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STYLES OF COPING RELATED TO DISTRESS

AMONG HIV-POSITIVE AFRICAN AMERICANS

A Dissertation

Presented to the Faculty of

Pacific Graduate School of Psychology

Palo Alto, California

In Partial Fulfillment of the

Requirements for the Degree of

Doctor of Philosophy in Psychology

by

Malik Muhammad

May, 2008
 UMI Number: 3396768

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 STYLES OF COPING RELATED TO DISTRESS

AMONG HIV-POSITIVE AFRICAN AMERICANS

Malik Muhammad

Pacific Graduate School of Psychology, 2008

A cross sectional study compared the coping styles of 60 African American men

and women to 101 White males and females. This study was done to examine what

specific adaptive and also maladaptive coping styles are used by HIV- positive African

Americans compared to Whites. The goal was to tease out any specific cultural

differences in how Africans Americans handle being HIV-positive.

Given the rise in new HIV-infection rates among African Americans, it is

important to examine what factors help increase the quality of life for this group of

people, specifically what coping and social support look like for this population. Social

support, referring to one’s immediate and extended network of family and friends that

can be called on in times of need, was operationalized as satisfaction with one’s social

support network.

Compared to Whites, African Americans utilized spirituality to cope with being

HIV-positive more often, had greater satisfaction with social support, showed greater

endorsement of spiritual beliefs, and were also more likely to utilize denial as a coping

strategy to deal with being HIV-positive. For African Americans, the greater the access

to community resources the less mood disturbance, the greater utilization of denial as a

coping style the higher their mood disorder, and the less the mood disturbance the less

behavioral disengagement. Also, the use of denial as a coping tool should be examined to

see if it may have a positive effect on adjusting to and living with being HIV-positive.
Future research may also focus on developing more culture-specific questionnaires for

HIV-positive African Americans that identify what African Americans with HIV

consider as having access to community resources, what qualifies as spiritual growth,

how they identify when they are becoming depressed, and also how they asses their

overall mental health. More research needs to be conducted to see what coping styles are

utilized by HIV-positive African Americans that prevent the use of negative denial as

coping strategy.

One of the limitations of the study was its small sample size. It was also a highly

distressed, highly impoverished population. The White sample consisted of primarily low

SES, homosexual participants, which restricted the generalizability of the findings. The

hypotheses were also examined using a cross-sectional design and data from a sample of

convenience that was drawn from a larger study.

© Copyright 2007

by

Malik Muhammad

All Rights Reserved

ii
 STYLES OF COPING RELATED TO DISTRESS

AMONG HIV-POSITIVE AFRICAN AMERICANS

This dissertation by Malik Muhammad, directed and approved by the candidate’s

committee, has been accepted and approved by the Faculty of Pacific Graduate School of

Psychology in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

IN PSYCHOLOGY

May 15, 2008

William Froming, Ph.D.
Vice-President for Academic Affairs

Dissertation Committee:

__________________________________________
Peter Goldblum Ph.D
Chair

__________________________________________
Leonard Beckum Ph.D
Committee Member

__________________________________________
Cheryl Koopman Ph.D
Committee Member

This dissertation was approved with the signatures of those indicated on this page. The
original signatures are on file with the dissertation copy in the PGSP Library.

iii
 DEDICATION

This work is dedicated to my mom. She always says, “People come into your life

for reasons and seasons.”…I have been blessed to have her in my life for every season no

matter how rough.

iv
 ACKNOWLEDGEMENTS

How do you eat an elephant?.....Once piece at a time.

That was my mantra through this entire process. I am forever indebted to my mother for

all of her support. I want to thank my committee, Dr. Peter Goldblum, my academic mom

Dr. Cheryl Koopman, and Dr. Leonard Beckum, for their consistent encouragement. I am

grateful for Dr. Norman Chambers who saw me before I could see myself. I am indebted

to all of the men in our Wednesday night men's group in San Diego for teaching me what

jewels I have inside and that love doesn’t always come with a smile. I persevered because

of all of my friends in San Diego and the Bay Area for spending time talking and just

being with me when nothing in the process made sense. I want to say thank you to my

ancestors for having a dream. I hope I have not let you down. I want to also acknowledge

that this research was funded by NIMH grant MH54930 and manuscript preparation was

supported, in part, by NIMH Center Grant P30-MH52776, David Spiegel, M.D.,

Principal Investigator.

v
 TABLE OF CONTENTS

Page

DEDICATION……………………………………………………….………….……….iv

ACKNOWLEDGEMENTS……………………………………………………………....v

LIST OF TABLES……………………………………………………………………......ix

CHAPTER

I. REVIEW OF LITERATURE...……........…….....………………………..…...1

HIV/AIDS Incidence among African Americans in the United States…...1

Stigma and Racism……………………………..........................…………3

HIV Stigma…….……………………...…………………………..3

Stigma and Employment.................................…………………….7

Racism and African American Health...……………....…………..9

Coping Styles………..………………………………………..................13

Coping Styles and HIV/AIDS………..……………………..........15

Coping Styles of African Americans Dealing with Racism.…......19

African Americans Coping with HIV……………………….......21

Social Support and African Americans…………………………….........22

Kinship Networks……….………………………………….........27

Spirituality as a Coping Mechanism……….……………………...….….34

Purpose of the Study……….…………………………………................41

Research Hypotheses……….………………………………..…..41

vi
II. METHOD ……….………………………..............................…...........……..44

Exclusion Criteria……….………………………………….....................45

Informed Consent……….………………………………...................…..46

Design and Procedures…………………………………………......….…47

Registration and Randomization…....…………………….…...…47

Measures…………...…............…………………………….........48

The Profile of Mood States…...........……………….……48

UCLA Social Support Inventory………..............………..49

The COPE……...........….....……………………………. 49

Access to Community Resources Scale…....….................50

Principles of Living Scale...................…....…...................51

III. RESULTS.........................………………………………………………......52

Participants……...........……………………………………………….....52

Statistical Results.....……………………………………………………..54

Hypothesis 1……………………………………………………...54

Hypothesis 2……………………………………………………...56

Hypothesis 3………………………………………………...……57

Hypothesis 4…………………………………………………...…57

Hypothesis 5……………………………………………...………57

Hypothesis 6……………………………………………...………57

Hypothesis 7……………………………………………………...58

Hypothesis 8…………………………………………………...…58

vii
 IV. DISCUSSION.......……………………………………………….............….59

Summary of Results……………………………………………………...59

Hypothesis 1……………………………………………………...59

Hypothesis 2……………………………………………………...60

Hypothesis 3……………………………………………………...61

Hypothesis 4……………………………………………………...61

Hypothesis 5……………………………………………………...62

Hypothesis 6……………………………………………………...62

Hypothesis 7……………………………………………………...63

Hypothesis 8……………………………………………………...64

V. Conclusions...............................................................…………………............65

Study Limitations……………………....………………………...65

Clinical Implications……………………....……………………..66

Research Implications…………………....……………………....67

REFERENCES………………...………………………………………..........................70

viii
 LIST OF TABLES

1. Summary of Demographic Characteristics and Medical Status Analyzed by

Ethnicity.............................................................................................................................53

2. Results of Comparing African Americans to Whites in Living with HIV on Coping

through Spirituality, Social Support, Access to Community Resources, Satisfaction with

Social Support, Spiritual Beliefs, Cope Denial, Cope Behavioral Disengagement, POMS

Depression-Dejection, POMS Total Mood Disturbance, and Spiritual Growth….……...55

3. Correlations of Mood Disturbance among African Americans Living with HIV with

COPE Spirituality, Satisfaction with Social Support, Spiritual Beliefs, Access to

Community Resources, COPE Denial, COPE Behavioral Disengagement, and Level of

Completed Education………………..........................................................................…..56

ix
 1

CHAPTER I

LITERATURE REVIEW

The incidence of HIV (Human Immunodeficiency Virus) infection and AIDS

(Acquired Immunodeficiency Syndrome) among African Americans has been on the rise

throughout the population, regardless of sexual orientation. This group faces the double

stigma and discrimination of race and having a disease loaded with social

misunderstanding; both can pose barriers for individuals seeking medical treatment and

social support. Historically, African American communities have social mechanisms

within them that help members cope with crises and day-to-day distresses. Little research

has been conducted on what, if any, coping mechanisms are helpful for African American

individuals living with HIV or AIDS.

HIV/AIDS Incidence among African Americans in the United States

In order to examine the coping styles of African Americans with HIV or AIDS, it

is necessary to first understand the impact this disease is having on the African American

community. AIDS in the United States has primarily been perceived as a disease that

affects White gay men who have sex with other White men. Over the past decade, given

the growing infection rates in the heterosexual population, this perception has been

proven inaccurate. In particular, African Americans, who represent approximately 12%

of the population of the United States, account for over 50% of new HIV cases (AIDS

Epidemic Update, 2004). The alarming increase in incidence has pushed this disease into

epidemic proportion among African Americans in the United States.

 2

Since the onset of this epidemic, African Americans have consistently been

disproportionately affected, with this disparity continuing to increase (AIDS Epidemic

Update, 2004). Mirroring the White community, the primary method of transmission of

this disease among African Americans is through unprotected sex. However, unlike the

White population, African Americans present a larger percentage of HIV infections

arising from the sharing of needles during intravenous drug use. Unprotected

heterosexual sex presents the primary means of infection among African American

women, who make up 72% of new HIV diagnoses among all U.S. women (AIDS

Epidemic Update, 2004).

During the period of 1999-2002, the southern region of the United States reported

the largest proportion of AIDS diagnoses among African American women. Among new

HIV patients within the African American community, the highest rates were found

among women age 23-34 years of age (Epidemiology of HIV/AIDS among Non-

Hispanic Black Women in the United States, 2005). According to the Centers for Disease

Control and Prevention 2003 HIV/AIDS Surveillance Report, among African American

males, the primary infection pathways were 33% male-to-male contact, 16% injection

drug use, and 13% heterosexual contact (CDC HIV/AIDS Surveillance Report, 2004).

Among African American females the primary rates of transmission were dominated by

heterosexual contact at 42% with injection drug use at 37% and sex with an injection

drug user at 13% (CDC HIV/AIDS Surveillance Report, 2004).

 3

Stigma and Racism

African Americans who are HIV-positive are forced to face not only the burden of

their life-threatening illness but also the burden of their association with both minority

ethnic status and having a disease that carries a social stigma. This creates compounded

distress in their lives.

HIV Stigma

There is a common perception and belief that HIV is an illness that impacts

mainly minorities (Poindexter & Linsk, 1999), and sometimes groups on the fringe of

society such as drug users, sex workers, and gay men. According to Herek & Glunt,

“AIDS-related stigma” carries a deeper level of discrimination than normally experienced

by individuals facing other illnesses or social prejudices (1988). The stigma associated

with the HIV-positive diagnosis can affect a range of life domains, including family,

work, and health-care.

In a study on HIV-related stigma, Poindexter and Linsk (1999) interviewed 19

African American women who were caregivers to HIV-positive family members residing

in the Chicago area. These caregivers were recruited through fliers distributed in HIV-

related social and health agencies. From January to August 1996, individuals participated

in one-time, semi-structured, qualitative interviews regarding their perceptions of and

experiences with HIV-stigma. All interviews were open-ended and audio-taped. The

study focused on three research questions: 1) What is the evidence of HIV-related stigma

in this population of HIV-positive caregivers? 2) How did the experience of HIV-related

 4

stigma affect these caregivers? and 3) What are the connections between HIV-related

disclosures, HIV-related support, and HIV-related stigma?

