HIV-related stigma and subjective well-being: The mediating role of the Belief in a Just World

Abstract

The primary aim of this study was to explore the relationship between the domains of HIV-related stigma and subjective well-being in people living with HIV (N = 90), giving a special emphasis to the role of Belief in a Just World. A significant relationship emerged between the domains of stigma and the components of subjective well-being, which is not direct, but is rather mediated by Belief in a Just World. The findings indicate that exposure to stigma can lead to a decrease in Belief in a Just World, which potentially leads to a sense of lack of control over one’s life, with a final, negative outcome for subjective well-being.

Keywords

Belief in a Just World HIV stigma well-being

Introduction

Stigma is a phenomenon which attracts the interest of various scientific disciplines. The fact that it has been studied from a number of different viewpoints and in various contexts makes its precise definition all the more difficult. Most HIV researchers and theorists rely on Goffman’s (1963) understanding that stigma occurs when an individual is in possession of “an attribute which is discredited in a certain society” This attribute is connected to negative evaluations and stereotypes, which is why stigmatized individuals are exposed to discrimination, ostracism, and contempt (Major and O’Brien, 2005). As a result, barriers to reaching important life resources like medical care, work, and education are formed. People living with HIV (PLHIV) are a population which is confronted with these problems on a daily basis. In addition, the HIV-related stigma is often multilayered. This means that PLHIV are perceived as possessing other devalued attributes such as homosexuality, promiscuity, or drug abuse. Research has shown that when HIV-positive people were presented as being homosexuals, injection drug users, or prone to changing sexual partners, they were perceived much more negatively than if they were presented as heterosexuals in a stable relationship (Crandall et al., 1997; Herek and Capitanio, 1999).

In the Republic of Serbia, there are currently 2276 HIV-infected people. In a national study conducted by the Institute of Public Health of Serbia, 30 percent of the participants reported exposure to some form of stigma and discrimination in the past 12 months. The most commonly reported forms were as follows: medical staff withholding the provision of services, social isolation, job loss after the seropositive status is involuntarily disclosed to bosses, and gossiping (Krtinić, 2013). Facing these kinds of experiences on a regular basis usually has negative outcomes for PLHIV. Research has shown that these people’s exposure to stigma is correlated with an increased rate of depression and anxiety (Earnshaw et al., 2013; Herek et al., 2013), low medication adherence (Dlamini et al., 2009), and lower levels of life satisfaction (Heckman, 2003). These are the reasons why reducing HIV-related stigma is so important. However, despite the fact that the relationship between HIV stigma and the mentioned outcomes has been noted many times, the mechanism which lies at its core has rarely been studied. Certain studies have indicated the existence of factors which can have an adaptive role in circumstances of stigma-related stress, such as optimism (Ammirati et al., 2015), spirituality (Porter et al., 2015), and purpose in life (Litwinczuk and Groh, 2007).

