http://orcid.org/0000-0002-3206-6819
Figures
Abstract
Background
HIV-associated vulnerabilities—especially those linked to psychological issues—and limited mental health–treatment resources have the potential to adversely affect the health statuses of individuals. The concept of resilience has been introduced in the literature to shift the emphasis from vulnerability to protective factors. Resilience, however, is an evolving construct and is measured in various ways, though rarely among underserved, minority populations. Herein, we present the preliminary psychometric properties of a sample of HIV-seropositive Puerto Rican women, measured using a newly developed health-related resilience scale.
Methods and design
The Resilience Scales for Children and Adolescents, an instrument with solid test construction properties, acted as a model in the development (in both English and Spanish) of the HRRS, providing the same dimensions and most of the same subscales. The present sample was nested within the Hispanic-Latino longitudinal cohort of women (HLLC), that is part of the NeuroAIDS Research Program at the University of Puerto Rico (UPR), Medical Sciences Campus (MSC). Forty-five consecutively recruited, HIV+ women from the HLLC completed a demographic survey, the HRRS, and the Beck Depression Inventory-I, Spanish version.
Results
The results demonstrate excellent overall internal consistency for the total HRRS score (α = 0.95). Each of the dimensional scores also evidenced acceptable internal consistency (α ≥ 0.88). All the dimensional and subscale content validity indices were above the 0.42 cut-off. Analysis revealed a significant negative correlation between the HRRS total score and BDI-I-S (r(45) = -0.453, p < 0.003).
Conclusion
Albeit preliminary in nature, the present study provides support for the HRRS as a measure to assess resilience among individuals living with chronic medical conditions. Minority populations, especially non-English speaking ones, are understudied across the field of medicine, and when efforts are made to include these patient groups, measurement is rarely tailored to their unique cultural and linguistic experiences. The HRRS is a measure that addresses these notable voids in the medical literature.
Citation: Jimenez-Torres GJ, Wojna V, Rosario E, Hechevarría R, Alemán-Batista AM, Matos MR, et al. (2017) Assessing health-related resiliency in HIV+ Latin women: Preliminary psychometric findings. PLoS ONE 12(7): e0181253. https://doi.org/10.1371/journal.pone.0181253
Editor: Alexandra Kavushansky, Technion Israel Institute of Technology, ISRAEL
Received: July 8, 2016; Accepted: June 28, 2017; Published: July 19, 2017
Copyright: © 2017 Jimenez-Torres et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The IRB that approved this study has not authorized the public sharing of data. Data are from the Hispanic-Latino Longitudinal Cohort of Women (HLLC), which is part of the NeuroAIDS Specialized Neuroscience Research Program (SNRP) at the University of Puerto Rico (UPR), Medical Sciences Campus (MSC) and data are contained as part of the study cohort database. Access to data from this cohort and related studies is managed by Dr. Valerie Wojna (valerie.wojna1@upr.edu).
Funding: The study was funded by National Center for Research Resources (NCRR) grant U54RR026139, the National Institute on Minority Health and Health Disparities (NIMHD) grant U54MD007587, the National Institute of Neurological Disorders and Stroke (NINDS) S11NS046278 and U54NS43011 awarded to the University of Puerto Rico, Medical Science Campus, and National Institute of Mental Health (NIMH) Center for Novel Therapeutics of HIV-associated Cognitive Disorders Pilot Project grant R25MH080661 part of the G12 RR003050 awarded to John Hopkins University. Additionally, this research was partially supported by the Menninger Clinic Foundation and McNair Medical Institute. Dr. Madan is a McNair Scholar. The study follows the guidelines on good publication practices. The study sponsors were not involved in any aspect of the research activities. Thus, the authors were independent of study sponsors in the context of the research. The authors have no other potential conflicts of interest to disclose.
Competing interests: The authors received funding from Menninger Clinic Foundation for this study. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.
