glutenous carbs (like oatmeal, dense breads, etc), stomach distention, especially as a result of liquids (i.e., don't overeat and if you do, don't drink liquid for a bit), smoking, peppermint, chocolate (though note that chocolate is a great source of copper - see below). Things that tighten the LES include: protein, betain HCL (in my experience at least), marijuana (even small amounts), melatonin (at least in my experience), and rest. You can still eat things like fat and chocolate provided you combine them with offsetting factors. For example, I eat a fairly high-fat diet but make sure to include protein at night (when I am not rested). I also only eat dark chocolate in the morning (and never before exercise). If I eat really wrong and don't want to suffer through the heartburn, a little weed prevents reflux for hours and hours. Btw, I don't take any acid suppression any more, apart from an occasional tums.
At a more fundamental level, it is not clear what causes hiatal hernias to form. If nutritional deficiencies are involved, my money is on vitamin K, copper, zinc, and collagen/gelatin (i.e., nutrients that are involved in forming/strengthening connective tissue). There is some support for this in the literature (but it is scant).
Perhaps if you avoid LES relaxations P& reflux for a long enough time, during which you eat in a manner that provides your body with what it needs to build strong connective tissue, you can repair a hiatal hernia. That's what I've been trying to do for the past 6 months.
My name is natasha and I also have a hiatal hernia. I'm only 16. It's been almost 2 years since i was diagnosed. I can't yawn at all and get enough oxygen. In the heat I can't even hardly stand up because my arms/shoulders ache and I feel like I can't breathe. I can't stay bent over long enough to tie my shoes or I'll get light headed and dizzy and not be able to breathe. I was on omeprozole 20mg for a few months, then my doctor put me on nexium 60mg because the omeprozole was doing nothing. That didn't help at all either so they switched me back to omeprozole. Now I have ear infections in both my ears (have had them a little over a year) and really bad headaches every day from the time I wake up to the time I go back to sleep. I am in band and color guard (the flag spinners) is what I do. It's hard for me to continue with it though. I have to take way more breaks than anyone else and I can't even do most of the warm ups we do because then I'd be too tired and out of breath to do the marching. I haven't found anything that helps but peanut butter and jelly sandwiches are one of the very few things I can eat without feeling sick and breathless. (I don't like peanut butter or jelly though).
I've had symptoms of, guess you would call it incipient hiatal hernia, just very occasionally, when I was eating SAD. Yes, it went away completely since I went paleo. I can wolf down my food like a - well, like a wolf. Once or twice I feared it was coming back because a long stringy piece of gristle wants to straddle the epiglottis or whatever, but no, it's just because I'm being a pig - er, wolf.
My older sister has full-blown symptoms, I think she'd panic attack even from gristle.
I've never had a hiatal hernia, but I used to take a daily Prilosec, Tagamet before meals and Tums "as needed" after meals (all the time). My gut was a mess and reflux raging despite all of these. About 2 years ago, I started transitioning to the Paleo diet. I don't eat perfectly "clean" now, but I am pretty close. My only regular "cheat" would be one nightly light beer. Sometimes, I will have some ice cream.
What sticks out during my transition to Paleo was the effect grains had and have on my reflux. I kicked the pills and grains about the same time two years ago and have not taken Prilo, Tagamet or Tums since then. On occasion, I will say "what the hell" and eat some bread or other grain (e.g. hamburger actually on the bun). Boom. Reflux.
My advice is to get clean on your diet, and in your circumstances, "clean" means strict, at least until things heal. Drop the drugs asap and don't look back. It might lead to a week of discomfort, but you will be far better off in the long run. Best wishes.
My 80 year old dad had a hiatal hernia and took prilosec everyday. He went primal and tried to get off the meds and was miserable. We tried enzymes, probiotics, did not help. I can't find the link right now, but it is somewhere on this site, possibly under "gerd". It was a link to some research done in Brazil with melatonin and some other supplements. The melatonin dosage was 6mg every evening. Bottom line was this helped my dad tremendously. He only takes prilosec occasionally now.
I've been curious of this as well. Now in my late 20s, I've been taking some form of acid meds for twenty years now due to a hiatal hernia. If I miss my meds, or something I eat decides to fight back, I basically have to curl into a ball and wait for the burning and pain to pass—sometimes a day or two before I'm pain free. I've been unable to find much info about hiatal hernia treatment as it correlates with Paleo, and sadly, most GI docs just keep pushing medicine or surgery.
I look forward to hearing more about others' experiences with this. Best wishes, everyone!


