Background
HIV is a global public health problem with an estimated 36.7 million people living with HIV(PLHIV) and 2.1 million people newly infected with HIV in 2015 [
1]. New HIV infection is associated with high infectivity due to the high viral loads detected in the first few months since the initial HIV infection occurs [
2]. Newly diagnosed PLHIV, commonly defined as those who have been diagnosed as HIV positive for <12 months [
3‐
6], is an important subgroup because a large proportion of them infect HIV recently and have high viral loads. Among those newly diagnosed HIV-positive men who have sex with men (MSM), about 30% to 60% are newly infected cases [
7‐
9]. Such MSM have high prevalence of condomless anal intercourse and thus promote secondary HIV transmission [
10]. Many of them have mental health problems as they encounter extreme difficulties when adjusting to their newly acquired HIV status [
11]. How people look at the disease is considered to be associated with mental health problems and disease related behaviours [
12]. Improvement of people’s view towards the disease can promote better health outcomes [
13,
14].
Illness representation is used to define patients’ beliefs and expectations about an illness or somatic symptom [
15,
16]. Cognitive representation and emotional representation are two types of inter-related illness representations. The Self-Regulatory Model (SRM, also known as the Illness Perception Model or Common Sense Model) specifies that health-related threats (a stimulus) would activate both cognitive and emotional representation processes (e.g. sadness, worry and anger), and such cognitive and emotional representations would affect the mode of coping strategies. The outcomes of the coping strategies would then be appraised, and the illness representation and subsequent coping strategies would be modified. The Illness Perception Questionnaire (IPQ) and the Revised Illness Perception Questionnaire (IPQ-R) have been developed to assess illness representation in different disease groups [
17,
18]. By using the IPQ or IPQ-R, studies have shown that illness representation is associated with health-related outcomes among patients with acute or chronic diseases, such as self-care, service utilization, treatment adherence and mental health [
12,
19,
20]. Improvement in illness representation among patients with a chronic disease can reduce mental health problems and increase health behaviours [
21,
22].
China also faces an ongoing HIV epidemic and reported more than 0.50 million PLHIV at the end of 2014 [
23]. Male-to-male sexual behaviour has become one main transmission route of HIV infection. The proportion of reported newly diagnosis HIV cases attributed to male-to-male sexual behaviour increased from 2.5% in 2006 to 25.8% in 2014 [
23]. Among these newly diagnosed HIV-positive MSM, about 60% were considered to be infected with HIV recently [
7]. At the moment of diagnosis and months after diagnosis, illness representation on HIV would be newly formed and more adjustable. Positive changes in illness representation on HIV may potentially facilitate positive attitude and emotion towards the disease, impacting coping strategies and quality of life. However, the IPQ-R for measuring PLHIV’s perception towards HIV infection has not been fully validated. In the present study, we investigated the psycho-metric properties of the Chinese IPQ-R, including the factor structure, internal consistencies, and correlations with some external variables (depression and posttraumatic growth) among newly diagnosed HIV-positive MSM in China, and further investigated how these MSM looked at the disease.
Results
Characteristics of the participants
The average age of the participants was 32.2 years (SD = 10.5 years); 53.8% were <=30 years old; 44.4% had attended colleges/universities;62.2% were employed full time; 48.0% had had a monthly income over 2000 RMB (about $312 USD). Two-thirds of them were single or divorced (66.7%), whilst 10.7% were cohabitating with a male partner and about one-fifth of them were currently married to a woman (21.8%). Of all the participants, 61.8% were diagnosed with HIV within the six months prior to the interview (average time since diagnosis = 5.6 months; SD = 3.8 months). About one-fifth (20.4%) of them had been receiving free antiretroviral treatment.
CFA results
The results showed a poor goodness of fit, with CMIN = 1310.726 (df = 512, p < 0.001), GFI = 0.728 and RMSEA = 0.083. Therefore, EFA was applied to establish a new factor structure.
EFA results
The EFA of the Emotional Response subscale identified a single factor which accounted for 67.8% of the total variance (KMO test = 0.89; Bartlett’s sphericity test = 874.4; p < 0.001). The item-subscale correlation coefficients of this subscale ranged from 0.46 to 0.84 (p < 0.05). The Cronbach alpha was 0.90.
