The International Journal of Psychosocial Rehabilitation

Life Satisfaction and Pessimism in HIV Positive People

(A Comparative Study from India)





Selwyn Stanley, Ph.D
Lecturer in Social Work
University of Plymouth, UK.

selwyn.stanley@plymouth.ac.uk


V. Sethuramalingam, Ph.D.
Lecturer in Social Work
Bharathidasan University, Tiruchirappalli, India.



S. Sathia, Ph.D.
Guest Lecturer
Bharathidasan University, Tiruchirappalli, India.








Citation:
Stanley, Sethuramalingam, & Sathia (2013)  Life Satisfaction and Pessimism in HIV Positive People:
A Comparative Study from India. 
 International Journal of Psychosocial Rehabilitation. Vol 18(1) 95-104




Abstract
The manifestation of negative psychological states has been a recurrent theme in the HIV literature. This study explored the life satisfaction of HIV positive persons in India along with the extent of hopelessness (pessimism) manifested in them. HIV positive adults (N=309), registered with Network for Positive People a NGO in Tamilnadu, India constituted the respondents for this investigation. They were administered the Hopelessness Scale (Beck et al., 1974) and the Satisfaction with Life Scale (Diener, 1985). Respondents were compared on the basis of gender and marital status. Data analysis revealed that female respondents and those who were ‘single’ showed a significant difference from male respondents and those married and scored higher on pessimism and lower on life satisfaction. Further, the life satisfaction score showed highly significant negative correlations with the overall hopelessness score and its sub-dimensions. These findings are in consonance with the Western literature and show poorer emotional states in HIV positive persons from India and indicate areas for intervention which merit attention.

Key words: Pessimism, Life satisfaction, Gender, Marital status, India.



Introduction
Official statistics reveal that 2.47 million people in India were HIV positive, with 39% of this population being women (UNAIDS, 2010). Indian society today, in spite of Western influences and an increased shift towards consumerism and urbanisation continues to foster very traditional outlooks particularly relating to marital life, sexual and gender appropriate behaviour. Women's familial roles as daughters, wives and mothers are expected to take precedence over other social roles (Sitaraman, 1999). Being single and not married is an uncomfortable position for women to be in and they are viewed with mixed perceptions as being ‘unfortunate’ and ‘easy game’ for men. Is it surprising then that being female and HIV infected carries an enormous amount of stigma in this conservative culture? While the status of women has been improving over the years, it continues to be governed by chauvinistic norms and social inequalities particularly for the majority of women in rural and semi-urban communities and those belonging to the middle and lower socio-economic strata as is the background of the majority of subjects in this study.  

The literature shows that besides being confronted by a plethora of psychosocial difficulties, there is also substantial morbidity associated with HIV in adults. Social stigma, discrimination, isolation and psychological distress are recurrent themes in the extant literature. Given the complexities of family and social life in India, it is not surprising that HIV and AIDS carry undertones of ‘immorality’ and those who are HIV positive experience stigma, discrimination and ostracisation. Such issues have been well documented in the Indian HIV literature (Mawar, Sahay, Pandit, & Mahajan (2005); Majumdar (2004); UNAIDS, 2001).

Several studies with Indian populations have investigated quality of life and related correlates in HIV infected people (Subramanian et al., 2008; Wig et al., 2006). Life satisfaction is an important determinant of one’s subjective well being and is the overall assessment of feelings and attitudes about one’s life at a particular point in time and along with positive and negative affect is one of three major indicators of well-being (Diener, 1984). Life satisfaction has been correlated with greater physical / functional wellbeing, elevated perceptions of social support, increased use of active coping strategies and fewer experiences of AIDS related stigma and discrimination (Heckman, Somlai, Sikkema, Kelly, & Franzoi, 1997). HIV-related stigma is a complex phenomenon experienced in both the personal and social realms (Buseh et al., 2006). Women reporting HIV discrimination had higher mean score of stress, suicidal ideation, depressive symptoms, number of unprotected sexual episodes; had lower means score of self esteem and quality of life (Wingood et al., 2007). The chronic illness quality of life (CIQOL) model theorizes that life satisfaction in persons living with a chronic illness such as HIV disease is a function of illness-related discrimination, barriers to health care and social services, physical well-being, social support, and coping (Heckman, 2003).

Hopelessness is the experience of despair or extreme pessimism about the future, and as such, is part of the "cognitive triad" (along with a negative view of oneself and one's world) (Beck, Rush, Shaw & Emery, 1979). Hopelessness may be composed of interrelated facets, representing negative feelings about the future, loss of motivation and negative future expectations (Craighead & Nespor, 2001). Hopelessness is the polar opposite of hope and includes sub-processes of helplessly giving up everything (including hope) and living in emptiness in the face of an assumed non-existing future, collapsing mentally, and becoming paralyzed without reason to live (Kylmä, 2005). Despair and hopelessness are possible elements in the life situation of persons living with HIV and for significant others living with them (Kylmä, Vehviläinen-Julkunen &  Lähdevirta, 2001) and it has been seen that seropositive individuals, whether symptomatic or not had higher levels of hopelessness (Catalan et al., 1992).

