INFLUENCE OF COPING STRATEGIES ON LIFE SATISFACTION AMONG HIV POSITIVE STUDENTS IN SECONDARY SCHOOLS IN NAIROBI COUNTY OF KENYA

INFLUENCE OF COPING STRATEGIES ON LIFE SATISFACTION AMONG HIV POSITIVE STUDENTS IN SECONDARY SCHOOLS IN NAIROBI COUNTY OF KENYA
?
ABSTRACT
HIV and AIDS remain a significant global public health challenge and in the Kenyan context is a generalized epidemic affecting all sectors of society. One of the sub-populations known to engage in HIV risk behaviour is the High School student population. Living with HIV and AIDS in a learning institution could influence quality of life and life satisfaction negatively affecting the ability of students to complete their studies. The aim of this study is to investigate the influence of coping strategies that are associated with life satisfaction among Secondary School students who are living with HIV.
The objectives of the study are as follows:
i. To establish the influence of problem-focused coping strategy on life satisfaction among HIV positive students
ii. To determine the influence of emotion-focused coping strategy on life satisfaction among HIV positive students
iii. To establish the influence appraisal-focused coping strategy on life satisfaction among HIV positive students
iv. To determine the influence of occupational-focused coping strategy on life satisfaction among HIV positive students
The methodology to be used will be secondary data analysis of data that will be collected during the Secondary School HIV and AIDS Programme (SSAIDS) survey to be conducted during the second term of 2018 and the first term of 2019 among students in 22 Kenyan Secondary School institutions (SSs). The study will utilize only the student component of the original study to investigate the prevalence of self-reported life satisfaction among the general student population as well as prevalence of self-reported life satisfaction among students who are infected with HIV. Secondary Schools will be categorized into large, medium, and small categories based on the numbers of staff and students so as to allocate sample sizes among the Secondary Schools. Each Secondary School population will be stratified by location and class and then clusters of students will be selected for the study using standard randomization techniques. Self-administered questionnaires will be used to obtain demographic, socioeconomic, education-related data, behavioural and psychological characteristics such as self-esteem, optimism and life satisfaction. Life satisfaction will be assessed using a single-item measure within the questionnaire. The questionnaire will also be used to obtain information on demographic, socioeconomic, behavioural, and other life satisfaction related factors. Data will be analyzed using the Statistical Package for Social Science (SPSS) and presented frequency distributions, means, percentages and standard deviations on selected aspects on coping strategies.
?
INTRODUCTION
Since 1981 when the first case of HIV was diagnosed, HIV and AIDS has taken the lives of approximately 75 million people worldwide (UNAIDS, 2000; Brouillard-Coyle, 2004; Nyaga, 2016). In the USA, and dependent areas, Center for Disease Control and Prevention estimated the cumulative number of diagnoses of AIDS through 2005 with roughly an additional 300,000 cases unaware of their HIV status. The US attention has turned on prevention strategies which necessitates addressing the mental health needs of the individual. Globally, an estimated 35.3 million people were living with HIV in 2012. Sub-Saharan Africa is the region most a?ected by HIV, accounting for 25 million people living with HIV, 1.6 million estimated new HIV infections, and 1.2 million estimated HIV and AIDS related deaths in 2012 (KAIS,2012). According to the 2014 statistics, about 2million adolescents between the ages of 10 and 19 years were living with HIV worldwide (UNESCO, 2012; UNICEF, 2015). Adolescents account for about 5% of all people living with HIV and about 12% of new adult HIV infections. Regions with the highest number of HIV positive adolescents are Sub-Saharan Africa and South Asia the report continues to say. Of the 2 million adolescents living with HIV about 1.6 million (82%) live in Sub-Saharan Africa (UNAIDS, 2000; Brouillard-Coyle, 2004).
The last decade witnessed significant progress in scaling up access to HIV treatment and care. By end of 2012, more than 9.7 million people from low- and middle-income countries were receiving ART. Corresponding to this effort, HIV-related mortality has declined. However, global ART coverage is still inadequate at 61%, and most people living with HIV do not know their serostatus (UNAIDS, 2000). Early diagnosis and treatment can reduce HIV progression and prevent transmission, but adolescents are less likely than adults to be tested, access care, remain in care and achieve viral suppression.
Between 2005 and 2012, HIV-related deaths among adolescents increased by 50% while the global number of HIV-related deaths fell by 30% (UNAIDS, 2000). This increase in HIV-related deaths was due primarily to poor prioritization of adolescent’s in national HIV plans, inadequate provision of accessible and acceptable HIV treatment and care (HTC) services and lack of support for adolescent to remain in care and adhere to the anti-retroviral therapy(ART). As a result, it led to treatment failure and the high rate of morbidity and mortality. The AIDS-related deaths increased from 39,000 in 2001 to approximately 83,000 by 2001(UNAIDS, 2000; Brouillard-Coyle, 2004).
In Asia, HIV and AIDS epidemic appeared much later, around mid-1980s and by 1990, Thailand and India accounted for the majority of infections (Hall, Cockrel and Hall 2011). In Thailand, HIV prevalence among injecting drug users increased rapidly from less than 1% in late 1987 to about 50% in 1990. A decline in new infections followed with the country’s exemplary success with it’s a 100% condom promotion campaign among sex workers and clients. Similarly, in the Yunan Province in China, HIV infections were generally concentrated among injecting drug users and sex workers by 1993, 10% to 30% of injecting drug users were found to be HIV positive.
On the other hand, HIV and AIDS has become a major health threat in the Indian Sub-continent. As of June 2000, 98,451 HIV-seropositive cases were detected, with 12,389 cases of AIDS and an estimated 3.7 million people infected with HIV (NACO/UNICEF, 2000; Hall et al, 2011). The spread of HIV in India is predominantly by the heterosexual route and the infection is spreading rapidly among women. The prevalence of HIV infection among male patients suffering from various sexually transmitted diseases (STDs) has increased from 3.3-3.5% in 1988 to 8.6-14% in 1992 in metropolitan cities like Madras and Bombay especially among female sex workers.
