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Social support, social stigma, health, coping, and quality of life in older gay men with HIV

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Larry Z Slater
Abstract:
With the advent of antiretroviral therapy, people with HIV/AIDS are living longer and managing their HIV infection as would an individual with any other chronic disease. As life expectancy increases, quality of life has progressed as an emerging issue for older adults with HIV/AIDS. A majority of people living with HIV in the U.S. are still gay men, who thus comprise a large portion of those who are growing older with the disease. The aims of the descriptive, correlational study were to: (1) explore the relationships among age, race, socioeconomic status, health, social support, social stigma, coping, perceived health, and quality of life in older gay men with HIV; and (2) identify the best predictors of quality of life among the aforementioned variables, based on the theory of stress, appraisal, and coping by Lazarus and Folkman. A convenience sample of 60 older gay men (ages 50-65) with HIV participated in the study, of which 57% were white and 95% were taking HIV medications. Participants had, on average, been HIV positive for 17.9 years, reported 5.5 medical comorbidities other than HIV, and were taking 7.5 medications per day. There were no differences in reported quality of life by race or socioeconomic status. Age, social support, perceived health, and problem-focused coping were significantly and positively correlated to quality of life, while medical comorbidities, social stigma (homonegativity, HIV stigma, ageism), and emotion-focused coping were all significantly and negatively associated with quality of life (p<0.01). When the significant variables were entered into regression analysis, medical comorbidities (-), emotional/informational support (+), HIV stigma (-), and emotion-focused coping (-) remained as significant predictors of quality of life, accounting for 64% of the variance in quality of life. Future studies should examine the effects of social support, social stigma, and coping on quality of life in different populations of older gay men with HIV. Also, longitudinal studies are needed to determine potential cause and effect relationships among social support, social stigma, coping, and quality of life, prior to designing and testing interventions aimed at increasing health and quality of life in this population. Keywords: aging, coping, gay, HIV, quality of life

TABLE OF CONTENTS

Page

ABSTRACT

................................ ................................ ................................ ........................

ii

ACKNOWLEDGEMENTS

................................ ................................ ...............................

i v

LIST OF TABLES

................................ ................................ ................................ .............

ix

LIST OF FIGURES

................................ ................................ ................................ ..........

xi i

LIST OF ABBREVIA TIONS

................................ ................................ ..........................

xiii

CHAPTER

1

INTRODUCTION

................................ ................................ ................................ ......... 1

Conceptual Framework

................................ ................................ ................................ .. 3

Antecedents

................................ ................................ ................................ .............. 4

Age and race

................................ ................................ ................................ ...... 5

Health

................................ ................................ ................................ ................. 6

Socioeconomic Status

................................ ................................ ........................ 6

Social Support

................................ ................................ ................................ .... 7

Processes

................................ ................................ ................................ .................. 8

Social Stigma

................................ ................................ ................................ ..... 9

Perceived Health

................................ ................................ .............................. 10

Coping

................................ ................................ ................................ .............. 10

Outcomes

................................ ................................ ................................ ............... 11

Conceptual Models

................................ ................................ ................................ 12

Statement of

the Problem

................................ ................................ ............................. 14

Purpose of the Study

................................ ................................ ................................ .... 17

Research Questions

................................ ................................ ................................ 18

Hypotheses

................................ ................................ ................................ ............. 19

Definition of Terms ................................ ................................ ................................ ...... 20

Assumptions

................................ ................................ ................................ ................. 24

Summary

................................ ................................ ................................ ...................... 24

2

REVIEW OF LITERATURE

................................ ................................ ...................... 26

The Concept of Quality of Life

................................ ................................ .................... 27

Quality of Life and Aging

................................ ................................ ...................... 33

Quality of Life and Homosexua lity

................................ ................................ ....... 34

vi

TABLE OF CONTENTS

(continued)

Page

Quality of Life and HIV

................................ ................................ ......................... 36

Quality of Life Summary

................................ ................................ ....................... 38

Age and Quality of Life

................................ ................................ ............................... 38

Race

and Quality of Life

................................ ................................ .............................. 47

Health and Quality of Life

................................ ................................ ........................... 55

Socioeconomic Status and Quality of Life

................................ ................................ .. 62

Social Support and Qu ality of Life

................................ ................................ .............. 73

