Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

The Inner Working of Trauma: A Qualitative Assessment of Experiences of Trauma, Intergenerational Family Dynamics, and Psychological Well-Being in Women With HIV in South Carolina

LaDrea Ingram, EdD, CHES; Shan Qaio, PhD; Xiaoming Li, PhD; Morgan Deal

Abstract

Women with HIV are more likely to have a history of traumatic and stressful life experiences. The current study examines experiences of traumatic and stressful life events, issues co-occurring with experiences of trauma, and intergenerational family dynamics regarding trauma and psychological well-being in women with HIV. The study was guided by the theoretical approach of an integrative translational model that incorporates trauma-related factors into a psychosocial framework. Data were collected from interviews with 20 women with HIV and analyzed for thematic categories. Thematic analysis indicated that traumatic life events of women with HIV included experiences of loss, sexual assault, and homelessness. Women with HIV also experienced issues co-occurring with trauma, including substance use and mental illness. The current study adds to the existing body of research by including an analysis of intergenerational family dynamics and psychological well-being. Implications for health care professionals and recommendations for translating research into practice are also discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 23–31.]

Abstract

Women with HIV are more likely to have a history of traumatic and stressful life experiences. The current study examines experiences of traumatic and stressful life events, issues co-occurring with experiences of trauma, and intergenerational family dynamics regarding trauma and psychological well-being in women with HIV. The study was guided by the theoretical approach of an integrative translational model that incorporates trauma-related factors into a psychosocial framework. Data were collected from interviews with 20 women with HIV and analyzed for thematic categories. Thematic analysis indicated that traumatic life events of women with HIV included experiences of loss, sexual assault, and homelessness. Women with HIV also experienced issues co-occurring with trauma, including substance use and mental illness. The current study adds to the existing body of research by including an analysis of intergenerational family dynamics and psychological well-being. Implications for health care professionals and recommendations for translating research into practice are also discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 23–31.]

Rising HIV rates among women are an issue of national concern. According to Machtinger, Wilson, Haberer, and Weiss (2012), the number of women with HIV in the United States has more than tripled since 1985. Research has identified racial and ethnic differences in HIV rates, including particularly high rates among women of color (Centers for Disease Control and Prevention [CDC], 2018; Machtinger et al., 2012). Despite representing only 30% of the U.S. population (United States Census Bureau, 2014), Black and Latina women make up more than three quarters of women recently diagnosed with HIV/AIDS (Machtinger et al., 2012), and HIV rates among women of color in the deep South are an issue of growing concern. A CDC (2015) report warned that African American women face a disproportionate burden of HIV, accounting for 69% of all HIV diagnoses among women in the South. To exacerbate matters, states in the deep South are among the worst in the nation in terms of health care services for women of color, and Black women in the South are often poorly educated and among the lowest income earners in the country (National Council on Black Civic Participation, 2015).

Traumatic stressors have been found to negatively impact the health of individuals living with HIV/AIDS (Nightingale, Sher, Mattson, Thilges, & Hansen, 2011; Schneiderman, Ironson, & Siegel, 2005). Experiences of stressful and traumatic life events (i.e., traumatic stressors) predict non-adherence to treatment in individuals with HIV (Neigh, Rhodes, Valdez, & Jovanovic, 2016). In a review of the literature, Neigh et al. (2016) found that biological responses presented in individuals with posttraumatic stress disorder (PTSD) are similar to those presented in individuals with HIV. Similar to PTSD, HIV can disrupt brain function and alter neuronal communication. Neigh et al. (2016) concluded that:

…while HIV and PTSD have similar risk factors and the order of manifestation can vary, once present in combination, these two conditions are positioned to create a feed-forward cycle of interaction at both the behavioral and neurobiological levels. These multi-faceted interactions have the potential to alter response to treatment for either independent disorder.

Active interaction between PTSD and HIV can exacerbate neurobiological symptoms and consequently lead to poorer health outcomes (Neigh et al., 2016). Biological factors such as social–behavioral epigenetics and intergenerational responses to trauma have also been explored as factors in health outcomes among individuals with HIV (Brave Heart, 2003; Kellermann, 2001). Kellermann (2001) called for an integrative view of intergenerational influences of trauma that explores the potential influences of biological predisposition, individual developmental history, family system, and social situation.

