The health and longevity for people living with HIV (PWH) has significantly improved with the development of antiretroviral therapies (ART; Vance et al., 2019). HIV has shifted to a chronic lifelong illness with the focus now on helping PWH to have a better physical, mental, and social health and well-being (Xu et al., 2018). Studying quality of life (QoL) is important for understanding how the challenges of living with HIV affect well-being, with a focus on protective factors that may inform intervention targets (Fang et al., 2015).
Despite improvement in health care, PWH face challenges that affect their QoL, such as stigma and discrimination (Turan et al., 2017), lack of social support (Wani, 2020), and homelessness (Fang et al., 2015). As PWH age, they face additional challenges such as cognitive and neurological problems, social isolation, economic instability, challenges with everyday functioning, and other age-related comorbid diseases (Vance et al., 2019). Not all PWH who face these challenges will experience a reduction in their QoL. Emerging studies have identified a subset of PWH who experience successful aging (Fazeli, Woods, et al., 2020). Individual or intrapersonal resilience resources may allow some PWH to deal with or recover from adversity, thus increasing the likelihood of having a higher QoL and well-being (Fang et al., 2015). Several factors have been identified and conceptualized as intrapersonal resilience resources, including hardiness, grit, self-esteem, self-efficacy, optimism/positive thinking, coping, spirituality/religiosity, and perseverance (Ledesma, 2014). Resilience resources have shown associations with several health outcomes among PWH, including neurocognitive and everyday function (Fazeli, Woods, et al., 2020), biomarkers such as allostatic load (Fazeli, Waldrop-Valverde, et al., 2020), and HIV health behaviors/outcomes (Dulin et al., 2018). Yet less is known about the association between a broad range of intrapersonal resilience resources and QoL among aging PWH.
The purpose of this article was to systematically review studies examining intrapersonal resilience resources and their association with QoL outcomes among middle-aged and older PWH, and it is the first study to specifically examine these associations in this population. This review investigates the naturalistic intrapersonal resilience resources PWH use to impact their QoL. Studying intrapersonal resilience resources is particularly important because they may be more modifiable in interventions, compared with interpersonal resources such as social support. These resources are also within the individual and thus may be available, even in the absence of other interpersonal resources. Understanding the influence of intrapersonal resilience resources on QoL outcomes is important among aging PWH because a large proportion of PWH are transitioning to older adulthood, and such knowledge may inform clinical interventions, overall HIV health care, and treatment outcomes for older PWH.
Methods
Search Strategy
The methodology for this study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement: an updated guideline for reporting systematic reviews (Page et al., 2021). The review was preregistered with The International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42021279028] before the review being initiated. The systematic search procedure was performed by a qualified librarian, who searched CINAHL Plus (through EBSCO), PubMed (through National Library of Medicine), PsycINFO (through ProQuest), and EMBASE (through Elsevier) between March 15 and 16, 2023. Databases were searched using terms and concepts related to intrapersonal resilience resources ("resilience, personality, hardiness, grit, self-efficacy, optimism/positivity thinking, coping, spirituality/religiosity, perseverance, and psychological factors") and QoL ("quality of life-social/mental/physical, well-being-social/personal/mental/physical, mental/physical health, and life satisfaction, and activities of daily living"). The combination of search terms that were used are displayed in Table 1. The search was restricted to articles published in 2000 and later because this was the time when more effective ART (i.e., protease inhibitors) began to emerge and be used with regularity, changing the treatment landscape and prognosis of HIV (Vance & Robinson, 2004).
The following inclusion and exclusion criteria were used. First, all articles had to be peer-reviewed and present original empirical data; review articles, editorials, and other types of articles were not included. Second, all articles had to have a primary focus on intrapersonal or individual resilience resources, as opposed to interpersonal factors such as social support and stigma. Third, these articles must have focused on QoL/well-being as an outcome. Only global measures of mental or physical health-related QoL (HRQoL) were included, and specific physical illnesses (e.g., chronic pain) or mental disorders (e.g., depression/anxiety) were excluded. Fourth, only observational, cross-sectional, and longitudinal studies and quantitative data from mixed method studies were included. Intervention studies were not included. Intervention studies were excluded to first establish the naturalistic intrapersonal resilience resources that impact QoL in PLWH; this remains a necessary first and foundational step before examining resilience interventions. Fifth, the target population of study must have included middle-aged and older PWH (40+). If a study had a mixed sample of younger and older PWH, the results of older PWH (40+) must have been analyzed separately to be included. Finally, all articles must have been published/available in English.
