AIDS Behav (2008) 12:139–145 DOI 10.1007/s10461-007-9214-y
ORIGINAL PAPER
Emotional Support and Affect: Associations with Health Behaviors and Active Coping Efforts in Men Living with HIV Nathan T. Deichert Æ Erin M. Fekete Æ Jessica M. Boarts Æ Jennifer Ann Druley Æ Douglas L. Delahanty
Published online: 3 March 2007 Ó Springer Science+Business Media, LLC 2007
Abstract The present study represents a cross-sectional examination of the relationship between affect, social support and illness adjustment in men diagnosed with HIV/AIDS. Positive and negative affect were examined as separate mediators of the relationship between emotional support received from a primary support provider and illness adjustment in 105 men living with HIV. Results suggested that depressive symptoms emerged as a mediator between emotional support and engaging in healthy lifestyle behaviors (assessed by summary index). In contrast, positive affect emerged as the primary mediator between emotional support and greater amounts of active coping. Overall, findings suggested that emotional support from close others was indirectly associated with health behaviors and coping through recipients’ affective states, and that these positive and negative affective states had differential relationships with multiple aspects of illness adjustment in men living with HIV.
N. T. Deichert E. M. Fekete J. M. Boarts D. L. Delahanty Department of Psychology, Kent State University, Kent, OH, USA J. A. Druley Department of Psychology, Cleveland State University, Cleveland, OH, USA N. T. Deichert (&) Department of Molecular Virology, Immunology, and Medical Genetics, The Ohio State University College of Medicine, 193 McCampbell Hall, 1581 Dodd Dr., Columbus, OH 43210, USA e-mail:
[email protected]
Keywords Emotional support Positive affect Active coping Health behaviors Depression
Introduction Illness management strategies such as engaging in healthy lifestyle behaviors (e.g., exercise, healthy diet, medication adherence) and active coping (i.e., employing realistic strategies in order to change a problem or situation, Lazarus & Folkman, 1984) are associated with delayed disease progression and a better quality of life in people living with HIV (PLWH; Clingerman, 2004; Solano et al., 1993). As such, it is important to understand the factors that promote the use of such strategies. Psychosocial factors, such as emotional social support, are believed to indirectly impact physical health by influencing both health behaviors and affective states (Uchino, 2004). Thus, the purpose of the current study was to examine how emotional support from close others is associated with affective states in a sample of men living with HIV, and how these affective states, in turn, are associated with a broad range of men’s health behaviors and active coping efforts. Emotional support refers to an individual’s attempts to alleviate or prevent negative affect in another (Heller & Rook, 1997). Previous research has found an association between emotional support and both greater positive affect and lower negative affect in PLWH (Gonzalez et al., 2004). Furthermore, emotional support has been associated with better illness management strategies for PLWH, including higher rates of medication adherence (Godin, Cote, Naccache, Lambert, & Trottier, 2005; Gonzalez et al., 2004)
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and more active coping efforts (Leslie, Stein, & Rotheram-Borus, 2002). Active coping efforts are particularly important for PLWH, as they have been linked to better psychological (Burgess et al., 2000) and physical health outcomes (Solano et al., 1993). Although previous research has provided a compelling link between support and better illness management strategies, relatively little attention has focused on the mechanisms through which support increases health behaviors and coping efforts. Specifically, evidence exists to suggest that both positive and negative affective states may be pathways through which support influences illness management strategies in PLWH. Research using such populations has found evidence of a direct link between affect and health outcomes. Previous findings suggest that greater levels of negative affect (i.e., depression) are associated with lower levels of medication adherence (Ammassari et al., 2004), riskier sexual behaviors (RotheramBorus, Rosario, Reid, & Coopman, 1995) and faster disease progression (Leserman et al., 2002). Furthermore, depression has also been associated with more avoidant (Weaver et al., 2005) and less active coping (Catz, Gore-Felton, & McClure, 2002) in PLWH. The few studies examining the relationship between positive affect and health in PLWH suggest that positive affect is associated with greater medication adherence, higher CD4 cell count and lower viral load (Ironson et al., 2005), as well as lower mortality (TedlieMoskowitz, 2003). Research directly examining affect as a mediator of the relationship between social support and illness management provides evidence of an indirect association through affect. For example, Simoni and colleagues (2002) established that depressive symptoms accounted for the relationship between individuals’ need for support and the extent to which they engaged in medical