The relationship between social roles and psychosocial adjustment in women with AIDS: A structural equation model

Background: Acquired Immunodeciency Syndrome/AIDS is a new social phenomenon that affects almost all the aspects of the social and economic life of individuals. The present study was conducted for the path analysis of the relationship between social roles and psychosocial adjustment in women with AIDS. Methods: This cross-sectional study was conducted in 2019 on 240 women with AIDS who referred to the Counseling Center for Behavioral Diseases of Imam Khomeini Hospital in Tehran. The eligible individuals entered the study through convenience sampling and data were collected using ve questionnaires, including the Psychosocial Adjustment to Illness Scale, the Perceived Social Support Scale, the Multidimensional Health Locus of Control Scales, the Illness Perception Questionnaire, the Experiences in Close Relationship Scale and a socio-demographic checklist. Data were analyzed using SPSS-16 and Lisrel-8.8 software. Results: According to the results of the path analysis, internal health locus of control and patient's age have a signicant positive relationship with psychosocial adjustment only through the direct path, and among them, patient's age has the greatest positive and direct relationship (B=0.139).In the indirect path, education, external health locus of control, anxiety in experiences of close relationships, and perceived support have the greatest relationship with psychosocial adjustment, and among these variables, education has the highest positive relationship (B=0.06).Illness perception, avoidance in experiences of close relationships and chance locus of health control are associated with psychosocial adjustment through both direct and direct paths, and among these variables, chance locus of health control has the greatest overall relationship with psychosocial adjustment (B=0.238). Conclusion: Based on the results, social roles and physical health are directly/indirectly associated with psychosocial adjustment, which emphasizes the need to pay more attention to all three aspects of psychosocial health, especially in this vulnerable group of the society and relationship of social roles with psychosocial adjustment in women with AIDS.


Background
Acute Immune De ciency Syndrome (AIDS) is not only one of the major challenges and health threats in the world, but is also now recognized as a biomedical and sociocultural issue [1]. According to World Health Organization's (WHO) reports, the number of women infected with the virus worldwide has reached more than 50% of all the cases. In Iran, the rate of HIV-positive women has risen from 7 percent in 2015 to 11 percent in 2016 and 17 percent in 2017, which means both increasing cases of infection in women and also increased access to HIV testing among women [2]. This disease is a new and unique social phenomenon that affects almost every aspect of the social and economic life of individuals [3]. It also leads to decreased self-esteem and increased vulnerability, isolation, confused thoughts and mental problems such as depression, anxiety, stress and sleep disorders in patients [4,5].
Patients with HIV/AIDS are faced with numerous physical and mental health problems. In 1946, the WHO offered a three-dimensional de nition of health encompassing biological, psychological, and social aspects. In most countries, however, both the psychological and social dimensions of health have been largely overlooked by health system administrators and country planners, and Iran has not been exempted from this rule either [6].
The concept of psychosocial adjustment to illness has received great attention over the past few decades. Proper adjustment allows the patients to make changes that guarantee their health [7]. Adjustment refers to the personal characteristics that each person uses for their psychosocial management and to improve their life [8].
Social roles are one of the most important factors affecting adjustment to illness. Based on the proposed model for the relationship between social role quality and mental health (Fig. 1), women with chronic diseases who have a high social role quality adjust better to their disease [9]. People play different social roles in the society, and these roles are the result of personal and group efforts by them to reap the bene ts of their accumulated roles and prevent the incidence of social problems, such as the feeling of social alienation [10]. According to this model, the locus of health control and physical health are other factors that affect mental health [9]. The locus of health control is a concept in psychology based on which the patient's perceptions of health control have three distinct dimensions [11].
In the majority of studies in this group, only one or two aspects of the health dimension have been examined, and there are no or very limited studies on all the three dimensions of health, i.e. physical, psychological and social dimensions. In light of these issues and given the importance of AIDS, this study seeks to perform a path analysis of social roles in relation to psychosocial adjustment in women with AIDS.
The present study is part of a larger study examining the status and relationship of social roles with psychosocial adjustment in women with AIDS.

