Abstract
In the United States, Black women living with HIV face various individual (e.g. trauma) and structural (e.g. racism) adversities. However, resilience is understudied among Black women living with HIV. A total of 100 Black women living with HIV in the United States completed measures of resilience, general self-efficacy, self-esteem, post-traumatic growth, trauma symptoms, trauma-related cognitions, and depressive symptoms. Regressions controlling for age and education indicated that higher resilience was associated with higher general self-efficacy (β = .39, p < .001), higher self-esteem (β = .48, p < .001), higher post-traumatic growth (β = .34, p < .01), lower post-traumatic cognitions (β = –.36, p < .001), lower trauma symptoms (β = –.29, p < .01), and lower depressive symptoms (β = –.38, p < .001). Our findings suggest potential targets for interventions.
Introduction
Black women account for the majority of women diagnosed and living with HIV in the United States, and they experience higher HIV-related morbidity and mortality compared with women of other racial/ethnic groups (Centers for Disease Control and Prevention, 2016, 2018). The elevated risk and burden of the HIV epidemic for Black women is linked to both structural and psychosocial factors including racism, poverty, violence/trauma, and stigma (Blackstock et al., 2015; Dale et al., 2018; Kelso et al., 2014; Urbaeva and Warner, 2018). Resilience has been defined as a combination of both adaptive coping strategies and traits such as humor, persistence, and flexibility in the context of or following adversity (Campbell-Sills and Stein, 2007). In the face of numerous adversities and inequities, many Black women living with HIV (BWLWH) may cope adaptively and be resilient (Dale et al., 2018; Dale and Safren, 2018). However, the HIV literature is limited in terms of capturing and depicting resilience among BWLWH (Dale et al., 2014a, 2014b; Dale and Safren, 2018; Kelso et al., 2014; Logie et al., 2014).
Existing quantitative literature on resilience among women with HIV have found important associations between resilience (as a predictor) and mental and physical outcomes. Among a sample of women at risk for HIV and living with HIV from the Women Interagency HIV Study (WIHS; Bacon et al., 2005), Dale et al. (2015) found that higher resilience was associated with higher health-related quality of life and lower depressive symptoms, and that resilience moderated the relationship between childhood sexual abuse history and depressive symptoms. Dale et al. (2014b) also found that among women living with HIV, higher resilience was related to higher HIV medication adherence and lower likelihood of having a detectable HIV viral load, and that resilience moderated the relationship between trauma histories and HIV medication adherence. WIHS researchers have also linked higher resilience with lower trauma symptoms among women with HIV (Spies and Seedat, 2014).
Beyond physical and mental health associations of resilience, the literature has also noted associations between higher resilience and other factors among women with HIV. For instance, researchers have found that higher resilience is associated with higher social support (Dale and Safren, 2018; Logie et al., 2014). Furthermore, researchers have found that higher resilience is related to lower gender roles (prescribed norms for women such as sacrificing one’s needs to care for others and silencing their thoughts and feelings to maintain harmony in relationships) among women with HIV (Dale et al., 2014a). Although not in samples of women, a study also reported an association between higher resilience and higher post-traumatic growth (experiencing positive growth from a traumatic event; Yu et al., 2017).
Given that the HIV literature is only at the early stages of investigating resilience among people living with HIV and developing approaches to enhance resilience, it is important to examine the various factors that may be associated with resilience. For BWLWH, it is particularly important to research correlates of resilience, which may provide insights on strategies to enhance resilience among BWLWH. This article builds on the small body of literature on resilience among women with HIV by examining among BWLWH and histories of trauma, the relationships between resilience, self-efficacy, self-esteem, post-traumatic growth, depressive symptoms, post-traumatic stress symptoms, and post-traumatic cognitions. Findings may provide important insights on factors to address when aiming to enhance resilience among BWLWH.
Methods
Participants
This sample was recruited between October 2017 and May 2018 in an urban city in the Southeast United States, as part of an intervention study for BWLWH who had experienced trauma. Recruitment efforts consisted of the distribution of flyers and posters at hospitals, community health centers and clinics, community-based organizations, and community events. Once potential participants contacted the study staff via phone, they were screened for eligibility. To be eligible for an in person baseline assessment, participants had to meet the following inclusion criteria on the phone: (1) English speaking, (2) age 18 or older, (3) identify as Black and/or African American, (4) biologically female, (5) prescribed antiretroviral therapy (ART) for HIV for at least the last 2 months, (6) History of abuse/trauma, and (7) possibility of either low ART adherence, detectable viral load within the past year, and/or missed HIV-related medical visits within the past year.
Baseline assessment spanned 2 weeks and consisted of an initial visit and second visit at the research institution. At the initial visit, participants gave written informed consent, completed self-report measures/surveys via Research Electronic Data Capture (REDCap, a secure web-based application; (Harris et al., 2009)) and engaged in a semi-structured clinical interview.