According to UNODC (2002), the youth between the ages of 15-24 years living with HIV in India is approximately 10.3 million. The caused for this was through early marriages, premarital sexual relations, increasing trafficking and prostitution. Furthermore, 40% of adolescents start taking drugs and fall victim of substance abuse between 15 and 20 years. Over 35% of all reported cases in India occur among young people in the age group of 15 and 24 years (NACO/UNICEF, 2001).
The UNAIDS report of December, 2009 states that the total number of people infected with AIDS in Eastern Europe was 1.5 million, up 66% from 2001 (Hall, Cockrel and Hall 2011). In England and Wales, the prevalence of HIV infections in 15-44 year olds has increased from 32,400 in 2001 to 54,500 in 2008, which is equivalent to 1.5 to 2.4 per 1000 persons.
South Africa has the fastest-growing HIV/AIDS epidemic in the world; about 10% of those infected world-wide live in South Africa. In May 2001, at least 4.7 million South Africans were reported to be HIV positive, 56% of them women (Centre for the Study of AIDS, University of Pretoria). Infection rates varied by province: 8.7% in Western Cape, 29.3% in Gauteng, and 36.2% in Kwa-Zulu Natal. By 2005, at least six million South Africans were expected to be HIV positive and 2.5 million would have died of AIDS or a related illness. Mortality rates will double by 2010, and life expectancy will drop from a high of 68 years to less than 40 years (Maree and EbersÖhn, 2002).
According to Irwin and Elam (2011), the HIV and AIDS virus has been in Southern Africa since the late 1970s, and their response to it has been biomedical. Their understanding of the universality of the HIV and AIDS pandemic on the other hand is more recent: They are only starting to define the complex character and ferocity of this social, economic and cultural disaster. While the virus infects millions of South Africans, all are affected by the pandemic as productivity declines, public services cost more, family structures threaten to collapse, child mortality increases and poverty deepens (Gradwell, 2004). HIV/AIDS brings reduced opportunities, decreased nurturing support and socialization, and therefore increased petty or violent crime, along with increased morbidity and mortality, and these will mark the South African society for at least the next century the study shows (Irwin et al, 2011).
The HIV/AIDS projection model commonly used in South Africa suggested that from 2000, 4-5% of 15-19 year olds will be newly infected each year, and a further 5% of those who are 20-24 years old. The number of orphans, children under 15 who have lost one or both parents, will climb steadily throughout the coming decade, reaching a peak of 2.5 million in South Africa by 2012. These rises are not inexorable (Coombe, 2001).
According to a UNAIDS “Report On Global HIV/AIDS Epidemic” (2000; Umeh,1997), Uganda is one of the countries which has brought down its estimated prevalence rate to around 8% from a peak of close to 14% in the early 1990s with strong prevention campaigns. Zambia is also following suit. Yet, even in these countries, the suffering generated by HIV infections acquired years ago continues to grow, as millions of adults fall ill and die and as households, communities and whole sectors of the economy stagger under the burden.
In 1980 when AIDS first appeared in Uganda, Ugandans mused at its emaciating effect and gave it the euphemistic name of “slim” (Umeh, 1997). Uganda became the ?rst government on the continent to recognize the danger of HIV to national development, and took active steps to ?ght its spread through action by the Government and other groups in society, including religious leaders and community development organizations. This broad based approach to the epidemic contributed to a reduction in HIV infections among young pregnant women living in towns and cities. Gratifyingly, data from a large community-based study now show a similar fall in infection rates in rural Uganda. HIV prevalence rate among 13–19-year-old girls has fallen signi?cantly over an eight-year period, while the rate in teenage boys has remained roughly stable (UNAIDS, 2000; Gradwell, 2004). Probably, a large increase in condom use may have contributed to these lower rates of infection (and to the signi?cant decline in teenage pregnancies that accompanied it).
Kenya has had the fastest-growing number of new HIV infections in sub-Saharan Africa in the last decade (Muchangi, 2016). The report shows that between 2005 and 2015, the number of new HIV cases grew by an average of 7.1 per cent per year, one of the highest increases in the world. The number of new infections decreased over the same period in Rwanda, Somalia and Uganda. With at least six per cent prevalence rate, Kenya is also one of a small set of countries where HIV prevalence was more than 2.5 per cent of the population in 2015. The Lancet study shows that the number of Kenyans dying from HIV-related conditions has declined by half from 120,670 in 2005 to 51,700 in 2015 the report goes on to say. HIV prevalence fell from 7.2 to 5.6% and the incidence rate from 0.7 to 0.4%. This is attributed to improvements in linkage to care and the roll-out of antiretroviral therapy (Carter, 2014). On the other hand, declining incidence in Kenya coincides with similar declines in new HIV infections reported by at least 26 countries in Africa, Asia, and the Caribbean between 2001 and 2012.
Among the youth aged between 15-24 years, prevalence of HIV infection was estimated to be 11-15% for women and 4-9% for men in 1999 (UNAIDS, 2003; UNICEF, 2002). The latest report by NACC shows that the youth aged 15-24 years living with HIV are estimated to be 268,588 (18%) in 2015 (KAIS,2012;NACC, 2015). While new infections in the age group is approximately 35,776 (46%) and is concentrated in the high HIV prevalence are the report goes on to say. Teenage pregnancy is also a concern with approximately 30% of unmarried adolescent girls conceiving by the age of 20 years.
STIs other than HIV are also a cause of concern especially as they relate to an increase in susceptibility to HIV infections. Recent statistics released by Kenyatta National Hospital stated that 36% of young women aged 15-24 years visiting antenatal clinics tested positive for an STI other than HIV (Gallant, 2005).
