Perceived stigma and life satisfaction: experiences of urban African American men living with HIV/AIDS.

The purpose of this study was to explore associations and relationships between the domains of perceived stigma and life satisfaction in a sample of HIV-infected African American men in an urban setting. A descriptive cross-sectional survey design method was used. Participants include a convenience sample (N = 55) of urban African American males who self-identified as having HIV/AIDS. Study participants completed a questionnaire that included sociodemographic indicators (age, education, length of time since diagnosis, subjective health status, clinical status) as well as instruments designed to measure perceived stigma (personalized stigma, negative self-image, disclosure concerns, and public attitudes) using the perceived stigma scale and life satisfaction scale. A majority of the men perceived being stigmatized along the domains of personalized stigma, negative self-image, disclosure concerns, and public attitudes, all of which were inversely associated with life satisfaction. A hierarchical regression analysis identified four stigma domains that accounted for 40.2% of variance in life satisfaction after adjusting for sociodemographic variables. Mediational analysis indicated that the domains of personalized stigma and public attitudes operated through negative self-image to influence life satisfaction. Findings from this study suggest that HIV-related stigma is a complex phenomenon experienced in both the personal and social realms. Reducing stigma through targeted interventions may aid individuals with HIV/AIDS to better adhere to treatment regimens and improve their life satisfaction.

Keywords: HIV/AIDS, African American males, perceived stigma, health system barriers, life satisfaction, quality of life

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There is overwhelming agreement among public health professionals that the HIV/AIDS epidemic is a critical health problem for African Americans. Of all males living with AIDS in the United States at the end of 2003, the Centers for Disease Control and Prevention (CDC) reports that more than one-third (37.2%) were African Americans (CDC, 2003a, 2003b). In 2003, based on confidential laboratory reporting in 31 states, the estimated incidence rate of AIDS among persons 14 years of age or older in the United States was nearly three times greater for males than for females (CDC, 2004). Non-Hispanic African American males were eight times more likely than non-Hispanic white males to be newly diagnosed with AIDS and three times as likely as Hispanic men. The CDC estimates that between 1999 and 2003, 59% of newly diagnosed AIDS cases were in men who had sexual contact with men (MSM) and 23% in men who injected illegal drugs. Most new AIDS cases for which MSM is the HIV exposure category are now among MSM of color. They face barriers to HIV counseling, testing, and care (CDC, 2002). African Americans have the least favorable long-term AIDS survival rate (CDC, 2004). The HIV/AIDS epidemic has differentially had an impact on the African American community, in particular African American males.

To reduce the HIV/AIDS disparity in the African American community, multiple strategies must be taken to increase the rate of voluntary HIV testing, to decrease the risk of transmission of HIV/AIDS, and to increase access to healthcare and social services as well as the use of life-extending treatment. Adherence to antiretroviral therapy has been shown to improve quality of life (Mannheimer et al., 2005). Although HIV/AIDS threatens both longevity and quality of life (Heckman, 2003), quality of life and factors that may affect it such as stigma have received limited attention in the literature to date.

STIGMA AS AN OBSTACLE TO PREVENTION, TREATMENT, AND CARE

HIV/AIDS is a disease that may be perceived by the afflicted person as highly stigmatizing when the stigma has been internalized (Lee, Kochman, & Sikkema, 2002). Moral stigma based on the modes of transmission of HIV/AIDS through male-to-male sexual contact, sex work, and the use of injected drugs may be imposed by others (Reidpath & Chan, 2005). Additional stigma may be incurred by individuals who come from a racial/ethnic minority and/or an economically disadvantaged back ground. Reidpath and Chan (2005) have referred to multiple sources of stigma as being "layered." In another study, Berger et al. (2001) conducted a psychometric assessment of an HIV stigma scale (N = 318), and four factors emerged: personalized stigma, disclosure concerns, negative self-image, and concerns with public attitudes toward people living with HIV infection. This instrument had good construct validity and internally consistent reliabilities, with coefficient alphas between .90 and .93 for the subscales and .96 for the 40-item measures (Berger et al., 2001). These investigators found that self-esteem scores were correlated negatively with all the perceived stigma scores and were most strongly associated with negative self-image related to stigma.

