The change in the epidemiological profile and clinical characteristics of HIV/AIDS observed in several countries is characterised by the chronification of this pathology. Patients living with HIV face many challenges to their quality of life. This area requires research into new variables and relationships between the clinical characteristics of the illness and the patients.
The time perspective, defined as the subjective and often unconscious way in which an individual perceives time, has been recognised as an important variable for understanding health and illness behaviours (Boyd and Zimbardo, 2005).
The perception of time (past, present and future) may influence the attitudes and behaviours of people living with HIV and, consequently, affect psychosocial and physiological aspects of their lives and health (Barak, 2006; Préau et al, 2007). Among other aspects, psychosociological involvement, including emotional state, mood and optimism, is directly related to the immune system and is associated with the number of cluster of differentiation 4 (CD4) cells (Segerstrom, 2001).
Studies have revealed that a negative affective style triggers a negative immune response and leads to a greater disease risk (Barak, 2006; Préau et al, 2007). Negative and positive feelings interfere with the reactions of the immune system and there are indications of significant associations between time perception and the quality of life of people with HIV (Préau et al, 2007). A future-oriented time perspective has been found to be related to a lower probability of engaging in risky behaviours in people with HIV (Rothspan and Read, 1996).
Zimbardo and Boyd (2008) argued that when people are focused on the past, they may recall negative memories that can cause depressive thoughts. Individuals who are intensely focused on the hedonistic or fatalistic present may experience moments when they are tempted to participate in high-risk behaviours and, being fully future oriented, are at risk of further frustration about life.
Time perspective, as a psychological circumstantially determined construct, may be related to sociodemographic factors. Some studies have pointed to socioeconomic deprivation being associated with the fatalistic present and the negative past, which in turn are related to depression, whereas a positive future and past orientation have been negatively associated with psychiatric disorders (Zimbardo and Boyd, 1999; Boniwell and Zimbardo, 2004; Guthrie et al, 2009).
When reviewing the literature, no studies were found that correlated the time perspective with sociodemographic, clinical and behavioural factors in the context of HIV. Consequently, the objective of this study was to analyse the relationships between sociodemographic, clinical and behavioural variables and the time perspective in Brazilians living with HIV. We hypothesised that the time perspective of people living with HIV may vary according to sociodemographic, clinical and behavioural characteristics. Considering the particularities of the life situations of subjects living with HIV, these relationships can inform the practices of healthcare and nursing.
Methods
Participants and study design
This was a cross-sectional study with a non-probability convenience sample. Data collection was performed in four specialised HIV care services located in the state of Rio de Janeiro, Brazil, in 2016.
A total of 281 people living with HIV were invited to participate in the study. At the time they were all under the care of the specialised HIV care services. To collect data, two instruments were used:
Participants were invited to take part in the research study on a voluntary basis. The ethical and legal aspects were completed in accordance with Resolution 466/12 of the National Health Council, and was approved by the Committee of Ethics in Research of the Municipal Health Secretariat of Rio de Janeiro (registration number: 47411315.7.3001.5279; number of opinions: 1.441.788).
Time perspective (dependent variable)
The time perspective was evaluated using the ZPTI-25, an instrument composed of 25 items divided into five subscales, representing propositions about beliefs, preferences and values of time experiences, namely (Cecilio, 2019):
Each ZPTI-25 item was scored on a Likert scale from 1 to 5 and the average of items from each subscale was used as a time perspective score.
ZTPI-25 had its psychometric properties (reliability and validity) tested in a sample of people living with HIV in Brazil. This version was considered adequate, with satisfactory adjustment, and a stable structure and it maintained satisfactory internal consistency indexes (Cecilio 2019).
