Table Of ContentTESTING A MODEL OF HEALTH-RELATED QUALITY OF LIFE
IN WOMEN LIVING WITH HIV
by
Nahed Alsayed
BS, George Mason University, 2004
MSN, University of Pittsburgh, 2011
Submitted to the Graduate Faculty of
School of Nursing in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
University of Pittsburgh
2015
This dissertation was presented
by
Nahed Alsayed
It was defended on
December 2, 2015
Susan A. Albrecht, PhD, RN, CRNP, FAAN, Department of Health & Community Systems,
School of Nursing
Susan M. Sereika, PhD, Department of Health & Community Systems, School of Nursing
Martha Ann Terry, PhD, MA, Department of Behavioral and Community Health Sciences,
Graduate School of Public Health
Dissertation Chair: Judith A. Erlen, PhD, RN, FAAN, Department of Health & Community
Systems, School of Nursing
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Copyright by Nahed Alsayed
2015
iii
Testing a Model of Health-Related Quality of Life in Women Living with HIV Infection
Nahed Alsayed, PhD
University of Pittsburgh, 2015
The diagnosis of HIV infection in women may adversely affect their health and their health-
related quality of life (HRQoL). At present, research about women living with HIV infection
and the multiple factors that contribute to their HRQoL is limited. The purpose of this study was
to test the revised model of HRQoL by Wilson and Cleary (Ferrans et al., 2005) using a
secondary analysis of baseline data from 178 women who participated in two independent
randomized controlled studies. This linear model includes inter-related components (biological
function, symptoms, functional status, and general health perceptions) which lead ultimately to
HRQoL. The primary aim was to examine the relationships among the five components of the
model. The secondary aim was to examine the relationships among the individual (i.e. age,
children, race, marital status, education) and environmental (i.e. HIV-related stigma, social
support) characteristics that may impact biological function, symptoms, functional status, general
health perceptions, and overall HRQoL among women living with HIV infection. Observed
variables included: biological function (CD4 count and viral load), symptoms (depressive
symptoms and energy/fatigue), functional status (physical and social functioning), general health
perceptions (overall general health and mental health), environmental factors (social support and
HIV-related stigma), and HRQoL (satisfaction with life and overall quality of life). Structural
equation modeling (SEM) and path analysis were performed on multiple path models to examine
the hypothesized multivariate relationships proposed in the revised Wilson and Cleary model of
HRQoL (Ferrans et al., 2005). Originally, a latent path model was planned. Due to problems with
the measurement model, the latent path model was simplified and observed and hybrid path
models were created. While the two main models for the primary and secondary aims did not fit
well, post hoc modified models adding a path from symptoms to general health perceptions
provided an adequate model fit. Women with lower viral loads, lower depressive symptoms,
lower HIV-related stigma, higher social support, higher physical functioning, and higher general
health perceptions had higher overall HRQoL. The results of this study have the potential to
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assist healthcare professionals in improving health-related quality of life for women living with
HIV infection.