The study found stigma was closely related to whether the HIV-positive patients

had disclosed their status to their families. For those who reported disclosure, the stigma

of being HIV-positive was felt immediately. The reactions ranged from no awareness of

discrimination to total ostracism by family and friends.

Six of the participants chose to “pass” as normal (not disclosing their HIV-

positive status) or present the illness as something else (such as cancer or pneumonia).

Eleven of the respondents who went to church reported they chose to withhold their

status from members of their congregation, including their pastor. It is likely that as

African Americans continue to believe they will be discriminated against due to their

illness, they will continue to choose the safer route of not-disclosing (Derlega, Winstead,

Greene, Serovich and Elwood, 2002). These findings suggest that even though African

Americans are heavily affected by this disease, talking about it publicly to even those to

closest to them, is still felt by many as being too risky.

Due to limited resources and access to health care, low-income African

Americans with any disease may find it difficult to keep up with the physical and

financial demands associated with making medical appointments and participating in the

medical system. When the social stigma of being an HIV-positive patient at a clinic is

added, some African Americans may feel that this is too much to bear.

This is borne out in Reece’s (2003) study that sought to discover strategies to

assist HIV-service providers in eliciting more effective ways to help their HIV-positive
 5

clients become more consistent in making their medical appointments for mental health

care. This study particularly focused on low-income, inner-city individuals who were

receiving their HIV-related health care from public health systems.

During the initial mental health assessment, participants completed questionnaires

that assessed demographics, physical health status, mental health status, health beliefs,

and perceived HIV-related stigma. Following the initial assessment, participants were

tracked to determine whether they returned for their initial therapy session. Those who

did not keep their initial scheduled appointments, who did not call to reschedule, or who

failed to show up to a rescheduled appointment within 30 days following the initial

assessment were considered to be “drop-outs.” The rate for these drop-outs was related

to four issues: a) ethnicity, b) perceived barriers, c) HIV-related stigma, and d) decreased

T-cell count.

Reece’s findings suggest that HIV-related stigma may prevent effective

communication with medical providers and, thus, compliance with medical treatments,

thereby reducing the likelihood of improvement in psychological functioning. Until these

factors are addressed in the social services model, HIV-related stigma may serve as an

invisible barrier that could detract from an individual’s physical health because patients

might present themselves for medical care only when an HIV-related health crisis

demands it.

Additionally, Valdiserri (2002) pointed out that assumptions can be made about a

person’s behavior that can impact the kinds of information given by health care

professionals and can influence the choice of treatment. For example, when assuming a
 6

male patient is heterosexual, the physician only offers information regarding sexual

contact with women. This limits the treatment or prevention options the patient is given.

HIV prevention efforts are also thwarted by assumptions and discrimination.

Myrick (1999) investigated HIV communication programs used to reach African

American men who have sex with men. He found that not only did economic

disadvantage restrict access to health care and limit the effective communication

programs that address prevention, but discrimination by sexual orientation and race did

so as well. He suggests that prevention programs be led by members of the target group

and in places where the group participants feel safe and welcome.

This research also identified another area of stigma. Many health facilitators feel

they work more effectively if they have an identified group whom they are treating; i.e., a

group of African American men who partner with other men or a group of African

American women who have sex with both men and women. This places a burden on the

participants of a group to identify their behaviors that will label themselves. This is

problematic because many fear being marginalized by their being placed in a category.

Also, some individuals may be very unsure or confused about their sexual identity and

are uncomfortable making a sexuality declaration one way or the other.

In addition, Myrick also points out that certain geographic areas require health

care programs specific to their region, but do not fit into any ethnic or cultural group.

People living in the South of the U.S., for example, tend to be very reticent about

sexuality in general and prefer not to talk about it. Discussions about sexual orientation or

HIV issues, therefore, are more difficult to initiate within some communities in the South.
 7

Moreover, Bottonari, Roberts, & Ciesla (2005) found in their study of White

HIV-positive males that adherence to treatment plans (keeping medical appointments and

taking medication as directed) can be affected by the perception of additional stresses.

When individuals also had depression or neurotic symptoms, they did not adhere to

treatment plans as well as when they did not perceive as much stress. Therefore, stigma

and discrimination can seriously impact treatment protocols for these individuals.

Stigma and Employment

Due to medical breakthroughs in the development of treatments for HIV-positive

people, the average life expectancy of persons living with AIDS has continued to increase

over the last decade (Walch, Lezama, & Giddie, 2005). Given this increased life

expectancy, many HIV-positive people are now part of, or, are re-entering the work-

force. Returning to the workplace may be very difficult for people living with HIV. It is

important to consider what some of the obstacles may be, and also what supports may

need to be in place to assist with their transition back into the work-force.

To assist with this process, Goldblum and Kohlenberg (2005) developed the

Client-Focused Model of Considering Work. The model consists of four domains

(medical, financial/legal, psychological, and vocational) that influence how well people

living with HIV return to work. The primary focus of the model is to emphasis that the

ultimate responsibility for making work-related decisions “rests solely with the client” (p.

116).

The model of Considering Work for persons with HIV has four phases:

contemplation, preparation, action, and resolution. In the contemplation phase, clients ask
 8

themselves, “Is any change feasible?” In the preparation phase, clients ask, “What kind of

change is best?” In the action phase, clients consider the question, “How do I achieve the

goal?” and in the resolution phase, they think, “Has the pressure to change resolved?”

The Considering Work Model provides a framework for persons living with AIDS to

consider options about returning to work and to develop a plan for returning to work

(Goldblum & Kohlenberg, 2005).

For HIV-positive people who are considering re-entering the work force, the issue

of disclosure almost inevitably arises. Many stresses come with this decision. Timmons

and Lynch-Fesko (2004) conducted a qualitative analysis of the experiences and work

needs of 29 subjects ages 25 to 57 who were HIV-positive. Recruitment was done

primarily through AIDS services through the Massachusetts Department of Public

Health. To gain the insights of individuals living with HIV/AIDS, participants

participated in one of four focus groups that shared their primary employment issues,

their reasons for working, barriers in their lives, and how they felt about receiving

support from state services. The duration of each focus group was 90 minutes.

The research findings revealed that employment, as such, was perceived as

valuable. Participants reported that employment served as a central source of “well-being

and dignity” (p. 5). Consistently across all four focus groups, participants stated that their

ongoing desire to work was associated not only with monetary benefit but also with

increased self-esteem and self-fulfillment. As one participant said:

You keep your mind distracted with work. It helps us rehabilitate ourselves in a

positive way. All of this contributes to the quality of life. It is always better to
 9

work. It is something that motivates you, which fulfills you, that actually [gives]

something in return. (Timmons and Lynch-Fesko, 2004, pg. 3)

For those individuals who were able to return to work, deciding whether or not to

disclosure their HIV-positive status at work became an immediate dilemma. Many

participants spoke about their experiences with discrimination or the uncomfortable

feelings they encountered in regard to their health status. One participant explained the

reason for his decision not to disclose at the workplace:

They called me in the office and they said...we really want to know so we can

help you...and get you the proper care and all that subtle stuff. But when it came

down to it... [they wanted to know] so that they could get rid of me. (pg. 5)

Another shared the fallout of disclosing his HIV status: "I noticed a big change in

their attitude towards me as far as the way they treated me. It was almost to the point of

being hostile at times, which I was surprised at" (pg. 5).

Given the emotional benefits that gainful employment confers on HIV-positive

individuals who desire to enter the work force, these findings suggest a preliminary

conclusion. Addressing the issue of work-place stigma, in particular, the negative impact

it can have on HIV-positive individuals’ psychological well-being is of paramount

importance.

Racism and African American Health

Historically, racism has limited the access to both medical care and psychological

health care for many African Americans. Moreover, racism itself may prove to have a

deleterious effect on the physical and mental health of many present-day African
 10

Americans. Sanders Thompson (2002) suggests the impact of racism may have created a

mental stress that may be unique to African Americans.

Williams and Williams-Morris (2000) defined racism as:

[An] ideology of inferiority in which population groups are categorized and

ranked with some being inferior to others. This often leads to the development of

negative attitudes and beliefs towards racial out groups (prejudice) and

differential treatment of members of these groups by both individuals and societal

institutions (discrimination). (p. 257)

Nevertheless, it is clear that African Americans do experience discrimination in

health care. Heslin, Andersen, Ettner, & Cunningham (2005) used multivariate analysis

to compare reports from 2,207 people with HIV with a survey of 404 physicians who

treated them, paying particular interest to race and ethnicity. Criteria of interest regarding

physicians dealt with the number of patients they saw with HIV-related illnesses and the

physicians having specific training in HIV/AIDS. Compared to Whites, minority

populations (African-American, Asian, Native American, First Nations, and Pacific

Island people) were less likely to have HIV specialists treat them on a regular basis. A

surprising result of this study revealed that Latinos were seen by more physicians with

HIV expertise than any of the other groups including Whites. The researchers could not

determine the cause for this, though it may be rooted in the interest in HIV-related

disorders among physicians in specific geographic areas that also had higher

concentrations of Latinos. This may also have been a factor in the locations where other

minorities sought medical care.

 11

In contrast, Schuster, Collins, & Cunningham (2005) studied a representative

sample of 2,466 HIV-infected adults in order to determine whether participants perceived

discrimination in the medical profession and what types of health care providers

displayed it. Of all adults, 26% reported being discriminated against, and 8% said that

they had been refused health care. Ironically, more Whites reported perceived

discrimination (32%) than African Americans (17%). The participants claimed that they

felt discrimination across all areas of the medical profession, with physicians (54%)

being the top offenders. Nurses and other clinical staff (39%), dentists (32%), and

hospital staff (31%) following closely behind. Case managers and social workers (8%)

were reported be the least offenders.

Shuster et al. (2005) suggest that some groups often under report their experience

with discrimination for several reasons. Individuals who experience racism frequently

may minimize their experiences with discrimination in order to preserve their personal

dignity. Some may avoid calling attention to it because it is unsettling. Others may also

feel shame and think they deserve what happened. Still others may attribute HIV stigma

and discrimination as being race related, being a woman, or being gay, lesbian, or

bisexual. Or, some individuals may have become so accustomed to or hardened against

discrimination in one form or another that they assume it is part of their daily experience.

Even so, Sellers, Caldwell, Schmeelk-Cone, & Zimmerman (2003), found

perceived racism to be associated with higher levels of distress (2003). Their research

focused on two facets of racial identity: the level to which participants identify their race

as a key component of their personality ("race centrality") and the extent to which the
 12

participants assessed others as having negative beliefs about their culture ("public

regard.") Compared to subjects who reported low and medium levels of centrality, Sellers

et al. (2003) found that participants who demonstrated high race centrality reported less

stress when faced with racism. This suggests that those African Americans who identify

positively with their culture utilize a form of coping that may be derived solely from the

security they find in identifying with being African American.

Siegel, Karus, Raveis, and Hagen (1998) investigated the psychological

adaptation among HIV-positive women by looking at whether the shift in level of

adjustment was based on race or ethnicity. Their findings support the common belief that

minority women living with HIV/AIDS are likely to be at high risk for experiencing

difficulty in adjusting to their illness due to social economic status (Gurung, Taylor,

Kemeny, & Myers, 2004; Jenkins & Guarnaccia, 2003).