Join us at the Cleveland Holistic Collab on Sunday March 18th from 2-4:30pm as we welcome our Special Guest, Olga Tzogas from Smugtown Mushrooms. She will lead an interactive workshop sharing her passion and knowledge of the adaptogenic benefits of Medicinal Mushrooms! Co-hosting and joining Olga will be Lauren Porochonski of the Cleveland Holistic Collab, contributing her passions and stories of foraging for fungi, as well.
Humans have had a long relationship using mushrooms & Fungi for food, medicine & ceremony. Olga will be discussing the history behind our ethnomycological journey and ways we can access what they can provide. Explore how amazing mushrooms can be for your health, immune system & your general wellness!
We will go through various different kinds of mushrooms and what qualities they offer to us then everyone will be taking home the beginning of their very own mushroom tincture!! Exploring even, mushrooms & Fungi that can be found in our Bioregion!
Her journey with Fungi and plants started over ten years ago. Working with these allies by foraging in both urban & more wild settings, and learning to identify their use for food and medicine.
In 2011, Smugtown Mushrooms was established because there was a need for mushrooms education, growing supplies, workshops, events & community based science in her area. While learning more and embracing the never-ending, unlocked potential mushrooms & fungi have to help heal both people, planet & soul. She teaches workshops throughout the continent about wild mushroom identification, medicinal mushrooms, biology, and mushroom cultivation.
*The information provided at this workshop is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this web site is for general information purposes only. The Medicinal Mushrooms presented, formulated in tea and food are Non-Psychoactive and are safe for human consumption, provided there are no allergies that would prevent handling or consumption.


text:
Q: Horizontal axis labels not appearing in Google charts when using object literal notation Link to the website: http://tecnicosolarboat.tecnico.ulisboa.pt/boatdata/graficos.html
Then in the first selection box choose "Tensão Bateria" and in the second one choose "5 Horas".
As you can see there is no scale in the horizontal axis. If you chose "SOC" in the first selection box you can compare.
The comments in the code explains it better:
function VOLTAGE_chart() {
    var tempo = document.getElementById("janela").value;
    var mysqlData = $.ajax({
        url: "php/voltage_chart.php",
        dataType: "JSON",
        async: false,
        data:{},
        success: function(x){
            return x;
        }
    }).responseJSON;
    if (mysqlData == null){
        alert("Não há dados a apresentar!");
        return;
    }

    var phpDate = mysqlData[0]["time"].split(/[^0-9]/);
    var date = new Date (phpDate[0],phpDate[1]-1,phpDate[2],phpDate[3],phpDate[4],phpDate[5] );

    var data = google.visualization.arrayToDataTable([
        [{id: 'time', label: 'Time', type: 'date'},
         {id: 'voltage', label: 'Voltage', type: 'number'}]
         // using the above code cause the hAxes thicks to dissapear

      /*['Time', 'Voltage']
        [date, parseFloat(mysqlData[0]["Voltage"])]*/ // This works but I need to give the first row out of the for loop so that google chart understands the data type
    ]);

    for (i = 0; i < Object.keys(mysqlData).length; i++) {
        phpDate = mysqlData[i]["time"].split(/[^0-9]/);
        date = new Date (phpDate[0],phpDate[1]-1,phpDate[2],phpDate[3],phpDate[4],phpDate[5] );
        data.addRows([[date,parseFloat(mysqlData[i]["Voltage"])]]);
    }

    var startDate = new Date( date );
    startDate.setMinutes(date.getMinutes() - tempo);

    var options = {
        title: 'Voltage',
        legend: { position: 'none' },
        vAxes:
        {0: {title: 'Voltage (V)', viewWindow:{min:34, max:45}, gridlines: {count: 12}, ticks: [34,35,36,37,38,39,40,41,42,43,44,45] } },
        hAxes: {0: {title: 'Time', format:'H:m:s', viewWindow: {min: startDate, max: date}  } },
        pointSize: 5
    };
    var chart = new google.visualization.LineChart(document.getElementById('VOLTAGE_chart'));
    chart.draw(data, options);
}