Social Stigma and Quality of Life

................................ ................................ ............... 86

Internalized Homonegativity

................................ ................................ ................. 88

Internalized HIV Stigma

................................ ................................ ........................ 91

Ageism

................................ ................................ ................................ ................... 97

Perceived Health and Quality of Life

................................ ................................ .......... 99

Coping and Quality of Life

................................ ................................ ........................ 102

Summary

................................ ................................ ................................ .................... 110

3

METHODOLOGY

................................ ................................ ................................ .... 116

Study Design

................................ ................................ ................................ .............. 116

Study

Sample

................................ ................................ ................................ ............. 117

Sample Size and Po wer Analysis

................................ ................................ ......... 117

Procedures

................................ ................................ ................................ .................. 118

Protecti on of Human Subjects

................................ ................................ ............. 118

Recruitment of Study Participants

................................ ................................ ....... 121

Data Collection

................................ ................................ ................................ .... 123

Variable Measures

................................ ................................ ............................... 125

Demographic Questionnaire

................................ ................................ .......... 125

Psychosocial Questionnaire

................................ ................................ ........... 128

Data Manage ment and Analysis

................................ ................................ ................ 135

Study Limitations

................................ ................................ ................................ ....... 137

4

ANALYSIS AND RESULTS

................................ ................................ .................... 138

Description of the Sample

................................ ................................ .......................... 138

Development of the Coping Scale

................................ ................................ ............. 147

Instrument Reliability

................................ ................................ ................................ 148

Findings Related to the Research Questions

................................ .............................. 150

Research Question 1

................................ ................................ ............................ 150

Hypothesis 1 ................................ ................................ ................................ ... 150

Hypothesis 2 ................................ ................................ ................................ ... 153

Research Question 2

................................ ................................ ............................ 158

Demographics

................................ ................................ ................................ 159

Hypothesis 3 ................................ ................................ ................................ ... 163

Hypothesis 4 ................................ ................................ ................................ ... 163

vii

TABLE OF CONTENTS (continued)

Page

Social Support

................................ ................................ ................................ 164

Social Stigma

................................ ................................ ................................ . 166

Perceived Health

................................ ................................ ............................ 170

Coping

................................ ................................ ................................ ............ 171

Quality of Life ................................ ................................ ................................ 173

Hypothesis 5 ................................ ................................ ................................ ... 175

Hypo thesis 6 ................................ ................................ ................................ ... 175

Hypothesis 7 ................................ ................................ ................................ ... 175

Research Question 3

................................ ................................ ............................ 1 76

Hypothesis 8 ................................ ................................ ................................ ... 189

5

FINDINGS , CONCLUSIONS, IMPLICAT ION S , AND

RECOMMENDATIONS

................................ ................................ ........................... 181

Discussion of the Study Sample

................................ ................................ ................ 181

Discussion of the Study Findings

................................ ................................ .............. 184

Hypothesis 1 ................................ ................................ ................................ ......... 185

Hypothesis 2 ................................ ................................ ................................ ......... 188

Hypo thesis 3 ................................ ................................ ................................ ......... 190

Hypothesis 4 ................................ ................................ ................................ ......... 193

Hypothesis 5 ................................ ................................ ................................ ......... 195

Hypothesis 6 ................................ ................................ ................................ ......... 196

Hypothesis 7 ................................ ................................ ................................ ......... 197

Hypothesis 8 ................................ ................................ ................................ ......... 199

Conclusions

................................ ................................ ................................ ................ 202

Implications ................................ ................................ ................................ ................ 204

Recommendations

................................ ................................ ................................ ...... 206

REFERENCES

................................ ................................ ................................ ................ 207

APPENDICES

A

IRB APPROVAL LETTER

................................ ................................ ................. 225

B

IRB - APPROVED CONSENT DOCUMENT

................................ ..................... 227

C

LETTERS OF SUPPORT

................................ ................................ .................... 232

D

STUDY RECRUITMENT MATERIALS

................................ ........................... 237

E

STUDY INTERVIEW QUESTIONNAIRE

AND RESPONSE CARDS

........... 242

viii

TABLE OF CONTENTS (continued)