recommendations. Similarly, Gonzalez et al. (2004) examined both depression and positive affect as potential mediators of the relationship between emotional support and medication adherence. Results revealed that positive affect, but not depression, accounted for the relationship between higher levels of support and greater medication adherence. Although the mediation effects of positive affect held after controlling for depression, the study was limited in that it did not examine the simultaneous effects that depression and positive affect may have on illness management. Further, it did not examine indicators of illness management other than medication adherence, such as general health behaviors and coping efforts. The current study extends previous research by examining positive affect and depression as simulta-
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neous mediators of the relationship between emotional support and broader aspects of illness management (e.g., health behaviors and active coping efforts) in a sample of men living with HIV (MLWH). Although medication adherence is of paramount importance for PLWH, maintaining a healthy lifestyle is also important in preventing illness progression (Clingerman, 2004; Solano et al., 1993). Thus, a unique aspect of our study is that it assesses an index of multiple health behaviors rather than solely focusing on medication adherence. Based on prior theory and research, we hypothesized that receiving emotional support would be associated with engaging in more health behaviors and active coping efforts. In addition, we expected that these links would be mediated by positive and negative affective states. More specifically, we expected greater emotional support would be associated with less depression and more positive affect, which in turn, would be associated with engaging in higher levels of health behaviors and more active coping efforts.
Method Participants and Procedures Data were collected from 109 adult men over the age of 18, who were HIV+ or diagnosed with AIDS, and who indicated that they had a primary support provider. All methods were reviewed and approved by the Institutional Review Board of the University through which the study was conducted. If participants were eligible, they were referred to study investigators through local social service agencies. Men completed a questionnaire anonymously and were monetarily compensated upon completion. Four men were dropped from the analyses due to missing data, yielding a final sample of 105 men. The sample averaged 39.2 years of age (SD = 7.0), and over half (65.7%) had at least some college education. Participants consisted mostly of AfricanAmerican (48.6%) and Caucasian (37.1%) men, although Hispanic (12.4%), Asian (1.0%) and Indian (1.0%) men also participated. Most participants were not currently employed (61.9%) and reported an average monthly income of less than $1000. The majority of the sample (60.0%) identified their sexual orientation as homosexual, with a smaller proportion identifying themselves as heterosexual (13.3%), bisexual (13.3%), men who have sex with men (MSM; 10.5%), or celibate (2.9%).
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Approximately half of the sample (49.5%) rated their health as being either very good or excellent, and a smaller proportion reported that their health was good (28.6%) or fair to poor (21.9%). The average number of years men had been HIV positive was 8.01 (SD = 4.6), and the most severe illness symptoms reported were low energy/fatigue (30.0%), diarrhea (22.8%), shortness of breath (18.9%), and night sweats (16.3%). Measures Emotional Support The emotional support scale (Stephens & Clark, 1997) consisted of 9 items (e.g., showing affection, listening, being empathic) rated on a scale from 1 (rarely or none of the time) to 4 (most or all of the time). Participants reported the extent to which they had received emotional support from their primary support provider over the past two months. Items were summed and had a potential range of 9 to 36. The mean amount of emotional support men reported receiving was 24.37 (SD = 7.32; observed range = 9–36; a = .90). Depression The Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977) is a 20-item scale assessing levels of depression during the past week, with higher scores indicating more depressive symptoms. A CES-D cutoff score of 17 has been established as an adequate predictor of depression in chronic illness populations (Katz, Kopek, Waldron, Devins, & Tomlinson, 2004). In the present sample, slightly more than half of participants (55.2%) scored 17 or higher on this scale, with a mean CES-D score of 20.40 (SD = 12.53; observed range = 0–58; a = .91). Positive Affect The 10-item positive subscale of the Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) was used to assess positive affect. Men rated the extent to which they had experienced positive affective states (e.g., interested, enthusiastic) over the past week on a scale of 1 (very slightly or not at all) to 5 (extremely). Scores were summed and could range from 10 to 50 with higher scores indicating greater levels of positive affect. The mean positive affect in men was 30.70 (SD = 10.55; observed range = 10–50; a = .95).
