Social Support

Social Network Structure and Social Support in HIV-Positive Inner City Mothers Edythe S. Hough, EdD, RN Morris A. Magnan, PhD, RN Thomas Templin, PhD Hesham F. Gadelrab, PhD

It has been documented that social support influences health outcomes of persons with chronic illnesses. The incidence of HIV and AIDS among minority women is growing at an alarming rate, but little is known about social support in this vulnerable population, and even less is known about the social network conveying that support. Guided by the convoy of social networks model, this study describes the social networks in a sample of HIV-positive, urbandwelling mothers (N ⫽ 147) by stage of disease (i.e., asymptomatic, symptomatic, AIDS) and examines relationships between social network structure and social support. Hierarchical linear modeling showed that women’s social networks were disproportionately populated by children, and network members of women with AIDS were significantly older than network members of HIV-positive women with or without symptoms. Profile analyses showed that women’s perceptions of the quality of social support differed according to the proportion of family members populating different segments of the social network. Key words: social support, social network, HIVpositive mothers

An increasing proportion of newly diagnosed HIV and AIDS cases are being reported among minority urban women. The majority of women in the United States with HIV are women of color. African American and Hispanic women account for 80% of the women with HIV, and, in 2000, over 63% of all women with AIDS were African American (Centers

for Disease Control and Prevention [CDC], 2003). AIDS was the third leading cause of death among African American women ages 25 to 44 (CDC, 2003), many of whom are mothers. Consequently, in addition to suffering from a life-threatening condition, many HIV-infected women are faced with additional challenges such as coping with single parenthood, poverty, and racism. Social support has been found to be a critical factor in coping with HIV (Hays, Chauncey, & Tobey, 1990; Kyle & Sachs, 1994; Rodgers, 1995). However, research examining the importance of social support has focused primarily on White gay/ bisexual men, and results may have limited generalizability to poor urban African American women. Hough, Brumitt, Templin, Salzt, and Mood (2003), in a study of HIV-infected African American mothers, found that effective coping (i.e., characterized by a woman’s ability to make meaning of her experiences) was positively related to her social support. Mothers with adequate social support were more likely to use effective coping strategies and to exhibit Edythe S. Hough, EdD, RN, is a professor in the College of Nursing at Wayne State University, Detroit. Morris A. Magnan, PhD, RN, is an associate professor in research in the College of Nursing at Wayne State University, Detroit. Thomas Templin, PhD, is an associate professor in research in the College of Nursing at Wayne State University, Detroit. Hesham F. Gadelrab, PhD, at the time of the study, was a doctoral candidate and research assistant in the College of Nursing at Wayne State University.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 16, No. 4, July/August 2005, 14-24 doi:10.1016/j.jana.2005.05.002 Copyright © 2005 Association of Nurses in AIDS Care

Hough et al. / Social Network and Support in HIV⫹ Mothers

decreased mood disturbance. These results point to the importance of social support as a buffer against the deleterious effects of HIV-related stress on a mother’s ability to cope with her diagnosis. However, to obtain a more complete picture of the social support system and an understanding of the sources of support, information is needed regarding the characteristics of the social networks of these women.

Social Networks The term social networks refers to the structural characteristics of an individual’s informal support network as opposed to a formal network of paid support providers. A model that provides a framework for the study of social networks across the life span is the Social Convoy Model (Kahn & Antonucci, 1980). The social convoy is represented as a series of three concentric circles surrounding an individual. Inclusion of persons in a convoy circle is determined by the individual’s emotional attachment to the person as well as by the role of the person in relation to the focal individual. Thus, persons occupying the innermost circle of an individual’s social convoy are likely to be important support providers with whom the focal individual feels very close. Membership in the second circle suggests a degree of closeness to the focal individual as well as relationships that are based on more than just fulfillment of a role. Finally, members of the third circle are thought to be close to the focal individual but usually in a very role-prescribed manner. In its entirety, the convoy model evokes an image of a protective layer of family, friends, and others who “surround the individual and help in the successful negotiation of life’s challenges” (Antonucci & Akiyama, 1987, p. 516) as the individual moves through life. Changes in the convoy are hypothesized to occur across normative life transitions, in response to nonnormative events, or as a result of individual maturation. The relationship of social network characteristics to perceptions of social support, psychological wellbeing, and health-related outcomes has not been studied extensively in HIV-positive persons. However, the literature suggests that the size of one’s social network seems to be less important to health outcomes than its composition. For example, re-

