QUALITY OF LIFE, OPTIMISM/PESSIMISM, AND KNOWLEDGE AND ...

Women’s Health Issues 18 (2008) 301–309

QUALITY OF LIFE, OPTIMISM/PESSIMISM, AND KNOWLEDGE
AND ATTITUDES TOWARD HIV SCREENING AMONG
PREGNANT WOMEN IN GHANA

Cheryl A. Moyer, MPHa,b,c*, Geraldine Ekpo, BSc, Cecilia L. Calhoun, BAc,
Jonathan Greene, BSc, Sujata Naik, MPHd, Emily Sippola, BAa,

David T. Stern, MD, PhDa,b,c,e,f, Richard M. Adanu, FWACS, MPHc,g,
Isaac O. Koranteng, BSc, MB, ChBg, Enyonam Yao Kwawukume, MBBSg, and

Frank J. Anderson, MD, MPHc,d

aGlobal REACH, University of Michigan Medical School, Ann Arbor, Michigan
bDepartment of Medical Education, University of Michigan Medical School, Ann Arbor, Michigan
cMinority and Health Disparities International Research Training Program (MHIRT), Center for Human Growth and Development,

University of Michigan, Ann Arbor, Michigan
dDepartment of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan

eDepartment of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
fAnn Arbor VA Hospital, Ann Arbor, Michigan

gDepartment of Obstetrics and Gynecology, University of Ghana, Accra, Ghana

Received 13 April 2007; accepted 6 February 2008

Objective. We sought to explore optimism/pessimism, knowledge of HIV, and attitudes
toward HIV screening and treatment among Ghanaian pregnant women.

Method. Pregnant women in Accra, Ghana, completed a self-administered questionnaire
including the Life Orientation Test–Revised (LOT-R, an optimism/pessimism measure), an
HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of
health-related quality of life [HRQOL]), and a demographic questionnaire. Data were
analyzed using t-tests, ANOVA, correlations, and the ␹2 test.

Results. There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and
mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for
HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the
sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were
willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs
(ARVs) were readily available and might prevent maternal-to-child transmission. Neither
optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening.
Optimism was negatively correlated with HIV knowledge (p ‫ ؍‬.001) and was positively
correlated with having never been tested before this pregnancy (p ‫ ؍‬.007).

Conclusion. The relationship between optimism/pessimism and HIV knowledge and screen-
ing behavior is worthy of further study using larger samples and objective measures of testing
beyond self-report.

Supported by Grant Number T37 MD001425-08, from the National Center of Minority Health & Health Disparities, National Institutes of
Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of
Health.

* Correspondence to: Cheryl A. Moyer, MPH, Research Director, Global REACH, Research Investigator, Department of Medical Education,
University of Michigan Medical School 715 E. Huron, 2W Loft, Ann Arbor, MI 48104; fax: 734-998-6105.

E-mail: [email protected].

Copyright © 2008 by the Jacobs Institute of Women’s Health. 1049-3867/08 $-See front matter.
Published by Elsevier Inc. doi:10.1016/j.whi.2008.02.001

