Coping with HIV Related Stigma and Well-Being - Springer Link

J Happiness Stud (2013) 14:709–722 DOI 10.1007/s10902-012-9350-6 RESEARCH PAPER

Coping with HIV Related Stigma and Well-Being Pilar Sanjuań • Fernando Molero • Marıá Jose´ Fuster Encarnacioń Nouvilas

•

Published online: 5 May 2012 Ó Springer Science+Business Media B.V. 2012

Abstract The goal of this study was to analyze the relationships to be found among stigma perception, active and avoidant coping strategies, and subjective and psychological well-being in a sample of 133 people with HIV. The results showed that stigma perception and avoidant coping strategies (venting, self-blame, denial, behavioural disengagement and substance use) were positively associated, whereas, both stigma perception and avoidant coping were negatively associated with different measures of well-being (affect balance, self-acceptance and environmental mastery). These negative relationships between stigma perception and the three well-being measures were mediated by the use of avoidant coping strategies. Results suggest that psychosocial intervention programs for people who report psychological distress arising from prejudice must be aimed at developing appropriate ways to deal with this prejudice. Intervention programs should also include strategies to directly increase well-being since from a positive psychology viewpoint certain interventions have been shown to do so, and HIV research has also shown that well-being is associated with lower mortality rates. Keywords Stigma perception Subjective well-being Psychological well-being Active coping Avoidant coping Affect balance

1 Introduction The experience of living with HIV involves a high level of stress. As well as other demands they may have to meet, people with HIV need to adapt to living with a chronic disease as well as coping with the stigmatization they may experience from society. As this stigmatization is recurring and intense, it is considered to be one of the most powerful stress factors (Miller and Major 2000). Stigma perception significantly increases reactions to stress, which apart from having an adverse effect on psychological well-being (Berger P. Sanjuań (&) F. Molero M. J. Fuster E. Nouvilas Facultad de Psicologıá, Universidad Nacional de Educacioń a Distancia (UNED), C/Juan del Rosal, 10-Ciudad Universitaria, 28040 Madrid, Spain e-mail: [email protected]

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et al. 2001), is also associated with the practice of unhealthy habits as well as the nonpractice of healthy ones (Pascoe and Smart Richman 2009). Therefore, the main goal of this study was to analyse the relationships among stigma perception, coping and well-being in a sample of people with HIV. Stigma towards people with HIV arises and persists due to the perception of the possibility of transmission through casual or social contact (a lot of people still believe the infection to be contagious and are afraid of contracting it in their daily activities and thus react with social rejection), the perception of serious illness, (the illness is powerfully life threatening), the responsibility perception (generally, they are believed to be responsible for contracting the infection through acts like unprotected sex for example), and the fact that the illness is associated with behaviour that violates their moral norm (homosexuality and drug use) (Bos et al. 2008). Basically, one can distinguish between stigmatization received from others and that perceived by oneself. Through the process of stigmatization from others, individuals with a certain characteristic, in this case, with HIV, are the object of prejudice, discrimination, negative stereotypes and exclusion (Bunn et al. 2007). On the other hand, the key to stigma perception is that the person realizes their real or potential social undermining, their nullification or their limitation of opportunities and the negative change in their social identity (how others see me) (Berger et al. 2001). Stigma perception has a powerful impact on people’s psychological well-being since the negative reactions they have experienced or anticipated, plus their own awareness of their devalued social identity contributes to creating negative assessment of oneself and symptoms of distress and social withdrawal (Berger et al. 2001; Miller and Major 2000). Different studies have confirmed these facts since they have revealed that stigma perception is positively associated with depression, anxiety, hopelessness and loneliness (Berger et al. 2001; Bunn et al. 2007; Logie and Gadalla 2009; Mak et al. 2007; Vanable et al. 2006). It must be pointed out that not only does this distress affect psychological functioning but it also contributes to the progression of the illness. In this sense, high levels of distress have been associated with a reduction in CD4 cells (indicating a weaker immune system), an increase in the viral load and a faster progression of AIDS (Chida and Vedhara 2009; Ironson et al. 2005). It is a proven fact that the way people cope with stress can reduce or increase the effect of adverse events on psychological functioning and emotional well-being, in both the long and the short term (Lazarus and Folkman 1984). The effectiveness of the coping strategies used is a complex matter which depends on the nature of the stressor, to what extent it can be controlled and the duration of the coping process (Lazarus 1999). However, in general terms, it could be stated that strategies which imply efforts to control situations like finding solutions or planning a course of action (primary control) or those coming from within oneself, like changing one’s own negative assessments of situations to more positive ones (secondary control) (Heckhausen and Schulz 1995; Rothbaum et al. 1982) are associated with better well-being. While strategies centered on disengagement from the situation or on emotion intensification are negatively related to well-being (Anderson 1996; Folkman and Moskowitz 2000; Litman and Lunsford 2009; Sanjuań et al. 2011b; Stanton et al. 2007). Although there is still no consensus (see Skinner et al. 2003), the most common terms used to refer to these two major types of strategies, are active and avoidance strategies respectively. In people with HIV in particular, this pattern of results is confirmed since the use of coping strategies based on avoidance (denial, disengagement, etc.) has been shown to be inversely associated with well-being (Ashton et al. 2005; Brincks et al. 2010; Grant-Smith

