HIV testing intentions and cognitive reappraisal among Latino emerging adults

Abstract

Negative emotions related to HIV testing may influence an individual’s intentions to test for HIV. However, emotion regulation strategies such as cognitive reappraisal which involves reframing the meaning of an event to modify one’s emotional response to it may potentially help to regulate these emotions and facilitate decisions to get tested for HIV. In this exploratory study, we examined the association between cognitive reappraisal and HIV testing intentions and whether this association differs by gender. Cross-sectional data were collected from a convenience sample of 157 Latino emerging adults aged 18–25 years living in Arizona and Florida through an online survey. Hierarchical logistic regression models were used to analyze the data. Results indicated that cognitive reappraisal was significantly associated with HIV testing intentions (aOR: 1.44, 95% CI:1.04–1.99) and that this association was specific to females (aOR: 2.48, 95% CI: 1.39–4.43). Our results demonstrate the potential of cognitive reappraisal to facilitate HIV testing intentions among females. HIV prevention interventions should incorporate cognitive reappraisal training to regulate and adapt to the negative emotions associated with HIV testing in efforts to increase HIV testing.

Introduction

HIV testing is critical to reduce the number of undiagnosed HIV cases, receive HIV treatment and prevent transmission (Li et al., 2019). Yet, the prevalence of HIV testing is low among Latino emerging adults aged 18–24, a group with the second highest rate of HIV diagnoses among emerging adults in the United States (U.S.) (CDC, 2018; Van Handel et al., 2016). Both female and male Latino emerging adults have a lower prevalence of HIV testing compared to non-Latino Black emerging adults (Latino males: 26.8%, Latina females: 46.5%; non-Latino Black males: 45.3%, non-Latino Black females: 59.9%) (Van Handel et al., 2016), which increases their risk for undiagnosed HIV.

Despite the CDC recommendation for routine HIV testing, a significant proportion of Latinos and young people report having never been offered an HIV test as their main reason for having never been tested for HIV (Febo-Vazquez et al., 2018). Therefore, encouraging people to voluntarily seek HIV testing is important to increase uptake of HIV testing. Social-cognitive theories, such as Theory of Planned Behavior propose that a key determinant of performing a health behavior is the individual’s intentions to perform the behavior (Ajzen, 1991). Thus, HIV testing intentions may be particularly important in the decision-making process of whether and when to get tested for HIV.

Emotional responses to HIV testing might influence an individual’s intentions to test for HIV. Negative emotions related to HIV testing, such as fear, shame, and anxiety, which may be rooted in HIV stigma deter seeking HIV testing (Joseph et al., 2011; Lin et al., 2017). Therefore, the ability to regulate these emotions may be an important protective factor for HIV testing behavior. One potential emotion regulation strategy is cognitive reappraisal. Cognitive reappraisal involves reframing or reinterpreting the meaning of an event to modify one’s emotional response to it (Gross, 1998). In the context of HIV testing, cognitive reappraisal may help to mitigate negative emotions related to HIV testing, find the benefits of testing, and facilitate the decision to get tested. However, these potential benefits of cognitive reappraisal on HIV testing decision making may be more likely for females, as they have a greater tendency to engage in reappraisal as compared to males (Nolen-Hoeksema, 2012).

No previous studies have examined cognitive reappraisal in the context of HIV testing. Therefore, this exploratory study aimed to examine the association between cognitive reappraisal and HIV testing intentions among Latino emerging adults and whether this association differs by gender. We hypothesized that 1) higher levels of cognitive reappraisal will be positively associated with HIV testing intentions, and 2) the association between cognitive reappraisal and HIV testing intentions will be moderated by gender in such a way that the association would be stronger for females than males.

Methods

A cross-sectional online survey study (Project on Health among Emerging Adult Latinos-Project HEAL) was conducted to collect data from a convenience sample of 200 Latino emerging adults. Only 157 participants that had initiated sexual debut and had no missing data on the outcome variable were included in this study. The study was approved by the Institutional Review Board of Florida International University. More details on the procedures for Project HEAL are published elsewhere (Cano et al., 2020).

Measures

HIV testing intentions were assessed with the question, “How likely is that you will get tested for HIV in the next 12 months?” Responses included 1=very unlikely, 2=somewhat unlikely, 3=somewhat likely, 4=very likely. Those participants that responded very likely and somewhat likely were coded as “1=having intentions to get tested for HIV” (as these acknowledged a potential likelihood of getting tested for HIV in the future), and those that responded very unlikely and somewhat unlikely were coded as “0=not having intentions to get tested for HIV.”

Cognitive reappraisal was measured using the six-item subscale from the Emotion Regulation Questionnaire (Gross & John, 2003) with responses ranging from 1=strongly disagree to 7=strongly agree. Mean scores indicated higher use of use cognitive reappraisal (Cronbach’s α=.92).