302 C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309

Introduction South Africa, Uganda, and Zimbabwe; Peltzer, Mpofu,
Baguma, & Lawal, 2002). Yet previous studies of
The concepts of optimism and pessimism—or how optimism/pessimism have been contradictory in their
an individual generalizes positive and negative ex- implications for HIV risk and screening. One study of
periences to predict future outcomes— have been under HIV-negative gay men reported that optimists re-
study by psychologists and psychiatrists for more than 2 ported having fewer anonymous sexual partners than
decades (Peterson & Seligman, 1984; Peterson, Vail- did pessimists (Taylor et al., 1992). In another study
lant, & Seligman, 1988; Scheier & Carver, 1985; Wiebe looking at the intentions of sexually active inner city,
& Smith, 1997) However, it has only been in recent minority adolescents, optimists reported stronger in-
years that health researchers have begun to explore tentions of avoiding unsafe sex (Carvajal, Garner, &
the link between cognitive predispositions like opti- Evans, 1998). However, in a study of adolescent girls
mism/pessimism and factors such as perceived at risk for HIV, those scoring higher in optimism were
health-related quality of life (HRQOL), behavioral less likely to expose themselves to information about
intentions, health behaviors, and health outcomes. HIV testing and were less likely to follow through
And despite a few studies addressing the relationship with an actual test than were those who scored lower
between optimism/pessimism and HIV screening in optimism (Goodman et al., 1995).
(Brown, O’Grady, Farrell, Flechner, & Nurco, 2001;
Goodman, Chesney, & Tipton, 1995; Perkins, Leser- Previous research suggests that optimism/pessi-
man, Murphy, & Evans, 1993), no published research mism may also affect how people assess their HRQOL,
to date has been conducted among pregnant women independent of their true health status. In a study of
in Africa. The results of such research could prove chronic hepatitis C patients (Moyer, Hussain, Fontana,
especially interesting given the likelihood— given access Schwartz, & Lok, 2000; Moyer, Fontana, Hussain, Lok,
to ARVs— of preventing maternal-fetal transmission of & Schwartz, 2003), researchers found that even when
HIV if the mother’s serostatus is known at the time of health status was controlled, pessimists had decidedly
delivery. worse HRQOL scores than optimists or so-called real-
ists (those with the most accurate understanding of
There are an estimated 270,000 –380,000 people liv- the implications of chronic hepatitis C). Interestingly,
ing with HIV in Ghana, a country with approximately optimists’ HRQOL scores closely mirrored the scores
22 million residents (UNICEF, 2007). The estimated of the general US population, despite their chronic
HIV prevalence is 2.3% for adults Ͼ15 years old, and hepatitis C. This is especially noteworthy because
3.9% for young pregnant women (ages 15–24 years) in numerous studies have shown chronic hepatitis C
the capital city of Accra (UNICEF, 2007). As many as patients to have significantly lower QOL than the
13.4% of pregnant women in some rural areas have general population, even when other factors are con-
tested positive for HIV (National AIDS/STI Control trolled in statistical analysis. This raises significant
Programme, 2000); however, many Ghanaians may questions about the potentially protective effects of
not know their HIV status and statistics may under- optimism versus the deleterious effects of pessimism.
represent the true burden of HIV in Ghana (Aggor,
2006). Although access to health care services varies This study addresses several of the questions raised
widely from the rural regions in the north of Ghana to by the literature surrounding optimism/pessimism,
the capital city in the south, the government has made HRQOL, and their potential relationship to HIV
a concerted effort to address access issues with regard screening. This study builds on an existing collabora-
to HIV/AIDS treatment. The National AIDS Control tive study underway in West Africa to explore the role
Program and the Ghana AIDS Commission work to that optimism/pessimism plays among Ghanaian
coordinate and mobilize HIV-related resources. As of pregnant women.
2004, there were 29 voluntary counseling and testing
centers, 19 prevention of mother-to-child transmission Research Questions
sites, and 4 ARV therapy sites providing ARV medi-
cations to people living with HIV/AIDS. Uptake is 1. Are there socioeconomic, demographic, or health-
inconsistent, but large private and government subsi- related variables that are associated with opti-
dies make treatment available to patients for $5–$10 a mism/pessimism and HRQOL among Ghanaian
month. There are also several nationwide efforts un- pregnant women?
derway to expand ARV utilization.
2. How does optimism/pessimism relate to knowl-
In this context, identifying correlates to screening edge of HIV, previous testing behavior, attitudes
behavior and attitudes toward ARV treatment is be- toward HIV screening, and attitudes toward ARV
coming increasingly important. Studies have docu- treatment in this population?
mented a link between positive attitudes toward HIV
screening and actually getting tested, including a
study conducted in four countries in Africa (Nigeria,

C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309 303

Methods scores on the pessimism items) create the overall
optimism score. This overall score treats pessimism as
This study was a cross-sectional assessment of Gha- the opposite of optimism, and reflects a respondent’s
naian pregnant women presenting for prenatal care at overall dispositional optimism. The items reflecting
the Obstetrics and Gynecology Clinic at the Nogouchi optimism (such as, “In uncertain times I usually
Research Institute/Medical School at the University of expect the best”) can be summed to create the opti-
Ghana in Accra, Ghana. The clinic is housed in a mism subscale. The items reflecting pessimism (such
public hospital that is also the largest government as, “If something can go wrong for me, it will,” or
hospital in Ghana. Patients from all over Ghana travel “I rarely count on good things happening to me”) can
to this clinic to receive their care. be summed to create a pessimism subscale. In this
way, the subscales can be used to examine optimism
Women were recruited as part of a larger study that and pessimism as separate constructs. No official
grew out of a long-standing collaboration among “cut scores” have been developed for the LOT-R
Ghanaian, United Kingdom, and United States coun- (Nelson, McMahon, Joffe, & Brensinger, 2003), and
terparts (Klufio, Kwawukume, Danso, Sciarra, & John- typical analysis involves treating the summary score
son, 2003). Women were asked to participate in an and subscale scores as separate continuous vari-
hour-long interview that included a battery of survey ables. Thus a high optimism subscale score does not
instruments while they waited for their appointment. necessarily mean a low pessimism subscale score.
On randomly selected days, the specific instruments Although data on optimism/pessimism among Af-
for each study were alternately included in the overall rican populations is limited, the LOT-R has been
battery of instruments being administered. used successfully in Ն1 study of Ghanaian college
students (Eshun, 1999).
All survey instruments were pilot tested in focus
groups of Ghanaian pregnant women before the onset An HIV knowledge and test acceptance instrument
of this study. Individual items and response options was used; it was designed to assess women’s knowl-
that were problematic were revised and retested to edge of HIV, attitudes toward HIV screening and
ensure maximum validity of data collection. In addi- treatment, and perceived risk of getting infected. The
tion, all instruments were translated into the most instrument was based on items from Family Health
commonly used local dialects (Akan and Ga) for those International’s Behavioral Surveillance Surveys as
patients who do not speak English, and then back- well as other validated instruments available at the
translated to ensure comparability. English is the Population Council’s AIDSQuest website (AIDSQuest,
national language in Ghana, yet many patients are 2007). Although these instruments have been used
more comfortable speaking in their local dialect. Thus, widely in Africa, no previous studies to our knowl-
the researchers included non-English language instru- edge have used these measures among Ghanaian
ments as an option for data collection. pregnant women. The final instrument used in this
study contained 7 questions addressing women’s
Instruments for this study included the Life Orien- knowledge about HIV, 6 items pertaining to women’s
tation Test–Revised (LOT-R, an optimism/pessimism thoughts about getting an HIV test and self-reported
measure), the Short Form 12 (SF-12, an HRQOL mea- HIV testing both ever and during the current preg-
sure), a survey on HIV knowledge, attitudes toward nancy, 2 questions about ARV treatment acceptance,
HIV screening and ARV therapy, self-reported HIV as well as 6 items addressing perceived risk of infec-
testing, and a demographic questionnaire. tion. The 7 knowledge items were summed to create
an overall HIV knowledge score.
The LOT-R (Scheier, Carver, & Bridges, 1994) is a
revision of the original LOT (Scheier & Carver, 1985), Knowledge questions assessed understanding of
devised to determine individual differences in opti- risk of transmission, including whether one could get
mism/pessimism. This instrument has been validated HIV from a mosquito, from sharing food, or from
in Ն5 countries (United States [Scheier & Carver, witchcraft, as well as an understanding of the role of
1985], Brazil [Bandeira, Bekou, Lott, Teixeira, & Rocha, sex with multiple partners and the use of condoms in
2002], Germany [Herzberg, Glaesmer, & Hoyer, 2006], getting or preventing HIV transmission. Test accep-
Norway [Schou, Ekeberg, Ruland, Sandvik, & Kare- tance items included general questions about previ-
sen, 2004], and China [Lai & Yue, 2000]) and has been ous testing behavior without asking for the results of
shown to have high reliability among pregnant women those tests, and ARV acceptance items asked women
(Killingsworth-Rini, Dunkel-Schetter, Wadhwa, & whether they would get tested if they knew ARVs
Sandman, 1999; Scheier & Carver, 1985; Terrill, Fried- were available and affordable in Accra. Finally, items
man, Gottschalk, & Haaga, 2002). Its 10 items generate addressing perceived risk of infection included ques-
an overall optimism score, as well as 2 possible tions such as how many people in their community
subscales: affirmation of optimism and affirmation of did they think had HIV, what level of risk they
pessimism. Each item is rated on a 5-point Likert scale thought they might have of getting HIV in the next 12
from strongly agree to strongly disagree. All items
summed (after removing the fillers and reversing the

