Allen J. LeBlanc

The forms and mechanisms of stress proliferation: the case of AIDS caregivers

Processes of stress proliferation are explored in a sample of informal caregivers to people with AIDS. Proliferation refers to the tendency for stressors to beget stressors. Two forms of proliferation are explored, each based on the distinction between primary and secondary stressors. Among AIDS caregivers, primary stressors are the hardships rooted in the caregiving role. Secondary stressors result from primary stressors, but arise in roles and activities outside of caregiving. One form of proliferation is the expansion of primary stressors, reflected in an increase in role overload and a growing sense of being a captive of the caregiver role. Expansion is largely driven by the course of AIDS and the elevation of demands it places on the caregiver. The second form of proliferation is the surfacing of secondary stressors in social and leisure life and in the occupational realm. This form arises from the strains imposed by the emerging caregiver role on the other roles and activities of the caregiver. It is proposed that the systematic assessment of proliferated stressors can help illuminate the dynamic connections between stress and health.

Same-Sex Legal Marriage and Psychological Well-Being: Findings From the California Health Interview Survey

OBJECTIVES We examined whether same-sex marriage was associated with nonspecific psychological distress among self-identified lesbian, gay, and bisexual adults, and whether it had the potential to offset mental health disparities between lesbian, gay, and bisexual persons and heterosexuals. METHODS Population-based data (weighted) were from the 2009 adult (aged 18-70 years) California Health Interview Survey. Within-group analysis of lesbian, gay, and bisexual persons included 1166 individuals (weighted proportion = 3.15%); within-group heterosexual analysis included 35 608 individuals (weighted proportion = 96.58%); and pooled analysis of lesbian, gay, and bisexual persons and heterosexuals included 36 774 individuals. RESULTS Same-sex married lesbian, gay, and bisexual persons were significantly less distressed than lesbian, gay, and bisexual persons not in a legally recognized relationship; married heterosexuals were significantly less distressed than nonmarried heterosexuals. In adjusted pairwise comparisons, married heterosexuals had the lowest psychological distress, and lesbian, gay, and bisexual persons who were not in legalized relationships had the highest psychological distress (P < .001). Psychological distress was not significantly distinguishable among same-sex married lesbian, gay, and bisexual persons, lesbian, gay, and bisexual persons in registered domestic partnerships, and heterosexuals. CONCLUSIONS Being in a legally recognized same-sex relationship, marriage in particular, appeared to diminish mental health differentials between heterosexuals and lesbian, gay, and bisexual persons. Researchers must continue to examine potential health benefits of same-sex marriage, which is at least in part a public health issue.

The physical costs of AIDS caregiving

Informal care has become an increasingly important element in the delivery of health and social services to people living with HIV disease or AIDS (PWAs), yet the provision of such care does not come without costs to the caregiver. Instead, caregiving imposes burdens that may compromise caregiver health. Common ailments among AIDS caregivers were examined with two waves of data from a diverse sample of informal care providers in Los Angeles and San Francisco (N = 642). Symptoms of poor physical health are markedly present among AIDS caregivers and are significantly associated with care-related demands and stressors. This stress and health relationship varies significantly between caregivers who are HIV seropositive and those who are seronegative. Care-related effects are more direct among seronegative caregivers who are perhaps less overwhelmed with the maintenance of their own health. For all caregivers studied, level of depression and prior physical health are strong correlates of these physical ailments. Implications of these results are discussed.

Stress and Mental Health Among Midlife and Older Gay-Identified Men

OBJECTIVES We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage. METHODS We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n = 202; average age = 56.91 years; age range = 44-75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States. RESULTS Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects. CONCLUSIONS Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.

Examining HIV-related Knowledge Among Adults in the U.S.*

Supplemental AIDS data from the 1987 National Health Interview Survey indicate that adults in the U.S. know the most frequent modes of HIV transmission, but lack a more comprehensive understanding of HIV and AIDS. Elements from a diffusion model were isolated to create a path-analytic framework for examining the effects of population or recipient characteristics and information sources or communication channels on HIV-related knowledge with these data. This multivariate analysis suggests that persons of lower socioeconomic status, older adults, those from racial/ethnic minority groups, those living outside of metropolitan areas, men, and those citing mass media (television or newspapers) as their primary source of information about HIV and AIDS have slightly lower levels of HIV-related knowledge. Decomposition of the effects in the path analysis suggests that use of information sources or channels, as measured by survey data, accounts for little of the observed variation in HIV-related knowledge. The implications of these results for future research and HIV-related education are discussed.