The youth in Kenya are vulnerable to HIV due to a variety of factors, which vary across ethnic and clan groups. They include; early onset of sexual activity; a high value placed on young male virility countered by strict norms of young female virginity; a lengthening period of adolescence; cultural norms; peer pressure; environmental factors; sexual scripts; rates of poverty which foster the exchange of sex for money; traditional absence of parent-child communication on issues related to sexuality; and limited access to medical care and reproductive health information (Gallant, 2005; Pernaap, Chanda and Ezerike, 2011).
The table below is an extract from the NACC Report showing the National HIV and AIDS estimates for 2015:

Indicator 2015
People living with HIV(all ages 1.5 (1.3-1.7) million
Annual HIV infections(all ages) 77,600 (58,533-111,870)
Annual AIDS – related deaths(all ages) 35,800 (27,000-47,000)
HIV prevalence(adults aged 15-49) 5.91 % (5.23-6.84%)
HIV incidence(adults 15-49) 0.35 % (0.26-0.51%)
Adults 15+ living with HIV 1,420,000 (1,250,000-1,620,000)
Annual new HIV infections(adult 15+) 71,000 (54,000-101,000)
Annual AIDS related deaths(adult 15+) 30,800 ( 23,300-40,500)
Children(0-14years)living with HIV 98,200 (82,000-117,300
Annual new HIV infections (Children 0-14 years) 6,600 (4,080-9,910)
Annual AIDS-related deaths(Children 0-14) 5,000 (3,510-6,760)
HIV prevalence(Young Adults 15-24);Male 2.26 (1.64-3.19) million
HIV prevalence(Young Adults 15-24);Female 3.97 (3.26-5.12) million
Annual new HIV infections (young adults 15-24); Male 12,500 (8,270-19,000)
Annual new HIV infections(young adults 15-24);Female 23,300 (17,400-33,000)
Annual AIDS deaths(young adults 15-24) 3,850 (2,650-5,750)
Adolescents living with HIV(10-19) 133,000 (114,000- 162,000
Annual new HIV infections (adolescents 10-19) 18,000 (10,500-29,500)
Annual AIDS deaths (adolescents 10-19) 2,700 (2,110-3,710)

The national HIV prevalence trend among the youth shows that the HIV prevalence peaked at a level of 12-13% among females and 6-7% among males in mid-1990s.The HIV prevalence declined to about 3% among females and 1.5% among the males in 2006 and had stabilized since, the report says.
The report goes on to say that the total number of People Living with HIV in Kenya 268,588(18%) were among the youth aged 15-24 years in 2015. More than 55% of those youth living with HIV are from six high HIV prevalence counties in Kenya, namely Homa Bay (34,812), Kisumu (31,779), Siaya (27,838), Migori (18,411), Nairobi (23,671), and Mombasa(10,105).
Total annual new HIV infections in Kenya were 77,648 with young people contributing 35, 776 (46%). There were 3,850 AIDS-related deaths among the youth aged 15-24 years, which was about 11% of the total AIDS-related deaths in 2015. More than half of these deaths occurred in nine of the of the 47 counties namely, Homa Bay (414), Kisumu (378), Siaya (331), Nairobi (267), Migori (219), Mombasa (159), Nakuru (137), Kakamega (135) and Busia(102).
The statistics show that adolescents in Kenya are greatly affected by the HIV pandemic. However, because of expansion of HIV treatment, survival rates, life expectancy and quality of life for learners living with HIV and AIDS has greatly improved. Most studies which have been done on HIV and AIDS are on children and adults but very few studies have been done on adolescents (UNAIDS, 2000) yet they are the cornerstone of any nation.
Young people living with HIV refers to a broad chronological age range from 10 to 24 years, reflecting key conceptual and pragmatic implications of the experience of very young adolescents (10-14) years, older adolescents (14-18) years and young adults (18-24) years. They represent a group whose needs are complex, shifting and too often unaddressed (UNAIDS, 2000). It is important to understand what in the environment they are living in affects them and therefore making it difficult to cope with the health condition.
International aid agencies have devoted billions in order to halt the spread of and provide treatment for HIV and AIDS in the region and Kenya in particular. Increasing access to rapid HIV tests and ARV medication, preventing mother-to-child transmission of the virus, male circumcision campaigns, and public awareness programs are some examples of internationally funded initiatives (UNAIDS, 2010).
In Kenya, ARVs are provided at no cost in all government funded health institutions. This has enabled people living with HIV and AIDS to continue contributing to the economy without their lives being cut short by the pandemic. However, the stigma associated with HIV and AIDS prevents many people from getting tested, thus many people do not know their HIV status, and do not, therefore, start using ARVs in time if infected (Juma, 2001; Nyaga, 2016). Consequences associated with HIV and AIDS-related stigma include isolation, fear of disclosing HIV status, and discrimination. Patients of some diseases, such as HIV and AIDS and tuberculosis acquire certain identities that are difficult to dispel, and once afflicted, they struggle to shed the “victim” identity. They argue that HIV and AIDS-related stigma is socially constructed and is evident through negative attitudes and prejudice towards people living with HIV and AIDS and the groups they come from (Nyaga, 2016).
With rapid expansion of HIV treatment, survival, life expectancy and quality of life for people living with HIV (PLHIV) has significantly improved. However, delayed anti-retroviral therapy (ART) initiation remains a challenge in many settings, including high-income countries (Naswa and Marfatia, 2010). Multiple factors related to health-care delivery systems contribute to delays in ART initiation and poor adherence to ART and retention in care. These include diagnosis of HIV at an advanced stage, poor linkage to and retention in HIV care after testing positive and loss to follow-up (LTFU), which is particularly high in the period between testing and initiation of ART. Additional patient-related factors for delayed initiation of ART include legal and/or familial constraints around disclosure, and lack of emotional and financial support (Abraham-Pratt, 2010; Naswa et al, 2010).