15

searchers incorporating specific providers of social support (e.g., family, friends, partner) have reported that family members are not viewed as particularly helpful to HIV-positive persons. In fact, the majority of studies suggest that friends provide more support than family to HIV-infected individuals (Burgoyne & Saunders, 2000; Friedland, Renwick, & McColl, 1996; Hays, Catania, McKusick, & Coates, 1990; Hays et al., 1990; Hays, Magee, & Chauncey, 1994; Johnston, Stall, & Smith, 1995; Namir, Woolcott, Fawzy, & Alambaugh, 1987; Schwarzer, DunkelSchetter, & Kemeny, 1994; Stowe, Ross, Wodak, Thomas, & Larson, 1993). Explanations offered for friends being more supportive than family have included both the social stigma associated with HIV (Barroso, 1997) and issues stemming from problematic life styles before contracting HIV (Owens, 2003). Epidemiological studies (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997; Flaskerud & Winslow, 1998) suggest that individuals who engage in diverse social networks live longer than those with fewer types of social relationships, and Cohen (1988) proposed that the more isolated HIV-positive women are, the more susceptible they might be to delayed healthcare and disease progression. To date, no published work details the characteristics of the social networks of poor urban minority HIV-positive mothers. There is a great need for information about the social networks of HIV-infected mothers because of the potential for the illness to exert extreme burdens on a woman’s social support system. First, there is the issue of stigma which, despite over two decades of media coverage of the successful treatment of the disease, is still an issue, especially among African Americans. Stigma leads to secrecy and its main consequence: the presence of few knowledgeable people that the person can rely on in times of needed support (Armistead & Forehand, 1995). Additionally, HIV-infected mothers, like HIV-infected gay men, may enter this phase of their life with weakened social networks because of their own past behavior and transgressions (Owens, 2003). Finally, as a mother gets increasingly more ill, the social network may simply become more depleted because of her decreased ability to maintain reciprocal relationships (Hudson, Lee, Miramontes, & Portillo, 2001) leaving the woman with limited and perhaps inadequate sources of social support at a

16

JANAC Vol. 16, No. 4, July/August 2005

time when it is needed most for her and her children (Dorsey, Chance, Forehand, Morse, & Morse, 1999; Dorsey, Klein, & Forehand, 1999).

Social Support Social support is the functional imperative of the social network. Social support, an omnibus concept, is broadly defined as the subjective feeling of belonging; of being accepted, loved, esteemed, valued, and needed for oneself, not for what one can do for others (Moss, 1973). Several dimensions of social support, namely emotional, informational, and instrumental support, are seen recurrently in the social support literature. Emotional support has been defined as providing esteem and affiliation to others (Norbeck, Lindsey, & Carrieri, 1981, 1983). Instrumental support includes financial or housing assistance (Gielen, McDonnel, Wu, O’Campo, & Faden, 2001), and informational support has been reported as giving advice and information on social, health, or employment matters (Turner, Hays, & Coates, 1993). Assessments of social support often include the function it serves (i.e., emotional, instrumental, informational) as well its availability, desirability, and frequency of occurrence. The data clearly indicate that quality of social support influences coping, psychological wellbeing, and health-related outcomes in persons with a chronic illness (DiMatteo & Hays, 1981; Schwarzer & Leppin, 1989; Taylor & Aspinwall, 1990; Wortman & Conway, 1985), including in persons with AIDS (Britton, Zarski, & Hobfall-Li, 1993; Grummon, Rigby, Orr, Procidan, & Reznikoff, 1994; Hays, Turner, & Coates, 1992; Linn, Lewis, Cameron, & Kimbrough, 1993; Nott, Vedhara, & Power, 1995; Pakenham, Dadds, & Terry, 1994). Despite a strong tendency toward secrecy among HIV-infected individuals, the beneficial effect of social support on psychological distress has been demonstrated consistently among samples of gay men with AIDS (Leserman, Perkins, & Evans, 1992; Namir et al., 1987; Namir, Alumbaugh, Fawzy, & Wolcott, 1990; Ostrow et al., 1989; Zich & Temoshok, 1990) and HIV-infected women (Clark et al., 1995; Demi et al., 1995; Nannis, Semple, & Patterson, 1995). Clark et al. reported that HIV-infected women who were less depressed were more likely to

have a confidante. Also, greater availability of social support has been reported to be associated with less depressive symptomatology in women (Bluestone, 1995; Demi et al., 1995; Nannis et al., 1995; O’Leary, Wadhwani, Gebelt, & Frenkel, 1995). However, Bluestone cautioned that, although social support may buffer depression when there are few infection-related symptoms, social support may be a less effective buffer as the illness progresses. One study of social support in poor minority HIVpositive women (Klein et al., 2000) reported that HIV-infected women received less social support than a sociodemographically similar group of uninfected women. Research examining the specific providers of social support has suggested that for many with HIV, family members are not viewed as being as helpful or supportive as friends. This result has been particularly salient among those who contracted the virus through homosexual sex or drug use (Johnston et al., 1995; Stowe et al., 1993). In other words, relationships with family members may have been strained before the diagnosis. It is not clear how this process may apply to heterosexual women. Hudson et al. (2001), from a study of a group of ethnically diverse women in San Francisco, reported limited social interactions with family and friends and a low level of perceived social support. Limited perceived social support was a significant predictor of distress in this sample of women. The use of active behavioral coping strategies has been positively associated with both the size and satisfaction with one’s social support network (Leserman et al., 1992; Namir et al., 1987, 1990; Nannis et al., 1995). Hough et al. (2003) tested a model of mother and child coping and adjustment in relation to maternal HIV in a sample of inner-city African American women. Accounting for 36% of the variance in child adjustment, the maternal variables reported to be significant predictors in the model were maternal HIV-associated stressors, maternal emotional distress, child social support, child coping, and quality of the parent-child relationship. In particular, mothers with adequate social support were more likely to use effective coping strategies such as seeking information and using positive reappraisal; they also exhibited decreased emotional distress. Hough et al. (2003) also reported that the