Traumatic and other stressful life experiences have also been linked to increased rates of high-risk sexual and drug use behaviors in patients with HIV. In a longitudinal study of 611 individuals with HIV in the Southeastern United States, Reif et al. (2011) found that emotional stress and substance use were significantly associated with traumatic experiences in individuals with HIV or AIDS. A meta-analysis found that exposure to traumatic events and recent PTSD in HIV–positive women has increasingly become a health crisis for women, especially among women of color (Machtinger et al., 2012). Experiences of sexual violence in childhood or adolescence are highly prevalent among women with HIV and are frequently associated with an increased likelihood of experiencing depression and anxiety in adulthood (Willie, Overstreet, Sullivan, Sikkema, & Hansen, 2016).

The Substance Abuse and Mental Health Services Administration (SAMHSA; n.d.) defines individual trauma as resulting from:

an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.

Based on the definition provided by SAMHSA (n.d.), trauma can be described within the context of two major components: (a) the sum of an event and (b) the effects of the event on an individual's physical and psychosocial wellness.

Trauma exposure among women with HIV has been well documented; however, little research has focused on the relationship of life events and trauma to ecological factors such as individual level factors and interpersonal relationships across generations, family dynamics, and psychological wellness. Therefore, the current study uses an integrative translational theoretical model to integrate trauma-related factors into a psychosocial framework to (a) explore experiences of trauma in women with HIV; (b) identify issues cooccurring with trauma in women with HIV; and (c) identify intergenerational family dynamics related to trauma and psychological well-being in women with HIV. In addition, this study offers recommendations for health care practice with the primary objective of translating the study's research findings into practice.

Integrative translational health disparities research can be defined as the integration of “research that links or translates basic science (biological, genetic, social, political, and environmental) discoveries to practical, applicable strategies and effective policies to improve health outcomes in health disparities populations” (Dankwa-Mullan et al., 2010, p. S20). There is a strong rationale for integrative translational approaches to qualitative analysis, as such approaches highlight the multiple human dimensions in health care by uncovering the perceptions, experiences, and behaviors of patients while addressing complex issues in health care (Tripp-Reimer & Doebbeling, 2004). HIV health disparities among women with HIV include complex factors; qualitative methods are useful for addressing such complexities.

Method

Participants

The study was grounded in a larger qualitative study with 20 women with HIV and 10 health care workers providing HIV–related care and service in South Carolina. Researchers focused on interviews with 20 women with HIV for the specific research aims. Mean age of women with HIV was 48.5 years. Approximately 65% of women with HIV lived in an urban setting, and the sample comprised mostly women of color, who made up 85% of the study participants (Table 1).

Demographic Characteristics of Women with HIV (N = 20)

Table 1:

Demographic Characteristics of Women with HIV (N = 20)

Sample Procedure

Potential eligible participants were selected via purposive sampling. A list of potential eligible participants from eight counties in South Carolina was provided by the University of South Carolina Immunology Center and AIDS Healthcare Foundation organizations. Interviewers then arranged phone calls or visits to introduce potential participants to the study. After assessing eligibility, women meeting study inclusion criteria were invited to participate in the study.

The overarching inclusion criteria encompassed women with HIV who were recruited based on their demographic profiles and health status. Eligibility criteria included individuals who: (a) lived in South Carolina; (b) were women 18 years or older; (c) had a confirmed diagnosis of HIV or AIDS; and (d) were willing to participate in the study, including an in-depth interview. Candidates who were unable to respond to an interview due to a disability or incarceration or institutionalization for drug use or sex work were excluded from participation in the study. No candidates were excluded based on race or ethnicity.