With object literal notation:

Without object literal notation (this one is a different chart but the code is the same):

Sample of the data:

A: After 2 days of searching and testing I found out that changing "type: 'date'" to "type: 'datetime'" solved the problem.
Old code:
var data = google.visualization.arrayToDataTable([
    [{id: 'time', label: 'Time', type: 'date'},
     {id: 'voltage', label: 'Voltage', type: 'number'}]

Correct code:
var data = google.visualization.arrayToDataTable([
    [{id: 'time', label: 'Time', type: 'datetime'},
     {id: 'voltage', label: 'Voltage', type: 'number'}]

redpajama_set_name: RedPajamaStackExchange


The U.S. Supreme Court handed down a decision Thursday night blocking Wisconsin's voter I.D. law, reversing the decision of the seventh circuit court of appeals, and allowing the November election to go forward without onerous new restrictions on voting rights.
The decision removes an enormous obstacle to voting for an estimated 300,000 Wisconsin voters who lack the necessary ID required by one of the most onerous voter ID laws in the nation.
"The application to vacate the September 12, 2014 order of the United States Court of Appeals for the Seventh Circuit presented to Justice Kagan and by her referred to the Court is granted and the Seventh Circuit's stay of the district court's permanent injunction is vacated," the opinion states.
Groups challenging the voter ID law had appealed to Justice Elena Kagan to block the law.
"Permitting this law to go into effect so close to the election is fueling voter confusion and election chaos in Wisconsin," the ACLU's Dale Ho wrote, "particularly for the many voters who have already cast their ballots. Voters deserve a fair shake, and this last-minute disruption changes the rules of the game in an election that is already underway, and risks locking out thousands of voters. The stakes are extremely high."
Justices Scalia, Alito, and Thomas joined a dissent, writing that the Court could not vacate a stay unless a lower court "clearly and demonstrably erred" in the application of "accepted standards." Still, the dissenting justices acknowledged, "there is a colorable basis for the Court's decision due to the proximity of the upcoming general election." And, the dissent conceded, "it is particularly troubling" that absentee ballots had been cast "without any notation that proof of photo identification must be submitted."
Before the Supreme Court's decision, the state had planned to discard absentee ballots without counting them if absentee voters did not produce photo ID after the fact.
Wisconsin's voter ID law was "one of the strictest in the nation," the appeal to the Supreme Court noted. Yet not a single instance of in-person voter fraud, which voter ID is intended to deter, has been charged in Wisconsin.
The seventh circuit's ruling, putting voter ID back into effect at the last minute "virtually guaranteed chaos at the polls and irreparable disenfranchisement of many thousands of registered Wisconsin voters," the appeal noted.
"On the other side of the ledger, the State made no factual showing at trial—and the panel made no mention—of any harm to the State from postponing implementation of the new voter ID law until after the election. The panel's decision thus is "guarding against a problem"—in-person voter fraud—that Wisconsin 'does not have and has never had.' "


Dean is a consulting arborist, botanist and ecologist specialising in eucalypts. He also established and maintains the Currency Creek Arboretum in South Australia, for which he received a Centenary Medal from the Governor-General for service to the community. In 2015, he received the Bjarne K Dahl Medal for providing an outstanding contribution to eucalypt conservation and education.