Hough et al. / Social Network and Support in HIV⫹ Mothers

amount of social support experienced decreased as HIV symptoms increased. Although the literature clearly demonstrates the importance of social support in the lives of HIVpositive persons including HIV-infected women, we have little knowledge regarding the characteristics of the social network conveying the needed support. Moreover, theory and research suggest that the diagnosis of HIV as well as disease progression—from asymptomatic to symptomatic to AIDS—precipitate a reconfiguration of the social network, which may adversely affect the quality of social support provided. To the best of the intestigators’ knowledge, the social networks of HIV-infected mothers have not been studied and the relationship between social network structure and social support in this vulnerable population has yet to be determined. This report will (a) describe the structural characteristics of the social networks of HIV-positive mothers at different stages of the disease (i.e., asymptomatic, symptomatic, and AIDS), and (b) examine the relationship between social network structure and social support characteristics (i.e., desirability, availability, frequency, helpfulness) reported by women in this particularly vulnerable population. This information will provide caregivers with important information necessary for the design and implementation of nursing interventions to strengthen and improve the social support systems of HIV-positive women.

Method Sample The sample for this study consisted of 147 HIVpositive women living in the metropolitan Detroit area. These women were young (M ⫽ 36.1 years; SD ⫽ 7.1), predominantly African American (86%), and single (78%). Although most of the women were receiving public assistance (97%), they were very poor with an average monthly household income of only $712. The average time since diagnosis was a little more than 5 years (M ⫽ 62.8 months; SD ⫽ 39). Using the CDC’s classification system for HIV status (Osmond, 1998), 57% of the women were asymptomatic, 18% were symptomatic, and 25% had AIDS.

17

Procedure and Measures Eligible women were clients of a participating clinic/agency who identified themselves as being HIV-infected with confirmation by agency records. The women were recruited from community-based AIDS service organizations, case management agencies, and medical clinics in the metropolitan Detroit area to participate in a larger study investigating the effects of mother-child coping and adjustment to HIV (Hough et al., 2003). Contact between the recruitment coordinator and the subjects occurred either face to face during a regularly scheduled agency visit or by a subject-initiated telephone call after referral by a caseworker. During the initial contact, subjects were asked a number of screening questions to determine their eligibility and willingness to participate in the study. The recruitment coordinator then scheduled an appointment for subjects to come to Wayne State University to be interviewed. Transportation and childcare were provided to facilitate subject participation in the study. Subjects were paid $50 on completion of the interview. Social network was assessed using the convoy model of social networks described by Antonucci (1986) and Antonucci and Akiyama (1987). Network membership was established by giving subjects a target diagram consisting of three concentric circles with the word you written in the innermost circle. Subjects were told that each circle should be thought of as including “people who are important in your life right now” but who are not equally close to you. To identify memberships in the innermost circle, subjects were told to think about “people to whom you feel so close that it is hard to imagine life without them.” Such persons were listed in the innermost circle of the network diagram. The same procedure was followed to determine memberships for the middle circle, described as including “people you do not feel quite that close to but who are still very important to you,” and for the outer circle, described as including “people you feel less close to but who are still important to you.” Structural characteristics of the social networks were determined by asking subjects to provide additional information about the first 10 people listed in their social network diagram. Thus, structural characteristics of networks included not only circle place-

18

JANAC Vol. 16, No. 4, July/August 2005

ment (i.e., inner, middle, outer) but also relationship to the focal person (e.g., child, family, friend), age, distance between the residence of the focal person and the network member, frequency of telephone calls, and frequency of visits. Scores for these additional network variables were computed by averaging values across memberships within circles. For example, for respondent 1, an inner-circle age score was obtained by determining the average age of network members listed in the innermost circle. Middle-circle and outer-circle age scores were computed in the same way. This yielded from 1 to 3 average age scores per subject depending upon how the first 10 network members were distributed across circles. This procedure was repeated for other structural characteristics. Social support, a component of network function, was assessed using a questionnaire developed for a study of social support and physical and psychological distress among gay men diagnosed with AIDS or AIDS-related complex (Zich & Temoshok, 1990). Using this eight-item instrument, subjects provided self-ratings on four components of social support (i.e., desirability, availability, frequency, and helpfulness) on a 5-point Likert-type scale. A ninth item was added to assess satisfaction with support for child caretaking responsibilities (“he/she helped me by taking care of my children when I couldn’t”). In this sample, alpha coefficients for desirability, availability, frequency, and helpfulness were .84, .89, .84, and .83 respectively. Data Analysis All data were analyzed using Statistical Package for the Social Sciences 11.5 (SPSS, Inc., Chicago, IL). Our data were inherently unbalanced because of the fact that network memberships across circles differed from subject to subject. Therefore, hierarchical linear modeling was used to analyze social network characteristics by HIV status and circle placement because it offers the distinct advantage of making it possible to analyze unbalanced data at any level. Profile analysis was used to determine whether the pattern of social support characteristics (i.e., desirability, availability, frequency, and helpfulness) differed by circle composition (e.g., high or low percentage of children in the circle).

Analyses of the size of the social network convoy was based on the total number of network members (N ⫽ 1,979) identified by the respondents. However, detailed information about network members was obtained only on the first 10 members identified by each respondent. Consequently, analyses involving network characteristics other than size were based on a network membership of N ⫽ 1,329.

