The Role of Perceived Social Support in Loneliness.17

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Copyright Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

The role of perceived social support in loneliness andself-esteem among children affected by HIV/AIDS:

a longitudinal multilevel analysis in rural China

Shan Qiaoa

, Xiaoming Lia,b

, Guoxiang Zhaob

,Junfeng Zhaob and Bonita Stantona

Objectives: To delineate the trajectories of loneliness and self-esteem over time amongchildren affected by parental HIV and AIDS, and to examine how their perceived socialsupport (PSS) influenced initial scores and change rates of these two psychologicaloutcomes.

Design: We collected longitudinal data from children affected by parental HIV/AIDS inrural central China. Children 6 18 years of age at baseline were eligible to participate inthe study and were assessed annually for 3 years.

Methods: Multilevel regression models for change were used to assess the effect ofbaseline PSS on the trajectories of loneliness and self-esteem over time. We employedmaximum likelihood estimates to fit multilevel models and specified the between-individual covariance matrix as unstructured to allow correlation among the differentsources of variance. Statistics including 2 Log Likelihood, Akaike InformationCriterion and Bayesian Information Criterion were used in evaluating the model fit.

Results: The results of multilevel analyses indicated that loneliness scores significantlydeclined over time. Controlling for demographic characteristics, children with higherPSS reported significantly lower baseline loneliness score and experienced a slower rateof decline in loneliness over time. Children with higher PSS were more likely to reporthigher self-esteem scores at baseline. However, the self-esteem scores remained stableover time controlling for baseline PSS and all the other variables.

Conclusions: The positive effect of PSS on psychological adjustment may imply a

promising approach for future intervention among children affected by HIV/AIDS, inwhich efforts to promote psychosocial well being could focus on children and familieswith lower social support. We also call for a greater understanding of childrenspsychological adjustment process in various contexts of social support and appropriateadaptations of evidence-based interventions to meet their diverse needs.

2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

AIDS2014, 28 (Suppl 3):S369S377

Keywords: children affected by HIV/AIDS, China, loneliness, psychologicaladjustment, self-esteem, social support

Introduction

By the end of 2011, an estimated 17.3 million children(no more than 18 years of age) globally had lost one orboth parents to AIDS; a far greater number faced the

potential of losing their parents to HIV/AIDS [1].Children who have lost one or both parents to AIDS(AIDS orphans) and children who are living with one orboth HIV-positive parents (vulnerable children) areoften referred as children affected by HIV/AIDS.

aPrevention Research Center, Carman and Ann Adams Department of Pediatrics, School of Medicine, Wayne State University,Detroit, Michigan, USA, and bInstitute of Behavior and Psychology, Henan University, Kaifeng, China.

Correspondence to Shan Qiao, Prevention Research Center, Hutzel Building, Suite W534, 4707 St Antoine, Detroit, MI 48201,USA.

Tel: +1 313 745 7981; fax: +1 313 745 4993; e-mail: [email protected] [email protected]

DOI:10.1097/QAD.0000000000000338

ISSN 0269-9370 Q 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins S369
mailto:[email protected]:[email protected]://dx.doi.org/10.1097/QAD.0000000000000338http://dx.doi.org/10.1097/QAD.0000000000000338mailto:[email protected]:[email protected]


2/9Copyright Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

Although over 90% of children orphaned by AIDS in theworld live in Africa, the situation of children affected byAIDS in other developing countries, including China, hasdrawn increasing attention[2]. The Chinese governmentestimated in 2004 that at least 100 000 Chinese childrenhad been orphaned by parental AIDS; many of theseorphaned children reside in Henan, an agricultural

province in central China with a population of 96.7million [3]. The HIV/AIDS epidemic in Henan wasmainly caused by unhygienic plasma collection amongpoor farmers from the late 1980s to early 1990s[4]. Thepractice of unhygienic plasma collection (no testing forHIV and other blood-borne infections, reusing needlesand other contaminated equipment) resulted in numerousHIV infections and a rapid spread of HIVamong the localpopulation[5].

Compared to children orphaned by other causes, childrenaffected by HIV/AIDS may face additional psychosocialchallenges including stigma, discrimination and social

isolation [6,7]. These challenges are associated withpersistently unresolved grief [8] and prolonged psycho-logical problems[9,10]. There has been a growth of theglobal literature on psychological adjustment among thisvulnerable group of children, particularly on positivefactors related to promoting resilience. One such positivefactor is social support.

