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Psychological well-being of housewives living with HIV/AIDS: stigma and forgiveness

Introduction: Housewives living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) encounter both social and psychological issues that are mainly associated with stigmatization as a result of their medical condition. Stigmatization is even stronger among housewives living with HIV as compared with husbands living with the same virus. The reason of this unequal stigmatization can originate from social expectations of feminine behavior as well as the common association between sexually transmitted infections and extramarital sex or drug abuse. This study aimed to investigate the  influence of stigma and forgiveness toward psychological well-being among housewives living with HIV/AIDS. Material and methods: This was a cross-sectional study, with purposive sampling used to select participants based on characteristics and the  objective of  the  study. The  study was community-based and involved one hundred and twelve housewives living with HIV/AIDS. Information about HIV infection by a husband were obtained from self-reports. All participants signed an informed consent. Data collection was carried out for two months and information were collected with the use of questionnaires. The derived data were analyzed using stepwise regression. Results: Stigma and forgiveness influenced psychological well-being of housewives living with HIV/ AIDS. Instrumental stigma and symbolic stigma were both negatively correlated with psychological well-being, respectively (β = –0.705, β = –0.769; p < 0.01). Moreover, interpersonal forgiveness positively related to psychological well-being (β = 0.356, p < 0.01). Conclusions: Forgiveness helped housewives to live more in the present moment and to reconcile with the past. Forgiveness could influence personal outcome and have a positive impact on a relationship. The act of forgiveness was significantly influential on the standard of health and well-being. Limitation of  the  study was that all variables were measured by self-report, which may have some bias. Hence, further research is required to measure all variables by an in-depth interview, exploring attitudes toward stigma and forgiveness. HIV AIDS Rev 2020; 19, 1: 24-29 DOI: https://doi.org/10.5114/hivar.2020.93158