Introduction
In 2010, there were 10,731 new cases of HIV/AIDS in Hispanics; 15.8% of those cases were in Puerto Rico, alone [1]. The rates of women contracting the disease were higher in Puerto Rico (24.7%) than in the continental US (15.95%) [1]. HIV+ Puerto Rican women are at increased risk for developing depressive symptoms [2, 3], neurocognitive impairments associated with HIV [4–6], having poor adherence to therapy [7] and frequently experiencing violence [8],. Limited available resources constrain public health efforts in Puerto Rico to provide care for people living with HIV/AIDS [9], including hindering those efforts aimed at implementing evidence-based mental health interventions [10].
HIV-associated vulnerabilities—especially those linked to psychological issues—and limited mental health–treatment resources have the potential to adversely affect the health status of HIV+ Puerto Rican women by increasing stress [11–13]. A number of factors can affect the extent to which an individual feels capable of managing these vulnerabilities, in turn influencing his or her ability to cope with stressors. Cognitive appraisal enables individuals to exercise their judgment and assess the significance of stress (primary appraisal) and the coping options available within that individual’s means (secondary appraisal). In this study, we address primary cognitive appraisal as a mechanism underlying HIV+ Puerto Rican women’s resilience to stressors.
The concept of resilience has been introduced in the HIV/AIDS literature [14–18] to shift the emphasis from vulnerability to protective factors, especially taking into consideration flexibility as a means of facilitating healthy adaptation and potentially decreasing vulnerability to psychiatric disorders [19]. Resilience has been identified as a protective factor for individuals living with HIV/AIDS, from developing clinically significant depression [18, 20, 21]. Supportive relationships, emotion regulation, and sense of mastery have been identified as key dimensions that foster resilience [22, 23]. Resilience, however, is an evolving construct that is operationalized and measured in various ways [24].
Herein, we introduce the term health-related resilience (HRR), defined as an individual’s ability to make inferences regarding a given health-related stressor or adverse event and to withstand the difficulties associated with the stressor or, alternately, to overcome the stress caused by the adverse event. [25]. Resilience not only relates to an individual’s cognitive–behavioral capabilities but also to that individual’s ability to properly identify and use available resources to help him or her cope with the health-related stressors by modifying that stressor, thereby adapting to the required changes [24, 26]. Resilience provides an individual with a way to identify both adaptive and maladaptive approaches in the regulation of stress, potentially affecting that person’s ability to benefit from mental health treatment [27, 28]. Despite the growing recognition of the influence of resilience in influencing a person’s ability to cope with the stressors of living with HIV, few studies have assessed resilience in HIV+ adults [29]; fewer have assessed resilience in Hispanic HIV+ adults [30–32], especially Hispanic HIV+ women [2, 18, 33]. The complex socio-demographic characteristics of this underserved population are notably missing from the HIV literature.
Despite a growing interest in studying resilience, little empirical research has addressed the associated multidimensional nature of the construct. A theory-based instrument measuring constructs previously associated with resilience exists, but it was intended for use with children and adolescents [34]. The Dispositional Resilience Scale (DRS) [35] and the Connor-Davidson Resilience Scales (CS-RS) [36, 37] have been used to evaluate HIV+ individuals [18, 38–41]. However, the DRS was originally intended to measure the impact of an air disaster on health [35], and the CD-RS, though originally developed in various cohorts of adults, has been used in children and adolescents to measure childhood trauma [36, 37]. Other well-known scales have examined resilience to developmental changes [42] and resilience as a personality trait [43–45]. To date, most scales and interventions have focused on risk factors, not being intended specifically as tools to be used in the development of recommendations for patients who live with comorbid mental health and chronic physical conditions, such as do many HIV+ individuals. To fill this notable void, we developed the Health-Related Resilience Scale (HRRS) and present herein the preliminary psychometric properties from a pilot sample of HIV+ Puerto Rican women.
