The Effect of Stress Management Training on Stigma and Social Phobia in HIV‐positive women

Objectives: This study was to investigate the effect of stress management training on the stigma and social phobia of HIV‐positive women. Methods: This semi-experimental was conducted on 55 HIV‐positive using census sampling. The participants referred to Shohada Comprehensive Health Center in Hamadan, west of Iran, in 2017. Stress management training was conducted in 5 sessions for a group of 8-10 participants. The data collection tools were Berger HIV Stigma and Connor Social Phobia Scale. The questionnaires were filled before and 2 weeks after the intervention. Results: The mean age of participants was 38.5 and the duration of HIV infection was 6.5 years. 55% of patients were married and 80% were infected by sexual intercourse. The findings showed that there was a significant difference between the mean scores of stigma and social phobia before and after the intervention (P<0.05). Conclusions: Stress management training has been effective in the decrease of stigma and social phobia among HIV positive women.

regard, stress management skills can help individuals to control themselves while facing situations, people, events, or excessive demands [ 11 ]. Nwobi et al. (2018) showed that stress management training has significantly reduced the symptoms of depression, anxiety, and perceived stress. It can also improve the social life satisfaction of PLWHA people [ 12 ].
Regarding HIV infection among women, stigma and social phobia induced by cultural and social variables in Iran is a major health challenge that requires appropriate and effective interventions. Therefore, the aim of this study was to determine the effect of stress management training on stigma and social phobia among HIV-positive women. In addition, the study moved further to suggest health care measures based on the obtained results.

Design and Participants
This semi-experimental study was conducted on 55 HIV-positive women referring to Shohada Comprehensive Health Center in Hamadan city in Iran, from May to September 2017. The population composed of 60 positive HIV women, 5 of whom were excluded from the sample since they did not have the willingness to participate in the study. The obtained results of the study before and after the intervention were compared. The study inclusion criteria were residency of Hamadan province, history of 6 months of HIV infection, definitive diagnosis of the disease (based on Rapid Test, Enzyme-Linked Immunosorbent Assay (ELISA), Western Blot, polymerase chain reaction (PCR) Diagnostic Tests), no psychiatry disease, absence of physical and mental disabilities, lack of a stressful experience in the last month, minimum level of reading and writing literacy.
People who were absent for more than two sessions were excluded from the study.
Data collection tools of 0-68. Scores of normal people are less than 20, and people with very severe social phobia gain a score of more than 51. Scores above 20 represent high social phobia and scores lower than 20 represent low social phobia [ 18 ]. Campbell-Sills et al. confirmed the reliability of Connor's social phobia scale using test-retest method (α =0.94) [ 19 ]. In the current study, the Persian translated version of the Connor Social Phobia Scale was used, which has been previously used in numerous studies in Iran [ 20 , 21 ]. In current study, the reliability of the questionnaire was confirmed with Cronbach's alpha coefficient (α=0.93). Session 4: The session began by a review of the tasks related to the previous session. The session continued to practice relaxation and diaphragmatic breathing, examine the exist barriers for doing tasks, study the reinforcement methods related to self-confidence, teach social skills, and practice the seven basic steps to learn these skills, such as active listening, frankness and honesty, self-knowledge, and awareness raising.

Intervention
Session 5: The session began by a review of the tasks related to the previous session. In the next step, the instructors introduced the relaxation method as a therapeutic method, taught contraction method and the muscle relaxation, practiced the methods and resolved all ambiguous aspects regarding the application of the skills, planned for practicing household resignation.
Data collection method: The questionnaires were completed by the participants on the first and the last sessions. This means that the participants filled out the questionnaires before and after the intervention.

Statistical analysis
The SPSS software (version 25) was employed for data analysis using descriptive (mean and standard deviation) and inferential statistics (paired t-test and Pearson Correlation).
The Kolmogorov-Smirnov test was used to verify the normal distribution of data.

Results
The findings showed that the mean age of the participants was 38.5±8.6 years. The mean duration of HIV infection was 6.5±3.8 years. Regarding the marital status of the subjects, 55% of them were married. In addition, 80% of the cases were infected to HIV through sexual intercourse (Table 1).
According to Table 2 Furthermore, the findings showed that the mean and standard deviation of social phobia before the intervention was 24±17.4, which decreased after the intervention to 11.2±9.68. In other words, educational interventions enhanced the management skills of social phobia among HIV-positive women. As can be seen in Table 3, the paired t-test indicated a significant difference between the mean scores of social phobia in HIV-positive women before and after the intervention (P<0.05).
The results also revealed a significant positive correlation between stigma and social phobia (r=0.528, P<0.01) ( Table 4). In other words, there was a direct two-way relationship between these two variables, meaning that stigma affects social phobia directly and social phobia affects stigma directly.

Discussion
The aim of this study was to determine the effect of stress management training sessions The findings of the current study also revealed that there was a relationship between stigma and social phobia. In other words, it can be said that stigma and social phobia are two phenomena that are influenced by social and cultural factors, which are considered in many studies as the challenges for patients with HIV [ 26 , 31 , 35 ]. Although this study provided insightful findings, it suffered from some limitations. Firstly, there was no control group in the study due to the limitation of the research community. The secondly, training sessions were implemented for a short period of time because of the personal and family problems of some patients.

Implication
The results of this study can be used in the clinics for care and treatment programs.
Moreover, to provide counseling services, the health care team can use counseling services combined with therapeutic drug interventions to maintain and improve the mental health of these patients.

Conclusion
The obtained results of the current study revealed that stigma and social phobia are big challenges for HIV-positive women since these people are always judged by others and are subjected to labeling and rejection. These problems originate from the negative beliefs about the nature of HIV/AIDS among ordinary people in the community. These problems can also have a negative impact on the treatment and care process. Therefore, the investigation and identification of these problems, which are often influenced by cultural

Availability of data and materials
The data set is available from the corresponding author who is also the Principal Investigator of the study.