Personal fatalism and low optimism concerning the future, and greater life dissatisfaction has been reported in women at highest risk for HIV (Somlai & Heckman, 2000). In addition, hopelessness has been identified as a significant factor in suicidal ideation (Kendall, 1992; Hall, Platt & Hall, 1999) and may also cause adjustment problems (Pergami, Catalan, Hulme, Burgess & Gazzard, 1994; Moneyham et al., 1997) thus hindering everyday life in HIV positive people. Furthermore, high psychological distress has been found to have an impact on their survival (Palombi, Mancinelli, Liotta, Narciso & Marazzi, 1997).

Since very early in the AIDS epidemic, a great deal of research attention has been directed toward understanding the psychosocial impact of HIV and identifying the coping issues that confront persons living with HIV (Bogart et al., 2000). This becomes particularly relevant if we are to provide appropriate interventions to enhance the overall quality of life of persons living with HIV. This study looks at the manifestation of pessimism and the extent of life satisfaction in HIV positive persons in India. Given, the wide-ranging socio-cultural differences between Indian and Western societies, and the status of women in particular, it would be of interest to compare if the results of this study are in consonance with the Western literature. The study also seeks to explore differences if any in the manifestation of these dimensions between male and female respondents and those who were single and married besides examining correlations between the subject dimensions studied and background socio-demographic variables of the respondents. The endeavour is also to develop a statistical model that would best explain the manifestation of life satisfaction in subjects and to ascertain the extent to which pessimism contributes to this domain being studied.
Sample Selection:

Tiruchirappalli or Trichy as it is popularly known is a thriving industrial and educational hub, located centrally in the South Indian state of Tamilnadu. The Network for Positive People (NPT+) in Tiruchirappalli, is a NGO working with HIV positive people and the respondents of this study were chosen from those registered with this agency. This comprised of 347 persons, of which 118 were male and 229 female.  At the point of data collection, seven persons had died and 31 were not willing to participate in the study while the remaining agreed to participate.  Data was finally collected from 309 respondents (male-100, female-209).
Instruments used:

The Satisfaction with Life Scale (SWLS) (Diener, Emmons, Larsen & Griffin, 1985) is a global measure of life satisfaction. It consists of 5-items that are completed by the individual on a 7 point Likert scale with responses ranging from strongly disagree to strongly agree. Several studies have examined the internal consistency of the SWLS and alpha coefficients have repeatedly exceeded 0.80 (Pavot & Diener, 1993). The reliability value for the satisfaction with life scale in the present study was Alpha 0.89.
The Beck Hopelessness Scale (BHS) (Beck, Weismann, Lester & Trexler, 1974) is a self-report instrument that consists of 20 true-false statements designed to assess the extent of positive and negative beliefs about the future. Each of the 20 statements is scored from 0 or 1. A total score is calculated by summing the pessimistic responses for each of the 20 items and could range from 0 to 20. The BHS takes less than 5 minutes to complete. A principal components analysis of the BHS for suicide attempters revealed three components: (1) feelings about the future, (2) loss of motivation, and (3) future expectations (Beck, Weismann, Lester & Trexler, 1974). High internal reliability across diverse clinical and nonclinical populations with Kuder-Richardson reliabilities ranging from .87 to .93 have been reported (Beck & Steer, 1988). The BHS is one of the most widely used measures of hopelessness and has been widely used in India as well. The scale has excellent internal consistency and test-retest reliability. The reliability value in the present study for the BHS was Alpha 0.82.

Socio-demographic background of respondents:
Respondents had a mean age of 33.3 years. More than half of them had basic school education and 25% were illiterate. Most of them were agricultural labourers (45%) and 21% were not employed. The average monthly family income was Rs.3427 ($75). The majority (76%) belonged to nuclear families. Married respondents comprised 52% of the sample and the remaining were single. Most of them (37%) had a family size of four members

The average period of infection was 3.7 years and most of them had the infection for two to four years (41%). Majority (60%) of the women had contacted the infection from their husbands. Majority (64%) were in phase II of HIV/AIDS with a CD4 count of 201-500. The majority (55%) were taking Anti Retro Viral Therapy and 58% were attending regular counselling sessions.