On the other hand, Siegel, Schrimshaw, and Pretter (2005) suggest that African

American women with HIV experience more perceived personal growth from coping

with their illness. They conclude that this may be because these women have had

multiple stressors in their lives, including discrimination, and therefore have strategies in

place in order to cope with difficulties in life.

Looking at communication pathways and coping strategies in context with

ethnicity and community behaviors is necessary for developing effective HIV prevention

and treatment programs. Croteau, Nero, & Prosser, as early as 1993) called for the need

for a culturally-sensitive approach to HIV prevention programs. They recognized that

negative misinformation about sexuality within minority groups (specifically African

 13

Americans, Latinos, women, and gay and bisexual men) were barriers to HIV prevention

programs. In addition, misconceptions about HIV and AIDS along cultural lines among

these populations also were barriers to effective behavior change. If an individual was a

member of more than one of these groups (e.g. an African American bisexual woman),

this created even more difficulties for these individuals because there were multiple areas

for possible discrimination (i.e. being a woman, being gay, and being African American).

This has spurred community health agencies to create ways to target minority

populations. In 2005, the LA County Department of Health Services, the Office of AIDS

Programs and Policy, and the UCLA Center for HIV Identification, Prevention, and

Treatment Services hosted a two-day symposium that addressed HIV prevention

programs for Latino and African American gay and bisexual men. In the framework that

social biases were barriers to access to accurate health care information, the symposium

concluded that HIV prevention programs need to frame their messages in the social

context of the cultural groups they wanted to serve. They also needed to bring this

message directly to their target population and in a manner that was respectful and

appropriate to that community (Brooks, Etzel, & Hinojos, 2005).

Coping Styles

Richard S. Lazarus’ book, Psychological Stress and the Coping Process (1966),

was, in large part, responsible for establishing a contextual way to research stress and

coping (Folkman & Moskowitz, 2004). Before this, most research related to coping

focused on pathology, and answers to these pathologies were sought out in the
 14

examination of the unconscious (Folkman & Moskowitz). Lazarus (1966) opened the

field by examining coping processes beyond those used as a defense mechanism. He

looked at how such strategies are used by everyday people to manage the stresses of day-

to-day living. His model consisted of three distinct processes: primary appraisal

(becoming aware of a threat to oneself), secondary appraisal (initiating a solution to

handle the threat), and coping (carrying out the solution to eliminate the threat) (Carver,

Weintraub, & Scheier, 1989). The solutions in the secondary appraisal varied with

individuals.

Folkman and Lazarus (1980) further refined these coping strategies around their

own definition, which was “cognitive and behavioral efforts to manage internal and

external stress” (p. 222). It used both problem-focused coping and emotion-focused

coping. Problem-focused coping was defined as “behavioral management of the external

stimuli in the individual’s environment and may include creating new techniques” (p.

222). These new techniques were seen as developing new solutions or learning new

skills. Emotion-focused coping was considered “regulating of internal conflict, which is

often generated by the individual’s belief that he or she is powerless to a situation” (p.

222). This form of coping permits avoidant behaviors. Each style of coping is constantly

available; however, which one becomes activated is driven by the context and mental

assessment from the individual’s threat appraisal (Simoni & NG, 2000).

Brown and Nicassio (1987) added another dimension to coping styles research by

identifying them as passive or active. Passive coping styles are present when individuals

surrender their control to others. In contrast, active coping styles involve a direct attempt
 15

by the individual to play a more active role in dealing with a problem (Brown &

Nicassio).

Coping Styles and HIV/AIDS

To explore the effectiveness of stress and coping on adjustment to HIV/AIDS,

Pakenham and Rinaldis (2001) posited that the positive impact of stress-buffering as a

coping tool would be revealed through their study. They also sought to support the

position that when faced with a high-threat appraisal, an individual will be shielded

against elevated levels of stress by being able to call actively upon their coping strategies

and resources (Finney, Mitchell, Cronkite and Moos, 1984). In addition, they focused on

the extent to which the HIV-related problem provided potential for personal growth,

personal challenge, or the strengthening of a relationship. One hundred and fourteen

HIV-positive gay or bi-sexual men (80% were White) were interviewed to obtain

demographic information, current health status, and HIV-testing history. The participants

were then given a series of self-administered questionnaires. The Illness Parameters Scale

was used to assess the number of HIV-related symptoms participants were experiencing,

and the social support measure for research in HIV/AIDS (Zich & Temoshok, 1987) was

used to obtain a measurable score for each participant’s level of coping resources. To

assess coping strategies, the researchers administered the Ways of Coping Checklist-

Revised (Vitaliano, Maiuro, Russo, & Becker, 1985), asking participants to indicate on a

five-point Likert scale the level at which they had relied a specific coping strategy over

the past week in order to cope with an identified HIV-related problem on the HIV-
 16

problem checklist. In addition, the Life Orientation Test (Scheier and Carver, 1985) was

used to measure optimism.

The study also used a model which defined levels of appraised challenge. It

explored the quality of an individual’s adjustment to a chronic illness across seven

domains (psychological distress, health care, work, sexual relations, and extended family,

social and domestic activities). Regarding appraised challenge, (Pakenham & Rinaldis,

2001) found that the manner in which subjects faced their illness served as a predictor of

how well they would adjust. The more perceived controllability (the extent to which the

identified problem could be changed or endured) was associated with better physical

health.

Pakenham and Rinaldis (2001) also found that individuals who reported utilizing

a passive, avoidant coping style presented with higher levels of depression and global

distress, while those who relied on a problem-focused coping style had less depression. In

addition, problem-focused coping was shown to have a relationship to lower levels of

depression, and optimism was found to be an effective stress buffer on social adjustment

to living with HIV/AIDS.

Though their results showed some correlation between social support and fewer

incidences of depression and better adjustment, they were surprised by one finding. Their

evidence did not reveal support for the buffering effect of social support. Pakenham and

Rinaldis (2001) argued that this may be a flaw in Zich and Temoshok’s instrument

because it did not speak to areas of social support specific to HIV/AIDS. Pakenham’s

previous research (1998) found that emotional support was identified most as being
 17

helpful. Even so, Pakenham and Rinaldis (2001) removed two seeking social support

items from the Ways of Coping Checklist-Revised, which may or may not have provided

evidence for the positive effects of social support, Nevertheless, they urged clinicians to

use stress management strategies, including social support.

In contrast, two studies by Jenkins and Guarnaccia (2003) developed measures of

concerns and coping with anticipated or actual HIV infection do support the value of

social support. In Study I, 270 anonymous HIV test clients were recruited from a county

health department. Of the sample, there were 106 gay/bisexual men, 97 heterosexual

women, 65 heterosexual men, and two lesbian women. This sample was dispersed across

race with 86% Caucasian, 8% African American, 5% Hispanic, and 1% other ethnicities.

To cross-validate the scales, Study II was conducted at a private (not state-

funded), self-identified, gay community HIV clinic. These participants were 123

gay/bisexual men and 24 lesbian/bisexual women, with 58 heterosexual women and 19

heterosexual men. Across racial groups, they were 87% Caucasian, 6% Hispanic, 3%

African American, and 3% from other ethnicities.

In both studies, participants completed a questionnaire that asked them to

anticipate their responses if they were to have a sero-positive result on an HIV test. The

results found gay/bisexual men were more likely to utilize support from the gay

community than to rely on a larger, broader support system. Heterosexual men were the

least likely to seek out any type of support.

A study of women, Gurung, Taylor, Kemeny, and Myers (2004) supports the

inefficacy of social support. These researchers followed 350 African American, Latina,
 18

and White women over a six-month period to assess the relationship among HIV status,

socioeconomic status, and chronic burden to depression over a period of time.

Specifically, they examined the moderation of these effects by psychological resources

(e.g., social support, optimism, and coping style). Gurung et al. found none of the

psychological resources utilized by the participants, such as optimism, social support, and

coping, were shown to be helpful in lessoning the effects of the chronic burden of being

HIV-positive and the depression associated with it.

These findings are troubling because they suggest that there may be some

segments of the population that does not seek or will not seek social support or for whom

social support does not buffer stress. Since neither of these studies was designed to look

for racial disparities among their findings, further research is necessary in order to

examine what supports African American men, especially heterosexual males, utilize to

determine how community organizations, clinicians, and family members could be better

able to support them.

Other research has revealed the ability of coping styles to inhibit or help with the

adaptation to living with the HIV virus (DeMarco, Ostrow, & DiFranceisco, 1999;

Gurung, Taylor, Kemeny, & Myers, 2004). Stein and Rotheram-Borus (2004) explored

coping styles of youth living with HIV. Conducted over a 21-month period, 393 young

people living with AIDS were recruited from their adolescent clinical care site located

within one of four AIDS epicenters: Los Angeles, New York, San Francisco, and Miami.

The mean age of the participants was 21 years, from a pool ranging from 13 to24, with

25% identified as African American, 20% as Caucasian, 4% as Asian, 37%, as Hispanic

 19

American, and 14% who did not identify any one specific racial/ethnic group.

Researchers conducted two baseline assessments at three-month intervals.

Passive coping was found to be associated with poor adaptation to the illness.

Environmental stressors (e.g., low socioeconomic status) had an impact on concurrent

AIDS symptoms, signs of depression, and an escapist coping style. Adolescents who

reported a higher level of self-esteem were more likely to use a more active coping style.

In a previous study, Simoni and Ng (2000) examined the relationship between early

trauma and the coping styles and psychological adjustment of women living with HIV

infection. They found, like Siegel et al. (2005), that dealing with a prior life trauma

influenced how these women handled the stress of being HIV-positive, not necessarily in

positive ways. For example, since poorly educated, underemployed HIV-positive

individuals were more likely to rely on an avoidant coping style, these subjects showed

higher levels of depressive symptomology. This research is compelling in regard to

populations that historically have experienced trauma because of discrimination, racism,

or oppression.

Coping Styles of African Americans Dealing with Racism

Though certain coping strategies are activated to address the insults and injustices

from racism, the specific types of coping responses that are activated are not always

clear. Plummer and Slane (1996) uncovered that for African Americans it did not matter

whether they used a problem-focused or emotion-focused coping strategy. They did find

overall that fewer coping skills were used when dealing with racial stress compared to

when dealing with general stress.

 20

The promotion of problem solving skills in the African American community may

help to reduce racism-related stress and may also serve to foster mental well-being

(Barnes, 2005). To help determine which specific coping strategies African Americans

use when confronted with racism, Shorter-Gooden (2004) conducted a qualitative study

to examine how African American women cope with racism and sexism. The study

included 196 participants drawn from a larger study of 333 African American women

who participated in the African American Women’s Voices Project. The African

American Women’s Voices Project was a qualitative study that examined African

American women’s experiences and perceptions of racial and gender stereotypes, bias,

and discrimination (Jones & Shorter-Gooden, 2003).

The participants were selected from a larger sample and were included because

they indicated they had experienced both racism and sexism. The participants’ ages

varied between 18 and 77, with a median age of 38. The group was highly educated with

94% having attended some college.