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Health Behaviors Participants reported how often during the past two months they had engaged in various behaviors in order to stay healthy. Items for this scale were adapted from the General Health Behaviors measure developed by the Adult AIDS Clinical Trials Group [AACTG] (Chesney et al., 2000). The scale consisted of 11 items (e.g., eating right, exercising, avoiding stress) that were rated on a scale from 0 (never) to 3 (all of the time). Items were summed and could range from 0 to 33, with higher scores indicating greater engagement in health behaviors. The mean amount of health behaviors men reported was 20.57 (SD = 6.08; observed range = 1–32; a = .73). Although prior research has typically examined individual health behaviors, summing all health behaviors provided a more general assessment of healthy lifestyle. Active Coping A shortened version of the Ways of Coping Scale (WOC; Folkman & Lazarus, 1986) used in previous studies to measure coping efforts in PLWH (e.g., Ickovics et al., 2002) was used to measure active coping. Men indicated how often they had engaged in thirteen different behaviors (e.g., make a plan of action and follow it, rediscover what is important in life) over the past two months in order to cope with their illness on a scale from 1 (never) to 5 (very frequently). Items were summed and could range from 13 to 65, with higher scores indicating greater levels of active coping. The mean amount of active coping men reported engaging in was 46.16 (SD = 10.85; observed range = 13–65; a = .93). Analysis Plan Hierarchical multiple regression analyses were used to test the study hypotheses. Tests of mediation were conducted according to procedures set forth by Baron and Kenny (1986). Measures of both positive affect and depression were simultaneously included in each test of mediation. To test for the significance of the indirect effects, we used Sobel’s (1982) z-test. Covariates were selected by examining bivariate correlations and chi-square analyses between each of the dependent variables and a variety of sociodemographic (e.g., age, race, income, education), health (e.g., self-rated health, illness symptoms, HIV status), and relationship characteristics (e.g., current relationship status). To be conservative in testing our
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hypotheses, any variables that were significantly correlated with a dependent variable at P < .10 (rather than the traditional level of P < .05) were retained as control variables in all analyses. For analyses involving health behaviors, health status, illness symptoms and relationship status were retained as covariates and accounted for 14% of the variance. For analyses involving active coping, income, health status, and relationship status were retained as covariates, accounting for 10% of the variance. Table 1 presents the bivariate correlations between covariates and study variables.
Results To establish the first step of mediation, we examined the direct effects between emotional support and men’s reports of health behaviors and active coping. After controlling for sociodemographic variables, higher levels of emotional support were related to engaging in more health behaviors (b = .26, SE = .09, P < .01), and greater active coping efforts (b = .38, SE = .11, P < .001). To examine the second step in testing mediation, relationships were examined between emotional support and both mediators (i.e., depression and positive affect). For the model examining men’s health behaviors, emotional support was associated with less depression (b = –.38, SE = .09, P < .001) and more positive affect (b = .41, SE = .09, P < .001). Similarly, in the model examining men’s active coping efforts, emotional support was related to less depression (b = –.32, SE = .09, P < .001) and more positive affect (b = .38, SE = .09, P < .001). To establish the third link necessary for testing mediation, we examined the relationships between each mediator and each outcome variable (i.e., health behaviors, active coping). For health behaviors, higher levels of depression were associated with fewer health
behaviors (b = –.25, SE = .11, P < .05), but positive affect was not related to health behaviors (b = .16, SE = .11, ns). For active coping efforts, higher positive affect was associated with more active coping efforts (b = .38, SE = .11, P < .001), but depression was not related to active coping (b = .04, SE = .11, ns). In the final test of mediation, we examined the relationship between emotional support and men’s health behaviors and active coping after simultaneously adjusting for depression and positive affect. As shown in Fig. 1, the link between emotional support and health behaviors was no longer significant after accounting for the effects of depression (from b = .26, P < .001 to b = .10, ns). The results of the Sobel test for mediation indicated that the indirect association between emotional support and health behaviors through depression was significant (z = 1.98, P < .05). The final model accounted for 30% of the variance in men’s health behaviors. As shown in Fig. 2, the relationship between emotional support and active coping efforts was reduced, but still significant, after accounting for the effects of positive affect (from b = .38, P < .001 to b = .25, P < .01). Again, the results of the Sobel test revealed that the indirect association between emotional support and active coping through positive affect was significant (z = 2.74, P < .01). The final model accounted for 33% of the variance in men’s active coping efforts.