Results and Discussion:

Table 1. Distribution of respondents on subject dimensions

Dimension

Mean

SD

Low

High

Life Satisfaction Score

18.7

6.4

148 (47.9%)

161 (52.1%)

Feelings about the Future

2.12

2.14

201 (65.0%)

108 (35.0%)

Loss of Motivation

4.62

1.81

143 (46.3%)

166 (53.7%)

Future Expectations

2.67

1.47

140 (47.3%)

169 (54.7%)

Overall Pessimism Score

9.41

4.47

170 (55.0%)

139 (45.0%)

 The respondents were classified into ‘low’ and ‘high’ groups based on their mean score and this is depicted in Table 1. It is seen that though marginally the majority were high on life satisfaction, they also scored high in terms of their loss of motivation and expectation about the future scores. Gender differences were assessed with the ‘t’ test and based on the mean score for all respondents (9.4), 12.9% of male and 32% of females were classified as being ‘high’ on the overall hopelessness score. The t value (Table 2) indicates a highly significant gender difference for the overall hopelessness score as well as for ‘feelings about the future’ but not for the other two sub-dimensions of the BHS. Female respondents have however obtained higher mean scores on all the sub-dimensions of the BHS indicating greater pessimism than their male counterparts.

Table 2. t test for respondents on subject dimensions distributed by gender

Dimensions

Sex

Mean

Std. Deviation

t

Life Satisfaction Score

 

Male

20.07

6.26

**2.662

Female

18.02

6.37

Feelings about the future

 

Male

1.54

1.87

***3.372

Female

2.40

2.21

Loss of Motivation

 

Male

4.60

1.77

0.122

Female

4.63

1.83

Future Expectations

 

Male

2.54

1.40

1.049

Female

2.73

1.50

Total Hopelessness Score

Male

8.68

4.20

*1.989

Female

9.76

4.56

                  

Significant gender differences were also seen on the life satisfaction score with male respondents obtaining a higher mean score. QOL studies in India have reported similar outcomes for men. Among HIV positive people, there are gender differences in access to treatment, care, economic income, and social and personal power and  women experience more barriers due to the lack of knowledge about HIV/AIDS, family responsibilities and the burden and fear of disclosure (Chandra, Satyanarayana, Satishchandra, Satish & Kumar, 2009).

Further, based on the mean score (18.6), 38.8% of male and only 8.9% of females were classified as being ‘high’ on life satisfaction. An earlier study from India (Wig et al., 2006) found that the most common emotional problems reported by HIV patients were anger, irritation, depression, tension and helplessness. Other experiences such as shock, denial, depression, helplessness, hopelessness, discouragement, guilt, anger and fear as the main emotional problems have also been observed (Chesney & Folkman, 1994). Some of the consequences of living with HIV include decreased (Lyketsos et al., 1996) or destroyed hope (Ingram & Hutchinson, 1999), despair (Mawn, 1998) and hopelessness (Siegel & Meyer, 1999) in dealing with a potentially fatal disease.

Table 3.  t Test for Respondents on Subject Dimensions Distributed by Marital status

Dimensions

Marital Status

Mean

Std. Deviation

t

Life Satisfaction Score

 

Married

20.03

6.07

*3.882

Single

17.26

6.45

Feeling about the future

 

Married

1.63

1.76

*4.300

Single

2.65

2.37

Loss of Motivation

 

Married

4.95

1.77

*4.300

Single

4.27

1.79

Future Expectations

 

Married

2.66

1.45

0.077

Single

2.67

1.49

Total  Hopelessness Score

 

Married

9.24

4.22

0.683

Single

9.59

4.73

            n- Married: 159, Single: 150; df=307; *p < 0.001



Table 3 presents the difference seen in respondents on all the subject dimensions when they were compared according to their marital status. This was considered to be important as it would be an indicator of companionship and support available. The results show a highly significant statistical difference with regard to the life satisfaction score. The mean scores reveal greater life satisfaction in respondents living with a spouse. Differences were also manifested on the two sub-dimensions of the BHS namely feelings about the future and loss of motivation. Mean scores revealed more pessimism regarding feelings about the future in single respondents and more loss of motivation in those married. These findings agree with an earlier Indian study (Singh et al., 1998) which found that those with higher family support had better QOL and reported more life satisfaction if their partner was part of the support. Western literature on this issue has also reported that hopelessness and depression is associated with low social support (Johnson et al., 2001).