Page

F

FACTOR AND RELIABILITY ANALYSIS FOR

THE STUDY COPING

SCALE

................................ ................................ ................................ ................. 263

ix

LIST OF TABLES

Table

Page

1

Summary of Selected Studies Comparing Quality of Life/Perceived Health

between Older and Younger Adults

................................ ................................ ............. 40

2

Summary of Relationships among Age and Quality of Life Domains

........................ 43

3

Summary of Studies Examining Age and Quality of Life/Perceived Health in

Gay/Bisexual Men and MSM

................................ ................................ ...................... 46

4

Summary of Selected Studies Examining the Relationship between Race

and

Quality of Life/Perceived Health

................................ ................................ ................. 50

5

Summary of Selected Studies Examining the Relationship between Comorbidities

and Quality of Life/Perceived Hea lth

................................ ................................ .......... 59

6

Summary of Relationships among CD4 Count

and Quality of Life

............................ 61

7

Summary of Selected Studies Examining the Relationship between SES and

Quality of Life/Perceived Health

................................ ................................ ................. 65

8

Summary of Relationships among Education, Income,

and Quality of Li fe

............... 72

9

Summary of Selected Studies Examining the Relationship between Social Support

and Quality of Life/Perceived Health

................................ ................................ .......... 78

10

Summary of Social Support and Quality of Life Studies using the MOS - SSS and

SSQ/ SSQ6

................................ ................................ ................................ ................... 83

11

Summary of Selected Studies Ex amining the Relationship between HIV Stigma

a nd

Quality of Life/Perceived Health

................................ ................................ .......... 93

12

Summary of Selected Studies Examining the Relationship between Perceived

Health

and Quality of Life

................................ ................................ ......................... 101

13

Summary of Selected Studies Examining the Relationship b etween Coping and

Quality of Life/Perceived Health

................................ ................................ ............... 106

14

Summary of Relationships among Coping Style and Quality of Life

....................... 110

x

LIST OF TABLES (continued)

Table

Page

15

Literature Review Summary of Relationships among Study Variables and

Quality of Li fe ................................ ................................ ................................ ............ 112

16

Summary of Effect Sizes in Quality of Life Studies for HIV+ Populations

.............. 119

1 7

Distribution of Study Sample by Recruitment Method

................................ ............. 123

18

Demographic Characteristics of the Sample

................................ .............................. 139

19

HIV - Related Characteristics of the Sample

................................ ............................... 142

20

Health

Care - Related Characteristics of the Sample

................................ ................... 143

21

List of Medical Comorbidities Present in the Sample

................................ ............... 144

22

Descriptive Statistics for Study Instruments

................................ .............................. 145

23

Internal Reliability Coefficients for Study Instruments

................................ ............. 148

24

Scale Comparison for the MO S - SSS

................................ ................................ ......... 151

2 5

Comparison of Physical Health (PHS) and Mental Health (MHS) Scores for

R ecent

Studies Using the MOS - HIV (Wu et al., 1991)

................................ ............. 152

2 6

Scale Comparison for the HAT - QoL

................................ ................................ ......... 154

27

Scale Comparison for the IHNI

................................ ................................ ................. 155

28

Scale Comparison for the Intern alized HIV Stigma Scale ................................ ......... 15 6

29

Item Comparison for the Ageism Survey

................................ ................................ .. 157

30

Correlations among Demographic Study Variables

................................ .................. 159

31

Correlations among Demographic Variables and Social Support, Social Stigma,

Perceived Health, and Coping ................................ ................................ .................... 161

32

Observed Racial

Differences in Coping

................................ ................................ .... 164

33

Correlations among the Social Support Measures

................................ ..................... 165

xi

LIST OF TABLES (continued)

Table

Page

34

Correlations among Social Support Measures and Social Stigma, Perceived

Health,

Coping, and Quality of Life

................................ ................................ .......... 167

35

Corr elations among the Different Types of Social Stigma

................................ ........ 1 68

36

Correlations among the Internalized Homonegativity

Domains

............................... 169

37

Correlations among the HIV Stigma Domains

................................ .......................... 169

38

Correlations among Social Stigma Measures a nd Perceived Health, Coping, and

Qu ality of Life ................................ ................................ ................................ ............ 170

