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Ageism, resilience, coping, family support, and

quality of life among older people living with HIV/
AIDS in Nanning, China

Yongfang Xu, Xinqin Lin, Shiyi Chen, Yanfen Liu & Hongjie Liu

To cite this article: Yongfang Xu, Xinqin Lin, Shiyi Chen, Yanfen Liu & Hongjie Liu (2016):
Ageism, resilience, coping, family support, and quality of life among older people living with
HIV/AIDS in Nanning, China, Global Public Health, DOI: 10.1080/17441692.2016.1240822

To link to this article: http://dx.doi.org/10.1080/17441692.2016.1240822

Published online: 19 Oct 2016.

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GLOBAL PUBLIC HEALTH, 2016
http://dx.doi.org/10.1080/17441692.2016.1240822

Ageism, resilience, coping, family support, and quality of life

among older people living with HIV/AIDS in Nanning, China
Yongfang Xua, Xinqin Lina, Shiyi Chena, Yanfen Liub and Hongjie Liuc
a
Nanning Center for Disease Control and Prevention, Nanning, People’s Republic of China; bNanning 4th
Hospital, Nanning, People’s Republic of China; cSchool of Public Health, University of Maryland, College Park,
MD, USA

ABSTRACT ARTICLE HISTORY

Although the HIV epidemic continues to spread among older adults Received 31 October 2015
over 50 years old in China, little empirical research has investigated Accepted 19 September 2016
the interrelationships among ageism, adaptability, family support,
KEY WORDS
and quality of life among older people living with HIV/AIDS Ageism; adaptability; family
(PLWHAs). In this cross-sectional study, among 197 older PLWHAs support; quality of life; older
over 50 years old, path analytic modelling was used to assess the people living with HIV/AIDS
interrelationships among ageism, resilience, coping, family
support, and quality of life. Compared with female PLWHAs, male
PLWHAs had a higher level of resilience and coping. There were
no significant differences in the scores of quality of life, ageism,
family support, HIV knowledge, and duration since HIV diagnosis
between males and females. The following relationships were
statistically significant in the path analysis: (1) family support →
resilience [β (standardised coefficient) = 0.18], (2) resilience →
ageism (β = −0.29), (3) resilience → coping (β = 0.48), and (4)
coping → quality of life (β = 0.24). In addition, male PLWHAs were
more resilient than female PLWHAs (β = 0.16). The findings
indicate that older PLWHAs do not only negatively accept
adversity, but build their adaptability to positively manage the
challenges. Family-based interventions need take this adaptability
to adversity into consideration.

Introduction
Older people living with HIV/AIDS (PLWHAs), defined as HIV-infected adults who are
over the age of 50 (Emlet et al., 2015; High et al., 2012), face at least two primary sources of
stigma: HIV-related stigma and age-related stigma (Palmore, 2001). With the advent of
antiretroviral therapy, PLWHAs live longer and HIV/AIDS has become a chronic con-
dition, posing new age-related challenges including disease management, stigma, and
quality of life. Stigma has been described as a quality that ‘significantly discredits’ an indi-
vidual in the eyes of others (Goffman, 1968). Although there is great variation in defining
or conceptualising stigma, it is generally considered to be ‘an attitude used to separate
affected individuals from the normalised social order’ (Gilmore & Somerville, 1994, p.
1340). The separation implies a process of devaluation, prejudice, discounting, discredit-
ing, and discrimination against the stigmatised group.

CONTACT Hongjie Liu hliu1210@umd.edu

© 2016 Informa UK Limited, trading as Taylor & Francis Group
2 Y. XU ET AL.