Results Social Network Structure Network size. The 147 mothers nominated a total of 1,979 network members, creating an average network of 13.46 members (Table 1). There was a significant main effect [F (2, 288.5) ⫽ 69.86, p ⬍ .01] in the number of network members across circles. As shown in Table 1, the innermost circle was more densely populated than the middle circle or the outer circle. Network size did not differ significantly by HIV status (i.e., asymptomatic, symptomatic, AIDS), and there was no significant interaction effect of HIV status by circle placement Age. The age of network members ranged from less than 1 year to 98 (M ⫽ 31.1; SD ⫽ 20.8). There were significant main effects of circle placement [F (2, 239.04) ⫽ 35.73, p ⬍ .01] and HIV status [F (2, 131.41) ⫽ 3.50, p ⬍ .05]. As shown in Table 1, members of the inner circle were younger than those of the middle or outer circles. Network members of subjects with AIDS were older than the network members of subjects who were asymptomatic or symptomatic. No significant HIV status by circle placement interaction was observed. Distance. Geographic distance from the focal person ranged from “live with” to about 200 miles away from the respondent, with an average of 25.5 miles in distance. A significant main effect for circle placement [F (2, 193.58) ⫽ 11.03, p ⬍ .01] was reported, indicating that network members in the inner circle lived closer than network members in the middle and outer circles. Distance did not differ significantly by HIV status and there was no significant HIV status by circle interaction.

Hough et al. / Social Network and Support in HIV⫹ Mothers Table 1.

19

Mean Values of Network Characteristics by Circle Placement and HIV Classification Circle Placement

Network Characteristic Size of network

Age of network members

Distance in miles

Telehone calls per month

Visits per month

HIV Class

Inner

Middle

Outer

Marginal Mean

Asymp. Symp. AIDS All Asymp. Symp. AIDS All Asymp. Symp. AIDS All Asymp. Symp. AIDS All Asymp. Symp. AIDS All

7.15 8.07 7.00 7.41 25.18 27.66 28.79 27.21 22.65 9.50 11.30 14.50 16.34 19.31 17.62 17.76 20.50 20.57 20.71 20.59

4.20 3.70 4.22 4.04 40.52 38.28 41.36 40.06 39.80 49.15 24.39 38.91 11.33 7.61 10.74 9.90 8.51 6.01 9.72 8.08

2.23 2.16 1.67 2.02 40.59 36.72 47.46 41.59 23.31 51.08 12.97 29.12 11.93 5.78 10.11 9.27 7.45 7.50 11.49 8.82

13.59 13.81 12.89 13.46 35.43 34.22 39.20 36.29 28.59 36.60 16.22 27.13 13.20 10.90 12.83 12.31 12.15 11.36 13.97 12.50

NOTE: Asymp. ⫽ asymptomatic, symp. ⫽ symptomatic.

Frequency of telephone calls. Frequency of contact between mothers and their network members ranged from 0 to 30, with a mean of 13.7 calls per month. Frequency of telephone calls differed significantly by circle placement [F (2, 177.53) ⫽ 19.71, p ⬍ .01] but not by HIV status. Members of the inner circle made telephone contact with focal subjects more than members in the other two circles. HIV status and circle placement did not interact significantly to influence the frequency of telephone calls. Frequency of visits. The average number of visits per month between mothers and their network members was 12.5. A significant effect of circle placement was reported [F (2, 210.31) ⫽ 67.95, p ⬍ .01]. Totals for each circle (see Table 1) showed that members of the inner circle made substantially more visits than members of the other two circles. There was no significant difference in the number of visits reported by persons in the asymptomatic, symptomatic, and AIDS groups. The interaction of HIV status and circle placement had no significant effect on the number of monthly visits.

Relationship to mothers. Table 2 presents the relationship of network members to the mothers. In the entire network, nearly 84% (83.9%) of the network members were family; 4.7% were husbands, 33.7% were children, and 45.5% were family other than children. The remaining 16.1% were friends (13.2%), health care professionals (2.1%), and higher beings (i.e., God, spiritual beings; .8%). A majority (69.9%) of the network members were nominated to the inner circle. Eighty-six percent of the inner circle members were children (47.1%) and family other than children (38.8%). Children were the most salient support members in the inner circle. In the middle and outer circles, family other than children were the most prominent members; 61.4% and 60.9%, respectively. The proportion of friends in the inner circle was only 6%, whereas the proportion of friends in the middle and outer circles was 28.6% and 34.8%, respectively. The investigators explored the role of four types of relationships (i.e., husband, children, family other than children, and friends) by HIV status and circle placement. There were no significant main effects for

20

JANAC Vol. 16, No. 4, July/August 2005

Table 2.