The study found African American women appear to use a spectrum of coping

styles to address sexism and racism. When it comes specifically to discrimination,

African American women were found to use three specific coping strategies: role flexing,

avoiding, and standing up and fighting back. They also used three specific internal

resources: resting on faith (the belief that God will take care of the problem), standing on

faith (the active process of carrying out actions with the belief that God is supporting

what they do), and valuing oneself. These internal resources, when combined with

leaning on the shoulders of others, were found to be particularly helpful tools in coping
 21

with discrimination. These tools appear to serve as a “cushion against what may feel like

an unassailable foe” (Shorter-Gooden, 2004, p.420).

In contrast, a study by Utsey, Ponterotto, Reynolds, and Cancelli (2000) identified

a relationship between avoidant coping styles and low self-esteem. Utsey et al.(2000)

suggest African Americans who prefer an avoidance coping style to deal with racist

confrontation do so out of “the intensity of ego threat produced by such personal

experiences” (pg.79). These findings suggest the greater the extent that individuals are

confronted with and avoid racism, the more likely they are to develop a maladaptive style

of dealing with the stress of racism, thereby resulting in a lowering of self-esteem.

African Americans Coping with HIV

Little research has been conducted specifically about how African Americans

cope with HIV. One study by DeMarco, Ostrow, and DiFranceisco (1999) set out to

examine the impact of detachment versus involvement coping on distress within a

racially diverse sample of gay men with and without HIV. The study gathered data from

297 self-identified gay men (215 were White and 82 were African American); 103 of the

participants were HIV-positive. The researchers focused on the impact of stress,

appraisals of control, coping, and physical symptoms on emotional distress within the

participants. DeMarco et al. (1999) found physical symptoms had a greater impact on

depression among White men compared to African American men. Stress was related

more closely to a detachment style of coping for African American men as compared to

White men. AIDS-specific stress was associated with greater distress and elevated use of

detachment among both African American and White men.

 22

To examine how African American families cope with having a family member

with HIV, Martin, Wolters, Klaas, Perez, and Wood (2004) examined coping strategies

among families of HIV-infected children and how these strategies relate to medical,

central nervous system, and family environmental factors. To measure family coping,

Martin et al.(2004) used the Family Crisis Oriented Personal Evaluation Scale (F-

COPES), a 30-item measure that accesses problem-solving and coping strategies of

families who are facing difficult situations. The F-COPES has five sub-scales that are

measured on a five point Likert scale (with “1” connoting “strongly agree” and 5

connoting “strongly disagree”). The five subscales are: Acquiring Social Support,

Seeking Spiritual Support, Reframing, Mobilizing Family Support, and Passive

Appraisal.

Martin et al.(2004) found the most frequently utilized coping strategies of the

families in their study were passive appraisal, reframing, and spiritual support. This study

is ground breaking in that it helps understand how African American families come

together as a network to support their HIV-positive family members.

Social Support and African Americans

Extended family and support networks have long served as the backbone of the

African American community. For African Americans living with HIV/AIDS, support

networks assume a role of even greater importance. This is especially true when the

patients come from a low economic background or have limited resources to cope with

their disease. For African Americans living with HIV/AIDS, several new stressors have
 23

to be addressed. These stressors include maintaining positive mental health, developing

problem-solving skills that will assist the patients in getting proper medical care and

access to services, and developing and maintaining a social support system on which they

can rely as they learn to cope with their life-threatening illness (Wilson & Tolson, 1990).

For many with HIV/AIDS, the people in their social support network may

influence the frequency the patient seeks consistent medical treatment. In a study

conducted by Knowlton, Hua, and Latkin (2005), the researchers set out to identify forms

and sources of social support that were associated with medical services utilization within

a medically under-served population of former and current intravenous injection drug

users living with HIV/AIDS in Baltimore, Maryland. Of the 295 African American

participants, nearly 34% were female. Participants were instructed to complete a battery

of questionnaires to develop a service use outcomes category. The study used a network

analysis to map the relationship between the participants and their social supports to gain

a comprehensive perspective on medical service use patterns for the HIV-positive

population in the Baltimore area.

The study found having more female members within their support networks was

significantly and positively related to the frequency with which participants consistently

visited a medical care provider. In fact, 57% of members of each support network was

female, with over half (52%) being family members. Moreover, each additional female

member of a support network increased the likelihood a participant would use medical

services by one fourth. In addition, participants reported that members of their support

networks provided emotional support (57%), financial assistance (58%), physical help
 24

(60%), and health advice (31%). Over half (56%) of the participants reported having a

consistent sex partner, whom they perceived as being supportive. Interestingly, having a

supportive sex partner was not found to be related to the participants’ access to medical

care.

Knowlton et al.(2005) suggest their findings represent "culturally normative care-

giving roles" for African Americans; i.e., that this group’s social support networks are

comprised mainly of women who provide emotional, instrumental, and monetary support.

These findings suggest emotional support plays a great part in the healthcare-seeking

attitudes of African Americans and, more importantly, it suggests the greater the amount

of emotional support the patient receives from females and kin, the more likely the

patient is to seek out proper HIV/AIDS health care.

Knowlton et al.(2005) also point out that males in African American families

have not been socialized to care giving roles as women have been. For this reason, they

speculate that neither men nor women seek them first when building their support

networks.

Nevertheless, social support can influence many areas of peoples’ lives in

negative ways. Cohen and Willis (1985) posited that social support can exert a positive

influence to help buffer individuals who are experiencing distress. For example, if

researchers examined low socioeconomic status as a stressful life experience, the

buffering hypothesis would posit having social support will serve to deflect the negative

impacts of low socioeconomic status. Bloor, Sandler, Martin, Uchino, and Kinney (2006)

conducted such a study to evaluate the associations between the access and adequacy of
 25

emotional support and the health-related quality of life among African Americans and

Whites, and individuals with varying socioeconomic status. Eight hundred and fifty-one

participants who resided in the suburban and rural North Carolina area were in the study.

Socioeconomic and psychosocial data was collected during face-to-face interviews that

where conducted in participant homes by trained research assistants.

A positive relationship between the availability of emotional support and physical

health-related quality of life was reported for Whites overall and also for Whites of lower

educational status and African Americans who had higher educational backgrounds. One

interesting and unexpected finding was that among African Americans with lower

educational backgrounds, emotional support was not found to be beneficial to their

mental health. Furthermore, for African Americans overall, having access to greater

emotional support was correlated with poorer understanding of their physical health.

Bloor et al.(2006) suggest the more people in one’s social network, the more

social pressure one may feel to follow the advice of others. In addition, the more people

giving advice the more difficult it becomes for the individual receiving the advice to

make a decision about what to listen to and what to ignore. The researchers point out that

there appears to be a social pressure that comes from having an abundance of support.

Ultimately, if support is given then ignored, the person receiving the support will have to

face the possible repercussions from those in their support network that may feel

disregarded. In these instances, social support appears to be a negative coping tool.

Even so, social support can play a positive role in the mental health and sexual

practices of HIV-positive African Americans. Serovich, Kimberly, Mosack, and Lewis

 26

(2001) conducted a study to examine the mental health outcomes of 24 HIV-positive

women (54% were African American) in relation to their perceptions of the social

support of family and friends. The study’s results echoed a previous study of homosexual

men (Kimberly & Serovich, 1999). That study found that gay men, who believed their

family members to be supportive, expressed an intention to practice less risky sexual

behaviors, and the more supportive family members homosexual men had, the more

likely they would follow out their intentions. Serovich et al.(2001) found women who

perceived they had positive social support had better mental health and were less likely to

participate in risky behaviors. Though women perceived friends as more important than

family, kinship support appeared to be more predictive of mental health; e.g., not feeling

lonely and reduced depression and stress (Serovich et al. 2001). These findings are

important because to the majority of HIV-transmissions result from unprotected sexual

contact.

Another area where social support is a factor is problem solving skills. Whitfield

and Wiggins (2003) conducted a study to examine whether measures of social support,

when combined with health status indicators, serve as predictors of how well African

American adults solve everyday problems. They also wanted to see if the relationship

between social support and everyday problem-solving skills is mediated by physical

limitations. Using data collected for the Baltimore Study on Black Aging in 1997, which

consisted of 249 elderly African American participants who lived either in the

community or in senior high-rise apartments and recruited through churches, senior

citizen homes, and foster-grandparent groups in the greater Baltimore, Maryland area,
 27

Whitfield and Wiggins (2003) applied step wise regression on the variables of

demographics, health, physical limitations, social support, and results of the Everyday

Problem Solving Test (Willis, Jay, Diehl, & Marsiske, 1992). To assess social variables,

a social support scale was drawn from the National Survey on Black Americans (Taylor,

1985), measuring the degree to which friends, family members, and others provide social

support to the participant and how much the individual gives out to others.

Whitfield and Wiggins (2003) revealed those individuals who provided greater

social support to others possessed higher levels of problem-solving skills. These findings,

coupled with those of Knowlton et al.(2005) and Serovich et al.(2001), suggest that

elderly African Americans, especially older women, in an individual’s social support

system are important to positive mental health outcomes for both the giver of social

support and those receiving it. For HIV-positive African Americans, social support can

be a primary component that influences the quality of life, physical well-being, mental

health, and the progression of the virus.

Kinship Networks

In America, the African American family is made up of nonspecific and diverse

extended family structures. Often consisting of both blood-kin and non-blood-kin

members, these family systems are typified by frequent interactions that manifest as

“social, emotional, and functional kinship networks” (Wilson & Tolson, 1990, p. 350).

Kinship networks have served the African culture since the time before slavery.

The family kinship patterns of today’s African American families can be traced to the

societies of West Africa and were continued in the United States (Gutman, 1976).
 28

African children were viewed and valued as an investment in the future (Scannapieco &

Jackson, 1996). To Africans, children were part of their mortality. Children were

cherished as gifts to carry on ancestral knowledge from one generation to the next. In

these traditional societies, there was no concept of illegitimate children (Scannapieco &

Jackson, 1996).

Even today, the importance of extended family is vital for the existence of the

family in other regions of Africa. Al Awad, El Hassan, and Sonuga-Barke (1992) studied

children in Khartoum, the capital of Sudan in East Africa, comparing those living in the

more Westernized family construct of a nuclear family and those in more traditional

multigenerational family. Despite the positive implications modernization, these

researchers found those children living in small nuclear families were over-dependent,

didn’t take care of themselves as well, had more sleep difficulties, and presented more

emotional and conduct problems. They also were less likely to have grandmothers as part

of their lives. Having involved grandmothers, serving as advisors to mothers, sources of

social support, and agents of socialization, was considered to be the most important factor

in normal social and emotional adjustment.

Further, the researchers conclude that social life in any traditionally-based culture

is informed by interdependence within the community at large and the relationships

within intergenerational kinship groups. These factors influence social conformity, which

is based more on feeling a part of the community and loyalty to the family. “In extended

families, the physical proximity, emotional intimacy, and (grand-) parental authority are

consistent with these ideals” (Al Awad, El Hassan, & Sonuga-Barke, 1992, p. 913).
 29

Without a doubt, the slave trade and the enslavement experience temporarily

destroyed these traditional African kinship patterns in America. Yet, the new patterns that

were created by the enslaved Africans still focused on kin and non-kin relationships,

which generated, in turn, non-blood relationships that were just as strong (Scannapieco &

Jackson, 1996). In antebellum America, the extended family was the central family unit

which served as the connection point for the community as a whole, and children became

the responsibility of the community (Martin & Martin, 1983).