AIDS caregiving and health among midlife and older women.

This study reports on analyses of survey data from 121 midlife and older women engaged in AIDS caregiving in Los Angeles and San Francisco. These data revealed that these women provided substantial support to persons living with HIV or AIDS (PWAs) despite other role commitments associated with family and work. Although the characteristics of these women differed according to their relationship to the PWA (mother, wife, sister, or friend), they tended to be similar with regard to both the amount of care provided and its impact on their health. The results indicated that the severity of the PWAs illness and the duration of caregiving were more consequential to health than were the hands-on tasks of caregiving.

Bereavement and the Loss of Mattering

INTRODUCTION Mattering is an important, albeit overlooked, component of self-concept. First specified by Rosenberg and McCullough (1981), it is potentially a powerful analytic tool. Rosenberg and McCullough viewed it as having multiple dimensions. First, it is based on ones understanding that he or she is the object of anothers attentions. Individuals are not likely to harbor a sense of mattering to a person if they are not an object on whom that person focuses at least some attention. Moreover, in order for attention to contribute to the sense of mattering, the attention must be of a certain quality; specifically, it needs to convey the understanding that one is a valued and important object to the other. The sense of mattering is thus based on the individuals conviction that what he or she thinks, wants, or does is of salient concern to others. A third dimension of mattering, central to the analysis presented in this chapter, is ones perception that others depend on her or him for something needed or wanted. The recognition that another person depends on us can be, according to Rosenberg and McCullough, a powerful reinforcement of mattering. As we will detail, the sense of mattering that stems from the knowledge that the satisfaction of the vital needs of another person depends on our assistance is a pivotal source of mattering in the population being studied here. We will show that the loss of that source can have deleterious consequences.

The integration of informal care, case management and community-based services for persons with HIV/AIDS.

This research examines the integration of informal and formal care for persons with HIV/AIDS. Data come from a panel survey of informal HIV/AIDS caregivers (N = 642) and are analyzed using a modified version of the Behavioral Model that allows for inclusion of predisposing, enabling and need characteristics of persons with HIV/AIDS and their caregivers. The outcome component of our model emphasizes the role of case management as an intermediary service designed to facilitate linkage to other services. Results indicate: substantial use of case management and other services among persons receiving informal care; characteristics of care recipients, caregivers and dyads directly influence case management and service use; case management positively influences service use at baseline and change in service use over time; and the association between case management and service use generates indirect influences on service use related to characteristics of care recipients, caregivers and dyads. These results highlight the importance of case management as a mechanism for integrating informal and formal care and demonstrate that service utilization is influenced by the social context of illness.

Met and Unmet Need for Medicaid Home- and Community-Based Services in the States

This study examined the met and unmet need for Medicaid personal care services (PCS) and home- and community-based service (HCBS) waivers across the states. Medicaid directors and state officials working with PCS and HCBS were interviewed by telephone in l998-1999 to collect descriptive and statistical data. A total of 26 states offered PCS to 467,487 participants in l998-1999, and 49 states offered waiver services to 561,510 participants in l997. In spite of wide variations in total HCBS participants per capita, 42 states reported inadequate waiver slots and waiting lists. Even in states with the highest participant rate per capita, state officials reported waiting lists for theHCBSwaiver programand many target groups that were not adequately covered by the current HCBS waivers. A number of barriers existed to expanding HCBS services, including an inadequate supply of home- and community-based providers, limited state legislative support for the programs, and federal regulatory barriers such as restrictions on need criteria.

Psychotherapy use and depression among AIDS caregivers

Psychotherapy use and depression among AIDS caregivers were examined with two waves of data from a panel survey of caregivers in Los Angeles and San Francisco (N = 472). Both were studied as outcomes driven by an array of determining factors (e.g., caregivers and care recipient health; care-related stress). AIDS caregivers exhibited relatively high rates of psychotherapy use (31% reported using at the time of initial interview). Care- related stress did not significantly predict the use of psychotherapy in either the baseline or longitudinal analyses. Instead, the health status, relationship, and living arrangements of the caregiver and the care recipient were the important correlates of psychotherapy use. Factors affecting depression over the course of caregiving were caregiver health status and care-related stress, particularly secondary stressors which arise as a consequence of, but not directly due to, caregiving. Thus, although the stressors of caregiving do not prompt the use of psychotherapy, they clearly led to an elevation in symptoms of depression, which is associated with psychotherapy use. Findings regarding the relation of psychotherapy to changes in depression over the course of caregiving also are discussed.