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et al. 2009; Kraaij et al. 2008; Pakenham and Rinaldis 2001; Rogers et al. 2005; Vosvick et al. 2002), while the use of coping strategies focused on solving problems and those centered on positive re-assessment of the situation are directly associated with well-being (Moskowitz et al. 2009). It has also been proved that the coping strategies used do not only affect well-being but also have an influence on the progression of the disease (Chida and Vedhara 2009; Ironson and Hayward 2008). As far as we know, in the research on coping carried out on samples of people with HIV, stigma coping has never been directly analysed, since previous studies have always concentrated on coping with the illness itself, diagnosis, or the stress associated with the fact that the individual is a person with HIV (Moskowitz et al. 2009). For that reason, in this study in particular, the participants were asked to indicate how they used a series of strategies in situations where they perceived they were being stigmatized. Furthermore, well-being is measured indirectly in most of the studies, mainly through depression and anxiety symptoms (Logie and Gadalla 2009; Mak et al. 2007; Moskowitz et al. 2009). Thus, and in keeping with the positive dimension of mental health, initially highlighted by the World Health Organization (1948), and now included in modern positive psychology (Seligman and Csikszentmihalyi 2000), one must remember that health is a state of physical, social as well as mental well-being and not merely the absence of mental disorders or symptoms. It is evident that even though one does not exhibit symptoms of anxiety or depression, that does not mean that the individual is well (Keyes 2002). However, the reality is that research has basically been centered on the study of these negative symptoms. For that reason, we study well-being in a direct way here, using subjective well-being measures along with psychological ones. These two approaches reflect different ways, albeit related and complementary ways, of understanding what being well means (Ryan and Deci 2001). Well-being is a complex construct which refers as much to optimal experience as it does to adequate functioning. Understanding well-being as an optimum is highlighted by the perspective based on subjective well-being, while adequate functioning is looked at from the perspective that focuses on psychological well-being. Subjective well-being (Diener 2000; Diener et al. 2002) is so called because it highlights that what is most important is not the objective measures on quality of life but how people subjectively perceive and interpret reality and how that, in turn, makes them feel. Subjective well-being has two components; an affective one or predominance of the positive affect over the negative one, denominated affect balance and another cognitive one or assessment of life satisfaction as a whole. As we have previously indicated, research on stigma has basically used indirect measures of well-being, such as anxiety or depressive symptoms, that is, the emotional aspect. In this study, while focusing on the positive side of well-being, we will also study the emotional component of subjective well-being or affect balance. The perspective that centers on psychological well-being (Ryff 1989a, b) defends that an individual is well not when he/she says so, but when his/her psychological functioning is optimal. This includes different characteristics like self-acceptance, maintaining positive relationships with others, autonomy, environmental mastery or purpose in life, among others. In this study, we will analyse two of these components, self-acceptance which means becoming aware of and accepting both one’s strengths and limitations, and environmental mastery, which means being able to cope with daily living. We focus on self-acceptance and environmental mastery because they are the dimensions of psychological well-being most related to affect balance (Compton 1998; Keyes

