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AIDS Care. Author manuscript; available in PMC 2010 Jan 9.
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PMCID: PMC2803757
NIHMSID: NIHMS166525

Stigma, social support, and depression among people living with HIV in Thailand

Abstract

Background

People living with HIV/AIDS (PLWHA) in Thailand face tremendous challenges, including HIV-related stigma, lack of social support, and mental health issues such as depression. This study aims to examine complex relationships among demographics, HIV-related stigma, and social support and their impact on depression among PLWHA in Thailand.

Methods

This study uses data collected in northern and northeastern Thailand. A total of 408 PLWHA were recruited and interviewed in 2007. HIV-related stigma was measured by two subscales: “Internalized Shame” and “Perceived Stigma.” Based on correlation analyses, hierarchical multiple regression models were used to examine the predictors of depression, social support, and HIV-related stigma, controlling for demographic characteristics.

Results

Correlational analysis revealed that depression was significantly associated with both dimensions of stigma: internalized shame and perceived stigma. Self-reported emotional social support was negatively associated with depression. We found that internalized shame and emotional social support were significant predictors of depression after controlling for gender, age, income, and education.

Conclusions

HIV-related stigma has a negative impact on psychological wellbeing of PLWHA in Thailand, and emotional social support remains a protective factor against depression. Intervention developers and clinicians working with PLWHA may find it useful to incorporate the association between stigma and depression into their programs and treatments, and to address social support as a protective effect for the mental health of PLWHA.

Keywords: depression, stigma, PLWHA, support, Thailand

Introduction

People living with HIV/AIDS (PLWHA) face tremendous challenges, including their mental health (Bartlett & Gallant, 2001; Derlega & Barbee, 1998; Kalichman, 1995, 2000). For example, in the United States (US), rates of depression among PLWHA have been reported to be twice as high, compared to those of the general population (Atkinson & Grant, 1994; Lyketsos et al., 1996). PLWHA have been found to report higher levels of loneliness, compared to the general population (Vance, 2006). In Thailand, depression has been examined mainly among adolescents, college students, and older adults (e.g. Khanthawichai, 2001; Ross et al., 2005; Srisaeng, 2003). Only a few studies have examined depression among PLWHA in Thailand, especially among women (Bennetts et al., 1999; Ross & Srisaeng, 2005).

HIV-related stigma is prevalent worldwide. According to Goffman (1963), stigma is conceptualized by society on the basis of what constitutes “deviance”; a stigmatized individual is someone with “an undesirable difference.” Stigmatization associated with HIV is also a process of devaluation, often used to produce social inequality and stress at the personal level (Hamra, Ross, Karuri, Orrs, & D'Agostino, 2005; Herek, 1999; Lee, Kochman, & Sikkema, 2002; Parker & Aggleton, 2003; Parker, Aggleton, Attawell, Pulerwitz, & Brown, 2002; Thomas et al., 2005). For example, perceived HIV stigma by PLWHA may discourage PLWHA from seeking care and may reduce adherence to antiretroviral (ARV) therapy (Foreman, Lyra, & Breinbauer, 2003; Malcolm et al., 1998; Vanable, Carey, Blair, & Littlewood, 2006; Ware, Wyatt, & Tugenberg, 2006). In Thailand, previous studies provided evidence that stigma could have a variety of negative effects on PLWHA, including delay in access to care (Busza, 2001) and isolation of PLWHA (Vanlandingham, Im-em, & Saengtienchai, 2005).

For many PLWHA, coping with HIV may be facilitated by their social support networks (McDowell & Serovich, 2007). Previous studies on the impact of social support among PLWHA suggested that perceived social support might act as a buffer to stress-related crises, such as depression (Johnson et al., 2001; Silver, Bauman, Camacho, & Hudis, 2003) and may aid in psychological wellbeing (Hays, Chauncey, & Tobey, 1990; Serovich, Kimberly, Mosack, & Lewis, 2001). In addition, past studies in the US provided evidence that perceived social support was inversely associated with levels of perceived stigma (Galvan, Maxwell Davis, Banks, & Bing, 2008). Ross and Srisaeng (2005) found that higher social support reported by HIV-positive pregnant women in Thailand was associated with a lower level of perceived stigma.