Introduction
Since human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) were initially discovered in Indonesia, there has been an alarming increase in the recorded number of HIV/AIDS cases annually. The cumulative data obtained by the Ministry of Health as of June 2018 revealed 301,950 cases of HIV and 108,829 of AIDS classified into numerous categories. It is a complicated reality that cannot be categorized, as several types of stigma are frequently observed in a stigmatized individual. Hence, for the clarity of this study, it is essential to examine these types of stigma.
Courtesy stigma refers to the stigma attached to individuals as a result of their affiliation with a stigmatized individual or group, even when they are not necessarily considered to possess the forbidden traits or behavior [12]. Instrumental stigma is primarily centered on the fear triggered by the stigmatized individual or an attribute possessed by his or her characteristics. In this case, the stigmatization of the individual or group is used as a tool to prevent or protect against the harm or undesirable outcome associated with the stigmatized person [13].
Symbolic stigma is rooted in pre-existing unpleasant attitudes and behavior for a group or an individual. The current situation of an individual or a group serves as a justification for expressing hostility, which previously existed for the group or individual in question. Symbolic stigma encompasses moral values and perceptions of good or bad qualities, which are socially and contextually framed and reframed [12].
Gloomy emotions bring an undesirable outcomes in people living with HIV such as drastically reduced level of CD4 (white blood cell type used by HIV virus to replicate and then 'kill' in a way to injure the immune systems decline), render them to be more vulnerable to the disease, experience depression, despair, and decrease in self-esteem [14]. To alleviate the effects of pessimistic emotions, housewives diagnosed with HIV are required to give up bitterness, feelings of guilt, remorse, anger, and hatred towards their husbands who had infected them. In individuals who are more willing to forgive, an increase in reducing the symptoms of depression and stress is visible [14]. Thus, some benefits can be favorable to HIV-infected housewife if she chooses to forgive her husband.
Forgiveness is a modality that is equipped with the potential of improving well-being and interpersonal relationships [15]. Forgiveness has conceptualized as intrapsychic, which takes place in the mind of the forgiver, and also theorized to be interpersonal or a social activity that occurs between people [16]. Forgiveness is adequately useful for overcoming a sense of remorse, guilt, fear, anxiety, and anger [16]. The act of forgiveness has an essential relationship with the level of human health and welfare, and this can be obtained through a couple of mechanisms. Firstly, the forgiveness of those who have hurt themselves beyond repair, provide support, and sustain the relationship between the victim and the infector. Secondly, the will to always try to forgive can regulate hostility within oneself [17].
Forgiveness can generate a replacement of negative emotions with positive ones, which develop the immune system. Forgiveness can be influential with regards to both physical and psychological health concerns. As a result of forgiveness, one can be relieved of anger, modify the damaging cogitation, and turn out to be a better example for people who have hurt them in the past. People who have a high tendency to forgive usually display greater enthusiasm towards cases within Indonesia. The cumulative tally of heterosexual risk factors is remarkably more significant than that of other risk factors such as homo-bisexual men, injecting drug abusers, blood transfusion, prenatal transmission, and other unknown factors [1].
Majority of people living with HIV/AIDS continue to suffer from this disease, and this condition has been established to have a significant impact on their psychological well-being [2]. The psychological well-being of an individual is an encouragement to enhance and realize the person's real potential. This can motivate an individual to strive for improvement of their standard of living to be higher or at least adequate to the situation [3]. There is an absence of psychological well-being, which is not present in cases of individuals living with unhealthy difficulty, especially that of chronic pain. People with a decent level of psychological well-being are those who are capable of accepting the overall good in both the present and the past, those who are capable of understanding and accepting their various characteristics regardless of good or bad qualities, and continue to live with a positive attitude towards life [3]. The perception of wellbeing perspective is quite applicable in comprehending desired outcomes and strengthening the likelihood of individual fulfilment and growth [4]. The psychological well-being is the indicator of an individual supporting one's health [5,6]. Likewise, psychological well-being is positively related to an individual's ability to display positive behavioral tendencies toward adaption and inversely related to the tendency to perform risky health behaviors [5,7].
General increase in amount of people infected by AIDS has affected growing number in women. Relatively low incomes, poor educational backgrounds, and low education levels as well as reproductive age and active heterosexual behaviors revealed that there is no group of population facing higher risk but a set of factors that expose people to the virus [8]. In the last three years, there has been an escalation in the number of people living with HIV who were housewives, since they are more vulnerable to HIV than sex workers. The aggregated number of HIV cases among housewives is substantially higher than that of sex workers [9], because a housewife is infected by HIV as a result of sexual relation with her husband without any protection [10]. Housewives are being infected with the deadly disease totally unawarded. Furthermore, they understand the magnitude and dangerous nature of HIV, but fail to consider themselves as being at risk to contract the disease. Their monogamous relationships with their husbands is thought to be safe enough to keep them out of the firm hold of HIV.
The assumption that a HIV-positive female is a sex worker -an immoral woman with no principles, is a glaring example of HIV-related stigma. These assumptions resulted in an undervalued identity as well as assigning an unwarranted smear of humiliation. Both psychosocial factors are associated with poor health outcomes [11]. Females with HIV are stigmatized and considered as tainted and deprived of scruples, particularly because HIV/AIDS is associated with sex, which is morally unaccepted [12]. Stigmatization has been life. Some previously completed studies have also established a relationship between the ability to forgive, life satisfaction, and stress experienced by individuals, and all this leads to healthy psychological well-being [18].
We conducted a quantitative study to investigate the psychological well-being of housewives infected with HIV/ AIDS. The urgency of this study was to explore how stigma and forgiveness influence psychological well-being among housewives with HIV/AIDS infected by their husbands. This study also focused on determining whether stigma and forgiveness influence psychological well-being. Hence, we firstly examined the relationship between stigma and psychological well-being. We hypothesized that instrumental stigma, symbolic stigma, and courtesy stigmas were negatively related to psychological well-being. Next, we examined the relationship between forgiveness and psychological well-being. Therefore, we assumed that intrapsychic and interpersonal factors positively influence psychological well-being.

Material and methods
The study was approved by our ethics committee (No. 12/Komet/FPsi/2018). This study was community-based and conducted in Medan, Indonesia. This community focuses on the empowerment of people living with HIV/AIDS. Participants were housewives infected with HIV/AIDS, members of the HIV community, which knew to be infected with HIV by their husbands, based on the self-report given. Purposive sampling used in inclusion criteria included housewives diagnosed with HIV, aged 18 to 60 years, attending routine clinical care, meeting peer groups in the HIV community, and willing to become a participant in this study. All participants signed an inform consent, which included informing the subject about her rights, the purpose of the study, and the procedures. During this study, 123 questionnaires were distributed to housewives infected with HIV/AIDS, out of which 112 returned fully answered. We set a margin of error as 5% to choose the sample size. The response rate of the survey was 91%. The results obtained were analyzed using the statistical package for social sciences (SPSS) 20.0 for Windows. Pearson correlation and stepwise regression models were used for relationship among variables and predictor of psychological well-being. P < 0.05 was considered significant and p < 0.01 was considered very significant.

