# Resilience to Stigma in Medical, Social, and Employment Contexts Among People Who Inject Drugs in Rural Ohio: Adapting the 10-Item Connor-Davidson Resilience Scale

## TL;DR

This study adapts a resilience scale to measure how people who inject drugs in rural Ohio cope with stigma in medical, social, and employment contexts, finding that resilience is linked to better engagement with HIV prevention.

## Contribution

A novel adaptation of the Connor-Davidson Resilience Scale to measure context-specific resilience to stigma among people who inject drugs.

## Key findings

- High resilience to HIV prevention-related stigma in medical contexts was associated with greater PrEP awareness and overdose response training.
- Resilience responses varied by stigma type and context, as shown through frequency distributions, Bland–Altman plots, and factor analysis.
- The adapted resilience scales showed strong internal consistency among 250 participants.

## Abstract

People who inject drugs (PWID) experience stigma related to drug use and HIV prevention, which can impede engagement with the HIV prevention continuum. Resilience may buffer against stigma’s harmful effects, but limited research has examined how resilience operates across different social contexts and stigma types among PWID. Using qualitative interviews and cognitive interviews, we adapted the 10-item Connor-Davidson Resilience Scale to measure resilience to drug use-related stigma and HIV prevention-related stigma among PWID in rural Appalachian Ohio in three contexts: medical, social, and employment. To validate the scale adaptations, we administered a quantitative survey. We assessed internal consistency using Cronbach’s alpha and fit Poisson regression models to test the association between high resilience and pre-exposure prophylaxis (PrEP) awareness and overdose response training. Among the 250 PWID who completed the quantitative survey, the six resilience scales demonstrated strong internal consistency. Examining frequency distributions, Bland–Altman plots, and factor analysis, we found the resilience responses varied by stigma type and context. Results of regression models indicated high resilience to HIV prevention-related stigma in the medical context was associated with PrEP awareness (adjusted prevalence ratio [aPR]: 1.37; 95% CI 1.05, 1.80) and overdose response training (aPR: 1.31; 95% CI 1.07, 1.61). Our study provides a novel approach to measuring context-specific resilience to stigma among PWID. Findings highlight the importance of tailoring interventions to both individual resilience and structural stigma, particularly in medical settings. Enhancing resilience and reducing stigma may support greater engagement with HIV prevention and harm reduction services in rural communities.

The online version contains supplementary material available at 10.1007/s10461-025-04915-4.