Stigma has multiple manifestations, including perceived, internalised, and enacted

stigma (Earnshaw & Kalichman, 2013; Liu, Xu, Sun, & Dumenci, 2014). Perceived
stigma refers to the fear of societal attitudes and potential discrimination perceived by a
stigmatised group (e.g. older PLWHAs) (Green & Platt, 1997). Similarly, enacted stigma
represents the extent that an individual actual experiences prejudice and/or discrimination
emanating from others (Green & Platt, 1997). Finally, internalised stigma is the extent to
which negative attributes and beliefs about elders are endorsed and accepted internally
(Earnshaw & Chaudoir, 2009). While research has focused on HIV-related stigma, age-
related stigma is largely ignored among older PLWHAs, especially in the developing
world.
Ageism is defined as the process of systematic stereotyping and discrimination
against people because of their old age (Buler, 2006). It includes both prejudices
(beliefs and attitudes) and discrimination (actions) towards ageing individuals based
on the belief that older adults are unattractive, unintelligent, unemployable, and men-
tally incompetent (Atchley & Barusch, 2004; Palmore, 1999). Exposure to unfavourable
ageism adversely impacts the attitudes, cognitions, and behaviour of older adults
(Allen, 2016). Older adults are often treated differently by healthcare providers com-
pared to their younger counterparts (Eymard & Douglas, 2012). Consequently, older
patients may not receive appropriate medications and procedures (Robb, Chen, &
Haley, 2002). Previous research has also documented that ageism affects mental
well-being and health conditions associated with chronic diseases (Allen, 2016;
Meisner, 2012).
The current literature exclusively focuses on identifying factors contributing to the
harmful impact of stigma on the lives of stigmatised people. This focus, however,
cannot explain why many stigmatised individuals function just as well as individuals
who are not stigmatised (Margaret, 2004; Miller & Kaiser, 2001). This phenomenon
could be due to an individual’s adaptive response to stigma stressors (Boardman et al.,
2011; Earnshaw, Bogart, Dovidio, & Williams, 2013; Thoits, 2011). The development of
adaptability to health adversity involves two processes: resilience and coping. Resilient
individuals display positive adaptation despite experiences of significant adversity
(Lutha & Cicchetti, 2000). It is a two-dimensional construct that implies exposure to
adversity (e.g. HIV infection and ageism) and the manifestation of positive adjustment
outcomes (e.g. social competence or well-being) (Allen, Haley, Harris, Fowler, & Pruthi,
2011; Lutha & Cicchetti, 2000). Personal resilience has been examined in relation to an
individual’s response to depression (Elisei, Sciarma, Verdolini, & Anastasi, 2013),
stigma (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2015), and quality of life (Bodde,
Schrier, Krans, Geertzen, & Dijkstra, 2013; Herrmann et al., 2011).
As the second adaptation process, coping is defined as continually changing behav-
ioural and cognitive efforts to manage external/internal demands that are appraised as
exceeding the individual’s resources (Lazarus & Folkman, 1984, 1987). Coping strategies
are either emotion-focused or problem-focused (Folkman & Lazarus, 1985; Lazarus,
1993). The problem-focused strategy aims at problem-solving or doing something to
alter the source of stress induced by stigma, while the emotion-focused strategy aims at
reducing or managing emotional distresses (e.g. denial, avoidance, or stigma). In
general, effective coping has been related to better psychological outcomes among
PLWHAs (Blashill, Perry, & Safren, 2011; Harding, Liu, Catalan, & Sherr, 2011;
 GLOBAL PUBLIC HEALTH 3