The 28 items of five cognitive representation subscales (i.e., Timeline-acute/chronic, Consequence, Illness Coherence, Personal Control and Treatment Control) were subjected to EFA. Seven factors with eigen-value >1 were extracted, accounting for 58.8% of the total variance (KMO test = 0.81; Bartlett’s sphericity test =1971.4; p < 0.001). Four items were removed for the following reasons: two items showed factor loading <0.40 on all seven factors (‘There is nothing which can help your condition’ and ‘Your illness is a serious condition’); one factor (Factor 7) consisted only of a single item (‘You have a clear picture or understanding of your condition’ of the original illness coherence subscale); one item (‘Having HIV has serious financial consequences’ from the original consequence subscale) did not match with the interpretations of the other items of the same factor (Factor 2). The final EFA model therefore consisted of six factors (58.09% of the total variance; KMO test = 0.80; Bartlett’s sphericity test = 1558.09; p < 0.001).
The first four factors contained items that were similar to those in the original subscales and were named: 1) Treatment Control, 2) Timeline-acute/chronic, 3) Illness Coherence and 4) Consequence (Table
1). Their Cronbach’s alphas were respectively 0.76, 0.69, 0.76 and 0.70. The items of the original Personal Control Subscale were split into two subscales which were named ‘Personal Control’ (Factor 5) and ‘Helplessness’ (Factor 6); their Cronbach alpha values were respectively 0.61 and 0.55. The item-total correlation coefficients of the six identified factors ranged from 0.21 to 0.65.
Table 1
Exploratory factor analysis of items from the main cognitive representation dimensions among newly diagnosed HIV-positive MSM
Treatment Control
|
Anti HIV medication can control your condition | 0.77 | 0.09 | 0.01 | −0.08 | 0.22 | −0.11 | TC |
Anti-HIV treatment will be effective in controlling your illness | 0.74 | −0.12 | 0.00 | 0.00 | 0.16 | 0.18 | TC |
Anti-HIV medication can control the progress of your HIV infection | 0.73 | 0.12 | −0.03 | −0.03 | −0.02 | −0.24 | TC |
The negative effects of your illness can be prevented by anti HIV therapy | 0.69 | 0.06 | 0.07 | 0.05 | 0.27 | −0.02 | TC |
You have the power to influence the course of your condition | 0.43 | −0.23 | 0.13 | −0.35 | 0.39 | 0.08 | PC |
Timeline-acute/chronic
|
Your condition is likely to be permanent rather than temporary | 0.18 | 0.72 | 0.00 | 0.09 | 0.09 | −0.02 | TA/C |
You expect to have HIV for the rest of your life | 0.25 | 0.72 | −0.08 | 0.13 | −0.12 | 0.06 | TA/C |
There is very little that can be done to improve your condition | −0.10 | 0.68 | 0.16 | 0.19 | 0.04 | −0.02 | TC |
You will get ill when the time comes whether you are taking anti HIV medication or not | −0.20 | 0.49 | 0.25 | 0.23 | −0.09 | 0.13 | TC |
Your condition will be in the same situation in a long time | 0.16 | 0.45 | −0.11 | −0.11 | 0.42 | 0.20 | TA/C |
Your condition will improve in time | 0.32 | −0.58 | 0.15 | −0.08 | 0.33 | 0.17 | TA/C |
Illness Coherence
|
Having HIV does not make any sense to you | −0.09 | −0.07 | 0.82 | 0.02 | −0.03 | 0.11 | IC |
You don’t understand enough about HIV | 0.11 | 0.07 | 0.77 | 0.07 | −0.15 | 0.06 | IC |
The HIV virus is a mystery to you | 0.02 | 0.06 | 0.67 | 0.18 | 0.21 | 0.10 | IC |