Social support can be defined as the existence andavailability of interpersonal relationships through whichan individual feels being cared about, valued and loved[11]. Perceived social support and actually receivedsocial support may differ; only perceived support has been

consistently associated with health[12]. The associationsbetween social support and physical health have beenfound reliable on aspects of the cardiovascular, endocrine,and immune systems[13]. Social support and its impactson psychological well being have also been welldocumented since the 1970s [14]. Social support canbuffer stressful life events to reduce risk of depressionamong both adults and children[15 17].

Children often seek social support from their parents andpeers to cope with stressful situations[18]. Lack of socialsupport may increase a childs vulnerability to stress andreduce available resources needed for psychologicaladjustment [19]. Despite the importance of this topic,limited research has examined the role of social support inpsychological adjustment of children affected by HIV/AIDS. Cluver et al. [20] reported that perceived socialsupport (PSS) was associated with fewer symptoms ofpost-traumatic stress disorder (PTSD) at all levels oftrauma among AIDS-orphaned children and adolescentsin South Africa. One study conducted in the UnitedStates by Orban et al. [21] suggested that adolescentsviewed social support and problem-solving as the mosthelpful coping strategies. A 2-year longitudinal studyamong adolescents (1118 years of age) affected by HIV/

AIDS in the United States indicated that adolescents withmore providers of social support reported lower levels ofdepression and fewer conduct problems [22].

On the basis of cross-sectional data in Henan, China, Honget al. [3] suggested significant associations of PSS withdepression, loneliness, self-esteem, future expectation,

peer social skills, and school interest among AIDS orphans.Wang et al. [5] further illustrated that PSS (and otherprotective factors such as future expectation and trustingrelationship with current caregivers) significantly mediatedassociations between risk exposures (stigma and lifeincidence of traumatic events) and negative psychologicaloutcome (depression). However, these studies were basedon cross-sectional data and might be insufficient to explorethe role of PSS in the process of psychological adjustment.In addition, some existing studies utilizing longitudinaldata have mainly focused on the depression [23,24]. Dataon other aspects of psychological adjustment (e.g. lone-liness, self-esteem) were still limited.

To address the lack of longitudinal studies on psychologicaladjustment of children affected by HIV/AIDS in China,we conducted the present study with two specificobjectives: to describe longitudinal trajectories of psycho-logical adjustment (loneliness and self-esteem) amongchildren affected by HIV/AIDS; and to examine if the PSSat baseline can predict the trajectories of loneliness and self-esteem after controlling childrens sex, age, orphan status,and family socioeconomic status (SES).

Methods

Study site and participantsThe longitudinal data were collected in 20052009 intwo rural counties (94% rural residents) in Henan,China. The two counties were similar in demographicand economic profiles (e.g. both counties were designatedas national poverty-stricken counties). Although actualprevalence data were not available to the public, bothcounties had experienced HIV epidemics due tounhygienic blood/plasma collection and were believedto have the highest prevalence of HIV infection in thearea[25]. We obtained village-level HIV surveillance datafrom the antiepidemic station in each of the counties toidentify the villages with the highest number of HIV/AIDS-related death or confirmed HIV infection.Children 618 years of age were eligible to participatein the study and were assessed annually for 3 years. Theparticipants (n 1625) in the first annual assessment(baseline) included 755 AIDS orphans (i.e. children wholost one or both of their parents to HIV/AIDS), 466vulnerable children (children living with HIV-positiveparents), and 404 comparison children who were fromthe same community and did not have HIV/AIDS-related illness or death in their families. Data were

370 AIDS 2014, Vol 28 (Suppl 3)



available from 1288 (79%) children at year 2 and from 984(61%) children at year 3.

Sampling procedureThe sampling procedure of this study has been describedin detail elsewhere[26]. Briefly, the AIDS orphans livingin centralized care settings were recruited from two

government-funded orphanages in each of the twocounties and the eight community-based group homesfor children orphaned by AIDS in one county[27]. TheAIDS orphans and vulnerable children from the family andextended family care settings were recruited with assistanceof the village leaders who helped us to generate lists offamilies caring for orphans or families with confirmeddiagnosis of parental HIV infection. We visited the familieson the lists and invited the eligible children to participate inthestudy. Only onechildper familywas recruited. If severalchildren in one family met the inclusion criteria, werandomly selected one child. If none of the children in aselected family was available to participate, we visited the

next family on the list. The comparison group wasrecruited from the same villages where we recruited AIDSorphans and vulnerable children by similar approach. Theresearch protocol, including consenting procedures, wasapproved by the Institutional Review Boards at WayneState University in the United States and Beijing NormalUniversity in China.