The impact of HIV and AIDS cuts across all sectors of economic activities and social life. The pandemic is a continuously evolving, progressive disaster. The HIV virus in principle is simple to avoid and is not particularly contagious but the most deadly because it embodies itself in the most vital of forces especially, the biological urge that keeps human beings going. Hence, the epidemic penetrates, the core of social life: rights of woman, norms of abstinence and masculinity, workplace behavior, conventions of family life and privacy and the concept of sin, decency, lust, deviance, prostitution and drug addiction. It therefore, infiltrates not only the code of life but also the core of the private lives and sometimes the secret lives. Within the period of 2 decades, the HIV and AIDS epidemic has become a global development disaster with implications for health, human development, food production, economy, national security and the likes. It has also gradually become a leading cause of morbidity and mortality amongst those in their reproductive and economically productive years (Pernaap, Chanda and Ezerike, 2011).All of these issues pose potentially greater challenges and stress to adolescents, who must develop some coping mechanisms in order to survive.
According to Sein (2001), one of the main aims of management for a child dealing with a chronic illness should be to help cope with the reality of having an illness. Self-esteem is an important aspect of the coping mechanism and it could be promoted through intellectual and creative skills as well as through physical activities such as play and sports. A supportive atmosphere, which encourages expression of feelings, is also a powerful coping mechanism. Relationships, such as those with peers, may be critical in coping with long-term illness. Close peer relationships are an important source of support. The development of emotional and behavioral problems in children and adolescents are likely to impact academic performance as well. It has been recognized that children’s problems in one sphere of life, for instance at home or in school, cannot be treated in isolation. Pediatric specialists and school counselors should collaborate more closely because they deal with common psychosocial issues.
Long-term solutions will need to be crafted for these children because the impact of HIV and AIDS will linger for decades after the epidemic begins to wane. Even if rates of new infections were to level off in the next few years, the long incubation period means mortality rates will not plateau until 2020. Thus, the proportion of orphans will remain unusually high at least through 2030. For a variety of reasons, little attention has been paid to the situation of adolescents infected by HIV and AIDS and how they cope with their sero-positive status. Greater understanding of the impact of HIV and AIDS on adolescents is important in the design and evaluation of programmes to support children living in difficult circumstances (Foster and Williamson, 2000)
In severely affected communities, HIV and AIDS has an impact on children, families and communities, which is incremental. The continuous attrition rate of deaths in young adults leads to social and economic impacts, which increase with the severity and duration of the epidemic. The impact of HIV and AIDS on children and families is compounded by the fact that many families live in communities which are already disadvantaged by poverty, poor infrastructure and limited access to basic services. Strategies for coping of extended families have negative impacts on children in households indirectly affected by HIV and AIDS, thus enlarging the overall impact and number of children affected. For example, children may experience reduction in their quality of life when their mother goes to provide home care for an HIV and AIDS-affected relative or because of transfers of money to a sick relative’s household. Children may see their standard of living deteriorate when cousins come to live with them following the death of an aunt or uncle (Foster et al, 2000).
The purpose of this study is to find out the influence of coping strategies on life satisfaction among HIV positive students in secondary schools in the Nairobi County, Kenya.
Statement of the Problem
By 1999, approximately 18.8 million people around the world had died of aids, 3.8 million of them children and nearly twice that many – 34.3 million – are now living with HIV, the virus that causes AIDS (UNAIDS, 2000). Of the 49.7 million HIV infections that had occurred worldwide by late 1999, 72% were in sub-Saharan Africa; 84% of AIDS deaths, 91% of child HIV infections and 94% of child AIDS deaths worldwide have occurred in Africa. Of children orphaned by AIDS throughout the world, 95% have occurred in Africa where numbers of orphans will continue to rise throughout the next decade reaching 40 million by 2010 according to the report.
As earlier indicated, the HIV prevalence trend among the youth in Kenya shows that the HIV prevalence peaked at a level of 12-13% among females and 6-7% among males in mid-1990s.The HIV prevalence declined to about 3% among females and 1.5% among the males in 2006 and had stabilized since (NACC, 2016). The NACC report further indicates that the total number of People Living with HIV in Kenya 268,588 (18%) were among the youth aged 15-24 years in 2015. More than 55% of those youth living with HIV are from six high HIV prevalence counties in Kenya, namely Homa Bay (34,812), Kisumu (31,779), Siaya (27,838), Migori (18,411), Nairobi (23,671), and Mombasa (10,105).
Nairobi County contributed to 11.3% of the total number of people living with HIV in Kenya with 14% being young people aged 15-24 years. According to Kenya HIV County Profile (NACC, 2016) there were 10,758 adolescents (10-19 years) living with HIV in 2015 while the annual HIV infections was 1,035. These are school going adolescents who are found in our learning institutions. This population makes this study necessary.

OBJECTIVES
The objectives of the study are:
i. To establish the influence of problem-focused coping strategy on life satisfaction among HIV positive students
ii. To determine the influence of emotion-focused coping strategy on life satisfaction among HIV positive students
iii. To establish the influence appraisal-focused coping strategy on life satisfaction among HIV positive students
iv. To determine the influence of occupational-focused coping strategy on life satisfaction among HIV positive students
RESEARCH QUESTIONS
The research intends to answer the following question:
i. What is the influence of problem-focused coping strategy on life satisfaction among HIV positive students?
ii. How does emotion-focused coping strategy influence life satisfaction among HIV positive students?
iii. What is the influence of appraisal-focused coping strategy on life satisfaction among HIV positive students?
iv. How does occupational-focused coping strategy influence life satisfaction among HIV positive students?
Hypotheses of the Study
Ha1 There is a significant relationship between problem-focused coping strategy and life satisfaction among HIV positive students.
Ha2 There is a significant relationship between emotion-focused coping strategy and life satisfaction among HIV positive students.
Ha3 There is a significant relationship between appraisal-focused coping strategy and life satisfaction among HIV positive students.
Ha4 There is a significant relationship between occupational-focused coping strategy and life satisfaction among HIV positive students.
Significance of the Study
This study aims at finding out the influence of coping strategies on life satisfaction among HIV positive students in secondary schools, in Nairobi County of Kenya. Findings of the study will help educators and managers to come up with strategies of assisting learners living with HIV and AIDS.

