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UNIVERSITY OF GHANA 
COLLEGE OF HUMANITIES  
SCHOOL OF SOCIAL SCIENCES 
 
 
EXPEREINCES OF FORGIVENESS, PSYCHOLOGICAL HEALTH-
RELATED QUALITY OF LIFE AND IMMUNOLOGICAL 
MARKERS:  
A STUDY AMONG PEOPLE LIVING WITH HIV/AIDS IN GHANA. 
 
 
 
 
BY 
 
JUDITH ANSAA OSAE-LARBI 
(10205090) 
 
 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA,                            
LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT 
FOR THE AWARD OF PHD PSYCHOLOGY DEGREE 
 
 
 
 
JULY, 2018 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
DECLARATION 
Having gone through the required procedures, I hereby present this thesis as an original 
piece of work I have personally undertaken in the Psychology Department, University of 
Ghana, and one which has never been presented in part or in full to any university or 
institution for the award of any degree. All references made to others have been duly 
acknowledged.  
 
 
.................................                                                                                  .............................. 
JUDITH ANSAA OSAE-LARBI                                                            DATE 
(CANDIDATE)      
 
 
This thesis has been submitted under the supervision and approval of  
 
................................. 
                                                                               ................................. 
 
PROF. C. C. MATE-KOLE                                                                    DATE 
(PRINCIPAL SUPERVISOR)  
 
 
................................. 
                                                                              ................................. 
 
PROF. ANGELA OFORI-ATTA                                                          DATE  
 (SUPERVISOR)  
 
 
.................................                                                                              ................................. 
 
DR. BENJAMIN AMPONSAH                                                             DATE 
(SUPERVISOR)  
 
 
..............................                                                                                  ................................ 

DR. ANNABELLA OSEI-TUTU                                                               DATE 
 (SUPERVISOR)  
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
ABSTRACT 
The role of forgiveness of perceived offenses in health has gained empirical attention for 
about three decades now in various areas including the area of Human Immunodeficiency 
Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS). This study aimed at 
investigating the relationship between forgiveness of offenses directly related to one’s 
HIV/AIDS-positive status and two health outcomes – psychological health-related quality 
of life (PHRQOL) and immune functioning, measured by change in cluster of 
differentiation 4 (CD4) cells. Employing an explanatory mixed method design, cross-
sectional survey data was first collected on a total of 325 people living with HIV/AIDS 
(PLWHA) receiving antiretroviral therapy (ART) across HIV outpatient clinics at the 
Korle-Bu, Komfo Anokye, and Tamale Teaching Hospitals in Ghana. Participants 
completed validated forgiveness measures across three contexts – intrapersonal, 
interpersonal, and spiritual. Multivariate regression analyses revealed that forgiveness, 
particularly positive attitudes toward God and decisional forgiveness of self, uniquely 
predicted PHRQOL and change in CD4 cell count respectively in adjusted analyses. 
However, health behaviours did not moderate the forgiveness-health relationship in all 
contexts. To expound on the survey findings, a follow-up phenomenological study on the 
lived experiences of forgiveness of HIV-related offenses among 15 of the survey 
participants using a semi-structured interview schedule was conducted. Using 
interpretative phenomenological analysis, six themes emerged indicating that forgiveness 
was experienced as internal and external actions confirmed by the experience of positive 
psychological changes within the offended. These changes held meaning for participants’ 
psychological health, their physical and socioeconomic wellbeing, as well as for adhering 
to ART, engaging in protective sexual behaviours, and living a new, focused, and 
purposeful life. Overall, the findings complementarily lend support to the Stress and 
Coping Model of Forgiveness, the Biopsychosocial Contexts of Framework of 
Forgiveness in HIV/AIDS, and the Afrocultural Social Ethos Framework. Namely, among 
PLWHA in Ghana, forgiveness as an adaptive coping strategy for perceived HIV-related 
offenses may hold benefits for psychological and immune health possibly through the 
stress response system and also positive health behaviours, and that among other factors, 
values for communalism and spirituality may facilitate forgiveness experiences via social 
support and religious beliefs and practices. These findings hold important implications for 
theory building, clinical practice, policy development, and for public health and health 
psychology practice. There is the need for health psychologists through collaborations 
with clinicians, public health professionals, and policy makers to develop and implement 
culturally-relevant forgiveness assessments and interventions suitable for use in clinical 
settings. These, together with existing ART-adherence counselling protocols, may support 
PLWHA to appropriately cope with any perceived offenses and emotional pain, and to feel 
motivated to engage in adherent and protective behaviours, both of which behaviours are 
necessary for curbing secondary transmission of HIV/AIDS.  
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
DEDICATION 
To Seth Osae-Larbi and Mary Osae-Larbi; I couldn’t have asked for better parents.  
I am indebted to you. Remain blessed in Christ. 
 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
ACKNOWLEDGEMENT 
To God Most High, through Christ Jesus, be all the glory for granting me life, health, and 
a solid system of support from my family – Dad, Mum, Lydia, Eben, Twum, Charity, 
Fabby, and sweetest Chuchu – May God smile on you all for your love, prayers, and 
unflinching support! 
 
I am extremely grateful to my supervisors; Prof. C. C. Mate-Kole, Prof. Angela Ofori-
Atta, Dr. Benjamin Amponsah, and Dr. Annabella Osei-Tutu, for their expert supervision 
and constant encouragement. It has been a blessing to be supervised by this team led by 
Prof. Mate-Kole, who personally took it upon himself to ensure in countless ways, that I 
complete this project in time.  
 
My sincere thanks go to the UG-Carnegie Foundation for their timely financial support 
with my tuition and research costs and to Prof. Yaa Ntiamoah Badu for her dedication to 
supporting timely completion of graduate studies.  
 
Many thanks go to the Templeton Foundation; I owe the idea of this thesis to the 
Foundation for funding the Forgiveness in West Africa Project and covering part of my 
research costs. I am also grateful to Prof. Everett Worthington for leading this project and 
for providing instrumental support and expert feedback on this thesis.  
 
My sincere thanks go to all my participants and the participating hospitals for the 
opportunity to take off this novel project in Ghana. I am grateful to Dr. Vincent Ganu, Mr. 
Stephen Gyamfi, and the entire HIV counselling team at Korle-Bu, for their support with 
the data collection. Many thanks go to Mr. Oppong, Head of Pharmacy, Chest Clinic, and 
to Dr. Dompreh, Head of Virology Unit, Komfo Anokye Teaching Hospital. I also 
acknowledge the support of Commander Nyarko and Dr. Manu of the Public Health Unit, 
37 Military Hospital.  
 
I particularly thank Emmanuel Dziwornu for his unceasing instrumental and emotional 
support throughout this journey; Emma, Apke. I am also grateful to Isaac Badu and all 
those who helped with the data collection and analyses to ensure rigor and timely 
completion of this work.  
 
A big thank you again goes to Prof. David L. Sam, Prof. Seth Oppong, Dr. Doku, Dr. 
Vincent Boima, Dr. Ernest Yorke, Dr. Dzifa Dey, and Dr. Amissah Arthur for their expert 
feedback. Many thanks also go to Miss Mary Ampomaah for her emotional support.  
 
