استرس و شاخص های مدل فرا تئوری رفتارهای مدیریت استرس در زنان مبتلا به HIV مثبت

Objective: Women are particularly prone to stress with respect to living with HIV. Stress management behaviors can mediate the stress response and improve health outcomes in HIV-positive individuals. The purpose of this descriptive cross-sectional study was to examine stress and Transtheoretical Model (TTM) indicators of stress management behaviors in HIV-positive women. Methods: 126 HIV-positive women recruited from diverse HIV-care clinics in northeast Ohio completed standardized self-report research instruments to measure stress, stress management behaviors, stage of change, self-efficacy, and decisional balance (pros and cons). Results: Women reported higher levels of stress in the later phase of HIV infection (P<.05). Highly stressed women in this study reported infrequently using stress management behaviors and a low level of perceived efficacy to manage stress although they perceived the pros of managing stress to be high (P<.01). Stress management behaviors were significantly related to stage of change (P<.01), self-efficacy (P<.01), and the cons of managing stress (P<.05). Graphed patterns of decisional balance examined by stage of change and stress management behavior were atypical in this sample. Conclusions: Clinicians and researchers can use the TTM to describe behavioral indicators of stress management in HIV+ women. However, further research is needed to more fully understand behavioral processes HIV+ women can use to adopt and maintain stress management behaviors.

Women comprise a rapidly expanding segment of the population infected with HIV [1] and HIV+ women have reported high levels of stress [2], [3] and [4]. In general, women have been culturally and socially reared to be caregivers to their partners and their children without respect to their own health needs and HIV+ women are no exception in this matter [5], [6], [7] and [8]. Many HIV+ women have HIV-infected partners and children; some of these children are also HIV+ [6], [7], [9], [10] and [11]. Some HIV+ women yearn for an intimate relationship with an understanding partner and put themselves at severe health risks in order to establish that relationship [5], [12], [13] and [14]. Additionally, many women living with HIV have limited financial resources [5], [7], [8], [15], [16] and [17] and personal histories of abuse [3], [5], [7], [18], [19], [20] and [21] further challenging their abilities to live well with HIV infection. Women and minorities have also reported feelings of helplessness and frustration with respect to getting adequate care for and managing their HIV infection within the context of their complex lives [3], [6], [7], [10], [11], [13], [14], [16], [20], [21] and [22]. HIV-positive women can use health-promoting stress management behaviors to enhance their physical and emotional well-being [23], [24], [25], [26], [27], [28], [29] and [30]; however, adopting and maintaining a new behavior is challenging. Adopting and maintaining a health-promoting behavior can be even more daunting within the context of HIV infection [31], [32] and [33]. While the Transtheoretical Model (TTM) of Behavior Change has been used extensively to describe and facilitate behavior change in other populations [34], [35], [36], [37], [38] and [39], it has been understudied in describing and enhancing health-promoting behaviors in women already infected with HIV. The TTM of Behavior Change [40] provides an integrative framework for understanding how individuals adopt and maintain target behaviors. Constructs in the model include stage of change, self-efficacy, decisional balance, and the processes of change. The key construct unique to the TTM is the Stage of change referring to a person's readiness to engage in a behavior. The stages of change are identified as Precontemplation (not intending to make a change in the near future), Contemplation (considering a change within the next 6 months), Preparation (currently making small steps toward a new behavior), Action (engaging in a new behavior for a period less than 6 months), and Maintenance (engaging in the behavior for more than 6 months) [40]. Self-efficacy refers to the belief that one can carry out the target behavior and is based on the work of Bandura [41]. Decisional balance [40] and [42] is composed of two separate constructs, the pros and cons of a target behavior, that can be measured independently and used to determine a ‘balance sheet’ of comparative gains and/or losses associated with engaging in a target behavior. Additionally, the model purports that the balance sheet comparing pros and cons is variable over time depending on an individual's stage of change. Lastly, the Processes of change refer to cognitive (or experiential) and behavioral strategies an individual or interventionist can use to facilitate the adoption or maintenance of a behavior across the five stages of change [40]. Despite the plethora of published research concerning the TTM, research to support the utility of this behavioral model to enhance the adoption and maintenance of health-promoting behaviors for persons already infected with HIV is limited. The majority of TTM research has been conducted with relatively well-educated, HIV-negative, and predominantly Caucasian samples. In the area of HIV, the TTM literature has focused on primary HIV prevention by examining the use of safer sexual practices. These primary prevention