Percentages for Social Network Relationships by Circle Placement and HIV Classification

Circle Placement Inner circle

Middle circle

Outer circle

Entire network

Relationship to Focal Person

HIV Class

Number of Network Members

Husband

Asymp. Symp. AIDS ALL Asymp. Symp. AIDS ALL Asymp. Symp AIDS ALL Asymp Symp AIDS ALL

515 175 239 929 184 57 67 308 62 10 20 92 761 242 326 1,329

4.7 6.3 6.3 5.4 2.7 7.0 3.0 3.6 1.6 0.0 0.0 1.1 3.9 6.2 5.2 4.7

Children

Family Other Than Children

Friends

Health Care Professionals

Higher Being

51.5 41.7 41.8 47.1 2.7 1.8 4.5 2.9 0.0 10.0 0.0 1.1 35.5 31.0 31.6 33.7

36.9 39.4 42.3 38.8 60.3 64.9 61.2 61.4 59.7 60.0 65.0 60.9 44.4 46.3 47.5 45.5

4.9 7.4 7.5 6.0 29.9 26.3 26.9 28.6 35.5 30.0 35.0 34.8 13.4 12.8 13.2 13.2

1.2 4.0 0.8 1.6 4.3 0.0 4.5 3.6 3.2 0.0 0.0 2.2 2.1 2.9 1.5 2.1

1.0 1.1 1.3 1.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.8 0.9 0.8

NOTE: Asymp. ⫽ asymptomatic, symp. ⫽ symptomatic.

circle placement or HIV status for husbands, and there were no significant interaction effects from HIV status by circle placement. However, significant main effects of circle placement were reported for children [F (2,221) ⫽ 128.3, p ⬍ .01], for family other than children [F (2,237) ⫽ 14.9, p ⬍ .01], and for friends [F (2,223) ⫽ 17.3, p ⬍ .01]. Thus, the inner circles of the women were more likely to be occupied by children, whereas their outer circles were populated by friends and family other than children. Social Network Structure and Social Support To investigate the relationship between social network characteristics and social support, three network variables were created to represent what appeared to be the most prominent features of the networks of these women, specifically: (a) the proportion of children in the inner circle, (b) the proportion of family other than children in the inner circle, and (c) the proportion of family other than children in the middle circle. Each of these variables was then dichotomized and coded as either high proportion or low proportion using the median as the cut point.

Profile analyses were performed using each of these dichotomous variables as the independent variable and the functional characteristics of social support (i.e., desirability, availability, frequency, and helpfulness) as the dependent variable. Results of profile analysis for the proportion of children in the inner circle revealed a significant difference in profiles [F (3, 435) ⫽ 2.96, p ⬍ .01]. Mothers falling above the median in the proportion of children in their inner circle rated their social support as less available, less frequent, and less helpful than those mothers who fell below the median. However, the two groups of mothers did not differ in their ratings of the desirability of social support. In terms of family other than children in the inner circle, a significant difference in profiles was reported [F (3, 435) ⫽ 2.7, p ⬍ .05]. Mothers above the median who reported family members other than children as their primary source of support in the inner circle rated their support as more available but less desirable. Social support frequency and helpfulness were rated almost the same by both groups of mothers. Mothers who fell above the median in reporting predominantly family other than children in the mid-

Hough et al. / Social Network and Support in HIV⫹ Mothers

dle circle reported experiencing significantly less social support [F (3,324) ⫽ 81.86, p ⬍ .01] on all dimensions (i.e., desirability, availability, frequency, and helpfulness).

Discussion This report provides a detailed description of the social networks of a group of poor HIV-positive, largely African American, inner-city mothers. It examines the social network characteristics of these women according to the stage of illness (i.e., asymptomatic, symptomatic, and AIDS) and relates social network structure to mother’s report of her extant social support. This study is a preliminary step in increasing our understanding of the interpersonal context (i.e., both social network structure and social support) of this highly vulnerable population of women. The women had no difficulty responding to the instructions on how to complete the convoy diagram and did so readily. This sample of 147 women named a total of 1,979 network participants, or an average of 13.46 per person. Although we could find no other report on the network size of HIV-positive persons, this is somewhat larger than those reported by women who abuse drugs, as was the case with the majority of the women in our sample. For example, Falkin and Strauss (2003) reported an average of 9 persons in their sample of drug-using women. Also, by comparison, Antonucci and Akiyama (1987) reported an average of 9 network members in a large sample of elderly persons. Consequently, on the basis of size it seems that this particular sample of HIVpositive women had fairly robust social networks. When we examined various network characteristics such as age, distance, frequency of telephone calls, and frequency of visits, we noted that the inner circles of these women were populated with significantly more younger people than were the middle and outer circles and that women with AIDS reported significantly more older people in their entire network than women who were either asymptomatic or symptomatic. Our result that network members of women with AIDS were older than network members of women who were asymptomatic or symptomatic is consistent with the theoretical claim that changing

21

life events precipitate a reconfiguration of one’s social network. One explanation for this latter result might be that as a woman progresses to full-blown AIDS, her social network becomes more populated with older people (i.e., parents, aunts, grandparents) taking on caregiving roles for either the mother or her children (Dorsey et al., 1999). As one might expect, women reported that inner-circle members lived closer and called and visited more than members of either the middle or outer circles. The fact that other characteristics of network structure (i.e., size, distance, and frequency of telephone calls) did not differ across different stages of the disease suggests that women were able to maintain these aspects of network structure despite changes in their disease status. Consistent with the result showing a greater number of younger people in the mother’s inner circle, we noted a preponderance of children (47.1%) in this circle. Taken together with the fact that very few friends were nominated for the inner circles and made up only about one-third of both the middle and outer circles, it appears that the social networks of these mothers contained relatively few friends and were somewhat top-heavy with children. This result is consistent with reports from qualitative studies in which HIV-positive women reported relying heavily on their children for a variety of supportive functions (Andrews, Williams, & Neil, 1993; Barosso, 1997). The preponderance of children populating the inner circles is worrisome and raises questions about how and to what extent children are able to meet the social support needs of their HIV-positive mothers. The relative paucity of friends and the preponderance of family in the social networks of the women also raise concerns, because of research suggesting that family members are not viewed as particularly helpful to HIV-positive persons (Johnston et al., 1995; Stowe et al., 1993). Further data analyses were conducted to examine the relations between social network structure and the mother’s overall satisfaction with the level of social support she was receiving. We found that mothers falling above the median in the proportion of their inner circle made up of children rated their social support as significantly less available, frequent, and helpful. This result has a number of important implications. Although children may provide mothers with HIV a reason to live, help them main-