To Mr. and Mrs. Obeng-Debrah: I can’t thank you enough for your exceptional 
instrumental support and love during my data collection periods in Kumasi! Also, to 
Zakaria Sayibu, for your humble assistance during my data collection periods in Tamale, I 
say thank you!  
 
I am full of thanks for the many friends who offered moral and prayer support along the 
journey, including Mr. Samuel Turkson, Yaw Asamoah, Richmond Ofosu-Gyamfi, Ruth 
Frempong, Dr. Philemon Gyasi-Antwi, and Mr. Amos Akwasi Aidoo. God bless you all. 
 
And now to my astute PhD colleagues and also our pacesetters, many thanks for your 
support! 
 
Finally, my sincere thanks go to my son in Christ; Joseph Nana Otchere Turkson. You 
have no idea just how much help you’ve been on this journey with your expert IT skills. 
Nana, medaase! 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
TABLE OF CONTENTS 
DECLARATION .............................................................................................................. i 
ABSTRACT .................................................................................................................... ii 
DEDICATION ................................................................................................................ iii 
ACKNOWLEDGEMENT ............................................................................................... iv 
TABLE OF CONTENTS ................................................................................................. v 
LIST OF TABLES .......................................................................................................... ix 
LIST OF FIGURES......................................................................................................... xi 
CHAPTER ONE .............................................................................................................. 1 
INTRODUCTION ........................................................................................................... 1 
1.0 Background ............................................................................................................ 1 
1.1 Problem Statement.................................................................................................. 8 
1.2 Aim of the Study ................................................................................................... 10 
1.3 Significance of the Study ....................................................................................... 11 
1.4 Summary and Organization of the Thesis ............................................................... 12 
CHAPTER TWO ............................................................................................................ 14 
THEORETICAL FRAMEWORK AND L ITERATURE REVIEW ................................ 14 
2.0 Introduction ........................................................................................................... 14 
2.1 Theoretical Frameworks ........................................................................................ 15 
2.1.1 The Stress and Coping Model of Forgiveness ................................................. 15 
2.1.2 The Biopsychosocial Framework of Contexts of Forgiveness in HIV/AIDS .... 19 
2.1.3 The Afrocultural Social Ethos Framework ...................................................... 23 
2.1.4 Summary of Theoretical Underpinnings .......................................................... 25 
2.2 Review of Related Literature ................................................................................. 26 
2.2.1 Forgiveness and Related Constructs ................................................................ 27 
2.2.2 Forgiveness and General Health Outcomes ..................................................... 33 
2.2.3 The Human Immuno-Deficiency Virus and Immune Functioning ................... 35 
2.2.4 HIV/AIDS and Psychological Health-Related Quality of Life ......................... 36 
2.2.5 Biopsychosocial Factors, Quality of Life, and Immune Health in HIV ............ 37 
2.2.6 Summary and Critique of Biopsychosocial Factors in HIV/AIDS.................... 46 
2.2.7 Forgiveness and Health Outcomes in HIV/AIDS: A Systematic Review ......... 47 
2.2.8 Summary and Critique of Forgiveness Studies in HIV/AIDS .......................... 56 
2.2.9 Gaps in Forgiveness in HIV/AIDS Studies ...................................................... 60 
2.3 Rationale for the Present Study .............................................................................. 62 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
2.4 Operational Definition of Terms ............................................................................ 63 
CHAPTER THREE ......................................................................................................... 65 
GENERAL METHODOLOGY ....................................................................................... 65 
3.0 Introduction ........................................................................................................... 65 
3.1 Research Approaches: A Brief Overview of Philosophical Assumptions ................ 65 
3.1.1 The Mixed Method Approach: Philosophical Underpinnings of the Study ....... 66 
3.2 Research Design: Explanatory Sequential Mixed Methods Design ......................... 68 
3.3 Research Setting .................................................................................................... 70 
3.4 Ethical Considerations ........................................................................................... 71 
CHAPTER FOUR ........................................................................................................... 73 
METHODOLOGY AND RESULTS FOR STUDY ONE ................................................ 73 
STUDY 1: Association between Forgiveness, Psychological Health-Related Quality of 
Life, and Immune Functioning in People Living with HIV/AIDS in Ghana ..................... 73 
4.0 Introduction ........................................................................................................... 73 
4.1 Research Questions ............................................................................................... 73 
4.2 Research Hypotheses ............................................................................................. 74 
4.3 Conceptual Framework Depicting the Hypothesized Model of the Study Variables76 
4.4 Study Design – Cross-Sectional Survey Design ..................................................... 77 
4.4.1 Study Population – People Living with HIV/AIDS ......................................... 78 
4.4.2 Sampling Strategy – Maximum Variation Purposive Sampling Technique ...... 78 
4.4.3 Inclusion and Exclusion Criteria ..................................................................... 79 
4.4.4 Sample Size – Three-Hundred and Twenty-Five People Living with HIV/AIDS
 ................................................................................................................................ 80 
4.4.5 Survey Instruments ......................................................................................... 81 
4.4.6 Pilot Study ...................................................................................................... 86 
4.4.7 Study Procedure and Data Collection .............................................................. 87 
4.4.8 Data Analysis and Underlying Assumptions ................................................... 88 
4.5 Results ................................................................................................................... 89 
4.5.1 Preliminary Analysis ....................................................................................... 89 
4.5.1.1 Factor Analysis ........................................................................................ 90 
4.5.1.2 Descriptive Analysis ................................................................................ 97 
4.5.1.3 Means, Normality, and Reliability of Study Variables ............................ 101 
4.5.1.4 Correlation Matrices .............................................................................. 103 
4.5.2 Hypotheses Testing ....................................................................................... 107 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
4.5.2.1 Hypotheses Testing for Intrapersonal Forgiveness .................................. 108 
4.5.2.2 Hypotheses Testing for Interpersonal Forgiveness .................................. 114 
4.5.2.3 Hypotheses Testing for Spiritual Context of Forgiveness ....................... 118 
4.5.3 Additional Analysis and Findings ..................................................................... 122 
4.6 Summary of Study One Findings ......................................................................... 125 
4.7 Brief Discussion of Study 1 Findings ................................................................... 126 
CHAPTER FIVE .......................................................................................................... 132 
METHODOLOGY AND RESULTS FOR STUDY TWO ............................................. 132 
STUDY 2: LIVED EXPERIENCES OF FORGIVENESS OF HIV-RELATED 
OFFENCES AMONG PEOPLE LIVING WITH HIV/AIDS IN GHANA ..................... 132 
5.0 Introduction ......................................................................................................... 132 