studies have used samples of uninfected women at high risk for HIV [43], [44] and [45], of HIV-positive women (to prevent the spread of infection) [45], of uninfected male and female college students [46], and of high-risk drug users [47] and [48] and their sexual partners [48]. However, secondary HIV prevention, that is helping HIV-positive people to stay as healthy as possible, is also a critical area of concern for clinicians and researchers. Our previously published pilot study [49] examined the relationship between the health-promoting behavior of stress management with TTM constructs (i.e. stage of change, self-efficacy, decisional balance) in women at risk for or infected with HIV; however, the sample size used for that study was heterogeneous and extremely small. Though stress management can be a critical health-promoting behavior for HIV-positive women, data to support the utility of the TTM to enhance stress management behaviors for HIV-positive women were lacking. Further examination was needed to evaluate the utility of this model to enhance secondary prevention behaviors for HIV-positive women. Therefore, the purpose of this descriptive cross-sectional study was to examine stress and TTM indicators of stress management in HIV-positive women.

The women in this study reported relatively high levels of stress compared with normative data published by Derogatis [51]. It is not surprising that women in the later phase of HIV reported higher levels of stress than women in the earlier phases. Women enrolled in this study had known of their HIV+ diagnosis for at least 6 months or more giving them time to acclimate to their positive serostatus. As the women became more symptomatic with respect to their HIV infection, they reported a higher level of distress and those in the AIDS phase of HIV reported the most stress. The levels of stress reported by this sample support the need for stress management interventions in similar groups of HIV+ women. Interestingly, those women reporting the highest levels of stress also reported infrequently using stress management behaviors to manage their stress. The quantitative and cross-sectional nature of this study limits the ability to explore this finding further. Health-promoting behaviors, such as stress management, are critical practices that HIV-positive women can use to enhance physical and psychological health and well-being. However, adopting these practices is challenging for women within the context of HIV. The TTM postulates that individuals move through a continuum of change in order to adopt and maintain a new behavior. Furthermore, the model indicates that adopting and maintaining the behavior is more likely when individuals feel they can engage in that behavior across a variety of situations and settings and when the pros of the behavior outweigh the cons of the behavior. While multiple studies have provided stage of change distributions for smoking cessation, stage distributions for other target behaviors have not been established [37]. The majority of women surveyed in this study indicated they were in the later stages of change for stress management. The breakdown of research participants within each of the stages was adequate to examine the hypothesized variable relationships in this study. As expected, stage of change and self-efficacy were significantly different across low to high levels of stress management behaviors in this study. Women in the earlier stages of change reported less use of stress management practices than their counterparts in the later stages of change (as depicted in Fig. 2). A similar trend in behavioral self-efficacy was seen across low to high levels of stress management practices and the differences in the levels of these practices were significant. It is noteworthy that the decisional balance variables, i.e. the pros and cons of stress management, did not perform as expected in the evaluation of stress management practices. The TTM purports that engaging in a behavior is more likely when the pros of the behavior outweigh the cons of the behavior. Thus, it was expected that the pros of the behavior would be initially low for those women using fewer stress management behaviors and higher for those using more stress management behaviors. Similarly, it was expected that the cons of stress management would be higher for those using less stress management behaviors and lower for those using more stress management behaviors. However, these expected patterns were not seen in this sample. Rather, the pros of stress management remained relatively stable over low to high use of stress management behaviors while the cons of stress management rose considerably (see Fig. 1). This unexpected finding concerning decisional balance with respect to reported use of stress management behaviors was further explored with stage of change. The theory indicates that a crossover pattern is expected in decisional balance across the stages of change such that in the earlier stages of change a pattern of low pros and high cons is expected. However, it is expected that the pattern changes during the earlier stages of change with the pros of the behavior rising in the contemplation stage and the cons falling between the preparation and action stages of the behavior [37]. Fig. 3 depicts that while the pros of stress management were not significantly different across the stages of change, the pattern was in the expected direction. The pros of stress