39

Correlations among Perceived Health and Coping and Quality of Life

.................... 171

40

Correlations among the Coping Domains

................................ ................................ .. 172

41

Correlations among Coping and Quality of Life

................................ ....................... 173

42

Correlations among Quality of Life Domains

................................ ........................... 174

43

Results of Stepwise Multiple Regression Analyses for Quality of Life Predictors

... 178

F 1

Factor loadings of Coping Scale Items

................................ ................................ ...... 265

F 2

Comparison of Coping Scales/Subscales between Current Study and Study by

Moneyham and Colleagues (1997 - 98)

................................ ................................ ....... 267

F 3

Descriptive St atistics and Internal Reliability for the Coping Scale .......................... 273

F 4

Correlations among Coping Scales

................................ ................................ ............ 274

xii

LIST OF FIGURES

Figure

Page

1

Conceptual Model based on Lazarus and Folkman (1984)

................................ ......... 13

2

Statistical Model and Algorithm for Testing Model - Derived

Relationships

............... 14

3

Quality of Life Components from Three Models

................................ ........................ 31

4

HAT - QoL Dimensions and the Lazarus and Folkman (1984) Model

....................... 134

5

Revised Statistical Model and Algorithm

................................ ................................ .. 177

xiii

LIST OF ABBREVIATIONS

ADAP

AIDS Drug Assistance Program

ADPH

Alab ama Department of Public Health

AIDS

acqu ired immune deficiency syndrome

CDC

Centers for

Disease Control and Prevention

FAHI

Functio nal Assessment of HIV Infection

CIQOLL

Chronic

Illness Quality of Life Ladder

HAART

highl y active antiretroviral thera py

HASI - P

HIV/AIDS Stigma Instrum ent for people living with AIDS

HAT - QoL

HIV/AIDS - Targeted Quality of Life instrument

HCSUS

HIV Cost and Services Utilization Survey

HIV

human immunodeficiency virus

IHNI

Interna lized Homonegativity Inventory

IRB

Insti tutional Review Board

ISEL

Interpersonal Support Evaluation List

MOS

Medica l Outcomes Study

MOS - HIV

Medical O utcomes Study HIV Health Survey

MOS - SSS

Medical Outco mes Study Social Support Survey

MSM

men who have sex with men

PCP

Preventive and Correct ive Proactivity Model of Successful Aging

QLI

Quality of Life Index

xiv

LIST OF ABBREVIATIONS (continued)

SES

socioeconomic status

SF - 36

Short Form (36) Health Survey

SSQ6

Social Suppor t Questionnaire, brief version

UAB

University of Alabama at Birming ham

WHOQOL

World Health Org anization Quality of Life group

1

CHAPTER 1

INTRODUCTION

With the advent of antiretroviral therapy, people with human immunodeficiency virus (HIV) are living longer and are managing their HIV infection as would an individual wi th any other chronic disease, such as diabetes or cancer.

T he Centers for Disease Control and Prevention (CDC, 2008) recently released statistics showing that persons age 50 and o lder account for 15% of new HIV

diagnoses and

24% of persons living with HIV .

The Alabama Department of Public Health (ADPH; 2011) released similar statistics, with 15% of new HIV diagnoses occurring

among persons 50 and older in the State of Alabama for 2010. D espite trends arou nd the world, a majority of HIV

cases in the U . S .

are among gay men .

As HIV has long been a gay disease

in the U . S . , gay men may represent a large portion of those growing older with HIV, as well as those who are older and newly diagnosed. The

CDC (20 10 ) reported that gay and bisexual men account for al most ha lf of all those living with HIV and

more than half of new infections, despite prevention efforts that target this population.

Quality of life , and not just health,

has emerged as an important issue for older adults with HIV disease. However, r esea rch on quality of life in older adults with HIV

remains limited

and is virtually nonexistent for older gay men with HIV . Of

particular concern is the paucity of research in older gay men with HIV,

despite the fact that gay men still comprise the largest p ortion of HIV - positive individuals in the U . S .

(CDC , 2010 ) .