304 C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309

months, what level of risk they thought their partner ture (Chang, 2002; Moyer et al., 2000; Moyer et al.,
might have of getting HIV in the next 12 months, and 2003; Ware et al., 1996; Ware et al., 2005) as well as
whether they might be able to convince their partner review by practicing clinicians. The variables assessed
to get tested. include age, number of pregnancies, other medical
conditions, previous treatment for mental health prob-
The SF-12 (Ware, Kosinski, & Keller, 1996) is a lems such as depressed mood or anxiety, previous use
12-item quality-of-life instrument derived from the of antidepressants for premenstrual dysphoric disor-
SF-36, an instrument used and validated around the der, and self-perceived health status. Mental health
world to determine self-assessed HRQOL. The SF- variables were assessed to help us to differentiate
36 —as well as the shortened SF-12— generates not between mental health issues and pessimism, con-
only summary scales of mental and physical function- cepts that can be intimately linked (Chang, 1996). It is
ing (MCS and PCS), but it also generates a profile of worth noting that Ghanaian women may see 1 of the
patients’ HRQOL across 8 domains: physical function- 45,000 traditional healers or 488 medical or counseling
ing (PF), role physical (RP), bodily pain (BP), general personnel in Ghana to address emotional health issues
health (GH), vitality (VT), social functioning (SF), role (World Health Organization, 2003).
emotional (RE), and mental health.
All women presenting for prenatal care were ap-
PF addresses such areas as ability to care for oneself, proached by trained research assistants with transla-
walk various distances, and participate in various tors, if necessary. To be eligible to participate, women
levels of activity. RP reflects the degree to which a needed to be Ն18 years of age, pregnant, and not
respondent’s physical health has impacted their abil- facing an imminent health crisis. The research was
ity to carry out their normal everyday duties. BP explained to each participant, and those who agreed to
reflects the presence of pain as well as the degree to participate signed a consent form that had been ap-
which it interferes with respondents’ lives. GH reflects proved by the Institutional Review Boards at the
a respondent’s overall assessment of their health sta- University of Michigan and the Noguchi Memorial
tus. VT reflects the amount of energy a respondent Institute for Medical Research at the University of
perceives themselves to have. SF represents the degree Ghana. The research assistant and translator then
to which a respondent’s health interferes with social interviewed each respondent for an average of 1 hour,
activities. RE refers to the degree to which a respon- marking her responses on paper copies of the instru-
dent’s emotional health affects their ability to carry ment. Each respondent was assigned a unique ID
out their normal activities. Mental health reflects a number, which was marked at the top of her com-
respondent’s rating of the frequency of positive and pleted interview. No other identifying information
negative affective states. The Physical Health Sum- was recorded.
mary Score (PCS) is calculated based on a combination
of PF, RP, BP, and GH scores. The Mental Health All data were entered into an Excel spreadsheet and
Summary Score (MCS) is calculated based on a com- cleaned. LOT-R and SF-12 scores were calculated
bination of VT, SF, RE, and mental health scores. using standard instrument scoring algorithms. Data
were then imported into SPSS statistical software
According to SF-36 developers, 12 of the original (SPSS Inc, Chicago, IL) for analysis. Frequencies and
SF-36 items accounted for Ն90% of the variance in basic descriptive statistics were calculated for all vari-
PCS-36 and MCS-36 in both general and patient pop- ables, including cross tabs to determine potential
ulations, and those same 12 items reproduced the relationships between key variables. Student’s t-tests
profile of the 8 SF-36 health concepts sufficiently for were used to compare means on continuous variables,
studies in which the length of the instrument may be and the ␹2 test was used to examine categorical data.
prohibitive (Ware et al., 1996; Ware, Kosinski, Turner- Correlations were conducted to examine the relation-
Bowker, & Gandek, 2005). In addition, the SF-36 ship between 2 continuous variables, such as SF-12
family of instruments has been translated, back trans- subscale scores and LOT-R scores. ANOVA with post
lated, and cross-culturally validated in Ͼ40 different hoc pairwise comparisons was use to compare multi-
countries, including South Africa and Tanzania (IQOLA, ple means on HRQOL subscales.
2007). Although there has not been published valida-
tion work in Ghana, the track record of validation in A p value of .01 was taken as statistically signifi-
other parts of Africa as well as our own pilot testing to cant for analysis regarding the LOT-R, HIV-related
ensure comprehension, comparability, and face valid- variables, and demographic variables. Because each
ity indicated that the SF-12 could be a useful measure analysis of the SF-12 involves 8 subscales, an alpha
of quality of life in this population. of .006 was chosen to define statistical significance
regarding the SF-12, based on the Bonferroni adjust-
The Demographic Questionnaire is a study-specific ment for multiple comparisons (Matthews & Fare-
instrument designed to determine basic patient char- well, 1988).
acteristics that might be associated with optimism,
pessimism, HRQOL, or pregnancy outcomes. This
instrument was developed based on previous litera-