Today kinship networks play an important role in the African American

community, especially in the lives of African American youth. Winston’s (2003)

interviews of ten custodial relatives (9 grandmothers and an aunt) of children whose

parents had died from AIDS revealed two predominant themes: Family and spirituality.

These relatives made sacrifices to raise children that were not their own because they felt

the children needed to be cared for by family members, not by foster homes or agencies.

This concept that the family is central to everything reflects the deeply rooted traditional

kinship system that made it possible for the African American family to survive and

retain its unique identity through slavery, racism, and economic oppression. Equally

important was having a spiritual relationship with God that supported and sustained these

grandmothers. Prayer and church services were sources of strength and survival.

In another study, Taylor (1996) examined the association between kinship

support, family management practices, and adolescent adjustment in African American

families. The study surveyed 155 African American adolescents (58 male, 97 female)

ages 14 to 19 years-old in a public high school in a large northeastern city. Seventy-six

 30

(49%) came from one-parent homes headed by the biological parent, most often, by the

mother; and 20 (13%) were from other family arrangements, e.g. living with relatives, in

foster care settings, or living with friends. Kinship social support was determined by a

measure developed by Taylor, Casten, and Flickinger (1993) that assessed the

adolescents’ perceptions of social support from their families in the domains of advice,

socializing, problem-solving, and counseling.

Taylor et al. (1996) found that kinship support influences the family climate and

also the specific practices in which parents engage. The study’s findings suggest that the

more adolescents perceive their families as relying on the kinship network for structure

and support, the more those young people perceive the homes they live in as organized

and their parents as involved in their education. Conversely, the study also indicated that

the more adolescents perceive their families as independent and existing outside of a

kinship network and family members as not reliable, the more the adolescents reported

high levels of psychological distress. This suggests that kinship networks continue to

serve as a highly effective coping tool for the African American community.

Woods’ (1996) research of American Indian, Japanese, and African American

grandmothers revealed the importance of extended kin within African American

households. The presence of grandmothers living in the same home with their young

daughters who were raising a child was found to be positively related to the child’s

mental health and behaviors, presumably because of the opportunities the grandmother

had to model effective parenting.

 31

This is finding has profound implications because in the United States between

1980 and 1990, the number of children living in households with grandparents or other

kin increased by 44% (Saluter, 1992). A third of these homes did not have either of the

child’s parents present. Furthermore, in 1997, there were 2.3 million grandmothers

raising grandchildren (Lugaila, 1998). Census data collected at the same time shows that

13.5 % of children lived with a grandparent or other family member. There are a number

of reasons for the increase in these numbers, including parental incarceration (Dressel &

Barnhill, 1994), substance abuse (Kelly, 1993; Minkler, Roe, & Price, 1992), mental

illness (Dowdell, 1995), homicide (Kelly & Danato, 1995), or AIDS (Joslin & Brouard,

1995; Winston, C., 2003).

Particularly as AIDS deaths increase, family networks will be necessary to care

for children whose parents have died. Non-parent custodial care, especially for aging

African American grandmothers, has complications. Cox (2002) work with a program

that sought to empower custodial grandparents in African American households revealed

that many grandparents do not tell their grandchildren or discuss with persons outside of

the more intimate family members the fact that their child died of AIDS. Many of the

grandparents were also conflicted about their own reactions to the disease, though they

gladly stepped in to raise their child’s own children. This finding was echoed in

Winston’s (2003) qualitative study of ten African American grandmothers who were

raising their grandchildren orphaned by AIDS.

In addition, many African American grandparents seek help first within their

extended kinship networks and then to neighbors and friends, the church, and last to
 32

mental health centers, crisis intervention programs, and medical facilities. They also

demonstrate distrust for institutions, specifically government agencies (Winston, 2003).

This has implications regarding the access to mental health and medical resources within

the community for African American grandparents and others in the kinship network.

Nevertheless, there may be a new dynamic forming within the African American

extended family. Barer (2001) in interviews of 96 African American grandmothers 85

years old or older over a six year period found a significant change within the African

American community. Because of the prevalence of senior housing, social security

benefits, geographic mobility, advanced age, and mobility issues, these grandmothers

were not as involved with their families as those in other generations. Senior housing

restrictions that limit who can stay overnight in a residence are curbing young family

members from moving in with a grandparent or great grandparent. In fact, Barer (2001)

reported that some of the grandmothers feared that other residents would complain about

noise if children even visited for an afternoon.

Having social security benefits also makes these elderly women less dependent on

their families for financial help but also makes them targets from dependents who need or

want money from them. Families are also spread out and not concentrated in the same

part of the city or even the same state. This makes it difficult for grandparents to keep

close ties to family members or even identifying whose children are whose within the

extended family. Finally, Barer (2001) noted that advanced age creates health and

mobility problems, making it even more difficult to visit family.

 33

Still, the support of extended family is important to African American families

and serves as a safety net when individuals do not have access to other sources of

financial, physical, or emotional assistance. Its usefulness as coping tool for HIV-positive

African Americans may be crucial to positive adjustment outcomes or the ability to

manage the disease.

Notwithstanding, there are indications that African American men are reluctant to

use social and familial networks for support because it may appear as a lack of strength.

This was especially true for older men. Mattis et al.(2001) studied 171 well educated,

African American men living in an urban environment to determine whether they shared

emotions or exchanged advice with male or female friends. Their findings indicated older

men (35-79) were less likely to share feelings or give advice to friends, regardless of

gender, whereas younger men (17-34) were more open to sharing feelings, giving advice,

and expressing vulnerability. Mattis et al.(2001) indicate contemporary young men have

“a greater range of acceptable gender role identities than men did in the past” (p. 228).

This may prove insightful in designing new programs for therapy or access to social

support and community resources.

In addition, African American men of any age who have sex with men may not be

taking advantage of familial or social support. Gant and Ostrow’s (1995) study of 17

African American and 16 White men who had been diagnosed with HIV but were

asymptomatic supported other studies that said that African American men did not seek

out or find material support from their social networks, especially their families, and not

from the gay community. This is in contrast to their White counterparts who looked
 34

toward the gay White male community for support (Friedman, Sotheran, &Abdul-

Quader, 1987).

Gant and Ostrow (1995) posit several reasons for this finding, including

suggesting that the measures in their study may not have been sensitive to the kind of

emotional support these men needed. They speculate that all of the participants were

asymptomatic and perhaps did not see a need yet for additional support. This would be in

keeping with the model of strength and independence that is fostered within the

traditional African American family. In addition, the researchers suggest that African

American men who have sex with men may not want to be labeled as gay or bisexual and

therefore do not seek support from the gay community. They also may feel marginalized

because of their race. More importantly, though strong kinship networks are important to

them, African American men who have sex with men may fear repercussions from those

close to them because of the behaviors that led to their illness.

Regardless, kinship networks and social support are intertwined with African

American life. Extended family, like the presence of religion, has been a constant and

important coping tool in times of adversity and for daily stresses.

Spirituality as a Coping Mechanism

Since the middle passage (the two-month voyage across the Atlantic that African

slaves were forced to endure inside the bowels of save ships headed to the Americas),

African Americans have used spirituality and religion as a means of coping to face the

challenges of living. For African Americans with HIV, spirituality can serve as a primary
 35

coping tool that has long standing cultural roots. The term spirituality refers to an

underlying religious presence in one’s everyday life that is not directly influenced by a

structured or organized institution (Levin, 1996). Religion is a structured organization of

spiritual beliefs.

The importance of religion and spirituality was supported by Mattis et al.(2001)

when they examined whether religion and spirituality was important in the lives of

African American men 17 to 79 years old. Their findings clearly indicated spirituality and

religion were important factors throughout every age group. However, younger men (17-

20 years old) and older men (35-79) were somewhat more religious. Moreover, religion

helped shape the younger men’s (17-34) positive relationships with other men.

In a more in depth study, Wallace and Bergeman (2002) theorized that both

religiosity and spirituality can be utilized as tools which individuals activate during times

of stress to assist in coping with and in adapting to unwanted changes in life. The study

assessed two key terms: a) protective factors and b) reserve capacity. The term

“protective factors” refer to psychosocial and biological factors that guide one’s early

childhood development (Werner, 1990). “Reserve capacity” refers to the latent potential

(what Wallace and Bergeman call the “core of strength”) we hold in reserve and tap into

when adversity arises, which helps individuals regain their center and move toward an

adaptive level of coping with stresses (Baltes, 1987).

From recorded personal accounts of seven African American women and three

African American men, Wallace and Bergeman (2002) drew significant themes from the

data, using thematic analysis and categorization. Religiosity and spirituality to some
 36

extent informed the participant’s sense of self, fueled the need to serve others (to give

social support), was a significant means of coping with adversity, and needed to be

expressed throughout the lifespan. The participants also revealed that religion gave them

a sense of purpose, and the understanding of that purpose added meaning to their lives. It

also allowed them to feel a sense of hope and therefore some control over their lives even

in the face of discrimination, ill health, or their families’ problems. This study, however,

did not explore the deeper and more personal, but harder to define and measure, concept

of spirituality and its varied expressions in peoples’ lives.

Nevertheless, for many African Americans, spirituality serves as a foundation

from which they can launch into an unpredictable and sometimes unsafe world. Many

African American elders pass on useful tools to young people through spiritual tales to

help socialize the youth in their community. In an ethnographic study titled, “Gathering

the Spirit,” Haight (1998) summarized research that describing the beliefs of African

American adults at a particular Baptist Church about how African American children are

taught and socialized in Sunday school. They also examined how this coping style was

later used to develop an intervention to foster resilience in African American children.

An example of the use of storytelling was described by Mrs. H., a member of the

congregation. She recounted an experience with racism as a little girl in which she and a

group of her friends were called names. Mrs. H related the story to her mother and asked

why people hated people of their race. Her mother turned to stories in the Bible as she

always did whenever adversities occurred and began to teach her about the dangers of

hate. Ultimately, Mrs. H. realized she and her friends were not the victims in this
 37

interaction; her tormentors were the victims, because when people hate, it destroys the

spiritual part in them. According to Haight (1998), spiritual storytelling such as this is

how many African Americans teach resilience to children, either at home or at church.

For African Americans, spirituality continues to serve as a support throughout life

and is neither limited to nor called upon only in certain life experiences. Mattis (2002)

examined the religious/spirituality styles and modalities utilized by African American

women to cope with adversity. Twenty-three African American women were randomly

selected from a convenience sample from a larger study of 123 African American women

who participated in a survey of stress and coping. The study revealed eight non-

overlapping themes that helped to elaborate the role of religiosity and spirituality in the

process of finding meaning and coping. The results suggest that religion/spirituality help

African American women to a) interrogate and accept reality, b) gain the insight and

courage needed to engage in spiritual surrender, c) confront and transcend limitations, d)

identify and grapple with existential questions and life lessons, e) recognize purpose and

destiny, f) define character and act within subjectively meaningful moral principles, g)

achieve growth, and h) trust in the viability of transcendent sources of knowledge and

communication. Participants reported that when faced with confrontations that left them

feeling “fragmented,” they were able to use their spirituality as a coping tool to "maintain

psychological integrity" (p.312).

Religion and spirituality are also important to African American men. Herndon

(2003) sought to examine how spirituality assists African American college males in

handling the stress they experience on predominately White college campuses. Often
 38

African American men on these campuses must seek out support from resources that are

more likely to be found off campus and that often are of a spiritual nature and likely

include religious practices.

