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The effectiveness of psychosocial interventions on quality of life (QOL) among people living with HIV has been validated, including mobile health (mHealth) interventions. However, it is unclear which components of such interventions account for these effects.
This study aims to examine positive coping as a potential mediator of the effects of an mHealth intervention on QOL among people living with HIV.
For this secondary analysis, we used data from an mHealth-based randomized controlled trial, Run4Love, which was conducted to improve QOL and mental health outcomes of people living with HIV. A total of 300 participants were randomly assigned to the intervention group to receive the adapted cognitive-behavioral stress management courses and regular physical activity promotion or the waitlist control group in a 1:1 ratio. Our analysis focused on positive coping and QOL, which were repeatedly measured at baseline and at 3-, 6-, and 9-month follow-ups. Latent growth curve models were constructed to explore the mediating role of positive coping in the effects of the mHealth intervention on QOL.
Positive coping served as a mediator in the effect of the mHealth intervention on QOL for up to 9 months. The mHealth intervention had a significant and positive indirect effect on the slope of QOL via the slope of positive coping (
The longitudinal findings suggest that positive coping could be a crucial mediator of the mHealth intervention in enhancing QOL among people living with HIV. These findings underscore the importance of improving positive coping skills in mHealth interventions to improve QOL among people living with HIV.
Substantial improvements to and increased coverage in antiretroviral therapy have resulted in extended life expectancy of people living with HIV, leading to over 1.25 million HIV seropositive survivors in China [
The literature suggests that psychosocial interventions such as cognitive-behavioral stress management (CBSM) programs can improve QOL in a variety of populations with chronic diseases, including people living with HIV [
A considerable amount of research has focused on exploring factors associated with QOL, with positive coping being one factor that has received substantial attention [
Previous studies exploring the mediators of the effects of interventions on improving QOL have mostly been conducted in face-to-face settings [
To bridge the gaps in the existing literature, we used longitudinal data from the Run4Love study to examine the mediating role of positive coping on QOL in an mHealth intervention. The Run4Love study was a WeChat (Tencent)-based RCT to examine the intervention effects of an adapted CBSM course with physical activity promotion compared with usual care in people living with HIV. In this study, we hypothesized that the mHealth intervention would enhance the use of positive coping strategies in people living with HIV, which in turn was related to the significant improvement in QOL over time.
The study used data from an mHealth-based RCT, Run4Love (ChiCTR-IPR-17012606) [
The trained research staff recruited participants from the infectious disease outpatient department of the only hospital designated for HIV care and treatment in Guangzhou. Patients who showed interest in the study were invited to participate in a consultation session to receive further information about the program and complete a screening questionnaire. Patients were eligible to participate if they met all of the following inclusion criteria: (1) aged ≥18 years, (2) HIV seropositive, (3) having elevated depressive symptoms (Center for Epidemiologic Studies-Depression score ≥16), and (4) using WeChat, the most popular instant messaging mobile program in China, with more than 1 billion active users worldwide [
Participants who met the aforementioned eligibility criteria and provided written informed consent were enrolled in the study. Under the guidance of the research staff, participants were asked to complete electronic questionnaires in the outpatient department at baseline and 3-, 6-, and 9-month follow-ups. Participants would receive 50 RMB (ie, approximately US $8) or gifts of equivalent value (eg, a yoga mat) as an incentive for completing each assessment.
Participants in the intervention group received a 3-month WeChat-based intervention, which consisted of the adapted CBSM course and physical activity promotion [
Participants in the control group received a brochure on nutrition and healthy living style. They would be offered the Run4Love program as soon as the study was completed (ie, 9 months after their enrollment).
QOL was measured using the 31-item World Health Organization Quality of Life HIV short version (WHOQOL-HIV BREF) at baseline and 3, 6, and 9 months. The WHOQOL-HIV BREF has been widely used among people living with HIV with proven reliability and validity [
Positive coping was measured using the 12-item subscale of the Simplified Ways of Coping Questionnaire with good reliability and validity in the Chinese populations [
Demographic characteristics included age, gender, marital status, educational level, sexual orientation, employment status, family monthly income, and duration of HIV infection (years).
The intention-to-treat principle was applied to all analyses in this study. Descriptive analyses of demographic characteristics, QOL, and positive coping were performed. Differences in outcome measures and baseline characteristics between the intervention and control groups were evaluated using the 2-tailed
The analyses of the mediation effect were conducted in 3 steps [
Second, 2 conditional LGCMs were specified to separately examine the impact of the intervention on QOL and positive coping. The conditional models were extensions of the unconditional models to incorporate the variable of intervention group assignment (ie, intervention group=1 and control group=0) as a covariate.
