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Chen C, Wu Q, Zhao J, Zhao G, Li X, Du H, Chi P. Enacted Stigma Influences Bereavement Coping Among Children Orphaned by Parental AIDS: A Longitudinal Study with Network Analysis. Psychol Res Behav Manag 2023; 16:4949-4958. [PMID: 38089527 PMCID: PMC10712676 DOI: 10.2147/prbm.s423707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/27/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose The study aims to understand how enacted stigma influences bereavement coping at the style (scale) level and the specific pathways at the strategy (item) level. Methods The longitudinal data of 755 children orphaned by parental Acquired Immune Deficiency Syndrome (AIDS) in rural China were used. Grief processing and deliberate grief avoidance were measured at wave 1 (baseline) and wave 2 (one-year follow-up) to reflect bereavement coping in the contexts of being with family members, being with friends, being with community members, and being alone. Enacted stigma that measured at wave 1 was used to assess the experienced stigma of these AIDS-orphaned children. Network analyses were run following regressions. Results Controlling for demographics and baseline-level bereavement coping, multivariate regressions revealed that enacted stigma at wave 1 significantly predicted grief processing and deliberate grief avoidance at wave 2. Network analyses showed that, for grief processing, stigma increased searching for meaning alone and with friends and expressing feelings to community members, which then provoked the same strategy across contexts. Meanwhile, stigma triggered the deliberate grief avoidance network by initially suppressing the expression of feelings to community members. Conclusion Enacted stigma contributes to bereavement coping. Stigma stirs up complex feelings but forces AIDS-orphaned children to suppress expressions, and it increases needs to process grief through meaning making but cuts supporting forces by promoting avoidance. Interventions are imperative to reduce stigma, improve emotion regulation, and facilitate meaning making for people bereaved by stigmatized deaths.
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Affiliation(s)
- Chuqian Chen
- Department of Medical Humanities, Southeast University, Nanjing, Jiangsu, People’s Republic of China
| | - Qinglu Wu
- Institute of Advanced Studies in Humanities and Social Sciences, Beijing Normal University, Zhuhai, Guangdong, People’s Republic of China
| | - Junfeng Zhao
- Institute of Psychology and Behavior, Henan University, Kaifeng, Henan, People’s Republic of China
| | - Guoxiang Zhao
- Department of Psychology, Henan Normal University, Xinxiang, Henan, People’s Republic of China
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | - Hongfei Du
- Institute of Advanced Studies in Humanities and Social Sciences, Beijing Normal University, Zhuhai, Guangdong, People’s Republic of China
| | - Peilian Chi
- Department of Psychology, Faculty of Social Sciences, University of Macau, Macau, People’s Republic of China
- Centre for Cognitive and Brain Sciences, University of Macau, Macau, People’s Republic of China
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Zhang L, Wu S, Roslan S, Zaremohzzabieh Z, Chen Y, Jiang Y. Intervention effect of group counseling on social support and post-stress growth of orphans and vulnerable children in China. Front Psychol 2022; 13:962654. [PMID: 36092123 PMCID: PMC9453856 DOI: 10.3389/fpsyg.2022.962654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022] Open
Abstract
Orphans and vulnerable children fall under the category of children who are at risk of exposure to more stressful circumstances and receive less social assistance compared to other children. This study aims to investigate the impact of group counseling based on social intervention and psychological therapy (SSGPC) on social support and the perceived stress growth of orphans and vulnerable children. In one special educational needs school in Nanning, China, the SSGPC was developed and implemented. Using the social support and post-stress growth scales, the researchers investigated the effects of SSGPC on orphans and vulnerable children. Twenty-seven orphans and vulnerable children between the ages of nine and 12 were arbitrarily assigned to the experimental and control groups. A pre-test post-test method of quasi-experimental design was applied, with 13 participants in the experimental group and 14 in the control group. The results revealed that the intervention group had significantly higher scores for social support and post-stress growth than the control group. The SSGPC had significantly improved the levels of social support for orphans. The findings indicated that the SSGPC provided an effective way to improve social support and post-stress growth of orphans and vulnerable children.