In addition to the direct impact of stigma on those who are HIV-infected, studies have shown that stigma can also have repercussions on both the person who is infected and their close friends (Lichtenstein, 2003). Stigmatization, perceived or enacted, could lead to failure to disclose one's seropositive status and/or seek treatment (Lichtenstein, 2003; Paxton, 2002). Individuals become hesitant to be tested for the virus. Disclosure of HIV status becomes a dilemma because doing so can lead in some instances to rejection and in some cases even to physical violence (Chesney & Smith, 1999; Lee et al., 2002). The failure of not disclosing one's seropositive status may lead to self-imposed isolation, missed opportunities for seeking early treatment, and difficulty gaining access to both formal and informal services and networks that address healthcare and non-healthcare needs (Carr & Gramling, 2004; Chesney & Smith, 1999; Lee et al., 2002). By identifying HIV-infected African American men who perceive themselves to be stigmatized because of their condition, healthcare professionals may be better able to develop and target specific interventions aimed at reducing stigma. Studying the domains of stigma of HIV-infected individuals can be used to sensitize healthcare professionals to particular types of stigma that are amenable to effective interventions.

LIFE SATISFACTION AS A MEASURE OF QUALITY OF LIFE

Life satisfaction has been variously defined as contentment, harmony, or happiness (Anke & Fugl-Meyer, 2003) or as optimism about one's life and health (Crawford, Allison, Zamboni, & Soto, 2002; Somlai et al., 2000). As individuals who are HIV-infected increasingly live longer, it is critical for healthcare providers and researchers to understand how stigma and other factors may affect life satisfaction. How does the perception or experience of HIV/AIDS affect life satisfaction among those who are HIV-infected? Limited published research exists on how life satisfaction differs by ethnic minority groups or gender. In one multi-ethnic study, however, Portillo et al. (2005) found that individual characteristics, physiological factors, symptom status, functional status, and general health perception made statistically significant contributions to life satisfaction in persons with HIV/AIDS. Among the few studies that exist on the relationship between stigma and life satisfaction, Heckman (2003) found that HIV-infected women reported less life satisfaction and faced more barriers to healthcare and social services than did men.

A high level of satisfaction with life can be viewed as successful adaptation to or coping with the HIV infection. In a study of fatalism, current life satisfaction, and risk for HIV infection among gay and bisexual men, Kalichman, Kelly, Morgan, and Rompa (1997) found that the motivation to initiate and maintain risk-reducing behaviors was less common among participants who were dissatisfied with their lives. Steps are more likely to be taken to preserve one's well-being when individuals have a positive view of their present life situation and want to live longer (Kalichman et al., 1997). These investigators concluded that some men who have sex with men (MSM) engage in high-risk sexual behavior because they are less optimistic about their future.

SELF-RATED AND PERCEIVED HEALTH STATUS AND OTHER CONTEXTUAL FACTORS

Self-rated or perceived health measures have been used increasingly in biobehavioral, health-promotion, and chronic disease research (Heinrich, 2003; Kawachi, Kennedy, & Glass, 1999; Kim, Bramlett, Wright, & Poon, 1998). Poor perceived health is strongly predictive of adverse health outcomes (Kawachi et al., 1999). Because HIV/AIDS is a chronic disease, it is increasingly imperative to enhance the health status of individuals living with HIV/AIDS. Personal factors such as age, gender, social class, and presence of chronic disease may affect the health status of persons with HIV/AIDS (Kalichman et al., 1997; Wilson & Cleary, 1995). Existing research shows inconsistent results regarding how much influence these factors have on a patient's subjective perception of his health (Kawachi et al., 1999). Individuals who perceive themselves as ill often might be less confident about their health and their ability to maintain hope, practice self-care, and engage in risk-reducing behaviors (Kalichman et al., 1997; Hunt, McEwan, & McKenna, 1985; Hunt & McEwan, 1980). In a study of enhancing the perceived health of HIV seropositive men, Heinrich (2003) found significant positive paths from hope to perceived health.

To our knowledge, no information exists on the role of self-rated health in life satisfaction of HIV-infected African American men. An assessment of perceived health status in this population (controlling for demographic factors) would help enhance healthcare professionals' understanding of the psychosocial problems African American males experience while living with HIV/AIDS. The aim of the present study was to explore associations and relationships between the domains of perceived stigma and life satisfaction among a sample of HIV-infected African American men in an urban setting.

METHODS

DESIGN AND PARTICIPANTS

For this cross-sectional descriptive study, survey questionnaires were administered to a sample of African American males (18 years or older) who reported having been diagnosed with HIV infection (N = 55). The mean age of the participants was 48.84 years (SD = 7.67; range 23 to 66 years). The mean years since being diagnosed with HIV infection was 10.79 CSD = 6.4). Twenty-seven percent of the participants reported having less than a high school education, and 67% had an annual income of less than $10,000.