Participants were given US$50 total (US$25 at initial visit and US$25 at second visit) for the baseline assessment to reimburse them for their time and efforts. The Institutional Review Board of the University of Miami approved all study procedures.
Measures
Self-report Sociodemographic Survey
This survey captured information including age, country of birth, education level, annual income, employment status, living situation, number of children, religious affiliation, relationship status, sexual orientation, and HIV viral load status (i.e. detectable vs undetectable).
Connor-Davidson Resilience Scale 10
The Connor-Davidson Resilience Scale (CD-RISC) 10 is a 10-item scale that captures resilient coping and traits (Campbell-Sills and Stein, 2007). Scale items include “I am able to adapt when changes occur” and “I try to see the humorous side of things when I am faced with problems.” Respondents answer on a 5-point Likert-type scale with options ranging from “not true at all” to “true nearly all the time.” The CD-RISC 10 has shown good evidence of reliability (Cronbach’s alpha of .85) and validity in the literature (Campbell-Sills and Stein, 2007). In the present sample, Cronbach’s alpha was .89.
Post-traumatic Growth Inventory
The Post-traumatic Growth Inventory (PGI) measures psychological growth following a traumatic experience via 21 items (Tedeschi and Calhoun, 1996). Sample items include “I established a new path for my life” and response options on a 6-point Likert-type scale range from “I did not experience this change” to “Very great degree.” The PGI has shown good internal consistency (Cronbach’s alpha of .90) and validity in previous studies (Tedeschi and Calhoun, 1996). Cronbach’s alpha was .95 in the present study.
General Self-efficacy Scale
The General Self-efficacy Scale (GSE) is a 10-item scale that measures a person’s belief that they can perform tasks and cope with stressors (Schwarzer and Jerusalem, 1995). Items include “I can solve most problems if I invest the necessary effort” and “If I am in trouble, I can usually think of a solution,” Participants provide responses on a 4-point Likert-type scale ranging from “Not at all true” to “Exactly true.” The GSE has demonstrated great reliability (Cronbach’s alpha .86 to .94) and validity in prior research (Schwarzer and Jerusalem, 1995). In the current sample, Cronbach’s alpha was .91.
Rosenberg Self-esteem Scale
The Rosenberg Self-esteem Scale (RSE) is a 10-item scale that captures an individual’s self-esteem (Sinclair et al., 2010). Sample items include “On the whole, I am satisfied with myself” and “I take a positive attitude toward myself” and participants respond on a 4-point Likert-type scale (e.g. strongly disagree to strongly agree). The scale showed good internal consistency in the literature (Cronbach’s alpha of .90) and in the present study with a Cronbach’s alpha of .79.
Davidson Trauma Scale
The Davidson Trauma Scale (DTS) scale is a 17-item measure that measures symptoms of post-traumatic stress disorder (PTSD) that fall within three clusters of PTSD symptoms (i.e. re-experiencing, avoidance, and arousal) (Davidson et al., 1997). A sample item is “Have you ever had painful images, memories, or thoughts of the event?” Using 5-point Likert-type scales, the DTS captures both the frequency of each PTSD symptom (e.g. 0 = not at all, 4 = everyday) and the related distress (e.g. 0 = not at all distressing, 4 = extremely distressing). DTS is a commonly used trauma measure that has shown excellent reliability (Cronbach’s alpha of .99) and validity in the literature (Davidson et al., 1997). Cronbach’s alpha was .94 in the current sample.
Post-traumatic Cognition Inventory
The Post-traumatic Cognition Inventory (PTCI) is a 36-item scale that captures trauma-related thoughts (Foa et al., 1999). Respondents answer items such as “The event happened because of the way I acted” on a 7-point Likert-type scale (ranging from totally disagree to totally agree). The PTCI has demonstrated excellent reliability (Cronbach’s alpha of .97) and validity in existing literature (Foa et al., 1999). In the current sample, Cronbach’s alpha was .96.
Center for Epidemiologic Studies Depression Scale
The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item measure of current depressive symptoms (Radloff, 1977). Sample items include “I had crying spells” and “I felt lonely.” It has shown great reliability (Cronbach’s alphas of .85 to .90) and validity in previous studies (Radloff, 1977) and the Cronbach’s alpha in the present sample was .88.
Analyses
SPSS version 24 was used to conduct all statistical analyses. All 100 participants who completed baseline assessments were included in analyses. Multivariable linear regressions controlling for covariates of age and education were conducted to analyze the associations between resilience, self-efficacy, self-esteem, post-traumatic growth, depressive symptoms, trauma symptoms, and post-traumatic cognitions.
Results
Socio-demographic characteristics
A total of 100 BWLWH participated in this baseline assessment study. Their socio-demographic characteristics and the descriptive statistics on study measures are presented in Table 1. In brief, women’s average age was 49 (range = 22%–67%), 64% completed high school or above, 63% had an annual income of less than US$12,000, 62% were on disability, and 72% were renting a home or apartment. A total of 96 to 100 percent of women responded to all the measures (Table 2).