Interview Procedures

One interviewer conducted all 20 interviews from early October to late November 2016. The interviewer had an extensive history working with individuals with HIV, with a culmination of 20 years' experience with 17 years working with this population in South Carolina. The interviewer also had existing relationships with approximately one third (n = 6) of participants; the interviewer's relationship with participants ranged from not having an existing relationship with the participant to having known the participant for 16 years. Prior to participating in the interviews, participants were provided a detailed description of the study design, its purpose, and a summary of potential risks and benefits of participation. The date and time of interviews was mutually agreed upon by the interviewer and participants. Only one interview was rescheduled as requested by a participant due to a time conflict. When interviews were scheduled, participants selected private areas in settings that were convenient and comfortable for them, such as their houses and other public settings (e.g., a conference room in public libraries, offices of the local AIDS Services Organization).

Audio equipment was used to record each interview. The interviewer also noted the setting, interview number, and factors that could affect the quality of the interview (such as the presence of others). When necessary, the interviewer introduced her experience of working with individuals with HIV to build trust with participants and prompt the interviews. A $25 gift card was given to each of the women with HIV following their participation in the interviews. The same procedures were repeated during each interview. Average length of interviews was approximately 40 to 50 minutes.

Instruments

The interviews were conducted based on a guide prepared by study investigators (S.Q., X.L.) and further informed by key stakeholders that have direct experience working with women with HIV. The interviewer first asked participants for basic demographic information such as age, race, and marital status, and then asked questions following the interview guide. A few example questions included: Do you have psychological issues that bother you? What life experiences or events bother you now? Are there things that you are worried or anxious about? The main themes of the interview guide focused on questions regarding well-being and quality of life of women with HIV and factors that influenced their well-being. Researchers asked participants to recall life experiences that had profound impacts on their wellness, and to describe how these experiences specifically influenced their behaviors and physical and psychological health. Researchers also asked about the social context in which individuals experienced life events or trauma, such as with family or friends or in a church, the neighborhood, or the community.

Data Analysis

Following the interviews, recordings were transcribed verbatim and de-identified. Three research assistants (M.D. and others) transcribed all of the interview recordings and two research staff (L.I., S.Q.) as well as the interviewer examined and edited the transcripts. Data analysis was guided by Braun and Clarke's (2006) framework for semantic thematic analysis. First, the research team became familiarized with the data by reading and re-reading five transcripts. Data were initially coded using the study's theoretical model and analysis was conducted using NVivo 11. A codebook was developed to cover the codes drawn from the interview guides and the new codes that emerged during the thematic coding process, such as traumatic life events, psychological wellness, and chronic stress. Each transcript was then coded based on overarching themes and subthemes that were extracted from interview data, and quote excerpts and coding memos were developed according to themes. The codes were defined and refined to generate the finalized themes. Three researchers (L.I., S.Q., M.D.) independently coded the transcripts; all coding disagreements were discussed and resolved through discussions. Representative and verbatim quotes were selected to illustrate key findings.

Ethical Considerations

The University of South Carolina Institutional Review Board approved this study. Participation was voluntary. Informed written consent was obtained prior to each interview, and participants were made aware that they could withdraw from the study at any time without consequence. In addition, procedures for participant confidentiality were implemented. Participant interviews were conducted in private rooms, and following the interviews, recordings were transcribed verbatim, de-identified, and destroyed. The interviewer's codebook identifying the name of the participant for each recording was also destroyed.

Results

The sample mainly included HIV–positive women of color (n = 17, 85%) with ages ranging from 22 to 67. Based on a series of interviews, three categories emerged as significant themes: Life Events and Experiences of Trauma; Impact of Life Events on Psychological Well-Being; and Intergenerational Family Dynamics.

Life Events and Experiences of Trauma

Most women cited life events and experiences of trauma. Three major subthemes emerged from the interviews: (a) experiences of loss; (b) housing and homelessness; and (c) sexual assault. Participants' experiences are highlighted and illustrated by quotes in the following subsections.

