STIGMA CONSCIOUSNESS, COPING STRATEGIES AND CD4 COUNTS OF PERSONS WITH HIV/AIDS
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.
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 & Hesson-Mclnnis, 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.