Path Analysis of Physical symptoms, emotional support, self-esteem, and depressive symptoms in HIV-positive perinatal women in Thailand

Evidence shows that depressive symptoms are associated with faster progression to AIDS in HIVinfected populations. Physical symptoms, self-esteem, and emotional support have been reported to play a major role in contributing to depressive symptoms. However, comparisons of different sources of support— specifically family vs. friends— have only been made in a few previous HIV studies. Therefore, the objectives of this study among HIV-positive perinatal Thai women were to examine: 1) both the direct and indirect effects of physical symptoms and emotional support on depressive symptoms; 2) which source of support is more significant, family or friends; and 3) the direct effect of self-esteem on depressive symptoms. Results revealed that half of the participants experienced major depressive symptoms. Physical symptoms and self-esteem both had direct effects on depressive symptoms. Emotional support, from friends and family, had an indirect effect on depressive symptoms. Treating physical symptoms and increasing self-esteem through emotional support, could help decrease depressive symptoms in the target population. Finally, it is crucial that routine screening for depressive symptoms is established at all HIV clinics for perinatal women in Thailand. DOI : 10.14302/issn.2324-7339.jcrhap-12-147 Corresponding author: Ratchneewan Ross, College of Nursing; Kent State University; Kent, OH 44242. Email: rross1@kent.edu


Introduction
presence of physical symptoms, low emotional support, low self-esteem, and poor physical health. 11,12,[14][15][16][17][18][19] Studies in various countries have found that HIV-positive perinatal women with low self-esteem tend to report more depressive symptoms than those with high self-esteem. 11,12,17,20 Qualitative studies have found that HIV-positive pregnant women in Thailand with low self-esteem are more likely to be depressed than those with high self-esteem, and stigmatization related to the infection seemed to be an antecedent of low self-esteem. [21][22][23] Further, perinatal women with HIV tend to have low self-esteem and negative personal perceptions that lead to depression. They consider themselves as inferior or incapable women and fear being condemned both on a moral level and for having failed as mothers. 24 Studies have found that HIVpositive pregnant and postpartum Thai women worry constantly about their infant's health, fearing that the fetus/infant has been infected. 22,25,26 Negative perceptions about the infant's health can compound the mother's negative feelings of being incompetent and have been positively linked to depressive symptoms in Thai and U.S. postpartum women. 12,27 Emotional support also plays a major role in contributing to depressive symptoms. In Thailand, emotional support from family and friends has been negatively related to depressive symptoms in postpartum women 28,29 and HIV-positive pregnant women. 11 However, to our knowledge, the two sources of support have not been compared in most previous HIV studies, 12,[14][15][16]18 except in one study among HIVpositive women 19 and youth in the USA. 30 Family support was found to be related to less depression among young US individuals. 30 With only limited support, HIV-positive individuals are more likely to exhibit depressive symptoms. 11,21,22,31 Other correlates of depressive symptoms include a history of psychiatric disorders, 32,33 low income, 34 and low levels of education. 35 The objectives of this study were to examine among HIV-positive perinatal Thai women: 1) both the direct and indirect effects of physical symptoms and emotional support on depressive symptoms; 2) which source of support is more significant, family or friends; and 3) the direct effect of self-esteem on depressive symptoms. We hypothesized that physical symptoms and emotional support had both direct and indirect effects on depressive symptoms, while self-esteem had a direct effect on depressive symptoms ( Figure 1). We also hypothesized that family is a stronger source of support than friends in the target population.  40 An initial path analysis was constructed and run to examine the relationships among physical symptoms, combined

Results
The average age of the participants was 26.4 (SD=5.4) with each averaging one child per family.
Approximately half of the participants were unemployed (45%), most lived with their spouse (90%), and more than half reported they did not make enough money (62%). About half of the participants had known their HIV status for over 6 months. Three out of four (75.5%) reported no physical symptoms. The top three frequent symptoms reported included fatigue (n=32), anemia (n=27), and weight loss (n=15). Table 1 shows each key variable's mean, standard deviation, total score, and possible score range.   Figure 2 shows that depressive symptoms were predicted by physical symptoms, combined emotional support from family and friends, and self-esteem which together accounted for 32% (R 2 = .32) of the explained variance in depressive symptoms. Significant standardized direct, indirect, and total effects are presented in Table 3 for this model and the other models which will follow. Table 4 shows values of model fit indices for this model and other models which also will follow. The path coefficients from physical symptoms to self-esteem, from physical symptoms to combined emotional support, and from combined emotional support to depression were not significant ( Figure 2). Therefore, the model was trimmed by excluding non-significant paths and reanalyzed.        confidence interval of RMSEA is wide, indicating possible estimate instability. 41 The R 2 value of .31 for depressive symptoms in the trimmed model was slightly smaller than that of the initial model. Statistically, physical symptoms had a positive direct effect on depressive symptoms, while self-esteem had a negative direct effect on depressive symptoms (Figure 3). Combined emotional support had no direct effect but did have an indirect effect on depressive symptoms through selfesteem (Table 3). Table 5 shows the maximum likelihood estimates of the trimmed path model with combined emotional support from family and friends.
To examine the effect of family support vs.
friend support, we ran two models separately-one with friend support and the other one with family support.   (Table 3). This friend support model was found to fit the data less well than the combined support model, based on different model fit indices (Table 4). The R 2 value of .31 for depressive symptoms in this model was slightly smaller than that of the initial model. Table 7 shows the family support model's maximum likelihood results. Figure 5 shows a nonsignificant covariance between physical symptoms and family and friend support. The model fits the data best among all four models, based on various model fit indices (Table 4). The R 2 value of .30 for depressive symptoms in this model was slightly smaller than that of the initial, trimmed, and friend support models.
Statistically, physical symptoms had a positive direct effect on depressive symptoms, while self-esteem had a negative direct effect on depressive symptoms. Family support had no direct effect but did have an indirect effect on depressive symptoms through self-esteem ( Figure 5). Again, Table 3 summarizes the significant standardized direct, indirect, and total effects, and R 2 values in depressive symptoms for all of the four models.

Discussion
This study is the first to examine both the direct