Covariates

Perception of HIV risk, sexual risk behaviors, lifetime history of HIV testing and HIV stigma were included as covariates to reduce potential confounding effects (Evangeli et al., 2018; Glasman et al., 2010; Meadowbrooke et al., 2014). Perception of HIV risk was coded as 0=none and 1=small/moderate/high, sexual risk behaviors as having >1 sexual partners, sex under the influence of alcohol or drugs, or unprotected sex in the past 3 months, and lifetime history of HIV testing as 1=Yes and 0=No. HIV stigma was measured using the 3-item stigma sub-scale concerns with public attitudes (Reinius et al., 2017) (α=.85). Sociodemographic variables were also included and are listed in Table 1.

Table 1.

Characteristics of Participants by HIV Testing Intentions (n=157).

	HIV Testing Intentions
Characteristic	Yes	No
	n (%)	n (%)	χ2 a	p-value
Total	86 (54.8)	71 (45.2)
Gender			.27	.601
Male	40 (52.6)	36 (47.4)
Female	46 (56.8)	35 (43.2)
Partner Status			.01	.913
Single	55 (54.5)	46 (45.5)
Has Partner	31 (55.4)	25 (44.6)
Sexual or Gender Minority Status			7.64	.006
Heterosexual	66 (50.0)	66 (50.0)
Sexual or Gender Minority	20 (80.0)	5 (20.0)
Nativity Status			2.81	.094
Immigrant	22 (44.9)	27 (55.1)
U.S. born	64 (59.3)	44 (40.7)
Current College Student			1.06	.304
Yes	60 (57.7)	44 (42.3)
No	26 (49.1)	27 (50.9)
Education Level			5.70	.017
No Bachelor’s Degree	57 (49.1)	59 (50.9)
Completed Bachelor’s Degree or Higher	29 (70.7)	12 (29.3)
Employment Status			.09	.761
Employed	73 (55.3)	59 (44.7)
Unemployed	13 (52.0)	12 (48.0)
Health Insurance			2.57	.108
Yes	74 (57.8)	54 (42.2)
No	12 (41.4)	17 (58.6)
Study Site			8.35	.004
Miami-Dade County, Florida	31 (42.5)	42 (57.5)
Maricopa County, Arizona	55 (65.5)	29 (34.5)
Sexual Risk Behaviors in the Past 3 Months			.20	.652
Yes	68 (55.7)	54 (44.3)
No	18 (51.4)	17 (48.6)
Perception of HIV Riskb			1.67	.196
None	29 (48.3)	31 (51.7)
Small/Moderate/High	56 (58.9)	39 (41.1)
Lifetime History of HIV Testingb			21.76	<.0005
Yes	66 (70.2)	28 (29.8)
No	20 (32.3)	42 (67.7)
	M(SD)	M(SD)	t-valuec	p-value
Age	21.6 (2.03)	21.4 (2.07)	.527	.599
HIV Stigma	9.07 (2.07)	9.11 (1.68)	−.129	.897
Cognitive Reappraisal	5.18 (1.26)	4.93 (1.23)	1.27	.208

^aAll expected cell frequencies were greater than five for chi-square tests.

^bNumbers may not sum up to n=157 due to missing data.

^cThe assumption of homogeneity of variances was met based on p-value >.05 on Levene’s tests of equality of variance.

Statistical analysis

Hierarchical logistic regression (HLR) was used to examined predictors of HIV testing intentions. Only sociodemographic variables with a p-value< 0.10 in the bivariate analyses were included in the final model. Block 1 included the sociodemographic variables, block 2 perception of HIV risk, sexual risk behaviors, lifetime history of HIV testing and HIV stigma, and block 3 the cognitive reappraisal score. In block 4 an interaction term was added (gender x cognitive reappraisal), and stratified models were fitted by gender.

Results

A total of 86 (54.8%) participants had intention to test for HIV in the next 12 months. Table 1 compares all variables by HIV testing intention groups.

Predictors of HIV testing intentions

Table 2 shows present the adjusted odds ratios (aOR) and 95% confidence intervals (CIs) from the HLR model. The key finding was that cognitive reappraisal had a statistically significant association with HIV testing intentions (aOR:1.44, 95%CI:1.04–1.99).

Table 2.

Hierarchical Logistic Regression Model Predicting Intentions to Test for HIV in the Next 12 Months among Latino Emerging Adults (n=154).