Findings of the study will help the teachers to understand the plight of learners living with HIV and be able to offer them psychosocial support.

Findings of the study will help teacher counsellors to deal with consideration and therefore help learners living with HIV cope with the condition.
Findings of the study will help parents/guardians provide support to the learners living with HIV and therefore make it easier for them to cope with the condition.
Findings of the study will be useful in the development of effective health-related policies and programmes to prevent stress-induced illness and promote learners health.
Scope and Limitation of the Study
This study will investigate the influence of coping strategies on life satisfaction among HIV positive learners in secondary schools, in Nairobi County of Kenya. Gender categories, which will be used, will be male and female. The category of schools, which will be used, include sub-county, county and national schools. The age bracket to be used in the study will be 14-18 years because according to the Kenya AIDS Indicator Survey (KAIS, 2012) of the new HIV infections, 29% are between 15- 24 years (UNESCO, 2013). The study will also include educators in secondary schools.
Content related limitations will be overcome by clear wording of test items. The study will use correlation method that cannot determine causality between variables but it will seek to find out relationships between variables.
Assumptions of the study
The study assumes that the respondents are of sound mind and self-conscious enough to respond to items about learners living with HIV.
The study also assumes that the variable under study have a normal distribution in the population of learners living with HIV in public secondary schools in Nairobi.
The study will also assume that the respondents will be honest in their responses to give accurate information on the variables under study.

Conceptual Framework
Conceptual framework is a visual graphical presentation of the construct of a study and the presumed relationship among them. The concepts that constitute a conceptual framework support one another. This study is guided by the conceptual framework presented in Fig.1.1, according to the researcher’s conceptualization about coping strategies and life satisfaction among sero-positive HIV secondary school students.
The discovery of a sero-HIV positive is characterized as an emotionally devastating and profoundly stressful event. As a result of the stress, the learner will try to use various coping strategies to relieve the stress
Coping Strategies

Dependent variable

Intervening Variables
Figure 1.1 Coping strategies
Source: Researcher

Learners living with HIV must develop a coping strategy to deal with their new seropositive status. This may be consciously or unconsciously developed. There are four main types of coping strategies; problem-focused strategy, emotion-focused coping strategy, appraisal-focused coping strategies and occupational-focused coping strategy. This involves processes that actually change this relationship and are action-centered forms of coping (i.e., confrontation, planful-problem solving, and seeking social support).
Emotion-focused coping strategy processes only change the way in which the relationship is attended to (i.e., escape/avoidance, distancing, denial, and positive reappraisal). They are emotion-focused or cognitive coping strategies, because they involve mainly thinking rather than acting to change the person-environment relationship
Problem-focused coping involves goal-oriented, action-based strategies that are aimed at altering the cause of the stress.
Emotion-focused coping strategies are focused at managing the emotions provoked by stressors. Emotion-focused coping involves internal restructuring of cognitions which consequently change the meaning assigned to a given situation, and therefore change the corresponding emotional reaction
As they suffer losses of self from the consequences of chronic illness and experience diminished control over their lives and their futures, affected individuals commonly not only lose self-esteem, but even self-identity. Hence, suffering such losses results in a diminished self. It is difficult to comprehend the life-changing effects of a chronic illness.
The most significant challenges associated with chronic illness, are the physical challenges associated with symptoms of the illness or condition. Visible, external symptoms can be easier to cope with, as they are more obvious and often more “treatable.” It can be easier to deal with symptoms that can be seen by and explained to everyone; invisible, internal symptoms are often more difficult to describe, prove and cope with. The invisible symptoms of chronic illness can be constant and are often more severe than the visible symptoms, but because they are unseen and generally not measurable, they are easier for both medical professionals and friends and family to discount. A person with chronic invisible symptoms may suffer in silence to avoid appearing “whiny.” In many cases, overcoming these challenges requires cooperation between the patient, family and friends, caregivers and other medical professionals (Drummond, 2004).
Theoretical Framework
This study is grounded on the social support theory. It is suggested that social support maintains, or sustains the organism by promoting adaptive behavior or neuro-endocrine responses in the face of stress of other health hazard (Cobb, 1976). This theory hypothesizes that “poor social ties reduce feedback and individuals becomes confused and his or her susceptibility to disease increases (Coyne and Downey, 1991). Social support theory is mainly about social ties and social integration. The family is the primary social support, which can be marital and/or parental relationships because it provides the individual with a sense of meaning, purpose and an important set of obligation, which in turn influences the individual’s motivation and lifestyle (Lum, 2007). More so, the family connection is an example of primary group ties that influence the social integration of individuals into other social networks. Help or assistance and support from friends and others can alleviate and or prevent some stressful life events, can provide a sense of belonging and positive reinforcement, and can improve satisfaction with life. In addition, social support has an effect even in the absence of stressful life events, through greatly improving the individual’s standard of living
Definition of Terms
Chronic illnesses- Chronic illnesses are long-term or permanent medical conditions that have recurring effects on everyday life. Common chronic illnesses include asthma, cancer, diabetes, eating disorders, sleep disorders, and traumatic brain injury. Less common, but no less severe, illnesses include sickle cell disease, seizure disorders, and HIV/AIDS (Shaw, Glaser, Stern, Sferdenschi, & McCabe, 2010).
Coping Mechanism- an adaptation to environmental stress that is based on conscious or unconscious choice and that enhances control over behavior or gives psychological comfort
HIV-Human Immunodeficiency Virus. This is the virus that attacks the immune system making the individual prone to attack by opportunistic disease. The HIV virus causes AIDS and it is transmitted through bodily fluids (mainly blood and semen) and stays in the body for life, even though the person carrying it may not show any signs of illness.
AIDS-Acquired Immune Deficiency Syndrome. AIDS is a disease which is caused by deficiency in the body’s immune system. It is a syndrome because there are a range of different symptoms which are not always found in each case. It is acquired because AIDS is an infectious disease caused by a virus, which is spread from person to person through a variety of routes (UNAIDS, 2000).
