HIV stigma has remained to be a hindrance to the attempts in curbing the global epidemic of HIV/AIDS (Stangl, Lloyd, Brady, Holland, & Baral, 2013). Most are hesitant in undergoing HIV testing because of the fear that they might be HIV positive or to seek treatment if affected, this contributes in making AIDS the “silent killer,” since people refuse to breathe a word of it or take necessary precautions because of the fear of social disgrace (Omosanya, Elegbede, Agboola, Isinkaye, & Omopariola, 2014).HIV-related StigmaStigma, as a concept, involves labeling a person or group and connecting the label to its most undesirable behavior. It may come in various forms such as verbal abuse, gossip, isolation, humiliation, rejection or neglect of individuals (Deng et al., 2007; Thomas, 2016 as cited by Rubens, 2016). In 2003, Parker and Aggleton (as cited by Harper, Lemos, & Hosek, 2014) recognized HIV-related stigma as a process of social exclusion the powerful dominate those with less power, which results in a devaluation. On the other hand, Yuh, Ellwanger, Potts, Ssenyonga (2014) defined HIV stigma as a “social phenomenon that degrades individuals with HIV” and is something that results to negative behaviors of prejudice, discounting, discrediting, and discrimination toward PLHIV and those that may be associated or linked with them. As cited by Rubens (2016), several studies have been repeatedly stating that the very nature of transmission of HIV/AIDS, which is through sexual contact, especially men who have sex with men, is the one that initiates or causes high levels of stigmatization. Stigma was also said to be the chief reason that the AIDS epidemic continues to devastate societies around the world (Omosanya, et al., 2014).There are aspects of HIV-related stigma or mechanisms through which stigma may be experienced by those living with HIV. These aspects include anticipated stigma, enacted stigma and internalized stigma. Anticipated stigma is when an HIV-positive individual becomes aware and fearful of prejudice and discriminations that may eventually lead him to constant avoidance and concealment of the disease (Rubens, et al., 2016). Enacted stigma is the discrimination itself experienced. In worst cases, it may include acts of violence and marginalization (Rueda, et al., 2016). Lastly, internalized stigma refers to the endorsement of negative beliefs, views and feelings of oneself as it relates to one’s HIV-positive status characterized by self-blame and self-deprecation (Rueda, et al., 2016). These multidimensional aspects of HIV-related stigma only show that the negative perception towards being HIV-positive can be experienced in various ways. However, according to a study by Parker and Aggleton in 2013 (as cited in Rubens, 2016), the forms in which stigma and discrimination manifest depends on the sociocultural context of the individual, cultural diversities and complexities. The focus of the study is on internalized HIV-related stigma. This type of stigma of HIV/AIDS may even have more severe consequences than perceived or enacted stigma (Phillips, Moneyham & Tavakoli, 2011). Internalized HIV-related stigma refers to the shame and negative self-image of PLHIV, which may result to psychological disorders such as depression, low self-esteem and isolation (Fatoki, 2016). Therefore, it can bring about unfavorable effects on the interpersonal outcomes and have an impact on physical and psychological health among PLHIV, pessimistic thoughts on one’s HIV status makes it difficult for PLHIV to disclose their status (Overstreet, 2013). In 2002, Herek, Capitanio, & Widaman (as cited by Harper, Lemos, & Osek, 2014) reported that expressions of HIV-related stigma has been decreasing in the United States, internalized stigma is still present, which poses a threat to the long term coping and adjustment with the infection. According to the Medical Monitoring Project by Centers for Disease Control and Prevention (CDC) in February 2018, almost 8 out of 10 HIV-positive individuals in the United States report feeling internalized HIV-related stigma. They defined this type of stigma as when a person living with HIV experiences negative feelings or thoughts about their HIV status. In the same project, statistics showed that feelings of difficulty to tell others about their HIV infection, guilt or shame and feelings of being “dirty” and worthless are evident. Several studies have focused on internalized HIV-related stigma due to the damaging effect on the physical and mental health of an individual (Kalicman, Leickness, Cloete, Mthembu, Mkhonta, & Ginindza, 2009 as cited by Rael, & Hampanda, 2016). It is expected that PLHIV, who have higher internalized stigma are reported with worst cases of depression because they experience self-hatred (Lewis, 1998 as cited by Rael, & Hampanda, 2016), self-abasement (Simbayi, Kalichman, Strebel, Cloete, Henda, Mqeketo, 2007 as cited by Rael, & Hampanda, 2016), and social isolation (Crandall & Coleman, 1992 as cited by Rael, & Hampanda, 2016) that can worsen depression among PLHIV. HIV Medication adherenceAntiretroviral therapy (ART) is known for effectively delaying the progression of HIV/AIDS from a manageable chronic illness to a terminal illness (Yu, et al., 2014). Delaying the progression of the disease is achieved through various mechanisms of action which eventually delay the rapid growth of the virus that weakens the immune system. It is also critical to viral suppression and maintenance of the health status and quality of life among PLHIV (Genberg, 2015). Therefore, adherence is necessary to avoid the development of opportunistic infections such as tuberculosis and pneumonia and the progression of HIV to AIDS (Mao, Li, Qiao, & Zhao, 2017). Medication adherence is essential for PLHIV in order to achieve long-term positive health outcomes (Helms, et