Experiences of Loss. Many women reported experiences of loss, including loss resulting from the death of a loved one. One 39-year-old African American woman reported experiencing continued trauma in the aftermath of her mother's murder, which occurred when the participant was only 13 years old. Another 41-year-old African American woman described the loss of her baby during pregnancy as the worst experience of her life. The woman's experience highlighted health care providers' missed opportunity to provide her with trauma-informed care. The participant stated:

…the doctor took the phone from the nurse and told me, “Your son is going to die so gather your family. Your son is going to die.” The doctor said, “You see your son, he's dying or he's already dead.” He then asked “Do you want to hold him before he dies?” He continued by saying “You don't want to bond with your son before he dies, it won't do anything if you don't want to.” He listened to his heart rate and said, “Oh he's died.” Without my permission the nurse pulled the plug on my son's life. I sat there and cried; they send me home early. That was one of the worst things happened in my life apart from the HIV diagnosis.

Housing and Homelessness. Housing and homelessness also emerged as a subtheme of life events and experiences of trauma. As a result of the 2015 South Carolina flood, a 45-year-old African American woman's house was destroyed, which she described as:

Totally ruined. Totally gone. And nobody is able to help—I'm still trying to find that help. It looks like it might be unsuccessful, but right now my main concern is that I have my family.

Likewise, a 39-year-old African American woman discussed her experiences of homelessness, which were often a result of her substance use:

I have been homeless…and at the times when I was homeless, it was by choice. I had chosen to get high, stay where I could. Sleep behind apartment buildings…

Sexual Assault. Several women had experienced sexual assault during their childhood and as adults. A 48-year-old White woman reported: “I have experienced sexual assault and domestic violence.” One 53-year-old African American woman referenced her experiences of sexual assault and abuse as an issue co-occurring with HIV: “Because see, I have other issues besides being HIV positive, like um, being molested, being raped, being abused, being sodomized.” All women who reported experiencing sexual violence had been victimized by an individual in close proximity to them, such as family members, friends, and other individuals close to the family. A 33-year-old African American woman described being raped by her friend:

…He was a friend. We were sitting on the couch one day, he was sitting in the couch and I was sitting in the chair like right here, and we were playing dominoes or cards or something, and he started asking me random questions. We were laughing, joking, kickin' it. Next thing I know, he got up. I thought he got up to give me a hug or get a drink or something, he just got up. And he head-butted me. The next thing I remember from that was I was laying on the floor butt naked and he was doing whatever he wanted to do to me.

Most women who experienced sexual violence were victimized by a family member. A 47-year-old African American woman described how she had been raped by her uncle, as well as other staff employed by her uncle, while living with him and her aunt:

Um, by, um.… and my aunt…my father's brother's wife, her brother…And then the whole entire staff they had, the male staff they had in the compound. So my escape was when they took me to boarding school. That was my salvation. And I've never looked back. My goal was if I pass and I work hard enough and get a good education, nobody would ever be able to touch me again. And I made sure of that. I've never gone back. I've never looked back.

Some women experienced sexual assault over an extended period from childhood through adolescence. A 53-year-old African American woman referenced her experience of being molested when she was a child: “…it happened from when I was 5 years old to when I was 9. And it was a family member.” Another African American woman (age 47) described being molested as a child over a period of 11 years: “Well, I was molested from the age of 5 to 16.”

Impact of Life Events on Psychological Well-Being

Substance use and PTSD were common issues co-occurring with trauma that negatively impacted participants' overall psychological well-being. A 45-year-old African American woman discussed drinking alcohol to cope with loss: “Well, I really laid back on the alcohol. I was an alcoholic when I lost my friend.” She also specifically described losing her house as a cause of PTSD:

...I backed up on the alcohol and so far I still walk a lot with my daughter and a lot of things. But ever since I lost my home, I've been in a traumatized state. It's like PTSD. Right now, honestly, I have to go over there soon and get the last little bit of my stuff out because they're evicting me from their property.

A 41-year-old African American woman described her PTSD diagnosis and her perceptions of a car accident after losing her son: “I was in a very bad accident in 2014; I was diagnosed with PTSD.”

Some participants experienced depression resulting from life events and trauma. A 53-year-old African American woman discussed the trauma associated with her HIV diagnosis and clinical outcomes and how the fear of death led to her depression:

Uh, so, it was when my CD count [i.e., white blood cell count] had dropped and my viral load had climbed, so I went into a deep depression, and I just shut down. And the fear came in, and then I had a friend that, she went in the hospital and she died, and for me, when I went through something like that…the fear set in that that could be me. So I had to go back to therapy. Because then the fear that I was going to die…

Likewise, a 48-year-old White woman was admitted to the Department of Social Services (DSS) because of her mental state. She stated, “I have been in DSS custody because I was unable to care for myself.”