DATA COLLECTION AND PROCEDURES

Individuals were recruited through advertising at a local African American community-based organization in a Midwest urban area. Participants were also recruited by word-of-mouth endorsement by other participants. Potential subjects interested in volunteering for the study were reached directly by the investigators or through the designated local African American health organization. The investigators arranged for a mutually convenient time and place, where a participant was interviewed. The University of Wisconsin-Milwaukee Institutional Review Board reviewed and approved the study for the Protection of Human Subjects. Signed informed consent was obtained prior to beginning the data collection.

INSTRUMENTS AND STUDY MEASURES

Data were obtained on the following sociodemographic and HIV status variables: age, education, income, length of years since diagnosis, and clinical status of the disease. Clinical status or stage of the disease was reported by the participants.

A single-item measure was used to assess self-rated health status. The self-rating of health (single- and multidimensional items) is a global health assessment technique that is increasingly being used in sociological and epidemiological studies. Studies suggest that the self-ratings of health are valid and reliable indicators of health-related quality of life (Segovia, Bartlett, & Edwards, 1989; Fylkesness & Forde, 1991). Participants were asked: How would you rate your overall health at the present time? A five-point response format was used, with choices ranging from 1 (poor) to 5 (excellent). A higher score indicates perception of health as good. The validity and reliability of single-item ratings of self-rated health status have been established by the Rand's Health Insurance Study (Ware, Davies-Avery, & Donald, 1978). As demonstrated by preliminary regression methods, neither clinical status nor perceived health contributed significantly to the models. Consequently, these variables were not used in the hierarchical regression models. Rather, the measures are reported as descriptors of the sample.

MEASURES OF HIV STIGMATIZATION

Perception of stigma as experienced by participants in our study was assessed using the HIV Stigma Scale (Berger et al., 2001). This 40-item tool includes four subscales. Personalized stigma (18 items) addresses the perceived consequences of other people knowing that the respondent has HIV, including losing friends, feeling that people are avoiding them, and having regrets about having told people. Disclosure concerns (10 items) are related to controlling information, keeping one's HIV status secret, or worrying that those who know about the respondent's HIV status will tell others. Negative self-image (13 items) refers to feeling unclean, not as good as others, or bad as a person because of being HIV-infected. Concern with public attitudes (20 items) refers to what "most people" think about a person with HIV or what "most people" with HIV can expect when others learn they have HIV infection.

In the development of this instrument, Berger et al. (2001) utilized an alpha extraction with oblique rotation, which allows the factors to be correlated to each other. Subscales consisted of all items that loaded .50 or better on that factor (Berger et al., 2001). Sixteen items loaded on more than one factor and were used in multiple factors. The total score, representing a single construct, was calculated by computing the sum of the 40 items.

Participants were asked to indicate their feelings or perceptions about a statement on a scale of 1 (strongly disagree) to 4 (strongly agree). Two items: "I never feel ashamed of having HIV" and "I never feel I have to hide the fact I have HIV" are reverse scored so that a higher score indicates less agreement. Each scale or subscale's score is calculated by simply adding the values of the items belonging to that scale or subscale. The range of possible scores depends on the number of items in the scale. The total HIV Stigma Scale score can range from 40 to 160 (1 X 40 items to 4 X 40 items). The personalized stigma subscale scores can range from 18 to 72. For the disclosure subscale, scores can range from 10 to 40. For the negative self-image subscale, scores can range from 13 to 52. For the public attitudes subscale, scores can range from 20 to 80. Higher scores on any of the subscales are indicative of increased perceived stigma. In the study by Berger et al. (2001), the Cronbach alpha for the overall HIV Stigma Scale was .96, and the alphas for the subscales ranged from .90 to .93. Reliability coefficient alphas were also calculated for the total stigma scale and each of the four subscales in our study. Cronbach's alpha for the total stigma scale was .93, and for the subscales the Cronbach's alpha ranged from .80 to .91.

Life satisfaction has been defined as a "global evaluation by the person of his or her life" (Pavot, Diener, Colvin, & Sandvik, 1991, p. 150). In our study, life satisfaction was assessed using a four-item subscale from the Holmes Targeted HIV Quality of Life instrument (Holmes & Shea, 1998). Participants were asked questions related to their enjoyment of life, feelings of being in control of their life, satisfaction with how socially active they were, and whether they were pleased with how healthy they have been. Response categories ranged from 1 (all of the time) to 5 (none of the time). Higher scores indicated better life satisfaction. Holmes and Shea (1998) reported an internal consistency reliability coefficient for the life satisfaction subscale of .90. The computed Cronbach's alpha for the life satisfaction subscale in the current study was 0.87.