2

A number of psychosocial variables and processes have been identified that may be associated with health and quality of life for individuals living with HIV and account for individual differences

in outcomes. Key among these are the type of stressors experienced by older adults with HIV, how they perceive or appraise

such stressors, their personal resources for coping with such stressors, and the effectiveness of their coping skills (Lazarus & Fo lkman , 1984). For example, quality of life of older adults with HIV has been positively associated with the availability of social support as well as their satisfaction with the support that is available

(Crystal et al., 2003;

Liu et al., 2006; Swindells et al., 1999) . Quality of life has also been positively associated with perceived health (Bova, 2001; Buseh, Kelber, Hewitt, Stevens, & Park, 2006; Chesney, Chambers, Taylor, & Johnson , 2003) . On the contrary, quality of life has been negatively associat ed with increased medical comorbidit ies

(Briongos Figuero, Bachiller Luque, Palacios M artin, Gonzalez Sagrado, &

Eiros Bouza, 201 1; Jia et al., 2007; Liu et al. ) and perceived social stigma, including stigma related to one’s homosexuality, HIV - pos itive sta tus, and age (Dowshen, Binns, & Garofalo , 200 9 ;

Emlet, 2006a; Galvan, Davis, Banks, & Bing, 2008).

Coping also impacts quality of life, with active/problem - focused

coping positively associated with quality of life and more passive/ emotion - focused coping n egatively associated with quality of life

(Burgess et al., 200 0 ; Kowal et al., 20 08 ; Swindells et al.).

A consistent finding is that quality of life is associated with health outcomes for individuals with HIV. In a sample of Black men with HIV, Buseh

and

colleagues

(200 6 ) noted that higher levels of perceived quality of life were associated with higher self - rated perception of health. Swindells and colleagues (1999) examined quality of life in a

3

multisite longitudinal study of HIV positive patients. One

of their important findings was that those individuals who died during the course of the study had significantly lower quality of life scores at baseline, leading them to conclude that lower perceived quality of life may lead to faster disease progression

and death.

Such findings, however, must be viewed cautiously when considering potential causal relationships. The relationship between quality of life and health outcomes may be due to their association with other factors that are more directly linked t o

health outcomes. McCain and Cella (1995), in their study of stress and HIV disease in men, found that decreased quality of life was significantly associated with increased psychological stress. Leserman and colleagues (1999) found that increased stress

was significantly associated with declining

CD4 counts and increased viral load. Thus t he relationship of quality of life to health outcomes may be indirect through quality of life’s association with such factors as psychological stress and health behavi ors, which are more directly linked to health outcomes. For example, poor quality of life may occur when psychological distress is high; in turn, psychological distress may contribute to poor adherence to antiretroviral therapy (Holzemer et al., 1999; Sin g et al., 1996) and subsequently more rapid disease progression.

Conceptual

Framework

The theory of stress, appraisal, and coping, formulated by Lazarus and Folkman (1984), served as the framework for this study. Lazarus and Folkman defined stress as any

relationship between a person and their environment that a person appraises as exceeding his or her resources and harmful to his or her well - being. The process by

4

which a judgment is made as to whether or not the person - environment relationship is stress ful is termed cognitive appraisal. Coping is the process by which a person manages the demands of the stressful situation and the emotions that occur in response to the situation.

There are significant individual differences in the experience of and out comes of psychological distress. The theory by Lazarus and Folkman (1984) takes into account individual characteristics of the person and the nature of the stressful situation, which account for individual differences in the experiences and outcomes of ps ychological stress. They used the term antecedents

to describe these individual person and situation characteristics, which define the context in which stress occurs. They also described three types of adaptational outcomes

of psychological distress, nam ely social functioning, morale, and somatic health. Finally, they used the term processes

to encompass the cognitive appraisal and coping mechanisms that serve as mediators of the relationship between the antecedents and the adaptational outcomes.

Ante cedents

Antecedent variables, according to Lazarus and Folkman (1984), are characteristics of the person/environment transaction involved in a stressful life situation that interdependently influence how an individual perceives and responds to difficult l ife situations. Person and environmental factors can act either as vulnerability factors (e.g., increase vulnerability stress) or as resistance resources (e.g., decrease vulnerability to stress). Examples of person and environmental resistance resources include good health, previous experience, economic resources, and social support. Resistance resources are

5

important because they support positive appraisals of situations and effective coping. In contrast, person and environmental vulnerability factors may include poor health, lack of prior experience dealing with a particular situation, and lack of social support. Unlike resistance resources, vulnerability factors contribute to appraisal of situations as threatening and to less effective coping respons es. There are also characteristics of stressful life situations that influence cognitive appraisal and coping, and include such characteristics as novelty (no previous experience), uncertainty, and duration of the situation.