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et al. 2002; Sanjuań 2011). Studies conducted from a cultural psychology perspective have also shown that self-esteem and competence perception, which are constructs very similar to those of self-acceptance and environmental mastery respectively (Chamberlain and Haaga 2001), are the best predictors of subjective well-being in individualistic cultures (Heine et al. 2001). In agreement with the evidence previously presented, we expected stigma perception to be negatively related to the different measures of well-being (affect balance, self acceptance, and environmental mastery). On the other hand, we also expected coping with stigma perception, based both on primary control and on secondary control, (active coping) to be positively associated with the well-being measures, while coping centered around avoidance was expected to be negatively related to well-being. Finally, we also expected the relations between stigma perception and well-being to be mediated by the coping strategies employed.

2 Method 2.1 Participants To recruit participants, we contacted a national association of people living with HIV based in Spain. Associates were informed on the general purposes of the research via e-mail. They were asked to send the written informed consent if they wanted to participate. Once this consent was completed, they were provided with the link through which they could access the platform and, anonymously, answer the questionnaires. The application period for possible participants was 2 months. The only inclusion requirement was to be living with HIV and to be able to understand Spanish. One hundred and thirty-three people living with HIV (mean age = 39.11 and SD = 8.18, ranging from 19 to 74) participated in this study. Of these, 73 % were men, 71 % were in employment and only 10 % were either married or living with a partner. On average, the participants had completed 14 years of education. Forty-seven (35.4 %) had finished elementary school, 49 (36.8 %) had finished high school, and 37 (27.8 %) were holders of a university degree. The time from the diagnosis ranged from 1 month to 26 years with an average of 10.01 years (SD = 6.78). 2.2 Procedure and Measures These voluntary participants were asked to complete the Spanish versions of the following questionnaires: Brief Coping Operations Preference Enquiry (B-COPE; Carver 1997). This self-report assesses 14 coping strategies through 28 items. Participants were asked to report how often they used these different strategies to cope with stigma in 5-point Lykert type scales ranging from ‘‘1’’ (‘‘I haven’t been doing this at all’’) to ‘‘5’’ (‘‘I’ve been doing this a lot’’). Although coping has traditionally been conceptualized as either problem-focused or emotion-focused (Lazarus and Folkman 1984), recent research has found that coping strategies do not have different impact on problems or emotions (Litman and Lunsford 2009). Moreover, factor analytic studies have shown that COPE scales do not clearly load on problem or emotion focused factors. In particular, one of the factors obtained includes strategies oriented towards both primary (planning and acting), and secondary control (acceptance and more positive re-evaluation) of the problem, while the other factor