Another factor to which adaptive effects are ascribed is Belief in a Just World (BJW). According to the Just world hypothesis (Lerner, 1980), people feel the need to believe that they are living in a just world, and that everyone gets precisely what they deserve. That way, they make a sort of “pact,” according to which if they behave fairly, only fair outcomes will come their way. BJW, then, can be understood as a kind of positive illusion, since it encourages people to perceive the world as a stable, organized place in which everyone knows what is coming to them. This enables them to try and attain long-term goals, to establish interpersonal relations, and to behave in accordance with socially regulated rules (Furnham, 2003). As a result, we can expect BJW to have a positive effect on mental health, which has been proven in a large number of studies: a highly pronounced BJW correlates negatively with symptoms of depression, and correlates positively with one’s self-image and life satisfaction (Correia et al., 2009; Dzuka and Dalbert, 2002; Ritter et al., 1990). The question is, what is the role of BJW in the case of people who are victims of life’s outcomes which are deemed to be unjust, such as tragedies, serious illness, exposure to stigma and discrimination? Unjust outcomes potentially present a challenge to BJW, and to the sense of order and control over life that it offers (Dalbert, 2001). Some authors believe that in the case of these victims, a strong need to maintain their perception of the world as a just one will persevere, that BJW is a stable characteristic which will neither decrease nor increase, and that it will play an adaptive role in stressful situations. In the studies by the aforementioned authors, it was determined that participants with higher BJW saw themselves as significantly less exposed to discrimination (Lipkus and Siegler, 1993), did not perceive a negative outcome as unfair (Hafer and Olson, 1998), and perceived stress as less serious or easier to cope with (Tomaka and Blascovich, 1994). A positive correlation was also determined between BJW and life satisfaction (Dzuka and Dalbert, 2002; Major et al., 2002), while victims of car accidents with high BJW reported higher current happiness (Janoff Bulman and Wortman, 1977). The results, however, are not uniform. On a sample of individuals belonging to minority ethnic groups, it was noted that the more the participants perceived themselves as victims of discrimination, the less they perceived the world as a just, which was ultimately followed by a decreased sense of subjective well-being (Schaafsma, 2013). Similar findings were determined on a sample of individuals who were often exposed to workplace bullying (mobbing) (Cubela Adoric and Kvartuc, 2007). These results suggest that BJW is not very stable, and that exposure to negative life events can lead to its decrease, with an ultimate, negative outcome for subjective well-being. The noted inconsistencies in the results, among other things, can be a consequence of the fact that reactions to negative outcomes differ depending on the type of negative outcome (Furnham, 2003). For example, even though they do not mention any exposure to stigma, some authors have noted that BJW will increase in situations when an individual is faced with severe traumatic events (e.g. the death of a child). However, if an individual is faced with less severe traumatic events (robberies, break-ins, and attacks), the BJW has a tendency to decrease (Corey et al., 2015).

The present study

Bearing in mind that PLHIV are often exposed to stigma and discrimination, and that this endangers their subjective well-being, the following question imposes itself: what, if any, is the role of BJW? Will it remain stable and serve as a sort of coping mechanism, so that PLHIV perceive themselves less as victims of stigmatization, or, will it decrease under exposure to stigma, which will, ultimately, develop low life satisfaction and negative emotional reactions? Until now, we have found no studies which have dealt with the relationship between these variables on the aforementioned sample. It was hypothesized that: (1) the domains of stigma examined will have a negative correlation with life satisfaction and positive affect, and have a positive correlation with negative affect; (2) BJW will have a significant role in the relation between the domains of stigma and subjective well-being examined. To test this hypothesis, mediation analysis was used, and two groups of models were examined: we first started with the theoretical assumption that the BJW will be a stable, dispositional feature of the participants, and that those individuals with high levels of it will perceive themselves to a significantly lesser extent as victims of stigma (Lipkus and Siegler, 1993). Thus, in these models, the role of the independent variable was assigned to the BJW, the role of the mediator to the domain of stigma, and that of the dependent variable to the components of subjective well-being. In the alternative group of models, the role of the independent variable was assigned to the domain of stigma, and the mediator was the BJW. The assumption was that the BJW would decrease under the influence of exposure to stigma, which would have negative consequences on subjective well-being (Cubela Adoric and Kvartuc, 2007; Schaafsma, 2013).

Method

Design, procedure, and sample

The study design was cross-sectional. It was carried out at the Clinic for Infectious Diseases in Niš, the Republic of Serbia, with the approval of the Ethics Committee from the Clinical Center in Niš. Medical staff introduced the study to the patients, and if they were interested, a meeting was held with the researcher to determine whether they met the criteria. The participants needed to be HIV positive, 18 years of age or older, and able to read and understand the Serbian language. The sample consisted of 90 individuals living with HIV, mostly men (n = 79), with the average age of 41.64 years (SD = 9.12). The remaining demographic characteristics can be found in Table 1. Written informed consent was obtained from all participants.