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Affiliation(s)
- Lyuci Zhang
- Department of Education and Music, Hezhou University, Hezhou, China
| | - Sumei Wu
- Department of Education, Guangxi Normal University, Guilin, China
| | - Samsilah Roslan
- Department of Foundation Studies, Faculty of Educational Studies, Universiti Putra Malaysia, Serdang, Malaysia
| | - Zeinab Zaremohzzabieh
- Department of Foundation Studies, Faculty of Educational Studies, Universiti Putra Malaysia, Serdang, Malaysia
| | - Ye Chen
- Faculty of Human Ecology, Universiti Putra Malaysia, Serdang, Malaysia
| | - Yuqin Jiang
- Department of Education and Music, Hezhou University, Hezhou, China
- Faculty of Human Development, Universiti Pendidikan Sultan Idris, Tanjung Malim, Malaysia
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McDaniel HL, Harrison SE, Fairchild AJ, Li X. Future Orientation Among Children Affected by Parental HIV in China: An Exploratory Analysis of Complex Interactions. FRONTIERS IN SOCIOLOGY 2022; 7:899537. [PMID: 35874445 PMCID: PMC9300854 DOI: 10.3389/fsoc.2022.899537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
We utilized an exploratory analytic approach to examine predictors of children's future beliefs, an internal asset associated with resilience among children affected by HIV, with emphasis on complex interactions among multisystem factors. Children (N = 1221) affected by parental HIV in China reported on psychosocial functioning, as well as internal, familial, and community resilience assets. Exploratory data analysis was conducted using a binary segmentation program. Six binary splits on predictors accounted for 22.78% of the variance in future expectation, suggesting interactions between children's perceived control of their future, loneliness, caregiver trust, and social support. Four binary splits accounted for 23.15% of the variance in future orientation, suggesting multiway interactions between control of the future, loneliness, social support, and perceived stigma. Findings suggest combinations of resilience factors are associated with children's positive future beliefs. Implications for screening, prevention, and intervention among Chinese children affected by parental HIV are discussed.
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Affiliation(s)
- Heather L. McDaniel
- School of Education and Human Development, University of Virginia, Charlottesville, VA, United States
| | - Sayward E. Harrison
- Department of Psychology, College of Arts and Sciences, University of South Carolina, Columbia, SC, United States
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Amanda J. Fairchild
- Department of Psychology, College of Arts and Sciences, University of South Carolina, Columbia, SC, United States
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
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Jiang Y, Li X, Harrison SE, Zhang J, Qiao S, Zhao J, Zhao G. Effects of a Multilevel Resilience-Based Intervention on Mental Health for Children Affected by Parental HIV: A Cluster Randomized Controlled Trial. JOURNAL OF CHILD AND FAMILY STUDIES 2022; 31:1094-1105. [PMID: 36875685 PMCID: PMC9979773 DOI: 10.1007/s10826-022-02236-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 06/18/2023]
Abstract
The present study aimed to examine the efficacy of the Child-Caregiver-Advocacy Resilience (ChildCARE) intervention, a multilevel resilience-based psychosocial intervention, on mental health outcomes, including depressive symptoms, school anxiety, and loneliness, among children affected by parental HIV in central China. Seven hundred and ninety children (51.6% boys, 6-17 years of age) affected by parental HIV were randomly assigned by cluster to a control group or one of three intervention groups designed to test the three conditions of the ChildCARE intervention (child-only, child + caregiver, child + caregiver + community). Linear mixed-effects modeling was performed to test the intervention effect at 6, 12, and 18 months. The intervention did not yield significant changes in mental health outcomes in the child-only group at any follow-ups, whereas significant reductions in depressive symptoms and loneliness were observed in the child + caregiver group at 12 months. The observed intervention effects were not sustained at 18 months. Also, children who received the additional community component that, was implemented after 12 months did not show larger improvements in mental health outcomes than the control group at 18 months. Lastly, older children (i.e., ≥12 years) were found to benefit more from the intervention than their younger counterparts (i.e., <12 years). Overall, the findings provide some support for the promise of multilevel resilience-based interventions in improving mental health of children affected by parental HIV, but more research is needed to further determine whether multilevel resilience-based interventions can yield sustained effects on mental health.