C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309 305

Table 1. Patient Demographics (n ϭ 101) Mean, ϮSD (Range) the lowest overall LOT-R quartile had delivered more
babies than women in the highest quartile (p ϭ .01).
Variable 29.7 Ϯ 4.8 (18–42) Those with the highest overall optimism scores were
31.78 Ϯ 7.6 (11–43) more likely to have a higher level of education (p ϭ .01).
Maternal age (yrs) 2.42 Ϯ 1.28 (1–6)
Weeks gestation 1.03 Ϯ 1.02 (0–4) In subscale analyses, pessimism subscale scores did
Number of pregnancies (including current) not significantly correlate with optimism subscale
Previous deliveries Percent scores (r ϭ .128; p ϭ .205 [not significant]). Thus,
women with the highest pessimism subscale scores
Highest level of education 6.2 were not necessarily the same women with the lowest
Primary 27.8 optimism scores. Conversely, those who were most
Middle 29.9 optimistic were not necessarily the least pessimistic.
Secondary 36.1
Beyond secondary 86.1 Knowledge of HIV and Acceptance of HIV Screening
93.1 Overall optimism and the LOT-R pessimism subscale
Work for money 28.0 were both correlated with HIV knowledge at p ϭ .001
Married 20.8 (r ϭ Ϫ.383 for overall LOT-R; r ϭ .365 for pessimism
Nulliparous 15.0 subscale). This indicates that the more optimistic (and
Ongoing health issues 19.0 less pessimistic) a woman was, the less she knew
Pregnancy complications about HIV. Optimism/pessimism was not related to a
Ever seen doctor/counselor for emotional 15.8 woman’s perceived risk of acquiring HIV, whether she
had been tested for HIV during this pregnancy,
problems whether she would be willing to be tested for HIV, or
Ever taken prescription medication for whether she would be willing to accept ARV treat-
ment if necessary. However, the optimism subscale of
emotional problems the LOT-R was significantly associated with the vari-
able “tested for HIV before this pregnancy.” Those
Results women who reported not being tested before this
pregnancy were slightly more optimistic than those
Data were collected on 101 pregnant women. Patient who reported being tested in the past (p ϭ .007).
demographics are given in Table 1, and HIV-related
variables are described in Table 2. In summary, this Perceived risk of acquiring HIV was significantly
was a group of women who were likely to be married, associated with a woman’s perceived risk of her
work for pay, have had Ն1 previous pregnancy and partner getting HIV (p Ͻ .001). Perceived risk of
delivery, and were in their third trimester of preg-
nancy. They were also well-educated, with 36% hav- Table 2. HIV-Related Variables
ing gone beyond secondary education. With regard to
HIV, they were knowledgeable, with 100% having Variable Percent
heard of HIV, 51.3% obtaining a perfect HIV knowl-
edge score, and three quarters obtaining Ͼ85% on a Heard of HIV/AIDS 100.0
test of HIV knowledge. Slightly more than half had Perfect HIV knowledge score 51.3
ever been tested, and the vast majority felt as though Ͼ85% correct HIV score 76.3
they were at no or little risk of being infected with Tested for HIV before this pregnancy 27.7
HIV. Tested for HIV during this pregnancy 46.5
Total % ever tested for HIV 59.4
Optimism/Pessimism Of those not tested during current pregnancy, % willing 64.2
Overall mean LOT-R scores were 15.6 (standard devi-
ation [SD], 3.8; range, 8 –24). Mean subscale scores to get tested if test were offered 89.0
were 11.0 (SD, 1.4; range, 7–12) for optimism and 7.3 If ARVs were readily available, % of all respondents
(SD, 3.7; range, 0 –12) for pessimism. Overall LOT-R 96.0
scores were associated with currently seeing a doctor who would get tested
or other health care provider for emotional issues (p ϭ % of all respondents who would accept ARV treatment 62.0
.001), with those seeing a health care professional 31.0
being less optimistic than those not (mean 12.8 versus if necessary 6.0
16.1). LOT-R scores were not significantly associated Perceived risk of getting HIV
with any other demographic or health-related vari- 1.0
able, including age, marital status, pregnancy compli- No risk
cations, self-rated “difficulty” of the pregnancy, or Small risk 62.2
ongoing comorbid conditions. Moderate or great risk 28.6
Don’t know 3.0
When examined by quartile, those with the lowest Perceived risk of partner getting HIV
overall optimism scores were significantly more likely No risk 6.1
to report being under the care of a health care provider Small risk
for emotional problems (p ϭ .01). In addition, those in Moderate or great risk
Don’t know