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includes disengagement strategies (denial, avoidance) and amplification of emotions (Carver et al. 1989; Litman and Lunsford 2009; Yi-Frazier et al. 2010). The results of the exploratory factor analysis conducted with the current data confirm those obtained in the studies mentioned above, since two factors were obtained, which accounted for 19.36 and 18.34 % of the variance. Venting, self-blame, denial, behavioural disengagement and substance use subscales were included in the first factor, with loads that ranged from 0.59 to 0.83. Active coping, planning, and positive reframing subscales were included in the second factor, with loads that ranged from 0.74 to 0.87. Given that the rest of the subscales had loads lower than 0.5, they were not considered. On the other hand, we must take into account that the brief COPE (Carver 1997) was developed by reducing the number of items of original subscales at 2, to overcome the excessive length of COPE. Although most of the subscales show adequate reliability coefficients, others, only reach reliability coefficients between 0.5 and 0.6, given the low number of items. Therefore, Carver himself advised selecting those subscales that are most interesting in terms of the sample as well as the objective of the study. In accordance with factorial analytic findings and Carver’s recommendation, two scores labelled as active and avoidant coping strategies were computed by averaging item scores corresponding to subscales which were included in each of those two factors. Higher scores indicate greater use of different strategies. In the current sample, a coefficients were 0.87 and 0.85, respectively. Previous studies, which have used the Spanish version of Brief-COPE with different samples, have supported this same structure with confirmatory factor analysis and adequate reliability (Morań et al. 2010; Pe´rez and Sanjuań 2012; Sanjuań et al. 2011a). Positive and Negative Affect Schedule (PANAS; Watson et al. 1988). This is a 20-item measure that evaluates positive (10 items) and negative affect (10 items). Participants were asked to report how they usually felt in 5-point Lykert-type scales ranging from ‘‘1’’ (‘‘I rarely o never feel so’’) to ‘‘5’’ (‘‘I feel so frequently’’). Positive and negative affect scores were computed by averaging items of positive or negative affect scales respectively. In the current sample, alpha coefficients for positive and negative affect were both 0.91. The negative affect score was subtracted from the positive affect score to obtain a measure of affect balance. Thus, a positive score reflects a predominance of positive over negative affect, while a negative score reflects a predominance of negative over positive affect. One advantage of affect balance over one-dimensional measures of positive and negative affect is that it controls the extremity biases (Schimmack and Diener 1997). The Spanish version of the PANAS has been used extensively with excellent reliability coefficients (Sandin et al. 1999; Sanjuań 2011). Scales of Psychological Well-Being (SPWB; Ryff 1989a, b). This is a 29-item selfreport instrument which evaluates six dimensions that point to different aspects of effective psychological functioning. We only evaluated two of these six dimensions: self-acceptance (4 items) and environmental mastery (5 items). Items are scored on a 5-point Lykert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores were computed by averaging the corresponding items for each of these dimensions. Higher scores on these dimensions reflect greater positive psychological functioning. Alpha coefficients obtained for the present study were 0.74 for self-acceptance, and 0.53 for environmental mastery. The Spanish version of the SPWB has shown adequate or excellent reliability coefficients in different samples (Dıáz et al. 2006; Van Dierendonck et al. 2008). Prejudice Perception Scale (PPS; Molero et al. 2012). For current study purposes a questionnaire to measure HIV-related stigma perception was developed. The items of this questionnaire were drawn from previous research on HIV stigma conducted in Spain

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(Molero et al. 2011). This was taken from subtle and blatant prejudice literature, and from content analysis of focus groups. Given that discrimination primarily affects the individual through the internalization of this discrimination, and since this internalization is contained in the subtle prejudice subscale, the results presented here refer exclusively to this subscale, which consists of 3 items. Participants were asked to report to what extent they agreed with statements that refer to the perception of rejection and mistrust in 5-point scales ranging from ‘‘1’’ (‘‘strongly disagree’’) to ‘‘5’’ (‘‘strongly agree’’). Said items were as follows: ‘‘Even in the cases where I seemed to be accepted, I believe that at the bottom of it all, there is mistrust because I am a person with HIV’’; ‘‘Although sometimes there is no direct rejection, people treat me differently when they know that I am a person with HIV’’; and ‘‘I also feel that people don’t trust me because I have HIV’’. Higher scores indicate greater stigma perception. In the current sample, alpha coefficient of this subscale was 0.76. Studies conducted with different samples have found that this subscale shows adequate reliability (Molero et al. 2012).

3 Results To test for possible differences between men and women, one-way analyses of variance were conducted, with all the variables analysed in this study as dependent variables. Results showed that there were no significant differences in any of the analysed variables between both groups. In order to verify whether demographic variables (age, education, and occupational and marital status) and time since diagnosis had any effect on psychological variables of interest, correlations between them were calculated. The only correlation that reached statistical signification was that between marital status (coded as 0 = with partner and 1 = no partner) and affect balance (0.24, p \ 0.02), which indicated that those who had partners reported less affect balance. Correlations calculated between the psychological variables (stigma perception, coping strategies and well-being) and their descriptive statistics are presented in Table 1. As can be observed, stigma perception was negatively associated with all the well-being measures, while it was positively related to avoidant coping strategies. Avoidant strategies were also shown to be negatively related to all well-being measures. Active coping,