Heckman et al., 2001; Kerr, Miller, Galos, Love, & Poole, 2013; McIntosh & Rosselli, 2012).
As reported from a meta-analysis of 63 studies, coping is associated with greater psycho-
logical and physical well-being among PLWHAs (Moskowitz, Hult, Bussolari, & Acree,
2009).
To manage stigma and retain good quality of life, individuals may draw on the
resources available to them in order to develop their personal resilience and coping
skills (Boardman et al., 2011). In fact, social support, especially, family support, has
been considered as an important resource for establishing resilience (Earnshaw et al.,
2015). In contrast to the individualist culture of Western society, Chinese culture is
collectivist (Triandis, 1995), in which individuals are not viewed as independent
units. Chinese people have been deeply influenced by Confucian philosophy which
emphasises the importance of placing family needs above personal needs (King &
Bond, 1985; Liu, 2001). Following this philosophy, Chinese are generally more likely
to sacrifice their own interests to promote family values and feel a sense of obligation
and responsibility to their family (Chen & Fan, 2010; Murray-Johnson et al., 2001; Tri-
andis, Bontempo, Villareal, Asai, & Lucca, 1988). When facing stigma, discrimination
and other HIV-related adversities, a strong and supportive family is one of the first
lines of defense. According to our and others’ studies (Li et al., 2008a; Zang, Guida,
Sun, & Liu, 2014), it becomes particularly important for families to stay close and
support each other when they face HIV-related challenges. Adequate family support
may promote the development of adaptability to adversity and maintain better
quality of life.
Recent theoretical and empirical work calls for research on positive-response mechan-
isms against stigma (Earnshaw et al., 2013; Earnshaw et al., 2015). However, few studies
have explored the way in which older PLWHAs develop and maintain personal resilience
and coping strategies to reduce the impact of stigma on their quality of late life. The lack of
such research has limited our understanding of protective mechanisms against stigma and
development of effective interventions to promote adaptability and improve the lives of
older PLWHAs and their close associates.
We conducted an exploratory study among older PLWHAs in which we hypothesised
the interrelationships among adaptability (resilience and coping), family support, enacted
ageism, and quality of life that were represented in the relational-path diagram (Figure 1).
Specifically, we hypothesised that (1) strong family support was positively associated with
stronger resilience which led to greater coping, (2) resilience reduced or mitigated the
adverse impact of enacted ageism on quality of life, and (3) strong family support was
associated with better quality of life. The development of our hypothesis is based on the
literature review, theory of stigma as discussed above (Goffman, 1968; Palmore, 2001),
and our experience with stigma research (Liu, Feng, Rhodes, & Liu, 2009; Liu, Xu, Lin,
Shi, & Chen, 2013).

Methods
The study protocol and consent procedures were reviewed and approved by the Insti-
tutional Review Board of Guangxi Center for Disease Control and Prevention. In accord-
ance with the approved protocol, written informed consent was obtained from all study
participants prior to data collection.
4 Y. XU ET AL.

Figure 1. Hypothesised paths among ageism, adaptability, support, and quality of late life.

Study sites and subjects

This exploratory cross-sectional study was conducted in Nanning, the capital city of
Guangxi province. Guangxi ranks second among China’s 31 provinces in terms of the esti-
mated number of PLWHAs in 2011 (Ministry of Health of the People’s Republic of China,
March 31, 2012). The major HIV transmission routes are needle sharing and heterosexual
sex.
Study subjects were recruited from a hospital that was designated by the local
Department of Health to diagnose and treat HIV/AIDS patients. Eligibility criteria
for PLWHAs included PLWHAs who were at least 50 years old and able to participate
in a face-to-face interview. Using the list of PLWHAs in the hospital, we consecutively
selected and invited eligible older PLWHAs on the list. Staff from the Nanning Center
for Disease Control and Prevention read and explained the informed consent forms to
participants if they were illiterate. After providing informed consent, participants
received a face-to-face paper questionnaire interview in a separate room in the
hospital. A total of 212 eligible older PLWHAs, 12 refused to participate, and 3 did
not provide information on some key variables and were thus excluded from data
analysis.

Measures
The English instruments were translated into Chinese by research members who were
fluent in both languages. The Chinese version of the items was then distributed to research
team members who reviewed and modified the wording to make it appropriate for the
Chinese context.
Quality of life in the month prior to the interview was measured by the Chinese
Quality of Life Scale (Phillips et al., 2002; Zhu, Wang, & Zhong, 2011). Study subjects
were asked to rate six quality of life items related to (1) physical health, (2)
 GLOBAL PUBLIC HEALTH 5