Abbreviation: ARV, antiretroviral drug.

306 C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309

acquiring HIV was not associated with any other vent them from putting themselves at risk of HIV,
sociodemographic or health-related variable. thus reducing their perceived need to get tested.
Scheier et al. (2001) argue that perhaps optimists go to
When asked if a woman thought she might be able greater lengths than pessimists to verify their part-
to convince her partner to get an HIV test, the RE ner’s HIV status, thus knowing they themselves were
subscale of the SF-12 significantly divided the group. at a lower risk. However, it is equally possible that
Those who said they would not be able to convince optimism is a product of— or at least associated
their partner to get an HIV test had significantly lower with—ignorance of the true risks of HIV.
RE scores than those who said they could convince
their partner to be tested (p Ͻ .001). It is worth noting that optimism/pessimism was not
related to a woman’s perceived risk of acquiring HIV.
HRQOL However, 93% of our sample said they had no or small
Quality of life as measured across the 8 subscales and risk of getting HIV. It is possible that with a larger
2 summary scores of the SF-12 did not significantly sample size we might have detected an association
correlate with optimism/pessimism as assessed by the between optimism/pessimism and perceived HIV
LOT-R. The data did suggest a trend toward lower risk.
quality-of-life scores among women with the lowest
LOT-R scores, but results were not statistically signif- Another interesting finding in these data is that
icant. The physical health summary scale of the SF-12 women with the highest pessimism subscale scores
(PCS) was significantly associated with reporting on- were not necessarily the same women who had the
going health issues (p ϭ .001), with those respondents lowest optimism scores. Conversely, those who were
with lower PCSs being more likely to report ongoing most optimistic were not necessarily the least pessi-
health issues such as heart trouble, lung problems, mistic. This lends credence to the LOT-R creators’
gastrointestinal issues, diabetes, or other ailments re- assertion that optimism and pessimism can be seen as
quiring a doctor’s care. In addition, reporting preg- 2 separate constructs, rather than as 1 construct along
nancy complications was associated with a trend a continuum.
toward lower PF (p ϭ .01).
Optimism/pessimism did seem to be related to
The VT subscale was negatively correlated with current treatment for emotional issues (p ϭ .001).
number of weeks gestation (r ϭ Ϫ.229; p ϭ .03), the Although this could be taken to mean that optimism/
GH subscale was negatively correlated with the over- pessimism is just a proxy for mental health issues,
all assessment of how easy the pregnancy was (r ϭ several factors suggest that such an interpretation
Ϫ.227; p ϭ .023), and the RP subscale was negatively would be inaccurate. First, the pessimism subscale of
correlated with the number of times a woman had the LOT-R did not significantly correlate with any of
been pregnant (r ϭ Ϫ.217; p ϭ .03). But none of these the mental health-related variables assessed, and it is
associations met our strict criteria for significance. most likely that pessimism would be linked with
mental health issues rather than optimism. In addi-
Discussion tion, neither the overall LOT-R nor its pessimism
subscale was associated with the SF-12 mental health
Optimism/pessimism was not significantly associated subscale or the MCS. If optimism/pessimism were a
with basic demographic characteristics, self-rated proxy for mental health issues, clearly mental HRQOL
health status, quality of life, or HIV test acceptance ought to parallel LOT-R scores. This study suggests
among the Ghanaian pregnant women in our sample. that at least among this sample of Ghanaian pregnant
This is noteworthy given previous studies that women, optimism/pessimism is a separate construct
showed a direct linear relationship between opti- than mental health.
mism/pessimism and HRQOL among patients in the
United States (Moyer et al., 2003; Schou, Ekeberg, & With regard to quality of life, this study showed
Ruland, 2005). some expected results. Data suggest that the Ghanaian
women in our sample had lower VT scores the farther
Optimism scores in this sample did correlate with along they were in their pregnancies, lower GH scores
having been tested for HIV before this pregnancy (p ϭ if they reported having difficult pregnancies, and
.007) and HIV knowledge (p ϭ .001). Interestingly, lower RP scores if they had been pregnant previously.
those who were not tested before this pregnancy and Yet to put these numbers into perspective, when
had the least knowledge of HIV were the most opti- compared with published data regarding pregnancy
mistic. This raises questions of whether optimism is, in and HRQOL using the SF-36, Ghanaian women in this
fact, denial or lack of understanding of potential risks. study report much better GH and VT and less BP than
In the case of not being tested before this pregnancy, pregnant women in the United States (Hueston & Kasik-
one could argue that optimism might help women to Miller, 1998; Larrabbee, Monga, Eriksen, & Helfgott,
make better decisions about their behavior and pre- 1996; McKee, Cunningham, Jankowski, & Zayas,
2001). These published data reflect samples of general
US pregnant women (Hueston & Kasik-Miller, 1998),