Intergenerational Family Dynamics

Intergenerational family dynamics, including behavioral patterns transmitted and traced through family lines, were cited by several interviewees. Among study participants, substance use was the most cited behavior across generations and families. An African American woman cited the long history of substance use through the generations of her family: “Um, actually, I had left home at 12, my mom and dad both used crack, and I felt like I couldn't take it no more, so I actually raised myself from 12 to now…” She highlighted raising her sister since age 13, despite her own personal challenges of addiction, as well as her concerns with her sister's current substance use: “She smokes cocaine. My sister she worries; I just want her to do better.” She also discussed her father's continued substance use and how it was hindering their current relationship: “Even after all these years my dad still smokes. He still gets high. So me and him ain't in a room too long together.”

Participants' excerpts demonstrate a historical generational impact of substance use linked to parental separation. Some participants were separated from their parents at an early age as result of parental substance use. Similarly, many participants were separated from their children due to substance use and resulting criminalization. A 39-year-old African American woman described experiencing the loss of her mother at age 13 and how it led her to substance use: “I mean, maybe you know, half of that stuff that did bother me, I've actually dealt with it with God. But my mama was murdered when I was 13. So I started smoking crack at 13 years old.” The same participant discussed the loss of her children to the foster care system: “Well, when I was in active addiction, I lost rights to my kids.” Likewise, a 60-year-old African American woman described the loss of her children due to substance use: “My kids were taken away from me when I was using drugs.”

An African American woman described her substance use and how it prevented her from achieving housing stability and her family's unwillingness to take her in as result of her drug abuse:

My problem was too…my sister used to say, “If you ain't in my house by the time I lock my door, you ain't getting in tonight”…You can't even blame her. 'Cause she already knew I was an addict. She wasn't going to tell me “No, but no you ain't gonna walk my stuff up out of here while I'm sleeping.”

Women described the influence of family members on their choice to engage in substance use for the first time. For example, a 53-year-old African American woman discussed how she started engaging in substance use through her sister's influence:

…My sister, she was doing too, and I just walked past her door one day, and she didn't see me looking at her. So I'm looking, I'm peeping at her, and I'm seeing what she's doing, and…so one day I cleaned up my living room. And there's a vial thing in the couch. ‘Cause I always clean the couch up. And I found a vial and I said, “Imma try this.” And that was it.

Family mental illness also emerged as part of the intergenerational family dynamics for women with HIV. A 54-year-old African American woman cited concerns about her son's mental illness: “...he's hallucinating, and he flipped out. But I'm still dealing with this, and this is a real stress on my heart.” She also described mental illness in more than one child, “yeah, so I've dealt with mental illness for a long time, with my kids.” She discussed one of her daughter's mental illness and substance use, stating: “she's having problems with mental illness, addiction.” She indicated experiences of stress related to her family: “I started smoking cigarettes, um, within the last year, because of stresses, but mostly that had to do with family stress the last year and a half that I had going on.” In this case, the mother and daughter had a history of psychological distress and possible reliance on maladaptive coping mechanisms, including substances (i.e., cigarettes and drugs).

Some women experienced stress and anxiety as a result of their observations of unhealthy generational patterns of behaviors. For example, a 53-year-old African American woman discussed her anxieties about her grandchildren due to their parents' behaviors: “…I'm just fearful [for] the mother...she's from one abusive relationship to another. It's that cycle. How do we break that cycle?”

Discussion

There is little research on the intergenerational aspects of trauma and trauma's overall impact on interpersonal relationships and family dynamics in women with HIV. The current study sought to add to the existing body of research by highlighting intergenerational factors and historical traumas in women with HIV and their impact on the overall family dynamics of women with HIV. This study provides critical information on trauma and mental illness and their ability to transmit across generations, highlighted directly from the voices of women with HIV. Participants' excerpts indicated a history of substance use, mental illness, stress, and trauma that was deeply rooted in intergenerational factors and family dynamics. The study results emphasize the complex nature of behavioral patterns that reoccur across family lines as a result of predisposed behaviors passed down through generations. To date, there has been little focus on intergenerational transmission of health behaviors.