Survey procedureEach participating child in the study was asked tocomplete a confidential assessment inventory in Chinese,including measures of demographic characteristics, PSS,and psychological adjustment. For children older than

8 years, the survey was self-administered; for youngerchildren or children with limited literacy, the interviewersread the survey items to the children and recordedchildrens oralresponses to each question.The interviewerswere graduate students and faculty members in educationand psychology from the local universities, and receivedextensive training on research ethics and survey method-ology prior to engaging in the data collection. Theyprovided necessary clarification or instruction to thechildren when needed. The entire assessment inventorytook about 7590 min, depending on the age of thechildren. Younger children (e.g. those 8 years old) wereoffered a 1015-min break after every 30 min ofassessment. Parents or caregivers were not allowed to staywith the children during the data collection. Each childreceived an age-appropriate gift (toys or school supplies) atcompletion of the assessment as a token of appreciation.

MeasuresDemographic characteristicsAge, sex, orphan status (AIDS orphans, vulnerablechildren, and comparison children), parental education(elementary school, middle school, high school), andthe main occupational activities (farmers or nonfarmers)in which their parents were engaged currently or before

their death were collected from each child. A compositescore was created to estimate each childs family SES basedon parental education and occupation. Specifically,parental education (both father and mother) was recodedas 1 for more than elementary school education and 0 forno more than elementary school; and parental occupationwas recoded as 1 for nonfarming occupation and 0 for

farming occupation. The SES score ranged from 0 to 4,with a higher score indicating a better family SES.

Perceived social supportWe used a modified version of the multidimensional scaleof PSS [28] to assess PSS among the children [3]. Themodified version consists of 16 PSS items measuring PSSfrom four sources: family, friends, teachers, and significantothers (e.g. a special person). The sample items include Ican get the emotional help and support I need from myfamily, I can count on my friends when things gowrong, my teachers really try to help me, and I have aspecial person who is a real source of comfort to me. All

items have a 5-point response option ranging from neverto all the time. The internal consistency estimate(Cronbacha) for this scale is 0.88 for the current studysample. A sum score was calculated for the PSS scale, witha higher score indicating a higher level of PSS.

LonelinessThe 16-item Chinese version of the Childrens LonelinessScale (CLS)[29]was used to assess the childrens perceivedloneliness. The sample items include I dont have anyoneto play with and I have nobody to talk to. All the CLSitems have a 5-point response option ranging fromstrongly disagree to strongly agree. A sum score was

calculated, through appropriate recoding, as a compositescore of loneliness with a higher score indicating a higherlevel of loneliness. The Cronbach a ranged from 0.78 to0.86 over time for the current study sample.

Self-esteemThe children were also asked about their global feelings ofself-worth and self-acceptance using the Self-Esteem Scale[30], which was introduced into China over two decadesago [31]. The Self-Esteem Scale consists of 10 items with a4-point response option from strongly disagree tostrongly agree. Sample items include I feel that I havea number of good qualities and I am able to do things aswell as most other people. We recoded all the negativelyworded items so that higher scores indicated higher levelsof self-esteem. This scale demonstrated an acceptableinternal consistency for the current study sample. TheCronbach a ranged from 0.60 to 0.76 over time.

AnalysisWe calculated descriptive statistics to generate ademographic profile of the study sample across threeannual assessments. Attrition analysis was performed bycomparing the difference between participants whoremained in the follow-up and the ones who were lost to

Perceived social support among HIV-affected childrenQiaoet al. S371


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of PSS. The trajectories were similar for the groups oflow-level and medium-level baseline PSS. The trajectoryfor groups with a high level of PSS was more leveled offthan the one for the other two groups, which indicates aslower rate of decrease for the higher PSS group.

Generally, the level of self-esteem was slightly improvedover the 3 years for all levels of baseline PSS. Theimprovement from year 1 to year 3 for groups of low andmedium-level baseline PSS was 0.16 and 0.06 points,respectively. The trajectory for the group of low-level


Table 2. Sample characteristics and attrition analysis.

Year 1Year 2 Year 3

Total (N1625) Loss (n337) Nonloss (n1288) Loss (n304) Nonloss (n984)

Demographic characteristicsSex

Boys 826 (51%) 178 (53%) 648 (50%) 165 (54%) 483 (49%)Girls 799 (49%) 159 (47%) 640 (50%) 139 (46%) 501 (51%)

Age (SD) 12.85 (2.21) 14.32 (2.10) 12.47 (2.02)MMM 13.72 (1.81) 12.08 (2.03)MMM

Orphan statusAIDS orphans 755 (47%) 186 (55%) 569 (44%) 168 (55%) 401 (41%)Vulnerable children 466 (29%) 82 (24%) 384 (30%) 67 (22%) 317 (32%)Comparison children 404 (25%) 69 (21%) 335 (26%)MM 69 (23%) 266 (27%)MM