management are lowest in the precontemplation stage and rise as expected with contemplation with a slight decline across the remaining stages of change. In examining this finding with the cons of stress management, a most unusual pattern emerged with this sample. The cons of stress management were actually highest in the preparation stage of change falling during the action and maintenance stages of change to a level just above that in the precontemplation and contemplation stages of change. These unexpected findings concerning the pros and cons of stress management behavior call for further research in this area. Stress has adverse effects on the immune system via neurohormonal pathways; thus, high levels of stress can extremely adversely affect the immune system of an HIV+ person [15] and [56]. Diverse stress management behaviors can enhance health while living with HIV but the ways in which HIV-positive women in particular adopt and maintain new behaviors is complex. Women are traditionally diagnosed later in the course of their HIV infection and generally care for others before caring for themselves [57]. And while HIV infects women of all races and socioeconomic levels, the majority of HIV-positive women are poor and socially disadvantaged [57]. Thus, while HIV-positive women perceive the benefits (or pros) of managing their stress via cognitive and behavioral practices, they also recognize the challenges (or cons) of engaging in these behaviors over time when so much is competing for their attention. The majority of women comprising this sample are mothers while 22% of the women are grandmothers. Financial and social resources for these women were also somewhat limited. Examining secondary prevention for HIV-positive women within these contexts is critical. It is possible that the other factors may have contributed to this unexpected finding. The instruments used to measure stress management practices and decisional balance in these women may not have adequately captured the stress management feelings and behaviors of these research participants. Indeed, the average number of stress management behaviors reported in this sample of relatively young women was lower than the average number of stress management behaviors reported by older adults with Parkinson's Disease [58]. Reasons for the level of stress management behaviors used or the perceived high cons of stress management behavior in this sample were not qualitatively evaluated in this study. Lastly, the sample size used for this study was adequate but smaller than most TTM studies evaluating decisional balance. This study is useful in providing preliminary TTM information for researchers and clinicians in the area of examining secondary prevention via stress management behaviors in HIV-positive women. While primary prevention within the area of HIV is critical, so is keeping HIV-positive people healthy as long as possible. Thus, more research focusing on secondary prevention for HIV-positive people is needed. While women and men experience high levels of stress in living with HIV, we believe that women in particular need to have culturally competent and stage-based interventions developed especially for them. That is, women experience unique challenges in living with HIV and frequently have constraints in the time and effort they have available to them to engage in health-promoting behaviors. Health-promoting stress management behaviors can be inexpensive and appropriate for women regardless of their phase of HIV infection. However, HIV-positive women need to use health-promoting behaviors in order to benefit from them. A key construct in the TTM not evaluated in this study is the processes of change. As previously mentioned, the processes of change are strategies that an interventionist or individual can use to facilitate behavior across the continuum of change. There are 10 processes of change divided into either experiential or behavioral strategies [37]. The theory indicates that experiential processes are predominantly used in the early stages of change while the behavioral process are used mainly in the later stages [49]. While processes of change information would have been useful in evaluating strategies HIV-positive women use to change their behavior, these data were not able to be collected at the time of this study. Researchers and clinicians can use the TTM of Behavior Change to design and test interventions to enhance health-promoting behaviors in HIV-positive women. While a large number of studies have found that health-promoting behaviors such as stress management enhance health and the quality of life, there has been a lack of attention to just how HIV-positive women, in particular, are to adopt and maintain these health-promoting behaviors. Future research in this area should build on the knowledge that stress management enhances health and that interventions to enhance the adoption of health-promoting behaviors are needed. A first step in this program of research could involve descriptive work evaluating the ways in which HIV-positive women make changes within the context of their daily life and within the constraints of limited financial and social resources. Certainly, interventions targeted toward enhancing behavioral change using a process approach is an area of inquiry that will benefit individuals infected with HIV, clinicians, and researchers. Further cross-sectional and longitudinal research in this area is needed.