The relationships among depression, stigma, and social support among PLWHA in Thailand have not been well established. With a sample of 408 PLWHA in northern and northeastern Thailand, we examined correlations among HIV stigma, social support, and depression as well as their relationships with demographic characteristics. In particular, we explored the ways in which PLWHA’s perceived stigma and social support affect their level of depression. Empirical evidence about the relationships between these factors will provide better understanding of these challenges facing PLWHA in Thailand and scientific foundations for future intervention development.

Methods

Participants and setting

This study uses data from a randomized controlled family intervention trial in the Northern and Northeastern regions of Thailand. These data were collected in 2007 from four district hospitals in the two regions (two district hospitals per region). Initial screenings of PLWHA were conducted in the district hospitals and performed by healthcare workers and research staff specifically hired for the study. Once the PLWHA had been screened and had agreed to participate in the study, written informed consent was obtained. Following informed consent, a trained interviewer administered the assessment to the PLWHA using Computer Assisted Personal Interview (CAPI). During the interview, PLWHA were asked about their demographics, including age, gender, annual income, and educational status, and questions about their perceived stigma, social support, and depression. A total of 410 individuals voluntarily participated in the assessment. Refusal rate was approximately 5% across the four study sites. Because of multiple missing data points, 408 participants are included in this current study.

Approval of this study was obtained from Institutional Review Boards from the University of California at Los Angeles, and the Thailand Ministry of Public Health Ethical Review Committee for Research in Human Subjects. All participants received 300 Baht (equivalent to $10) for their assessment participation.

Measures

We used multi-item scales to measure depression, stigma, and social support (Table 1). Depression was assessed with a 15-item depression screening test that was developed and used previously in Thailand (Thai Department of Mental Health, 2004). These questions asked about problems that had bothered participants in the past week (e.g. feeling blue most of the time), with response categories from zero (not at all) to three (usually (5–7 days a week)). A summative composite scale was developed, with the range of 0–45 and an excellent Cronbach’s alpha of 0.91.

Table 1
Assessment questions and scales used in this study.

HIV-related stigma measures were adapted from scales that were developed, based on the work of Herek and Capitanio (1993), and validated by the Thai investigators in the Nakhon Ratchasima Province, Thailand (Apinundecha, Laohasiriwong, Cameron, & Lim, 2007). After conducting exploratory factor analysis, we identified two factors that were conceptually identified as Perceived Stigma and Internalized Shame. Perceived stigma was created based on eight items, and Internalized Shame was measured based on nine items, as shown in Table 1. Response categories ranged from one (strongly disagree) to five (strongly agree). Summative composite scores were created for perceived stigma (range = 8–40) and internalized shame (range = 9–45), with Cronbach’s alphas of 0.75 and 0.81, respectively.

Emotional Social Support was constructed as a composite variable based on the two subscales (emotional/informational support and affectionate support) in the Medical Outcomes Study Social Support Scale (Sherbourne & Stewart, 1991). The social support scale included both emotional/informational support, measured by eight items, and affectionate support including three items. Responses to individual items ranged from one (none of the time) to five (all of the time). We combined the two subscales because they were highly correlated to yield a composite scale with a satisfactory internal consistency (α = 0.86). This summative composite score ranged from 11 to 55.

Data analysis

All analyses were performed using SAS statistical software version 9.1(SAS Institute, Inc., Cary, NC). First, descriptive statistics were used to describe PLWHA’s demographics, depression, internalized shame, perceived stigma, and emotional social support. Second, Pearson correlation coefficients were calculated to examine the relationship between depression, internalized shame, perceived stigma, and emotional social support, as well as demographic variables such as age, gender, income, and education. Third, a series of multiple regression analyses were conducted to examine associations among PLWHA’s perceived stigma, internalized shame, emotional social support, and depression, simultaneously controlling for the effects of participants’ age, gender, income, and education. Regression coefficients estimation and their significant levels are reported.