22

JANAC Vol. 16, No. 4, July/August 2005

tain a healthier life style, and provide love and affection (Andrews et al., 1993), they also present a complex set of developmental requirements for such things as nurturance, material goods, and safety, just to mention a few. Perhaps these developmental requirements of children outweigh their ability to provide social support to their mothers. Contrary to Barosso’s (1997) suggestion that HIV-positive mothers who rely on their family do not need to reassemble their social networks, our results suggest that a reassembly is very much needed. Mothers may receive some degree of support from their children, but it may not provide them with either the type or amount of support needed to deal with the multiple stressors associated with being poor, having HIV, and trying to raise a family in an impoverished social environment. These mothers are in great need of assistance, not only to maintain their current network that places their children at the forefront but also to enhance their networks with adult friends and family members who can relieve both the mother and her children of some of their burdens. The result showing an almost complete lack of professional caregivers in the lives of these women is disappointing and suggests that professional nurses, among others, have not established themselves as potential sources of support for this group of women. A great deal of attention needs to be paid by nurses and other health professionals to learning how to communicate and intervene in the social support systems of HIV-positive women and their children. One starting point for nurses is to advocate for the assessment of the social network and social support available to HIV-positive women as a part of their ongoing care. Mothers who are relying mainly on their children for social and emotional support need to be assisted in maintaining a delicate balance between their role as mother and their role as an individual with a chronic illness. One area of assistance relates to the process of disclosure of her HIV status to her child, because this has been identified as an important threat to the stability of their relationship (Vallerand, Hough, Brumitt, Pittiglio, & Marviscin, 2004). HIV-positive mothers are also in need of respite care for their children as well as parenting advice and counseling. The availability of respite care is particularly important because of evidence suggesting that, in general, women exhibit more so-

matic complaints as a result of being worn down by nurturing role demands. These results point to a number of directions for future research. First, since little is known about the social network structures of impoverished inner-city African American mothers, the results of this study need to be validated with women of a similar socioeconomic background who are HIV negative. In addition, further work is needed to identify the determinants of the mother’s social network composition, whether these factors change over the course of her illness, and to what extent the children have an impact on the mother’s ability to form and maintain supportive relationships with adults. The children in our study were key providers of social support for their HIV-positive mothers, but little is known about the effect this has on the individual child. How do these children manage this burden? Are there gender differences or differences related to the child’s knowledge and understanding of HIV? And finally, what kinds of support services do mothers and children need and find acceptable? Because professionals played such a minute role in the interpersonal lives of this sample of women, future research needs to explore the effectiveness of intervening at the extended family and community levels as well as with the individual. In summary, we described the social network structure of HIV-positive mothers across a number of dimensions and at various stages of their disease. In addition, we examined the mothers’ level of satisfaction with the social support conveyed by their social network. Our results suggest that there is much to be learned from studying social networks and social support concurrently rather than in isolation. An important implication of our study has to do with the level measurement of constructs. In this sample of women, the relationship between network structure and social support was observed only when a distinction was made between family members who are adults and family members who are children. Using this approach, it became evident that social support varied according to the proportion of children occupying specific segments of social networks of HIVpositive mothers.

Hough et al. / Social Network and Support in HIV⫹ Mothers

Acknowledgement This research was supported by National Institute of Nursing Research Grant No. NR04349.