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Affiliation(s)
- Yanping Jiang
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | | | - JiaJia Zhang
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - Shan Qiao
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | - Junfeng Zhao
- Institute of Behavior and Psychology, Henan University, Kaifeng, Henan, China
| | - Guoxiang Zhao
- Department of Psychology, Henan Normal University, Xinxiang, Henan, China
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Wu Q, Zhao J, Zhao G, Li X, Du H, Chi P. Long-Term Trajectories of Depressive Symptoms Among Children Affected by Parental HIV: A 12-Year Follow-Up Study. AIDS Behav 2022; 26:2713-2722. [PMID: 35165794 DOI: 10.1007/s10461-021-03572-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 01/07/2023]
Abstract
The present study explored the trajectories of depressive symptoms over 12 years spanning from childhood to emerging adulthood and the between-trajectory differences in psychosocial adjustment among Chinese children (N = 492, 52.8% boys, aged 6 to 18 years at baseline) affected by parental HIV. Rebounding (12.6%), resilient (64.8%), and improving (22.6%) trajectories were identified. Individuals in the rebounding trajectory reported the highest levels of psychological distress and the lowest levels of subjective well-being, positive self-regard, and personal strengths in adulthood. Individuals in the resilient trajectory reported lower levels of psychological distress and negative affect than those in the improving trajectory. The findings support the development of programs by policymakers and practitioners to improve the psychosocial adjustment of children who have been affected by parental HIV while considering individual differences in the trajectories of depressive symptoms.
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Kivumbi A, Byansi W, Ssewamala FM, Proscovia N, Damulira C, Namatovu P. Utilizing a family-based economic strengthening intervention to improve mental health wellbeing among female adolescent orphans in Uganda. Child Adolesc Psychiatry Ment Health 2019; 13:14. [PMID: 30899327 PMCID: PMC6410516 DOI: 10.1186/s13034-019-0273-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 02/17/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND It is estimated that almost 20% of the world's adolescents have experienced or are experiencing a mental health problem. Several factors have been associated with the onset of adolescent mental health disorders, including poverty, child abuse and violence, particularly among adolescent girls. This paper examines the effect of participating in a family-based economic strengthening intervention on the mental health well-being of female adolescent orphans impacted by HIV/AIDS in rural Uganda. METHODS Data utilized in this study was from the Bridges to the Future Study (2011-2016), an economic empowerment intervention aimed at improving health outcomes of orphaned children. Adolescents were randomly assigned to either the control condition receiving bolstered standard of care services for orphaned adolescents; or one of two treatment conditions receiving bolstered standard of care as well as an economic empowerment intervention comprising of a child development account, a mentorship program and workshops on financial management and microenterprise development. Data was collected at baseline, 12- and 24-months post intervention initiation. Multilinear regression analyses were conducted to examine the impact of an economic empowerment intervention on mental health functioning of female participants over time. Mental health functioning was measured by: (1) the Child Depression Inventory; (2) Beck Hopelessness Scale; and (3) Tennessee Self Concept Scale. RESULTS Analysis results show an improvement in mental health functioning over time among female participants receiving the intervention compared to their control counterparts. Specifically, compared to participants in the control condition, participants receiving the intervention reported a reduction in depressive symptoms from baseline to 12-months follow-up (b = - 1.262, 95% CI - 2.476, - 0.047), and an additional 0.645-point reduction between baseline and 24-months follow-up (b = - 1.907, 95% CI - 3.192, - 0.622). Participants receiving the intervention reported significant improvement in their reported self-concept from baseline to 24 months follow-up (b = 3.503 (95% CI 1.469, 5.538) compared to participants in the control condition. CONCLUSIONS Empowerment of young girls, either in the form of peer mentorship and/or economic strengthening seems to significantly improve the overall mental health functioning of adolescent girls impacted by HIV and AIDS in low-income settings.