Table 1 Correlations and descriptive statistics 1 1. Stigma perception

2

3

4

5

6

–

2. Active coping

0.08

3. Avoidant coping

0.29**

– 0.00

–

4. Affect balance

-0.42**

0.28**

-0.58**

–

5. Self-acceptance

-0.23*

0.21*

-0.39**

0.64**

–

6. Environmental mastery

-0.27*

0.22*

-0.39**

0.51**

0.59**

–

Mean

3.44

3.23

1.93

0.65

3.41

3.31

SD

0.91

0.85

0.68

1.33

0.76

0.64

* p \ 0.01,** p \ 0.001

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however, was not related to stigma perception but it was positively associated with all measures of well-being. To test whether coping strategies were mediating variables linking stigma perception to well-being measures, the procedure outlined by Baron and Kenny (1986) was followed. The first step in testing for mediation is to check for statistically significant association between the predictor and criterion variables. In this study, all the relationships could be tested for mediation since stigma perception, here the predictor variable, had statistically significant correlations with affect balance, self-acceptance and environmental mastery, which are the criterion variables (see Table 1). The next step is to establish a statistically significant association between the predictor (stigma perception) and mediator variables (active and avoidant coping strategies). As seen in Table 1, stigma perception only significantly correlated with avoidant coping, therefore, only mediation of said strategies can be tested. Finally, it should determine whether the inclusion of avoidant coping as a mediator decreases the relationships between the predictor and criterion variables. To this end, three hierarchical regression analyses were conducted (one for each well-being measure), entering stigma perception into the equation on Step 1, and avoidant coping on Step 2. Additionally, when affect balance was the criterion variable, marital status was previously entered into the equation to control for its effect, since as noted earlier, this variable was significantly correlated with affect balance. The results of these regression analyses have been summarized in Tables 2, 3 and 4. Mediation would occur when the inclusion of the mediating variable (avoidant coping) into the regression equation decreased the relationship between the predictor (stigma perception) and criterion variables (affect balance, self-acceptance and environmental Table 2 Hierarchical regression analysis to predict affect balance Predictor

b

t

Model R2 = 0.04, F(1,132) = 4.41*

Step 1 Marital status

0.24

2.10* R2 = 0.22, F(2,131) = 14.19**

Step 2 Marital status Stigma perception

0.15 -0.42

1.72 -4.79** R2 = 0.41, F(3,130) = 23.09**

Step 3 Marital status

0.17

2.24*

Stigma perception

-0.29

-3.96**

Avoidant coping

-0.45

-5.67**

* p \ 0.05, ** p \ 0.001 Table 3 Hierarchical regression analysis to predict self-acceptance Predictor

b

t

R2 = 0.05, F(1,132) = 7.02*

Step 1 Stigma perception

Model

-0.23

-2.65* R2 = 0.17, F(2,131) = 13.46**


-0.12

-1.45

Avoidant coping

-0.36

-4.35**

* p \ 0.01, ** p \ 0.001

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716 Table 4 Hierarchical regression analysis to predict environmental mastery b

Predictor

t

Model R2 = 0.07, F(1,132) = 10.05**


-0.27

-3.17** R2 = 0.18, F(2,131) = 13.93**


-0.17

-2.04

Avoidant coping

-0.34

-4.08**

* p \ 0.05, ** p \ 0.001

mastery), and when the mediating variable simultaneously, significantly predicted the criterion variable. According to these regression analyses, it can be said that the negative relationships between stigma perception and affect balance, self-acceptance and environmental mastery were mediated by the use of avoidant coping strategies. These associations between stigma perception and well-being were reduced, but non-zero, indicating that avoidant coping strategies are a partial mediator. To test whether the reduction in the relationship between stigma perception and wellbeing measures was significant, when avoidant coping strategies were included as variable in the regression model, the procedure outlined by Sobel (1988) was followed. The Sobel procedure provides Z statistic with which to assess significance in the reduction of the relationship. Zs obtained through Sobel0 s test were -3.14 for affect balance, -3.22 for selfacceptance, and -3.43 for environmental mastery (all ps \ 0.001). Therefore, the negative relationships between stigma perception and different well-being measures were significantly reduced with the inclusion of avoidant coping as a mediator (see Figs. 1, 2 and 3).