5.1 Research Questions ............................................................................................. 132 
5.2 Study Design – Interpretative Phenomenology..................................................... 133 
5.2.1 Rationale for Study 2 .................................................................................... 134 
5.2.2 Participants and Sampling Procedure –Purposive sampling ........................... 134 
5.2.3 Inclusion and Exclusion Criteria ................................................................... 135 
5.2.4 Data Collection Instruments – Semi-structured Interview Schedule ............... 136 
5.2.5 Pilot Study .................................................................................................... 136 
5.2.6 Study Procedure ............................................................................................ 137 
5.2.7 Analytic Strategy –Interpretative Phenomenological Analysis....................... 138 
5.3 Trustworthiness of Data Analysis and Findings ................................................... 140 
5.4 Results ................................................................................................................. 141 
5.4.1 Introduction .................................................................................................. 141 
5.4.2 Characteristics of Interview Participants ....................................................... 142 
5.4.3 Superordinate Themes, Themes, and Subthemes ........................................... 143 
5.4.4 Superordinate Theme A: HIV-Specific Offense Experiences ......................... 143 
5.4.4.1 Theme 1: Offense Nature ....................................................................... 143 
5.4.4.2 Theme 2: Offense Responses ................................................................. 149 
5.4.5 Superordinate Theme B: Experiences of the Forgiveness Process.................. 152 
5.4.5.1 Theme 1: Personal Actions and Changes ................................................ 152 
5.4.5.2 Theme 2: Realities, Conditions, And Rationalization .............................. 158 
5.4.6 Superordinate Theme C: Implications of Forgiveness ................................... 165 
5.4.6.1 Theme 1: Restoration, Development, and Preservation ........................... 165 
5.4.6.2 Theme 2: Focused Life ........................................................................... 168 
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5.4.7 Summary ...................................................................................................... 173 
5.4.8 Brief Discussion of Study 2 Findings ............................................................ 176 
CHAPTER SIX ............................................................................................................. 186 
GENERAL DISCUSSION ............................................................................................ 186 
6.0 Introduction ......................................................................................................... 186 
6.1 Overview of the Thesis ........................................................................................ 186 
6.2 Summary of Findings .......................................................................................... 187 
6.2.1 Study One – Study Two Points of Convergence ............................................ 188 
6.2.2 Study One – Study Two Points of Divergence ............................................... 191 
6.3 Revised Model..................................................................................................... 195 
6.4. Contributions of the Present Study ...................................................................... 196 
6.4.1 Contributions to Knowledge ......................................................................... 196 
6.4.2 Contributions to Research ............................................................................. 197 
6.4.3 Theoretical Contributions and Implications ................................................... 198 
6.5 Practical Implications of the Study ...................................................................... 199 
6.5.1 Implications for Clinical Practice .................................................................. 199 
6.5.2 Implications for Policy .................................................................................. 200 
6.5.3 Public Health Implications of the Study ........................................................ 201 
6.5.4 Implications for Health Psychology Practice in Ghana .................................. 203 
6.6 Limitations of the Study ...................................................................................... 204 
6.7 Recommendations for Future Research ................................................................ 205 
6.8 Conclusion .......................................................................................................... 206 
REFERENCES ............................................................................................................. 208 
APPENDICES .............................................................................................................. 227 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
LIST OF TABLES 
Table 2.1: Temoshok and Wald’s (2005) hypothesized biopsychosocial contexts and 
consequences of unforgiveness of HIV-specific offenses. ............................. 21 
Table 4.1:  Item Loadings on the Decision to Forgive Other Scale ................................... 92 
Table 4.2: Item Loadings on the Decision to Forgive Self Scale ...................................... 93 
Table 4.3: Item Loadings on the Emotional Forgiveness of Other Scale .......................... 94 
Table 4.4: Item Loadings on the Emotional Forgiveness of Self Scale ............................. 95 
Table 4.5:  Item Loadings on the PATG and the NATG Scales ........................................ 96 
Table 4.6:  Item Loadings on the WHOQOL-BREF Psychological Health Domain ......... 97 
Table 4.7: Sociodemographic characteristics of survey respondents ................................ 98 
Table 4.8:  Clinical characteristics of survey respondents ................................................ 99 
Table 4.9: HIV-specific offense characteristics of survey respondents ........................... 100 
Table 4.10:  Summary of means, normality, and reliability of study variables ................ 102 
Table 4. 11: Summary of correlations between sociodemographic, clinical, independent, 
and dependent study variables .................................................................... 104 
Table 4.12: Summary of correlations among psychosocial, independent, and dependent 
study variables ............................................................................................ 106 
Table 4.13: Summary Coefficients of Self-Forgiveness Predicting Psychological Health-
Related Quality of life ................................................................................ 109 
Table 4.14: Summary Coefficients of Decision to Forgive Self Predicting Change in CD4 
Cell Count .................................................................................................. 110 
Table 4.15:  Summary Results of Moderation Analysis on the Intrapersonal Forgiveness–
Psychological Health-Related Quality of Life Relationship......................... 111 
Table 4.16: Summary Result of Moderation Analysis on the Decision to Forgive Self–
Change in CD4 Cell Count Relationship. .................................................... 111 
Table 4.17: Summary of Final Model of Psychological Health-Related Quality of Life 
Regressed on Self Forgiveness Controlling for Covariates .......................... 112 
Table 4.18: Summary of Final Model of Change in CD4 cell Count Regressed on Decision 
to Forgive Self Controlling for Covariates .................................................. 114 
Table 4.19: Summary Results of Coefficients for Interpersonal Forgiveness Regressed on 
Psychological Health-Related Quality of life .............................................. 115 
Table 4. 20: Summary Results of Moderation Analysis on the Interpersonal Forgiveness–
Psychological Health-Related Quality of Life Relationship......................... 116 
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Table 4.21: Summary of Final Model Results of Relationship between Interpersonal 
Forgiveness and Psychological Health-Related Quality of Life Controlling for 
Covariates .................................................................................................. 117 
Table 4. 22:  Summary Results of Positive Attitudes toward God Regressed on 
Psychological Health-Related Quality of Life ............................................. 119 
Table 4.23:  Summary Results of Moderation Analysis on the PATG–Psychological 
Health-Related Quality of Life Relationship. .............................................. 120 
Table 4.24: Summary of Final Model Results of Relationship between Positive Attitudes 
Toward God and Psychological Health-Related Quality of Life Controlling for 
Covariates .................................................................................................. 121 
Table 5.1: Background Characteristics of Interview Participants ................................... 142 
Table 5.2:  Summary of Themes, Subthemes and Supporting Quotes ............................ 174 
  