In an investigation of intergenerational transmission of parents' health risk behaviors to adolescents, Wickrama, Conger, Wallace, and Elder (1999) found that fathers' health risk behaviors were more likely to transmit to their sons' health risk behavioral outcomes and mothers' health risk behaviors were more likely to transmit to their daughters' health risk behavioral outcomes. Nadel and Thornberry (2017) indicated that mothers' adult substance use is a consistent predictor of child behavioral outcomes. Researchers concluded that intergenerational substance use depends on the sex of the parent and at what point in the parent's life course substance use occurs. The current study findings align with previous research in supporting the significance of intergenerational factors in overall health behavioral choices and psychological well-being; however, more research is needed in the area of intergenerational transmissions of health behaviors specifically in women with HIV.

Several themes were supported by the existing body of empirical research to include the experience of loss highlighted in excerpts from interviews of women with HIV. One participant discussed the loss of her house during the 2015 South Carolina flood and expressed feelings of PTSD. According to Cepeda, Saint Onge, Kaplan, and Valdez (2010), loss of resources is strongly correlated with negative mental health outcomes, whereas disaster exposure increases psychological distress and anxiety. In addition to loss as a result of a disaster, participants also highlighted losses through the death of loved ones. An analysis by the National Epidemiologic Survey on Alcohol and Related Conditions found that unexpected death was one of the most common traumatic experiences reported and that it was likely to be described as respondents' worst traumatic experience (Keyes et al., 2014). In support of this finding, one participant in the current study cited the death of her son as one of the worst experiences of her life. This respondent also indicated that the physician treating her son had not communicated with her in a compassionate manner, which highlights the need for trauma-informed practices that include effective patient–provider interactions and supportive and comforting communication when a patient experiences a traumatic life event. Positive patient–provider interactions are critical to health care practice to ensure that patients do not experience additional trauma immediately following a traumatic event, also known as medical trauma. Hall and Hall (2013) asserted that individuals who have experienced medical trauma are at greater risk of developing PTSD, anxiety, depression, complicated grief, and somatic complaints. Compassionate care has been found to increase adherence to physician guidelines and recommendations, reduce anxiety, and enhance patient recall, thus facilitating treatment (Post, 2011; van Osch, Sep, van Vliet, van Dulmen, & Bensing, 2014).

One participant highlighted that her experiences had separated her from her parents and that she left home at age 12 because of substance use in the home. This experience aligns with the work of Davies and Allen (2017), which indicated that trauma in the home significantly increases the chance that youth will choose to run away and remain separated from their families. Youth who run away or stay separated from family are subsequently more likely to exhibit school disengagement, depression, emotional distress, and greater use of substances (Edinburgh, Harpin, Garcia, & Saewyc, 2013; Tucker, Edelen, Ellickson, & Klein, 2011). In addition to being associated with substance use, running away from home has been strongly associated with suicidal behavior in adulthood, even when controlling for childhood adversities (Edinburgh et al., 2013; Meltzer, Ford, Bebbington, & Vostanis, 2012). Future research should explore suicidal ideation in women with HIV who have experienced trauma in the home that led them to run away. This line of research will provide greater insight into the level of association between suicidal ideation and responses to trauma in women with HIV.

Many participants responded to trauma through substance use and experiences of PTSD and depression. Research has found that individual responses to trauma include depression, substance use, and physical illness, leading to consequences such as impaired immune functions (Carlson & Dalenberg, 2000). This consequence is particularly significant for women with HIV, as they already have compromised immune systems. Future research that includes a deeper analysis of responses to traumatic events and the factors that influence responses, such as coping and resilience; perceptions of the traumatic event; biological factors (e.g., genetic predisposition, vulnerability, resilience to trauma); and developmental level at the time of trauma is suggested. The current study did not explore how trauma impacts treatment outcomes such as medical adherence and overall clinical outcomes, and future research should examine the re-experience and recurring experience of trauma and its impact on treatment outcomes in women with HIV.