DATA ANALYSIS

All data from the study instruments were coded, entered, verified, and analyzed using SPSS version 13.0 for Windows. Means, standard deviations, and frequency distribution were used to describe the participants' socio-demographic and contextual characteristics. An item analysis of the questions composing the stigma subscales was performed. Questions being endorsed (an "agreed" or "strongly agreed" response) by 50% or more of the respondents are presented. Bivariate correlations were computed to examine the relationship between all of the measures. Hierarchical linear regressions were performed to assess for the effects of stigma in explaining life satisfaction of the men living with HIV/AIDS in the sample controlling for age, education, and length of time since diagnosis.

Berger et al. (2001; see Table 1) found that the negative self-image subscale was the most independent among the factors. For this reason, negative self-image was examined as a possible mediating factor between other dimensions of stigma and life satisfaction. Using the procedures suggested by Baron and Kenny (1986), three criteria had to be met when testing for mediation: (a) the predictor variable (perception of stigma) must be significantly correlated to the mediator (negative self-image), (b) the mediator must significantly predict the criterion variable (life satisfaction), and (c) when the relationships in the first two conditions are controlled, a previously significant relationship between the predictor and the criterion variable is substantially reduced or no longer significant. Education and income were significantly associated (r = 0.59, p < .001) with each other. With 71% of the sample having supplemental Social Security income (SSI) as their source of income, education was chosen to be used in the regression analysis.

The variables age, level of education, and length of time since diagnosis were controlled for in all of the analyses. Statistical significance was set at p < 0.05. With a sample of 55 urban African American males, a power analysis indicated the study would have a power of 0.80 to detect an effect size as small as .30.

RESULTS

CHARACTERISTICS OF PARTICIPANTS

Fifty-five African American males between 23 and 66 years of age (M = 48.84; SD = 7.7), participated in this study. The majority of participants were unemployed (88.9%) and single (83.6%). Most men (72.1%) had a high school diploma, 36% had some college education, and 14.5% were college graduates. About 75% of the men had been diagnosed with HIV infection for more than five years with an average length of diagnosis of 11 years (SD = 6.4). Over half (63.6%) identified their sexual orientation as bisexual or homosexual. Seventy-one percent of the men reported having Social Security as their source of income. The majority (85%) of the men had health insurance that was provided by a state or federal government program.

The men had faced the paradox of disclosing their HIV positive status. When asked about the pattern of disclosure of their condition to others, 73% of the participants had chosen the option of "selective disclosure," with only (14.5%) indicating nondisclosure. Participants described themselves as asymptomatic (49.5%), symptomatic (31%), and having "full-blown" AIDS (18.5%).

Despite their illness, most of the participants were satisfied with their own health. Responding to the question "In general how would you rate your overall current health?," 10.9% said their health was excellent, 54.5% said it was very good or good, and 30.8% said it was fair or poor. There was a significant difference in the self-perception of health based on clinical stage of the disease. Participants who were asymptomatic had a mean self-rated health score of 3.48, significantly better than those with full-blown AIDS, whose mean score was 3.14 (F = 4.568, df = 2,52, p = .015).

DOMAINS OF PERCEIVED SOCIAL STIGMA

Items on the Berger Stigma subscales that were endorsed by 50% or more of the participants are displayed in Table 1. The subscales of stigma were significantly correlated to each other. As perception of personalized stigma, public stigma, and negative self-image increased, perceptions or fear that stigma would be experienced when HIV positive status was disclosed increased. Stigma related to disclosure was strongly correlated with personalized stigma, public stigma, and negative self-image (r = .545, r = .671, and r = .658, respectively).

PERSONALIZED STIGMA

Most of the men (87%) perceived that people with HIV/AIDS are rejected when others find out about their seropositive status. More than three-fourths (79%) regretted having told others that they were HIV-infected. The same proportion (79%) also reported that some individuals who knew they were HIV-infected grew more distant from them. The scores for the subscale Personalized stigma ranged from 25 to 72 (maximal range = 18 to 72) with a mean of 49.31 (SD = 9.02).