Fathers educationElementary school 568 (36%) 123 (37%) 445 (36%) 114 (38%) 331 (34%)Middle school 597 (38%) 124 (37%) 473 (38%) 124 (42%) 349 (36%)High school 134 (8%) 33 (10%) 101 (8%) 22 (7%) 79 (8%)Do not know 294 (18%) 52 (16%) 242 (19%) 39 (13%) 203 (21%)

Mothers educationElementary school 757 (48%) 161 (49%) 596 (48%) 144 (49%) 452 (48%)Middle school 421 (27%) 97 (30%) 324 (26%) 84 (29%) 240 (26%)High school 70 (4%) 11 (3%) 59 (5%) 9 (3%) 50 (5%)Do not know 318 (21%) 60 (18%) 258 (21%) 58 (20%) 200 (21%)

Fathers occupation

Farmers 879 (57%) 212 (64%) 667 (55%) 182 (62%) 485 (53%)Nonfarmers 663 (43%) 118 (36%) 545 (45%) 112 (38%) 423 (47%)

Mothers occupationFarmers 1141 (75%) 250 (79%) 891 (78%) 243 (84%) 648 (71%)Nonfarmers 378 (25%) 67 (21%) 311 (22%) 46 (16%) 265 (29%)

SES (SD) 1.38 (1.11) 1.34 (1.08) 1.41 (1.11) 1.31 (1.05) 1.44 (1.13)PSS (SD) 3.07 (0.86) 3.18 (0.80) 3.04 (0.88)M 3.10 (0.91) 3.03 (0.87)Mental health measuresLoneliness (SD) 2.43 (0.71) 2.35 (0.69) 2.45 (0.71)M 2.45 (0.68) 2.45 (0.72)Self-esteem (SD) 2.87 (0.42) 2.90 (0.40) 2.87 (0.42) 2.86 (0.46) 2.87 (0.41)

PSS, perceived social support; SES, socioeconomic status.MP



baseline PSS with an upward curve indicated a higherincrease in self-esteem score from year 2 to year 3 (0.07)than the one from year 2 to year 1 (.002). However, forthe group of medium-level baseline PSS, the improve-ment in self-esteem was bigger from year 1 to year 2 (0.09)than the one from year 2 to year 3 (0.05). The mean scoreof self-esteem for the group of high-level baseline PSSincreased, but then declined, although the trajectoryillustrated an overall upward trend over the 3 years. Theself-esteem level was significantly higher in the group ofhigh-level baseline PSS than the other groups at eachassessment point.

Predictive factors of psychological changeThe results of the multilevel regression models aresummarized in Table 4. The estimated coefficients forfixed-effects parameters and variance components (ran-dom effects) are listed under models A through D for eachpsychological measure.

Consistent with the mean pattern as shown in Table 3, theloneliness score decreased over time (model B). The

unconditional growth model (model B) showed that theintercept of loneliness score (g00) was 2.635, decreasingby 0.235 points per year. The significant coefficient ofPSS in model C indicated that high baseline PSS waspredictive of lower initial loneliness score. The coefficientof the PSS-by-year interaction suggested that the rate ofdecline in the loneliness score was slower among

participants reporting higher baseline PSS (b 0.063,P



depressive symptoms among children affected by HIV/AIDS[23,24]. Our study indicated that the score of self-esteem did not significantly change over time after

adjusting for demographic characteristics and baselinePSS. The rate of decrease in loneliness differed by thelevels of baseline PSS with a slower rate of declineamong children with a higher PSS. There are twopossible explanations for this finding. First, childrenwith higher baseline PSS expressed lower baselineloneliness. Thus, there might be a ceiling effect forthe decline of the loneliness score over time amongthese children. Second, there may be one or moreunidentified confounders that were not included in ourdata analysis but moderated the effects of PSS on thechange of loneliness score over time. For example,living arrangement may be a potential moderator for theeffect of PSS on the loneliness.

The multilevel model analysis also revealed somesignificant covariates and interaction terms such as theinteraction term between age and assessment year. Thissignificant interaction term implied that younger childrenexperienced a faster decline of loneliness than the olderchildren. Given the wide age range of our sample (618

years), our finding suggests that child age is a potentiallyimportant predictor of decline in loneliness and earlyintervention is warranted to provide timely psychologicalsupport for children affected by HIV/AIDS.