Sociodemographic, clinical and behavioural characteristics (independent variables)
These were:
Data analysis
Descriptive statistics procedures were used to express the results as absolute and relative frequencies, means and standard deviations, and minimum and maximum values. Simple and multiple linear regression analyses were conducted to evaluate the relationships of sociodemographic, clinical and behavioural variables with the scores of each subscale of the time perspective. Multiple models were constructed using the backward method, in which all the independent variables were initially incorporated into the models, and subsequently the variables with the highest values of a were removed one by one in stages until the critical level of 0.20 had been reached. Thus, all variables that reached an a≤0.20 were maintained in the model for adjustment purposes. The significance level adopted in the study was 5% (a=0.05). Data were analysed with IBM SPSS Statistics for Windows (IBM Corp., SPSS 21.0, 2012).
Results
The sociodemographic, clinical and behavioural characteristics of the participants are presented in Table 1. A total of 281 people living with HIV, ranging in age from 18 to 72 years (mean = 41.1 years, standard deviation (SD) = 12.8 years) participated in the study. The mean values ± standard deviation of time since HIV diagnosis and time of HAART use were: 126.1 ± 89.9 months and 100.0 ± 82.1 months, respectively. The majority of the sample were men, living in large cities, with a high school education, who were engaged in some remunerated activity and were religious.
| Variable | % of answers (n=281) | n (%) | Mean ± SD | Variable | % of answers (n=281) | n (%) | Mean ± SD | |
|---|---|---|---|---|---|---|---|---|
| City | 100 | Source of information on HIV | 100 | |||||
| Small or medium | 48 (17) | Social media/sites in general | 187 (66.5) | |||||
| Big | 233 (83) | Scientific/professional environment | 94 (33.5) | |||||
| Age (years) | 100 | 41.1 ± 12.8 | HIV diagnosis time (months) | 98 | 126.1 ± 89.9 | |||
| Gender | 100 | Use of HAART | 100 | |||||
| Male | 193 (69) | No | 16 (6) | |||||
| Female | 88 (31) | Yes | 265 (94) | |||||
| Schooling | 100 | Time of HAART use (months) | 98 | 100.0 ± 82.1 | ||||
| Elementary school | 48 (17) | Sexual orientation | 100 | |||||
| High school | 162 (58) | Heterosexual | 144 (51) | |||||
| Higher education | 71 (25) | Homosexual/bisexual | 137 (49) | |||||
| Occupation | 100 | Form of HIV infection | 100 | |||||
| No remunerated activity | 95 (34) | Sexual way | 234 (83) | |||||
| Remunerated activity | 186 (66) | Non-sexual way | 47 (17) | |||||
| Religion | 100 | Consider themselves ill | 100 | |||||
| Without religion | 74 (26) | No | 234 (83) | |||||
| With religion | 207 (74) | Yes | 47 (17) | |||||
| Marital status | 100 | Self-reported health status | 100 | |||||
| Have a partner | 139 (49) | Negative health | 48 (17) | |||||
| Do not have a partner | 142 (51) | Positive health | 233 (83) |
n: absolute frequency; SD: standard deviation; HIV: human immunodeficiency virus; HAART: highly active antiretroviral therapy
The main reported information source on HIV was social media and general sites and most interviewees used HAART. The majority of participants reported that they believed that they had become sexually infected, did not consider themselves to be ill, and had a positive health self-perception. Distributions observed for marital status (not having a partner vs. having a partner) and sexual orientation (heterosexual vs. homosexual bisexual) were similar.
The time perspective scores according to each subscale are presented in Figure 1. The mean scores ranged from 2.75 (hedonistic present) to 3.85 (future). Taking into account the 95% confidence interval (CI), it is verified that the highest time perspective score was observed in the future subscale, followed by the positive past subscale. By contrast, the lowest time perspective scores were verified in the hedonistic present and fatalistic present subscales.