Methods
Scale development
The Resiliency Scales for Children and Adolescents, an instrument with solid test construction properties, acted as a model in the development (in both English and Spanish) of the HRRS, providing the same dimensions and most of the same subscales. The sense of mastery dimension (SMD) is composed of the optimism, self-efficacy, and adaptation subscales. The sense of relatedness dimension (SRD) is composed of the trust, social support, comfort, and tolerance for differences subscales. The emotional reactivity dimension (ERD) is composed of the sensitivity, recovery, and balance subscales. The balance subscale is not in the RSCA, which uses instead a subscale for impairment [34]; the substitution was made in the HRRS in the interest of emphasizing strengths rather than weaknesses. The construction of the HRRS followed DeVillis’s (2003) guidelines for scale development [46]. Although the HRRS applied most of the concepts for dimensions and subscales that are present in the RSCA, the HRRS’s operational definitions for dimensions and subscales, as well as for individual items, were created using an inductive approach [47]. Each item is rated on a 5-point, Likert-type scale, ranging from never (0) to always (4) (See Table 1). Items and instructions for respondents were initially created in the Spanish language and were written at the sixth-grade reading level. To confirm the consistency of its content, the scale was translated from the Spanish to the English language, and then back-translated from the English to the Spanish language by two different qualified bilingual clinical psychologists. See Table 2 for the Spanish version of the HRRS.
INSTRUCTIONS: Read each phrase carefully. Circle the answer that best indicates the way you thought and felt (never, rarely, sometimes, frequently, always) about each one in the previous 7 days. Remember that there are no right or wrong answers.
INSTRUCCIONES: Lee cada frase cuidadosamente. Circula la respuesta que mejor indique la forma en la que has pensado y te has sentido (Nunca, Casi nunca, Raras veces, A veces, Siempre) durante los últimos 7 días. Recuerda que no hay respuestas correctas ni incorrectas.
Procedure
The present sample was nested within the Hispanic-Latino longitudinal cohort of women (HLLC), that is part of the NeuroAIDS Research Program at the University of Puerto Rico (UPR), Medical Sciences Campus (MSC) with internal review (IRB) written approval Universidad de Puerto Rico, Recinto de Ciencias Medicas, Comite de Derechos Humanos (IRB), with all participants signing and receiving copies of stamped approved consent forms. Access to data from this cohort and related studies is managed by Dr. Valerie Wojna (valerie.wojna1@upr.edu). This unique cohort of Puerto Rican, Spanish-speaking, and HIV+ women was characterized with respect to the viral immune profiles, neurological function, and neuropsychological performance of its member women [2, 50]. Our cross-sectional data were collected between August 2010 and January 2011. All the participating seropositive women were screened at their primary HIV clinics at the Puerto Rico Medical Center (the Clinic for Sexually Transmitted Diseases and the Longitudinal Mother–Infant Clinic) and community-based organizations.
HIV+ women aged 21 to 65 years were recruited if they fulfilled the inclusion criteria of (1) presenting a nadir CD4 cell count of 500 cells/mm3 or less or a viral load of greater than 1,000 copies/ml while being active recipients of combined antiretroviral treatment (cART) (2) and having completed at least ninth grade (the minimum educational level required for some of the neuropsychological [NP] tests); active self-reported substance users were screened out. Women with a history of neurodegenerative disease or prior CNS infection (e.g. toxoplasmosis), neuropsychiatric disorders, active infections, or either current or past head trauma were excluded [2]. During her only site visit, each participant completed a demographic survey, the HRRS, and the Beck Depression Inventory I, Spanish version (BDI-I S) [48, 49].
Study sample
All subsequent analyses are based on 45 consecutively recruited, HIV+ women from the HLLC with a mean age of 46 years (range, 32–63); described previously elsewhere [2]. Most of the participants were born and educated in Puerto Rico, went through the same or a similar education system, and had the same or a similar socio-economic status. Only 13% (n = 6) of the participating HIV+ women had been prescribed medication for symptoms of depression. The inclusion criteria screened out self-reported illegal substance users. However, drug testing revealed that a total of 16% (n = 7) of the HIV+ women were positive for one or more illegal substances on the day of the test. Drug testing indicated that five participants were positive for cocaine and two were positive for marijuana. The seven HIV+ women who tested positive for illegal substance use were included in this study after neuropsychological examination suggested that they were qualified to participate at the time of testing.