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Affiliation(s)
- Apollo Kivumbi
- International Center for Child Health and Development, P.O. Box 1988, Circular Rd, Masaka, Uganda
| | - William Byansi
- 0000 0001 2355 7002grid.4367.6Brown School, Washington University in St. Louis, St. Louis, USA
| | - Fred M. Ssewamala
- International Center for Child Health and Development, P.O. Box 1988, Circular Rd, Masaka, Uganda ,0000 0001 2355 7002grid.4367.6Brown School, Washington University in St. Louis, St. Louis, USA
| | - Nabunya Proscovia
- 0000 0004 1936 8753grid.137628.9New York University Silver School of Social Work, New York, USA
| | - Christopher Damulira
- International Center for Child Health and Development, P.O. Box 1988, Circular Rd, Masaka, Uganda
| | - Phionah Namatovu
- International Center for Child Health and Development, P.O. Box 1988, Circular Rd, Masaka, Uganda
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Li X, Harrison SE, Fairchild AJ, Chi P, Zhao J, Zhao G. A randomized controlled trial of a resilience-based intervention on psychosocial well-being of children affected by HIV/AIDS: Effects at 6- and 12-month follow-up. Soc Sci Med 2017; 190:256-264. [PMID: 28215430 PMCID: PMC6205509 DOI: 10.1016/j.socscimed.2017.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/24/2017] [Accepted: 02/05/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Global literature suggests that resilience-based interventions may yield improvements in psychosocial well-being for vulnerable children, but limited data are available regarding the efficacy of such interventions among children affected by parental HIV/AIDS. OBJECTIVE To evaluate initial efficacy of a multi-level resilience-based intervention among children affected by parental HIV/AIDS in China in improving children's psychosocial well-being and resilience-related outcomes. METHOD Seven hundred-ninety children, 6-17 years of age, were recruited from rural China. Children were either AIDS orphans or were living with one or two parents infected with HIV/AIDS. Children and primary caregivers were randomly assigned to participate in a 4-arm trial to evaluate the Child-Caregiver-Advocacy Resilience (ChildCARE) intervention. This resilience-based psychosocial intervention provides programming at three levels (child, caregiver, community). Survey data were collected at baseline, 6-months, and 12-months in order to examine efficacy of the child-only and child + caregiver arms in improving children's psychological resilience. RESULTS Intervention groups displayed improvements in several resilience-related outcomes at 6- and 12-month follow-ups, including self-reported coping, hopefulness, emotional regulation, and self-control. The child-only intervention arm showed some fading of intervention effects by 12-months. CONCLUSION Preliminary findings suggest that the ChildCARE intervention is efficacious in promoting psychosocial well-being of children affected by parental HIV/AIDS in rural China. Targeting both children and caregivers for psychosocial intervention may be effective in improving children's resilience. Additional evaluation and modifications, including the inclusion of booster sessions, should be considered to further strengthen the program.
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Affiliation(s)
- Xiaoming Li
- Department of Health Promotion, Education, and Behavior, University of South Carolina, 915 Greene St., Columbia, SC, USA.
| | - Sayward E Harrison
- Department of Health Promotion, Education, and Behavior, University of South Carolina, 915 Greene St., Columbia, SC, USA.
| | - Amanda J Fairchild
- Department of Psychology, University of South Carolina, 1512 Pendleton St., Columbia, SC, USA.
| | - Peilian Chi
- Department of Psychology, University of Macau, Room 3053, Humanities & Social Sciences Building, E21 Avenida da Universidade, Macau, China.
| | - Junfeng Zhao
- International Research Center for Psychological Health of Vulnerable Populations, Henan University, Kaifeng, China.
| | - Guoxiang Zhao
- International Research Center for Psychological Health of Vulnerable Populations, Henan University, Kaifeng, China.
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Sharp C, Jardin C, Marais L, Boivin M. Orphanhood by AIDS-Related Causes and Child Mental Health: A Developmental Psychopathology Approach. ACTA ACUST UNITED AC 2015; 1. [PMID: 27668289 DOI: 10.16966/2380-5536.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
While the number of new HIV infections has declined, the number of orphans as a result of AIDS-related deaths continues to increase. The aim of this paper was to systematically review empirical research on the mental health of children affected by HIV/AIDS in the developing world, specifically with an eye on developing a theoretical framework to guide intervention and research. Articles for review were gathered by following the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA standards), reviewed and then organized and synthesized with a Developmental Psychopathology framework. Results showed that the immediate and longterm effects of AIDS orphanhood are moderated by a number of important risk and protective factors that may serve as strategic targets for intervention. Research and clinical implications are discussed.