al., 2016). It refers to a person’s degree of response to the agreed recommendations of a drug in terms of its amount, frequency, dosage, time and route of administration. However, there have been researches from other countries that a number of PLHIV struggle to maintain adherence to the antiretroviral treatment due to its life long use. Genberg (2015) categorized the factors that may affect ART adherence into four major groups: medication and health concerns, stigma, family responsibilities and problems with schedule and routine. This research suggests that majority of HIV patients that are taking ART have their own self-perceived barriers when it comes to adhering to their medication regimen.Some barriers are also related to the misconceptions about antiretroviral therapy such as the severe side effects that could affect their ability to function adequately so postponing the negative side effects of ART in the body by not taking their medications. On the other hand, the concern of HIV patients is accessibility to medication for HIV/AIDS so increased access to antiretroviral therapy (ART) has positive impacts in reducing the fatality rate of the disease and paved way to allowing PLHIV in sustaining their economic and social roles within their families and communities. Several practitioners, activists, and researchers proposed that improving the access to medications would result to a decline in prejudice and discrimination associated with HIV (Treves-Kagan, Steward, Ntswane, Haller, Gilvydis, Gulati, Barnhart, & Lippman, 2016).HIV stigma and medication adherence HIV-related stigma has been recognized as a major restraint towards protective behaviors such as HIV testing, medication adherence and disclosure of HIV status (Gwadz, et al., 2018). It produces feelings of shame, guilt and concern when it comes to the disclosure of their health status, which in turn leads to negative self-image perception. In worst-case scenarios, through these negative perceptions, some mood disorders may arise such as major depressive disorder, anxiety and panic attacks. In fact, in comparison to the population, patients living with HIV/AIDS report to have two to three times increased rates of depressive disorders. However, a weak and non-significant association between HIV stigma and lost to follow up in HIV medications was found in a study by Evangeli, et al. (2014). Data from Treves-Kagan (2016) explain why both may simultaneously be true, because a major influence of stigma is ingrained from fear of what might happen, which consequently discourages people from seeking testing and treatment.In a similar way, self-stigma has a significant impact to every aspect of an individual’s life. Internalized stigma is shown through decreased self-esteem and increased depression. According to Corrigan, 2004 (as cited by Monicah, G.N., 2014), the low self-esteem that comes from internalized stigma is usually manifested by feelings of shame which interferes with a person’s life goals and quality of life. Depression is associated to people with low self-esteem, which led them to stigmatize themselves (Latalova, Kamaradova, Prasko, 2014), which again eventually limit social interactions and impair occupational functioning. In relation to this, current researches reveal that depressive symptoms and medication adherence are strong correlates of stigma-related experiences and suggest that HIV related stigma increases the individual’s vulnerability to depressed moods. When patients are bothered by the prejudices and judgments that they experience, it makes them deny their disorders and delay seeking or initiating proper treatment or care. In a study by Kamaradova, et al. (2016), patients who manifested lower self-stigma levels tend to have better adherence while those who voluntarily discontinued their medication showed higher self-stigma levels. Aside from depression and low self-esteem, several studies have investigated on mediating mechanisms for the negative effects of internalized HIV stigma on medication adherence. Some of these are loneliness, social support and other related psychosocial factors. It was also found out that one factor of failing to adhere to medications is the lack of knowledge, fearing that drugs are dangerous or that because of stigma around, HIV is a curse making them feel that living is no longer an option (AIDS Society, 2016). The association of HIV-related stigma with poor adherence to medications, as proven, would further aggravate a PLHIV condition and maladaptive coping, which leads to poor quality of life.Motivational VideoMotivation, in general, can be derived from the five basic needs in the growth and development of humans. Abraham Maslow’s theory of Human Motivation proposed that motivation is the outcome of a person’s attempt in fulfilling these basic needs. The use of motivation as an intervention may come in various forms such as brochures, group interactions, seminars and video materials that may increase the knowledge of the students. Findings from previous studies have shown the efficacy of video material such as video presentations or clips in the improvement of motivation and increased participation from the subjects (Berk, 2009; Goldstein & Driver, 2015 as cited by Park & Jung, 2016).Video presentations are utilized to improve the strict adherence of health care professionals when it comes to the standard protocol and execution of interventions needed in order to achieve optimum patient care. Video presentations are not just effective tools for learning but also significant in clinical training as it enhances the adherence of health care professionals to standard protocols (Kandler, Tscholl, Kolbe, Seifert, Spahn, & Noethiger, 2016).Researchers stated that video-based interventions to be effective, efficient, and superior to the traditional method for patient