The symptoms of your condition are puzzling to you | 0.12 | 0.06 | 0.58 | 0.39 | 0.10 | 0.23 | IC |
Consequence
|
Having HIV has major consequences on your life | −0.10 | 0.27 | 0.30 | 0.72 | 0.04 | 0.00 | CO |
The fact that you have HIV causes difficulties for those who are close to you | 0.12 | 0.01 | 0.13 | 0.72 | 0.05 | 0.12 | CO |
Having HIV strongly affects the way others see you | −0.03 | 0.28 | 0.17 | 0.57 | 0.01 | 0.08 | CO |
Having HIV does not have much effect on your life | 0.16 | −0.07 | 0.08 | −0.65 | 0.25 | 0.18 | CO |
Personal Control
|
There is a lot which you can do to control your condition | 0.21 | −0.22 | 0.08 | −0.17 | 0.72 | −0.09 | PC |
What you do can determine whether your condition gets better or worse | 0.19 | 0.12 | 0.11 | 0.00 | 0.69 | −0.30 | PC |
The course of your condition depends on you | 0.28 | 0.01 | −0.27 | 0.27 | 0.56 | 0.03 | PC |
Helplessness
|
Nothing you do will affect your illness | −0.03 | −0.02 | 0.15 | 0.03 | −0.07 | 0.78 | PC |
Your actions will have no affect on the outcome of your condition | −0.08 | 0.09 | 0.17 | 0.03 | −0.08 | 0.74 | PC |
Cronbach’s Alpha | 0.76 | 0.69 | 0.76 | 0.70 | 0.61 | 0.55 | |
Initial Eigenvalues | 4.11 | 3.61 | 2.52 | 1.46 | 1.18 | 1.07 | |
Cumulative % of variance explained | 17.13 | 32.17 | 42.65 | 48.75 | 53.65 | 58.09 | |
Item-total correlation coefficients | 0.42-0.64 | 0.21-0.53 | 0.53-0.59 | 0.43-0.65 | 0.34-0.46 | 0.38 | |
An EFA extracted three factors among eight causal attribution items (59.27% of the total variance; KMO = 0.62; Bartlett’s test = 307.92;
p < 0.001). The Cronbach alpha values were 0.86, 0.49, and 0.29, respectively (Table
2). As the internal consistency was too poor for Factor 2 and Factor 3 and as Factor 1 only consisted of two items, the causal attribution items were considered individually in the subsequent analyses.
Table 2
Exploratory factor analysis of items from the causal attribution dimension among newly diagnosed HIV-positive MSM
God’s punishment | 0.90 | 0.07 | 0.08 |
God’s will | 0.89 | 0.10 | 0.20 |
Carelessness | −0.08 | 0.75 | 0.13 |
Did not understand the risk | 0.23 | 0.61 | −0.07 |
Believed it could not happen to self | 0.39 | 0.55 | −0.11 |
Being deceived | −0.09 | 0.49 | 0.46 |
Alcohol/drug use | 0.07 | −0.26 | 0.74 |
Chance/bad luck | 0.23 | 0.24 | 0.65 |
Cronbach’s Alpha | 0.86 | 0.49 | 0.29 |
Initial Eigen values | 2.33 | 1.29 | 1.12 |
Cumulative % of variance explained | 29.18 | 45.34 | 59.27 |
Item-total correlation coefficients | 0.77 | 0.21-0.34 | 0.18 |
Summary statistics and inter-correlations of the factors/items constructed
The mean scores and standard deviations for the derived factors/items are shown in Table
3. Except for a few items of causal attribution, the magnitudes of the floor effect (alcohol/drug use attribution: 25.3%) and the ceiling effect (e.g., carelessness attribution: 41.3%) were acceptable. Results of the descriptive statistics showed that the score of the Emotional Response, Consequence, Treatment Control, Personal Control, Timeline-acute/chronic and Illness Coherence were above the midpoint, and the score of Helplessness was below the midpoint. As for causal attribution, participants had the highest score on “carelessness”, followed by “believed it could not happen to self”. Other scores on causal attribution were below the midpoint and “alcohol/drug use” received the lowest score.