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Affiliation(s)
- Carla Sharp
- Department of Psychology, University of Houston, Houston, TX 77024, USA
| | - Charles Jardin
- Department of Psychology, University of Houston, Houston, TX 77024, USA
| | - Lochner Marais
- Centre for Development Support, University of the Free State, South Africa
| | - Michael Boivin
- Department of Neurology & Ophthalmology, Michigan State University, USA
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Li X, Chi P, Sherr L, Cluver L, Stanton B. Psychological Resilience among Children Affected by Parental HIV/AIDS: A Conceptual Framework. Health Psychol Behav Med 2015; 3:217-235. [PMID: 26716068 PMCID: PMC4691449 DOI: 10.1080/21642850.2015.1068698] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
HIV-related parental illness and death have a profound and lasting impact on a child's psychosocial wellbeing, potentially compromising the child's future. In response to a paucity of theoretical and conceptual discussions regarding the development of resilience among children affected by parental HIV, we proposed a conceptual framework of psychological resilience among children affected by HIV based on critical reviews of the existing theoretical and empirical literature. Three interactive social ecological factors were proposed to promote the resilience processes and attenuate the negative impact of parental HIV on children's psychological development. Internal assets, such as cognitive capacity, motivation to adapt, coping skills, religion/spirituality, and personality, promote resilience processes. Family resources and community resources are two critical contextual factors that facilitate resilience process. Family resources contain smooth transition, functional caregivers, attachment relationship, parenting discipline. Community resources contain teacher support, peer support, adult mentors, and effective school. The implications of the conceptual framework for future research and interventions among children affected by parental HIV were discussed.
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Affiliation(s)
- Xiaoming Li
- Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Peilian Chi
- Department of Psychology, University of Macau, Macau, China
| | | | - Lucie Cluver
- Oxford University, Oxford, UK and University of Cape Town, South Africa
| | - Bonita Stanton
- Wayne State University School of Medicine, Detroit, MI 48201, USA
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Qiao S, Li X, Zhao G, Zhao J, Stanton B. The role of perceived social support in loneliness and self-esteem among children affected by HIV/AIDS: a longitudinal multilevel analysis in rural China. AIDS 2014; 28 Suppl 3:S369-77. [PMID: 24991910 PMCID: PMC6233999 DOI: 10.1097/qad.0000000000000338] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To delineate the trajectories of loneliness and self-esteem over time among children affected by parental HIV and AIDS, and to examine how their perceived social support (PSS) influenced initial scores and change rates of these two psychological outcomes. DESIGN We collected longitudinal data from children affected by parental HIV/AIDS in rural central China. Children 6-18 years of age at baseline were eligible to participate in the study and were assessed annually for 3 years. METHODS Multilevel regression models for change were used to assess the effect of baseline PSS on the trajectories of loneliness and self-esteem over time. We employed maximum likelihood estimates to fit multilevel models and specified the between-individual covariance matrix as 'unstructured' to allow correlation among the different sources of variance. Statistics including -2 Log Likelihood, Akaike Information Criterion and Bayesian Information Criterion were used in evaluating the model fit. RESULTS The results of multilevel analyses indicated that loneliness scores significantly declined over time. Controlling for demographic characteristics, children with higher PSS reported significantly lower baseline loneliness score and experienced a slower rate of decline in loneliness over time. Children with higher PSS were more likely to report higher self-esteem scores at baseline. However, the self-esteem scores remained stable over time controlling for baseline PSS and all the other variables. CONCLUSIONS The positive effect of PSS on psychological adjustment may imply a promising approach for future intervention among children affected by HIV/AIDS, in which efforts to promote psychosocial well being could focus on children and families with lower social support. We also call for a greater understanding of children's psychological adjustment process in various contexts of social support and appropriate adaptations of evidence-based interventions to meet their diverse needs.
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Affiliation(s)
- Shan Qiao
- Prevention Research Center, Carman and Ann Adams Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Xiaoming Li
- Prevention Research Center, Carman and Ann Adams Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan, USA
- Institute of Behavior and Psychology, Henan University, Kaifeng, China
| | - Guoxiang Zhao
- Institute of Behavior and Psychology, Henan University, Kaifeng, China
| | - Junfeng Zhao
- Institute of Behavior and Psychology, Henan University, Kaifeng, China
| | - Bonita Stanton
- Prevention Research Center, Carman and Ann Adams Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan, USA
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