education. Video-based intervention can be conducted in both settings, clinical or home-based, offering the opportunity for the clients to watch the video again. Also, videos or visual aids provide an engaging platform to facilitate health information visually and significantly increase the attention and recall of health education information, most especially to those clients with low health literacy (Rosaasen, Mainra, Bryson, Nhin, Shoker, Wilson, Padmanabh, and Mansell, 2018).Another study was conducted to test the efficacy of Video-Based Contact Intervention (VBCI) in improving the attitudes of primary care nurses toward people who are mentally ill. The results show that the use of VBCI is very effective in enhancing the attitudes of primary care nurses toward people with mental illness. The intervention done was correlated to the feedback that exemplified positive improvement of the attitudes of nurses toward stigmatized people. In conclusion, it was proven that VBCI or video presentation is an effective means to improve the attitudes of an individual towards stigmatized people (Ng, Rashid, & O’Brien, 2017).HIV-related stigma interventions are lacking domestically because of the diversity in culture of the population and that is why it is essential to develop people-centered interventions that include their cultural beliefs to promote HIV prevention, care, and treatment in decreasing HIV-related stigma (Brown, Macintyre, & Trujillo, 2003; Heijnders, & Van Der Meij, 2006; Mahajan et al., 2008; Stangl, Lloyd, Brady, Holland, & Baral, 2013 as cited by Rivera et al., 2015). A video presentation was developed to decrease the stigma and the results show that HIV stigma was lower among those who viewed the video presentation compared to those who did not, as well as, low educational level and unemployment are associated with HIV related stigma (Darrow, Montanea, & Gladwin, 2009; Lentine et al., 2000 as cited by Rivera et al., 2015).2.2 Theoretical FrameworkAccording to Roy’s Adaptation Model, persons are the main focus of nursing and are holistic adaptive systems in constant interaction with the environment, which is described by Roy as all influences, circumstances and conditions that surround and affect the behavior and development of persons or groups. “It is the changing environment that stimulates the person to make adaptive responses” (Andrews & Roy, 1991). Persons receive stimuli from both the environment and one’s self. This model gives emphasis on the concept of adaptation of the person. The regulator and cognator are seen as Roy as methods of coping, the regulator coping subsystem is accountable for the automatic response through chemical, neural, and endocrine coping processes, whilst the latter through self-concept, role function adaptive modes and interdependence, “responds through four cognitive-emotive channels: perceptual information processing, learning, judgment, and emotion” (Andrews & Roy, 1991).A response to a stimuli are made through four adaptive modes: The physiological-physical adaptive mode, which involves the physiological processes to meet the basic needs associated with oxygenation, nutrition, elimination, activity, rest, and protection. The self-concept group identity adaptive mode, which aims to know who one, is and how one would act in society. Roy defined one’s individual self-concept as “the composite beliefs or feelings that an individual holds about him- or herself at any given time” (Roy & Andrews, 1999). The components of self-concept include the physical self, which includes sensation and body image, the personal self, which involves self-consistency, self-ideal, and moral-ethical spiritual self. Role function adaptive mode focuses on the roles that persons play in the society, and the Interdependence adaptive mode is involved with the interactions the people make in the society. (Alligood, 2014).Stigma was conceptualized by Goffman (1963) as any kind of attribute that an individual may possess which would render him/her disqualified from social acceptance, possession of this trait also makes the individual have a significant negative social value.An individual who experiences stigma also undergoes a stressful situation wherein he/she internalizes negative beliefs, feeling and opinions towards himself/herself (Logie, Newman, Chakrapani, & Shunmugam, 2012). Persons have various needs in order to adapt, especially when one’s health is altered. In this context, the Roy Adaptation model becomes relevant since HIV/AIDS related stigma may either threaten or promote a person’s existence. A wealth of evidence reveals that HIV stigma, or social discrediting and devaluation associated with HIV has unfavorable impacts on the health of PLHIV (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013). This research focused on the Physiological-physical adaptive mode and the self-concept group identity adaptive mode, through the Physiological-physical adaptive mode, the subjects would respond to the motivational video and be able to meet the goal of increasing medication adherence because of the necessity to fulfill and maintain their physiologic needs, and through the self-concept group identity adaptive mode the subjects would be able to fulfill the goal of reducing internalized stigma and to increase medication adherence, since this mode deals with the human’s beliefs and feelings about himself/herself. Nursing, according to Roy has the goal of promoting adaptive responses and managing the environmental stimuli by “altering, increasing, decreasing, removing, or maintaining them” (Roy & Andrews, 1999) is the primary focus of nursing interventions. In this study, the researchers made use of a motivational video as a nursing intervention to promote medication adherence by reducing internalized stigma among PLHIV.
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