Measures
The efficiency of the measurement tools was evaluated by constructed validity, which was designed to measure the capability of specific factors to fulfil their functions components of psychological well-being scale, and were developed according to six dimensions of psychological well-being: autonomy, environmental mastery, personal growth, positive relations, purpose in life, and self-acceptance [3]. Likert scale comprising of five answer choices was used: strongly agree -5, agree -4, neutral -3, disagree -2, and strongly disagree -1.
Factor analysis of psychological well-being scale revealed that: 1. The loading factor value for "autonomy" ranged from 0.583 to 0.786; 2. The loading factor value for "environmental mastery" ranged from 0.546 to 0.732; 3. The loading factor value for "personal growth" ranged from 0.675 to 0.833; 4. The loading factor value for "positive relations" ranged from 0.583 to 0.786; 5. The loading factor value for "purpose in life" ranged from 0.632 to 0.826; 6. The loading factor value for "self-acceptance" ranged from 0.579 to 0.757. Cronbach's a coefficient of reliability was 0.926.
The AIDS stigma scale was designed according to the categories of stigma, which included instrumental stigma, symbolic stigma, and courtesy stigma [13]. Participants were requested to respond using the five-point scale, which consisted of answers: always -5, often -4, sometimes -3, rarely -2, and never -1. Factor analysis of AIDS stigma scale disclosed that 1. The loading factor value for instrumental stigma ranged from 0.535 to 0.831; 2. The loading factor value for symbolic stigma ranged from 0.644 to 0.898; 3. The loading factor value for courtesy stigma ranged from 0.639 to 0.802. Cronbach's a coefficient of reliability was 0.965.
Forgiveness scale was designed using two dimensions of forgiveness: intrapsychic and interpersonal [16]. Participants were requested to respond using the provided fivepoint scale, which comprised of answers: strongly agree -5, agree -4, neutral -3, disagree -2, and strongly disagree -1. Factor analysis of forgiveness scale disclosed that 1. The loading factor value for intrapsychic ranged from 0.673 to 0.851; 2. The loading factor value for interpersonal ranged from 0.753 to 0.819. Cronbach's a coefficient of reliability was 0.868.

Results
This study involved 112 housewives infected with HIV/ AIDS, with age ranging from 18 to 60 years, average 39.94 years (SD = 6.87). Majority of participants (83.1%) completed high school. In terms of the length of marriage, approximately half of participants had been married for one to five years (57%), with more than half having between one and three children (71.4%).
The result of Pearson correlation analysis revealed that stigmatization and forgiveness were considerably associated with psychological well-being. Instrumental stigma, symbolic stigma, and courtesy stigma were shown to be inversely related to psychological well-being. Furthermore, the dimensions of forgiveness such as intrapsychic and interpersonal were established to be directly related to psychological well-being. The results are presented in Table 1. Table 2 shows the summarization of the multiple regression analysis results using two major steps.
Step 1: instrumental stigma and symbolic stigma were both negatively correlated with psychological well-being, respectively (bins = -0.705, bsym = -0.769; p < 0.001). Moreover, courtesy stigma was trivially related to psychological well-being (bcou = -0.239, p = 0.142). The inclusion of these variables in this model accounted for 28.6 per cent of psychological well-being.