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
LIST OF FIGURES 
Figure 2.1: Application of the Stress and Coping Model of Forgiveness to HIV/AIDS .... 19 
Figure 2.2: Application of the SCMF, BPSFCF, and ASEF to forgiveness in HIV/AIDS . 26 
Figure 2.3: Flow chart of search strategy, appraisal, and extraction of retrieved papers .... 49 
Figure 3.1: Research process for the two-phase study design adapted from Bilinski et al., 
2013 ............................................................................................................. 69 
Figure 4.1: Conceptual framework of the association between forgiveness, psychological 
health-related quality of life, and immune function marker. .......................... 77 
Figure 6.1: Revised model of the relationship between forgiveness and the outcomes of 
PHRQOL and change in CD4 count. .......................................................... 195 
  
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
CHAPTER ONE 
INTRODUCTION 
1.0 Background 
Forgiveness, throughout history, has remained one of the most important healing 
forces of emotional pain and buffers against mental breakdown. It is a coping strategy for 
dealing with offenses that involves transformations in cognitions, emotions, and 
behaviours of the offended person (Toussaint & Worthington, 2017). While it is typically 
considered a religious dogma/practice, forgiveness has been a focus of scientific research 
for over three decades now across various fields of psychology, including health 
psychology (Worthington, 2005). At present, the extant data linking forgiveness to health 
points out an association between this pro-social behaviour and different aspects of health 
and wellbeing (e.g., Akhtar & Barlow, 2016; Woodyatt, Worthington, Wenzel, & Griffin, 
2017; Toussaint, Worthington, & Williams, 2015). This critical role of forgiveness in 
health may be attributed to its ability not only to neutralize negative responses (e.g., 
bitterness) to offenses, but also, to stimulate a sense of hope and other positive emotions 
and thoughts capable of driving healthy behaviours (Toussaint & Worthington, 2017; 
Woodyatt et al., 2017). Unfortunately, among the significant population of people living 
with HIV and AIDS (PLWHA), particularly in the sub-Saharan region, the health benefits 
of forgiveness have been under-researched. It is against this background that the present 
study sought to investigate the association between forgiveness and two health outcomes – 
psychological health-related quality of life (PHRQOL) and change in cluster of 
differentiation-4 (CD4) cell count – in people living with HIV/AIDS in Ghana.  
Forgiveness can be defined as a freely made choice to forgo negative cognitive, 
emotional, and behavioural responses toward a person who caused a hurt, and work 
toward developing positive cognitive, emotional, and behavioural responses (Enright & 
Fitzgibbon, 2000). This definition points to forgiveness as a process that begins with a 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
reduction in unforgiveness, which is the prolonged negative psychological responses 
(thoughts, emotions, and behavioural motivations) that an individual may experience in 
relation to a perceived offense (Harris & Thoresen, 2005). Examples of these negative 
responses include anger, guilt, regret, isolation, bitterness, and motivations to revenge 
against or avoid the offender (Toussaint & Worthington, 2017; Toussaint, Owen, & 
Cheadle, 2012). The latter part of the process entails the eventual experience of positive 
psychological responses in place of the negative unforgiving ones. These positive 
responses may include empathy, benevolence, compassion, hope, and love (Toussaint & 
Worthington, 2017; Toussaint et al., 2012). Worthington, Witvliet, Pietrini, and Miller 
(2007) in emphasizing the role of emotions in the forgiveness process, distinguish between 
these two main stages as decisional forgiveness and emotional forgiveness. They define 
decisional forgiveness as change in a person’s behavioural intentions toward a transgressor 
(e.g., intending not to take revenge against the offender). It is reported that decisional 
forgiveness may lead to emotional forgiveness, however, it is possible to grant decisional 
forgiveness while still experiencing negative emotions toward the offender (Lichtenfeld, 
Buechner, Maier, Fernández-Capo, 2015). Thus, Worthington and colleagues (2007) 
define emotional forgiveness as replacement of negative unforgiving emotions with 
positive other-oriented emotions.  
Indeed, forgiveness is duly acknowledged by researchers in the area as but one of 
many coping mechanisms for reducing unforgiveness (Toussaint & Worthington, 2017). 
However, evidence supports its considerable health benefits compared to other coping 
strategies (Witvliet, Van Tongeren, & Luna, 2015). The evidence for the effects of 
forgiveness on health in general, has been found across a range of medical, psychological, 
and other outcomes. These include improvement in depression, post-traumatic stress 
disorders, perceived life stress, cardiovascular disorders, and immune functioning (e.g., 
Akhtar & Barlow, 2016; Toussaint et al., 2012; Toussaint et al., 2015; Woodyatt et al., 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
2017). In HIV/AIDS, Akhtar and Barlow (2016) in a meta-analysis, found that forgiveness 
improved mental health for people living with the infection. 
 
Current State of the HIV/AIDS Epidemic and Treatment 
The Human Immunodeficiency Virus (HIV) and its consequent end stage disease – 
Acquired Immune Deficiency Syndrome (AIDS) – have plagued societies for more than 
three decades now. At present, it constitutes one of the most significant global health 
challenges, with about 6000 new HIV infections being recorded around the world each 
day (Kharsany & Karim, 2016; World Health Organization (WHO), 2017a). Of the 
estimated 36.7 million people living with the condition worldwide, the sub-Saharan 
African region disproportionately bears about 70% of this burden (Kharsany & Karim, 
2016; WHO, 2017a). In Ghana, statistics by the Joint United Nations Programme for 
HIV/AIDS (UNAIDS, 2016) indicates that as of 2016, an average of 290,000 people were 
living with HIV/AIDS. More than 90% of this number were adults aged 15 years and over, 
with women constituting a larger proportion (62%) (UNAIDS, 2016). The 2016 HIV 
Sentinel Survey Report further revealed a prevalence rate of 2.4% in the same year 
(BusinessGhana, 2017; Ghana AIDS Commission (GAC), 2016). This is an interestingly 
high rate, considering the country’s relatively small population of approximately 28.3 
million (Ghana Statistical Service, 2016). And the fact that this figure (2.4%) “represents a 
second consecutive upsurge” from the rates recorded in 2014 (1.6%) and 2015 (1.8%) 
respectively (BusinessGhana, 2017, p.1).  
Over the years, the tremendous advancements in antiretroviral therapy (ART) has 
seen HIV/AIDS progress from its initial fatal state to its current chronic illness state 
(Colvin, 2011; UNAIDS, 2015a). Presently, reports indicate significant decreases in 
morbidity and mortality coupled with a global increase in lifespan of people living with 
HIV/AIDS (PLWHA) (Colvin, 2011; Nakagawa, May, & Phillips, 2013; WHO, 2017b). 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Indeed, among PLWHA, who initiate ART before immune cell count falls below 350 
cells/µL, it is reported that life-expectancy may be comparable to that of HIV-negative 
individuals (Antiretroviral Therapy Cohort Collaboration (ATCC), 2017; Cairns, 2014; 
Nakagawa et al., 2013; Ripa, Chiappetta, & Tambussi, 2017).  
 