psychological health, (3) economic circumstances, (4) work/housework, (5) family

relationships, and (6) relationships with non-family associates on a scale of 1 (very
poor) to 5 (excellent). The score ranged between 6 and 30 (Cronbach’s reliability
alpha (α) = 0.68). The Resilience Measurement Scale was adapted from the Brief Resi-
lience Scale (Smith et al., 2008) and the Resilience Scale for Adults (Friborg,
Hjemdal, Rosenvinge, & Martinussen, 2003). It includes seven indicators that
measure one’s personal competence, strength, and positive adaptation with four
answer choices: strongly disagree (0), disagree (1), agree (2), and strongly agree (3)
(sample items: ‘I tend to bounce back quickly after hard times’; ‘I have a hard time
making it through stressful events’). Its score ranged between 0 and 21 (α = 0.73). A
revised Coping Self-efficacy scale measured confidence in performing coping behaviours
when faced with life challenges (Chesney, Neilands, Chambers, Taylor, & Folkman,
2006). It consists of 15 indicators that measure problem-focused coping and the
ability to positively manage unpleasant emotions and stressful events. Subjects were
asked ‘When you are having problems, how confident or certain are you that you
can do the followings?’, with four answer choices: No, I cannot do it at all (0); No,
I cannot do it (1); Yes, I can do it (2); and Yes, I definitely can do it (3) (sample
items: ‘Make a plan of action and follow it when confronted with a problem’; ‘Sort
out what can be changed, and what cannot be changed’). The score ranged between
0 and 45 (α = 0.89). Enacted ageism refers to the extent an individual actual experi-
ences prejudice and/or discrimination towards the older PLWHAs, emanating from
others (Green & Platt, 1997; Palmore, 1999). The 15-item scale is adapted from the
Ageism Survey (Palmore, 2001) and the Perceived Age Discrimination Scale (Banas,
2007). Subjects were asked if they had experienced prejudice or discrimination due
to their age, with two answer choices (yes and no). Scores ranged between 0 and 15
(sample items: ‘I was told that I was too old for doing that’; ‘A waiter or waitress
ignored me because of my age’; α = 0.86). The level of family support was measured
by asking subjects to rate the level of support they actually received from each of
the four types of family members, that is, spouse, children, brothers and sisters, and
other family members with four possible response options: no support (1), low
support (2), moderate support (3), and always receive support (4) (composite score
range: 4–16). HIV knowledge regarding HIV transmission and prevention information
was measured by 11 true or false questions (score range: 0–11).

Data analysis
Pearson correlation coefficients were estimated to describe the degrees of associations
among variables of interest. Path analytic modelling was performed to test the hypoth-
esised interrelationships shown in Figure 1. Standardised coefficients (β) for all paths
were estimated. The goodness-of-fit of models was assessed by the value of χ 2/degree of
freedom (recommended value ≤ 5) (Hooper, Coughlan, & Mullen, 2008; Wheaton,
Muthén, Alwin, & Summers, 1977), root-mean-square error of approximation
(RMSEA) ≤ 0.08, standardised root-mean-square residual (SRMR) ≤ 0.08, and Compara-
tive Fit Index (CFI) ≥ 0.90 (Hooper et al., 2008). These analyses were completed using
Mplus 7.31 (Muthen & Muthen, Los Angeles, CA, USA).
6 Y. XU ET AL.

Results
Description of the study sample and measurement
Among 197 older PLWHAs, 71.6% (141) were male. The mean age was 59.7 year old
[Standard deviation (SD) = 7.54]. Two-thirds of the PLWHAs were rural residents and
52.7% were minorities (including Zhuang, Yao, Miao, and other ethnicities). Education
level was relatively low for older PLWHAs, 36% received primary school education or
no education. The median duration since their HIV diagnosis was 2 years (interquartile
range (IQR): 1–4 years). Compared to female PLWHAs, male PLWHAs were older and
received higher education (Table 1).
The mean for the quality of life score was 19.5 (SD = 2.42), 13.2 (SD = 2.31) for resili-
ence, 27.4 (SD = 5.14) for coping, and 12.6 (SD = 2.54) for family support. On average,
PLWHAs experienced a number of 4.3 events of enacted ageism (4.7 for males and 3.8
for females). Compared with female PLWHAs, male PLWHAs had a higher level of resi-
lience and coping. There were no significant differences in the scores of quality of life,
enacted ageism, family support, HIV knowledge level, and duration since HIV diagnosis
between males and females.