References Andrews, S., Williams, A. B., & Neil, K. (1993). The motherchild relationship in the HIV-positive family. IMAGE: Journal of Nursing Scholarship, 25, 193-198. Antonucci, T. C. (1986). Measuring social support networks: Hierarchical mapping technique. Generations, X(4), 10-12. Antonucci, T. C., & Akiyama, H. (1987). Social networks in adult life and a preliminary examination of the convoy model. Journal of Gerontology, 42, 519-527. Armistead, L., & Forehand, R. (1995). For whom the bell tolls: Parenting decisions and challenges faced by mothers who are HIV seropositive. Clinical Psychology: Science and Practice, 2, 239-250. Barroso, J. (1997). Social support and long-term survivors of AIDS. Western Journal of Nursing Research, 19, 554-573. Bluestone, H. H. (1995). Factors affecting distress in European American women with HIV disease [Abstract]. Program and abstracts of the HIV infection in women conference: setting a new agenda: February 22-24, 1995, Sheraton Washington Hotel, Washington, D.C. (p. 124). Richmond, VA: Philadelphia Sciences Group. Britton, P. J., Zarski, J. J., & Hobfall-Li, S. E. (1993). Psychological distress and the role of significant others in a population of gay/bisexual men in the era of HIVAIDS Care, 5(1), 43-54. Burgoyne, R. W., & Saunders, D. S. (2000). Perceived support in newly registered HIV/AIDS clinic outpatients. AIDS Care, 12, 643-650. Centers for Disease Control and Prevention (2003). HIV/AIDS among U.S. women: Minority and young women at continuing risk. Retrieved October 21, 2004, from http://www.ced. gov/hiv/pubs/facts/women.htm Clark L Schoenbaum, E., Solomon, L., Schuman, P., Fiore, T., & Moore, J. (1995). Concealment of HIV infection and psychological distress [Abstract]. Program and abstracts of the HIV infection in women conference: setting a new agenda: February 22-24, 1995, Sheraton Washington Hotel, Washington, D.C. (S26). Richmond, VA: Philadelphia Sciences Group. Cohen, S. (1988). Psychosocial models of the role of social support in the etiology of physical disease. Health Psychology, 7, 269-297. Cohen, S., Doyle, W. J., Skoner, D. P., Rabin, B., & Gwaltney, J. M. (1997). Social ties and susceptibility to the common cold. Journal of the American Medical Association, 277, 1940-1944. Demi, A., Bakeman, R., Moneyham, L., Sowell, R., Cohen, L., Seals, B., et al. (1995). The relationship of family structure to psychological distress of HIV infected women [Abstract].

23

Program and abstracts of the HIV infection in women conference: setting a new agenda: February 22-24, 1995, Sheraton Washington Hotel, Washington, D.C. (p. 110). Richmond, VA: Philadelphia Sciences Group. DiMatteo, M. R., & Hays, R. (1981). Social support and serious illness. In Gotlieb (Ed.), B. H. Social networks and social support: Vol. 4. (pp. 117-148). Beverly Hills CA: Sage. Dorsey, S., Chance, M. W., Forehand, R., Morse, E., & Morse, P. (1999). Children whose mothers are HIV infected: Who resides in the home and is there relationship to child psychosocial adjustment? Journal of Family Psychology, 13, 103117. Dorsey, S., Klein, K., & Forehand, R. (1999). Parenting selfefficacy of HIV-infected mothers: The role of social support. Journal of Marriage and the Family, 61, 295-305. Falkin, G. P., & Strauss, S. M. (2003). Social supporters and drug use enablers: A dilemma for women in recovery. Addictive Behavior, 28, 141-155. Flaskerud, J. H., & Winslow, B. J. (1998). Conceptualizing vulnerable populations health-related research. Nursing Research, 47, 69-78. Friedland, J., Renwick, R., & McColl, M. (1996). Coping and social support as determinants of quality of life in HIV/AIDS. AIDS Care, 8, 15-31. Gielen, A. C., McDonnel, K. A., Wu, A. W., O’Campo, P., & Faden, R. (2001). Quality of life among women living with HIV: The importance of violence, social support, and selfcare behaviors. Social Science and Medicine, 52, 315-322. Grummon, K., Rigby, E. D., Orr, D., Procidano, M., & Reznikoff, M. (1994). Psychosocial variables that affect the psychological adjustment of IVDU patients with AIDS. Journal of Clinical Psychology, 50, 488-502. Hays, R. B., Catania, J. A., McKusick, L., & Coates, T. J. (1990). Help-seeking for AIDS-related concerns: a comparison of gay men with various HIV diagnoses. American Journal of Community Psychology, 18, 743-755. Hays, R. B., Chauncey, S., & Tobey, L. A. (1990). The social support networks of gay men with AIDS. Journal of Community Psychology, 18, 374-385. Hays, R. B., Magee, R. H., & Chauncey, S. (1994). Identifying helpful and unhelpful behaviors of loved ones: The PWA’S perspective. AIDS Care 6, 379-392. Hays, R. B., Turner, H., & Coates, T. J. (1992). Social support, AIDS-related symptoms, and depression among gay men. Journal of Consulting and Clinical Psychology, 60, 463-469. Hough, E. S., Brumitt, G., Templin, T., Salzt, E. & Mood, D. (2003). A model of mother-child coping and adjustment to HIV. Social Science & Medicine, 56, 643-655. Hudson, A. L., Lee, K. A., Miramontes, H., & Portillo, C. J. (2001). Social interactions, perceived support, and level of distress in HIV-positive women. The Journal of the Association of Nurses in AIDS Care, 12(4), 68-76. Johnston, D., Stall, R., & Smith, K. (1995). Reliance by gay men and intravenous drug users on friends and family for AIDSrelated care. AIDS Care, 7(3), 307-319.