Data analyses
All analyses were performed using Microsoft Excel (2010) and the Statistical Package for the Social Sciences (SPSS) software (version 17.0).
Reliability
Reliability was calculated using Cronbach’s alpha [51] for the global score of the HRRS, each of the three-dimensional scores, and each of the 10 subscales.
Content validity
Content validity was evaluated using Lawshe’s technique, which requires the objective judgment of subject matter experts (SME) to determine the congruence of items with conceptual definitions [52]. For the HRRS, SME were considered qualified to assess the HRRS based on their experiences working with HIV+ populations, as well as past work on resilience and psychometrics. The SME were instructed to pair individual items with dimensions/subscales that represented the measured construct by classifying items as essential or not essential. A content validity ratio was calculated from the responses provided by the SME.
Predictive validity
Predictive validity was evaluated based on the correlation between the HRRS, the three dimensions of the HRRS, and the Beck Depression Inventory I, Spanish version (BDI-I S; [48, 49]), which is a widely used, and an established screening test that assesses the severity of the symptoms of depression in the 14 days prior to screening. We hypothesized that higher levels of resilience would be associated with lower levels of depression.
Ethics
This study conformed to guidelines set forth in the latest version of the Declaration of Helsinki. The study design was approved by the University of Puerto Rico, Medical Sciences Campus, institutional review board (IRB). Participants provided informed consent to participate in the study after receiving a full explanation of all the procedures.
Results
Reliability
The results demonstrated excellent overall internal consistency for the total HRRS score (α = 0.95). Each of the dimensional scores also evidenced acceptable internal consistency (α ≥ 0.88). The internal consistency for each of the ten subscales was variable, ranging from acceptable to unacceptable. See Table 3 for details, including descriptive statistics for HRRS total score, each of the dimensions and subscales, and reliability statistics.
Content validity
Data for content validity were collected from a total of 20 SME. Based on the Lawshe technique, when 20 judges have evaluated the instrument, the expected validity index is 0.42 [52]. An item analysis of the initial 50 items resulted in the elimination of three items from each dimension. An additional item was excluded so that there would be an equal number of items per subscale, resulting in three items per subscale, for a total of 30 items. All the dimensional and subscale content validity indices were above the 0.42 cut-off; see Table 4 for details.
Predictive validity
Analysis revealed a significant negative correlation between HRRS total score and BDI-I-S (r(45) = -0.453, p < 0.003). All three dimension of the HRRS were also negatively correlated with the BDI-I-S (SDM: r(40) = -0.344, p < 0.03; SRD: r(40) = -0.390, p < 0.02; and ERD: r(40) = -0.428, p < 0.006).
Discussion
Albeit preliminary in nature, the present study provides support for the HRRS as a measure to assess resilience among individuals living with chronic medical conditions. This measure is the first of its kind, having high levels of internal consistency as well as data to support its validity. Our group of SME examined and confirmed the HRRS’s content validity. The predictive validity was supported by correlations of the HRRS’s correlations in the expected direction with an established measure of depression. The measure is easy to interpret, with higher scores indicating greater resilience. The strengths of the study include the availability of the measure in two languages (English and Spanish) and founding preliminary psychometric properties of the measure based on a high-risk and vulnerable patient population in HIV+ Latina women from Puerto Rico. Minority populations, especially non-English speaking ones, are understudied across medicine [53–56], and when efforts are made to include these patient groups, measurement is rarely tailored to their unique cultural and linguistic experiences. The HRRS is a measure that addresses these notable voids in the medical literature.
Findings from this study highlight the inverse relationship between HRRS and depressive symptoms. This relationship is consistent with the limited existing literature. Lower levels of resilience have been noted in individuals receiving psychiatric care compared to healthy individuals [57]. Thus, an effort to improve health-related resiliency may provide an additional target for interventions aimed at addressing the needs of individuals with chronic health conditions. Early efforts have found that interventions that foster resilience have a positive impact not only on resilience but also on social support, as well as improving the mental health status of HIV+ individuals, and these treatment gains were shown to be sustainable for up to 3 months post-intervention [58]. Interventions that foster the development of health-related resiliency may represent a less threatening form of treatment, relative to more traditional psychiatric interventions, and may be easier to disseminate through health promotion efforts, especially in the clinical course of a given chronic medical condition. These efforts may be especially relevant to an already stigmatized patient population [59, 60–62], such as that consisting of those living with HIV.