Results of correlation analysis

Correlation analysis indicated that quality of life was significantly and positively correlated
with resilience, coping, and family support, but was negatively correlated with enacted
ageism. Resilience was positively associated with coping and family support, but was nega-
tively correlated with ageism. Ageism was negatively correlated with family support and
coping (Table 2).
We used multivariate regression to further analyse the association between enacted
ageism and quality of life by adjusting for gender, age, education, residence, ethnicity,

Table 1. Social demographics, ageism, adaptability, and quality of life among older PLWHAs.
Male (n/%) Female (n/%) p-Value
Education .02
Primary school or less 42 (29.8) 29 (51.8)
Middle school 59 (41.8) 16 (28.6)
High school or above 40 (28.4) 11 (19.6)
Ethnicity .62
Majority 65 (46.1) 28 (50.0)
Minority 76 (53.9) 28 (50.0)
Residence .89
Rural 97 (68.8) 38 (67.9)
Urban 44 (31.2) 18 (32.1)
Mean (SD) Mean (SD)
Age (years) 60.5 (8.13) 57.8 (5.37) .02
Ageism 4.7 (3.91) 3.8 (3.89) .12
Family support 12.6 (2.64) 12.6 (2.26) .85
Resilience 13.4 (2.36) 12.5 (2.07) .02
Coping 28.0 (5.46) 26.0 (3.90) .01
Quality of life 19.5 (2.42) 19.6 (2.46) .88
Duration since HIV diagnosis (year)a 2.0 (1–5) 2.0 (1–4) .77
HIV knowledge 9 (6–11) 9 (5–10) .13
a
Median and IQR.
 GLOBAL PUBLIC HEALTH 7

Table 2 . Correlations among ageism, adaptability, family support, and quality of life.
Coping Enacted ageism Family support Quality of life
Resilience 0.49** −0.29** 0.16* 0.35**
Coping 1.00 −0.18** 0.12 0.28**
Enacted ageism 1.00 −0.14* −0.17*
Family support 1.00 0.17*
Quality of life 1.00
*p < .05.
**p < .01.

duration since HIV diagnosis, and HIV knowledge. Ageism was independently associated
with quality of life (regression coefficient: −0.12; p < .01).

Path analysis of the hypothesised relationships

As illustrated in Figure 2, the following paths indicated statistically significant associations:
(1) family support → resilience (β = 0.18), (2) resilience → enacted ageism (β = −0.29), (3)
resilience → coping (β = 0.48), and (4) coping → quality of life (β = 0.24). In addition, male
PLWHAs were more resilient than female PLWHAs (β = 0.16).
The following paths did not show a statistically significant association: (1) ageism →
quality of life, (2) family support → quality of life, (3) ageism → coping, and (4) family
support → coping. Resilience was not significantly associated with age, education, resi-
dency, ethnicity, duration since HIV diagnosis, and HIV knowledge. Among the four fit
indices, three indices (except CFI) indicated that the path model fit the data well (χ 2/df
= 2.03; RMSEA = 0.07; SRMR = 0.05, and CFI = 0.82).

Figure 2. Standardised coefficients for associations in the path analysis.