Challenges in HIV/AIDS, Unforgiveness, and Forgiveness 
Despite the exceptional advancements in treatment, PLWHA continue to face 
many challenges that can affect health. For instance, reports indicate that in spite of the 
current manageability of HIV/AIDS, both physiological and psychosocial outcomes 
continue to be lower than expected (Basavaraj, 2010; Liping, Peng, Haijiang, Lahong, & 
Fan, 2015; McMahon, Elliott, Bertagnolio, Kubiak, & Jordan, 2013; Nakanjako et al., 
2016). Also, compared to the general population, quality of life (QOL) is reportedly lower 
for PLWHA (Basavaraj, 2010; Liping et al., 2015). In response to the persisting 
suboptimal outcomes, behavioural science researchers in the area have sought to identify 
factors capable of influencing health and being modified by interventions.  
One factor that has been identified for years now, but which has received relatively 
little attention is unforgiveness of offenses directly related to a positive HIV/AIDS status. 
Although currently a manageable chronic illness, HIV/AIDS continues to be associated 
with various difficulties which have the potential to arouse unforgiveness in people with 
the illness (Temoshok & Wald, 2005). First of all, reports indicate that being infected with 
HIV continues to arouse a wide range of emotions. These include shock, panic, anger, 
despair, sense of helplessness or vulnerability, fear and numbness (Fabianova, 2011; Silva 
et al., 2015). Even though some of these responses may be adaptive at the initial stages 
following a positive diagnosis, if prolonged, they may lead to unforgiveness and its 
associated negative health consequences (Temoshok & Wald, 2005; Wald & Temoshok, 
2004a).  
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Secondly, HIV/AIDS remains an infectious disease transmissible by two of the 
most intrinsic human desires – sexuality and procreation (Temoshok & Wald, 2005). 
Therefore, infection with the HIV virus continues to arouse life-changing questions that 
cut across many spheres of life. These include questions such as “how do I get married and 
have children without infecting my spouse and/or children after living a risky lifestyle?”; 
“has my partner been unfaithful and/or intentionally non-disclosing and un-protective?”; 
“how do I come to terms with infecting my child even if unintentionally?” (Temoshok & 
Chandra, 2000). Such sensitive and life-changing situations may cause PLWHA to 
experience the negative cognitions, emotions, and behaviours characteristic of 
unforgiveness towards those they may perceive to be responsible for their HIV-positive 
status (Temoshok & Chandra, 2000; Temoshok & Wald, 2005). These may include 
themselves (e.g., for engaging in risky sexual behaviours), other persons (e.g., an 
unfaithful spouse) or an institution (e.g., the healthcare institution over contaminated 
blood transfusion or delays in providing timely prophylaxis following HIV risk exposure).  
Also, the long-standing challenge of HIV-related stigma, discrimination, labelling, 
out-casting and other negative attitudes continues to be reported among PLWHA (Catona, 
Greene, Magsamen-Conrad, & Carpenter, 2016). Such negative attitudes may awaken a 
threat to self-esteem as well as a threat to the sense of inclusion of PLWHA (Temoshok & 
Wald, 2005). If directly experienced as a result of one’s positive status, they may likewise 
arouse bitterness and other negative attitudes characteristic of unforgiveness towards 
perpetrators of such attitudes (Temoshok & Wald, 2005).   
According to Temoshok and Chandra (2000), PLWHA who believe that God 
allowed them to acquire HIV may also harbour anger towards God. These may include 
those who acquired the infection through mother-to-child transmission, sexual abuse, or 
other causes that may be perceived as no direct fault of theirs. It may also include those 
who believe that God may be punishing them for some reason. All these challenges may 
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be considered as sources of HIV-related offenses that may arouse unforgiveness 
(Temoshok & Chandra, 2000; Temoshok & Wald, 2005).  
It has been reported that unforgiveness of offenses directly related to one’s HIV-
positive status may negatively impact on critical health outcomes (Harris & Thoresen, 
2005Temoshok & Chandra, 2000; Temoshok & Wald, 2005; Wald & Temoshok, 2004a). 
On the other hand, forgiveness of HIV-related offenses has been proposed as a coping 
strategy that may improve both physiological and psychological health in this important 
population. While very few forgiveness studies have been carried out in the particular 
context of HIV and AIDS. The extant literature in the area suggests that forgiveness is 
associated with positive HIV/AIDS treatment outcomes including improved immune 
functioning and QOL (e.g., Gates, 2012; Owen, Hayward, & Toussaint, 2011; Wald & 
Temoshok, 2004a).  Studies have also found associations between forgiveness and positive 
health-promoting behaviours including medication adherence (Wald & Temoshok, 
2004b).  
 
Psychoneuroimmunology and Forgiveness in HIV 
Theoreticians and researchers have attempted to explain the mechanisms by which 
forgiveness, and for that matter psychosocial factors, may play a role in health (e.g., 
Temoshok & Wald, 2005; Worthington et al., 2007). One such explanation is the concept 
of psychoneuroimmunology, which concerns how mind-body interactions influence 
health. It is the study of the association between psychological processes (cognitions, 
emotions, and behaviours), neural and endocrine function, and immune processes (Daruna, 
2012).  
In HIV/AIDS, Temoshok and Wald (2005) have theorized that the role of 
forgiveness in health may play out via two main pathways. The first is a direct 
psychoneuroimmunological consequence of forgiveness. While this mechanism remains to 
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be fully understood, they conceptualize unforgiveness as a stressful response, and hence 
the opposite – forgiveness – of which may be beneficial to health (Temoshok & Wald, 
2005). Specifically, they theorize that the positive and stress-free psychological responses 
of forgiveness directly reduce physiological activation of the stress response system, 
reducing the release of cortisol which is linked to many illnesses (Temoshok & Wald, 
2005). However, unforgiveness is theorized to impact health negatively “through the 
pathways of chronic sympathetic nervous system hyperarousal and increased allostatic 
load” (Harris & Thoresen, 2005, p. 323; Saplosky, 2005). According to Woodyatt and 
colleagues (2017), forgiveness coping eases the stressful burden of unforgiveness, 
restoring a state of physiological and mental equilibrium. 
The second hypothesized pathway linking forgiveness to health is through health 
behaviour motivation (Temoshok & Wald, 2005; Woodyatt et al., 2017). It has been 
suggested that experiencing prolonged negative responses such as cycles of rumination, 
resentment, bitterness, guilt, and/or blame, may dampen an individual’s motivation to 
effectively engage with important health demands (Woodyatt et al., 2017). Studies have 
also found that forgiveness promotes health outcomes via motivation to engage with 
positive behaviours including seeking and accepting of social support (Green, 
DeCourville, & Sadava, 2012; Webb, Hirsch, Visser, & Brewer, 2013; Woodyatt et al., 
2017). Others have found associations with medication adherence and protective sexual 
behaviours (Wald & Temoshok, 2004a, 2004b; Webb et al., 2013).  
In effect, the psychology of forgiveness lies in the capacity of the latter to 
manipulate physiological processes via transformation in fundamental psychological 
processes (cognitions, emotions, behavioural motivations, and actual behaviours) 
(Toussaint et al., 2015; Woodyatt et al., 2017; Worthington, 2005). In the particular case 
of HIV and AIDS, the relevance of forgiveness lies in the health-related transformations 
that may be realized across intrapersonal, interpersonal, and spiritual contexts of the 
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experience of unforgiveness as related to HIV-specific offenses (Temoshok & Wald, 
2005).  
 