Age and R ace

Lazarus and Fol kman (1984) stated that as a person ages, the sources of stress that they must face and manage also change. This requires adaptations in appraisal and coping in order to secure more positive outcomes. In studies of older adults with HIV, older age has be en associated with fewer economic resources (Joyce, Goldman, Leibowitz, Alpert, & Bao, 2005; Speer et al., 1999) ,

poorer health (Vance, Mugavero, Willig, Raper, & Saag, 2011), less social support (Shippy & Karpiak, 2005; Vance & Woodley, 2005), more stigma

(Vance, 2006) ,

and poorer quality of life (Crystal et al., 2003; Piette, Wachtel, Mor, & Mayer, 1995; Pitts, Grierson, & Misson, 2005).

Lazarus and Folkman (1984) identified culture as having a major influence on the outcomes of difficult life situation s. Culture influences how individuals both appraise and respond to such situations. As culture encompasses the practices, belief systems, daily rituals ,

and practices of an ethnic group , self - described race

is often used in research as a measure for cult ure. In research, race

has been linked to differences in income

6

(David & Knight, 2008; Speer et al., 1999), social support (Emlet, 2006b), stigma (Emlet, 2007), perceived health (Mosack et al., 2009), coping styles (Leserman, Perkin s, & Evans, 1992; Speer

et al. ), and quality of life (Cummings & Jackson, 2008; Vyavaharkar, Moneyham, Murdaugh, & Tavakoli, 2011). Age and race

are considered antecedent person factors in the Lazarus and Folkman (1984) model.

Health

Older adults highly value health and functi onal status (Farquhar, 1995; Rowe & Kahn, 1998). Changes in health can pose a number of stressors for older adults, particularly in relation to novelty, predictability, and event uncertainty (Lazarus & Folkman, 1984). New illnesses, symptoms, or medicati ons require older adults to continuously reappraise their health and determine how to cope with health issues to maintain quality of life. Older adults with HIV have been shown to have a greater number of medical comorbidities and take more medications pe r day than younger adults with HIV (Vance et al. , 2011). Studies have shown that increases in comorbidities can have a negative impact on perceived health and quality of life ( Briongos Figuero

et al. , 2011; Jia et al., 2007; Liu et al., 2006 ). In the Laz arus and Folkman model, total comorbidities and total medications are considered situation factors.

Socioeconomic S tatus

In examining social support networks, Lazarus and Folkman (1984) described a social structural component that can shape values and beh avior, having a direct effect on appraisal and coping. Structural components relate to the social order or, more

7

specifically, to an individual’s class or place in society. These social structural components may also be related to an individual’s materi al or financial resources. Socioeconomic status is a term that is often used to examine the social structural component of an individual’s social environment. It may include a measure of material resources (income) and education (used to improve class an d material resources), among others. In recent studies of persons living with HIV, lower income was associated with greater stress (Koopman et al., 2000) and higher income with better quality of life (Liu et al., 2006; Lyons, Pitts, Grierson, Thorpe, & Po wer, 2010 ; Swindells et al., 1999). A higher level of education was associated with better health status (Ackerman et al., 200 0 ; Pereira & Canavarro, 2011). Education and income, as components of socioeconomic status, are considered resistance resources in the Lazarus and Folkman model.

Social S upport

Lazarus and Folkman (1984) described social support as a vital resource that an individual must draw upon for surviva l. As a resistance resource, social support

is postulated to have a direct effect on bot h cognitive appraisal and coping efforts. Social support can support more positive appraisals of individual life situations and support more effective coping. Social support can serve to reduce uncertainty and worry and provide the individual with a mean s of distraction, emotional support, sympathy and empathy, and helpful information. Lazarus and Folkman further expanded on the concept of social support, stating that there is a clear distinction between the number and types of social relationships and t he perception of the value of such relationships. The number of social relationships is termed the social network. The perception of social relationships is

8

termed perceived social support. Finally, Lazarus and Folkman proposed that there are different types of social support, such as emotional, informational, or tangible, and the type of support must also be considered in addition to the size of the social network and the perception of the quality of support that is available.