Table 1.

Demographic characteristics of the sample.

Variable	Category	Mean (SD) or %
Relationship status	Single	50.8%
	Married/in a relationship	33.9%
	Divorced	13.6%
	Widowed	1.7%
Employment status	Employed	44.1%
	Retired	18.6%
	Unemployed	37.3%
Length of time since HIV diagnosis		7.88 (8.24) years
Education	No school	1.7%
	Elementary	8.5%
	High school	52.5%
	College graduate	37.3%
Sexual orientation	Homosexual	35.6%
	Bisexual	18.6%
	Heterosexual	45.8%

Measures

The HIV stigma scale (Bunn et al., 2007) examines daily exposure to stigma in four domains: (1) personalized stigma—the items refers to experiences such as rejection, loss of friends, loss of support, and a sense that the participant is being avoided by others; (2) disclosure concerns—the items in this domain refer to the behavior of the participants which they use to control the information on their seropositive status; (3) negative self-image—the feeling that the person is different, less worthy than others, with feelings of guilt and shame for their HIV-positive status; and (4) concern with public attitudes measures what the person with HIV believes other people might think about him/her. All the items were presented on a four-point Likert scale, with responses indicating the degree of agreement/disagreement (1 = “strongly disagree,” 2 = “disagree,” 3 = “agree,” 4 = “strongly agree”). Responses were scored so that higher scores indicated higher levels of perceived exposure to a certain domain of stigma. The scale in our study had a satisfactory level of reliability for all four domains (Table 2).

Table 2.

Intercorrelations, mean values, and SDs of measures.

	1	2	3	4	5	6	7	8
1. PS	–
2. DC	.27*	–
3. NSI	.55**	.46**	–
4. CWPA	.55**	.40**	.49**	–
5. BJW	−.48**	−.08	−.49**	−.43**	–
6. NA	−.48**	.24	.60**	.36**	−.60**	–
7. PA	−.33*	−.09	−.41**	−.21	.31*	−.26*	–
8. LS	−.25*	−.11	−.46**	−.31*	.66**	−.58**	.42**	–
Mean (SD)	2.23 (0.96)	3.21 (0.67)	2.23 (0.72)	3.24 (0.60)	3.46 (0.99)	22.51 (9.68)	33.93 (9.12)	3.28 (1.07)
α	.79	.95	.72	.80	.76	.91	.84	.87

PS: personalized stigma; DC: disclosure concerns; NSI: negative self-image; CWPA: concern with public attitudes; BJW: Belief in a Just World; NA: negative affect; PA: positive affect; LS: life satisfaction.

p < .05; **p < .01.

The personal belief in a just world scale (Dalbert, 2001) consists of seven items. An example of an item on the scale is “I think I generally deserve what is happening to me in my life,” and each item is presented on a six-point Likert scale. Higher summed scores indicate a greater BJW. A version adapted to the Serbian language environment was used (Cubela, 2001).

In accordance with Diener’s (2000) model of subjective well-being, the cognitive component was measured with a scale of life satisfaction, and the affective component on the Serbian Inventory of Affect, based on the Positive and Negative Affect Schedule (SIAB-PANAS) scale.

The satisfaction with life scale (Diener et al., 1985) includes five items on a five-point Likert scale. The overall score indicates life satisfaction, whereby a higher score indicates greater life satisfaction. For the purpose of our study, we used the adapted version from the work of Penezić (1996).

SIAB-PANAS (Mihic et al., 2014) consists of 20 items which measure the emotional state of the participant on two dimensions (positive and negative affect) over a certain period of time. The scale represents an adapted version of the PANAS scale (Watson et al., 1988), where the participants are expected to note for each of the offered emotions just how strongly on a scale from 1 to 5 they have felt it over the past few weeks. By adding up the values, depending on whether the emotions are of negative or positive affect, the overall scores are formed for these two dimensions.