Design
This cross-sectional study was conducted in 2019 at the Counseling Center for Behavioral Diseases of Imam Khomeini Hospital in Tehran. This center serves as the main referral center for patients with AIDS and has the highest records of AIDS cases and was selected for this reason.
Sampling took place through the convenience method until the determined sample size was reached.

Inclusion criteria
Being an Iranian woman aged 18-45 years with AIDS and having health records in the select center, a CD4 less than 500 (as per the center's treatment protocol), minimum reading and writing literacy, a sexual partner, and no other self-reported psychological or physical illnesses.

Exclusion criteria
Incomplete completion of the questionnaires and the self-reported use of psychotropic substances during the study, which did not allow proper responding to the study questions.

Data collection and de nition of terms
Data were collected using ve questionnaires, including the Psychosocial Adjustment to Illness Scale (PAIS), the Perceived Social Support Scale (PSSS), the Multidimensional Health Locus of Control Scales, the Illness Perception Questionnaire (IPQ), the Experiences in Close Relationships (ECR) Scale and a sociodemographic checklist.
To examine social roles, which are de ned as the product of personal and group efforts by individuals to reap the bene ts of their accumulated roles and prevent many social problems, such as the feeling of social alienation [12], three questionnaires were used, namely the ECR, PSSS and a socio-demographic checklist. In this study, physical health was assessed using two questionnaires, namely the Multidimensional Health Locus of Control Scales and the IPQ.

Socio-demographic checklist
A researcher-made checklist including items on age, education, occupation, marital status, insurance status, number of children, and method of a iction were completed for all the participants.

Psychosocial Adjustment to Illness Scale
The Psychosocial Adjustment to Illness Scale (PAIS) consists of 46 items in seven domains, including health care orientation, vocational environment, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress. Scoring is on a 4-point scale from zero to three. The sum of the scores of each component was divided by the number of items in that component and the mean was considered that component's compatibility score, and the sum of all the scores was divided by the total number of items and the mean total score was taken as the total score. The validity and reliability of this tool was calculated in Iran in 2013 and the scale's Cronbach's alpha was calculated as 0.94 [13]. The present study assessed the reliability of the tool in the target group and the Cronbach's alpha coe cient for the total score of psychosocial adjustment was calculated as 64.1.

Experiences in Close Relationships (ECR) Scale
The Experiences in Close Relationships (ECR) is a 36-item tool that measures adult attachment in two dimensions (18 items each), namely attachment-related anxiety and attachment-related avoidance in close relationships. The items are answered on a Likert scale from 'strongly agree' to 'strongly disagree' (1-7), and each person receives a score from 6 to 42 in the avoidance dimension and 3 to 21 in the anxiety dimension of each domain of relationship. The rst four items are reverse scored. The validity and reliability of this questionnaire have been assessed in Iran by Seyedi et al. in 2013 [14]. The present study also assessed the reliability of this questionnaire in the target group and its Cronbach's alpha coe cient was found as 63.3% for anxiety and 84% for avoidance.

Perceived Social Support Scale
The Perceived Social Support Scale (PSSS) is a 12-item tool designed by Zimmett et al. (1988) to assess perceived social support from three sources, namely the family, friends, and signi cant others. To obtain the total score, the scores of all the scale items are summed up and divided by their number -that is, 12 [15]. The present study assessed the reliability of the questionnaire in the target group and the Cronbach's alpha for social support was reported as 0.91.

Illness Perception Questionnaire
The Illness Perception Questionnaire (IPQ) was designed by Broadbent et al. in nine subscales based on the revised form of this questionnaire, and its rst eight items are scored from 1 to 10 while item nine is open-ended and asks about the three major causes of the disease in respective order. Each subscale measures one component of illness perception. In Iran, the validity and reliability of this questionnaire were examined by Bazzazian. The Cronbach's alpha coe cient of the questionnaire was reported as 0.8 and its retest reliability coe cient after a six-week interval was reported as 0.42 to 0.75 for the different items [16]. The present study examined the reliability of this questionnaire in the target group and reported a Cronbach's alpha coe cient of 62.4 for the entire scale.
The Multidimensional Health Locus of Control Scales was developed by Wallston and DeVellis in 1978. This questionnaire has 18 items in three subscales (internal locus of health control, powerful others locus of control and chance health locus of control). Each scale consists of six items, which are measured using a 6-point Likert scale ('strongly disagree' =1 point to 'strongly agree' =6 points). In Iran, this scale was rst translated and localized by Meshki, Ghafrani Pour, Azad Fallah and Hajizadeh (2007), and the reported coe cients were 70% for internal health locus of control, 75% for powerful others locus of control and 69% for chance locus of control [17]. The present study re-evaluated the reliability of each dimension in the target group and reported Cronbach's alpha coe cients of 47.5 for the internal locus, 59.2 for the powerful others locus and 58.6 for the chance locus. First, the researcher visited the counseling center of Imam Khomeini Hospital and identi ed the eligible candidates and briefed them on the study objectives.