DISCLOSURE CONCERNS

Individuals with HIV/AIDS were very concerned about controlling information about their condition. Some individuals were guarded about whom to tell while others worked hard at keeping their HIV status a secret. Some of the most salient findings from the disclosure concerns subscale were as follows: 93% of the men were worried that people might be judgmental of them after they learned that they are HIV positive; 91% stated they were very careful whom to tell about their HIV positive status; and 87.3% worried about being discriminated against because of their HIV status. The scores for the subscale disclosure concerns ranged from 21 to 40 (maximal range = 10 to 40) with a mean of 30.08 (SD = 4.51).

PUBLIC ATTITUDES

Perception of the public's attitude toward people living with HIV/AIDS contributes to understanding the impact of stigma. Eighty-seven percent of the participants perceived that people with HIV are treated like outcasts; 80% indicated that telling someone was risky; and three-fourths reported that some people blamed them for having contracted HIV. The scores for the subscale public attitudes ranged from 29 to 80 (maximal range = 20 to 80) with a mean of 56.01 (SD = 9.66).

NEGATIVE SELF-IMAGE

This subscale consists of nine items relating to feelings of isolation, shame, and guilt associated with having been diagnosed with HIV infection. The scores for the subscale negative self-image ranged from 16 to 52 (maximal range = 13 to 52) with a mean of 32.82 (SD = 7.19).

TOTAL STIGMA SCORE AND RELATIONSHIP BETWEEN SUBSCALES

The total HIV stigma score from the Berger scale was created by calculating the sum of the 40 items. The total score for this sample ranged from 73 to 160 with a mean score of 110.36 (SD = 17.36). The total score was inversely associated with life satisfaction (r = -.570, p < .001), indicating that as the perception of stigma increases, life satisfaction decreases. The subscale negative self-image was significantly correlated with personalized stigma (r = .813, p < .001), public attitudes (r = .843, p < .001) and disclosure concerns (r = .658, p < .001). This finding suggests that as stigma increased in the public or personal domain the respondent experienced increased negative self-image. Disclosure concerns also increased significantly as self-image worsened.

RELATIONSHIP OF DEMOGRAPHIC AND CONTEXTUAL FACTORS TO STIGMA AND LIFE SATISFACTION

Life satisfaction was not significantly associated with age, income, level of education, or length of time since diagnosis (Table 2). Clinical stage of the disease and subjective impression of health status were significantly associated with life satisfaction. Participants with better health status and in the early stages of HIV disease reported higher life satisfaction.

A significant association was observed between self-rated health and personalized stigma (r = -0.335, p < .001), perceptions of public attitudes (r = -0.393, p < .001), and concerns about disclosure (r = -0.282, p < .001). As education level increased, perceptions of personalized stigma (r = -.436, p < .001), public attitudes (r = -.460, p < .001), negative self-image (r = -.530, p < .001), and disclosure concerns (r = -.382, p < .001) decreased. The length of time since diagnosis was not associated with any of the stigma subscales.

INFLUENCE OF STIGMA ON LIFE SATISFACTION

A hierarchical multiple regression analysis was carried out to evaluate the influence of stigma on life satisfaction. After adjusting for the demographic variables of age, level of education, and years since diagnosis, stigma accounted for 40.2% of the variance in explaining life satisfaction (Table 3). As personalized stigma and negative self-image increased, life satisfaction decreased. Other sociodemographic variables (public attitudes and disclosure concerns) did not significantly contribute to predicting the life satisfaction of the participants, so they were not included in the final model. Men who perceived increased personalized stigma and negative self-image reported less satisfaction with their lives.

MEDIATION OF NEGATIVE SELF-IMAGE ON THE RELATIONSHIP BETWEEN DOMAINS OF STIGMA AND LIFE SATISFACTION

The first two conditions for mediation specified by Barron and Kenny (1986) were met: the predictor variables public attitudes, personalized stigma, and disclosure concerns were significantly correlated to (1) life satisfaction (the criterion variable) and (2) negative self-image (the mediator). The mediating effect of negative self-image on the relationship of the domains of stigma and life satisfaction (3) was tested by a series of hierarchical regressions (Table 4).

Independent of age, education, and length of time since diagnosis, both public concerns and personalized stigma significantly predicted life satisfaction (Table 4, Model 1). Disclosure concerns had no effect on life satisfaction and therefore did not meet the criteria for mediation. As personalized stigma and public concerns increased, life satisfaction decreased. When negative self-image was added to each of the models (Table 4, Model 2), the other stigma domains were no longer significant, thus meeting the criterion for mediation. Thirty-seven percent of the variance in life satisfaction was explained by public concerns in the presence of a negative self-image. Disclosure concerns had a small but significant effect (Model 1) on life satisfaction whereas, in the presence of a negative self-image, 21% of the variance in life satisfaction was explained (Model 2).