Third, a parallel-process LGCM was constructed to evaluate whether the intervention was effective in improving QOL via the mediator variable of positive coping. The parallel-process model was a combination of the aforementioned 2 conditional LGCMs, which simultaneously estimated the trajectories of QOL and positive coping, and incorporated intervention group assignment as a covariate. The mediation effect was tested based on bias-corrected 95% bootstrapped CIs with a resampling of 5000 [
Model fit was evaluated using chi-square test statistics and other indexes, including the Tucker-Lewis index (TLI), the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR). An LGCM with adequate model fit should meet the following criteria: TLI>0.90, CFI>0.90, RMSEA<0.08, and SRMR<0.08 [
Descriptive statistics for baseline characteristics are shown in
Baseline Characteristics of the participants in the Run4Love randomized controlled trial (N=300).
Variables | Total (N=300) | Intervention (n=150) | Control (n=150) | |||
Age (years), median (IQR) | 27.5 (24.5-31.3) | 27.4 (24.3-31.1) | 27.8 (24.6-32.2) | .29 | ||
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.13 | |||||
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Male | 277 (92.3) | 142 (94.7) | 135 (90) |
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Female | 23 (7.7) | 8 (5.3) | 15 (10) |
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.10 | |||||
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>High school | 182 (60.7) | 98 (65.3) | 84 (65) |
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≤high school | 118 (39.3) | 52 (34.7) | 66 (35) |
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.73 | |||||
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Single or divorced or widowed | 262 (87.3) | 132 (88) | 130 (86.7) |
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Married | 38 (12.7) | 18 (12) | 20 (85.3) |
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.29 | |||||
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Employed | 251 (83.7) | 123 (82) | 128 (85.3) |
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Unemployed | 49 (16.3) | 27 (18) | 22 (14.7) |
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.20 | |||||
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≥7000 (US $1100) | 124 (41.3) | 68 (45.3) | 56 (37.3) |
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<7000 (US $1100) | 176 (58.7) | 82 (55.7) | 94 (62.7) |
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.03 | |||||
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Homosexual or bisexual or uncertain | 245 (71.7) | 130 (86.7) | 115 (76.7) |
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Heterosexual | 55 (18.3) | 20 (13.3) | 35 (23.3) |
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Duration of HIV infection (years), median (IQR) | 1.7 (0.6-3.7) | 1.7 (0.6-4.0) | 1.8 (0.6-3.9) | .62 | ||
Positive coping, mean (SD) | 18.4 (5.8) | 18.4 (5.5) | 18.3 (6.2) | .92 | ||
Quality of life, mean (SD) | 77.0 (9.2) | 77.4 (9) | 76.6 (9.4) | .44 |
Repeated measures of the outcome variable (ie, QOL) and potential mediator (ie, positive coping) at the 4 assessment points are presented in
Repeated measures of quality of life and positive coping of the participants in the Run4Love randomized controlled trial.
Variables | Quality of life, mean (SD) | Positive coping, mean (SD) | ||||
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Interventiona | Controlb | Interventiona | Controlb | ||
Baseline | 77.43 (9.03) | 76.59 (9.42) | .44 | 18.39 (5.46) | 18.32 (6.15) | .92 |
3 months | 82.54 (12.03) | 76.63 (11.08) | <.001 | 20.79 (7.33) | 17.70 (5.88) | <.001 |
6 months | 83.51 (12.88) | 76.32 (12.96) | <.001 | 21.03 (7.48) | 17.38 (6.59) | <.001 |
9 months | 83.48 (13.17) | 76.54 (13.34) | <.001 | 20.95 (7.75) | 18.31 (6.41) | .003 |
aFor variables in the intervention group, the sample sizes were 150, 139, 132, and 133 at baseline and 3-, 6-, and 9-month follow-ups, respectively.
bFor variables in the control group, the sample sizes were 150, 135, 133, and 127 at baseline and 3-, 6-, and 9-month follow-ups, respectively.
Repeated measures of quality of life (QOL) and positive coping of the participants in the intervention and control groups over time. Error bars represent 95% CIs.
Repeated measures of the 6 domains in quality of life (QOL) of the participants in the intervention and control groups over time. Group 1 and Group 0 represent the intervention and control groups, respectively.