Results

Table 2 shows the descriptive statistics, the bivariate correlation coefficients of the variables in the study, and the reliability coefficients. A significant correlation was noted between the aforementioned domains of stigma, BJW, life satisfaction, and positive and negative affect, which satisfies the criterion for mediational analysis.

In order to check for the presence of mediation, we used the bootstrapping method (Preacher and Hayes, 2008) with 5000 samples, and 95 percent confidence intervals. It is believed that mediation exists if the intervals do not include a zero. Age and length of time since the HIV diagnosis were included as covariates. The analysis did not include disclosure concerns domain and any of its relationships to the components of subjective well-being, considering the fact that these relationships were statistically non-significant. For the same reason, no mediation analysis was carried out in the case of the relationship between the concern with public attitudes and positive affect. Due to the relatively small sample size, we decided to check the statistical power of the mediation analysis conducted within the research. After using David E. Kenny’s Medpow app, post hoc power analysis indicated that all analyses had more than satisfactory power (exceeding .90).

First, we tested the group of models in which BJW had the status of an independent variable, domains of stigma had the status of the mediator, and subjective well-being was the dependent variable. However, none of these models indicated a statistically significant indirect effect. Then, we decided to examine alternative models, with the assumption that BJW would be a significant mediator of the relationship between the domains of stigma and components of subjective well-being. The mediation analysis of these models has provided the following results.

After the BJW was included in the analysis, the statistically significant correlation between personalized stigma, negative self-image, and concern with public attitudes on the one hand, and life satisfaction on the other, became non-significant. Thus, the results indicate the complete mediation of the BJW. The more the participants perceived themselves as victims of the stigma, the lower their BJW, which in the end had a negative correlation with life satisfaction (Table 3). Similar results were found when negative affect was the dependent variable (Table 4). From Table 5, we can conclude that the BJW is not a significant mediator in the relationship between stigma and positive affect.

Table 3.

Indirect effects of stigma on life satisfaction via BJW, including B (SE).

	Effect of IV on M	Effect of M on DV	Direct effect	Indirect effect	CI for indirect effect
Personalized stigma	−.49 (.12)*	.75 (.12)*	.09 (.12)	−.37 (.11)*	−.62/−.19
Negative self-image	−.68 (.16)*	.62 (.12)*	−.26 (.16)	−.42 (.13)*	−.72/−.20
Concern with public attitudes	−.72 (−20)*	.70 (.12)*	−.05 (.20)	−.50 (.19)*	−.92/−.22

CI: confidence interval; DV: Dependent variable; M: Mediator; IV: Independent variable.

p < .05.

Table 4.

Indirect effects of stigma on negative affect via BJW, including B (SE).

	Effect of IV on M	Effect of M on DV	Direct effect	Indirect effect	CI for indirect effect
Personalized stigma	−0.49 (0.12)*	−3.82 (1.07)*	2.57 (1.18)*	2.26 (0.90)*	0.83/4.29
Negative self-image	−0.68 (0.16)*	−3.82 (1.07)*	5.52 (1.48)	2.59 (0.99)*	1.20/5.27
Concern with public attitudes	−0.72 (0.20)*	−5.25 (1.14)*	2.05 (1.90)	3.78 (1.39)*	1.47/6.93

CI: confidence interval.

p < .05.

Table 5.

Indirect effects of stigma on positive affect via BJW, including B (SE).

	Effect of IV on M	Effect of M on DV	Direct effect	Indirect effect	CI for indirect effect
Personalized stigma	−0.49 (0.12)*	1.77 (1.29)	−2.21 (1.33)	−0.87 (0.61)	−2.34/0.07
Negative self-image	−0.68 (0.16)*	1.27 (1.27)	−4.26 (1.75)*	−0.86 (0.79)	−2.65/0.56

CI: confidence interval.

p < .05.

Discussion

The research was conducted with the aim of more closely studying the relation between stigma to which PLHIV were exposed and subjective well-being. The assumption was that BJW might have an important role at the base of the mechanisms with which stigma influences the components of subjective well-being.