1.1 Problem Statement 
 HIV/AIDS continues to be associated with challenging experiences that are 
capable of arousing negative and painful thoughts, emotions, and behavioural motivations 
toward self, others, or God, despite the remarkable advancements in treatment over the 
years.  It is possible that these stressful unforgiving responses to perceived HIV-related 
offenses may have a negative influence not only on patient reported outcomes, but also, on 
immunological markers such as CD4 cell count (Harris & Thoresen, 2005; Temoshok & 
Wald, 2005). This is because various forms of psychological stress have long been 
associated with reduced response to antiretroviral drugs and lower recovery of CD4 cells 
via increased sympathetic nervous system activity that may trigger immune responses 
(Amanor-Boadu et al., 2016; Cancer Network, 2002; Rehm & Konkle-Parker, 2017). 
Thus, it is implied that forgiveness coping with perceived HIV-related offenses could hold 
important health benefits for the millions of PLWHA, particularly in the sub-region. In 
that, the stress-relieving potential of forgiveness can arouse the parasympathetic nervous 
system in counteraction to the effects of the sympathetic nervous system, triggering 
positive immune responses.  
Unfortunately, with few exception, studies are lacking on the influence of 
forgiveness on health among PLWHA. In non-Western societies, to my knowledge, no 
study has yet been identified to the best of the researcher’s knowledge, that has considered 
this potential relationship. The available studies in the area have been carried out in 
typically Western and individualistic settings such as the United States (Ironson et al., 
2011; Owen et al., 2011; Wald & Temoshok, 2014b). Thus, at present, knowledge of the 
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potential influence of forgiveness as related to physiological and psychosocial health in 
PLWHA in Ghana and the wider sub-region is lacking.  
 Of the existing forgiveness-HIV/AIDS studies, greater attention has been paid to 
forgiveness as a global construct, with very little focus on the relative impact of its major 
processes (decisional forgiveness and emotional forgiveness) on health. This may reflect a 
general caveat in forgiveness research, where theories are largely incorporative of these 
two processes yet, where little empirical evidence regarding their differences is available 
(Lichtenfeld et al., 2015). While it has been reported that emotional forgiveness may have 
more health benefits than decisional forgiveness, these reports are again, largely based on 
studies done in the typical individualistic settings of the West (e.g., Toussaint & 
Worthington, 2017; Worthington et al., 2007; Worthington & Scherer, 2004). In generally 
collectivistic African societies, people may tend to prioritize interpersonal/social harmony 
and may pay less attention to emotions (Dzokoto, 2010; Markus & Kitayama, 1991). Thus, 
it is likely that people may be quick to decide to forgive to maintain this harmony (Hook, 
Worthington, Utsey, 2009; Hook, Worthington, Utsey, Davis, & Burnette, 2012). There is 
a need to examine how the likely greater decisions to forgive may influence the health of 
PLWHA in these societies.  
 Furthermore, very little is known about the relationship between forgiveness and 
health across different contexts within which HIV-related offenses may be experienced. 
Generally, forgiveness of offenses may occur in three main contexts – intrapersonal, 
interpersonal, and spiritual – with various sub-contexts (e.g., feeling forgiven by God or 
others). However, studies in this area have tended to examine more of the interpersonal 
context of forgiveness, leaving a wide gap in knowledge of the contribution of other 
potentially important contexts (Webb, Bumgarner, Conway-Williams, Dangel, & Hall, 
2017). These include the self or intrapersonal and the spiritual contexts.  
 
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Finally, it is possible that cultural differences in psychological experiences 
(thoughts, emotions, and behaviours) may influence whether and how PLWHA may 
experience forgiveness of offenses related to their HIV-positive status. This may in turn 
affect health outcomes differently. However, at present, studies exploring forgiveness 
experiences of PLWHA using qualitative methods are lacking.  
The possible consequence of this primary problem – gross lack of forgiveness-
health studies among PLWHA, particularly in the sub-Saharan African region – is that 
HIV-related offenses and unforgiveness may go unassessed and may also be masked by 
other psychosocial problems. Therefore, understanding the association between 
forgiveness and health in a generally collectivistic context is necessary to inform 
development of culturally-relevant and -sensitive forgiveness interventions. 
 
1.2 Aim of the Study 
 The aim of this study therefore, was to determine as well as understand the 
association between forgiveness and two health outcomes – psychological health-related 
quality of life (PHRQOL) and change in CD4-cell count – among PLWHA in Ghana’s 
typical collectivistic societies. An explanatory sequential mixed method design beginning 
with a survey to ascertain the forgiveness-health relationship and followed by an in-depth 
phenomenological study to provide contextual explanations to any identified relationships, 
was employed to achieve this overall aim. Phenomenology is a type of qualitative research 
approach concerned with exploring in detail, participants’ personal (life-world) 
perceptions, experiences, or accounts of a phenomenon (Eatough & Smith, 2008; Smith & 
Osborn, 2004). The survey and interview data gathered were respectively subjected to 
statistical and qualitative analyses including multivariate regression analysis and 
interpretative phenomenological analysis (Eatough & Smith, 2008; Smith & Osborn, 
2004). Specifically, the objectives of the present study were to: 
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1. Investigate which stage/type of forgiveness is more engaged in among PLWHA in 
Ghana. 
2. Investigate the predictors of the types of intrapersonal, interpersonal, and spiritual 
forgiveness on PHRQOL and change in CD4-cell count.  
3. Examine the moderating effects of ART adherence, multiple sexual partner 
behaviour, and condom use behaviour on the association between forgiveness and 
the outcome variables – PHRQOL and change in CD4 cell count. 
4. Determine the predictive strength of the types/stages of the three forgiveness 
contexts on PHRQOL and change in CD4-cell count, controlling for key socio-
demographic, clinical, and psychosocial factors.  
5. Explore the lived experiences of forgiveness and the meaning these experiences 
hold for the health of PLWHA in Ghana in order to gain in-depth and cultural 
contextual insights into any directions of associations between forgiveness and the 
two outcome variables.   
 
1.3 Significance of the Study 
 In seeking to understand whether and how forgiveness relates to PHRQOL and 
immune markers among PLWHA in typical collectivistic societies, the present study 
would make important contributions to knowledge of the effects of forgiveness on health 
as well as contribute to the existing body of literature linking stress to immunological 
responses.  
The clinical significance of the present study lies in its potential to inform 
development of culturally-sensitive and -relevant forgiveness interventions, which may 
help to promote both psychological and immunological wellbeing. Such interventions 
could augment standard adherence counselling and other psychosocial support in clinical 
settings for PLWHA and similar illnesses associated with experiences which are capable 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
of arousing unforgiveness. These include sickle cell, cancer, diabetes, cardiovascular 
conditions. 
The socioeconomic benefit of the present study is that it may inform pioneering 
studies on forgiveness in the area of occupational health. Findings of such studies could 
improve the health and wellbeing of organizational members and promote organizational 
outcomes. 
For individuals living with HIV in largely collectivistic societies, an answer to the 
gap in knowledge of which stage of forgiveness – decisional or emotional – may be a 
better predictor of health outcomes, may help to tailor support at the most needed stages of 
the HIV care pathway. 
 Also, findings of this study may help to address a crucial public health issue – the 
secondary transmission of HIV by some infected persons, who may engage in health risk 
behaviours that could result from negative emotions and thoughts. Reports suggest a link 
between forgiveness of HIV-positive-related offenses and the adoption of measures to 
protect others from acquiring the virus (Wald & Temoshok, 2004b). Thus, in seeking to 
curb secondary transmission of HIV, this study may inform public health agents and 
policy makers of the need for integrating forgiveness assessments, interventions, and 
evaluation in HIV care protocols. 
Finally, the present study may inform future longitudinal and controlled studies 
that could help to ascertain whether forgiveness, compared to other forms of coping, may 
indeed cause increases in important health outcomes among PLWHA in this region.  
 