Repeated measures of the 6 domains in quality of life of the participants in the Run4Love randomized controlled trial.
Domains in quality of life | Interventiona | Controlb | |||
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Baseline | 13.91 (2.05) | 13.79 (2.39) | .66 | |
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3 months | 14.96 (2.45) | 13.95 (2.60) | .001 | |
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6 months | 14.98 (2.69) | 13.75 (2.77) | <.001 | |
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9 months | 14.80 (2.84) | 13.92 (3.00) | .02 | |
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Baseline | 12.17 (2.17) | 12.04 (2.08) | .60 | |
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3 months | 13.60 (2.50) | 12.42 (2.24) | <.001 | |
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6 months | 13.88 (2.54) | 12.66 (2.73) | <.001 | |
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9 months | 13.89 (2.83) | 12.64 (2.60) | <.001 | |
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Baseline | 14.40 (1.81) | 14.31 (2.10) | .70 | |
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3 months | 15.28 (2.04) | 14.20 (2.27) | <.001 | |
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6 months | 15.27 (2.23) | 14.38 (2.26) | .002 | |
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9 months | 15.32 (2.29) | 14.26 (2.38) | <.001 | |
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Baseline | 12.05 (2.13) | 11.75 (2.10) | .22 | |
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3 months | 12.37 (2.70) | 11.61 (2.22) | .01 | |
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6 months | 12.80 (2.54) | 11.46 (2.62) | <.001 | |
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9 months | 12.50 (2.53) | 11.62 (2.42) | .005 | |
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Baseline | 12.52 (1.93) | 12.58 (2.08) | .80 | |
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3 months | 13.22 (2.44) | 12.44 (2.15) | .005 | |
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6 months | 13.51 (2.45) | 12.45 (2.74) | .001 | |
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9 months | 13.62 (2.35) | 12.47 (2.56) | <.001 | |
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Baseline | 12.37 (3.00) | 12.11 (3.22) | .47 | |
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3 months | 13.11 (3.16) | 12.01 (3.29) | .005 | |
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6 months | 13.08 (3.37) | 11.62 (3.36) | <.001 | |
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9 months | 13.36 (3.22) | 11.63 (3.49) | <.001 |
aFor variables in the intervention group, the sample sizes were 150, 139, 132, and 133 at baseline and 3-, 6-, and 9-month follow-ups, respectively.
bFor variables in the control group, the sample sizes were 150, 135, 133, and 127 at baseline and 3-, 6-, and 9-month follow-ups, respectively.
The dropout rates were 8.7% (26/300; 11/150, 7.3% in the intervention group; 15/150, 10.0% in the control group), 11.7% (35/300; 18/150, 12.0% in the intervention group; 17/150, 11.3% in the control group), and 13.3% (40/300; 17/150, 11.3% in the intervention group; 23/150, 15.3% in the control group) at 3-, 6-, and 9-month follow-ups, respectively. The average completion rate of the 3-month Run4Love program among people in the intervention group was 50.8% (33/65) [
The results of the unconditional LGCMs indicated that both QOL and positive coping improved across the course of the study, and the largest improvement occurred at the 3-month follow-up. The path diagrams of these 2 unconditional LGCMs are presented in
The results of the conditional LGCMs indicated that the mHealth intervention had significantly positive effects on both QOL and positive coping across the course of the study. The path diagrams of these 2 conditional LGCMs are also presented in
Path diagrams of the unconditional latent growth curve models (LGCMs) for quality of life (QOL) and positive coping and the conditional LGCMs with intervention groups as a covariate. Observed variables are denoted by boxes. Latent variables are denoted by ovals. Unidirectional arrows indicate the effects of 1 variable on the other. Bidirectional arrows indicate the correlations. The nonsignificant paths are shown as dotted lines. Intervention is either the Run4Love intervention group or the waitlist control group. I: intercept; PC: positive coping; S: slope; 0: baseline; 3: 3-month follow-up; 6: 6-month follow-up; 9: 9-month follow-up.
The results of the parallel process LGCM indicated that the mHealth intervention was effective in improving QOL via the mediation effect of positive coping. The path diagram of the parallel process LGCM is presented in
Path diagram of a parallel process latent growth curve model for quality of life (QOL) and positive coping with intervention groups as a covariate. Observed variables are denoted by boxes. Latent variables are denoted by ovals. Unidirectional arrows indicate the effects of 1 variable on the other. Bidirectional arrows indicate the correlations. The nonsignificant paths are shown as dotted lines. Intervention is either the Run4Love intervention group or the waitlist control group. I: intercept; PC: positive coping; S: slope; 0: baseline; 3: 3-month follow-up; 6: 6-month follow-up; 9: 9-month follow-up.