One of the themes the study identified was that, for many, spirituality bolstered

resilience to stress, not only in academic life but in coping with racism. Participants

reported their faith and spirituality served them as a source of motivation to remain in

college. Spirituality and religion also provided a sense of purpose, direction, and focus on

daily tasks and goals. In addition, participants reported churches and the support

networks within them were extremely helpful to them as encouragement to stay in school

and to cope with the burdens of their academic load and otherwise social isolation

(Herndon, 2003).

Though the church is a cornerstone of African American spirituality, it is not the

only source of support and spiritual strength. Walls (1992) surveyed 98 African

Americans, age 65 to 104, recruited from African American churches in an urban area of

Pennsylvania. Participants indicated family members provided more emotional support

than their churches, but sought out church resources for instrumental support. Findings

also showed participants perceived church support as contributing to their feelings of

well-being. Walls (1992) also saw the potential for African American churches to

develop or implement health and wellness programs.

Croteau et al.(1993) agreed that the church was a natural gathering place for

health programs including those for HIV prevention programs. However, earlier

researchers (DiClemnet & Houston-Hamilton, 1989) saw churches as ineffective

 39

locations because members of the community did not think of churches as places that

would disseminate medical or health information. In truth, churches have been ideal

locations for health fairs, cancer screenings, and other awareness programs.

This has implications for African Americans with HIV/AIDS. In a highly relevant

study of issues around HIV-positive African Americans and coping styles, Coleman

(2003) conducted a qualitative descriptive study to examine the relationships across

spirituality, sexual orientation, mental well-being, and aspects of overall health status.

The subjects in the study were made up of 117 HIV-positive African American men and

woman. Due to the history of secrecy and prohibited disclosure of homosexuality within

the African American community, Coleman hypothesized that there would be a link

between changes in mental well-being and functional health status as it relates to the

sexual orientation of the participants.

The findings of this study showed that HIV symptoms, age, and sexual orientation

were closely associated with health status. Sexual orientation had a direct relationship

with the mental well-being, cognitive, physical, social and role functioning. Having a

purpose in life, which is often found in spirituality and religion, also had a positive effect

on mental well-being.

Spirituality is often used as a tool in coping with life’s challenges, but for gay

men with AIDS and their care giving partners, it is especially useful. The partners of gay

men with AIDS often endure several years of emotional pain that come from watching

their partners die (Richards, A Cree, & Folkman, 1999). In a follow-up study that

examined the spiritual phenomenon of caregivers after the loss of their partner, Richards
 40

et al.(1999) examined the qualitative and quantitative data from 70 participants from an

earlier cohort three to four years after the death of their partner.

Four themes emerged from the participants in the study. 1) Connections with a

higher power were experienced as active and participatory. 2) Spirituality was believed to

be part of the caregivers’ identity. 3) There was also a new strength and desire for living

that was a result of a new connection with the world, people, and relationships. 4) In

addition, there was a new paradigm that came from acceptance of one’s life path and the

natural growth that comes from it.

For 70% of the participants, death merely changed the form of the relationship.

For these participants, it allowed the relationship to grow deeper, allowing the

participants not to feel as if they where “clinging to the past” (p.123), but instead they

were reorganizing the present where the deceased assumes a new role in the living

partner’s day-to-day experiences.

This compelling study supports the growing importance for future studies to

examine the different styles of coping African American with HIV utilize; therefore

other HIV-positive people may have a clearer frame to use when they seek support.

Knowing what coping styles are successful as a tool for living with HIV can also help

clinicians’ better support the mental health of their HIV-positive clientèle. An

understanding of effective coping styles may help to bring HIV-positive African

American males into a more active role in the combating of HIV within the African

American community.
 41

Purpose of the Study

Previous research has identified few possible coping mechanisms that African

Americans use to reduce distress in coping with racism or to maintain a sense of

wellbeing or connection within the wider community. Kinship networks and spirituality

have been historically important to African American families, especially in the face of

family crisis. However, the construct of the extended African American family is altering

and the social roles of young African American men are also undergoing change. For

helping the person who has HIV or AIDS and is also African American, little is known

about how to intercede to help in a culturally sensitive manner. There has been little

substantive research conducted to identify specific coping styles that are effective in

helping to reduce distress among African Americans living with HIV. In order to remedy

this gap in the academic literature, this study was conducted to examine the relationship

of coping style to distress among African American men and woman who are HIV-

positive.

Research Hypotheses

The research hypotheses guiding this study sought to examine the

relationship between specific coping strategies, such as spirituality and access to

community resources, and signs of distress and adjustment revealed through

specific psychological and behavioral measures. They resulted in eight specific

hypotheses.
 42

Hypothesis 1: Significant group differences will be shown between

African Americans and Whites living with HIV on spiritual coping, access

to community resources, satisfaction with social support, spiritual beliefs,

denial, behavioral disengagement, depression-dejection, mood

disturbance, and spiritual growth.

Hypothesis 2: Among HIV- positive African Americans, less mood

disturbance will be associated greater use of spirituality as a coping

strategy.

Hypothesis 3: Among HIV -positive African Americans, less mood

disturbance will be associated with having greater satisfaction with social

support.

Hypothesis 4: Among HIV- positive African Americans, less mood

disturbance will be associated with greater endorsement of spiritual belief.

Hypothesis 5: Among HIV- positive African Americans, less mood

disturbance will be associated with higher access to community resources.

 43

Hypothesis 6: Among HIV- positive African Americans, less mood

disturbance will be associated with less use of denial as a coping strategy

to handle being HIV -positive.

Hypothesis 7: Among HIV -positive African Americans, less mood

disturbance will be associated with less behavioral disengagement as a

coping strategy to deal with being HIV positive

Hypothesis 8: Among HIV- positive African Americans less mood

disturbance will be associated with High SES as measured by level of

education.
 44

CHAPTER II

METHODS

This study was part of a larger, randomized clinical trial that examined the effects

of Supportive Expressive Group Psychotherapy (Spiegel et al., 1989) on quality of life

and health behavior in HIV-positive men and women. Participants were randomized

either to receive one year of group psychotherapy intervention plus educational materials

(treatment condition) or to receive educational materials without group psychotherapy

intervention (control condition). Baseline data were collected prior to randomization into

treatment or control groups.

Men and women who were medically documented as being HIV-positive were

recruited through local newspaper advertisements and four large county healthcare

facilities (Santa Clara Valley Medical Center, San Mateo County General Hospital, Ursus

Medical Group, and CARES Clinic). Health care providers and their support staff

disseminated brochures and referred clinic patients who were being seen for services in

the medical clinic to the larger study. Participants received $25 for completion of baseline

measures, $25 for completion of six-month follow-up questionnaires, and $25 for

completion of 12-month follow-up questionnaires.

Participants had to meet specific inclusion criteria. They had to provide informed

consent, have documented and serologically proven positive status (e.g. HIV infection),

be 18 years of age or older, and have sufficient proficiency in English to comprehend and

complete questionnaires and participate in group psychotherapy if so assigned. They also

 45

needed to live close enough to one of the psychotherapy groups to attend group meetings

on a weekly basis.

For this study, a sub-sample of 60 participants who identified themselves as

African American and another sub-sample of 101 Whites were identified from the overall

sample of 162 individuals who completed baseline questionnaires. Social support was

operational zed as satisfaction with social support.

Exclusion Criteria

Because specific psychiatric disorders could impair the participant’s ability to

respond to treatment and/or interfere with the treatment provided to others, exclusion

criteria were developed to identify such participants in the larger clinical trial. Those

evaluated by a trained psychologist to be at risk or unable to benefit from treatment, who

were at significant risk for suicide or had the potential to harm others, or who met DSM-IV

criteria for organic brain disorder, major depression, dissociative identity disorder,

psychotic disorders, or obsessive compulsive disorder were removed from the study. Also,

those were excluded who were under 18 years of age, were not proficient in English, were

intoxicated, appeared to be overtly hostile upon screening, or were currently attending a

support group or group therapy that focuses on HIV/AIDS.

Participants were asked to complete a baseline questionnaire that took

approximately two 90-minute sessions to complete. They also were required to complete

subsequent questionnaires at three, six, and twelve months after recruitment into the study,

although only the baseline data were included here. The assessment team explained to each
 46

potential subject about the need to randomly assign each individual to one of the two

treatment conditions. Persons who declined to participate after considering this requirement

of random assignment were excluded from the study.

Informed Consent

All subjects were asked to sign informed consent protocols approved by the Stanford

Committee on the Use of Human Subjects in Medical Experiments. Participants were also

asked to give their consent for researchers to access to all of their medical records, dating

from the beginning of the study and in the future.

Design and Procedures

This study was a cross-sectional descriptive study. For the hypothesis comparing

African-Americans to Whites, the independent variable was ethnicity and the dependent

variables were styles of coping. The dependent variable used was mood disturbance, and

the independent variables were specific coping styles spirituality, satisfaction with social

support, spiritual beliefs, access to community resources, denial, behavioral

disengagement, level of completed education.

Registration and Randomization

For participants to be registered in the larger study and randomly assigned to a

group, individuals had to be either approached at a health clinic for patients with

HIV/AIDS or called by the Psychosocial Treatment Laboratory at Stanford University. The

Research Assistant II examined each patient’s medical records and administered the
 48

Structured Clinical Interview for DSM-IV (SCID; Spitzer et al, 1988; 1994) to evaluate

medical and psychiatric eligibility. Each participant was randomly assigned to either

supportive-expressive group therapy or education after providing informed consent and

completing the screening process and baseline assessment. This procedure controlled for

contamination of baseline information through staff or subject knowledge of the treatment

assignment.

Measures

Five measures were used to discern the coping styles of African-Americans who

were HIV-positive and to determine their levels of distress for this study. They were the

UCLA Social Support Inventory, the COPE (brief version), and the Access to Community

Resources Scale.

The Profile of Mood States

The Profile of Mood States (POMS) (Lorr, McNair, et al, 1971, 1981, 1992,

2003) is a self- report measure that was developed to assess six specific aspects of mood

affect: tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-

inertia, and confusion-bewilderment. The Profile of Mood States consists of 65 items that

are recorded on a five-point Likert-type scale on which participants are instructed to

indicate their responses ranging from 0 for "Not at all" to 4 for "Extremely,” based on how

they felt during the past week, including that day.

The POMS was normed on four stratified populations: A) 400 adult volunteers

between the ages of 18-94 from diverse economic and ethnic backgrounds, B) 856
 49

college students from a large Eastern United States College, C) 170 elderly people 55 and

older, and D) 1000 psychiatric out-patients who completed the questionnaire during their

initial intake. The POMS was chosen as one of the measures for this study due to its

sensitivity to detect change over time and its ability to provide a measurable score for

total mood disturbance. It also has been shown to have a high level of internal

consistency, which has been shown to produce Cronbach alphas ranging from .87 to .95.

UCLA Social Support Inventory

The UCLA Social Support Inventory consists of 24 self-report items that ask

respondents to share their beliefs about the quality of social support they receive. This

measure is designed to determine four domains of social support (family, partner, friends,

and group/community) and four specific methods of social support (advice, assistance,

reassurance, and listening).

