ABSTRACT
The study examined the influence of stigma consciousness (a belief or feeling that one will be negatively stereotyped by others) and coping strategies (social support, information and problem) on the CD4 counts (measure of immune system) of People Living With HIV/AIDS (PLWHA) in Anambra state. 430 PLWHA (men=148 & women=282), age (M=35.73, SD=8.4) years served as participants. Three Anti Retroviral Therapy (ART) sites were randomly selected from the three senatorial zones of Anambra state. All PLWHA in the three ART sites’ enrolments were used. Measures of CD4 counts of PLWHA were obtained from ART records. Stigma consciousness was measured using stigma consciousness questionnaire Pinel (1999) while social support scale Turner, Frankel, and Levin (1983), information coping scale (Kalichman et al, 2006), and ways of coping inventory (Folkman & Lazarus, 1980) measured coping strategies. 4-way analysis of variance statistic revealed that stigma consciousness had significant influence on CD4 counts of PLWHA. Social support had significant main effect on CD4 counts of PLWHA. Information coping had significant main effect on CD4 counts of PLWHA. And, problem coping produced significant real effect on CD4 counts of PLWHA. The implication is that psychosocial variables influence immune system of PLWHA. Link between stigma consciousness and CD4 counts of PLWHA is extension of psychoneuroimmunology literature. Outcome of this study will be utilized by PLWHA, psychologists/counselors, healthcare workers, and policy makers. Discussions were based on immunocompetence model of Jemmott and Lock (1984) which holds that psychosocial stressors lower immune system efficiency. Gluhoski (1996) cognitive therapy was recommended for effective psychological intervention measures to reduce negative psychological conditions among PLWHA.
CHAPTER ONE
INTRODUCTION
Generally, the society devalues, rejects and discriminates against people infected with Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS). In turn people infected with HIV/AIDS become stigmatized and they live persistently with stigma consciousness, an expectation that one will be stereotyped (Pinel, 1999). Invariably, stigma consciousness spawns psychological devastation that can pose problems on management of HIV/AIDS, especially if the immune system of People Living With HIV/AIDS (PLWHA) as indicated in their CD4 counts are affected by such psychological devastation. (CD4 count is a measure of body’s immune system among PLWHA.) Then, anchorage and adjustment needed to improve their health can be achieved through application of
appropriate coping strategies or use of cognitive therapy.
Undoubtedly, PLWHA that are stigmatized experience stigma consciousness. Stigma consciousness is capable of influencing immune system among PLWHA thereby causing either health improvement or deterioration indicated in their CD4 counts. The primary function of immune system is to help the body resist disease (Rice, 1998). Low level of stigma consciousness favours immune system functioning while high stigma consciousness suppresses immune system functioning. CD4 count which measures immune system determines health condition of people living with HIV/AIDS. The strength of body’s immune system among people living with HIV/AIDS is determined through a test called CD4. People diagnosed HIV/AIDS positive are regarded as either living with HIV/AIDS or seropositive individuals. A healthy person has between 500 and 1600 CD4 counts. Mostly, PLWHA have CD4 counts below 350. This varies according to severity of the disease, and can improve with treatment, that is taking Antiretroviral Drug (ARV) through Anti Retroviral Therapy (ART) or even diets. ARV is any drug that is used for suppressing the action of HIV on CD4 counts while ART implies taking such drug as agreed or directed by the doctor. An individual high in stigma consciousness will be more concerned with how he/she appears to others Pinel (1999), a situation that can cause negative emotion. This will cause the individual so concerned to engage in application of one or more coping strategies such as, accessing social support, information coping (seeking or avoidance), and problem coping (focus or avoidance), to improve his or her health condition. An individual infected with HIV/AIDS who seeks correct information, accesses social support, and actually focuses on problems associated with managing HIV/AIDS is likely to develop positive emotion that will favour his/her CD4 counts.
CD4 count is used as index for measuring immune system among PLWHA.