	Model 1		Model 2		Model 3
Variable	aOR	95% CI	aOR	95% CI	aOR	95% CI
Block 1
Gender (Ref: Male)	1.18	.59, 2.38	1.11	.51, 2.40	1.28	.58, 2.85
Female
Sexual or Gender Minority Status (Ref: Heterosexual)	4.59*	1.54, 13.68	4.87*	1.47, 16.15	5.64*	1.65, 19.23
Sexual or Gender Minority
Nativity Status (Ref: Immigrant)
U.S. Born	1.16	.52, 2.61	1.03	.43, 2.45	.94	.38, 2.31
Education Level (Ref: No Bachelor’s Degree)
Completed Bachelor’s Degree or Higher	2.06	.91, 4.66	1.63	.66, 4.02	1.62	.65, 4.03
Study Site (Ref: Arizona)	.38*	.18, .81	.33*	.15, .77	.29*	.12, .70
Florida
Block 2
Perception of HIV Risk (Ref: None)
Small/Moderate/High	-	-	2.41*	1.09, 5.33	2.90*	1.27, 6.66
Lifetime History of HIV Testing (Ref: No)
Yes	-	-	4.32*	1.99, 9.39	4.61*	2.07, 10.27
Sexual Risk Behaviors (Ref: No)
Yes	-	-	.96	.40, 2.32	.85	.34, 2.12
HIV Stigma	-	-	.96	.78, 1.17	.94	.77, 1.15
Block 3
Cognitive Reappraisal	-	-	-	-	1.44*	1.04, 1.99

Notes:

^*p < .05;

Ref: Reference Group;

Block 1 Nagelkerke R²=.183, χ²(5) = 22.61, p<.0005;

Block 2 Nagelkerke R²=.319, χ²(9) = 41.89, p<.0005;

Block 3 Nagelkerke R²=.352, χ²(10) = 46.99, p<.0005.

Moderation analysis

In block 4, the interaction term between cognitive reappraisal and gender was statistically significant (p=.042). Results from the stratified model for females showed that a one-unit increase in cognitive reappraisal score was associated with being 2.48 more likely to have intentions to test in the next 12 months (aOR:2.48, 95%CI:1.39–4.43). For males, cognitive reappraisal was not significantly associated with HIV testing intentions (aOR:.95, 95%CI:.60–1.50).

Discussion

Our results indicated that cognitive reappraisal was positively associated with HIV testing intentions. Making a testing decision involves dealing with the potential of an HIV-positive status and the fear of facing negative consequences (Joseph et al., 2011; Lin et al., 2017). However, it appears that having the ability to reframe the meaning and associated emotions of HIV testing may facilitate the decision to test for HIV. Previous studies have shown that cognitive reappraisal is effective in decreasing the experience of fear and anxiety (Hofmann et al., 2009; Shore et al., 2017). This is because individuals who engage in reappraisal tend to look for the positive attributions and interpretations of an event, reducing their experience of negative emotions (Nolen-Hoeksema, 2012). Therefore, learning to use cognitive reappraisal may serve as an important protective factor to promote HIV testing. Nonetheless, other important factors such as limited access to healthcare services and cultural norms (e.g., gender roles, familism) may influence whether cognitive reappraisal and intentions to test for HIV will lead to HIV testing among Latinos, and should be taken into consideration. Particularly, limited access to healthcare is common among Latinos (mainly due to their low socioeconomic status and lack of health coverage), and has been found to be a strong determinant of whether a person will get tested for HIV in this population (Levison et al., 2018).

As expected, the positive association between cognitive reappraisal and HIV testing intentions was specific to females. This finding is in line with previous research that shows that females are more likely to engage in reappraisal as compared to males, which may be the result of gender differences in the appraisal of stressors (Tamres et al., 2002). Females experience more distressing and intense emotions and appraise negative events as more stressful than males (Nolen-Hoeksema, 2012). In the case of HIV testing, females may experience this event as being more stressful because they are more susceptible to and internalize more the negative cultural views and gender expectations surrounding HIV (Sandelowski et al., 2004). Therefore, using cognitive reappraisal to regulate negative emotions related to HIV testing may be more necessary for females than males.

This study has some limitations including the cross-sectional design, non-probability sampling, reliance on self-reported measures, and the use of a measure of cognitive reappraisal not specific to HIV testing. Also, this study only assessed intentions to test for HIV in the future and thus it would have been important to examine whether participants’ intentions translated into getting tested for HIV. Further, participants’ HIV testing intentions may have been impacted by previous history of HIV prevention services and social desirability bias.

Despite these limitations, these findings suggest that cognitive reappraisal is a promising emotion regulation strategy that may help people find the benefits of HIV testing (e.g., receiving HIV treatment and care) and facilitate their decision to get tested for HIV. HIV prevention programs should incorporate cognitive reappraisal training (e.g., reinterpretation (Denny & Ochsner, 2014) to regulate and adapt to negative emotions and facilitate HIV testing intentions (and potentially actual HIV testing) among Latino emerging adults. More research is needed on the specific positive and negative emotions related to HIV testing in this population and to determine which emotion regulation strategies might have the most influence on the decision to test for HIV.