Table 5. Recommendations for future outbreak stigma scales determined by a systematic review of scales for measuring infectious disease–related stigma.

Area	Recommendations
Design	A theoretical framework of stigma should be applied from conception of the scale to ensure all relevant domains of stigma are represented.
	Future scales should be co-designed with persons with lived experience of outbreak-associated stigma.
	Scale items should be informed by qualitative research alongside existing scales.
	When resources allow, scale design should be informed by a range of outbreak diseases and settings to enhance transferability of the scale. This should be facilitated by large public health institutions.
	Established best practices for ensuring cross-cultural equivalence (e.g., [23]) should be followed when translating and adapting scales for cross-contextual use.
Validation	Scale items should be formally assessed for content validity (including clarity, relevance, and comprehensiveness) by both experts in the field and relevant community members with lived experience of stigma.
	Confirmation of the structural validity of scales should precede internal consistency testing. Other forms of reliability, including test-retest reliability, should be routinely assessed alongside internal consistency.
	The cross-cultural validity of scales should be assessed across countries, diseases, and respondent profiles using multi-group factor analyses or Differential Item Functioning analyses.
	The responsiveness of scales should be assessed to ensure they have the ability to detect changes in stigma over time.
Use	Scales should be used in longitudinal and pre- and post-interventional studies to assess stigma trends over the course of an outbreak, rather than limited to cross-sectional use.
	When possible, representative sampling techniques should be adopted in administration of stigma scales.
	The results of studies assessing stigma during outbreaks, as well as the stigma scales used, need to be rapidly publicly disseminated with minimal access barriers such as paywalls.