Following the recommendations of the developers of the UCLA Social Support

Inventory, the researchers of this study directed the participants to answer the questions that

applied to living with HIV/AIDS. A five-point Likert- type scale was used to record how

often respondents reported feeling adequate support from their partners, friends, family

members, and groups or organizations. Responses ranged from 1 (”Never”) to 5 (“Very

Often.”). The social support scale produced very strong internal consistency.

The COPE

The COPE is a self-report inventory that was developed to assess coping

responses. The COPE measures the frequency with which respondents utilize14 specific

coping strategies to address a specific stressor. For the purposes of the study, participants
 50

were asked to answer the questions based on how they were dealing with “the stress of

living with HIV or AIDS in the past three months.” The items were scored on a 4-point

Likert-type scale, ranging from 1 (“I did not do this at all”) to 4 (“I did this a lot”).

A 24-item, brief version of the COPE was used for this study. The brief COPE

was created by its authors because of number of the reported “impatient” participants

previous researchers had witnessed while responding to the full questionnaire. The

number of duplicate items and the time it took to complete the questionnaire contributed

to the impatience the respondents felt (Carver, 1997). The brief COPE utilized in this

study consisted of 12 subscales (Active Coping, Planning, Positive-Reframing,

Acceptance, Humor, Religion, Denial, Using Emotional Support, Substance Use, Venting

of Emotions, Behavioral Disengagement and Self Distraction). The subscales of interest

were denial, behavioral disengagement, and spirituality.

Access to Community Resources Scale

The Access to Community Resources Scale (Koopman & Spiegel, 1994) was

originally designed for breast cancer patients. It is an eight-item scale that explores the

access the respondents had to finding and using community resources. This measure

looks at how often respondents were able to find affordable childcare, employment

information, transportation to the doctor, legal aid, medical supplies, assistance making

medical decisions, and financial support to help cover medical bills, rent, food, and other

basic essentials. Respondents are asked to report the ease or difficulty they experienced in

using each resource area on a 5-point Likert type scale with 1 being “never can get” up to

5 being “very easy to get.” Respondent are allowed to check “not applicable” to any
 51

resource area they believe does not apply to them. Means scores from all applicable items

are computed. High scores indicate that the respondent is capable of getting the necessary

resources with very little difficulty.

Principles of Living Scale

This measure was developed to assess participants’ utilization of three specific

strategies for interpreting life’s meaning. 1) Spiritual striving measures the attempt to live

and grow spiritually (e.g., “I try to forgive others who may have hurt or harmed me in

some way.”). 2) Spiritual beliefs and practices measures respondents' ability to derive life

meaning from spiritual beliefs and practices (e.g., “I gain strength in living from my

spiritual/religious beliefs.”). 3) Embracing life’s fullness measures respondents attempts

to live daily life as significantly as possible (e.g., “I feel alive and joyful at the ordinary

things of daily life.”). This measure has 17-items that assess participants’

religious/spiritual beliefs and practices. Respondents are asked to complete the first

thirteen items using a Likert scale where 1 was “Completely Agree” to 6 “Completely

Disagree.” Three items used a 5-point scale. An example of one of those items was

“Since I learned I was HIV positive, my spiritual /religious life is...” The answers ranged

from 1= “much better” to 5= “much worse.” Finally, one item used a 4-point scale.
 52

CHAPTER THREE

RESULTS

Participants

Descriptive data were compiled on both African American and White study

participants. Seventy-one percent of the African American sample was female compared

to 28% of the White sample. Of the African American female sample, 9.3% were self-

identified as lesbian compared to 24% in the White sample.

Seventy-one percent of all African Americans reported having some form of

religious affiliation, and only 17 % had no religious connection. In contrast, 59% of

Whites reported having some form of religious affiliation, while 34% had no religious

association.

In the White sample regarding education, the mean was 14.5 (SD=3.2) years of

completed education compared to a mean of 12.2 (SD=2.4) for the African American

participants. A majority of the African Americans were unemployed, 76.7% compared to

57% of the White sample. Thirty percent of the unemployed African Americans and 37%

of unemployed Whites reported being permanently disabled. Moreover, 47% of the

African American sample met the T-cell count criteria for AIDS.

In addition, 73% of African American participants were not married, but 26% of

others reported living as married. Forty-eight percent of Whites reported being single,

and 32% reported being married or living as married.

 53

Table 1. Summary of Demographic Characteristics and Medical Status Analyzed by

Ethnicity

Variable African American Sample White Sample

(N=60) n (%) (N=101) n (%)
Gender
Male Freq here 17 (28.3%) Freq here 72 (71.3%)
Female Freq here 43 (71.7%) Freq here 29 (28.7%)

Sexual orientation by
gender
Bi-sexual Male 1 (5.9%) 6 (5.9%)

Gay Male 7 (41.2%) 59 (81.9%)

Heterosexual Male 9 (52.9%) 7 (9.7%)

Bi-sexual Female 3 (5%) 1 (3.4%)

Lesbian Female 4 (9.3%) 7 (6.9%)

Heterosexual Female 34 (79.1%) 21 (72.4%)

Other Females 2 (4.6%) 0 (0%)

Other Males 0 (0%) 1 (1.1%)

Household Income
Less than $20,000 49 (81.7%) 51 (50.5%)

$20000-$39000 7 (11.7%) 18 (17.8%)

$40000-$59000 1 (1.7%) 9 (8.9%)

$60000-$79000 N/A 7 (6.9%)

$80000-$99000 N/A 7(6.9%)

$100,000 or above 1 (1.7%) 7(6.9%)

Total 58 (96.7%) 99 (98%)

Missing 2 (3.3%) 2 (2.0%)

Total 60 (100%) 101 (100%)

 54

Statistical Results

Each of the study hypotheses were examined and tested statistically.

Hypothesis 1

A t-test was used to examine hypothesis one. That hypothesis stated: Significant

group differences will be shown between African Americans and Whites living with HIV

on spiritual coping, social support, access to community resources, satisfaction with

social support, spiritual beliefs, denial, behavioral disengagement, depression-dejection,

mood disturbance and spiritual growth.

The statistical analysis of hypothesis one is presented in Table 2. There were

significant group differences found between African Americans and Whites, with African

Americans showing more positive results on spirituality to cope with being HIV- positive

(p <.001), greater satisfaction with social support (p <.05), stronger endorsement of

spiritual beliefs (p <.01) (a lower score on this measure shows stronger endorsement),

greater use of coping through denial (p <.001). Contrary to the hypothesis, however, there

were no significant findings for African Americans differing from Whites on access to

community resources, behavioral disengagement, spiritual growth, depression-dejection,

or total mood disturbance.

 55

Table 2. Results of Comparing African Americans to Whites in Living with HIV on

Coping through Spirituality, Social Support, Access to Community Resources,

Satisfaction with Social Support, Spiritual Beliefs, Cope Denial, Cope Behavioral

Disengagement, POMS Depression-Dejection, POMS Total Mood Disturbance, and

Spiritual Growth

African Americans Whites Living with

Living with HIV HIV
Measure M (SD) M (SD) t (df)
equal variances
assumed
COPE 5.9 2.19 4.43 2.166 4.13*** 158
Spirituality
Social Support 82.4 18.9 78.4 20.9 .013 158

Access to 3.8 .79 3.9 .8 1.2 156

Community
Resources
Satisfaction with 20.4 4.5 19.4 5.4 1.2* 156
Social Support
Spiritual Beliefs 34.4 22.3 46.5 22.4 3.3** 159
Cope Denial 1.6 .76 1.2 .43 4.3*** 157
COPE 1.4 .61 1.4 .58 .243 158
Behavioral
disengagement
POMS 13.7 9.7 13.9 12.4 .101 147
Depression-
dejection
POMS Total 40.7 29.9 40.1 38.01 .100* 147
Mood
Disturbance
Spiritual Growth 34.4 22.3 46.5 22.4 1.04 159

*p < .05. **p < .01. ***p < .001.

 56

Hypothesis 2

This hypothesis posited that among HIV- positive African Americans, less mood

disturbance will be associated with greater use of spirituality as a coping strategy. As

shown in Table 3, less mood disturbance was not found to be significantly associated

with greater use of spirituality as a coping strategy among HIV-positive African

Americans. This hypothesis was not supported.

Table 3. Correlations of Mood Disturbance among African Americans Living with HIV

with COPE Spirituality, Satisfaction with Social Support, Spiritual Beliefs, Access to

Community Resources, COPE Denial, COPE Behavioral Disengagement, and Level of

Completed Education

Measure Mood disturbance

Pearsons-r

COPE Spirituality -.060

Satisfaction with Social Support -.004

Spiritual Beliefs .083

Access to Community Resources -.320***

Cope Denial .343***

COPE Behavioral disengagement .448***

High SES -.105

*p<.05 **p < .01 ***p < .001
57

Hypothesis 3

The next hypothesis stated that among HIV -positive African Americans with

lower mood disturbance will have greater satisfaction with social support. The results did

not support this research hypothesis. Results indicated that there was no statistically

significant relationship between mood disturbance and satisfaction with social support

among HIV-positive African Americans.

Hypothesis 4

The fourth hypothesis stated that among HIV- positive African Americans, less

mood disturbance will be associated with greater endorsement of spiritual belief. Results

indicated that there was no statistically significant relationship found between mood

disturbance and use of spiritual belief among HIV-positive African Americans.

Hypothesis 5

This hypothesis stated that among HIV- positive African Americans, there will be

less mood disturbance associated with higher access to community resources. The results

indicated that there was a statistically significant negative relationship, r = -.320,

(p<.001), between less mood disturbance and higher access to community resources

among HIV-positive African Americans. For African Americans, greater access to

community resources was associated with less mood disturbance. This hypothesis was

supported.

Hypothesis 6

This research hypothesis posited among HIV- positive African Americans, less

mood disturbance will be associated with less use of denial as a coping strategy to handle
 58

being HIV -positive. The results supported this hypothesis. The findings indicate that

there was a statistically significant relationship, r =.343 (p<.001). This result showed less

mood disturbance was associated with less use of denial as a coping strategy to handle

being HIV positive among HIV-Positive African Americans. In other words, for HIV-

positive African Americans, the greater the use of denial as a coping strategy the higher

their mood disorder.

Hypothesis 7

This hypothesis posited among HIV -positive African Americans, less mood

disturbance will be associated with less behavioral disengagement as a coping strategy to

deal with being HIV positive. The results indicated there was a statistically significant

positive relationship found, r = .448 (p<.001). Less mood disturbance was associated

with less behavioral disengagement.

Hypothesis 8

The last hypothesis stated that among HIV- positive African Americans, less

mood disturbance will be associated with High SES as measured by level of completed

education. There was no statistically significant relationship found between less mood

disturbance and High SES as measured by level of education among HIV-Positive

African Americans. This hypothesis was not supported.

 59

CHAPTER 4

DISCUSSION

Summary of Results

The results of this study build on the existing research on the styles of coping

utilized by African Americans to handle the stresses caused by being HIV-positive. This

study offers new insights into how physicians and mental health experts may assist their

HIV-positive African American clients as they adjust to the medications and lifestyles

changes that are to come. This study established that HIV-positive African Americans,

compared to Whites, utilized different coping styles to handle being HIV-positive.