Although this study has a number of strengths, its limitations must be acknowledged. The small sample size of this study represents a major limitation, and as such, all conclusions should be taken as being preliminary. Future studies should further assess the psychometric properties in larger, more diverse patient populations, including those consisting of individuals with chronic medical conditions other than HIV. Additionally, future research should address standardizing the HRRS in both languages (Spanish and English) and for both genders. Finally, given the one-time administration of the HRRS, findings from this study are unable to address the issue of the temporal stability of the measure. Some conceptualize resilience as a personality trait [43, 45, 61], implying that there is an expected consistency in the pattern of resilience over time. When specifically examining health-related resilience, however, one might expect resilience to vary as a function of the chronicity of a given disease state as well as with respect to the expected fluctuations in health status common to many chronic medical conditions, including HIV. As such, resilience may vary with time across dimensions or in terms of a specific dimension [62]. Future studies should longitudinally assess health-related resilience, especially in the context of disease progression.
Conclusion
Limitations notwithstanding, the HRRS is the only bilingual (Spanish and English) measure to assess health-related resiliency in adults. The study described in this manuscript lends credence to the pertinence of the preliminary psychometric properties as determined by the instrument, which is itself intended as a measure to be used with HIV+ Puerto Rican women, an underserved and understudied population. Despite the homogenous patient population upon which the psychometric properties are based, the measure is likely to be of relevance across diverse chronic medical conditions. Health-related resiliency may be a less-threatening and less-stigmatizing target for interventions aimed at improving the wellbeing and quality of life of individuals living with chronic medical conditions.
Acknowledgments
The study was funded by National Center for Research Resources (NCRR) grant U54RR026139, the National Institute on Minority Health and Health Disparities (NIMHD) grant U54MD007587, the National Institute of Neurological Disorders and Stroke (NINDS) S11NS046278 and U54NS43011 awarded to the University of Puerto Rico, Medical Science Campus, and National Institute of Mental Health (NIMH) Center for Novel Therapeutics of HIV-associated Cognitive Disorders Pilot Project grant R25MH080661 part of the G12 RR003050 awarded to John Hopkins University. Additionally, this research was partially supported by the Menninger Clinic Foundation and McNair Medical Institute. Dr. Madan is a McNair Scholar. The study follows the guidelines on good publication practices. The study sponsors were not involved in any aspect of the research activities. Thus, the authors were independent of study sponsors in the context of the research. The authors have no other potential conflicts of interest to disclose.
References
- 1.
Centers for Disease Control and Prevention. Geographic Differences in HIV Infection Among Hispanics or Latinos—46 States and Puerto Rico, 2010. 2012 Contract No.: 40.
- 2. Wojna V, Skolasky RL, Hechavarria R, Mayo R, Selnes O, McArthur JC, et al. Prevalence of human immunodeficiency virus-associated cognitive impairment in a group of Hispanic women at risk for neurological impairment. J Neurovirol 2006;12(5):356–64. pmid:17065128.
- 3. Simoni JM, Ortiz MZ. Mediational models of spirituality and depressive symptomatology among HIV-positive Puerto Rican women. Cultur Divers Ethnic Minor Psychol. 2003;9(1):3–15. pmid:12647322.
- 4. Wojna V, Skolasky RL, McArthur JC, Maldonado E, Hechavarria R, Mayo R, et al. Spanish Validation of the HIV Dementia Scale in Women. AIDS Patient Care STDs. 2007;21(12):930–41. pmid:18154490.