8 Y. XU ET AL.

Discussion
This exploratory study documents quantitatively the interrelationships among enacted
ageism, resilience, coping, family support, and quality of life. The pathway from a
higher level of family support to increased adaptability, decreased ageism, and better
quality of life is particularly relevant to policy- and family-based interventions. Family-
based interventions may be effective in promotion and development of adaptability
which, in turn, could reduce the deleterious impact of HIV infection and ageism on
quality of life among older PLWHAs. The findings also provide some empirical evidence
that older PLWHAs may be able to overcome, respond, and adapt positively to HIV for
maintaining successful aging despite certain physical impairments or psychosocial stres-
sors (e.g. stigma). To our knowledge, it is the first study that investigates the potential
mechanisms through which personal adaptability mitigates the adverse impact of
enacted ageism on quality of life among older PLWHAs in China.
Older PLWHAs experienced, on average, four types of ageism events. Ageism may be
rooted in culture or social structures (Cuddy, Norton, & Fiske, 2005). The social structure
in China is embedded in close-knit family relationships (Triandis, 1995). Respecting the
elderly and caring for their needs are considered part of the traditional norms. Despite
these norms, Chinese people have moved away from the traditional family structure
and adopted a nuclear family orientation. According to Logan and Bian (2003), only
about a third of parents believed in the traditional family structure, where children
support their parents in old age. This shift in attitude may be due to the rapidly increasing
number of elderly people in China and the One-Child Policy that has increased the car-
egiving burden onto children (Logan & Bian, 2003; Peng, 2011; Wang, 2014). Contrary to
the common assumption that Chinese people tend to have more positive attitudes towards
their elders than Americans, a comparative study among college students in the US and
China (Luo, Zhou, Jin, Newman, & Liang, 2013) documents that Chinese students actually
hold more negative attitudes towards older adults than their American peers.
The findings of this study document a negative association between ageism and quality
of life, independent of older PLWHAs’ demographic characteristics, duration since HIV
diagnosis and HIV knowledge. Similar findings have been reported among US Chinese
older adults (Dong, Chen, & Simon, 2014) and older gay men with HIV (Slater et al.,
2015). PLWHAs are aware that they are stigmatised not only for living with HIV, but
for age-related stigma as well. Such awareness may result in negative psychological con-
sequences, such as distress and anxiety that can lead to depression (Chaudoir et al.,
2012). The combination of HIV infection and ageism could deteriorate well-being and
physical function and ultimately lead to poorer quality of life (Slater et al., 2015). While
the association between ageism and quality of life was significant in both the correlation
analysis and multivariate analysis, the association was not significant in the path analytic
model. The non-significant association between ageism and quality of life in the path ana-
lytic model may due to strong resilience that reduces or mitigates the adverse impact of
ageism on quality of life (i.e. a higher level of resilience was associated with reduced
ageism, and the reduced impact of ageism on quality life was no longer statistically signifi-
cant in the path analytical model). These results may indicate that older PLWHAs with
strong resilience and coping skills have ample ability to reduce the impact of stressors,
such as stigma. These results may also reflected the argument made by Earnshaw et al.:
 GLOBAL PUBLIC HEALTH 9

by protecting from stress, personal resilience may ultimately weaken the association
between stigma and health outcomes (2015).
Older PLWHAs may respond to ageism and maintain better quality of life through two
possible independent mechanism paths: directly via increased adaptability (resilience →
coping → quality of life) and indirectly through increased resilience against ageism (resi-
lience → ageism → quality of life). Facing adversity of HIV infection, some older PLWHAs
may negatively internalise or experience stigma associated with infection and ageism,
while others may positively confront challenges and develop resilience and coping skills
to reduce the consequence of HIV infection and ageism-related stressors. The self-built
adaptability empowers them to replenish and enrich supporting resources to surmount
the disadvantages associated with stigma (Oyserman & Swim, 2001). The findings have
important implications in developing effective intervention programmes that help older
PLWHAs to maintain better quality of life. Because personal adaptability reduces
ageism which is a substantial barrier to seek social support and to HIV treatment, the
development of interventions that help older PLWHAs to maintain better quality of life
should take the two mechanisms into consideration.
Research has documented that there are resources that individuals can use to develop
resilience including hardiness, self-esteem, social support, and spirituality (Earnshaw et al.,
2015). Because of the exploratory nature of the study, only three sets of variables were used
to predict resilience, including demographic characteristics, variables-related HIV infec-
tion (duration and knowledge), and family support. As documented in the path model,
older PLWHAs who received a higher level of family support were more likely to
develop resilience that persisted against ageism and promoted quality of life. Under the
cultural imperative of familial responsibility, families in China form an important safety
umbrella for PLWHAs (Liu et al., 2013), and family members are the primary caregivers
for treatment, psychosocial and financial support, and childcare (Li et al., 2008a). It is
especially true for older PLWHAs as they usually have limited social networks and
heavily depend on their family to develop strategies to respond to HIV infection and
ageism. As documented in our previous studies, PLWHAs perceived less stigma from
their family members (Wu, He, Guida, Xu, & Liu, 2015) and the majority of them dis-
closed their HIV status to their spouses and other family members (Zang, He, & Liu,
2015). However, family cannot satisfy all social and medical needs of PLWHAs. They
may seek support from others, especially medical professionals, outside of the family
realm. Given the existence of stigma, we do not know how likely older PLWHAs use
social support from outsiders to build personal resilience. Further research is needed to
investigate other recourses that older PLWHAs may use to build adaptability. Because
male older PLWHAs were more likely to develop resilience than females, interventions
should take this gender difference into consideration.
Previous research has suggested that clear knowledge and understanding of HIV infec-
tion plays an important role to develop PLWHAs’ resilience and coping skills (Kumar,
Mohanraj, Rao, Murray, & Manhart, 2015). However, our study did not demonstrate
that relationship. One possible explanation is that possessing good knowledge is necessary,
but not sufficient to develop resilience among Chinese older PLWHAs. The average score
of HIV knowledge was very high (9 out of 11) in this study population. The non-signifi-
cant association between the duration since HIV diagnosis and resilience may indicate that
building of resilience may be due to personal hardiness, family support, or environmental
10 Y. XU ET AL.