Hypothesis 1

Hypothesis one examined group differences between African Americans and

Whites living with HIV on spiritual coping, social support, access to community

resources, satisfaction with social support, spiritual beliefs, denial, behavioral

disengagement, depression-dejection, mood disturbance, and spiritual growth. African

Americans, compared to Whites, utilized their spiritual beliefs more often to act as a

coping tool when they dealt with issues of being HIV-positive. African Americans,

compared to Whites, also reported having higher satisfaction with support they received

from their friends,family, partners, and organizations they belong to. This may be related

to the strong immediate and extended family ties that were valued during slavery and

have now become part of the development of many African American support systems.
 60

African Americans, compared to Whites, were more likely to use denial of being

HIV-positive as a coping tool. Again, African Americans, since arriving here in America

as slaves, have had to face the reality of being captured and taken from their families and

homeland and have had to develop reality-based coping tools to survive. This situation

for African Americans is very different from Whites. Whites may be more likely to be

members of communities that do not require them to disclose their disease and are also

able to maintain their confidentially due to having better insurance and financial

resources compared to African Americans that are HIV-positive.

African Americans, compared to Whites, did not report experiencing less

depression-dejection or overall less total mood disturbance. This is consistent with the

resilience of the historical and contemporary African American community where

members develop a fighting mentality to combat life stressors. In previous research using

a fighting spirit has been found to be associated with better adjustment in coping with the

stressor of having a life-threatening illness. (Classen, Koopman, Angell, & Spiegel,

1996).

Hypothesis 2

This hypothesis sought to prove, among HIV- positive African Americans, less

mood disturbance would be associated greater use of spirituality as a coping strategy.

Less mood disturbance among HIV-positive African Americans was not found to be

associated with greater use of spirituality as a coping strategy. This lack of a significant

result may be due to how individuals utilize their spirituality. Some African Americans

may see their being HIV-positive as a punishment from God for past misbehaviors.
 61

Others may recognize that though spirituality maybe a strength and a hope, it cannot

always elevate them from the place where they are, whether it was dealing with slavery in

the past or dealing with crime and poverty in the present. This may also be due to the way

spirituality depicts the human condition as a “vale of tears” to be overcome only in the

afterlife. With that mindset, it is not surprising that even deeply spiritual people who are

HIV-positive would feel distress.

Hypothesis 3

Hypothesis 3 posited among HIV-positive African Americans less mood

disturbance will be associated with having greater satisfaction with social support. Less

mood disturbance was not found to be associated with greater satisfaction with social

support for African Americans with HIV. Ironically, this finding may be due to the

pressure that comes from one’s social support. It is also important to consider whether the

support is sought out versus given freely. The person who is giving the support may also

impact how it is being received. For example, support from one’s friends and family may

be received differently than support and guidance received by one’s pastor or fellow

churchgoers.

Hypothesis 4

This hypothesis stated among HIV- positive African Americans whether less

mood disturbance would be associated with greater endorsement of spiritual belief.

Among HIV-positive African Americans less mood disturbance was not found to be

associated with greater endorsement of spiritual beliefs. For African Americans, these
 62

results did not support the idea that endorsing spiritual beliefs is associated with better

emotional adjustment to being HIV-positive.

Hypothesis 5

Hypothesis 5 posited among HIV- positive African Americans less mood

disturbance would be associated with higher access to community resources. African

Americans that reported having the ability to access their local community resources

were found to have less mood disturbance. This supports the premise that African

Americans who feel they have more control over their immediate environment tend to

feel more confident and mentally secure. The results showed a negative relationship,

which suggests the need for more research to examine and clarify if African Americans

who are HIV-positive increase their access to community resources, whether they

simultaneously reduce the likelihood of becoming depressed or experiencing other

expressions of mood disturbance.

Hypothesis 6

Hypothesis 6 stated among HIV- positive African Americans less mood

disturbance would be associated with less use of denial as a coping strategy to handle

being HIV -positive. Support was found for a positive and modestly strong relationship

between mood disturbance and the use of denial as a coping strategy for HIV- positive

African Americans. More specifically, the use of lower levels of denial as a coping

strategy was associated with lower levels of mood disturbance. These findings can be

used to develop and then implement policies that encourage mental health workers to
 63

facilitate HIV-positive African Americans acceptance of their HIV diagnosis and reduce

higher levels of denial while encouraging healthy applications of low levels of denial.

Further, a focus on coping may yield reductions in psychiatric morbidities

commonly experienced among this population. Although, for this finding as well as for

others, no causal interpretation can be made with confidence given the descriptive and

cross-sectional nature of this study. Vos and De Haes (2007), in a 40-article journal

review, examined denial as a coping strategy in cancer patients. They found denial can be

an effective mechanism to buffer against stress and other overwhelming life-events.

Strategies designed to distract were effective in reducing distress, and passive coping was

found to diminish psychological well-being. They also found the effect of denial

appeared to be influenced by the type of denial used and that culture may mediate the

prevalence of denial utilized by an individual.

Hypothesis 7

Among HIV -positive African Americans less mood disturbance will be

associated with less behavioral disengagement as a coping strategy to deal with being

HIV positive. Less mood disturbance was not found to be associated with avoiding

disengaging behaviorally from the diagnosis. Thus, this hypothesis was not supported.

However, there may be other reasons why for an HIV-positive African American client,

this is a key component that has to be addressed early in treatment. When African

Americans who are HIV-positive keep clinic appointments and are compliant with

medical regimes, they not only are physically better able to function in their everyday

routines, but they may also feel more in control of their lives. However, these
 64

possibilities were not examined in this study and should be considered for future

research.

Hypothesis 8

Among HIV- positive African Americans less mood disturbance will be

associated with High SES as measured by level of education. No significant relationship

was found between levels of completed education mood disturbance. This relationship

should be re-examined in future research with HIV-positive African Americans who vary

more in their education levels.

 65

CHAPTER IV

CONCLUSIONS

This study found that resilience can serve as a buffer from stress. This finding

strongly suggests healthcare providers may have a tool to help them better identify those

that are at higher risk for mood disorders. Moreover, drafting ways in which African

Americans with HIV can better connect with members of their local communities and

draw support from them may positively impact how those with HIV live with their

disease.

This study also sheds light on the importance of having healthy coping skills. For

those who do not, adjustment to being HIV-positive may be more problematic. Those

with strong coping skills appear to handle the physical and social challenges of the

disease in a forthright manner. Acceptance of the disease and the practical determination

to work within the realities of its limitations are key to improving the overall quality of

life of these individuals.

Study Limitations

One of the limitations of this study was that it was based on a highly disabled and

distressed sample. It was also based on a sample of convenience. The instruments used

for the study were not designed for or normed on HIV-positive individuals, except for the

measures of social support and spiritual growth and spiritual beliefs.

In addition, the White sample was made up of a majority of low socioeconomic

status, gay, White males, which restrict the generalizability of the findings. This sample
 66

did not possess the variation among individuals nor the size necessary for more detailed

study. There was little variation in level of education, and the sample was drawn from a

treatment-seeking population. Given the small sample size, reliance on self-report

measures, and the use of a cross-sectional research design, there are serious limits to this

study's ability to develop causal interpretations of the results.

In addition, this study did not include an examination of anti-retroviral adherence,

treatment follow-up, participant drug use, and sexual history. All of these variables are

also part of an individual’s coping system, as well as possessing the ability to call upon

them when the individual becomes distressed. These are all subjects for future research

examining factors associated with distress among HIV-positive African Americans.

Clinical Implications

These findings suggest that HIV-positive patients, especially African Americans,

may require more access to community resources from their service providers and local

communities. Resilience may need to be a focus in therapy for psychologists working

with HIV-positive clients. Another clinical implication for HIV-positive individuals is the

use of reality testing in therapy which focuses on what is an actual threat from being

HIV-positive versus general paranoia that may come with adjusting to living with a life-

threatening illness. Therapists must place more emphasis on addressing the maladaptive

coping styles of their clients (avoiding high use of coping by denial and behavioral

disengagement) to help them develop more functional and reality-based coping skills.

However, in addressing maladaptive coping strategies, it is also important for therapists

to develop more culturally-sensitive training for their minority clients. In some

 67

minorities, what might appear to be a maladaptive coping style, such as talking loud or

using a lot of curse words to express their feelings, might simply be a healthy form of

venting.

Research Implications

Future research should use longitudinal research designs in order to better

understand the use and effects of various coping strategies over the course of the disease.

More research is needed to develop assessment tools for HIV-positive minorities. In

addition, culturally-sensitive treatments modalities need to be developed to help address

the coping styles that are called upon by HIV-positive minorities.

There were significant group differences found between African Americans and

Whites, with African Americans showing more positive results on spirituality to cope

with being HIV-positive (p <.001), greater satisfaction with social support (p <.05),

stronger endorsement of spiritual beliefs (p <.01), greater use of coping through denial (p

<.001). Contrary to the hypothesis, however, there were no significant findings for

African Americans differing from Whites on access to community resources, behavioral

disengagement, spiritual growth, depression-dejection, or total mood disturbance.

Less mood disturbance was not found to be significantly associated with greater

use of spirituality as a coping strategy among HIV-positive African Americans. Future

research may be used to see in what instances spiritually for HIV-positive African

Americans may not serve as a coping strategy.

Results indicated that there was no statistically significant relationship between

mood disturbance and satisfaction with social support among HIV-positive African
 68

Americans. More research needs to focus on what types of social support have a positive

impact overall mood for African Americans with HIV.

Less mood disturbance was not found to be associated with greater endorsement

of spiritual beliefs. Future research needs to focus on how Africans Americans with HIV

are utilizing their spirituality to cope with their disease. Research needs to identify it is

used as a tool that increases guilt or create healthy emotional buffers.

There was no statistically significant relationship found between mood

disturbance and use of spiritual belief among HIV-positive African Americans. Again,

future research should focus on the development of questionnaires that seek to define

spiritual belief and how it comes into play during the coping process for HIV-positive

African Americans.

The results indicated that there was a statistically significant negative relationship,

r = -.320, (p<.001), between less mood disturbance and higher access to community of

resources among HIV-positive African Americans. Research may want to focus on what

African Americans with HIV consider access to community resources compared to HIV-

positive African Americans that report they do not have any access.

This study showed less mood disturbance was associated with less use of denial

as a coping strategy to handle being HIV-positive among HIV-positive African

Americans. More research needs to be conducted in this area to see what coping styles

are utilized that prevent the use of denial as coping strategy.

The results indicated there was a statistically significant positive relationship

found, r = .448 (p<.001), that supported less mood disturbance associated with less
 69

behavioral disengagement. Future research should focus on examining this relationship

to see if actively engaging in the coping process of being HIV-positive is more beneficial

to HIV-positive African Americans' mental health, and, if so, what coping tools should

mental health professional be teaching their patients early in the process.

No significant relationship was found between levels of completed education and

mood disturbance. Research needs to examine the impact level of education has on access

to services and overall mood among HIV-positive African Americans.

Future research should focus on what components of spirituality, social support,

and the endorsement of spiritual beliefs are utilized by African Americans with HIV that

help them cope with their disease. Also, the use of denial as a coping tool should be

examined to see if it may have a positive effect on adjusting to and living with being

HIV-positive.

Future research may also focus on developing more culture-specific

questionnaires for HIV-positive African Americans that identify what African Americans

with HIV consider having access to community resources is, what qualifies as spiritual

growth, how they identify when they are becoming depressed, and also how they assess

their overall mental health.

 70

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