Table 2 presents the results of simple and multiple linear regressions for the prediction of time perspective (negative past and positive past) in the study participants. In the univariate analysis, age, education, and the search for information by scientific/professional methods indicated a negative association with the negative past score. Conversely, considering oneself ill was positively associated with a negative past score. In the multiple regression model, age and the search for information by scientific/professional means lost statistical significance; therefore, the adjusted analysis indicated that only schooling (negative association) and considering oneself ill (positive association) were independently related to the negative past score.
| Independent variable | Time perspective subscale | |||
|---|---|---|---|---|
| Negative past | Positive past | |||
| ß crude (P variable) | ß adjusted (P variable)* | ß crude (P variable) | ß adjusted (P variable)† | |
| Age | -0.010 (0.044) | -0.008 (0.085) | — | — |
| City (big) | — | — | -0.148 (0.282) | -0.254 (0.064) |
| Schooling (ordinal) | -0.437 (<0.001) | -0.380 (<0.001) | — | — |
| Marital status (having a partner) | -0.191 (0.126) | -0.192 (0.103) | — | — |
| Religion (religious) | — | — | 0.172 (0.145) | 0.217 (0.062) |
| Information source (scientific/professional environment) | -0.337 (0.010) | -0.230 (0.070) | — | — |
| Use of HAART (yes) | — | — | -0.475 (0.034) | -0.383 (0.099) |
| Time (length) of HAART use | — | — | -0.002 (0.001) | -0.002 (0.001) |
| Form of HIV infection (non-sexual pathway) | -0.272 (0.104) | -0.237 (0.133) | -0.182 (0.191) | -0.185 (0.184) |
| Considered themselves ill (yes) | 0.632 (<0.001) | 0.568 (<0.001) | — | — |
| Self-reported health status (positive health) | — | — | 0.238 (0.084) | 0.300 (0.029) |
—: variables removed from the model during the adjustment method HAART: highly active antiretroviral therapy; HIV: human immunodeficiency virus
For the positive past, the univariate analysis indicated that the use of HAART and the length of time of use of HAART were negatively associated with this outcome. In the multiple regression model, the length of use of HAART lost statistical significance, while the use of HAART remained associated with the positive past score; additionally, after adjusting the model, a positive health status, which was not associated in the univariate analysis, became positively associated with the positive past score (Table 2).
Table 3 demonstrates the results of simple and multiple linear regressions to predict the time perspective (fatalistic present and hedonistic present) in people living with HIV. In the univariate analysis, age, female gender, the use of HAART and non-sexual infection indicated a positive association with the fatalistic present score. By comparison, schooling was negatively associated with the fatalistic present score. In the multiple regression model, the form of HIV infection lost statistical significance; therefore, the adjusted analysis indicated that age, female gender, and the use of HAART were positively and independently associated with the fatalistic present score, while the schooling variable was negatively and independently associated with this outcome.
| Independent variable | Time perspective subscale | |||
|---|---|---|---|---|
| Fatalistic present | Hedonistic present | |||
| ß crude (P variable) | ß adjusted (P variable)* | ß crude (P variable) | ß adjusted (P variable)† | |
| Age | 0.009 (0.031) | 0.010 (0.032) | -0.012 (0.002) | -0.012 (0.002) |
| Gender (female) | 0.356 (0.002) | 0.258 (0.027) | -0.130 (0.241) | -0.176 (0.169) |
| Schooling (ordinal) | -0.340 (<0.001) | -0.289 (0.001) | -0.225 (0.004) | -0.269 (0.001) |
| Occupation (with remunerated activity) | — | — | -0.072 (0.082) | -0.165 (0.139) |
| HIV diagnosis time | <0.001 (0.499) | -0.001 (0.168) | — | — |
| Use of HAART (yes) | 0.509 (0.030) | 0.492 (0.044) | — | — |
| Form of HIV infection (non-sexual) | 0.349 (0.016) | 0.421 (0.142) | — | — |
| Sexual orientation (homosexual/bisexual) | — | — | 0.192 (0.064) | 0.189 (0.116) |
—: variables removed from the model during the adjustment method HAART: highly active antiretroviral therapy; HIV: human immunodeficiency virus
For the hedonistic present, the univariate analysis indicated that age and schooling were negatively associated with this outcome. In the multiple regression model, both variables remained associated with the hedonistic present score (Table 3).