Understanding the concept of stigma will enhance actual depiction of stigma consciousness. Stigma has been explained in various terms. For example social scientists have used stigma to denote socially undesirable characteristics and have been interested primarily in its discrediting effects on social interactions (Goffman, 1963; Herek, 1990). Furthermore, stigmatized individuals are regarded as members of the social groups “about which others hold negative attitudes, stereotypes, and beliefs, or which, on average received disproportionately poor interpersonal and/or economic outcomes relative to members of the society at large due to discrimination against members of the social category” (Crocker & Major, 1989). Thus, stigma denotes, but not limited to, undesirable characteristics of people that dichotomise the in-group and the out-group. The latter being stigmatized by the former. So, HIV/AIDS-related stigma can be seen as the negative attitudes, beliefs or stereotypes that people hold, that discriminate those living with HIV/AIDS.
Stigma can be categorized into two. Some recent literatures distinguished between enacted stigma, that is, actual experiences of stigma and discrimination and felt or perceived stigma, that is a stigmatized person’s fear or anticipation of discrimination and rejection, and internal sense of shame (Scambler, 1998; Swendeman, Rotheram-Borus, Comulada, Weiss & Ramos, 2006). Felt or perceived stigma is similar to stigma consciousness. The authors, further noted that felt or perceived stigma may cause people to shape their behaviours to avoid or reduce enacted stigma which may eventually slim their opportunities for seeking support and treatment. And this can bring about negative psychological conditions, leading to poor health condition among PLWHA by affecting their immune systems.
Researches have explained more subtle dimensions of HIV/AIDS stigma. For example, an exploratory factor analysis of an extensive
HIV/AIDS’ stigma measure for PLWHA identified four factors: personalized stigma (i.e., social rejection), disclosure concerns, negative self-image (i.e., internalized shame), and concern with public attitudes about people living with HIV/AIDS (Berger, Ferrans, & Lashley, 2001).
In modern usage of the term (stigma), a defining immediate reaction to the stigma seems to be avoidance by others. People act as if physical contact or even proximity to the stigmatized can result in some form of contamination (Pryor, Reeder, Yeadon & HessonMclnnis, 2004). Also, people choose to stand or sit at greater distances from the stigmatized, for example people living with HIV/AIDS, than the non-stigmatized (Mooney, Cohen, & Swift, 1992). Cursory observation has even shown that people avoid accepting edible items or sharing them with PLWHA.
Of course, the individuals who are stigmatized, whose conditions have degenerated into extensive HIV/AIDS’ stigma (Personalized stigma, disclosure concerns, negative self-image, and concern with public attitudes toward people living with HIV/AIDS), and who attempt to affiliate with normal people, may share the same experience of the painted bird (Jerzy Kosinski, as cited in Pryor & others, 2004).
The painted bird circled from one end of the flock to the other, vainly trying to convince its kin that it was one of them. But, dazzled by its brilliant colours, they flew around it unconvinced. The painted bird would be forced farther and farther away as it zealously tried to enter the ranks of the flock.
What could occupy the psychological conditions of the painted bird? The painted bird should really feel rejected, negative self-image, devalued, discredited, and internal sense of shame. Thus, the painted bird is likely to became stigma conscious, a situation in which the painted bird internalized those psychological conditions and become worried about them. Applied to people living with HIV/AIDS, that are stigmatized, there is likely to arise a condition of stigma consciousness that is, how likely they are to expect that others will negatively stereotype them because of their HIV/AIDS seropositive status.Thus, stigma consciousness is conceptualized in this study as psychological internal state, which disposes those living with HIV/AIDS to believe or feel that others will negatively stereotype them because of their HIV/AIDS seropositive status.
In fact, when people experience life-threatening illness such as HIV/AIDS, they tend to engage in self- reevaluation and negative social identities can be the outcome. And so, they tend to apply one or more copying strategies to shock-absorb the psychological devastations that occur. Coping involves cognitive processes that begin with perception of a stimulus. As soon as the individual living with HIV/AIDS perceives a condition as threatening, he or she engages in appraisal and evaluation of the extent to which any action he or she takes will be useful in saving the situation. The individual consciously or unconsciously propagates coping mechanism
immediately he discovers that as route to relief. Social psychological researches have shown that humans are active agents who have an amazing ability to recover from negative life events (Major, 1994; Taylor & Brown, 1988). However, this is only possible by consciously or unconsciously applying appropriate coping strategies.