C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309 307

HIV-negative pregnant women in the United States instruments is unlikely to yield significantly different
(Larrabbee et al., 1996), and low-income, minority results than comparisons using identical instruments.
women in late pregnancy (McKee et al., 2001). When
data from the Ghanaian women in this study were Another limitation is that the sample drawn in this
compared with these US-based studies, ANOVA indi- study was largely one of convenience. All women
cated significant differences among groups on all presenting to the clinic were asked to participate, and
subscales at p Ͻ .001, but post hoc pairwise compari- it is possible that the women presenting on the days in
sons indicate that Ghanaian scores were significantly which these study instruments were administered
higher for BP, GH, and VT, and significantly lower for were in some way different from the larger population
RE. Note that the mental health subscale scores do not of pregnant women in Ghana. The clinic in which this
differ. study was conducted reflects a broad range of women
in Ghana, but future studies would benefit from a
As mentioned, there are no established “cut points” design that includes random selection.
for optimism as measured by the LOT-R. Yet the
scores from our sample did seem to be better than the Another limitation of this study is that the only data
scores published in the literature of US women. Com- available on HIV testing behavior is self-report data.
pared with a similarly aged sample of US women There was no attempt to verify whether women had
(Scheier et al., 1994), the Ghanaian women in our indeed been tested in the past or tested during this
sample were significantly more optimistic (p ϭ .004). pregnancy. This study also did not include questions
This is consistent with previous findings indicating about women’s partner’s HIV status. If women knew
that Ghanaian college students are more optimistic their partner was HIV negative, for instance, they
than American college students (Eshun, 1999). might be less inclined to be tested. We had no way to
determine if that was the case.
Although cross-cultural comparisons were not the
focus of our inquiry, these comparisons do help to This study did not collect data regarding whether
provide valuable context in which to view our find- women were previously tested for HIV as part of
ings. Taken together, it seems that our sample of prenatal care for a previous pregnancy. Thus, it is
Ghanaian women was more optimistic and had better difficult to interpret the findings that 1) women who
quality of life than several cohorts of pregnant women had been previously tested for HIV seemed to be less
in the United States as published in the research optimistic than those who had not been tested, and 2)
literature. If these results are borne out in subsequent women with greater parity had lower optimism. It is
studies with larger sample sizes and a matched cohort possible that women who have had previous children
design, they raise many interesting questions about have also visited prenatal clinics and been more likely
why such differences may exist. to receive an HIV test. Future research needs to
explore the relationship between parity, prenatal care,
Limitations HIV testing, and optimism/pessimism.
There are several limitations to this study worth
discussing. First, the use of the LOT-R has not been This study included questions that were rather
validated for use among Ghanaian pregnant women. hypothetical in nature. For example, respondents were
However, the instrument has been used previously in asked if ARVs were available, would they get tested?
Ghana (Eshun, 1999) and it was carefully pretested in And if they tested positive for HIV, would they take
this population for comprehension before study im- ARVs? It is very easy to answer “yes” to such ques-
plementation. Our focus groups and pilot testing did tions when there are no consequences associated with
not indicate any difficulties in interpretation of these doing so. Although “intention” may be the closest
items. Nonetheless, the instrument would benefit measurable variable to “action,” it is not the same
from a more rigorous validation study in this popula- thing. Future research needs to solidify the relation-
tion. Similarly, although the SF-12 has been used all ship between intention and action in this population
over the world and translated into dozens of lan- regarding acceptance of HIV testing and treatment.
guages, the research literature does not indicate it has
been validated in Ghana. Nonetheless, focus group The final limitation to this study is that, despite
data suggest that respondents did not have trouble standardized written scripts, it is impossible to quan-
responding or comprehending the intent of the ques- tify the potential impact that the interviewers and
tions. translators may have had on the women’s responses.
Although data analysis showed no differences in
Another limitation is that comparison data for preg- responses by interviewer, it is unclear whether the
nant women was unavailable for the SF-12, so the presence of interviewers may have caused women to
comparisons referred to above were made using data respond more positively due to social desirability bias.
collected with the SF-36. The SF-12 is a subset of the Given that nearly one fifth reported ever being treated
SF-36 and has demonstrated significant correlation for mental health issues and 59% reported having had
with the SF-36, thus comparing results from the 2 an HIV test, it seems unlikely that social desirability
bias had an undue effect on the data. However,
reliable national data regarding mental health treat-

308 C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309

ment and percentage of pregnant women who have Goodman, E., Chesney, M. A., & Tipton, A. C. (1995). Relationship
been tested for HIV is not available for comparison. of optimism, knowledge, attitudes, and beliefs to use of HIV
antibody test by at-risk female adolescents. Psychosomatic Medi-
Potential Implications cine, 57, 541–546.