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Home/Lifestyle/Beardo Initiates a Country-Wide Man Hunt for INDIA'S NEXT Mr BEARDO
Beardo Initiates a Country-Wide Man Hunt for INDIA'S NEXT Mr BEARDO
Ayushi Mittal Follow on Twitter Send an email August 12, 2021
The Instagram campaign is designed to celebrate the journey of millions of Beardo's by giving them a platform to showcase their charm.
India, 11th August 2021: India's most loved men's lifestyle and grooming brand Beardo, today announced a nationwide search for India's Next Beardo, 2021. As an ode to the tribe of half a million Instagram followers that the brand serves, the search for 1 Ultimate Mr Beardo who stands a chance to win an exclusive modelling contract with the brand commenced on 10th August 2021. The hunt will also felicitate 4 category title holders – Mr Hot Bod, Mr Beard God, Mr Sexiest Hair and Mr Good Looks who will win a makeover at any one of Beardo Partner salons, a big Beardo goodies hamper, 1-year exclusive subscription to all of Beardo's new product launches, and most importantly, will be featured across Beardo's national & international social media platforms. Interested participants can log on to the dedicated website created to download a framed image that can be uploaded on their IG feed to participate.
More details on the process
A post shared by Beardo (@beardo.official)
Beardo's in-house panel of experts comprising of stylists, groomers, creators will vet all entries and shortlist 25 participants who will then battle it out for the ultimate winning title of Mr Beardo and four coveted category titles. The esteemed panel of judges will include Vishal Singh, Founder & President – Bharat Beard Club; Rohit Khandelwal, Mr World 2016, Actor & Influencer; Daena Sethna, Celebrity Stylist to Shah Rukh Khan, Amitabh Bachchan and more and Meghna Mehta, Head – Branded Content, Big Bang Social, Collective Artist Network. The shortlisted 25 Beardo's will be given fun challenges that would help the panel understand their personality and overall spunk to reach their final selection.
Read more:- Who is kathy hochul
Beardo is amongst the country's foremost thought leaders in the men's grooming and styling space and has dominated the market with its innovative product offerings over the last many years. The brand has become a force to reckon with across the men's grooming, styling, and now even lifestyle & fashion categories; with a strong presence in both the online and offline space. Built on the philosophy to make MEN feel sexy, confident, charismatic, and dapper, Beardo is now set to launch the Biggest Battle of masculine charm the country has ever seen.
The two-week-long hunt is currently inviting entries and will award FIVE titles, where each category winner will personify the characteristics of a true BEARDO impeccable style, charismatic personality, and killer looks.
Talking about the campaign, Sujot Malhotra, CEO at Beardo said, "Over the years we have witnessed men across the world embracing the Beardo within them and loving every minute of it. We are proud that we have been an instrumental part of getting the larger culture to celebrate the masculine charm through its quintessential mark the beard. To further this agenda of celebrating Manhood, we are proud to launch India's Next Beardo – a property that will allow us to give a platform to the most charismatic men out there to showcase their charm."
He further added, "I would like to urge all men who are passionate about how sexy they look to participate in huge numbers – WE ARE WATCHING and so is the WORLD."
Entry details for India's Next Beardo are available on Beardo's official Instagram handle (@beardo.official) and will close on 25th August 2021.
ABOUT BEARDO
Having dominated the men's online grooming and styling market for years, Beardo has become a force to reckon with their curated product offerings across men's grooming, styling and now lifestyle & fashion categories for men.
Beardo has a strong presence across all channels online as well as offline. In the offline markets, BEARDO has a pole position in salons across the country whereas in the online market BEARDO has its own website – www.beardo.in which sees network traffic of more than a million unique visitors every month. They also have a huge following across all social media platforms with a staggering 3.5 million followers on Instagram, YouTube and other platforms.
Leading influencers and celebrities like Suniel Shetty, Hrithik Roshan, Yash & K.L Rahul, BeYouNick, Bhuvan Bam, Ashish Chanchlani have been associated with the brand in the past along with many well-known influencers.
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text:
The Councils
L-Imdina
Ħad-Dingli
Ħal-Għargħur
Il-Mellieħa
L-Imġarr
Il-Mosta
In-Naxxar
Ir-Rabat
San Pawl il-Baħar
Is-Swieqi
L-Imtarfa
REĠJUN TRAMUNTANA
Reġjun Tramuntana emcompasses 12 local government councils. Information about and interaction with each council, is to be found throughout these pages.
The objectve of this site and the supporting mobile application is to give local residents and visitors the most updated information to date.
As this is a community project, we welcome and encourage any suggestions made to continually improve the content.
The Local Councils
Ħal Għargħur
About Reġjun Tramuntana
Reġjun Tramuntana.