DISCUSSION

Our research may serve as a study demonstrating associations and relationships between contextual factors, domains of perceived stigma, and life satisfaction among African American men living with HIV/AIDS in urban settings. Results from our study are especially important for healthcare professionals working with HIV-infected African American males, one of the fastest growing populations where new HIV cases occur in the United States (CDC, 2003a). Thanks to advances in clinical and biomedical research in the area of HIV drug development, opportunistic infections and mortality rates among individuals living with HIV infection have declined over the past decade. Many healthcare practitioners now see HIV/AIDS increasingly as a manageable chronic health condition. Therefore, research that enables healthcare practitioners to understand and improve life satisfaction in individuals living with HIV/AIDS is warranted.

Our findings suggest that targeting interventions to decrease personalized stigma and to increase the self-image of persons with HIV/AIDS may enhance life satisfaction in African American men. Health information marketing strategies need to be developed to increase the public's understanding of HIV/AIDS and the chronic nature of the disease. Furthermore, the public health message that risk of being infected with HIV/AIDS through casual contact is nonexistent needs to be "heard" in all segments of the population. While individuals may be taught ways to protect themselves from contracting HIV infection sexually, social and financial barriers to accessing and using male and female condoms and interventions such as needle exchange programs also need to be addressed. A broad and comprehensive approach is especially needed for disadvantaged communities and subpopulations who are disproportionately affected by the HIV/AIDS epidemic.

The African American men in this study reported experiencing HIV-related stigma in several domains that were associated with their ratings of life satisfaction. Unlike other studies that have used similar instruments, in our study life satisfaction was not significantly associated with the sociodemographic or contextual variables of age, income, level of education, or length of time since diagnosis. While authors have often found that, as the number of years since testing HIV-positive increase, perceptions of stigma are significantly lower across all stigma domains (Relf, Mallinson, Pawlowski, Dolan, & Deller, 2005), we found no such association in our study with this sample of African American men. Relf et al. posited that initially an HIV-positive test would lead to experiences of lower self-image and fear of disclosure and that such a reaction is compounded by perceptions of the public's attitudes. Although the HIV/AIDS literature suggests that an HIV-infected individual may gain more knowledge of HIV and some necessary skills in handling their illness, our findings showed that length of time living with HIV/AIDS among this sample does little to depersonalize or mitigate the stigma experienced or perceived in relation to life satisfaction.

Perhaps the men in this study may have experienced additional stigma related to the community or neighborhood in which they lived or to the perceived mode of how they contracted the infection (for example, sexual orientation or intravenous drug use). Reidpath and Chan (2005) suggest that some populations may experience "layered or doubled" stigma because of other factors not directly related to their seropositive status, including sexual orientation, injection drug use, ethnicity, and gender. If healthcare providers become cognizant of the complexities of stigma and the dynamic processes related to stigma and life satisfaction as perceived by HIV-infected African American men, they will more likely develop culturally relevant programs to reduce HIV-related stigma in the course of providing healthcare.

In this study, the combination of variables in the regression model explained less than half (40.2%) of the variance in life satisfaction. This raises the question whether other contextual factors may be associated with and influence life satisfaction among urban African American males. Although no published study was found that exclusively examined these factors among African American males, Portillo et al. (2005) found that individual characteristics, environment, physiological factors, symptom status, functional status, and general health perceptions contributed significantly to life satisfaction in a multi-ethnic population of which African Americans accounted for half of the study's sample. To our knowledge, there are also no published studies on the comparative analysis of the perceptions of stigma reflective of life satisfaction among African American men in comparison to other ethnic groups. The literature on quality of life among HIV individuals of which life satisfaction is a part consistently contains themes that emphasize the importance of social inequalities, socioeconomic status, and minority group membership associated with a poor quality of life (Hays et al., 2000; Wilson & Cleary, 1995). Future research on understanding life satisfaction in this population should include other variables, such as biological and physiological markers as well as broader contextual perspectives of life satisfaction. In future, a larger sample size with greater heterogeneity would be needed to examine those factors with little variability in this study.

LIMITATIONS OF THE RESEARCH

These findings should be viewed with the study's limitations in mind. First, the sample is a convenience sample of low socioeconomic status but higher than expected educational attainment. As a result, the findings should not be generalized to all African American men. Also, we had a modest sample size due to the challenges of accessing this hard-to-reach population. Nevertheless, our study had more than adequate power (.80) given the effect sizes of .30 and greater (Table 4). The cross-sectional design also limited us from inferring causal relationships between selected predictor variables and life satisfaction. Another limitation is the fact that the life satisfaction dimension included only four items and therefore may not fully reflect life satisfaction among African American males who are HIV-infected or living with AIDS.