Further, coping has to do with how people try to deal with a problem or handle the emotions such problem produce (Davison & Neal, 2001). Also, coping can be discerned as any action taken to reduce the effect of some stressful circumstances by an individual in his or her environment, or an escape from their adversity (Weber & Manning, 2001). Also, coping is the cognitive and behavioural efforts to manage specific external and/or internal demands appraised as taxing or exceeding the resources of the individual (Folkman & Lazarus, 1988). Thus, coping is said to have occurred when people engage in generating their assumed positive behaviours as responses to forces that affect them, while coping strategies imply application of any coping mechanism to checkmate negative psychological and
physical feelings.
People have different perceptions in terms of illness that threatens both their psychological and physical health. For instance, people living with HIV/AIDS may perceive HIV/AIDS infection as sickness that can infest anybody and decide to seek information on treatment, intervention, and supports whereas others may perceive it as an end to life and become hopeless. According to Carver (1998, as cited in Chukwudozie, 2008) such differences in perception could be among the strongest determinants of how individuals fare in situations of stressful or life-threatening experience, for example living with HIV/AIDS. These may determine how PLWHA fare with regards to their health as measured by CD4 count, which is the indicator of immune system.
There are many dimensions of coping, which people can adopt while in different experiences of life. To Lazarus and Folkman (1984, 1980) and Kalichman et al (2006) there are two broad dimensions of coping which include problem-focused and avoidant coping. This involves taking direct action to solve the problem or making efforts to reduce the negative emotional reactions to stress, for example, by distracting oneself from the problem, or relaxing and information seeking and avoidant coping which refers to seeking information that will be relevant for the solution of the problem or avoid information that will cause harm or emotional problem or distress. Such coping measures have psychological implications on immune system
functioning.
Scholars have argued that coping is not a generalised disposition that is aroused by situations that threaten people, but a specific behaviour that varies in the substance of people’s problems and social roles that they dispense. Thus, the effectiveness of coping choice is not only determined by how well they solve our problems and hardships, but also how well they prevent the hardships from resulting in damaging emotions (Scheck & Kinicki, 2000). Damaging emotion can affect health condition of PLWHA by reducing their immune systems as indicated in CD4 counts. Stigma consciousness and inappropriate application of coping strategies can cause damaging emotions among PLWHA, hence affecting their health by making immune system inactive.
It is possible that stigma consciousness could interact with coping strategies, for instance, social supports available to the individuals living with HIV/AIDS to influence their immune systems. Social support is the physical and emotional comfort given to people by their family, friends, co-workers and others. It is knowing that one is part of a community of people who love and care for one, and value and think well of one (Wikipedia, 2008). Social support can act as a moderating factor in the development of psychological and/or physical disease, for example, clinical depression, hypertension, and HIV/AIDS’ stigma consciousness as a result of stressful situations they produce.
Two types of social support have been identified (Davison & Neal, 2001). These include structural social support which refers to a person’s basic network of social relationships, for example marital status and a number of friends; and functional social support which has to do with the quality of a person’s relationships, for example, whether the person believes he/she has friends to call on in time of need (Cohen & Wills, 1985). In a study, Pryor and his colleagues (2004) found high proportion of family and friends being aware of serostatus of a person living with HIV/AIDS not to be associated with enacted stigma, that is actual experience and with lower perceived stigma, that is the feeling of anticipated stigma (stigma consciousness). Also, in the same study, men were found to report less perceived stigma than women. The authors noted that women tend to have higher levels of depression and anxiety than men regarding their HIV/AIDS status. And young women living with HIV/AIDS would appear to benefit from targeted interventions that help them cope with feelings and fears about HIV/AIDS infections. But, whether stigma consciousness will be implicated in influencing immune system among PLWHA remains unexplored in literature. Also, few studies have examined application of coping strategies such as social support, information coping, and problem coping as influencing the health condition of PLWHA by affecting their immune systems.
Statement of the Problem
Current statistics showed that reasonable population of
Nigerians is living with HIV/AIDS. For instance, Society for Family Health (2009) reported that the population of 39.9 million Nigerians was living with HIV/AIDS. These people living with HIV/AIDS need to be rehabilitated psychologically. No doubt, Anambra State has some proportions of that figure, hence its choice as area of study.