support, rather than the length of living with HIV. Some older PLWHAs may develop
strong resilience earlier than others. The average duration since HIV diagnosis was 2
years in this study population.
There are several limitations in this study. First, because of the nature of an exploratory
study, other important factors that potentially bolster resilience and coping skills were not
considered, including other recourses for the development of adaptability, gerontologic
factors, and interpersonal or network factors. Future large-scale studies are needed to
investigate factors that determine adaptation development for HIV and ageism among
this study population. Second, HIV-related stigma and other types of ageism (i.e. per-
ceived ageism and internalised ageism) were not assessed in this study. Future studies
are needed to investigate how the two types of stigma work together to influence
quality of late life. Third, our conceptualisation of the interrelated paths among adapta-
bility, ageism, family support, and quality of life are consistent with previous research
and theories. However, causality cannot be inferred from this cross-sectional study due
to potential temporal ambiguity bias. Longitudinal studies with repeated measures are
needed. Fourth, because the study using a convenient sample was conducted in one city
in China, the generalisation of the findings are limited. Large-scale or multicenter
studies are needed to address this important area and verify the findings of this study.
Fifth, Cronbach’s reliability alpha of the measurement scale of quality of life was relative
low (0.68). Cronbach’s alpha reported by the developers of the measurement scare was
0.84 in their study of risk factors for suicide in China (Li, Phillips, Zhang, Xu, & Yang,
2008b) and 0.81 in a study among drug users in China (Zhu et al., 2011).
Regardless of these limitations, the findings of this study documented that Chinese
older PLWHAs encounter adversity resulting from HIV infection and ageism. However,
older PLWHAs do not only negatively accept adversity, but build their adaptability to
positively manage the challenges. Ample family support can build adequate adaptability
(resilience and coping) which, in turn, reduces the impact of ageism on quality of life.
These findings may have important implications for the development of interventions
that target improving quality of life for older PLWHAs through adaptability to adversity.
As Chinese older PLWHAs seek comfort and support from their family members rather
than outsiders, a family-based intervention strategy may be potentially used to deliver
intervention messages, or to encourage older PLWHAs to adapt and adhere to HIV inter-
ventions and treatment. As PLWHAs age, future studies are needed to investigate and
understand the collective roles of factors at the personal, interpersonal, and environmental
levels on the development of resilience and coping among this vulnerable population in
developing countries.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by Nanning Department of Science and Technology: [grant number
20133169].
 GLOBAL PUBLIC HEALTH 11

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