In Japan, the number of new HIV/AIDS cases was 1,317 in 2018 (1,389 in 2017) [1]. The total number of reports for 1985–2018 was 30,149 (including those who subsequently died)[1]. Evidently, the number of HIV/AIDS patients is increasing annually in Japan.
The issue of the stigma surrounding HIV has been reported in numerous countries; it is apparent that HIV infection imposes a mental and physical burden[2–9]. In the most recent Japanese survey, 85.2% of participants stated that it was unsafe to reveal to others that they were HIV positive[10]; 65.9% declared that they were striving to ensure that no one around them realized their condition. These findings demonstrate that a significant stigma related to HIV[10] persists, which imposes a heavy burden.
Consequently, stress is high among people living with HIV (PLWH) in Japan. Specifically, in terms of mental health, PLWH are at higher risk of depression and anxiety disorder than the general population[10–12]. Thus, there is an urgent need to develop appropriate solutions.
These stressful conditions can damage the mental health of many individuals; however, some PLWH manage to stay healthy and even flourish[10]. Such concepts as stress-related growth (SRG), post-traumatic growth (PTG), and benefit finding (BF) have recently received attention as explanations for this phenomenon[13–15]. SRG is defined as “actual or veridical changes that people have made in relation to their experience with an identified stressful or traumatic event”[13]. SRG and PTG are similar in that both concepts reflect true developmental change that occurs owing to stress[16, 17]. According to Tedeschi and Calhoun, change occurs in the following three categories: self-perception; interpersonal relationships; and philosophy of life[18]. PTG is a form of growth that may occur as a result of high levels of stress and “seismic” events (e.g., natural disasters and war). By contrast, SRG arises from traumatic events as well as from chronic stressors (e.g., everyday stressors and care-giving responsibilities)[19–21]; thus, the concept of SRG covers a broader range of phenomena.
In general, the SRG scale (SRGS; 50 items)[13], PTG inventory (PTGI; 21 items)[18], perceived benefit scales (38 items)[22], and BF scale (BFS; 14–30 items)[23] are used to measure SRG. With all those scales, respondents evaluate the degree of change they have undergone as a result of their most stressful experiences with regard to each item. However, the scales do not agree regarding constructs. SRGS is a one-dimensional construct. PTGI is a five-dimensional construct that comprises the following: relating to others; new possibilities; personal strength; spiritual change; and appreciation[18]. The BFS consists of two dimensions: personal growth and acceptance. Thus, the number of dimensions involved in measuring SRG differs according to the scale employed; there is no single accepted approach.
One meta-analysis and a systematic review clarified that SRG was very strongly correlated to mental health[17, 24]. SRG affects both mental and physical health. However, compared with the number of studies on SRG and mental health, little research has investigated the correlation between SRG and physical health. Most studies found that SRG is related to improved physical health[25]. For example, Affleck et al. determined that among participants who reported SRG, the likelihood of subsequently suffering a heart attack was significantly lower[26]. The mechanism of the association between SRG and physical health may involve mental and biological factors, such as stress-coping strategies and responses to biological stress[19].
Some studies have investigated SRG in PLWH. For example, Milam found that in PLWH with high SRG, objective biological indicators, such as CD4 cell levels and disease progression, may proceed more slowly[27]. Carrico et al. determined that BF had a direct effect on depression in male and female PLWH[28]. Updegraff et al. observed that a positive change with SRG was negatively associated with depressive symptoms; they reported it was not associated with anxiety and general health among American female PLWH. The authors found that a negative change with SRG was positively associated with depressive symptoms and anxiety, and it was negatively associated with general health[29].
Using an original SRGS with American female PLWH, Siegel et al. determined that SRG was correlated with a lack of depressed moods[30]. Further, an investigation of the same group of participants verified that SRG had a direct effect on depression and exerted a stress-buffering effect; SRG was found not to have an association with physical health[31]. Littlewood et al. found that BF had a negative correlation with physical symptoms, a significant negative correlation with depression, and that BF had an indirect effect on depression through social support[15]. Sawyer et al. performed a meta-analysis of 38 studies on SRG in subjects with cancer and HIV (eight studies on HIV). They reported that SRG had a positive effect on positive mental health and physical health; it had a negative effect on negative mental health[32].
From the above studies, SRG is evidently a key concept in health promotion (including mental health) among PLWH. It appears that it will become increasingly important for support for PLWH to focus on SRG. Thus, it is apparent that several topics demand investigation. First, the relationship between SRG and physical or somatic symptoms among PLWH has not been sufficiently researched[33]. According to one systematic review, there is no a consensus on the relationship between SRG and mental health[33].
Second, with regard to measuring SRG, as described above, most investigations have used SRG measurement tools that are limited to positive changes, such as growth and benefit. However, some studies have reported that negative cognitive changes and experiences of loss apparently occur in response to illness[34]. Additionally, it has been asserted that negative survey items should be used as filler items in studies on growth and benefit owing to the high degree of social desirability bias.[35] Several studies on SRG have therefore simultaneously investigated positive and negative changes. For example, one study of HIV-positive participants developed a 10-item scale called the Impact on Self-Concept Scale; it comprised two subscales, one with seven items on self-loss and the other with three items on self-growth[36]. Another study of child patients with serious illnesses, rather than HIV-positive participants, developed and implemented an SRGS with two subscales of perceived benefit and perceived burden[35].
When psychological strength, partner bonding, and other such concepts are investigated, they have been found to grow stronger, become weaker, or remain the same after a traumatic event. Such cognitive changes could therefore be measured on a single axis with “no change” as the starting point. In fact, in the study on Japanese PLWH where HIV was caused by contaminated blood products, mentioned above, SRG was measured on a single axis.[37] We employed the same scale in the present study; rather than just assessing growth and benefit, we applied the concept of “perceived positive-negative change,” allowing measurement of negative changes on one axis.
Third, many studies have treated SRG as a single factor; thus, the relationship among its component elements have hitherto not been sufficiently elucidated. For example, the three elements suggested by Tedeschi and Calhoun (self-perception, interpersonal relationships, and philosophy of life) are strongly correlated as sub-concepts in the construct of SRG[18]. However, it is possible that those elements may function independently, i.e., some people may exhibit improvements in terms of self-perception but deterioration with interpersonal relationships. Further, an examination of the subscales should clarify correlations among them; it should also allow additional practical applications by providing more specific and concrete conceptual details.
Fourth, the effect of the time since HIV diagnosis on the extent of SRG has not been adequately investigated. Calhoun et al. theoretically demonstrated that the extent of generated SRG differs both quantitatively and qualitatively according to the length of time that passed since a traumatic event[38]. However, those studies were not limited to HIV-positive participants; they did not clarify how the time since the event was confirmed. To investigate the measurement and functions of SRG and apply study results to on-site practice, it is necessary to address the duration since the event.
Fifth, there is a lack of Japanese studies in this area. Notably, no investigations on SRG in PLWH have been undertaken; the exception is one report in which an association was found between SRG and depression in PLWH where HIV was caused by contaminated blood products[37].
On the basis of the above discussion, this study aimed to clarify the following three points among PLWH. First, we aimed to verify the three-factor model of stress-related growth scales. Second, we attempted to confirm the relationship impact between subscales of stress-related growth and mental health. Third, we aimed to confirm the relationships between subscales of stress-related growth and somatic symptoms. We also examined differences in the effects of stress-related growth on health by time since HIV diagnosis.