Table 3
Description of the derived factors/items of Chinese IPQ-R
Emotional Response | 6 | 6-30 | 21.02(5.40) | 1.33 | 2.67 |
Treatment Control | 5 | 8-25 | 18.28(3.28) | 0.44 | 5.33 |
Illness Coherence | 4 | 4-20 | 12.25(3.21) | 0.90 | 0.90 |
Timeline-acute/chronic | 6 | 9-30 | 21.14(3.52) | 0.44 | 0.44 |
Consequence | 4 | 4-20 | 13.99(3.20) | 0.44 | 4.44 |
Personal Control | 3 | 4-15 | 10.17(2.19) | 0.44 | 5.33 |
Helplessness | 2 | 2-10 | 5.05(1.70) | 6.67 | 1.78 |
Causal attribution |
God’s punishment | 1 | 1-5 | 2.53(1.16) | 16.89 | 8.44 |
God’s will | 1 | 1-5 | 2.54(1.17) | 18.22 | 8.89 |
Carelessness | 1 | 1-5 | 4.06(1.04) | 3.56 | 41.33 |
Did not understand the risk | 1 | 1-5 | 2.95(1.26) | 9.78 | 16.44 |
Believed it could not happen to self | 1 | 1-5 | 3.46(1.19) | 5.78 | 21.78 |
Being deceived | 1 | 1-5 | 2.81(1.14) | 8.00 | 12.00 |
Alcohol/drug use | 1 | 1-5 | 1.99(0.87) | 25.33 | 3.11 |
Chance/bad luck | 1 | 1-5 | 3.12(1.19) | 7.56 | 12.11 |
Correlation analysis showed that Emotional Response and Consequence were strongly correlated with each other (
r = 0.75,
p < 0.05; Table
4). These two factors were also both positively correlated with a number of causal attribution items (god’s will, god’s punishment, being deceived, did not understand the risk and chance/bad luck) and Timeline-acute/chronic (
r ranged from 0.14 to 0.43,
p < 0.05), and were negatively correlated with Treatment Control and Illness Coherence (
r ranged from −0.16 to −0.46,
p < 0.05). Illness coherence was also negatively associated with some causal attribution items (god’s will, god’s punishment, carelessness, being deceived and did not understand the risk), with
r ranging from −0.14 to −0.38 (
p < 0.05).
Table 4
Correlations matrix of the derived factors/items of Chinese IPQ-Ra
1 | Emotional Response | 1.00 | −0.21** | −0.46*** | 0.38*** | 0.75*** | −0.12 | 0.16* | 0.43*** | 0.30*** | 0.03 | 0.15* | 0.23*** | 0.25*** | 0.04 | 0.23*** |
2 | Treatment Control | | 1.00 | −0.06 | −0.08 | −0.16* | 0.51*** | −0.09 | −0.23*** | −0.17* | 0.26*** | 0.07 | −0.02 | −0.01 | −0.10 | 0.11 |
3 | Illness Coherence | | | 1.00 | −0.12 | −0.34*** | −0.01 | −0.30** | −0.23*** | −0.23*** | −0.22*** | −0.38*** | −0.26*** | −0.14* | −0.09 | −0.05 |
4 | Timeline-acute/chronic | | | | 1.00 | 0.38*** | −0.08 | 0.08 | 0.1 | 0.06 | 0.11 | 0.05 | 0.06 | 0.06 | −0.18** | 0.07 |
5 | Consequence | | | | | 1.00 | −0.08 | 0.10 | 0.30*** | 0.22*** | 0.05 | 0.14* | 0.23*** | 0.27*** | −0.03 | 0.16* |
6 | Personal Control | | | | | | 1.00 | −0.20** | −0.14* | −0.10 | 0.20** | 0.16* | −0.07 | 0.10 | 0.08 | 0.06 |
7 | Helplessness | | | | | | | 1.00 | 0.12 | 0.07 | 0.06 | 0.15* | 0.21** | −0.03 | 0.18** | 0.11 |
| Causal attribution | | | | | | | | | | | | | | | |
8 | God’s punishment | | | | | | | | 1.00 | 0.76*** | 0.05 | 0.18** | 0.25*** | 0.11 | 0.05 | 0.21** |
9 | God’s will | | | | | | | | | 1.00 | 0.11 | 0.20** | 0.27*** | 0.10 | 0.14* | 0.29*** |
10 | Carelessness | | | | | | | | | | 1.00 | 0.26*** | 0.20** | 0.23*** | −0.05 | 0.18** |
11 | Did not understand the risk | | | | | | | | | | | 1.00 | 0.28*** | 0.11 | 0.02 | 0.09 |
12 | Believed it could not happen to self | | | | | | | | | | | | 1.00 | 0.11 | −0.04 | 0.18** |