Screening and Selection
The search results of all the studies meeting the inclusion criteria were downloaded into Covidence software, and duplicates were removed. Two team members conducted an independent initial screening of the title and abstracts of all studies, and all conflicts were discussed and arbitrated by a third member of the research team. The interrater reliability (IRR; Cohen's kappa) of this initial title and abstract screening was 0.41, which is considered moderate IRR. Following this, full text of the studies was also independently screened to ensure that the eligibility criteria were met, which resulted in 100% agreement (Cohen's kappa IRR = 1.00), and thus, there was no need for a third reviewer. All the steps from the search results, screenings, final articles included, and reasons for exclusions are presented in a PRISMA flow diagram (Page et al., 2021; Figure 1). Table 2 summarizes the final studies. In addition to the formal database search, the reference list of articles that met the criteria were manually searched for other studies that may have been overlooked. The research team also searched Google Scholar and considered the authors' professional knowledge of existing studies. Five studies were reviewed and included based on this additional search.
Quality Assessment
The methodological and overall quality assessment of the articles were conducted by two members of the research team using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies (Moola et al., 2020). The JBI appraisal tool assesses various areas, such as inclusion criteria for the sample, description of study subjects and settings, accounting for confounding factors, measurement of the outcome variables, and use of appropriate statistical analysis. After independent assessment, the evaluators met to discuss any evaluation that differed and came to a final consensus. The final quality assessment is presented in Table 3.
Data Extraction
A data extraction template was created by the research team using Microsoft Word. The data were extracted by one member of the research team and was independently reviewed and verified by two other team members. The following data were extracted from each study: authors, year of publication, study design, participant characteristics (age, sex, sexual orientation), country the study was conducted in, resilience resources investigated, QoL examined, data analysis method, findings, strengths, and limitations.
Results
The initial search resulted in 1,400 records, from which 271 duplicates were removed, and the remaining abstracts were initially screened for inclusion. Following this first screening, the remaining studies were moved to full-text review. There were studies that appeared to meet inclusion criteria, but after full-text review, they were excluded. McGowan et al. (2018) examined resilience and physical and mental well-being in adults with and without HIV; however, the analysis of the data included participants who were younger than 40 years, and this study was excluded. Nineteen studies met the inclusion criteria (Table 2). Following the review from two members of the research team, the quality assessment indicated that all 19 articles were of adequate quality, meeting the overall JBI criteria (Table 3).
Study Characteristics
All 19 articles were cross-sectional studies, with sample size ranging from 38 to 914. Eight of the studies had a sample size greater than 200, seven had a sample size between 151 and 200, and four had a sample size less than 100. Twelve of the studies were published in the United States, three in China, one study each in Canada, Spain, Germany, and Iran. Seven of the studies focused on gay and bisexual men, three focused on both heterosexual and gay/bisexuals, whereas the remaining nine did not report data on sexual orientation. Only one of the studies had a sample of women only, eight had men only, and 10 had a mixture of both.
Overall, 13 of the 19 studies reported a mixed sample African American/Black and Caucasian/White. Seven studies had a predominantly African American/Black sample (Brown et al., 2023; Fang et al., 2015; Hampton et al., 2013; Hopkins et al., 2022; Nguyen et al., 2018; Porter et al., 2017, 2019), whereas six had Caucasian/White (Emlet et al., 2013, 2017, 2020; King & Orel, 2012; Kteily-Hawa et al., 2019; Slater et al., 2013). Only six studies (Brown et al., 2023; Emlet et al., 2017; Hampton et al., 2013; Nguyen et al., 2018; Porter et al., 2017, 2019) reported having Hispanic/Latino participants among their sample (range 4-34%). Five studies did not report data on race/ethnicity (Drewes et al., 2021; Fumaz et al., 2015; Huang et al., 2018; Liu et al., 2014; SoleimanvandiAzar et al., 2021) possibly due to the sample largely being homogenous. One study acknowledged ethnic differences within the sample, but the exact differences were unclear (Xu et al., 2018).