Coping Mechanism- an adaptation to environmental stress that is based on conscious or unconscious choice and that enhances control over behavior or gives psychological comfort (Hainault, 2013)
Perinatal HIV infection -Viral transmission from a HIV positive mother to a HIV negative child either pre-natally, during birth or during breastfeeding
Seropositive-A positive serum reaction to a test for antibiotics or other immune markers
?
CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter presents the review of literature by highlighting gaps in previous studies on coping strategies. Human beings are generally responsive to forces that threaten their existence. Such situations are often accompanied by unpleasant emotions called anxiety, which in turn lead to depression, depending on the intensity or severity. The threats range from daily life stressors to those that threaten their very existence.
The goal of human existence is to be happy and be free from pain. Anything that hinders the achievement of this goal is usually dealt with. According to Hawks (2008), a moderate level of stress can be a motivational factor and can be instrumental in achieving a dynamic adaptation to new situations. But if stress is intense, continuous or repeated, if a person is unable to cope, or if support is lacking, stress then becomes a negative phenomenon which can lead to physical illness and psychological disorder.
Stress is the body’s non-specific response to stressors in the environment; the tear and wear we experience in our life (Hawks, 2008, Lyles, 2005). The reaction to this is to fight or flee which in turn evokes a series of complex autonomic and endocrine changes that provide much of our ability to survive. To deal with such threat therefore, humans employ different strategies to ensure the attainment of the goal. Coping is the name given to the strategies used to ensure that goals are achieved.
According to Lyles (2005), coping is the way people manage stressful life conditions. It is an action taken by an individual to reduce the effect of stress and escape from adversity, Harun and Ago (2014) add. When the coping behavior is effective, the level of stress tends to be low or on the decline but, if the individual has ineffective coping skills, there is a tendency for stress to be higher Lyles (2005) asserts. The stress that a person undergoes is often accompanied by anxiety, which may in turn lead to depression depending on the intensity or severity (Harun et al, 2014).
One such stressful conditions is any terminal illness or disease. When an individual is diagnosed with a terminal illness and the fact that death is inevitable, creates a sense of fear (Harun et al, 2014). Such illnesses include cancer, leukemia, sickle cell HIV and AIDS etc.
Given the multitude of stressors that HIV-infected adolescents potentially face in their daily lives, effective coping may be of critical importance with respect to daily functioning and general well-being. Coping strategies involve cognitions and behavioral efforts that are directed at managing stressful events and corresponding negative emotions, which are either internal and/or external (Folkman & Lazarus, 1990; Abraham-Pratt, 2010).
The study will investigate the influence of various coping strategies on life satisfaction among HIV positive learners in secondary schools, in Nairobi County of Kenya. These strategies include appraisal-focused coping strategy, emotion-focused coping strategy, problem-focused coping strategy and occupational-focused coping strategy.

2.1 Problem-focused coping strategy and life satisfaction among HIV positive students
Problem-focused coping involves goal-oriented, action-based strategies that are aimed at altering the cause of the stress. Problem-focused coping is aimed at managing the external or environmental aspects of a stressor. Examples of problem focused coping in HIV include becoming active in one’s medical regimen such as seeking out information about HIV, and making healthy lifestyle changes
2.2 Emotion-focused coping strategy on life satisfaction among HIV positive students
Emotion-focused coping strategy only change the way in which the relationship is attended to. Examples of emotion-focused coping include avoidance and distraction including refusing to discuss HIV and attempting to forget about being HIV positive by not attending medical appointments (Johnson, 2002; Folkman and Moskowitz, 2004). They are emotion-focused or cognitive coping strategies, because they involve mainly thinking rather than acting to change the person-environment relationship. They involve internal restructuring of cognitions and consequently change the meaning assigned to a given situation, and therefore change the corresponding emotional reaction (Folkman et al, 2004). Johnson (2002) further indicates that individuals with HIV who utilized problem-focused coping experience less psychological distress than those patients who utilized emotion-focused strategies such as avoidance. However, literatures in this area of systematic study of coping strategies for learners living with HIV and AIDS are few (Harun and Ago, 2005)
In a study done on coping in parents with developmentally disabled children, Folkman et al (2004) found out that emotion-focused coping strategy was beneficial for relieving depression and anger because of the negative and isolating thoughts associated with parenting these children.
Harun et al (2005) did a study on 60 clients on the role of the choice of coping strategies for HIV and AIDS in Sani Abacha Hospital Damaturu while this study will use learners who are in high school. The clients were aged between 20-45 years while in this study, the respondents will be between the ages of 15-20 years. The results of the study did not support the hypothesis that male participants would likely employ problem –focused coping more than their female counterparts. For example, Namir and her colleagues (1987) found that increased depression was associated with emotion focused coping in a group of men living with HIV/AIDS. Emotion focused coping has not only been associated with depression, but also with increased disease progression. While, increased utilization of active coping strategies has been associated with reduced severity of HIV symptoms
2.3 Appraisal-focused coping strategy on life satisfaction among HIV positive students
Appraisal-focused is the personal interpretation of a situation; it is how an individual views a situation. Appraisals refer to direct, immediate, and intuitive evaluations made on the environment in reference to personal well-being. They are evaluative frameworks that people utilize to make sense of events. Appraisals provide a glimpse of how people subjectively experience their environments and are strong correlates of emotions.
Some sport psychologists regard cognitive appraisal as an important component of burnout. The perception of a situation can be the cause of a negative psychological reaction, rather than the situation itself. An athlete who loses a string of competitions can view it positively as a challenge and an opportunity to come back from adversity, or view it negatively as evidence that he or she will never be a successful competitor.