As we know, stigma is attached to HIV/AIDS. People living with HIV/AIDS who internalize stigma will be vulnerable to stigma consciousness. Stigma consciousness is likely to exacerbate the CD4 counts of those living with HIV/AIDS thereby reducing their immune systems. Therefore, management of HIV/AIDS will continue to pose problems unless psychosocial variables such as stigma consciousness, social support, information and problem copings are x-rayed and matched with appropriate intervention measures, for example Gluhoski (1996) cognitive therapy. Of course, investigations of psychosocial variables affecting immune system as measured in CD4 counts and matching them with appropriate intervention measures are the
concern of this study.
Psychologists have noted that individuals are unique. And as such, no two persons are exactly alike with respect to experiences relating to stigma consciousness. This implies that even PLWHA can differ in their level of stigma consciousness. Nevertheless, it is unclear whether stigma consciousness will influence immune system among PLWHA. To the best knowledge of the researcher, this problem has remained unstudied with respect to health implication among PLWHA with regards to their immune system, using CD4 count as measure.
It is clear that when an individual is infected with life-threatening illness, he/she will experience negative emotion or mood that will affect his or her immune system. Thus, the individual is bound to apply one or more coping strategies to shockabsorb psychological and physical devastation associated with such illness. People Living with HIV/AIDS are bound to apply a good number of coping strategies to build up hope for survival, improve their health and social well-being otherwise they become hopeless and fall prey to some psychological problems such as dissociation, health deterioration by reduction in immune system and may eventually commit suicide. This can be improved with application of appropriate coping strategies. This study considered social support, information coping, and problem coping as coping strategies necessarily applied by PLWHA in attempt to improve their health condition.
People living with HIV/AIDS who are highly bogged with stigma consciousness may suffer some social illnesses resulting from inappropriate application of coping strategies. Such social illnesses may include social withdrawal, lack of social affiliation, dissociation, anxiety, depression, hopelessness, emotional instability and cognitive imbalance, which affect health negatively. Such psychological problems may result to health deterioration by reducing immune system. Use of coping strategies may be important for health improvement. Such social problems without psychological intervention have presumably caused a young woman of 25 years old and HIV/AIDS seropositive from a community in Anambra State to commit suicide.
In fact, the circumstances surrounding the death of the young woman formed source of inspiration for this study to be conducted in Anambra State of south eastern Nigeria. The young woman’s husband died about three years after their marriage of a protracted illness believed to be HIV/AIDS. About one year after the death of her husband, the young woman became sick. When the young woman was diagnosed HIV/AIDS seropositive, she was believed to have been engulfed by stigma consciousness. Rather than seeking intervention, she decided to end up her life by committing suicide through drinking concoction. The idea to commit suicide became known through her mother, whom she disclosed to shortly before giving up. Her reason was to save face since many people must have known about her HIV/AIDS seropositive status, which was evidenced from her late husband’s case. This implies that PLWHA are bogged with internal states in form of emotions that make them experience stigma consciousness that impairs ability to apply appropriate coping strategies thereby affecting their health. Application of appropriate coping strategies and cognitive therapy as intervention measures would have saved her suicidal tendency resulting from stigma consciousness.
Some studies have started to build a psychology of the relatively powerless or disadvantaged by concentrating on the experiences of the stigmatized that are devalued, rejected, and discriminated groups such as PLWHA, by considering what responses they are likely to exhibit when coping with their negative conditions that may affect their health (e.g. Branscombe & Ellemers, 1998;
Crocker & Major, 1989; Crosby, 1982; Deschamps, 1982; Dion & Earn,
1975; Major, 1987, 1994; Swim, Cohen, & Hyers, 1998; Tajfel, 1978;
Tajfel & Turner, 1986; Branscombe, Schmitt, & Harvey, 1999;
Mummendey, Kessler, Link, & Mielke, 1999; Major & O’Brien, 2005; Siegel & Others, 1998; Pinel, 1999; Kalichman & Others, 2006).