CONCLUSIONS AND IMPLICATIONS

Findings from this study indicate that it is critical for healthcare and social services providers to first assess HIV-related stigma and understand the potential effect of such stigma on their clients. Because of the fast pace and limited time spent by healthcare providers with their clients, the primary care setting may be a challenging place to develop programs geared to assisting clients in reducing negative self-image and other stigmatizing experiences that may accompany their HIV diagnosis.

Some healthcare professionals may view the process of attempting to understand the emotional lives of their clients as a nonclinical intervention and therefore out of their realm of practice. Healthcare and social service providers must therefore provide care with concern for the dignity of their clients and refer individuals to sources of information and support groups. Permission to discuss stigma and strategies to minimize stigma and its negative effects in a nonthreatening or nonstigmatizing environment, whether in a patient-provider interaction or support group, may also improve adherence to treatment protocols.

In particular, cognitive restructuring (Bryant, Moulds, Guthrie, Dang, & Nixon, 2003; Foa & Rauch, 2004) may be helpful to address negative self-image and to counteract perceptions of stigma, which in our study were found to be most influential on life satisfaction. From our review of the literature on life satisfaction and quality of life, socioeconomic status along with a myriad of variables contribute to life satisfaction in patients suffering from chronic conditions (Anke & Fugl-Myer, 2003; Sagy, Antovovsky, & Adler, 1990). This would suggest that future research should be interventional and use multiple strategies to improve the well-being and life satisfaction of African American men living with HIV/AIDS. The strategies should include cognitive reappraisals, social support, and anticipatory guidance to reduce stigma. At the same time such strategies need to capitalize on support within the male African American community. It is critical that future research with African American men be designed and implemented using a community-based participatory research approach.

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AARON G. BUSEN

SHERYL T. KELBER

JEANNE B. HEWITT

PATRICIA E. STEVENS

University of Wisconsin-Milwaukee

CHANG GI PARK

University of Illinois at Chicago

Correspondence concerning this article should be addressed to Aaron G. Buseh, University of WisconsinMilwaukee, College of Nursing, 1921 East Hartford Avenue, Room 569, Milwaukee, WI 53211. Electronic mail: [e-mail].

Table 1
Proportion of Participants Who Endorsed the
Perceived Stigma Items on the Berger
Stigma Scale and Items Reflected in
Each Domain (N = 55) (a, b, c)

Stigma
Domain (d)    Perceived Stigma Items                       %

DC, PC        I worry that people may judge              92.7%
              me when they learn I have HIV.

DC            I am very careful who                      90.7%
              I tell that I have HIV.

DC, PC        Since learning I have HIV,
              I worry about people discriminating
              against me.                                87.3%

PC            People with HIV are treated                87.0%
              like outcasts.

PS, PC        Most people with HIV are rejected          87.0%
              when others find out.

DC            I worry that people who know               85.5%
              I have HIV will tell others.

PC            Most people are uncomfortable              80.0%
              around someone with HIV.

PS            I regret having told some                  78.2%
              people that I have HIV.

PS            I have been hurt by how people             78.2%
              reacted to learning I have HIV.

DC, PC        Telling someone I have                     77.4%
              HIV is risky.

PS            Some people who know I have                76.4%
              HIV have grown more distant.

PS, PC        Some people act as though                  75.5%
              it's my fault I have HIV.

PS            I stopped socializing with some            74.5%
              people because of their
              reactions to me.

DC, NSI       I work hard to keep my HIV a secret.       72.7%

PS, PC        When people learn you have HIV,            70.9%
              they look for flaws in your character.

PC            Most people believe that a                 70.9%
              person who has HIV is dirty.

DC            I have told people close to me to         6910.0%
              keep the fact that
              I have HIV a secret.

PC            Most people think that a                   67.9%
              person with HIV is disgusting.

PS            I have lost friends by telling             67.3%
              them I have HIV.

DC, NSI, PC   I avoid new friendships and                67.3%
              subsequently telling someone
              I have HIV.

PS, PC        Some people avoid touching me              61.8%
              once they know I have HIV.

PS, NSI, PC   As a rule, telling others that             61.1%
              I have HIV has been a mistake.

PS, NSI, PC   People who know I have HIV tend            60.0%
              to ignore my good points.