Table 4 illustrates the results of the simple and multiple linear regressions for the prediction of future subscale scores in the time perspective of the study participants living with HIV. In the univariate analysis, an occupation with remunerated activity and positive state of health indicated a positive association with the future score. In the multiple regression model, both factors were positively and independently associated with the future score.
| Independent variable | Time perspective subscale | |
|---|---|---|
| Future | ||
| ß crude (P variable) | ß adjusted (P variable)* | |
| Occupation (with remunerated activity) | 0.308 (0.001) | 0.250 (0.011) |
| HIV diagnosis time | -0.001 (0.169) | -0.001 (0.157) |
| Sexual orientation (homosexual/bisexual) | <0.001 (0.999) | -0.127 (0.153) |
| Self-reported health status (positive health) | 0.372 (0.001) | 0.310 (0.010) |
HIV: human immunodeficiency virus
Discussion
It is worth noting that this is the first study that has analysed the associations of sociodemographic, clinical and behavioural factors with the time perspective specifically in a group of people living with HIV.
As far as the time perspective is concerned, a harmonious life is the result of a balanced perception of all time dimensions. Fixating on one time perspective does not seem to contribute to a balanced life and to self-care. A totally future-oriented stance can contribute to time management, but it can also cause the individual to not enjoy the present moment by sacrificing present enjoyment for the future benefits. Equally, individuals attached to a positive past usually honour their responsibilities and obligations, but may be resistant to any changes proposed. Fixation with the positive past and future have been negatively associated with psychiatric disorders such as depression (Zimbardo and Boyd, 1999; Boniwell and Zimbardo, 2004).
It can be inferred that the study participants were more oriented towards the future and the positive past, characterising a predominantly positive time perspective. In general, the dimensions of the future are positive, configured in plans, goals and rewards as, when experiencing the present, the subject may value their present life and believe that goals can be achieved in the future (Zimbardo and Boyd, 1999).
Findings from a study in France that assessed the perception of time, quality of life, and factors related to the treatment of a similar group of people living with HIV pointed to the fact that the inclination towards the future and a positive past was associated with a trust relationship with the health professional (Préau et al, 2007). In addition, the study found that those individuals who look to a future and reconstruct a positive past have an improved quality of life and experience with the disease (Préau et al, 2007). Hypothetically, the orientation to these two time dimensions can contribute to coping, acceptance, adaptation, and overcoming problems in the case of people with chronic conditions such as HIV.
The results of the present study point to the research participants having lower orientations towards the fatalistic and hedonistic present. Other researchers noted that the greater the individual's age, the greater the orientation to the fatalistic present and the lesser orientation to the hedonistic present (Laureiro-Martinez et al, 2017).
People more oriented towards the fatalistic present, denoted by a strong belief in predetermined fate, may have little faith in efforts to achieve better health in the present or the future, while those who are more oriented towards the future may invest their daily energies in lifestyle changes that can improve their health status over time (Sansbury et al, 2014). In this perspective, the greater inclination towards the fatalistic present with the increase of the age of people living with HIV can also be based on conformism and the thought of a predetermined destiny, given the incurable nature of the pathology. According to one study, individuals in adulthood understand the present in a less hedonistic way (Laureiro-Martinez et al, 2017).
According to the present study, female participants have more fatalistic attitudes than males. This result can be attributed to the lower acceptance levels towards the disease, which is often due to the stigma around this type of sexually transmitted infection. There are other factors that may be linked with the fatalistic positioning of women with HIV, as indicated by Barbosa et al (2012), related to moral, cultural, religious and gender aspects that influence the affective, sexual and reproductive life before and after the diagnosis.
According to the present study, the higher the education level of the individual, the lower his or her orientation to the negative past, fatalistic present, and hedonistic present. The association of a higher educational level with future perspectives is expected, due to the fact that schooling opens perspectives of investment in the future. A higher educational level can provide better occupational conditions and, consequently, better health conditions (Guthrie et al, 2009). In this sense, it can be assumed that individuals living with HIV who have attended higher education institutions tend to have greater satisfaction and time perspectives that are more favourable to their health.