There are some limitations in the present study. First, ourstudy had a relatively high attrition during the 3-yearfollow-up (e.g. 39% for year 3). Whereas the baseline

scores of psychological measures were comparablebetween those who remained in the study and thoselost to the follow-up, the findings still could be biased asthe attrition was associated with an older age and being anorphan. Second, participants of the current study wererelatively young (mean age 12.85 years). Consideringdifferences in psychological adjustment for children indifferent developmental stages, caution should be used ingeneralizing the findings to children of other age groups.Third, in our analysis, the measure of PSS was notstratified by sources of social support or function of socialsupport.

Despite these limitations, our findings have severalimplications for future studies and intervention effortsregarding social support and psychological adjustmentamong children affected by HIV/AIDS. First, studieswith a longer period of follow-up and more assessmentpoints are needed to more accurately depict thepsychological adjustment trajectories by levels of baselinePSS. Attention is needed to attrition issues over time asthese children often experience dramatic changes in theirlife situation with advancing age (i.e. approaching lateadolescence or young adulthood). Additional analyticprocedures, for instance, cross-lagged analysis, may be


Table 4. Parameter estimates of multilevel regression models.

Parameter estimateb (SD)

Loneliness Self-esteem

Model A Model B Model C Model D Model A Model B Model C Model D

Fixed effectsIntercept (g00) 3.210 2.635 3.426

MMM 4.159MMM 2.902 2.824 2.620MMM 2.546MMM

Year (g10) 0.235 0.429MMM

0.764MMM 0.051 0.005 0.055PSS (g

01) 0.258MMM 0.231MMM 0.067MM 0.063MM

Sex (g02) 0.021 0.040Age (g03) 0.081

MMM 0.015AIDS orphans (g04)

1 0.390MMM 0.084Vulnerable children (g05)

1 0.523MMM 0.231MMM

SES (g06) 0.062MM 0.021

PSSyear (g11) 0.063MMM 0.052MMM 0.015 0.014

Sexyear (g12) 0.012 0.024Ageyear (g13) 0.034

MMM 0.003AOyear (g14) 0.100

MM0.012

VCyear (g15) 0.140 0.065SESyear (g16) 0.017

MMM 0.001Variance components (random effects)Within-person (d2

e) 0.318

MMM 0.198MMM 0.198MMM 0.193MMM 0.134MMM 0.121MMM 0.119MMM 0.119MMM

In initial status (d20) 0.119MMM 0.528MMM 0.477MMM 0.413MMM 0.061MMM 0.066M 0.006M 0.060M

In rate of change d21 0.066MMM 0.063MMM 0.056MMM 0.018M 2.406M 0.002

Covariance (s

01)

0.160

MMM

0.148

MMM

0.128

MMM

0.014

1.229

0.017Overall model fitting2LL 7707.994 7148.744 6985.318 6737.377 3698.82 3650.158 3535.045 3439.877AIC 7713.994 7160.744 7001.318 6773.377 3704.82 3662.158 3551.045 3475.877BIC 7198.424 7198.424 7051.505 6886.168 3723.05 3698.621 3599.615 3585.040

Note: 1. Comparison children as reference group. 2LL,2 Log Likelihood; AIC, Akaike Information Criterion; AO, AIDS orphans; BIC, BayesianInformation Criterion; PSS, perceived social support; SES, socioeconomic status; VC, vulnerable children.MP



employed to elaborate complicated and potentiallyreciprocal effects between social support and psycho-logical adjustment.

Second, empirical data are needed to test if social supportwith various functions and from diverse sources hasdifferent effects in psychological adjustment over time.

Extended families were still the main resources of socialsupport to AIDS orphans [35]. Peer support andaffiliations at school may also be emotionally beneficialand play a key protective role in the lives of AIDS orphans[3638]. Future psychosocial well being promotionefforts might especially focus on children and familieswith lower social support such as children who live inrural communities, those who are under the care ofnonparent caregivers or cross-generational caregivers,and/or children who are separated from their biologicalsiblings.

Third, in addition to the emotional and cognitive

adjustment examined in the current study, future studiesmay explore the role of social support in behavioraladjustment or behavioral change among children affectedby HIV/AIDS [39]. Finally, the positive effect of socialsupport on psychological adjustment may imply apromising approach for future interventions. To developand implement evidence-based intervention for childrenaffected by HIV/AIDS, we need to further explore thechildrens psychological adjustment process in variouscontexts of social support and to tailor interventioncontent to meet specific needs of these highly vulnerablechildren.

Acknowledgements

The study was supported by the National Institute ofChild and Human Development Grant #R01HD074221and the National Institute of Mental Health and theNational Institute of Nursing Research Grant#R01MH076488. The authors also want to thank

Joanne Zwemer for assistance with the manuscriptpreparation.

Conflicts of interestThere are no conflicts of interest.

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The Role of Perceived Social Support in Loneliness.17

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