- 5. Morales D, Acevedo SF, Skolasky RL, Hechavarria R, Santiago S, De La Torre T, et al. Translational spatial task and its relationship to HIV-associated neurocognitive disorders and apolipoprotein E in HIV-seropositive women. J Neurovirol. 2012;18(6):488–502. pmid:22972599
- 6. Morales D, Hechavarria R, Wojna V, Acevedo SF. YWHAE/14-3-3epsilon: a potential novel genetic risk factor and CSF biomarker for HIV neurocognitive impairment. J Neurovirol. 2013;19(5):471–8. pmid:23982958
- 7. Ciambrone D, Loewenthal HG, Bazerman LB, Zorilla C, Urbina B, Mitty JA. Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women. Women Health. 2006;44(4):61–77. pmid:17456464.
- 8. Cooperman NA, Simoni JM, Lockhart DW. Abuse, Social Support, and Depression Among HIV-Positive Heterosexual, Bisexual, and Lesbian Women. Journal of lesbian studies. 2003;7(4):49–66. pmid:24831384.
- 9. Asencio Toro G, Burns P, Pimentel D, Sanchez Pereza LR, Rivera Lugo C. Using a multisectoral approach to assess HIV/AIDS services in a western region of Puerto Rico. American Journal of Public Health. 2006;96(6):995–1000. pmid:16670220
- 10. Eller LS, Rivero-Mendez M, Voss J, Chen WT, Chaiphibalsarisdi P, Iipinge S, et al. Depressive symptoms, self-esteem, HIV symptom management self-efficacy and self-compassion in people living with HIV. AIDS Care. 2014;26(7):795–803. pmid:24093715
- 11. Saadat M, Behboodi ZM, Saadat E. Comparison of depression, anxiety, stress, and related factors among women and men with human immunodeficiency virus infection. J Human Reprod Sci. 2015;8(1):48–51. pmid:25838749
- 12. Leserman J, Petitto JM, Gu H, Gaynes BN, Barroso J, Golden RN, et al. Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors. Psychol Med. 2002;32(6):1059–73. pmid:12214787.
- 13. Mutumba M, Musiime V, Lepkwoski JM, Harper GW, Snow RC, Resnicow K, et al. Examining the relationship between psychological distress and adherence to anti-retroviral therapy among Ugandan adolescents living with HIV. AIDS Care. 2016;28(7):807–15. pmid:27294696.
- 14. Ebersohn L, Ferreira R. Coping in an HIV/AIDS-dominated context: teachers promoting resilience in schools. Health Educ Res. 2011;26(4):596–613. pmid:21441389.
- 15. Siegel K, Schrimshaw EW. The stress moderating role of benefit finding on psychological distress and well-being among women living with HIV/AIDS. AIDS Behav. 2007;11(3):421–33. pmid:17103124.
- 16. Mustanski B, Garofalo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34(1):37–45. pmid:17688395.
- 17. Siegel K, Schrimshaw EW, Pretter S. Stress-related growth among women living with HIV/AIDS: examination of an explanatory model. J Behav Med. 2005;28(5):403–14. pmid:16179979.
- 18. Farber EW, Schwartz JA, Schaper PE, Moonen DJ, McDaniel JS. Resilience factors associated with adaptation to HIV disease. Psychosomatics. 2000;41(2):140–6. pmid:10749952.
- 19. Svanberg POG. Attachment, resilience and prevention. J Mental Health. 1998;7(6):543–78.
- 20. Carrico AW, Bangsberg DR, Weiser SD, Chartier M, Dilworth SE, Riley ED. Psychiatric correlates of HAART utilization and viral load among HIV-positive impoverished persons. AIDS. 2010;25(8):1113–8. pmid:21399478.
- 21. Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiat. 2001;158(5):725–30. pmid:11329393.
- 22. Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psycholog. 2004;59(1):20–8. pmid:14736317.
- 23. Roisman GI. Conceptual clarifications in the study of resilience. Am Psycholog. 2005;60(3):264–5.
- 24. Windle G, Bennett KM, Noyes J. A methodological review of resilience measurement scales. Health Quality Life Outcomes. 2011;9:8. pmid:21294858
- 25. Rutter M. Resilience, competence, and coping. Child abuse & neglect. 2007;31(3):205–9. pmid:17408738.