Cognitive appraisals determine if an event will be perceived as stressful. When distress is high, some individuals may be motivated to enter psychotherapy, and some psychotherapists may explicitly target cognitive appraisals when providing treatment. Per Dienes, Torres-Harding, Reinecke, Freeman, and Sauer (2011), “cognitive therapies focus on an individual’s beliefs about the self, the world, and the future. The sources of pathology, and therefore the targets of therapy, are thoughts – maladaptive cognitions – that are frequently automatic and ingrained”. When maladaptive cognitive appraisals are thought to cause or maintain distress, impairment, or psychopathology, therapists may assist clients to question the evidence related to an appraisal, notice when irrational fantasies about potential consequences of some situation are linked to the experience of distress or impairment, and begin to respond to these situations in a more rational manner.
The appraisal view of stress was developed by Richard Lazarus. He suggested that an individual’s stress level is directly affected by their cognitive appraisal of the event that triggers the stress.
There are two stages of cognitive appraisal:
Stage 1
Primary appraisals. The initial evaluation of the situation comprises an assessment of the threat in the present situation.
Three kinds can be distinguished:
? Irrelevant
? Benign-positive
? Stressful – harm or loss, threat, challenge
When an event is perceived as negative in the primary appraisal process, the individual moves to stage 2.
Stage 2
Evaluation of the individual’s ability to cope with a situation, and of whether or not the individual has the materials to deal with the stimulus causing the stress. Secondary appraisal interacts with the primary appraisal to determine the emotional reaction to event.
During stage 2, if the individual finds that they do not have the materials to cope with the stimulus causing stress, it will determine the level of stress that is experienced. An example of this would be the reaction to snakes, which shows a great variation. A harmless garter snake might cause fear in some people and nothing in others.
Afterward, reappraisals occur: a continuous re-evaluation of the situation based on new information.
“In the top golfers’ eyes all shots are equal, and none is more equal that the others — something that fits nicely into my native Kiwi egalitarianism. And since all golf shots are equal, there’s no point in making value judgments on them. The top golfers just gather the data, and deliberately suppress any tendency to be either encouraged or discouraged by it. It’s just data: it doesn’t have a moral value.”
This statement suggest that top athlete’s use cognitive appraisal to devalue a particular situation or outcome neither judging it being good or bad. A situation or in this case, a singular golf shot, is what it is and nothing else. In professional golf, if the player were to allow a previous shot to dictate emotional levels, that player would experience a roller coaster of emotions on every hole since no shot, other than a hole in one, is considered perfect. By removing emotion and not placing a judgmental value on performance, like a particulate golf shot, the athlete is not held hostage psychologically by up and down swings in athletic performance or outcomes that sometimes are out of the athlete’s control.
2.3 Occupational-focused coping strategy on life satisfaction among HIV positive students
Fisher (2013) defines Occupational-focused approach as the attempt to focus one’s attention on occupation, to have occupation as the proximal (i.e., immediate) focus of the evaluation or the proximal intent of the intervention. In a study Lewis et al. (2002) investigated coping strategies of female adolescents infected with Human Immunodeficiency Virus (HIV) or the Acquired Immunodeficiency Syndrome (AIDS) and found that the most often utilized coping strategies identified by the adolescents were: listening to music, thinking about good things, making your own decisions, being close to someone they care about, sleeping, trying on their own to deal with problems, eating, watching television, daydreaming and praying. The adolescents also reported low utilization of certain maladaptive coping strategies such as alcohol and illicit drug usage. It has been found that for people with HIV or AIDS, those individuals who are more satisfied with their relationships, securely engaged with others, and more directly engaged with their illness are more likely to experience positive adjustment (Spiegel et al., 2002). Sikkema et al. (2000), Murphy et al. (2000), Heckman et al. (2000), Anderson et al. (2009) and Pittiglio et al. (2009) in different studies found results similar to the above studies. Pence et al. (2008) found that alcohol and drug use is common among HIV infected patients and is important determinants of secondary transmission risk and medication adherence. There were few differences in alcohol and drug use across socio-demographic characteristics. Stronger adaptive coping strategies were the most consistent predictor of less frequent alcohol and drug use, in particular coping through action and coping through relying on religion. Stronger maladaptive coping strategies predicted greater frequency of drinking to intoxication but not other measures of alcohol and drug use. Those with more lifetime traumatic experiences also reported higher substance uses. In a study, Yi et al. (2006) investigated and found that depression has been linked to immune function and mortality in patients with chronic illnesses. A factor such as poorer spiritual well-being has been linked to increased risk for depression and other mood disorders in patients with HIV. In a similar study Phillips et al. (2000) found statistically significant positive relationships were observed between hope and the total coping score, hope and managing the illness and between hope and spiritual activities. A statistically significant negative relationship was observed between hope and avoidance coping in African-American teenager. Similarly Sun et al. (2010) investigated psychological status, coping and psychosocial factors associated with people living with HIV/AIDS in a highly HIV-infected area of central China. The most frequently used coping style was confrontation. Both acceptance-resignation and avoidance coping styles were significantly correlated with high distress. Vosvickm et al. (2004), Olley et al. (2003), Michael et al. (2006) and Jenkins et al. (2003) also found similar results. Trevino et al. (2007) investigated the relationships between positive religious coping (e.g., seeking spiritual support) and spiritual struggle (e.g., anger at God) versus viral load, CD4 count, quality of life, HIV symptoms, depression, self-esteem, social support, and spiritual well-being in 429 patients with HIV/AIDS. In addition, high levels of positive religious coping and low levels of spiritual struggle were associated with small but significant improvements over time. Pakenham et al. (2001) found that better adjustment was related to an asymptomatic illness stage, fewer HIV-related symptoms, greater social support, challenge and controllability appraisals, problem-focused coping, and lower threat appraisals and reliance on emotion-focused coping. There was limited support for the stress-buffering effects of optimism. Heckman et al. (2002) have shown that participants who endorsed thoughts of suicide also reported more depressive symptoms, less coping self-efficacy, more frequently worried about transmitting their HIV infection to others, and experienced more stress associated with AIDS-related stigma.