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TABLE OF CONTENTS
LIST OF FIGURES ....................................................................................................................... xi
LIST OF TABLES ....................................................................................................................... xiii
ACKNOWLEDGEMENTS ......................................................................................................... xiv
1.0 INTRODUCTION ............................................................................................................... 1
1.1 SIGNIFICANCE OF THE PROBLEM: WOMEN, QUALITY OF LIFE, AND HIV ... 3
1.1.1 Model overview ........................................................................................................ 5
1.2 PURPOSE OF THE STUDY ......................................................................................... 11
1.3 RESEARCH AIMS ............................................................................................................. 11
1.3.1 Primary aim .................................................................................................................. 11
1.3.2 Secondary aim .............................................................................................................. 11
1.4 DEFINITION OF TERMS ................................................................................................. 12
1.4.1 HIV/AIDS .................................................................................................................... 12
1.4.2 Biological function....................................................................................................... 12
1.4.3 Symptoms .................................................................................................................... 13
1.4.4 Functional status .......................................................................................................... 13
1.4.5 General health perceptions ........................................................................................... 13
1.4.6 Overall quality of life ................................................................................................... 14
1.4.7 Characteristics of the individual .................................................................................. 14
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1.4.8 Characteristics of the environment .............................................................................. 14
2.0 LITERATURE REVIEW ....................................................................................................... 15
2.1 FACTORS AFFECTING WOMEN LIVING WITH HIV ................................................. 15
2.1.1 Disclosure .................................................................................................................... 16
2.1.2 Stigma .......................................................................................................................... 17
2.1.3 Mental Health............................................................................................................... 19
2.1.4 Quality of Life.............................................................................................................. 20
2.2 FACTORS INFLUENCING HRQOL ................................................................................ 21
2.2.1 Biological function....................................................................................................... 22
2.2.2 Symptoms .................................................................................................................... 23
2.2.3 Functional Status .......................................................................................................... 25
2.2.4 General Health Perceptions .......................................................................................... 26
2.2.5 Characteristics of the Individual and Environment ..................................................... 26
2.3 SUMMARY ........................................................................................................................ 30
3.0 METHODOLOGY ................................................................................................................. 31
3.1 PARENT STUDIES............................................................................................................ 31
3.1.1 Research Design of Parent Studies .............................................................................. 31
3.1.2 Sample.......................................................................................................................... 32
3.1.3 Sample Size and Power ................................................................................................ 33
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3.2 RESEARCH DESIGN ........................................................................................................ 34
3.3 DATA COLLECTION ....................................................................................................... 34
3.3.1 Overview of Data Collection Procedures .................................................................... 34
3.3.2 Data Management ........................................................................................................ 34
3.3.3 Human Subjects ........................................................................................................... 35
3.4 MEASURES ....................................................................................................................... 36
3.4.1 Overall Quality of Life................................................................................................. 36
3.4.2 Biological Function ...................................................................................................... 36
3.4.3 Symptoms .................................................................................................................... 37
3.4.4 Functional Status .......................................................................................................... 38
3.4.5 General Health Perceptions .......................................................................................... 38
3.4.6 Characteristics of the Environment .............................................................................. 39
3.4.7 Characteristics of the Individual .................................................................................. 40
3.5 DATA ANALYSIS ............................................................................................................. 40
3.5.1 Data Screening and Preliminary Analysis ................................................................... 40
3.5.2 Descriptive Statistics .................................................................................................... 42
3.5.3 Structural Equation Modeling (SEM) .......................................................................... 43
3.5.4 Path Analysis ............................................................................................................... 44
3.6 SAMPLE SIZE AND POWER ANALYSIS ...................................................................... 46
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3.7 STUDY AIMS .................................................................................................................... 46
3.7.1 Primary Aim............................................................................................................ 46
3.7.2 Secondary Aim........................................................................................................ 47
4.0 RESULTS ............................................................................................................................... 47
4.1 PRELIMINARY ANALYSIS ............................................................................................ 48
4.2 COMPARISON OF STUDIES ........................................................................................... 49
4.3 SAMPLE SUMMARY ....................................................................................................... 51
4.4 RESULTS OF CORRELATION ANALYSES .................................................................. 52
4.5 STRUCTURAL EQUATION MODELING Results ......................................................... 58
4.5.1 Model Fit ...................................................................................................................... 59
4.5.2 Strength of Relationships ............................................................................................. 76
5.0 SUMMARY AND CONCLUSIONS ..................................................................................... 80
5.1 STUDY SUMMARY.......................................................................................................... 80
5.2 DISCUSSION ..................................................................................................................... 82
5.2.1 Sample Characteristics ................................................................................................. 82
5.2.2 Association of Variables .............................................................................................. 83
5.2.3 Path Analysis ............................................................................................................... 86
5.3 LIMITATIONS ................................................................................................................... 90
5.4 IMPLICATIONS ................................................................................................................ 93
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5.5 CONCLUSION ................................................................................................................... 95
APPENDIX A: IRB Exemption Approval .................................................................................. 96
APPENDIX B: Figure Permissions ............................................................................................. 97
REFERENCES ........................................................................................................................... 100
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