However, none of the studies provided plausible explanation on the roles of stigma consciousness of the stigmatized individuals on their immune systems. In short, none was designed to tackle the problem. None, at least to the researcher’s awareness, investigated the influence of stigma consciousness on the immune system among PLWHA using CD4 count as measure. Thus, one of the problems of this study was to explore the influence of stigma consciousness on CD4 counts of people living with HIV/AIDS.
Social support has been shown to associate with health-related behaviours (e.g. Kaplan, Manuck, Williams & Straw, 1994; seeman &
Syme, 1989; Goodenow, Reisine & Grady, 1990; Davison & Neal, 2001). But few studies (e.g. Mulder, de Vroome, Van Griensven, Antoni & Standfort, 1999) have examined the association between social support and immune system using CD4 count as measure among PLWHA. However, these studies were not designed to examine the influence of different levels of social support or interaction with other variables on immune system among PLWHA. Thus, the second problem of this study was to examine the influence of social support on the immune system among PLWHA using CD4 count as measure, and also examine the interaction among stigma consciousness, social support, information coping and problem coping in influencing immune system using CD4 count.
Earlier studies have shown that problem-focused coping and information avoidant coping are related (Carver, Scheier, & Weintrant, 1989; Folkman & Lazarus, 1980; Miller & Mangan, 1983) and problem focused and avoidant coping styles are found to be related
(Kalichman, Benotsch, Weinhardt, Austin, Luke, & Cherry, 2003; Kalichiman & Others 2006) among PLWHA. This finding was made from the health information using the internet. However, the studies did not consider comparisons between those PLWHA who seek information and those who avoid information; those PLWHA who focus and those who avoid problem on their immune systems. Thus, the third and fourth problems of this study were to investigate the influence of information and problem copings on immune system among those living with HIV/AIDS.
Most social scientists, psychologists/counsellors or healthcare workers may feel aversive caring for people living with HIV/AIDS. This results from lack of understanding some internal states of PLWHA such as stigma consciousness and application of appropriate coping strategies. Often times, experts try to design intervention without considering available coping strategies. Of course, understanding stigma consciousness, and coping strategies implications of PLWHA will surely inform interventions designed to rehabilitate and improve the social well-being and overall health of people living with HIV/AIDS.
Finally, Gluhoski (1996) proposed the use of cognitive therapy by psychologists/counselors and other healthcare workers as intervention measure for people living with HIV/AIDS based on review of
literatures. There is a need to empirically test the effectiveness of such cognitive therapy as intervention measure for people living with HIV/AIDS in Anambra state. Therefore, in a follow up study, comparisons were made between those who received cognitive therapy and those who did not receive cognitive therapy on stigma consciousness, social support, information coping and problem coping.
Therefore, as a result of dearth in scientific knowledge in those areas, this study investigated the influence of stigma consciousness and coping strategies on immune system among people living with HIV/AIDS as indicated in their CD4 cell counts. And, the research provided cognitive therapy for managing HIV/AIDS.
Purpose of the Study
The general purpose of this study was to investigate the influence of stigma consciousness and coping strategies on the immune system among PLWHA as indicated in their CD4 counts. In a study, Pinel (1999) established stigma consciousness among women, gay men and lesbians using stigma consciousness questionnaire for women. This study did not consider investigating how stigma consciousness could influence immune system among PLWHA. So, one of the purposes of the present study was to compare participants who scored high and those who scored low in stigma consciousness scale on their immune system using CD4 counts as measure. Also, studies have considered some coping styles, for example social support, to predict health (Berkman, 1995: Ryff & Singer, 2000). And health risks are greater among lonely people, who often experience more stress, sleep less well, and commit suicide more often (Cacioppo, Hawkley & Bernstson, 2003). However, such studies did not consider the influence of high and low social support on immune system among PLWHA. Therefore, this study compared those who scored high with those who scored low in social support measures on their immune systems as indicated in CD4 counts.
Third, this study compared those who seek information with those who avoid information on their immune systems. Also, those who focus on problem were compared with those who avoid problem on their immune systems and finally, interaction effects of stigma consciousness, social support, information coping and problem coping on immune system among PLWHA were sought.