4 Discussion In this study, we investigated the relationships to be found among stigma perception, coping strategies and well-being in a sample of people with HIV. ** 0.29

AVOIDANT COPING

-0.42**

STIGMA PERCEPTION

-0.5 8**

(-0. 45 * *)

(-0.29**)

AFFECT BALANCE

Fig. 1 Standardized b coefficients, and standardized b coefficients reduced (in parentheses) when avoidant coping is introduced as a mediating variable between stigma perception and positive affect balance

* 0.29* STIGMA PERCEPTION

AVOIDANT COPING

-0.23*

-0.3 9** (-0. 36* *) (-0.12)

SELFACCEPTANCE

Fig. 2 Standardized b coefficients, and standardized b coefficients reduced (in parentheses) when avoidant coping is introduced as a mediating variable between stigma perception and self-acceptance

123


* 0.29* STIGMA PERCEPTION

717

AVOIDANT COPING

-0.27*

-0.3 9** (-0. 34* *) (-0.17*)

ENVIRONMENTAL MASTERY

Fig. 3 Standardized b coefficients, and standardized b coefficients reduced (in parentheses) when avoidant coping is introduced as a mediating variable between stigma perception and environmental mastery

Our study has shown that not only is stigma perception associated with distress measures like anxiety and depression, as other studies have previously shown (Logie and Gadalla 2009; Mak et al. 2007; Moskowitz et al. 2009), but it is also related to a reduced well-being, in particular to affect balance, self-acceptance and environmental mastery. In the same way that former studies, which have analysed coping with the illness, diagnosis or stress related to the illness (Ashton et al. 2005; Brincks et al. 2010; GrantSmith et al. 2009; Kraaij et al. 2008; Moskowitz et al. 2009; Pakenham and Rinaldis 2001; Rogers et al. 2005; Vosvick et al. 2002), the results of our study have shown that coping with stigma perception through strategies based on avoidance is inversely associated with well-being, while coping through strategies based on primary and secondary control, or active coping, is positively associated with well-being. Stigma perception, as well as sustaining a negative relationship with all the measures of well-being, is positively associated with the use of avoidance strategies. In fact, the inverse relationships between stigma perception and well-being are partially mediated by the use of avoidance strategies. Therefore, it could be said that the negative incidence of stigma perception on well-being is partly due to coping with the stigma experience through avoidance strategies. We want to draw attention to the fact that the perception of stigma did not significantly correlate with the use of active coping, which does not mean that people do not use active strategies to cope with stigma perception. It must be taken into account that people were asked to report the strategies used to cope with situations where they perceived stigmatization. Since the group average was not zero but 3.23 (see Table 1), we know that active strategies for dealing with situations of perceived stigma were used. We also know that the use of these strategies was positively associated with well-being. What this lack of relationship between stigma perception and active coping really means is that these two variables do not change concomitantly. On the contrary, the significant correlations found between stigma perception and avoidant coping means that the use of these strategies increases when more stigma is perceived. Given that certain psychosocial variables related to stigma, such as coping based on avoidance or psychological distress, have adverse effect on the progression of the disease (Chida and Vedhara 2009), the putting into practice of programs for psychosocial intervention is of utmost importance. Given that stigma contributes to the persistence of the illness, social intervention programs which prioritise eliminating or at least reducing prejudice from society are still required. In this sense, the programs which have proved to be most effective are those which supply reliable and accurate information on the illness and promote contact with people with HIV (Bos et al. 2008). On the other hand, alongside these programs aimed at prejudice elimination, a psychosocial intervention is also necessary. These programs should focus on all those

