Objective: To examine perceived stress, coping style, and symptoms of anxiety and depression in HIV+ Nepali women who were former commercial sex workers.
Design: Descriptive, correlational study based on Lazarus and Folkman's (1984) relational model of stress, appraisal and coping.
Population, Sample, Setting, Years: Convenience sample of 98 women living with HIV recruited in 1999 from a non-government organization (NGO) in Nepal. Selection criteria included female gender and HIV+ serostatus.
Variables: Sociodemographics, perceived stress, coping style, depressive symptoms and anxiety. Methods: Approval of a university institutional review board in the U.S. and permission for the study from the NGO in Nepal were obtained. Instruments were translated into Nepali. Following informed consent, due to low literacy levels, all questionnaires were interviewer administered. Questionnaires and their respective Cronbach’s alpha reliability coefficients included the Perceived Stress Scale (PSS) (.72), the Ways of Coping Questionnaire (problem focused scale [PFC]=.78; emotion focused scale [EFC]=.69), the Center for Epidemiologic Studies Depression Scale (CES-D) (.83), and the Symptoms Checklist-90 Anxiety Subscale (.69). Analytical methods included descriptive statistics and hierarchical regression analysis.
Findings: Mean age was 20.2 years (range 13-39 years); 96% had no formal education; 86% were not working. None were receiving medications or other treatments for HIV. Range of scores on the PSS was 19 to 33 (M=23.3; SD=3.18); Coping strategies were used in varying proportions: seeking social support (18%), positive reappraisal (15%), confrontive coping (13%), distancing (13%), problem solving (12%), self-controlling (10%), escape-avoidance (11%) and accepting responsibility (8%). Participants used significantly more PFC strategies (58%) than EFC strategies (32%) (t=87.1; df=97; p=.000). Depression scores ranged from 0-30 (M=3.35; SD=4.39); 97% scored below the cutoff score of 16. Based on Simpson et al’s (1996)'s observation that in non-Westernized societies symptoms of depression are somatic not affective, post-hoc analysis of the somatic subscale of the CES-D was conducted. Scores more than 1 SD above the mean indicated depressive symptoms. The mean for the subscale was 1.11 (SD=1.6); 18% of the sample scored positively for depression. The median score for anxiety was .10 (range 0-.70. Pearson's product moment correlations revealed significant negative relationships between perceived stress and problem focused coping (r=-.42, p=.000) as well as emotion focused coping (r=-.32, p=.001). Distancing (r=-.21, p=.04) and planful problem solving (r=-.35, p=.000) were significantly and negatively associated with anxiety. Problem focused coping (r=-.27, p=.007), distancing (r=-.24, p=.02) and self-controlling (r=-.22, p=.03) were associated with depression. In hierarchical regressions, age, perceived stress and eight coping style subscales were entered in that order. With depressive symptoms as the criterion variable, the combination of perceived stress (beta=.55; p=.000) and escape avoidance (beta=.35; p=.009) predicted 22% of the variance. With anxiety as the criterion variable, the combination of perceived stress (beta=.39; p=.002), problem solving (beta=-.34; p=.002), accepting responsibility (beta=-.26; p=.05), and distancing (beta=-.22; p=.05) predicted 24% of the variance.
Conclusions: Although the sample was young, poor and uneducated, perceived stress was relatively low and the incidence of psychological symptoms less than reported in other HIV+ populations. This may be due to relative improvement in perceived threats to their well-being; participants were rescued by the NGO because of their serostatus and no longer had to work as CSWs. Thus HIV disease may not have been appraised as highly harmful, threatening or challenging. Also, based on Eastern beliefs, individuals may interpret negative emotions and suffering as a normal part of life. The greater use of PFC versus EFC may also be related to Eastern beliefs in self-control and suppression of emotion. Other explanations for findings include the possibility of socially desirable responses and the fact that instruments were normed on populations in developed, industrialized countries.
Implications: This study provides a first look at stress, coping and psychological symptoms in this population as there are no published studies examining psychological factors in HIV+ female former commercial sex workers from Nepal or any other Asian country. Recent findings revealed a twofold higher mortality rate in HIV+ women with chronic depressive symptoms (Ickovics et al., 2001). In a population of women with no access to antiretroviral treatment for HIV disease, or prophylaxis for opportunistic infection, management of psychological symptoms may be an alternative means of slowing disease progression and reducing mortality. An understanding of cultural differences in psychological responses to living with HIV can provide the basis for interventions that can improve health outcomes as well as quality of life in women in non-Western countries living with HIV.
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