The town and villages making up Reġjun Tramuntana form a mosaic, a blend of old and new, with some having very old roots and history, while others came into being as a locality less than 30 years ago.
Some have large geographical boundaries and include several hamlets with varying population sizes. Others are smaller, but smaller does not mean less colourful or historic. All the localities have a number of common factors, yet they are all diverse and have a great significance for the region.
Indeed, each locality adds a touch of colour to the north. As the great French geographer Fernand Braudel used to say about the Mediterranean, there is unity in diversity. And there is unity in diversity in Malta's Reġjun Tramuntana as well.
Reġjun Tramuntana comprises of the 12 localities found in the Northern part of Malta.
Together, they make up our region, which is rich in diversity, home to a Maltese as well as many other nationalities. One can say that the Region has probably the largest number of third country nationalities living in our area, especially within San Pawl il-Baħar and Swieqi. In Vincent Galea's 2011 dissertation, some 72 different nationalities were recorded within the area of San Pawl il-Baħar. A decade later, this is much higher making the locality a truly multi-ethnic cosmopolitan area. The Region has around 120,000 residents which is 24.2% of the Island's population, and forms around 33% of Malta's total area.
The region boasts within its precincts the oldest city of Malta – L-Imdina. Established as the old Capital city of Malta by the Romans; one can also find Bronze Age villages, megalithic temples, Punic and Roman remains, and many other historic remains.
The rural element is common to all its localities. The area is in fact abundant in farmland, with agriculture being an important industry of the region. There are as well, numerous industrial parks primarily in Burmarrad.
Il-Mosta, and In-Naxxar. Pembroke, San Pawl il-Baħar, Mellieħa on the other hand are strongholds for the tourism industry with Mellieħa and San Pawl il-Baħar having a significant number of hotel beds, whilst l-Mdina, ir-Rabat and il-Mosta all being strong points on Malta's tourism map.
From scenic cliffs to rocky and sandy beaches, 6 of the Region's localities, namely Pembroke, in-Naxxar, San Pawl il-Baħar, Il-Mellieħa, L-Imġarr and Ir-Rabat are surrounded by the sea. Some of the best sandy beaches are found in il-Mellieħa and L-Imġarr. Il-Mellieħa is also home to the most popular dive site cluster in Ċirkewwa.
Fishing has been an important part of the local economy for these coastal towns, and this is evident even from the names – such as the Tunnara area in Mellieħa, from where a special method was used to catch Tuna. Nowadays, some of the major industry players in the fishing industry are found in our region. Tuna, Sea Bream and other fish are farmed in a number of areas then sold locally and abroad.
Our region is home to a wide range of associations, sporting communities and NGO's. There are 12 band clubs hailing from 8 localities, who also have 15 fireworks factories and or associations. Not all associations have their own factory but work within other facilities.
One finds a number of football facilities in our area, including the National Football ground as well as the National Basketball pitch. In addition, we have an airfield for model flyers and Malta's only track for auto and moto cross, besides an a 4×4 off-road site. There are as well 3 shooting ranges, two street sport venues and a plethora of other sporting clubs. One finds a number of Scout and Guide groups as well.
We decided to give more space to these organisations and hereby provide a platform to all our associations within our Region to promote themselves and their service. The value such associations contribute to the local community is one to be admired and commended
A Series of Blogs
Blogs about the Region
Find out what is going on in the region, to improve and maintain a better environment.
Contact us with any information that you may wish to have added to this Blog.
Contact us with any additions you wish to make here.
The intention is simply to produce a historical portfolio of Reġjun Tramuntana. Something that will be of benefit to all of us.
We expect this section to grow substantially as time goes by.
Anyone wishing to share information they possess about Heritage & Culture of the region is encouraged to contact us.
Community Social Projects
Projects, Events & Services continuously being set up for the benefit of the elderly
Y-ENGAGE
Regional Events, Projects & Activities for the young community
Different Needs
From Outings to Events. From Sports to Academic Subjects.
Our intention is to create a periodical newsletter of the Tramuntana region.
Full details of this will be published soon.
Please fill in the contact form to the left to receive the newsletter in your email box directly.
Region President
Just Say Hello – We would love to hear from you!
Permits Online
Reġjun Tramuntana | Copyright 2021


Probably about 8.5"x11.5" pencil on paper.
oh i dont knw mybloglog will discontinue..tq for the info.
and yes!!! i really had a good time..!cannot wait to go again !
I guess yahoo sent it to all who have account there. Maybe yours is landed in SPAM folder.


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