Discussion Results from our study suggest that emotional support is associated with engaging in greater levels of health behaviors and active coping efforts in men living with HIV. Moreover, our study revealed that depression and positive affect may be separate pathways through which support operates on men’s ability to manage their illness. Our results suggest positive and negative
Table 1 Bivariate correlations among covariates and main study variables 1 1. 2. 3. 4. 5. 6. 7. 8. 9. #
Emotional support Positive affect Depression Health behaviors Active coping Monthly income Self-reported health Illness symptoms Relationship status
3
– –.60*** .38*** .48*** .25** –.33*** –.17# .11
– –.43*** –.30** –.24* .30** .33*** –.06
4
5
6
7
8
– .44*** –.37*** .28** .42*** .14 –.14 .07 –.02
P< .10. * P< .05. ** P< .01. *** P< .001
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2
– .43*** .06 –.30** –.22* –.21*
– .17# –.23* –.06 –.17#
– –.19* –.07 –.01
– .48*** .01
– .03
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-.38***
Depression
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-.25* Health Behaviors
Emotional Support Positive Affect
.16
.41***
.26**/.10 ***p < .001. **p < .01. *p < .05.
Fig. 1 Positive and negative affective states as mediators of the relationship between emotional support and health behaviors in men living with HIV
-.32***
Depression
.04
Emotional Support
Active Coping
.38***
Positive Affect
.38**
.38***/.25** ***p < .001. **p < .01. *p < .05.
Fig. 2 Positive and negative affective states as mediators of the relationship between emotional support and active coping efforts in men living with HIV
affect are differentially related to illness adjustment, such that positive affect was associated with men’s ability to actively cope with the stressors associated with their illness condition, whereas fewer symptoms of depression were associated with men’s ability to engage in healthy behaviors. The current study provides more support for previous research in PLWH suggesting that positive and negative affect are important pathways through which support is associated with individuals’ ability to manage their illness (Gonzalez et al., 2004; Simoni, Frick, Lockhart, & Liebovitz, 2002). Our results suggest that emotional support was indirectly related to men’s ability to actively engage in managing their illness through increases in positive affect. Likewise, emotional support was associated with the extent to which men lived healthier lives through decreases in depressive symptoms. Although we hypothesized that emotional support would be associated with both health behaviors and active coping efforts by bolstering positive affect and alleviating distress, our results revealed that depression
and positive affect appear to differentially mediate our proposed models. Men who received greater emotional support also experienced greater positive affect and fewer depressive symptoms. Greater positive affect, in turn was associated with using more pragmatic strategies to cope with the stress of their illness, but was not associated with engaging in healthy behaviors. In contrast to this, we found that fewer depressive symptoms were associated with engaging in more selfcare behaviors such as eating a healthy diet, avoiding drugs and alcohol, and taking medications, but were not associated with men’s active coping efforts. This pattern of findings suggests that the associations between support and specific health outcomes may vary as a function of the emotional state elicited by support. Such findings are consistent with theories that positive and negative affective states are largely independent of each other (Watson & Clark, 1997). In addition, several theories of emotion suggest that different patterns of emotions are associated with specific action tendencies (e.g., Frijda, 1986; Frederickson, 1998). In this sense, positive emotions are argued to increase psychological resources and facilitate coping efforts (Salovey, Rothman, Detweiler, & Steward, 2000; Pressman and Cohen, 2005), whereas feelings of sadness or depression are associated with the desire to withdraw. Consistent with emotion theory and research, our study found that positive affect was associated with cognitive, rather than behavioral, aspects of illness management. Feeling interested, excited, and enthusiastic may have led men to feel as if HIV was a surmountable stressor, rather than an overwhelming obstacle. In contrast, our findings revealed that depression was associated with behavioral, rather than