13 | Being deceived | | | | | | | | | | | | | 1.00 | 0.04 | 0.20** |
14 | Alcohol/drug use | | | | | | | | | | | | | | 1.00 | 0.18** |
15 | Chance/bad luck | | | | | | | | | | | | | | | 1.00 |
Correlations between IPQ-R factors and external variables (depression and PTG)
Emotional representation was positively correlated with DASS depression (
r = 0.60,
p < 0.05) and negatively correlated with the PTG (
r = −0.51,
p < 0.05). All the four cognitive representation factors (Timeline-acute/chronic, Treatment Control, Illness Coherence and Consequence) were also significantly correlated with the DASS depression (
r ranged from −0.24 to 0.48,
p < 0.05) and PTG (
r ranged from −0.39 to 0.23,
p < 0.05). Personal Control was significantly correlated with PTG (
r = 0.17,
p = 0.01) but not with DASS depression (
r = −0.13,
p = 0.06), while Helplessness was not significantly associated with the two external variables (Table
5). In addition, three items of causal attribution (god’s will, god’s punishment and carelessness) were found to be significantly correlated with DASS depression (
r ranged from −0.14 to 0.31,
p < 0.05) and negatively correlated with PTG (
r ranged from −0.26 to 0.15,
p < 0.05). In addition, the item of ‘being deceived’ (attribution) was significantly associated with DASS depression (
r = 0.21,
p < 0.05) and the item of ‘chance/bad luck’ (attribution) was significantly associated with PTG (
r = −0.13,
p < 0.05).
Table 5
Correlations between IPQ-R subscales/items and external variablesa
Emotional Response | 0.60*** | −0.51*** |
Treatment Control | −0.24*** | 0.23** |
Illness Coherence | −0.34*** | 0.18** |
Timeline-acute/chronic | 0.14* | −0.17* |
Consequence | 0.48*** | −0.39*** |
Personal Control | −0.13 | 0.17* |
Helplessness | 0.04 | −0.11 |
Causal attribution
|
God’s punishment | 0.31*** | −0.26*** |
God’s will | 0.21** | −0.20** |
Carelessness | −0.14* | 0.15* |
Did not understand the risk | 0.14* | −0.08 |
Believed it could not happen to self | 0.01 | −0.11 |
Being deceived | 0.21** | −0.04 |
Alcohol/drug use | −0.03 | <0.01 |
Chance/bad luck | 0.13 | −0.13* |
Discussion
A number of studies have investigated the factor structure of the IPQ-R among different kinds of patients [
32,
34‐
36]. However, as far as we know, this is the first study to fully validate the IPQ-R structure among PLHIV in mainland China. The validation results allow us to use the IPQ-R for measuring PLHIV’s perceptions on HIV infection in future studies, and it also provides suggestions on the development of illness perception interventions which may promote PLHIV to have better health outcomes.
In this study, we have made some modifications in the validation process similar to other studies [
25,
35,
36]. It is common for researchers to delete some items and/or subscales of IPQ-R for contextual reasons. Hagger and colleagues have removed the Timeline-cyclical subscale as it is deemed irrelevant to patients who have been diagnosed with a condition that was largely asymptomatic [
35]. Other researchers have changed items of the Identity subscale [
36], removed items related to the Cause and Identity subscales [
25‐
27,
37], and changed wordings of some items [
26,
32]. Our practice was therefore appropriate.