- 26. Masten AS. Ordinary magic. Resilience processes in development. Am Psycholog. 2001;56(3):227.
- 27.
Goldstein S. Creating a Clinical Psychology of Resilience 2008 [cited 2009:[1–3 pp.].
- 28. Luthar SS, Cicchetti D, Becker B. The construct of resilience: a critical evaluation and guidelines for future work. Child Dev. 2000;71(3):543–62. pmid:10953923.
- 29. De Santis J. Exploring the concepts of vulnerability and resilience in the context of HIV infection. Res Theory Nurs Pract. 2008;22(4):273–87. pmid:19093664.
- 30. Rao D, Hahn EA, Cella D, Hernandez L. The health related quality of life outcomes of English and Spanish speaking persons living with HIV/AIDS from the continental United States and Puerto Rico. AIDS Patient Care STDs. 2007;21(5):339–46. pmid:17518526.
- 31. Siegel K, Meyer IH. Hope and resilience in suicide ideation and behavior of gay and bisexual men following notification of HIV infection. AIDS Edu Prev. 1999;11(1):53–64. pmid:10070589.
- 32. Thompson B. Lazarus Phenomena: an exploratory study of gay men living with HIV. Social Work Health Care. 2003;37(1):87–114. pmid:12921407.
- 33. Emlet CA, Tozay S, Raveis VH. "I'm not going to die from the AIDS": resilience in aging with HIV disease. Gerontologist. 2011;51(1):101–11. pmid:20650948.
- 34.
Prince-Embury S. Resiliency Scales for Children and Adolescents-A profile of Personal Strengths (RSCA). San Antonio, TX: Pearson Education; 2006.
- 35. Bartone PT, Ursano RJ, Wright KM, Ingraham LH. The impact of a military air disaster on the health of assistance workers. A prospective study. J Nervous Mental Dis. 1989;177(6):317–28. pmid:2723619.
- 36. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82. pmid:12964174.
- 37. Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor-davidson Resilience Scale (CD-RISC): Validation of a 10-item measure of resilience. J Trauma Stress. 2007;20(6):1019–28. pmid:18157881.
- 38. Spies G, Seedat S. Depression and resilience in women with HIV and early life stress: does trauma play a mediating role? A cross-sectional study. BMJ Open. 2014;4(2):e004200. pmid:24566532
- 39. Yuen WW, Wong WC, Tang CS, Holroyd E, Tiwari AF, Fong DY, et al. Evaluating the effectiveness of personal resilience and enrichment programme (PREP) for HIV prevention among female sex workers: a randomised controlled trial. BMC Public Health. 2013;13:683. pmid:23886280;
- 40. Dale S, Cohen M, Weber K, Cruise R, Kelso G, Brody L. Abuse and resilience in relation to HAART medication adherence and HIV viral load among women with HIV in the United States. AIDS Patient Care STDS. 2014;28(3):136–43. pmid:24568654
- 41. Dale SK, Cohen MH, Kelso GA, Cruise RC, Weber KM, Watson C, et al. Resilience among women with HIV: Impact of silencing the self and socioeconomic factors. Sex Roles. 2014;70(5–6):221–31. pmid:24932061
- 42. Wagnild GM, Young HM. Development and psychometric evaluation of the Resilience Scale. J Nurs Meas. 1993;1(2):165–78. pmid:7850498.
- 43. Block J, Kremen AM. IQ and ego-resiliency: conceptual and empirical connections and separateness. J Pers Soc Psychol. 1996;70(2):349–61. pmid:8636887.
- 44. Hjemdal O, Friborg O, Martinussen M, Rovenvinge J. Preliminary results from the development and validation of a Norwegian scale for measuring adult resilience. J Norwegian Psycholog Assoc. 2001;38(4):310–7.
- 45. Hjemdal O, Roazzi A, Dias Mda G, Friborg O. The cross-cultural validity of the Resilience Scale for Adults: a comparison between Norway and Brazil. BMC Psychol. 2015;3(1):18. pmid:26090106
- 46.