Results

Table 2 shows the characteristics of PLWHA in the study. Age ranged from 23 to 64 years. The mean age of the participants was 37.7 years (standard deviation (SD) =6.6). A majority of the sample, 72.5%, was female. Most participants (81.4%) received less than high school education. The average individual annual income was 27,194 Baht per year (equivalent to $850). The mean scores of Perceived Stigma, Internalized Shame, Emotional Social Support, and Depression were 21.5 (SD = 4.9), 24.3 (SD = 6.2), 39.3 (SD = 8.3), and 12.9 (SD = 8.4), respectively.

Table 2
Characteristics of study participants (N = 408).

The correlation coefficients among demographic characteristics, perceived stigma, internalized shame, emotional social support, and depression are shown in Table 3. Significant negative correlations were observed among emotional social support and internalized shame (r = −0.16, p = 0.001) and perceived stigma (r = −0.15, p < 0.05). Not surprisingly, PLWHA’s perceived stigma and their reported levels of internalized shame were also positively correlated (r = 0.65, p < 0.001). We found that levels of depression was significantly correlated with levels of internalized shame (r = 0.51, p < 0.001), perceived stigma (r = 0.40, p <0.001), and emotional social support (r = −0.22, p < 0.001).

Table 3
Correlation coefficients and significance levels among selected variables (N = 408).

Significant correlations were also found among PLWHA’s demographic characteristics and perceived stigma, internalized shame, emotional social support, and depression. Being female was also significantly correlated with their perceived stigma related to HIV/AIDS (r = 0.13, p = 0.007). Age was correlated with levels of internalized shame (r = 0.10, p = 0.041), and annual income was correlated with levels of perceived stigma (r = −0.15, p = 0.003) and emotional social support (r = 0.10, p = 0.05). Education was significantly correlated with levels of emotional social support (r = 0.10, p = 0.05). Depression was also significantly correlated with gender (being female) (r = 0.13, p = 0.007).

Table 4 shows the multiple regression models examining factors associated with perceived stigma, internalized shame, emotional social support, and depression. Controlling for selected independent variables, higher levels of internalized shame were associated with higher levels of perceived stigma (standardized beta (β) = 0.63, p < 0.0001). Lower levels of emotional social support were associated with higher levels of perceived stigma (β = −0.09, p = 0.02). In addition, lower income was significantly associated with higher levels of perceived stigma (β = −0.09, p = 0.02). The findings from regression on internalized shame, controlling for all selected independent variables, revealed that higher levels of perceived stigma were significantly associated with higher levels of internalized shame (β =0.65, p < 0.0001). Similarly, higher levels of perceived stigma were significantly associated with lower levels of emotional social support (β = −0.14, p =0.028), controlling for selected independent variables.

Table 4
Multiple regression on perceived stigma, internalized shame, emotional social support, and depression (N = 408).

The final regression model examining the predictors of depression revealed that higher levels of internalized shame were significantly associated with higher levels of depression (β = 0.43, p < 0.0001). In addition, lower levels of emotional social support were significantly associated with higher levels of depression (β = −0.14, p = 0.001). Controlling for all other variables, younger participants were more depressed than their older counterparts (β = −0.11, p = 0.013).

Discussion

HIV-related stigma, lack of social support, and mental health issues such as depression are some of the many challenges that PLWHA are facing around the world, including Thailand. Instead of examining these issues independently, this study explored complex relationships among them. We found that internalized shame reported by PLWHA was a significant predictor of depression, and PLWHA’s perceived stigma was significantly related to their internalized shame, although its effect on depression was not independently significant. This finding implies that there may be an indirect effect of perceived stigma on depression that is mediated through internalized shame. Our findings on the significant relationships between internalized shame and depression are consistent with previous studies (Epstein, 2001; Scheff, 2001; Wong & Cook, 1992; Wright, O’Leary, Balkin, 1989).