24

JANAC Vol. 16, No. 4, July/August 2005

Kahn, R. L., & Antonucci, T. C. (1980). Convoys over the life course: Attachment, roles and social support. In P. B. Baltes & O. G. Brim (Eds.), Life-span development and behavior (pp. 253-286). New York: Academic Press. Klein, K., Armistead, L., Devine, D., Kotchick, B., Forehand, R., Morse, E., et al., (2000). Socioemotional support in African American families coping with maternal HIV: An examination of mothers’ and children’s psychosocial adjustment. Behavior Therapy, 31, 1-26. Kyle, R. D., & Sachs, L. G. (1994). Perceptions of control and social support in relation to psychosocial adjustment to HIV/ AIDS. AIDS Patient Care, 8, 322-327. Leserman, J., Perkins, D. O., & Evans, D. L. (1992). Coping with the threat of AIDS: The role of social support. American Journal of Psychiatry, 149, 1514-1520. Linn, J. G., Lewis, F. M., Cameron, V. A., & Kimbrough, G. A. (1993). HIV-illness, social support, sense of coherence, and psychological well-being in a sample of help-seeking adults. AIDS Education and Prevention, 5, 254-262. Moss G. E. (1973). Immunity and social interactions. New York, NY: Wiley. Namir, S., Alumbaugh, M. J., Fawzy, F. I., & Wolcott, D. L (1990). Implications of different strategies for coping with AIDS. In L. Temoshok & A. Baum (Eds.), Psychosocial perspectives on AIDS: Etiology, prevention, and treatment (pp. 173-190). Hillsdale, NJ: Lawrence Erlbaum Associates. Namir, S. Woolcott, D. L, Fawzy, F. I., & Alambaugh, M. J. (1987). Coping with AIDS: Psychological and health implications. Journal of Applied Social Psychology, 17, 309-328. Nannis, E., Semple, S., & Patterson, T. (1995). HIV⫹ women and coping: Psychosocial predictors of “fighting spirit” [Abstract]. Program and abstracts of the HIV infection in women conference: Setting a new agenda: February 22-24, 1995 Sheraton Washington Hotel, Washington, D.C. (S32). Richmond, VA: Philadelphia Sciences Group. Norbeck, J. S., Lindsey, A. M., & Carrieri, V. L. (1981). The development of an instrument to measure social support. Nursing Research, 30, 264-269. Norbeck, J. S., Lindsey, A. M., & Carrieri, V. L. (1983). Further development of the Norbeck Social Support Questionnaire: Normative data and validity testing. Nursing Research, 32, 4-9. Nott, K. H., Vedhara, K., & Power, M. J. (1995). The role of social support in HIV infection. Psychological Medicine, 25, 971-983. O’Leary, A., Wadhwani, S., Gebelt, J., & Frenkel, L. (1995). Predictors of depression in the primary caregivers of HIVinfected children [Abstract]. Program and abstracts of the HIV infection in women conference: setting a new agenda: February 22-24, 1995, Sheraton Washington Hotel, Washington, D.C. (S102). Richmond, VA: Philadelphia Sciences Group. Osmond D. H. (1998). Classification and staging of HIV infection. HIV InSite Knowledge Base. Retrieved August 15, 1998, from www.hivinsite.ucsf.edu

Ostrow, D. G., Monjan, A., Joseph, J., VanRaden, M., Fox, R., Kingsley, L., et al. (1989). HIV-related symptoms and psychological functioning in a cohort of homosexual men. American Journal of Psychiatry, 146, 737-742. Owens, S. (2003). African American women living with HIV/ AIDS: Families as sources of support and of stress. Social Work, 48, 163-173. Pakenham, K. I., Dadds, M. R., & Terry, D. J. (1994). Relationships between adjustment to HIV and both social support and coping. Journal of Consulting and Clinical Psychology, 62, 1194-1203. Rodgers, A. Y. (1995). The relationship between changes in sexual support and adjustment to AIDS in gay males. Social Work in Health Care, 20, 37-49. Schwarzer, R., Dunkel-Schetter, C., & Kemeny, M. (1994). The multidimensional nature of received social support in gay men at risk of HIV infection and AIDS. American Journal of Community Psychology, 22, 319-339. Schwarzer, R., & Leppin, A. (1989). Social support and health: A meta-analysis. Psychology and Health: An International Journal, 3, 1-15. Stowe, A., Ross, M. W., Wodak, A., Thomas, G. V., & Larson, S. A. (1993). Significant relationships and social supports of injecting drug users and their implications for HIV/AIDS services. AIDS Care, 5, 23-33. Taylor, S. E., & Aspinwall, L. (1990). Psychosocial aspects of chronic illness. In Costa, Jr., & P. T. Vandenbos (Eds.), G. R. Psychosocial aspects of serious illness: Chronic conditions, fatal diseases and clinical care (pp. 3-60). Washington, DC: American Psychological Association. Turner, H. A., Hays, R. B., & Coates, T. J. (1993). Determinants of social support among gay men: The context of AIDS. Journal of Health and Social Behavior, 34, 37-53. Vallerand A. H., Hough E., Brumitt G., Pittiglio L., & Marviscin D. (2004, March). The process of disclosure between HIV positive mothers and their children. Competitive symposium. Symposium conducted at MNRS 2004 Annual Research Conference, March 28, St. Louis, MO. Wortman, C. B., & Conway, T. L. (1985). The role of social support in adaptation and recovery from serious illness. In Cohen & S. Syme (Eds.), S. L. Social support and health (pp. 281-302). New York: Academic Press. Zich, J., & Temoshok, L. (1990). Perceptions of social support, distress, and hopelessness in men with AIDS and ARC: Clinical implications. In Temoshok, & L. Baum (Eds.), A. Psychosocial perspectives on AIDS: Etiology, prevention, and treatment (pp. 173-190). Hillsdale, NJ: Lawrence Erlbaum Associates.