Procedures
Written consent was then obtained from them if they wished to participate in the study. The study questionnaires were then distributed among them to answer. The researcher was present at the center during this stage and answered any potential questions the respondents had. If the questionnaires could not be completed in a single session, the subjects were invited for a follow-up visit. There was no obligation or imposition to complete the questionnaires in the rst session and they could be completed at any time during the research. A separate space was allocated in the center for this purpose, so that the questionnaires could be completed without stress and others' presence.

Statistical analyses
This study examined the t of a conceptual model of path analysis (Fig. 1) to determine the concurrent relationship of psychosocial adjustment variables, social roles (experiences in close relationships, perceived support and socio-demographic characteristics), and physical health (locus of health control, illness perception). First, the normality of the quantitative variables was assessed by the Kolmogorov-Smirnov test. Path analysis is a generalization of the normal regression that, in addition to expressing the direct effects, also demonstrates the indirect effects and the effect of each variable on the dependent variables and can be used to provide a rational interpretation of the observed relationships and correlations. Data were analyzed in Lisrel-8.8 and SPSS-16 software.
The correlation results were analyzed using Pearson's correlation coe cient and the path analysis was expressed as beta. The level of signi cance was set at T-values > 1.96.

Results
In this study, data were collected from 240 women with Acquired Immunode ciency Syndrome/AIDS. According to the ndings, the mean age of the participants was 36.7 ± 6.6 years and the duration of their relationship with their sexual partner was 10.7 ± 4.4 years, and 88.3% of the subjects had a sexual partner (Table 1). According to the results of Pearson's correlation test, psychosocial adjustment was signi cantly correlated with internal and external loci of health control health control and chance, illness perception, perceived support, anxiety and avoidance in close relationships and patient's education. Among these variables, illness perception had the most signi cant positive correlation with psychosocial adjustment (r = 0.239, p = 0.01). (  Based on the results of the path analysis (Fig. 2), the internal locus of health control and patient's age were variables that were positively and signi cantly correlated with psychosocial adjustment through only one path, which is direct, and patient's age had the highest positive direct correlation among them (B = 0.13). In other words, patients' psychosocial adjustment increases with age. The next variable was the internal locus of health control, which had a signi cant, direct and positive correlation with psychosocial adjustment (B = 0.11). This variable indicates the person's belief in internal factors and own behaviors being responsible for his illness and health, and the higher are these beliefs, the higher becomes the individual's psychosocial adjustment.
According to the ndings, education, external locus of health control, anxiety in experiences of close relationships, and perceived support are signi cantly relation with psychosocial adjustment only through one path, which is indirect. Among these variables, education has the highest positive relation with psychosocial adjustment through illness perception (B = 0.05). In other words, the higher is the individual's education, the higher becomes their social psychological adjustment. Perceived support was the second variable that had the highest signi cant positive relation with psychosocial adjustment through the indirect path (B = 0.04). In other words, higher perceived support by the individual is associated with increased psychosocial adjustment through the mediating variables. Illness perception, avoidance in experiences of close relationships and chance locus of health control are related with psychosocial adjustment through both direct and indirect paths. Among these variables, the chance locus of health control had the highest general relationship with psychosocial adjustment (B = 0.23). This variable indicates the individual's degree of belief in his health depending on chance, fortune, fate and destiny, and the higher it is, the higher gets the degree of psychosocial adjustment. After this variable, illness perception had the most signi cant positive relationship with psychosocial adjustment (B = 0.18). In other words, the more is the person's perception of illness, the higher is his psychosocial adjustment (Table 3). The results of the model t indices show the favorableness and high t of the model and the rationality of the regulated relationships between the variables based on the conceptual model. Accordingly, the tted model is not signi cantly different from the conceptual model (Table 4).