The factor structure of the four cognitive representation subscales (Factors 1 to 4: Treatment Control, Illness Coherence, Timeline-acute/chronic and Consequence) and the Emotional Response subscale in this study are highly similar to those identified in the previous studies [
32]. Their Cronbach alpha values are acceptable (i.e., 0.7 or above). These five dimensions are also significantly associated with the two external variables (depression and PTG). We therefore suggest the use of these subscales in future studies to measure illness representation of HIV/AIDS. The original subscale on Personal Control is split into two new subscales (Factor 5 and Factor 6: Personal Control and Helplessness) and low internal reliabilities are observed. Consistently, other researchers have reported similar problems with the Control subscale [
32]. They suggest that the importance of control might vary across culture [
38], and that respondents may be confused about the wordings of several items of the subscale, especially those with negative wordings, such as ‘
nothing you do will affect the illness’ and ‘there is
nothing which can help your condition’ [
38,
39]. Other researchers have commented that such negative wordings may be ambiguous and confusing [
40]. The Personal Control and Treatment Control subscales for HIV/AIDS are conceptually important; our results also show significant correlations between Treatment Control and the two external variables. However, we have not found satisfactory internal consistency, particularly for the Personal Control subscale. Further studies are required before we are confident to use these subscales in studies on HIV-related illness representations.
The original items of the subscale on causal attribution (e.g. ageing, hereditary, family problems) are not applicable to HIV/AIDS. Reynolds et al. attempt to develop items that are relevant to HIV infection [
19]. In their study, common attributions include ‘carelessness’, ‘believed it could not happen to me’, ‘not understanding the risk’, ‘chance/bad luck’ and ‘being deceived’. The current study follows Reynolds’s suggestion and uses their items. The EFA results for these items showed a clear factor structure but low internal consistency. A lot of MSM believe that HIV infection will not happen to them as they have little knowledge about local HIV epidemic and are not aware of the serostatus of their partners. Alcohol use or drug use are widely considered to be associated with risky sexual behaviours and HIV infection [
41]. However, only a small proportion of newly diagnosed MSM considered it as the cause of HIV infection. This finding suggests that what we find from the research may be varied from what newly diagnosed MSM think. Future studies are needed to explore the attribution of HIV among MSM and to see whether their attribution differs from those who acquired HIV from other routes, and from those who have been diagnosed for a longer period of time.
Consistent with previous work [
18], the derived factors/items of IPQ-R for newly diagnosed HIV-positive MSM reveal some inter-relationships which are consistent with the existing literature. Negative beliefs of illness coherence, timeline-acute/chronic, consequence, and treatment control of HIV infection are related to negative emotional responses, implying potential links between cognitive and emotional representations. Leventhal et al. have postulated the internal relationships inside the SRM and assumed that peoples’ emotional representation towards a disease would influence their cognitive representation towards the disease, which finally affects their coping measures and health outcomes [
42]. The present study supports such notions and suggests that future studies are required to explore the relationship between cognitive and emotional representation, and their impact on coping and health related outcomes for better understanding of the SRM.
The scores of items and the derived subscales demonstrate that newly diagnosed HIV-positive MSM have negative perceptions toward HIV infection. They have a relatively high level of negative emotions towards HIV infection and consider HIV infection would bring serious consequences to them. On the contrary, they only score about midpoint in illness coherence, indicating that they have little knowledge of the disease. Such negative perceptions, according to the theory of SRM, may lead to negative or passive coping strategies and poor health outcomes. Newly diagnosed HIV-positive MSM are in the formative stage of their perceptions towards HIV/AIDS. Interventions to foster more positive changes on illness perceptions are warranted.
This study has some limitations. First, the study is conducted among newly diagnosed HIV-positive MSM whose characteristics may be different from those who have been diagnosed for a longer period of time, or those who are infected with HIV through other routes. Attention should be paid when using the derived subscales/items in other PLHIV subgroups. Second, the internal reliability of some factors (e.g., Personal control and Helplessness) is below satisfactory, and modifications of the items from these factors seem necessary. Third, about one fifth of eligible subjects refuse to participate in this study. Although the characteristics of this subgroup are unknown, they may be less likely to seek healthcare services or social support, and may have even more negative perceptions towards HIV/AIDS. Selection bias might therefore exist.