Kathryn et al. (2004) found that relationship between three HIV-specific coping strategies (cognitive coping strategies, denial, and religious coping) and quality of life (QoL) in HIV, predominately minority women on highly active antiretroviral therapy. Results suggest that utilization of certain coping strategies may lessen or heighten perceptions of life stressfulness, thereby influencing QoL in this understudied population. Kathleen et al. 2003 found that severity of grief reaction was associated with escape-avoidance and self-controlling coping strategies, type of loss and depressive symptoms. Julie et al. (2002) found that psychosocial correlates of adjustment to HIV and AIDS in a sample of HIV-positive persons men and women who are more satisfied with their relationships, securely engaged with others, and more directly engaged with their illness are more likely to experience positive adjustment. Mark et al. (2002) show relationships between coping strategies and psychological quality of life (QOL) among people living with HIV and AIDS. After controlling for demographic and AIDS-related factors, the maladaptive coping strategies used to deal with the stress of living with HIV and AIDS significantly lowers psychological quality of life as defined by cognitive functioning, mental health, and health distress. Developing adaptive coping skills to increase adaptive coping behaviors for dealing with living with HIV and AIDS may be a particularly effective intervention strategy to improve QOL. Leslie et al. (2008) examined the impact of emotional distress and social relationships on health-related outcomes of student teenagers living with HIV and AIDS, as mediated by active and passive coping styles in female. Sikkema et al. (2000) Jane et al. (2000) and Stacey et al. (2000) supports the study. Seth et al. (1997 and 2000) examine People living with HIV and AIDS experience emotional distress in response to negative changes in their health status. The coping strategies indicated that persons with lower health literacy skills more strongly endorsed negative affective states and maladaptive coping strategies compared to persons with higher health literacy skills. And lower health literacy was associated with greater symptoms of affective depression and poorer social support, whereas higher literacy was associated with greater negativistic thinking.
The above review of literature explaining the role of ways of coping has suggested their significant role influencing depression among HIV and AIDS patients. But their role is not as simple as it appears. They have to be studied in accordance with situations and in interaction with other variables. Moreover, one has to be careful in deciding whether to take coping as a trait or process

CHAPTER THREE: RESEARCH METHODOLOGY
3.0 Introduction
This chapter presents the methodological framework of the study. They include the research design, area of study, population of the study, sample and sampling techniques, instruments for data collection, validity and reliability, data collection procedures and data analysis.
3.1 Research Design
Research design is a plan for research that covers broad assumptions to detailed methods of data collection and analysis (Mugenda and Mugenda, 1999). This study will employ a mixed method approach, which involves using both qualitative and quantitative methods to study the same phenomena.
3.2 Area of Study
The area of study is Nairobi County, Kenya. Nairobi is bordered by Kiambu County to the North and East, Machakos County to the West and Kajiado County to the South. Nairobi County has eight Sub-Counties, namely: Dagoretti, Westlands, Kamukunji, Starehe, Kasarani, Makadara, Njiru and Embakasi.
The County covers an area of approximately 692 Km2 and a population of 4,232,087, of which 2,094,247 are males (49%) and 2,137,840 are females (51%). Children below 15 years constitute 34% of the population, while youth aged 15-24 years constitute 18% of the population (2015 KNBS Population Projections. HIV prevalence in Nairobi was comparable to the national prevalence at 6.1% (Kenya HIV Estimates 2015). The HIV prevalence among women in the county was higher (7.6%) than that of men (4.7%) indicating that women are more vulnerable to HIV infection than men in the County. The County contributed to 11.3% of the total number of people living with HIV in Kenya, and was ranked first nationally. By the end of 2015, 171,510 people were living with HIV, with 14% being young people aged 15-24 years and 5% being children under the age of 15 years (NACC, 2016).

?
3.3 Population of the Study
The population of the study is all the students living with HIV in Nairobi County. There are approximately 10,758 adolescents living with HIV aged 10-19 years. They are adolescents attending high school in Kibera Sub-County
3.4 Sample and Sampling Techniques
The study will use a sample composed of learners living with HIV for the qualitative and quantitative approaches in its mixed methods approach. Simple random sampling technique will be used to identify the survey participants to ensure representation of respondents.
The study will generate the sample using Israel’s (2013) formula,
n= N
1+ N(e2)
Where n=sample size, N=population size and e=level of precision (p=0.05)
3.5 Instruments for Data Collection
The instrument for data collection is a questionnaire. Demographic information will be collected using a profile that will include gender, age and class.
3.5.1 Questionnaire
The study will adopt the use of a questionnaire, which will be administered by the researcher. Items of the questionnaire will include coping strategies which the respondents use to cope with their status. It will be a four-point Likert style questionnaire.
3.6 Validity
The study will examine for validity and reliability. According to Mugenda and Mugenda (1999), validity is the extent to which an instrument measures what it is designed to measure. Content validity is the extent to which the content of the instrument, in terms of statements, questions or indicators represent the property being measured. The main instrument for this study is a questionnaire. Validity of the instrument will be established by consulting with the supervisor and research collegues in Jaramogi Oginga University of Science and Technology.
3.6.1 Reliability
Reliability is the degree to which a particular measuring procedure gives results over a number of repeated trials (Mugenda and Mugenda, 1999). Since testing will be the main threat to reliability, the instrument will be administered in one setting.
3.7 Data Collection Procedures
Appropriate dates for data collection will be arranged between the researcher and the schools for the study. On the material day, the class teacher and the researcher will administer the questionnaire. Respondents will be given clear instructions that will be on the first page of the questionnaire before filling their responses. They will be assured of the high confidentiality of the information that is why their names are not required. All the questionnaires will be numbered for ease of collection and to avoid data loss.
3.8 Data Analysis
The items will be coded, scored and data will be analyzed using the Statistical Package for Social Sciences (SPSS). Data will be presented in frequency distributions, means, percentages and standard deviations on selected aspects on coping strategies.
3.9 Ethical Consideration
Before the commencement of data collection, the researcher will obtain research authorization from the Ministry of Education. Once the permit is secured, the head teachers of the schools under the study will be informed by the researcher of her intention to carry out the study. High Confidentiality of the data will be maintained.