DeVellis RF. Scale development: theory and applications. Newbury Park, Calif: Sage; 1991.
- 47.
Spector PE. Summated rating scale construction: an introduction. Thousand Oaks, CA: SAGE Publication, Inc.; 1992.
- 48. Bernal G, Bonilla J, Santiago J. Confiabilidad interna y validez de construccion logica de dos instrumentos para medir sintomatologia psicologica en una muestra clinica: el inventario de depresion de Beck y la lista de cotejo de sintomas—36. Revista latinoamericana de psicología. 1995;27(2):207–29.
- 49. Bonilla J, Bernal G, Santos A, Santos D. A revised Spanish version of the Beck Depression Inventory: Psychometric properties with a Puerto Rican sample of college students. J Clin Psychology. 2004;60(1):119–30. pmid:14692014
- 50. Luo X, Carlson KA, Wojna V, Mayo R, Biskup TM, Stoner J, et al. Macrophage proteomic fingerprinting predicts HIV-1-associated cognitive impairment. Neurology. 2003;60(12):1931–7. pmid:12821735.
- 51.
Roa CR, Sinharay S, editors. Handbook of Statistics: Psychometrics. Amsterdam, The Netherlands: Elsevier; 2007.
- 52. Lawshe CH. A Quantitative Approach to Content Validity. Personnel Psychology. 1975;28(4):563–75.
- 53. Gwadz M, Cleland CM, Leonard NR, Ritchie AS, Banfield A, Riedel M, et al. Predictors of Screening for AIDS Clinical Trials Among African-Americans and Latino/Hispanics Enrolled in an Efficacious Peer-Driven Intervention: Uncovering Socio-Demographic, Health, and Substance Use-Related Factors That Promote or Impede Screening. AIDS Behav. 2013;17(2):801–12. pmid:22638865
- 54. DeFreitas D. Race and HIV clinical trial participation. J Nat Med Assoc. 2010;102(6):493–9. pmid:20575215.
- 55. Vutien P, Hoang J, Brooks L, Nguyen NH, Nguyen MH. Racial Disparities in Treatment Rates for Chronic Hepatitis C: Analysis of a Population-Based Cohort of 73,665 Patients in the United States. Medicine. 2016;95(22):e3719. PMC4900706. pmid:27258498
- 56. Oh SS, Galanter J, Thakur N, Pino-Yanes M, Barcelo NE, White MJ, et al. Diversity in Clinical and Biomedical Research: A Promise Yet to Be Fulfilled. PLoS Med. 2015;12(12):e1001918. pmid:26671224
- 57. Friborg O, Hjemdal O, Rosenvinge JH, Martinussen M. A new rating scale for adult resilience: what are the central protective resources behind healthy adjustment? International J Methods Psychia Res. 2003;12(2):65–76. pmid:12830300.
- 58. Yu X, Lau JTF, Mak WWS, Cheng Y, Lv Y, Zhang J. A pilot theory-based intervention to improve resilience, psychosocial well-being, and quality of life among people living with HIV in rural China. J Sex Marital Therapy. 2014;40(1):1–16. pmid:23656590
- 59. Norman LR, Abreu S, Candelaria E, Sala A. The effect of sympathy on discriminatory attitudes toward persons living with HIV/AIDS in Puerto Rico: a hierarchical analysis of women living in public housing. AIDS Care. 2009;21(2):140–9. pmid:19229682
- 60. Jimenez JC, Puig M, Ramos JC, Morales M, Asencio G, Sala AC, et al. Measuring HIV felt stigma: a culturally adapted scale targeting PLWHA in Puerto Rico. AIDS care. 2010;22(11):1314–22. pmid:20665283
- 61. Hjemdal O, Friborg O, Martinussen M, Rosenvinge J. Preliminary results from the development and validation of a Norwegian scale for measuring adult resilience. J Norwegian Psycholog Assoc. 2001;38(4):310–7.
- 62. Smith GC, BH Jr. Resilience in Adulthood and Later Life: What Does it Mean and Where Are We Heading? Ann Rev Gerontol Ge. 2012;32:3.