Across the 19 studies, all used traditional questionnaires administered at one time point (no studies used ambulatory assessments in daily life). Eleven studies investigated general resilience (measured as a dispositional/personality trait), four focused on spirituality, three focused on self-efficacy, and three focused on coping; personal mastery, health locus of control, adversarial growth (AG), and purpose in life were each the focus in single separate articles. Eight studies examined overall QoL, 12 investigated physical QoL, 12 investigated psychological QoL, two investigated environmental QoL, and one investigated social, spiritual and autonomy/independence QoL. Some studies examined multiple resilience resources and QoL outcomes.
Summary of Studies
The 19 articles are organized and summarized first based on the most frequently studied resilience resource and within arranged by year of publication. These are organized by General Trait Resilience, Spirituality, Self-efficacy, Coping, Purpose in Life, and AG.
General trait resilience
King and Orel (2012) investigated the association of general trait resilience, health locus of control, and psychosocial stress with physical and mental health HRQoL of 38 older gay and bisexual men with HIV (mean age 53.5 years, range: 45-85 years). Lower levels of resilience were associated with higher levels of mental distress (Kendall's tau-b = -.29, p = .016). There was also a positive association between internalized health locus of control and general health status (Kendall's tau-b = .258, p = .049).
Fang et al. (2015) investigated the mediating effects of resilience (measured with latent and observed variables in a structural equation model [SEM]) on the relationship between life stress and HRQoL, specifically physical, emotional, and functional well-being among 299 older gay and bisexual men living with HIV (mean age, 55 years). Resilience was positively associated with physical ([beta] = .33, p < .001), emotional ([beta] = .35, p < .001), and functional well-being ([beta] = .79, p < .001) and mediated the relationship between life stress and all three areas of well-being.
Fumaz et al. (2015) examined trait resilience and QoL among a sample of 151 older adult long-term survivors of HIV (mean age 50 years, range: 47-54 years, mean years diagnosed with HIV 21.2 years, range: 17.7-24.9 years). Using univariate regression analysis, moderate to high levels of resilience were associated with higher levels of physical QoL (OR = .97, 95% CI = 0.950 to 0.988, p = .002). Resilience was not associated with QoL when accounting for age.
Emlet et al. (2017) examined trait resilience and mastery as psychological resources and their association with psychological HRQoL among 335 gay and bisexual men living with HIV (mean age 58.32 years, range: 50-84 years). In a regression, resilience (b = 8.91, p < .01) and mastery (b = 8.67, p < .01) were both positively associated with psychological HRQoL when controlling for age, race, income, and education. When tested together in the same model, both resilience (b = 7.10, p < .01) and mastery (b = 4.77, p < .01) remained associated with psychological HRQoL.
Huang et al. (2018) examined trait resilience, well-being, and overall physical health among 160 older PWH (mean age 50.15 years, SD = 7.49). Bivariate correlations revealed that resilience was significantly associated with fewer physically unhealthy days (r = -0.43, p < .01), fewer mentally unhealthy days (r = -0.31, p < .01), and better general well-being (r = .40, p < .01). Using SEM, resilience mediated the association between marital relationship and all three well-being indictors (i.e., general well-being [[beta] = .07, 95% CI = 0.02 to 0.12], physically [[beta] = -0.32, 95% CI = -0.56 to -0.07], and mentally unhealthy days [[beta] = -.28, 95% CI = -0.53 to -0.03]). Resilience also mediated the association between family relationship, and only two of the well-being indictors (i.e., general well-being [[beta] = .31, 95% CI = 0.02 to 0.59] and physically [[beta] = -.14, 95% CI = -2.75 to -0.20]; the mediation was marginally significant for mentally unhealthy days [[beta] = -.12, 95% CI = -2.51 to -.01]).
Xu et al. (2018) investigated the interrelationship among ageism, trait resilience, coping, and QoL among 197 older PWH (mean age 59.7, SD = 7.54). Bivariate correlations showed that resilience (r = .35) and coping (r = .28) were both positively associated with QoL.
Kteily-Hawa et al. (2019) examined trait resilience and QoL among 398 older women living with HIV (mean age 55.81 years, SD = 5.25). Using regression, resilience was positively associated with HRQoL (adjusted coefficient [beta] = -.50, 95% CI = 0.30 to 0.70, p < .001), while controlling for demographic factors such as age, race, and income.