PS, PC        People have physically backed away         60.0%
              from me when they learn I have HIV.

DC            In many areas of my life,                  60.0%
              no one knows that I have HIV.

NSI           Having HIV in my body is                   58.2%
              disgusting to me.

PS, NSI, PC   I feel set apart and isolated              58.2%
              from the rest of the world.

PC            People with HIV lose their jobs when       56.4%
              their employers find out.

PS, NSI, PC   People seem afraid of me once              52.7%
              they learn I have HIV.

PS            Some people close to me are afraid
              others will reject them if it becomes
              known that I have HIV.                     51.9%

NSI           I feel guilty because                      50.9%
              I have HIV.

NSI           People's attitudes about HIV               50.0%
              make me feel worse about myself.

Note:

(a) The Berger stigma survey/questionnaire is scored on a
four-point Likert scale as "1 = strongly disagree";
"2 = disagree"; "3 = agree"; and "4 = strongly agree."

(b) For meaningful analysis and reporting, responses are
grouped into "strongly disagree/disagree" and
agree/strongly agree.

(c) Items endorsed by at least 50% or more participants.

(d) Factor loadings from the study by Berger et al. (2001):
PS = Personalized Stigma; DC = Disclosure
Concerns; PC = Public Concerns; NSI = Negative Self-Image.

Table 2
Correlation Matrix for Sociodemographic and
Contextual Factors with Stigmatization
Domains and Life Satisfaction

                                          Stigma Domains

Sociodemographic/           Personalized      Public       Negative
Contextual Variables           Stigma       Attitudes     Self-Image

Age                            0.146          0.137         0.168
Income                        -0.335 *       -0.387 **     -0.376 **
Education                     -0.436 **      -0.460 **     -0.560 **
Years since diagnosis         -0.24          -0.259        -0.119
Subjective health status      -0.335 *       -0.393 **     -0.385 **
Clinical stage of disease      0.172          0.169         0.215

                           Stigma Domains

Stigma Domains
Sociodemographic/            Disclosure        Life
Contextual Variables         Concernss     Satisfaction

Age                            0.020          -0.044
Income                        -0.244           0.192
Education                     -0.382 **        0.198
Years since diagnosis         -0.224          -0.003
Subjective health status      -0.282 *         0.346 *
Clinical stage of disease      0.036          -0.276

** Correlation is significant at the 0.01 level (2-tailed).

* Correlation is significant at the 0.05 level (2-tailed).

Table 3
Hierarchical Linear Regression Predicting Life Satisfaction of
African American Men Living with HIV/AIDS--Adjusted for
Demographic and Contextual Factors

Predictors                           Beta     Change [R.sup.2]

Step 1                                          0.041
  Demographic variables
  Length of time since diagnosis    -0.08
  Age                                0.077
  Years of education                -0.177

Step 2                                          0.402 **
  Personalized Stigma               -0.728 *
  Negative Self-Image               -0.573 *
  Public Attitudes                   0.553
  Disclosure Concerns                0.080

Total [R.sup.2] = 0.446, F (7, 47) = 5.409, p [less than or
equal to] .001

Note: * p [less than or equal to] 5.05
** [less than or equal to] p .001

Table 4
Standardized Beta Coefficients and Change in [R.sup.2] for
the Paths from Dimensions of Stigma to Life Satisfaction
with and without Mediating Effects of Negative Self Image

Stigma Dimensions                      Model 1

                             Without negative self image

                           Beta        F(df)      [R.sup.2]

Public concerns           -.565 **     4.71 **      .274 **
Negative self image                    (4,50)      -.648 **

Personalized stigma       -.65 **      7.045 **     .360 **
Negative self image                    (4,50)

Disclosure concerns       -.170        0.935        .070
Negative self image                    (4,50)      -.698 **

Stigma Dimensions                   Model 2

                             With negative self image

                             Beta        F(df)

Public concerns           -.071
Negative self image       5.84 **       .374 **
                          (5,49)

Personalized stigma       -.348
Negative self image       -.425 *       6.83 **
                                       (5.49)
Disclosure concerns       -.035
Negative self image       5.84 **       .309 **
                          (5,49)

Stigma Dimensions                 Model 2

                         With negative self image

                         [R.sup.2]    [R.sup.2]
                                       Change

Public concerns
Negative self image       .100 **

Personalized stigma
Negative self image       .351 *        .050 *

Disclosure concerns
Negative self image       .239 **

Note: Age, education and length of time since diagnosis
controlled for in all analyses. * p < .05, ** p < .001