Table 4. Correlations between subject dimensions and selected background variables

Subject Dimensions
 
Life Satisfaction Score Total Hopelessness Score Feelings about
 future
Loss of Motivation Future Expectations
Background Variables
Age 0.071 0.000 -0.019 0.022 0.001
Respondents Income 0.249*** -0.194*** -0.188** -0.120* -0.169**
Total Family Income 0.221*** -0.158** -0.169** -0.083 -0.133*
Size of Family -0.013 0.060 0.040 0.019 0.101
Duration of Infection 0.016 -0.137* -0.065 -0.155** -0.131*
CD4 Count 0.184*** -0.141* -0.117* -0.086 -0.152**

 Correlation is significant at the *0.05, **0.01 & ***0.001 level



The correlation coefficients in Table 4 show that the age of the respondents did not show significant correlation with any of the subject dimensions. However respondents’ income and their total family income are seen to correlate significantly positively with life satisfaction and negatively with hopelessness and its sub-dimensions. This indicates the importance of economic status in influencing the manifestation of these dimensions. This is consistent with an earlier Indian study which found that employment and higher income were associated with better QOL (Singh et al., 1998). The duration of infection is seen to be correlated negatively with the hopelessness score and loss of motivation perhaps indicating that pessimistic feelings are more for those who have had the illness recently and that with passage of time and increase in duration, there seems to be more stability. The CD4 count reflects the number of lymphocytes which goes down as the infection progresses. It is seen that this is again positively correlated with life satisfaction and negatively with the total hopelessness score and two of its sub-dimensions. These findings are in variance with another study (Hays, Cunningham & Sherbourne, 2000) that found that CD4 count was at most weakly associated with physical and mental health status.

Significant inter-correlations were obtained between the life satisfaction score and the overall hopelessness score (r = -0.47, p<0.001) and with feelings about the future         (r = -0.42, p<0.001), loss of motivation (r = -0.33, p<0.001) and future expectations  (r = -0.41, p<0.001). These negative correlations indicate that increase in pessimistic feelings about the future is associated with decrease in life satisfaction.

The final statistical procedure used was multiple regression analysis by treating the life satisfaction score as dependent variable, in order to identify its predictors. The scores of the three sub-dimensions of the BHS along with age, family income, respondents’ income, size of family, duration of infection and CD4 count were simultaneously introduced as independent variables into the model using the enter method. The final model was statistically significant (F=26.25; p<0.001) and extracted two sub-dimensions of the BHS namely, feelings about the future (β= - 0.25) and future expectations (β= - 0.23) along with the respondents’ income (β= 0.15) and their CD4 count (β=0.10) as significant predictors, together accounting for the manifestation of Life Satisfaction by about 25% (Adjusted R2=0.25). This R2 value of 0.25 translates into a Cohen’s effect (f2) value of 0.35 {based on the formula, f2=R2/(1-R2)} and is a fairly large effect (Cohen, 1988). The beta coefficients are used to compare the relative strength of the various predictors within the model and their negative value for the two sub-dimensions of the BHS indicate their negative influence on the dependent variable (life satisfaction).

Limitations:
The absence of a comparative group of HIV free individuals, disadvantages the analysis of this study. Further, the study does not take into consideration the progress of the infection and its associated influence on the subject dimensions studied. However, despite these limitations, it does make a significant contribution to the extant literature on HIV in India. Most previous studies have been carried out with small samples and the large sample included in this study, is a distinct methodological feature.
Implications for Psychosocial Intervention:

The findings of this study complement the literature in this area by highlighting the adverse psychological states experienced by HIV positive people and are pointers towards aspects which merit psychosocial intervention. The negative correlations between the pessimism score (and its sub-dimensions) and the life satisfaction scores and the results of the regression analyses, indicate that dealing with feelings of hopelessness through therapeutic procedures, both individual and group approaches, can significantly enhance life satisfaction in persons with HIV. Suicidal ideation is a recurrent theme seen in the HIV literature and often associated with depression and hopelessness (Chandra, Desai & Ranjan, 2005; Santosh, 2004). The suicide rate remains more than three times higher among HIV positive persons than in the general population (Kylmä, Vehviläinen-Julkunen &  Lähdevirta, 2001). Suicide is a complex biopsychosocial outcome of depression, hopelessness, isolation and lack of support, and HIV infection with all its negative connotations and discrimination can be a harbinger of future suicidal ideation or completed suicide (Chandra, Desai & Ranjan, 2005). Some of the psychiatric variables predicting suicidal ideation include past history of depression and presence of hopelessness (Santosh, 2004). To be able to help persons living with HIV through the processes of despair and hopelessness and to prevent the negative consequences of despair and hopelessness, these experiences must be understood more profoundly (Kylmä, 2005). It hence becomes important to inquire into the mood state of the individual and be alert to atypical signs of pessimism, feelings of worthlessness, and suicidality (Van Gorp and Buckingham, 1998) and to deal with these issues through counselling and psychotherapy. This is reiterated by the World Health Organization (2011) which states that counselling and social support can help people with HIV cope more effectively with each stage of the infection and enhance their quality of life. Infusing feelings of optimism and enabling people to deal more competently with issues that undermine their life satisfaction, by helping them overcome underlying feelings of pessimism, will help strengthen resilience and potentially insulate them from depression and suicidal ideation.


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