1.4 Summary and Organization of the Thesis 
 The HIV/AIDS infection constitutes one of the most devastating illnesses of all 
times. Being a highly stigmatized, long-term, and infectious illness bordering on sexuality 
and procreation, infection with HIV/AIDS is potentially challenging in various ways. 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Thus, it is possible that PLWHA may perceive offenses directly related to their HIV-
positive status. The experience of unforgiveness (prolonged negative thoughts, emotions, 
and behavioural motivations) in response to perceived offenses has been found to hold 
negative implications for health. However, forgiveness as a coping mechanism, has also 
been found to hold promise for mitigating the stressful burden of unforgiveness. 
Therefore, this six-chapter two-part study, aims to investigate the influence of forgiveness 
of HIV-specific offenses on the outcomes of PHRQOL and immune functioning (change 
in CD4-cell count) among PLWHA in Ghana. 
Beginning with an overview of forgiveness, Chapter one (Introduction) outlines the 
background to the study, problem statement, and the objectives and significance of the 
study. Chapter two presents a review of theoretical frameworks and an empirical review of 
studies in HIV/AIDS, including a systematic review of forgiveness studies in HIV. It 
concludes by highlighting the gaps in the extant forgiveness-HIV literature and presenting 
a list of operational definition of terms used in the study. Chapter three – General 
Methodology – follows with highlights on the mixed-method research approach employed, 
including the philosophical foundations and rationale for which this approach was 
adopted. The fourth chapter focuses on Study 1; a cross sectional-survey. It includes the 
methodology, results, summary, and brief discussion of the findings. Chapter five details 
the methodology, results, summary, and brief discussion of findings from Study 2 – the 
qualitative phase of the study. Chapter six consolidates and discusses findings from the 
two studies, emphasizing particularly on themes from the qualitative study that provide 
further explanations to the Study 1 findings. In addition, Chapter six addresses the 
limitations of the study, and draws out the theoretical, clinical, public health, and health 
psychology implications of the findings, as well as the scientific contributions of the study. 
Finally, the chapter concludes with recommendations for future research in the area of 
forgiveness and health of PLWHA.       
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CHAPTER TWO 
THEORETICAL FRAMEWORK AND L ITERATURE REVIEW 
2.0 Introduction  
 The experience of offenses or injustices is almost an inevitable life phenomenon. 
Depending on factors such as the perceived severity of the offense and its potential or 
actual consequence, the offended may shrug it off or may experience hurtful emotions in 
response to the offense. Harbouring painful emotions such as resentment, bitterness, guilt, 
anger, and fear has been widely reported to be stressful, to the extent that lay reports 
emphasize that letting go of these emotions makes one feel relieved or lighter (Toussaint 
& Worthington, 2017). Indeed, experts in forgiveness and health studies also suggest that 
stress-relief is possibly the primary mechanism underlying the association between these 
two factors. This chapter discusses relevant theoretical frameworks that may help to 
explain the forgiveness–health link. Specifically, the Stress and Coping Model of 
forgiveness (Lavelock et al., 2015; Toussaint & Worthington, 2017; Worthington & 
Scherer, 2004), the Biopsychosocial Framework of Contexts of Forgiveness in HIV/AIDS 
(Temoshok & Chandra, 2000; Temoshok & Wald, 2005), and the Afrocultural Social 
Ethos Framework (Jagers, Smith, Mock & Dill, 1997). How these frameworks together 
support the present study of forgiveness of HIV-related offenses and health is critically 
reviewed.   
The theoretical review is followed by a critical review of the empirical literature on 
important biopsychosocial factors in HIV/AIDS outcomes. This is followed by a 
systematic review of forgiveness studies to identify what is known so far in the specific 
situation of offenses perceived by PLWHA. Implications of the review findings for the 
present study including the study’s research questions are presented. The chapter closes 
with operational definitions of terms commonly used in this study.  
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2.1 Theoretical Frameworks 
2.1.1 The Stress and Coping Model of Forgiveness 
 The Stress and Coping Model of Forgiveness (SCMF) draws from the principles 
underlying Lazarus and Folkman’s (1984) transactional model of stress and coping. 
According to the SCMF, when an individual perceives a situation as offensive or hurtful, 
he/she may experience an injustice gap (Lavelock et al., 2015; Strelan & Covic, 2006; 
Toussaint & Worthington, 2017; Worthington, 2006; Worthington & Scherer, 2004). The 
injustice gap refers to the difference between the way the victim would prefer a 
transgression to be fully resolved and the way they perceive the situation to be currently 
(Exline, Worthington, Hill, & McCullough, 2003). It is directly proportional to 
unforgiveness such that the wider the injustice gap, the more unforgiveness a victim 
experiences in response to a perceived offense or injustice (Worthington & Scherer, 2004). 
Factors such as not accepting responsibility, a non-remorseful attitude, lack of sincere 
apology, or ongoing offensive behaviours from the perpetrator may widen the injustice 
gap, further increasing unforgiveness (Davis, Yang, DeBlaere, McElroy, & Van Tongeren, 
2016).   
According to Exline and colleagues (2003), unforgiveness is a complex 
combination of delayed negative emotions (e.g., resentment, hatred, bitterness, 
disappointment, hostility, anger, and fear) toward a person who has transgressed personal 
boundaries. It is further conceptualized as a stress reaction to appraisals of offenses, 
betrayals, wrongs, etc., all of which are referred to as interpersonal stressors (Berry, 
Worthington, Parrott, O’Connor, & Wade, 2001).  
Forgiveness on the other hand has been defined as an emotional juxtaposition of 
positive emotions (e.g., empathy, compassion, sympathy, altruistic love) against the 
negative (and stressful) emotions of unforgiveness resulting over time, in the 
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neutralization or replacement of all or part of the negative emotions with positive ones 
(Worthington & Wade, 1999). 
In line with these conceptualizations, the SCMF theorizes that when an individual 
experiences unforgiveness in response to a situation perceived as a wrongdoing, injustice, 
or threat (primary and secondary appraisals), and adopts forgiveness of the offender as a 
coping mechanism, the injustice gap perceived by the individual reduces. In turn, this 
reduces the stressful burden of the initial state of unforgiveness and its associated health 
risks (re-appraisal) (Lavelock et al., 2015; Strelan & Covic, 2006; Toussaint & 
Worthington, 2017; Worthington, 2006; Worthington & Scherer, 2004). Hence, according 
to the SCMF, while unforgiveness is stressful, forgiveness as an emotion-focused coping 
strategy reduces the stress of unforgiveness and is therefore related to health positively.   
 
The Stress and Coping Model of Forgiveness and HIV/AIDS 
 In the specific case of HIV/AIDS, a positive diagnosis may be perceived as an 
injustice or offense particularly in cases such as where the virus is perceived to have been 
acquired from an unfaithful and/or intentionally un-disclosing partner. Acquiring the virus 
via perinatal infection (from an infected mother to child), rape/sodomy, or through one’s 
line of work accidentally, may also be perceived as unjust/hurtful modes of transmission. 
Where an individual has no idea how they got the virus, diagnosis with HIV may likewise 
be perceived as an injustice or a punishment from God for a sin they may have committed. 
Also, PLWHV may experience unforgiveness towards themselves when they perceive that 
they may have unjustly infected others or themselves through their own risk behaviours. 
Furthermore, experiences of stigmatization, discrimination, isolation, and labelling among 
PLWHA may also be perceived as injustices or offenses directly related to one’s 
seropositive status. In addition, diagnosis with HIV may be perceived as a threat to one’s 
self-esteem, self-respect, social inclusion, peace of mind, and life goals like marriage and 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
child bearing (Temoshok & Wald, 2005). It may also be appraised as a threat to the safety 
of spouses, children, and other significant others.  
According to the SCMF, PLWHA who perceive that they can cope with their 
offensive HIV-related situation and adopt forgiveness as a coping mechanism, are more 
likely to experience a reduction in perceived stress. In turn, they may be more likely to 
record positive health outcomes (e.g., better PHRQOL and immune health), compared to 
those who report little to no forgiveness. Figure 1.0 illustrates application of the SCMF to 
the case of forgiveness of HIV-related offenses and two critical health outcomes – 
PHRQOL and CD4 cell count.    
 