The results of the bivariate analysis primarily indicate a negative correlation between personalized stigma on the one hand, and life satisfaction and positive affect on the other. In addition, a positive correlation was noted between the aforementioned domain of stigma and negative affect. The same pattern of results was noted in the case of a negative self-image and concern with public attitudes. Thus, the results confirm the hypothesis that stigma will relate negatively to the subjective well-being of individuals living with HIV.

Following that, the hypothesis that BJW will have a significant role in relation to stigma and subjective well-being was examined. A mediation analysis, which included the control of the potential covariates, was used when studying the two groups of models. In the first of these, the role of the independent variable was assigned to BJW and the role of the mediator to the domain of the studied stigma. This model is based on the theoretical assumptions that BJW will have a buffering effect, which can affect the extent to which the participants perceive themselves as victims of stigma (Lipkus and Siegler, 1993). We expected that the more the participants believed the world to be a just place, the less they would be prone to viewing themselves as victims, thus showing a higher level of life satisfaction, more frequent manifestations of positive affect, and more rare manifestations of negative affect. The results, however, did not indicate statistically significant indirect effects in these models, and so the hypothesis was not confirmed. Following that, we studied an alternative model. Within it, the role of the independent variable was assigned to the domains of stigma, and the role of mediator to BJW. This time, the mediation analysis indicated that the more the participants perceived themselves as victims, the less they believed in a just world, which resulted in lower life satisfaction and increased negative affect. Negative self-image, as well as concern with public attitudes, had the same indirect effect on life satisfaction and negative affect. Thus, the results are in line with the previous findings that frequent exposure to outcomes, which represent a challenge to BJW, can lead to its decrease among the participants (Corey et al., 2015; Cubela Adoric and Kvartuc, 2007; Ramos et al., 2013; Schaafsma, 2013). When individuals are exposed to cumulative negative events, such as rejection by their immediate and broader environment, a developed sense of shame and guilt, and a daily concern with the potential reactions of the public, it seems that the BJW will not remain stable, or have an adaptive role (Major et al., 2002). On the contrary, the decreased perception of the world as a just place among individuals living with HIV could develop in them a sense of unpredictability and lack of control over what is going on, irrespective of how the individual is behaving. This sense that the outcomes in life are completely determined by external factors and that fair behavior and invested effort will not necessarily ultimately pay off, could lead to decreased life satisfaction, and negative emotional reactions. For example, PLHIV are often shunned by their friends and family. It is possible that under the influence of decreased BJW, they may sense (consciously or unconsciously) that there is no point in putting in a lot of effort to establish interpersonal relations, as they will, eventually, end up with rejection and avoidance. That way, instead of seeking social support, PLHIV remain exposed to social isolation, which has a negative impact on well-being (Herek et al., 2013).

Limitations

Considering the fact that this is the first study (to our knowledge), which analyzes the relationship between the aforementioned variables on a sample of PLHIV, we cannot claim that we have fully explained the mechanisms which affect their relationships. Primarily, the cross-sectional nature of the study does not allow us to make any causal conclusions. Future researchers are especially recommended to carry out longitudinal studies, which would repeatedly evaluate and monitor whether, and how, BJW changes as a consequence of stigma, and what its influence on subjective well-being would be. In addition, the research sample is relatively small, which made it impossible for us to study any potential moderating effects of the registered sociodemographic variables. Although there were satisfactory power sizes in the current study, future research should select larger samples of PLHIV.

Despite the limitations cited, the results represent a good starting point for further study, and can be applied when counseling PLHIV. Health promoters should design interventions that enhance BJW and which could, indirectly, lead to a decrease in the perception of stigma and enhanced well-being. These interventions could be combined with those already designed for reducing HIV-related stigma in health workers, family members, or people in general (Brown et al., 2003; Pulerwitz et al., 2010).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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