Further, a follow up study was conducted to establish evidence for recommending Gluhoski (1996) proposed cognitive therapy as intervention measures for reducing stigma consciousness, increase social support, instill information seeking and problem focus behaviour on people living with HIV/AIDS. So, those who received cognitive therapy as intervention measure were compared with those who did not receive cognitive therapy as intervention measure on stigma consciousness, social support, information, and problem copings.
Relevance of the Study
People living with HIV/AIDS need to reduce their stigma consciousness and adopt one or more coping strategies for effective management. According to Crepaz et al (2008), many people living with HIV benefit from earlier HIV diagnosis and are successfully treated through strict adherence to highly active antiretroviral therapy (HAART). As treatment has evolved to transform HIV into a more manageable chronic disease, an increasing number of PLWHA face emotional and physical challenges as they cope with managing HIV/AIDS over their lifetime. These emotional and physical challenges can be managed if psychological factors such as stigma consciousness and coping strategies are implicated and properly addressed in immune system functioning among PLWHA. In fact, understanding stigma consciousness, and coping strategies, will inform intervention measures necessary to help people living with HIV/AIDS to improve in their immune systems. Illness such as HIV/AIDS attracts stigma which in turn leaves the victim with stigma consciousness that spawns social problems eminent of negative mood or emotions, for example, dissociation, withdrawal, low self-esteem, anxiety among others. High stigma consciousness and poor coping strategies exacerbate these social problems and that can invariably determine differences in immune system among PLWHA.
Undoubtedly, an answer that will explain differences in immune system among PLWHA within the purview of psychology will highlight their psychological internal states. This study provides the answer only when stigma consciousness and coping strategies are implicated in determination of immune system among PLWHA. Based on that, this study has social, therapeutic/counseling, and scientific implications.
In the societal settings, people living with HIV/AIDS feel dissociated from others. They always evaluate themselves with others. Most often, they have negative evaluation of themselves and remain with negative mood that can reduce their immune systems. This makes them have negative social identity of themselves. This also causes them to dissociate and withdraw from others. Thus, they have low interpersonal relationship with the normal people and even their doctor because of poor coping choice. The poor interpersonal relationship need to be improved. This study will utilize stigma consciousness and coping strategies to explain why PLWHA have different immune systems and the knowledge gained from this study will be useful in rehabilitating PLWHA socially.
Gluhoski (1996) proposed cognitive therapy for HIV/AIDS positive individuals, aimed at changing self view, which is considered appropriate intervention to the outcome of the present study. Understanding stigma consciousness and coping strategies will inform therapeutic/counselling interventions necessary to improve the wellbeing of PLWHA. There is growing evidence that counseling approaches (Brown, Macintyre & Trujillo, 2003) and cognitive therapy
(Gluhoski, 1996; Corrigan & Calabrese, 2005; Knight & others, 2006; Crepaz, et al, 2008; Scott-Sheldon, Kalichman, Carey & Fielder, 2008), are effective in helping stigmatized persons to cope with the negative consequences of perceptions of stigma thereby improving their health. This study used stigma consciousness and coping strategies to explain the use of counselling and cognitive therapy that can help PLWHA improve in their health conditions. Specifically, the study used cognitive therapy derived from Gluhoski (1996) cognitive therapy to explain influence of stigma consciousness and coping strategies on immune system among PLWHA.
Although, in the area of psychoneuroimmunology, studies have linked immune system with psychosocial variables such as grief caused by death of loved one, this study has scientific relevance in that it will be an extension of literature in that direction, by demonstrating a connection between stigma consciousness and CD4 count, a marker of immunity of PLWHA. To the best awareness of the researcher, this is the first study to demonstrate this. Empirical report on effectiveness of Gluhoski (1996) cognitive therapy provided strong evidence for its use particularly among PLWHA.
In summary, this study is a social psychological attempt to explain the differential health related behaviours among individuals living with HIV/AIDS. Thus, the study investigated the roles of stigma consciousness and coping strategies in contributing to the level of CD4 counts among PLWHA in Anambra state. The implication of stigma consciousness and coping strategies in contributing to immune system functioning have relevance in social and counselling/cognitive therapy. Also, it provided scientific contribution to cognitive therapy for PLWHA and psychoneuroimmunology.