To explore social components in depression, Scheff (2001) called for a complex multidisciplinary approach to understand the phenomenon of depression. According to his conceptual framework, in addition to biology and individual psychology, alienation, including shame and lack of community, may be an immediate cause of depression (Scheff, 2001). Our study provides further evidence to support this hypothesis by demonstrating the significant impact of both internalized shame and social support on depression. The results of this study have implications for future intervention and treatment programs for PLWHA. For example, mental stressors, such as depression, have been linked to more rapid progression to AIDS among PLWHA (Ross et al., 2005). Our findings on HIV-related stigma underscore the complex relationship between internalized shame and perceived stigma, and their relationship with depression. To address mental health problems associated with HIV/AIDS, researchers, program developers, and clinicians should also pay close attention to helping PLWHA to strengthen their self-esteem and their sense of belonging to a community, including the connections with other significant persons in their lives, while dealing with HIV-related stigma and discrimination in the community. Both social and psychological components should be integrated and incorporated into the programs.

Our findings on the significant association between perceived stigma and emotional social support are consistent with previous studies in Thailand, providing evidence that PLWHA who perceived negative community reaction were significantly more likely to report a decline in their social support over time (Vanlandingham et al., 2005). The study also revealed that lower emotional social support was significantly associated with higher depression. Again, this may imply that the impact of perceived stigma in community on PLWHA’s depression can be indirectly mediated through the lack of social support. This finding has significant implications of the mental health of PLWHA. Social isolation and stigma can prevent PLWHA from seeking and receiving social support, which can lead to their depression; depression and other mental health challenges may, in turn, create more isolation and deter their treatment seeking, including their ARV treatment adherence, and lead to their deterioration of health.

The findings from our study confirm an association between HIV-related stigma and depression. In Thailand, there is still a considerable stigma associated with mental illness. People living with HIV and depression have to cope with the double stigma of HIV and mental illness. Despite the epidemiological data on the low prevalence of depression among PLWHA, depression is prevalent among PLWHA and is under-diagnosed (Fulk, Kane, Phillips, Bopp, & Hand, 2004). This may result from the fact that may be the symptoms of depression are also symptoms of HIV itself. Moreover, stigma associated with both HIV and depression could also contribute to the gap. This study serves to remind medical and social service providers that stigma remains a barrier to adjustment, especially for PLWHA and depression.

There are some limitations to this study. First, we conducted data analyses based on cross-sectional data; therefore, causal interpretations of the results cannot be established. Second, the reliance on self-reported measures may be susceptible to information bias; for instance, those individuals who reported high levels of stigma were simply more likely to report psychological stress. Third, one major caveat around disclosure is the eligibility criteria for this study. There had to be at least one other family member who knew about the HIV status of the PLWHA in order to be eligible for recruitment. For example, patient registry data from the study sites in the Northeast indicate that 30% of PLWHA were ineligible for recruitment. The relationship between HIV-related stigma and depression among those who have not disclosed their status may potentially be even greater than those who participated in our study. Therefore, the selection criteria limit the generalization of the study findings to those without children and to those whose HIV status were not disclosed to their family members at the time the study was conducted.

Despite the limitations, our findings suggested robust associations between HIV-related stigma and depression, as well as the protective effect of emotional social support on depression. We considered several additional factors to ensure the robustness of our findings. For example, we conducted a series of sensitivity analysis and included additional variables (e.g. number of years being diagnosed with HIV, whether the patient is on ARV therapy) that may be related to depression. After controlling for these variables, the significant association between HIV-related stigma, emotional social support, and depression remained in the final model.

In conclusion, the linkage between HIV-related stigma and depression is not a simple, linear relationship; rather the negative impact of social stigma on PLWHA’s perceptions of themselves and social support around them may contribute to their mental health challenges such as depression. To improve psychological wellbeing of PLWHA in Thailand and around the world, we should address both HIV-related stigma as a risk factor and social support as a protective factor and incorporate both components in the program development.

Acknowledgements

This paper was completed with the support of the National Institute of Nursing Research (Grant NINR R01-NR009922). We thank our research coordinators, hospital directors, and health officers in Chiang Rai province (Mae Chan and Chiang Saen district hospitals) and Nakhon Ratchasima province (Pak Chong and Khonburi district hospitals). We thank our collaborators at the Thai Ministry of Public Health, Bureau of Epidemiology for their contributions to the study.

Footnotes

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