Sociodemographics and characteristics of Black women living with HIV.
GED: General Education Development.
Multivariable regressions among resilience and psychological variables.
CI: confidence interval.
Multivariable associations of resilience and psychological variables
The first set of multivariable linear regressions was run controlling for age and education with predictors of self-esteem and self-efficacy and resilience as the outcome. Results showed that higher self-esteem (β = .48, p < .001) and higher self-efficacy (β = .39, p < .001) were related to higher resilience. The second set of multivariable linear regressions controlling for age and education was conducted to investigate the associations between resilience (entered as the predictor) and outcomes of post-traumatic growth, depressive symptoms, trauma symptoms, and post-traumatic cognitions. Higher resilience was significantly associated with higher post-traumatic growth (β = .34, p < .01), lower depressive symptoms (β = –.38, p < .001), lower trauma symptoms (β = –.29, p < .01), and lower post-traumatic cognitions (β = –.36, p < .001).
Discussion
Among a sample of BWLWH with histories of trauma, we found several factors to be associated with resilience: higher self-efficacy, higher self-esteem, higher post-traumatic growth, lower depressive symptoms, lower trauma symptoms, and lower post-traumatic cognitions. With limited literature on resilience among BWLWH and histories of trauma, these findings highlight factors that may be targeted in interventions to promote resilience among this community. This is the first study to demonstrate associations between self-efficacy and self-esteem with resilience.
The positive associations between resilience and self-efficacy and self-esteem conceptually make sense. Self-efficacy is an individual’s ability to execute tasks well, therefore a person with high self-efficacy may be able to do what is needed in order to adapt and bounce back after adversities (i.e. be resilient). Similarly, a woman who is confident about herself and qualities (i.e. has high self-esteem), may approach her recovery after adversity in the same manner (i.e. “I can deal with whatever comes my way”). Also, if one is resilient post an adverse experience that may boost one’s self-esteem. The positive relationship between post-traumatic growth and resilience also suggests that women who were able to observe their growth following trauma and attribute some of that growth to surviving the trauma were higher in resilience. This is consistent with an existing publication among Chinese men who have sex with men (MSM) with HIV that found higher post-traumatic growth was also related to higher resilience (Yu et al., 2017).
A few of our findings between resilience and mental health symptoms were also aligned with existing literature, while one finding makes a novel contribution. Our findings that higher resilience relates to lower depressive symptoms and trauma symptoms in this sample of BWLWH with histories of trauma confirms prior work (Dale et al., 2015; Spies and Seedat, 2014) in general samples of women living with HIV and men and women with HIV who were with or without histories of trauma. These findings also suggest that higher resilient traits and coping could potentially help to decrease depressive symptoms and trauma symptoms for BWLWH and histories of trauma and therefore should be explored further in future research. Our finding that higher resilience relates to lower post-traumatic cognitions makes a novel contribution to the literature and highlights that resilient traits and coping such as believing that “I am not easily discouraged by failure” may help to lower or counteract negative post-traumatic cognitions such as “I am a weak person.”
Our findings should be understood within the context of a few limitations. First, this was a cross-sectional study design, which limits causal inferences. Second, all measures relied on participants’ self-report and therefore may be impacted by social desirability bias. Third, our findings may not be generalizable to all BWLWH in the United States since a screening criteria in order to be scheduled for an in person baseline assessment was the possibility of either low ART adherence (less than “excellent” self-reported adherence), detectable viral load within the past year, and/or one or more missed HIV-related medical visits within the past year. However, among our baseline assessment sample blood work showed that 67% had a current undetectable viral load and 33% had a current detectable viral load, which indicates that a large proportion of women were meeting the ultimate goal (undetectable) for HIV treatment/disease management. Despite the noted limitations, our findings imply that for BWLWH with histories of trauma, resilient traits, and coping strategies may be beneficial in addressing trauma symptoms, depressive symptoms, and post-traumatic cognitions. In addition, self-efficacy and self-esteem are positive factors associated with resilience that should be enhanced in interventions.
In summary, our findings add to the limited literature on resilience among BWLWH. This article reports new relationships between resilience, self-efficacy, self-esteem, and post-traumatic cognitions. It also confirms prior work on the associations between resilience and depressive symptoms (Dale et al., 2015) in a general sample of women with HIV (not specifically Black women) and resilience and trauma symptoms among men and women with HIV (Spies and Seedat, 2014). Furthermore, it confirms findings between resilience and post-traumatic growth that was only previously noted once in the literature (Yu et al., 2017). Our findings may inform interventions aimed at enhancing resilience among Black women with HIV and histories of trauma.
Footnotes
Acknowledgements
We would like to express our utmost gratitude to the women who participated in this research, community stakeholders, and research staff members.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in this publication and the principal investigator (S.K.D.) were funded by 1K23MH108439 from the National Institute of Mental Health. S.A.S. was funded by grant K24DA040489. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