This study has several important implications. The Herzberg, P. Y., Glaesmer, H., & Hoyer, J. (2006). Separating
first is that more research needs to be done to optimism and pessimism: A robust psychometric analysis of the
elucidate the true relationship between optimism/ revised Life Orientation Test (LOT-R). Psychological Assessment,
pessimism and HIV knowledge and future screening 18, 433– 438.
behavior. Are optimists in denial? Or are optimists
protecting themselves from HIV and therefore not Hueston, W. J., & Kasik-Miller, S. (1998). Changes in functional
concerning themselves with factual details about its health status during normal pregnancy. Journal of Family Practice,
transmission or getting tested? Are pessimists actually 47, 209 –12.
better off when it comes to HIV screening by prepar-
ing for the worst? Future research needs to address IQOLA Countries. (2007). International Quality of Life Association.
these questions. Available: www.iqola.org/countries.aspx. Accessed June 20,
2007.
The second is that, given our data’s suggestion that
the Ghanaian women in our sample are more optimis- Killingsworth-Rini, C., Dunkel-Schetter, C., Wadhwa, P. D., &
tic and have better perceptions of their GH, BP, and Sandman, C. A. (1999). Psychological adaptation and birth out-
VT than US women, further research is warranted to comes: The role of personal resources, stress, and sociocultural
discern some of the causative agents behind these context in pregnancy. Health Psychology, 18, 333.
differences. It also raises questions about cultural
norms and how they might translate to better emo- Klufio, C. A., Kwawukume, E. Y., Danso, K. A., Sciarra, J. J., &
tional and physical well-being. Johnson, T. R. B. (2003). Ghana POSTGRAD OB/GYN Collabo-
rative Residency Training Programme: Success story and model
A vital next step is determining whether differences for Africa. American Journal of Obstetrics and Gynecology, 189,
in emotional well-being and optimism during preg- 692– 6.
nancy translate to measurable differences in actual
HIV screening and/or acceptance of ARVs within the Lai, J. C. L., & Yeu, X. (2000). Measuring optimism in Hong Kong
larger population of Ghanaian women. Future re- and mainland Chinese with the revised Life Orientation Test.
search needs to be longitudinal in nature, include Personality and Individual Differences, 28, 781–796.
objective clinical data, and include larger sample sizes.
Larrabbee, K. D., Monga, M., Eriksen, N., & Helfgott, A. (1996).
References Quality of life assessment in pregnant women with the human
immunodeficiency virus. Obstetrics and Gynecology, 88, 1016 –
Aggor, R. (2006). Addressing the HIV epidemic in Ghana through 1020.
open and distance education. The Fourth Pan Commonwealth
Forum on Open Learning. Available: http://pcf4.dec.uwi.edu. Matthews, D. E., & Farewell, V. T. (1988). Using and understanding
Accessed June 22, 2007. medical statistics (2nd ed.). New York: S. Karger.

AIDSQuest. The HIV-AIDS survey library. (2007). Available: www. McKee, M. D., Cunningham, M., Jankowski, K. R., & Zayas, L.
popcouncil.org. Accessed June 20, 2007. (2001). Health-related functional status in pregnancy: Relation-
ship to depression and social support in a multi-ethnic popula-
Bandeira, M., Bekou, V., Lott, K. S., Teixeira, M. A., & Rocha, S. S. tion. Obstetrics and Gynecology, 97, 988 –993.
(2002). Validação transcultural do Teste de Orientação da Vida
(TOV-R). Estudos de Psicologia, 7, 251–258. Moyer, C. A., Fontana, R. J., Hussain, K., Lok, A. S. F., & Schwartz,
S. (2003). The role of optimism/pessimism in HRQOL in chronic
Brown, B. S., O’Grady, K. E., Farrell, E. V., Flechner, I. S., & Nurco, hepatitis C patients. Journal of Clinical Psychology in Medical
D. N. (2001). Factors associated with frequent and infrequent HIV Settings, 10, 41– 49.
testing. Substance Use & Misuse, 36, 1593–1609.
Moyer, C. A., Hussain, K., Fontana, R. J., Schwartz, S., & Lok, A.
Carvajal, S. C., Garner, R. L., & Evans, R. I. (1998). Dispositional (2000). The role of pessimism/optimism in HRQOL and mental
optimism as a protective factor in resisting HIV exposure in health in chronic hepatitis C (CHC) patients. Quality of Life
sexually active inner-city minority adolescents. Journal of Applied Research, 9, 267.
Social Psychology, 28, 2196 –2211.
National AIDS/STI Control Programme. (2000). Estimating national
Chang, E. C. (1996). Evidence for the cultural specificity of pessi- HIV prevalence in Ghana using sentinel surveillance data. Avail-
mism in Asians versus Caucasians: A test of the general negativ- able: www.policyproject.com. Accessed June 22, 2007.
ity hypothesis. Personality and Individual Differences, 21, 819 – 822.
Nelson, D. B., McMahon, K., Joffe, M., & Brensinger, C. (2003). The
Chang, E. C. (Ed.). (2002). Optimism & pessimism: Implications for effect of depressive symptoms and optimism on the risk of
theory, research, and practice. Washington DC: American Psycho- spontaneous abortion among innercity women. Journal of Women’s
logical Association. Health, 12, 569 –576.

