Distribution of study participants
In a 2013 survey conducted through medical institutions on Japanese HIV-positive participants (n = 1,100), the average age was 44.6 years; with 24.3% of participants, the time since HIV diagnosis was less than 3 years[41]. The participants in the present study (average age, 36.6 years; with 32.6% of participants the time since HIV diagnosis was less than 3 years) were somewhat younger and had learned about their diagnoses more recently. In the earlier survey, the participants were regular outpatients at nine Japanese central medical institutions; however, our sample included some participants who belonged to a different group (e.g., ones who had been found to be infected and were undergoing treatment) from those in the previous study. We consider our participants representative of the target population: our participants were all living in the same Japanese prefecture; they were seeing a doctor at a non-central medical institution; and they included individuals who had not yet been treated.
Factor structure and subscales of SRG
In the present study, we verified that the perceived positive and negative growth scale comprised three factors[18]. Further, we confirmed that the factor structure was a metric invariance model that was not based on the number of years since HIV diagnosis.
With regard to the mean score of the subscales, those of self-perception and interpersonal relationships were negative. Similar scales assessing PTG, the SRGS, and the BFS in previous studies showed only positive changes. The index used in the present investigation also showed negative changes; thus, it can be said that it depicts changes in cognitive beliefs more accurately than those used in previous reports. Additionally, the present results suggest that the event of receiving the HIV diagnosis and subsequent stressful experiences (such as self-management of the illness and stigmatization) caused negative cognitive changes; those changes may have occurred in approximately half of our participants.
Mechanism of association between mental health and SRG
With regard to the association between the two variables, as indicated in previous studies and review papers[31,33], we clearly observed a negative association between the subscales of the perceived positive and negative growth scale and mental health. Further, with respect to the association with mental health based on correlation between the subscales, the mechanism was different between the group with less than 4 years since HIV diagnosis and that with over 4 years.
First, in the group with less than 4 years since HIV diagnosis, self-perception had a direct effect on both depression and anxiety disorder; philosophy of life and interpersonal relationships exerted only an indirect effect, which was mediated by self-perception. This result indicates the extremely important role of positive changes in self-perception in maintaining and improving mental health in the 4 years following HIV diagnosis. This phenomenon may be caused by the bidirectional nature of self-perception and mental health concepts.
Second, in the group with over 4 years since HIV diagnosis, self-perception and interpersonal relationships were both associated with maintaining and improving mental health. It was also evident that in addition to self-perception and interpersonal relationships, philosophy of life was correlated with depression.
Mechanism of association between number of physical symptoms and SRG
The association between the number of physical symptoms and the perceived positive and negative growth scale was not sufficiently clarified in previous studies[29,31]; however, the present investigation suggests the possibility of a strong association. It is clear that as in the case of mental health, this association has mechanisms and effects that differ significantly depending on the number of years since HIV diagnosis. For example, in the group with less than 4 years since diagnosis, positive growth in self-perception was associated with reduced symptoms; however, it was also apparent that positive changes in interpersonal relationships were associated with increased symptoms. In the initial period after HIV diagnosis, it is possible that individuals with more symptoms seek help and establish personal connections. The 41 symptoms investigated in the present study included a wide range of audiovisual, respiratory, circulatory, digestive, dental, dermatological, musculoskeletal, urinary tract, and other symptoms. In future, it will be necessary to categorize these symptoms with greater precision and investigate their association with SRG.
For the group with less than 4 years since HIV diagnosis (unlike the other group), it was apparent that for both interpersonal relationships and self-perception, positive changes were correlated with reduced symptoms. It could be that personal connections, which took 4 or more years to develop, helped suppress symptom development. This finding also suggests that when both self-perception and interpersonal relationships are considered, positive growth in philosophy of life led to an increase in the number of symptoms. Thus, having more symptoms in 4 or more years since HIV diagnosis could lead to strong positive changes with philosophy of life owing to various difficult experiences.
Very few studies have examined the association between physical health and SRG: some investigations have even reported a positive relationship with good physical health. In the present study, it was apparent that there was a close relationship between the two. However, our results suggest that this relationship was not necessarily positive; it could also be negative. Therefore, in future, it will be necessary to examine physical symptoms from multiple perspectives.
Theoretical and practical suggestions
This study has produced the following two theoretical suggestions. First, regarding changes in respondents’ perceptions of themselves and their world, owing to chronic and acute stresses (such as negative events and illnesses), it would be more precise to measure both positive (such as growth and discovery of benefits) and negative aspects.
Second, this study found that though it is possible to measure SRG after a traumatic event regardless of the length of elapsed time, functions related to health differ greatly depending on the duration. Further, mental and physical health as well as the functions that act on them differ greatly depending on the SRG subscale. Not all elements of SRG have a positive influence on health. In future, it will be necessary to further investigate the functions of these subscales.
The present study also led to the following two practical suggestions. First, toward assisting PLWH, we found that personal and group relationships played an important role in creating positive changes regarding our respondents’ perceptions of life and of people around them. Moreover, particularly among PLWH with over 4 years since diagnosis, diverse educational programs and opportunities to take courses would be useful in facilitating adaptation to self-management and to produce changes in perceptions of themselves and others.
Second, it is possible that the perceived positive and negative growth scale could be applied as a self-management tool for PLWH. In this regard, it will be necessary also to consider developing intervention policies to promote positive cognitive change.
Limitations and future studies
This study clarified the structure of the SRG factors in Japanese HIV-positive males as well as the mechanism behind the associations among factors that affect mental health and physical symptoms. However, this study has a number of limitations.
First, with regard to sampling, this study was an open online survey, and it is possible that our sample was restricted to skilled users of computers and mobile terminals. Specifically, with our sample, the age range was lower than that of participants surveyed through medical institutions and a shorter time had passed since HIV diagnosis. The overall picture of Japanese PLWH has yet to emerge: it may not be that there was participant bias in our study or that the participant sample in the previous survey (contacted through medical institutions) was representative. However, in future, it will be necessary to confirm the reproducibility of our results among older participants who may have difficulty in accessing an Internet-based survey.
Second, the reliability of the perceived positive and negative growth scale used in this study has yet to be fully determined. Its internal consistency is somewhat low. While investigating the reproducibility in other samples, it will be necessary to investigate test-retest correlations.
Finally, with regard to the cross-sectional design, this study applied several hypotheses and models, which we sought to verify, based on the notion that SRG has an impact on mental health. Additionally, our results suggest that SRG has a bidirectional causal relationship with mental health. Owing to the limitations of investigating causal relationships with a cross-sectional study design, it will in future be necessary to conduct a detailed investigation of the reproducibility and causal relationships using a longitudinal design.