Implications for Health Care Research and Practice

First, the study results suggest the need for health care professionals to engage in more comprehensive holistic patient-centered care. This care includes culturally informed practices that seek to build strong relationships with patients and their families. Strong relationships will place health care professionals in a better position to develop a more comprehensive understanding of their patients' health needs and psychosocial determinants of health. Due to intergenerational factors, intervening at the family level can potentially reduce the impact of inter-generational transmission of trauma, especially in children of women with HIV.

Second, results suggest the need for trauma-informed care that “involves a broad understanding of traumatic stress reactions and common responses to trauma” (SAMHSA, 2014, p. 59). SAMHSA (2014) indicated that providers should be aware of how trauma affects treatment across the care continuum. Trauma-informed care will also increase health care professionals' understanding and recognition of trauma and their ability to respond to the effects of different types of trauma. Trauma-informed care can include asking patients about their experiences of trauma to identify those at risk while also facilitating opportunities for healing. In addition, trauma-informed care helps providers “understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services” (SAMHSA, 2014, p. 59).

Finally, the current study highlights the need for interventions for women with HIV who have experienced trauma. The interventions should provide women with HIV with mental health awareness, social groups, counseling, and other methods that promote empowerment and healing. Prevention strategies targeting women who experienced and/or are experiencing trauma can also serve as a key element of preventing future spread of HIV.

Limitations

The current study has some limitations. Given that the nature of qualitative research requires recall of lived experiences and traumatic events, some omissions or alterations may have impacted the accuracy of responses obtained. In addition, study participants were all receiving care at the time of the study and thus are not representative of women with HIV who are not currently receiving care. Finally, the study primarily included women of color from South Carolina, and the results may not be generalizable to the entire U.S. population. Nonetheless, identifying traumatic experiences in this region may be useful in tailoring health care interventions in an area with some of the highest rates of HIV in the country, as well as informing initiatives in other regions.

Conclusion

The study's findings indicate that experiences of trauma among women with HIV include loss, sexual assault, and homelessness. Regarding issues co-occurring with trauma, women who experienced trauma cited a history of substance use and PTSD. These results are consistent with prior research on experiences of and responses to trauma among women with HIV. The study adds to the existing body of literature by including an intergenerational family dynamic component in the context of trauma and psychological well-being. The study's findings offer practical implications for health care professionals and other individuals within the continuum of care. Ideally, the study implications will be used to develop (a) a family/patient-centered care model that is culturally informed to meet the needs of patients; (b) trauma-informed care; and (c) intervention strategies that address trauma in women with HIV.

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Demographic Characteristics of Women with HIV (N = 20)

Variablen (%)
Age (years) (mean [SD])48.9 (12.2)
  18 to 292 (10)
  30 to 392 (10)
  40 to 496 (30)
  50 to 595 (25)
  60 to 695 (25)
Race
  African American14 (70)
  White3 (15)
  Hispanic2 (10)
  African1 (5)
Marital status
  Single14 (70)
  Married3 (15)
  Separated2 (10)
  Widowed1 (5)
Children
  0 to 16 (30)
  2 to 38 (40)
  ≥46 (30)
Time since diagnosis (years)
  0 to 55 (25)
  6 to 104 (20)
  11 to 153 (15)
  16 to 202 (10)
  ≥216 (30)
Housing community
  Urban13 (65)
  Rural6 (30)
  Both1 (5)
Authors

Dr. Ingram is Postdoctoral Fellow, Dr. Qaio is Assistant Professor, Dr. Li is Professor and Endowed Chair, and Ms. Deal is Public Health Undergraduate Student, South Carolina Smart-State Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to LaDrea Ingram, EdD, CHES, Postdoctoral Fellow, South Carolina SmartState Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208; e-mail: ingram3@mailbox.sc.edu.

Received: June 03, 2018
Accepted: August 22, 2018
Posted Online: November 01, 2018

10.3928/02793695-20181023-01

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