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variables proven to have as much an adverse as a protective effect, not only on the life quality of people with HIV but also on the progression of the disease. As has been mentioned above, it has been found that psychological distress and the strategies based on avoidance are associated with faster progression of the illness (Chida and Vedhara 2009), while active coping strategies have a positive effect on the prognosis (Ironson and Hayward 2008). Furthermore, it has also been shown that the experience of positive affect is associated with a lower mortality rate in this group (Chida and Steptoe 2008; Moskowitz 2003). Considered all together, these findings bring to the fore the fact that psychosocial intervention should focus on eliminating, or at least reducing the use of avoidant strategies, while promoting the use of more effective active coping strategies and more positive assessment of situations. At the same time, the intervention should not just be centered on the elimination of negative symptoms like anxiety and depression, but also on the promotion of positive emotions and on a general increase in well-being. In this way, modern positive psychology proposes that well-being can be increased (Lyubomirsky et al. 2005), and there is already evidence that supports the effectiveness of certain interventions. Along these lines, different studies have shown that interventions promoting more positive cognitive restructuring, good interpersonal relationships, helping others or the pursuit of intrinsic goals increase positive emotions (Emmons 2008; Fredrickson 2008; King 2008). Positive emotions are also known to be beneficial to health and are associated with increased longevity (Chida and Steptoe 2008; Veenhoven 2008; Xu and Roberts 2010). These beneficial effects on health could be due to these emotions acting on the sympathetic and parasympathetic nervous systems, decreasing the activity in the former and increasing it in the latter (Chida and Steptoe 2008). Therefore, positive emotions can counteract even the adverse physiological effects brought on by negative emotions (Fredrickson et al. 2000), and may even be put forward as the mechanism that would allow us to explain why positive affect is associated with a lower mortality rate among people with HIV (Chida and Steptoe 2008; Moskowitz 2003). Our results have also shown that married couples or people living with a partner exhibit less positive affect balance and this still stands after considering the effects of stigma perception and the use of avoidance strategies taken together. In future studies, this relation should be researched in depth. There should be a wider representation of people with partners in the sample, since; only 10 % of the participants were in that situation in this study. On the one hand, the partner is one of the main sources of support, but he/she can also be an equally important source of conflict (Abbey et al. 1991; Herrington et al. 2008). On the other, perception of partner support changes according to sex, since males perceive more support from their partners than females do (Hildingh et al. 1997). Future studies should analyse the possible interactions among these variables, as that has not been researched here due to the aforementioned low number of people with partners as well as a scarce representation by women in this sample. In the studies on the effects of social support carried out on people with HIV, an inconsistent pattern of results has been found (Ironson and Hayward 2008). This could be due to a different partner support perception by men than by women as well as the possible source of conflicts coming from the couple itself. This study was subject to some limitations that deserve mention. First, although we haven’t found any differences between men and women in the variables of interest, these may possibly have emerged if the sample had been more balanced as regards the number of women (only 27 %). Second, only self-reports have been used. Future studies should include more objective measures which may clarify whether stigma perception affects not

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only well-being, but also disease progression, and whether this effect is direct or is mediated by coping strategies used to deal with stigma. Moreover, although all the scales used here have shown adequate or excellent reliability in previous studies, the environmental mastery subscale had, in this sample of people with HIV, a low reliability coefficient. A low reliability can limit the degree to which the scale correlates with other variables (Keyes et al. 2002); although our results show that this has not occurred. However, in future studies, if this low reliability is corroborated, an alternative measure with better reliability should be used. Third, we analyzed the relationships between stigma perception, coping strategies and well-being with a cross-sectional study. However, only longitudinal studies can provide insight on how the stigma perception and coping strategies used can affect well-being. Fourth, we could not have information on the health status of participants; however, it is known that poor health, especially whether it interferes with meaningful goals, may affect well-being (Diener et al. 1999). Although adaptation to illness and/or adjustment of goals can limit the effect of health on well-being, future research should assess both objective and subjective health indices, and analyze whether stigma perception and coping strategies still affect well-being after controlling health status. Despite these main limitations, this study provides new and interesting data about different effects of stigma perception and coping strategies on well-being in people with HIV. Acknowledgments Work on this paper was supported by a Spanish Science and Innovation Ministry Grant (number PSI2008-02966).

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