cognitive, aspects of illness management. Specifically, when emotional support was associated with greater experience of positive emotions, men reported higher levels of actively coping with their illness. Conversely, when support was associated with less despair and hopelessness, men engaged in healthier behaviors such as eating healthy foods, exercising, and taking their medications. The findings of the current study could be applied to interventions aimed at improving illness management in individuals living with HIV. As expected, both emotional support and affective states were found to be important predictors of health behaviors and active coping efforts. However, due to the likelihood of an indirect relationship between emotional support and health outcomes, interventions should focus on improving individuals’ levels of social support as well as their mood states, as addressing only one may
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produce less stable changes in behavior (Chesney & Darbes, 1998). Although the present study did not have objective indicators of men’s physical health (e.g., immune function), the results likely have implications for health outcomes. Both positive and negative affect have been linked to physical health outcomes in PLWH. Specifically, depression has been linked to faster disease progression (Leserman et al., 2002), whereas positive affect is associated with higher CD4 count and lower viral load (Ironson et al., 2005) as well as lower rates of mortality (Tedlie-Moskowitz, 2003). In addition, active coping and health behaviors have both been associated with physical health in PLWH. Greater active coping has been linked with higher natural killer cell cytoxicity (Goodkin et al., 1992) and slower disease progression (Mulder, Antoni, Duivenvoorden, & Kauffmann, 1995) in PLWH. Medication adherence has long been acknowledged as a primary predictor of physical health in HIV populations, including virologic failure (Paterson et al., 2000) and mortality (Wood et al., 2003). However, other health behaviors such as eating a healthy diet and engaging in physical activity are known to influence physical health outcomes, including immune function (Kiecolt-Glaser and Glaser, 1988). Future research examining the relationship among emotional support, affect, and illness management should include markers of physical health to gain a broader understanding of how psychological and environmental processes relate to physical health outcomes. Despite the strengths of our study, several limitations should be noted. One limitation of the current study is the cross-sectional nature of the data. Due to such data, it is not possible to examine the temporal relationship among support, affect, and health behaviors, and causal relationships cannot be explored. Future longitudinal research will allow researchers to confirm the direction of this relationship and test the possibility of alternative explanations (e.g., Weaver et al., 2005). Moreover, the use of ecological momentary assessments such as daily diaries (Stone & Shiffman, 1994) would provide valuable insight into the temporal ordering of daily emotional support, fluctuations in affect, and health outcomes. A second limitation of our study is the composition of our sample. Specifically, our sample consisted entirely of males diagnosed with HIV/AIDS. Thus, caution should be taken when generalizing our findings to other populations. However, findings from previous research suggest similar patterns of results in women living with HIV/AIDS (Gonzalez et al., 2004) as well
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as other medical populations (e.g., cardiac rehabilitation patients; Shen, McCreary, & Myers, 2004).
Conclusions Although extensive research exists on emotional support, affect, and illness management, few studies have attempted to examine how these factors relate to each other in the same model. The current study is among the first to examine the importance of both positive and negative affect as mechanisms through which emotional support relates to illness management strategies in PLWH. Moreover, results of our study highlight the importance of acknowledging multiple affective states, as each may have a differential impact on health outcomes. Receiving emotional support that simultaneously strengthens positive affective states and alleviates negative affective states may play an integral role in individuals’ ability to effectively manage HIV/AIDS.
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