Emlet et al. (2020) examined risk and protective factors, and poor health among 371 older gay and bisexual men (mean age 58.23 years). This study used the same cohort as their earlier research (Emlet et al., 2017); however, they examined additional resources and conducted mediational analysis. Regression analysis revealed that lower levels of trait resilience were positively associated with poor general health ([beta] = -.10, p < .05) and mediated the association between HIV status and poor general health ([beta] = .03, p < .05). The mediation showed that the association between HIV status and poor general health was higher for persons with lower levels of resilience. Spirituality was not associated with poor general health.
Hopkins et al. (2022) examined the association between trait resilience and QoL among 174 middle-aged and older PWH (mean age 51.30 years, SD = 7.03). In bivariate correlation analysis, resilience was positively associated with better physical (r = .20, p < .01) and mental (r = .42, p < .01) HRQoL. Multivariate linear regression, adjusting for covariates (SES, personality traits, depressive symptoms, cognitive performance, IADL declines), showed that resilience was a significant predictor of mental HRQoL ([beta] = .16, p = .02) but not physical.
Brown et al. (2023) examined the associations between trait resilience and QoL among 156 older PWH (mean age 58.4 years; SD = 7.8). The study examined global and six subdomains of QoL: physical functioning, psychological functioning, personal autonomy (independence), social relationships, environment, and spirituality. Multiple linear regression, adjusting for covariates (gender, age, race, ethnicity, education, employment, and years since diagnosis), revealed that resilience was significantly associated with global ([beta] = .03, p = .025), physical ([beta] = .24, p < .001), psychological ([beta] = .26, p < .001), personal autonomy/independence ([beta] = .15, p < .001), social ([beta] = .17, p = .004), and environment ([beta] = .32, p = .004) QoL.
Spirituality
Hampton et al. (2013) explored patterns of religiosity, spirituality, and existential well-being among 99 older gay and bisexual men living with HIV (mean age 55.53 years, SD = 4.91). The study revealed a significant positive association between spirituality/religiosity and existential well-being ([rho] = .62, p < .01).
Porter et al. (2017) examined the association between HIV stigma and psychological well-being and the mediating effect of spirituality among 914 PWH (mean age 55.5 years, SD = 4.87; range: 50-78 years). Using SEM, spirituality had a positive association with psychological well-being ([beta] = .59, p < .001) and partially mediated the relationship between stigma and psychological well-being ([beta] = -.15, p < .001). The negative relationship between HIV stigma and psychological well-being was lower for persons with high spirituality.
Porter et al. (2019) examined the mediating role of spirituality in the relationship between HIV stigma and psychological well-being among 364 heterosexual men and 247 gay/bisexual men living with HIV (combined mean age 55.69 years, SD = 4.98; range: 50-78 years). This study used a subsample of men from the same cohort as their earlier study (Porter et al., 2019). Using SEM, spirituality was positively associated with psychological well-being for both heterosexual ([beta] = -.51, p < .001) and gay/bisexual men ([beta] = .73, p < .001). Spirituality partially mediated the relationship between stigma and psychological well-being for both heterosexual ([beta] = -.12, p < .001) and gay/bisexual ([beta] = -.24, p < .001) men. The negative relationship between HIV stigma and psychological well-being was lower for persons with high spirituality.
Self-efficacy
Emlet et al. (2013) examined the risk and protective factors associated with physical and mental HRQoL among 226 older gay and bisexual men living with HIV (mean age 62.97 yeasr, SD = 7.32). Using multivariate linear regression, greater self-efficacy was significantly associated with better physical ([beta] = .35, p < .01) and better mental ([beta] = .55, p < .01) HRQoL, while accounting for covariates such as age, race/ethnicity, income, and education.
Liu et al. (2014) examined self-efficacy, well-being, and QoL among 31 PWH aged 50+ years (mean age 58.4 years, range: 50-80 years). Bivariate correlations revealed that perceived general self-efficacy was not significantly associated with physical QoL (r = -.13, p > .05), psychological QoL (r = .16, p > .05), social QoL (r = .26, p > .05), environmental QoL (r = .23, p > .05), or well-being (r = -.28, p > .05).
Coping
Slater et al. (2013) examined coping as a predictor of QoL in 60 older gay men living with HIV (mean age of 54.6 years, SD = 3.8; range: 50-65 years). In bivariate correlation analysis, there was a significant negative association with emotion-focused coping (avoidance) and QoL (r = -.55, p < .01). Using hierarchical linear regression, emotion-focused coping (avoidance) was negatively associated with QoL ([beta] = -.30, p < .001) when adjusting for covariates such as age and comorbidities.