Discussion
Based on the results of the structural equation model, psychosocial adjustment was signi cantly correlated with the internal locus of health control and age through the direct path and with education and perceived support through the indirect path. In addition, there was a signi cant correlation between psychosocial adjustment and illness perception, avoidance in close relationships and locus of health control/chance through both direct and indirect paths.
As stated, age had the most signi cant correlation with psychosocial adjustment. This nding is in agreement with the results reported by Nathalie Hauk et al. in 2019, who found that, as employees age, they gain more adaptive skills and adjustment, which help reduce the negative consequences of stress [18].
According to psychological theories, aging is associated with greater exibility, coping strategies, and competence in handling emotions [19].
Internal locus of health control was another variable that was directly correlated with psychosocial adjustment. Health control plays a role in the hopefulness and prevention of illness in people with chronic diseases. This factor makes the person feel in control and plays a role in their stress reduction and better adjustment. People who believe that they can play a role in controlling and preventing their illness believe in behaviors such as praying, worshipping, lifestyle changes and social interactions to improve their quality of life [11]. This nding is in line with the results reported by Zarrin Pour and A akseir, who found that people who scored higher on this locus were more likely to adhere to their treatment regimens [20].
Among the variables that were indirectly correlated with social psychosocial adjustment, education had the most signi cant positive correlation. In other words, psychosocial adjustment increases with the level of education. This factor contributed to this relationship through illness perception. Higher levels of education in patients with AIDS lead to improved knowledge and awareness about the disease [21]. Mirowsky et al. [22] found that when people are more educated, their interpersonal relationships become more stable and they adjust better to the environment, which are crucial for adhering to treatments and the maintenance and promotion of their health. Brunello et al. also found that the higher are people's awareness and education, the less stress and better adjustment will they experience [23].
Perceived support was the second variable that was most positively and signi cantly related to psychosocial adjustment on the indirect path. In other words, increased perceived support is associated with increased psychosocial adjustment. Dolatian et al. (2013) found that social support is indirectly correlated with quality of life in pregnant women [24]. In another study, Ahmadi et al. found that social support is a key determinant of health throughout life [25].
Koetsenruijter et al. reported that people with better social support have higher self-esteem, which contributes to their health as well [26].
Among the variables that were associated with psychosocial adjustment through both paths, the chance locus of health control showed the highest overall correlation. This variable indicates the degree to which the person believes in his health depending on chance, fate, fortune and destiny, and the higher it is, the higher is the level of psychosocial adjustment. Neipp et al. found that control beliefs predict psychosocial adjustment in women with cancer [27]. Illness perception was the second variable that was most correlated with psychosocial adjustment through both paths. Illness perception indicates the patient's organized cognitive representation of his illness and his beliefs about the different aspects of his new condition [28]. Many studies have been conducted on illness perception. Barbasioa et al. concluded that the greater is the perception of illness in people with systemic lupus erythematosus, the less are they likely to develop disorders such as depression [29]. Greco et al. also reported a signi cant correlation between illness perception and cardiovascular disease complications; that is, the lower was illness perception, the greater were cardiovascular disease complications [30]. Zelber-Sagi et al. also found a signi cant correlation between healthy eating habits and healthy lifestyle in patients with fatty liver [31].

Conclusions
Based on the results, social roles (perceived social support, experiences in close relationships, and perceived support) and physical health (health locus of control and illness perception) are either directly or indirectly or else through both paths correlated with psychosocial adjustment, which emphasizes the importance of paying greater attention to all three aspects of health, i.e. physical, psychological and social aspects, especially in this vulnerable group of the society.

Study limitations
This study was conducted only on women with AIDS and their spouses or sexual partners were not included due to their limited accessibility, which comprises one of the limitations. Funding:

Abbreviations
This study conducted without any funding Availability of data and materials: The current study datasets and analysis sheets are available and will be provided due to reasonable request Competing interests: The authors declare that they have no competing interests Social role quality and mental health of women with chronic diseases