Eshun, S. (1999). Cultural variations in hopelessness, optimism, and Peltzer, K., Mpofu, E., Baguma, P., & Lawal, B. (2002). Attitudes
suicidal ideation: A study of Ghana and U.S. college samples. towards HIV-antibody testing among university students in four
Cross-Cultural Research, 33, 227–238. African countries. International Journal for the Advancement of
Counselling, 24, 193–203.

Perkins, D. O., Leserman, J., Murphy, C., & Evans, D. L. (1993).
Psychosocial predictors of high-risk sexual behavior among
HIV-negative homosexual men. AIDS Education and Prevention, 5,
141–152.

Peterson, C., & Seligman, M. E. P. (1984). Causal explanations as a
risk factor for depression: Theory and evidence. Psychological
Review, 91, 347–374.

Peterson, C., Vaillant, G. E., & Seligman, M. E. P. (1988). Pessimistic
explanatory style is a risk factor for physical illness: A thirty-five-
year longitudinal study. Journal of Personality and Social Psychol-
ogy, 55, 23–27.

C. A. Moyer et al. / Women’s Health Issues 18 (2008) 301–309 309

Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Author Descriptions
Assessment and implications of generalized outcome expectan- Cheryl A. Moyer is the Research Director at
cies. Health Psychology, 4, 219 –247.
Global REACH at the University of Michigan Med-
Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing ical School and a faculty mentor for the NIH-funded
optimism from neuroticism (and trait anxiety, self-mastery, and Minority and Health Disparities International Re-
self-esteem): A re-evaluation of the Life Orientation Test. Journal of search Training Program (MHIRT) at the University
Personality and Social Psychology, 67, 1063–1078. of Michigan.

Scheier, M. F., Carver, C. S., & Bridges, M. W. (2001). Optimism, Geraldine Ekpo is a medical student and MHIRT
pessimism, and psychological well-being. In E. C. Chang (Ed.), trainee at the University of Michigan.
Optimism and pessimism: Implications for theory, research, and
practice (pp. 189 –216). Washington, DC: American Psychological At the time of this research, Cecilia L. Calhoun was
Association. an undergraduate student and MHIRT trainee at the
University of Michigan.
Schou, I., Ekeberg, O., & Ruland, C. M. (2005). The mediating role of
appraisal and coping in the relationship between optimism- Jonathan Greene is a medical student and MHIRT
pessimism and quality of life. Psycho-Oncology, 14, 718 –727. trainee at the University of Michigan.

Schou, I., Ekeberg, O., Ruland, C. M., Sandvik, L., & Karesen, R. At the time of this research, Sujata Naik was a
(2004). Pessimism as a predictor of emotional morbidity one year Research Associate in the Department of Obstetrics
following breast cancer surgery. Psycho-Oncology, 13, 309 –320. and Gynecology at the University of Michigan.

Taylor, S. E., Kemeny, M. E., Aspinwall, L. G., Schneider, S. G., At the time of this research, Emily Sippola was a
Rodriguez, R., & Herbert, M. (1992). Optimism, coping, psycho- Research Associate at Global REACH at the University
logical distress, and high-risk sexual behavior among men at risk of Michigan.
for acquired immune deficiency syndrome (AIDS). Journal of
Personality and Social Psychology, 63, 460 – 473. David T. Stern is the Director of Global REACH and
Associate Professor of Medicine and Medical Educa-
Terrill, D. R., Friedman, D. G., Gottschalk, L. A., & Haaga, D. A. F. tion at the University of Michigan.
(2002). Construct validity of the Life Orientation Test. Journal of
Personality Assessment, 79, 550 –563. Richard M. Adanu is a Senior Lecturer in Obstetrics
and Gynecology at the University of Ghana and a
UNICEF. (2007). At a glance: Ghana—Statistics. Available: www. faculty mentor for the MHIRT program.
unicef.org. Accessed June 21, 2007.
Isaac O. Koranteng is a Senior Resident in Obstetrics
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short- and Gynecology at the University of Ghana.
Form Health Survey: Construction of scales and preliminary tests
of reliability and validity. Medical Care, 34, 220 –233. Enyonam Yao Kwawukume is the Chief of Obstet-
rics and Gynecology at the University of Ghana.
Ware, J. E., Kosinski, M., Turner-Bowker, D. M., & Gandek, B.
(2005). How to score version 2 of the SF-12 Health Survey. Lincoln, Frank J. Anderson is an Assistant Professor of
RI: QualityMetric Incorporated. Obstetrics and Gynecology at the University of Mich-
igan, director of Global Initiatives for the Department,
Wiebe, D. J., & Smith, T. W. (1997). Personality and health: Progress and faculty mentor for the MHIRT program.
and problems in psychosomatics. In R. Hogan, J. Johnson, & S.
Briggs (Eds.), Handbook of personality psychology (pp. 891–918). San
Diego: Academic Press.

World Health Organization. (2003). Mental health components in
the Ghana Health Service. Available: www.who.int. Accessed
June 27, 2007.