SoleimanvandiAzar et al. (2021) investigated coping and positive state of mind among 160 Iranian older PWH ages 50 years and older (mean age 65.82 years, SD = 6.69). Bivariate correlation analysis showed that coping had a significant positive relationship with positive state of mind (r = .33, p < .001). Follow-up multivariate linear regression analysis showed a positive association between coping and positive state of mind ([beta] = .23, p < .001) when adjusting for age and education.
Purpose in life
Nguyen et al. (2018) explored risk and protective factors for HRQoL in older PWH (mean age 58.7 years, SD = 5.4). Compared with participants who reported poor/fair health, those with good/excellent health had greater purpose in life (p = .006). Using logistic regression, purpose in life was negatively associated with a greater odds of worse/lower health status (OR = 0.46, p < .01).
Adversarial growth
Drewes et al. (2021) explored AG as a mediator in the relationship between stigma dimensions (internalized, externalized) and self-rated health. The sample consisted of 839 older PWH (men and women) ages 50 years and older (mean age 56.9 years; SD = 6.3). Following regression analysis, AG was found to be negatively associated with poor self-rated health ([beta] = -.15, p < .001). After controlling for covariates (age, education), mediation analysis revealed that AG mediated the relationship between internalized stigma and self-rated health ([beta] = - 0.14, p < .01). Externalized stigma was not a significant predictor of AG in the mediational analysis on self-rated health ([beta] = .01; p = .34); therefore, AG was not found to be a mediator.
Synthesis
Across all 19 studies, most studies found a positive association between intrapersonal resilience resources and QoL outcomes among PWH. The majority of the studies investigated trait resilience measures. Across the studies, the effect sizes ranged from small to large, with most being at least medium or large effect sizes. Several studies found that resilience resources were associated with QoL outcomes over and above accounting for relevant covariates such as sociodemographic variables and health. Several studies found that resilience resources served as a mediator between risk factors to QoL (e.g., stigma), highlighting the connecting role of resilience resources (further details in the Discussion).
Discussion
This systematic review focused on the association between intrapersonal resilience resources and QoL outcomes among older PWH. In the 19 studies reviewed, resilience measured as an individual trait was the most common resilience resource examined, using measures such as the Connor-Davidson Resilience Scale or The Resilience Scale. Resilience was consistently defined as the individual's ability to recover from adverse experiences using personal resources or due to one's individual characteristics, and the measures used tapped into these factors. Trait resilience was positively associated with overall/general QoL, mental QoL, and physical QoL. Resilience was also found to mediate or indirectly affect QoL of older PWH when faced with various stressors, including general life stressors, stigma, and the stressors of living with HIV.
Spirituality emerged as another resilience resource that has been consistently examined across various studies. Spirituality was conceptualized as the use of spiritual belief or behaviors to manage stressors, such as praying or believing in a deity that protects against harm. Using this resource requires using one's own belief system to manage life challenges. Spirituality was positively associated with QoL and served as a protective factor (mediation) in the relationship between stressors and QoL.
Coping, self-efficacy, mastery, and purpose in life were less studied but had a similar positive association with QoL. Coping is the use of cognitive and behavioral strategies to manage stressful situations, whereas self-efficacy is conceptualized as an individuals' belief in their ability to execute a given behavior or overcome a particular challenge. Mastery was conceptualized as an individuals' sense of control over their own emotions, cognitions, behaviors, and general things that affect their lives. Purpose in life is seen as having an awareness of one's own goals and life path. These resources develop from various life experiences and self-knowledge and serve as individual protective factors.
Only four studies found no association between resilience resources and QoL outcomes. Emlet et al. (2020) found no association between QoL and spirituality. In their regression model, they included other variables of interest (e.g., resilience, LGBT community engagement, social support), and these factors may have better association with QoL. Liu et al. (2014) found no association between QoL and self-efficacy. This could be attributed to the small sample size (N = 31) and the lack of power to detect significant associations. Two studies found no association with trait resilience and QoL (Fumaz et al., 2015; Hopkins et al., 2022). Fumaz et al. (2015) reported that less than 20% of their sample had low resilience, suggesting limited variability of participants with high and low resilience and ultimately influencing the results. Hopkins et al. (2022) noted that the lack of association between resilience and physical QoL is consistent with some prior research that suggest that psychological factors may not always play a significant role in physical health and well-being. Overall, the association between resilience resources and QoL remained consistent across studies from different countries, suggesting that resilience is a universal resource across cultures.