Lazarus and Folkman (198 4) noted a number of studies that have shown how social relationships sustain health and conversely how low social support relates to negative health outcomes. Extensive research has demonstrated that social integration has substantial physical and mental

health benefits for older adults (e.g., Netuveli & Blane, 2008; Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2006; Rowe & Kahn, 1998; Zanninotto, Falaschetti, & Sacker, 2009). In addition, social support has been shown to be related to positive outcom es in people living with HIV (Fleishman et al., 2000; Larios, Davis, Gallo, Heinrich, & Talavera, 2009; Mavandadi , Zanjani, Ten Have, & Oslin, 2009; Liu et al., 2006; Swindells et al., 1999) and, more specifically, to ga y men living with HIV (Chesney et al . , 2003; Leserman et al., 1999).

Processes

Lazarus and Folkman (1984) proposed the outcomes of stressful life situations are determined by two processes, cognitive appraisal of the situation and coping efforts to manage the situation. These processes serve as mediators of the relationship between antecedents and outcomes in the Lazarus and Folkman model. Through the cognitive appraisal process, the individual evaluates the importance or significance of the stressful event and how it relates to his or her well - being. In addition, the appraisal process can affect not just the reaction, but the quality and intensity of the reaction. Lazarus and

9

Folkman identify three types of appraisal: primary, secondary, and reappraisal. Primary appraisal is the init ial judgment of potential harm or loss that may occur as a result of a life situation. Based on such appraisal, situations are categorized as benign (harm/loss is not likely to occur), irrelevant (there is nothing of importance to the individual that is a t stake in the situation), challenge (a positive outcome is likely to occur), or threat (something of importance to the individual is at stake, and harm/loss is likely to occur). Secondary appraisal relates to the identification and determination of what can and might be done to manage a stressful situation to either prevent or minimize harm/loss , and thus is the process that underlies coping responses . Reappraisal is a change in appraisal based on new information, either from person or situation factors or changing resources.

Social S tigma

For the current study, perceived stigma was investigated as a particular cognitive appraisal of the interaction of a person with their social environment. Stigma was defined by Goffman (1963), the father of social sti gma theory, as unacceptable or un desirable characteristic s

that impact an individual’s place in society. Such characteristics, however, may not always be

visible. Such is the case with stigmatized conditions like HIV disease. Despite this, many individu als perceive that they are stigmatized by the mere fact that they possess the stigmatized condition, whether it is visible to others or not. Perceived stigma is an important appraisal for individuals with HIV because it is based on the perception of the

Full document contains 290 pages
Abstract: With the advent of antiretroviral therapy, people with HIV/AIDS are living longer and managing their HIV infection as would an individual with any other chronic disease. As life expectancy increases, quality of life has progressed as an emerging issue for older adults with HIV/AIDS. A majority of people living with HIV in the U.S. are still gay men, who thus comprise a large portion of those who are growing older with the disease. The aims of the descriptive, correlational study were to: (1) explore the relationships among age, race, socioeconomic status, health, social support, social stigma, coping, perceived health, and quality of life in older gay men with HIV; and (2) identify the best predictors of quality of life among the aforementioned variables, based on the theory of stress, appraisal, and coping by Lazarus and Folkman. A convenience sample of 60 older gay men (ages 50-65) with HIV participated in the study, of which 57% were white and 95% were taking HIV medications. Participants had, on average, been HIV positive for 17.9 years, reported 5.5 medical comorbidities other than HIV, and were taking 7.5 medications per day. There were no differences in reported quality of life by race or socioeconomic status. Age, social support, perceived health, and problem-focused coping were significantly and positively correlated to quality of life, while medical comorbidities, social stigma (homonegativity, HIV stigma, ageism), and emotion-focused coping were all significantly and negatively associated with quality of life (p<0.01). When the significant variables were entered into regression analysis, medical comorbidities (-), emotional/informational support (+), HIV stigma (-), and emotion-focused coping (-) remained as significant predictors of quality of life, accounting for 64% of the variance in quality of life. Future studies should examine the effects of social support, social stigma, and coping on quality of life in different populations of older gay men with HIV. Also, longitudinal studies are needed to determine potential cause and effect relationships among social support, social stigma, coping, and quality of life, prior to designing and testing interventions aimed at increasing health and quality of life in this population. Keywords: aging, coping, gay, HIV, quality of life