Discussion
In our study, the stigma associated with HIV/AIDS has negatively influenced psychological well-being among housewives who were infected with HIV/AIDS, showing that the stigmatization has led to a decrease in psychological well-being. HIV is a long-term condition, which not only disturbs the physical health, but also initiates psychological and social problems due to the stigmatization and discrimination involved [19]. Stigma has a fixed amount of impact on health and well-being of individuals, mainly as it induces high rates of psychological distress among those infected with HIV/AIDS [20]. Housewives living with HIV are facing long-term challenges regarding their psychological wellbeing and general challenges that are principally associated with stigma. The challenges faced by housewives living with HIV are diverse and complicated, yet it seems like the extent of the psychosocial problems faced by these housewives are not being rigorously reviewed or elaborated. Being diagnosed to be HIV-positive, is undoubtedly one of the toughest challenges faced by people living with this disease. The results from the analysis of data of our study confirmed that stigmatization leads to isolation, especially of people unable to access social or peer support. Insufficient or lack of social support results in loneliness, which is a painful experience marked by the absence of a warm relationship, having adverse consequences for the emotional, physical, and spiritual well-being. Individuals who felt lonely, isolated, depressed, and rejected by the social environment indicated a low level of psychological well-being and were more prone to diseases [21]. A contemporary study confirmed that receiving social support from a substantial number of social network members can endorse positive psychological adjustments in people living with HIV [22]. A higher rate of social support was associated with a positive psychological effect on housewives living with HIV/AIDS. Furthermore, housewives liv-  ing with HIV who were satisfied with the amount of support available tended to experience less psychological distress, higher quality of life, and better developed self-esteem.
The results also revealed that instrumental and symbolic stigmas were considerably involved in predicting the psychological well-being of housewives living with HIV. Instrumental stigma was majorly derived from the fear of AIDS as being a communicable and lethal illness, along with the necessity to protect oneself from the disease [13]. Instrumental stigma reflects the apprehension often associated with any transmissible and deadly illnesses. The stages of HIV disease develop in periods; its symptoms are most apparent to others and could be perceived as repellent, unpleasant, or upsetting. Symbolic stigma derives its strength from the association of HIV with disliked groups related to HIV. The precise groups associated with AIDS in symbolic stigmatization vary to a certain degree across cultures, depending on the local epidemiology and preconception [13]. Stigma resulting from family and community refusal is one of the origins of stress and depression in people living with HIV.
Outcomes gathered from subsequent studies presented forgiveness to be positively influential on psychological well-being among housewives living with HIV/AIDS. Forgiveness contributed to increased psychological well-being among infected housewives and probably upgrading mental health indirectly through variables such as social support, interpersonal functioning, and health behavior [14,23]. The increase of self-forgiveness contributed significantly to satisfaction with life. Individuals who succeeded in letting go of bitterness and other negative emotions were better adapted to self-care and thus, potentially prevented the severity of complications [24]. Moreover, self-forgiveness probably plays a more crucial role than the forgiveness for others in the maintenance of health and well-being. It may be right to say that self-forgiveness is more beneficial than the forgiveness for others because the practice of health maintenance often involves an internal aspect of control (in order to remain healthy) that requires forgiveness directed internally.
For some people, forgiveness might be related to situations where they harmed other people, while for others, forgiveness might be associated with the negative feelings directed internally as a result of feeling guilty for allowing themselves to be hurt by others [25]. A heterosexual monogamous marriage, in which the husband has been unfaithful to his partner was analyzed. In this scenario, the adulterous husband was unsuspectingly infected with HIV and unknowingly transmitted the disease to his partner. In such a situation, a housewife may consider her husband to be responsible for the transmission of disease and thus finding forgiveness for others could be unfitting and difficult [25]. By forgiving each other, it appears that people can overcome the undesired impacts of conflict on their relationships. As observed in some cross-sectional and longitudinal studies, forgiveness was perceived to correlate with the improvement of interpersonal relationships between the forgiver and the transgressor [26,27]. In addition to its apparent relation-al benefits, forgiveness was also positively associated with psychological well-being [26].
Mutual forgiveness in marriage is influenced by four occurrences. Firstly, the offender needs to forgive the mistakes of their partner due to their desire to preserve and maintain a healthy marital relationship. Secondly, couples who developed a substantial commitment to their marriage have a vibrant long-term orientation of achievements to be accomplished. With this to be considered, the partner's misdeeds needs to be perceived as a mistake that should be forgiven in order to maintain the relationship and commitment. Thirdly, a couple with a strong commitment in their marriage ought to utilize mistakes in order to bring them closer and strengthen the strength of their relationship. Lastly, the existence of common interests between partners enhances the chance for mistakes to be excused by the couple [26].
This current study discovered that interpersonal forgiveness was a determinant for psychological well-being. As regards to housewives, interpersonal forgiveness was significantly negatively related to depression, psychoticism, and social dysfunction. Interpersonal forgiveness was on the other hand positively associated with healthier mental health status [28]. Previously conducted researches are consistent with the re-established notion that interpersonal forgiveness may result in decreased psychological distress symptoms. Interpersonal forgiveness might attain its association to well-being by influencing the forgiver's perceptions of his or her relationship with the infector because maintaining a proper degree of connection with others is a fundamental psychological need to ensure a progressive level of well-being [29].
Like every other conducted research, this study had some limitations. A small sample size as well as the use of non-probability sampling method excluded generalization of findings [30]. Another limitation regarding the sample was the minimal proportion of participants who disclosed that they were HIV-infected by their husbands. Participants in a survey answered questions and the data was based on self-reported answers. Results may be influenced by social desirability and recall bias. The generalizability may only be practical to those who decided to partake in the survey. Another limitation of this study was ensuring that their husbands infected participants with HIV. Further studies are required to validate the findings such as interviews.

Conclusions
The most vital factor responsible for the generation of the negative psychosocial effect of HIV and AIDS is the stigma. Consequently, taking actions towards curbing the stigmatization may be the most significant step required in order to improve the psychosocial well-being of HIV/AIDS-infected people. Housewives diagnosed with HIV experience the majority of emotional trauma identified with people facing a terminal illness. Forgiveness appears to be principally crucial in the marital relationship of such victims. Forgiveness plays a fascinating role in marriage, as spouses must frequently come to deal with the fact that they behaved in a way that was spiteful to their partner. Forgive and be forgiven is one of the most significant determinants of marriage fulfilment through its duration. Forgiving the husband for his misconduct is one possible means of providing closure, as regards to a painful or disturbing events in relationship. Forgiveness has substantial implications for long-term relationship outcomes as well as short-term patterns of interaction.