Likewise, it has been found that individuals who consider themselves to be ill have greater inclinations towards a negative past view, which affects their present.
The results of this investigation reveal that the longer the use of HAART, the less the orientation towards a positive past. This relationship can be attributed to the adverse effects that many individuals experience at the beginning of and throughout the treatment. Even today, with the evolution of treatments, there are difficulties for many users regarding HAART adherence. The lifestyle of a person living with HIV can be modified by adhering to HAART, requiring the observance of schedules and some systematisation regarding the intake of medicines, among other things, which can negatively affect the perception of a positive past.
On one hand, the authors observed a positive health perception associated with past positivity on the part of the participants in this study. On the other hand, this study points out that individuals who use HAART have greater orientations towards the fatalistic present. After the diagnosis of HIV and the resulting drug dependence, the user begins to experience conflict, since in addition to the wellbeing related to therapy, its possible abandonment can aggravate the disease and lead to greater difficulty in its control or to death (Gomes et al, 2011). Thus, it is assumed that the inclination towards the fatalistic present may be related to risky behaviour.
In relation to the participants who were working for remuneration during the period of the research, a greater orientation is observed towards the dimension of the future. By contrast, a study that related socioeconomic deprivation to time perspective found greater associations of people who were employed with the hedonistic present. Socioeconomic deprivation in the aforementioned study was related to the negative past and the fatalistic present (Guthrie et al, 2009). People with low socioeconomic status have worse evaluations of their health status than those with better financial conditions (Sorlie et al, 1995; Pamuk et al, 1998; Steenland et al, 2004).
Studies evaluating the employment situation and health-related quality of life among people living with HIV have indicated improvements in the wellbeing of those who are in remunerated employment (Rueda et al, 2011; Martin et al, 2012). It is presumed that, in this regard, the participants in the present study who were in remunerated employment had good perspectives regarding their health since they prioritised the future in their time orientation.
In general, adults with future-oriented perspectives have better healthcare practices, such as physical activity habits, condom use in sexual relationships, no substance abuse habits, and psychological wellbeing (Henson et al, 2006; Guthrie et al, 2014). In this sense, the future time perspective, a more pronounced characteristic of the participants of this study, is possibly a predictor of good healthcare practices in the search for a better quality of life.
From the results of this study it is possible to reaffirm the importance of incorporating the time perspective into nursing care practices, since this variable seems to play a significant role in the care and self-care of people living with HIV. Through qualified listening, involving relationships such as dialogue, bonding and welcoming, the nurse can, for example, understand possible conflicts, value experiences and pay attention to the needs that compose the lifestyle of people with HIV.
Limitations
The present study has some limitations that suggest that the results should be interpreted with caution. The cross-sectional delineation does not allow the establishment of a causal relationship between sociodemographic, clinical and behavioural factors with the time perspective. Moreover, as it is a subjective construct, the measured time perspective does not guarantee a definitive diagnosis and may vary over time. It is also important to highlight that the present study was constituted from a non-probability sample. Thus, the conclusions presented here are limited to the evaluated group and cannot be stratified for the entire population of Brazilian individuals living with HIV.
Conclusion
Based on the results presented, it is possible to conclude that the people living with HIV in the studied sample presented greater orientation towards the future and less orientation towards the fatalistic present and the hedonistic present. Higher schooling was associated with less orientation to the negative past, while considering oneself ill favoured orientation towards the negative past. Longer use of HAART was associated with less orientation to the positive past, while positive health status favoured a positive past orientation. Greater age, female gender, and the use of HAART favoured orientation towards the fatalistic present, whereas higher schooling levels were associated with less orientation for this time dimension; older age and schooling were associated with lower orientation towards the hedonistic present; and a remunerated occupation and a positive state of health favoured orientation towards the future.
More studies on this subject are needed. By using an integrated healthcare approach and considering the time perspective as a predictor of favourable behaviour or risk to health, all health professionals may stimulate individuals with HIV to take pride in their self-care and lead a healthier life.