Synthesis of Methodology
Study design
All the 19 studies were cross sectional. Associations between intrapersonal resilience resources and QoL over time need to be examined in longitudinal studies, which would provide insight on how resilience resources may change and develop over time, and how resilience resources may buffer negative impacts of stress on QoL and health outcomes and health behaviors. Fazeli et al. (2019) found that resilience attenuated the association between neurocognitive decline and everyday functioning. Fazeli, Woods, et al. (2020) and Fazeli, Waldrop-Valverde, et al. (2020) also found that resilience was associated with lower allostatic load, a composite biological marker of stress. Longitudinal studies should also examine how resilience resources may affect neurobiology and ultimately affect cognitive and everyday functioning. For example, Ourry et al. (2021) examined the association of QoL with structural, functional, and molecular brain imaging in community-dwelling older adults ages 65 years and older and found that physical QoL was positively associated with gray matter volume when adjusting for covariates, such as age, sex, education, and other domains of QoL. Similarly, Hahm et al. (2019) found a positive association between physical QoL and general health perception, and grey matter volume when accounting for other risk factors (e.g., smoking, alcohol use) and other comorbid conditions (e.g., depression, anxiety). The connection between resilience resources, QoL, and brain structure can be further explored among older PWH.
Sample
Half of the studies reviewed had a sample size below 200, which suggest the need for more studies with larger samples and sufficient power to detect meaningful associations. Most of the studies focused on gay and bisexual men and general adults (men and women), with only one study focusing specifically on women. More research is needed to investigate resilience resources among older PWH who are racial/ethnic minorities, of all genders and sexual orientations, and those who are disproportionately affected by HIV. Furthermore, given that the Deep South is an epicenter of the current HIV epidemic, further work is needed to examine resilience resources in this population of PWH who experiences a high burden of HIV disparities.
Data analysis
All 19 of the studies examined resilience resources through bivariate correlation analyses of QoL; however, 10 studies (Brown et al., 2023; Emlet et al., 2013, 2017, 2020; Fumaz et al., 2015; Hopkins et al., 2022; Kteily-Hawa et al., 2019; Slater et al., 2013; SoleimanvandiAzar et al., 2021; Xu et al., 2018) further examined associations between resilience resources and QoL outcomes in multivariable analyses. Five studies (Drewes et al., 2021; Fang et al., 2015; Huang et al., 2018; Porter et al., 2017, 2019) investigated the mediating role of resilience resources, whereas no study examined its potential moderating role. Mediation was investigated using regression analysis and SEM. Only eight studies explicitly mentioned accounting for possible covariates in their data analysis, whereas the remaining studies only examined unadjusted bivariate associations between resilience and QoL, which makes it unclear if resilience is associated with better QoL in the context of other important factors that may affect QoL (e.g., mood, demographics, SES). The studies in our review examined the mediating role of resilience resources and select psychosocial factors: general life stressors, challenges of living with HIV, family/marital support, and stigma (internalized and experienced). More research is needed to investigate the mediating and moderating role of various resilience resources in the relationship between psychosocial risk factors and QoL. Older PWH face issues, such as stigma, racism, sexism, ageism, homophobia, and transphobia, that negatively affect their QoL and well-being. Future research on the buffering or protective role of resilience resources is important to inform care for older PWH. HIV-related stigma is consistently one of the most significant barriers to positive HIV-related health outcomes and behaviors such as ART adherence (Turan et al., 2017) and the overall QoL of PWH (Turan et al., 2017). Turan et al. (2017) discussed the possibility of internalized stigma (individual accepting negative messages related to HIV and applying it to themselves) undermining the existing intrapersonal resilience resources and leading to poor HIV health outcomes. More research would be required to explore this potential association.