Estimates of the coefficients in the parallel process latent growth curve model for quality of life and positive coping (n=300).
Coefficient | Estimate | 95% CI | Standardized estimate | SE | ||||||||
Intervention→QOLa | 0.552 | −2.154 to 3.258 | 0.036 | 1.381 | .69 | |||||||
Intervention→positive coping | 2.592 | 1.124 to 4.060 | 0.398 | 0.749 | .001 | |||||||
Positive coping→QOL | 1.620 | 0.997 to 2.243 | 0.692 | 0.318 | <.001 | |||||||
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4.750 | 2.766 to 6.734 | 0.311 | 1.012 | <.001 | |||||||
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Intervention→QOL | 0.552 | −2.154 to 3.258 | 0.036 | 1.381 | .69 | |||||
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Intervention→positive coping→QOL | 4.198 | 1.189 to 7.207 | 0.275 | 1.535 | .006 |
aQOL: quality of life.
To the best of our knowledge, our secondary analysis of data from the Run4Love study is among the first efforts to examine the mediating role of positive coping in patients’ QOL in an mHealth-based RCT among people living with HIV. The results of LGCMs demonstrated that the Run4Love trial significantly improved positive coping among people living with HIV over 9 months, and the enhancement of positive coping led to significant improvement in QOL across the study. There was full mediation between positive coping and QOL in the Run4Love trial. Thus, our study revealed one of the potential mechanisms of improvement in QOL in mHealth-based CBSM interventions. To better design and implement effective interventions for people living with HIV, more studies are needed to investigate and identify the processes and/or mechanisms by which interventions lead to significant improvements in health outcomes, especially in emerging mHealth interventions [
Although several cross-sectional studies and 1 cohort study have examined the mediating role of positive coping on QOL [
In addition to the RCT design, the time point repeated measures and corresponding methodology of LGCM used in this study allow more conclusive findings and more abundant information for the mediation analysis or other research. Unlike cross-sectional data or pre- and postintervention data adopted in the previous literature, LGCMs that use longitudinal data allow the trajectory estimation of changes in outcome measures over time [
Given the critical role of positive coping in improving QOL, it is important to develop positive coping skills in mHealth interventions to improve participants’ QOL. Previous psychosocial interventions for people living with HIV found that training in active cognitive and adaptive behavioral coping strategies was effective in improving positive coping [
This study had several limitations. First, the self-reported data on positive coping and QOL in our study might have resulted in recall and social desirability biases. More objective measures, such as biomarkers, could be incorporated in future studies. Second, although participants were recruited from a large hospital for HIV treatment in Guangzhou with over 10,000 patients who were HIV seropositive, the sample was mostly from an urban setting and was predominantly male, particularly young men who have sex with men. Therefore, the generalizability of our findings should be treated with caution. Third, as all the 6 dimensions of QOL were improved in the intervention group at 3, 6, and 9 months, and the improvement was not limited to the mental health dimension, it is possible that the improvement in QOL was also related to other factors besides positive coping, such as reduced depressive symptoms, stress, and/or HIV-related stigma and increased social support [
In conclusion, this study found a full mediation effect of positive coping on QOL among people living with HIV in an mHealth intervention using 4 time point repeated measures and LGCMs. Future research and policies aimed at QOL improvement among people living with HIV should be designed with specific features that enhance the use of positive coping strategies.
cognitive-behavioral stress management
confirmatory fit index
latent growth curve model
mobile health
quality of life
randomized controlled trial
root mean square error of approximation
standardized root mean square residual
Tucker-Lewis index
World Health Organization Quality of Life HIV short version
This study was supported by the National Natural Science Foundation of China (grant 71573290) and China Medical Board open competition funding (grant 17-271). The funding sources had no role in the study design, data collection, statistical analyses, or writing of the manuscript.
YG and YZ had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. They contributed to the conceptualization and design of the study. YZ, MZ, CZ, YL, JQ, and HZ were responsible for the acquisition, analysis, or interpretation of data. YZ drafted the manuscript. YG, RH, AMW, and YZ conducted critical revision of the manuscript for important intellectual content. LL, WC, and CL provided administrative, technical, or material support. YG supervised the study.
None declared.