Instruments
All the studies reviewed used questionnaires administered at a single time point to measure resilience resources, which offer average, global, and retrospective impressions of resilience resources that can be affected by recall bias. Research on resilience resources can be enhanced with the use of ecologically valid contextual approaches such as experience sampling methods or ecological momentary assessment to systematically collect "real-time" data from participants because they occur within their natural environment (van Berkel et al., 2018). In such studies, participants would be asked to respond to queries through text messaging several times a day over several days (e.g., 7 days) on life stressors and the specific resilience resources used to navigate them. For example, when a stressor is reported, the type of stressor (e.g., work, relationships), severity, and initial appraisal (e.g., challenge vs. threat) would be reported, and then, follow-up questions would query on whether specific resources were employed (e.g., coping skills, positive reframing, enlisting social support). Such approaches can collect data on momentary stressors as they occur within one's environment, the resilience resources they employ at that given time, and examine how this ultimately affects outcomes such as health behaviors and mental health.
Limitations and Implications for Nursing Practice
The findings from this systematic review have important clinical implications for health care professionals working with older PWH. First, it highlights the significance of intrapersonal resilience resources in promoting QoL outcomes among older PWH. Health care providers should consider assessing and addressing resilience factors, particularly trait resilience, spirituality, coping strategies, self-efficacy, mastery, and purpose in life, as part of comprehensive care for older PWH. This could involve integrating brief assessments [e.g., subscales from the COPE Inventory (Carver et al., 1989)] during patient intake or at follow-up visits alongside existing tools currently used in clinical practice. By focusing on enhancing these resilience resources, health care professionals can potentially improve overall QoL, mental QoL, and physical QoL in this population.
In addition, the review emphasizes the mediating role of resilience resources in the relationship between stressors and QoL among older PWH. Health care providers should recognize that older PWH may face various stressors, including general life stressors, stigma, and the challenges of living with HIV. By supporting and strengthening resilience resources, health care professionals can help mitigate the negative impact of stress on QoL outcomes. This may involve incorporating interventions that promote spirituality, coping skills, self-efficacy, mastery, and a sense of purpose in life into the care plans of older PWH. Moreover, health care professionals should also address and combat HIV-related stigma because it is a significant barrier to positive health outcomes and QoL among PWH. By understanding the potential association between internalized stigma and intrapersonal resilience resources, health care providers can tailor interventions to reduce the impact of stigma on QoL and improve overall well-being for older PWH. For example, Fazeli et al. (2022) recognized the limited number of resilience resources-based interventions for older PWH and tested the feasibility of their pilot resilience-based intervention. Participants reported improvement in their resilience, mood, and ability to manage their HIV.
It is important to note some limitations of the review. The focus on intrapersonal resources excluded the examination of important interpersonal and community-based resources, such as social support, which are known to influence QoL among PWH. Health care providers should be mindful of the significance of these external resources and consider incorporating them into interventions and support networks for older PWH. Furthermore, the review primarily focused on older adults, and the generalizability of the findings to younger populations may be limited. Health care professionals should recognize that resilience factors and their impact on QoL that may differ among different age groups. Tailored interventions and support should be developed to address the unique needs of younger PWH. Finally, the review did not include intervention studies, and thus, the specific effects of resilience or stress-reduction interventions on QoL could not be determined. Future research should explore the effectiveness of interventions targeting resilience resources in improving QoL outcomes among older PWH.
Disclosures
No funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or nonfinancial interests to disclose.
Author Contributions
All authors on this paper meet the four criteria for authorship as identified by the International Committee of Medical Journal Editors (ICMJE); all authors have contributed to the conception and design of the study, drafted or have been involved in revising this manuscript, reviewed the final version of this manuscript before submission, and agree to be accountable for all aspects of the work. Using the CRediT taxonomy, the specific contributions of each author is as follows: Conceptualization and Methodology: S. Haase, R. Billings, D. Vance, P. Fazeli; Software, Investigation and Data curation: R. Billings; Formal analysis & Writing original draft: S. Haase; Writing-review & editing: P. Fazeli; D. Vance; R. Billings; Supervision and Validation: D. Vance, P. Fazeli.
KEY CONSIDERATIONS
Trait resilience, spirituality, and self-efficacy were the most common resilience resources investigated and were positively associated with the quality of life (QoL).
More research is needed to examine the mediating and moderating role of resilience resources in the relationship between psychosocial risk factors and QoL.
Longitudinal studies are important to investigate the long-term protective role of resilience resources in maintaining good QoL among older PWH, when faced with different stressors.
Understanding which resilience resources are beneficial for older PWH can be used to develop interventions to improve QoL.
References