Critique of the Stress and Coping Model of Forgiveness  
Indeed, the SCMF helps to map out a very plausible mechanism – stress relief – by 
which forgiveness may have its influence on health. Decades of studies on forgiveness 
have also found support respectively for the unforgiveness–negative health and the 
forgiveness–positive health link via increases/reduction in stress (e.g., Green et al., 2012; 
Harris & Thoresen, 2005; Temoshok & Wald, 2005; Toussaint et al., 2012; Toussaint, 
Shields, Dorn, & Slavich, 2016; Toussaint, Shields, & Slavich, 2016; Toussaint et al., 
2015; Worthington et al., 2007; Worthington & Scherer, 2004). 
Among PLWHA, evidence similarly suggest that potential stressors such as fear of 
disclosing positive status and perceptions of no psychosocial resources (e.g., perceived 
isolation and social rejection) have substantial negative effects on health outcomes. These 
include recovery, survival time, disease progression, CD4 cell count, depressive 
symptoms, and social support (Temoshok & Wald, 2005; Ullrich, Lutgendorf, & 
Stapleton, 2003).   
 
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 Despite the evidence found in favour of the Stress and Coping Model of 
Forgiveness, the model seems to place a biased emphasis on interpersonal offenses or 
forgiveness of others over other contexts within which offenses, unforgiveness, and 
forgiveness may be experienced. These include intrapersonal and spiritual contexts. For 
instance, Berry et al. (2001, p. 387) define unforgiveness as “a stress reaction to appraisals 
of interpersonal stressors that include transgressions, betrayals, offenses, and wrongs”. 
This definition seems to suggest that situations that are appraised as offenses and which 
may lead to the stressful reaction of unforgiveness are limited to interpersonal contexts 
between an individual and another individual or group. Toussaint and Worthington (2017, 
p.5) have also recently referred to forgiveness as “a good-fitting approach for coping with 
interpersonally stressful events where there is a clear culpable wrongdoer”, which also 
seems to exclude the role of forgiveness in “intrapersonally” or spiritually stressful 
situations.  
Contrary to the biased emphasis that the model seems to place on interpersonal 
forgiveness, it is argued that the model has often been used to explain fragments or 
specific dimensions of this complex and multifaceted construct at a time. For instance, it 
has been applied extensively to situations of injustices perpetrated by one’s self whether 
against one’s own self or another, warranting the application of self-forgiveness 
(Woodyatt et al., 2017). It may also be applied to offenses perceived to be the doing or 
punishment of God (Temoshok & Wald, 2005). Applying the SCMF to this context, it is 
posited that a positive change in attitudes towards God may yield positive health benefits 
(Ironson, Stuetzle, & Fletcher, 2006; Ironson, et al., 2011).  
 
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Figure 2.1: Application of the Stress and Coping Model of Forgiveness to HIV/AIDS    
(Lavelock et al., 2015; Strelan & Covic, 2006; Toussaint & Worthington, 2017) 
 
2.1.2 The Biopsychosocial Framework of Contexts of Forgiveness in HIV/AIDS  
 The social (interpersonal), individual (intrapersonal), and spiritual contexts within 
which forgiveness (or its converse) of perceived HIV-specific offenses may be 
experienced and have its impact on health, places the present study of forgiveness as 
associated with the outcomes of PHRQOL and immune functioning within a 
biopsychosocial framework.  
 According to Temoshok and Wald (2005, p. 336), “the role of forgiveness in the 
lives of persons living with HIV/AIDS is located within a biopsychosocial framework.” 
Indeed, the antecedents, processes, and consequences of forgiveness may all be explained 
within the context of the BPS framework (Engel, 1977). For example, the factors that 
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determine whether or not one would forgive a given offense may be biological (e.g., age), 
psychological (e.g., beliefs), or social (e.g., religiosity) in nature. The processes 
characteristic of forgiveness also involve changes in cognitions, emotions, and behaviours 
(psychological factors) in response to social phenomena such as the experience of 
injustices (Harris & Thoresen, 2005). Furthermore, the consequences of forgiveness could 
be biological/physiological (e.g., reduced activation of the stress-response system), 
psychological (e.g., reduced psychological distress) and social (increased acceptance of 
social support) (Harris & Thoresen, 2005, Toussaint & Webb, 2005).  
 Therefore, drawing on the BPS model, the Biopsychosocial Framework of 
Contexts of Forgiveness (BPSFCF) in HIV/AIDS first of all posits that biological, 
psychological, and social factors interact in a complex manner to affect HIV/AIDS health 
outcomes (Temoshok & Wald, 2005). Secondly, the BPSFCF theorize that forgiveness is 
an adaptive way of coping with stress that involves appropriate recognition and expression 
of emotions and which has both biomedical/psychoneuroimmunological (PNI) and 
psychosocial consequences. Thirdly, Temoshok and Wald (2005) within the BPSFCF 
further posit that the influence of forgiveness on HIV/AIDS health outcomes occurs 
through two main pathways; a direct biomedical/PNI pathway and an indirect pathway via 
psychosocial behaviours. For example, they hypothesize that along the PNI/biomedical 
cascade, forgiving an HIV-specific offence may lead to reduced stress and lower arousal 
of the hypothalamic-pituitary-adrenal-cortical (HPAC) axis. In turn, this may enhance 
immune functioning as well as HIV immuno-regulatory mechanisms, leading to improved 
response to HIV treatment.  
Along the psychosocial pathway, forgiveness of HIV-specific offenses is 
hypothesized to lead to an increased feeling of self-esteem, self-respect, self-value, trust, 
hopefulness, and empathy among other positive thoughts and emotions. These positive 
responses may lead to more adaptive behaviours including seeking and accepting social 
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support, attending HIV routine clinics, quitting or not initiating risk behaviours such as 
alcohol and substance abuse, forgoing suicidal thoughts and attempts, and also, 
communicating better with healthcare providers. These in turn may promote other 
important and more direct health behaviours such as adherence to ART and responsible 
sexual behaviours (Temoshok & Wald, 2005). These two behaviours are particularly 
critical to health outcomes in HIV/AIDS (Du et al., 2015; Sikkema et al., 2010; US 
Department of Veterans Affairs (USDVA), 2017). Table 2.1 summarizes the hypothesized 
BPS consequences of the converse of forgiveness (unforgiveness) across intrapersonal, 
interpersonal, and spiritual contexts of the experience of HIV-specific offenses.  
Table 2.1: Temoshok and Wald’s (2005) hypothesized biopsychosocial contexts and 
consequences of unforgiveness of HIV-specific offenses.  
Context of  Perceived Psychosocial Resulting Biomedical 
Unforgiveness Offense Consequences Behavioural Consequences 
Situations  Consequences  
Intrapersonal Promiscuity, Low self-esteem Drug & alcohol Stress, immune 
Infection of guilt, self-blame, abuse, poor eating & dysfunction, 
others shame, regret, sleeping behaviours disease 
depression (bhvs) progression 
Interpersonal Unfaithful Anger, mistrust Poor ART adherence, Treatment failure, 
partner, Stigma, resentment, fear, risky sexual STDs co-
Sexual abuse, disappointment behaviours infection, HIV re-
mother-to-child infection 
Spiritual Born with HIV, Anger, despair, Suicidal thoughts/ Multisystem 
accidental hopelessness, behaviours, isolation, breakdown 
acquisition, hostility,  withdrawal  (mental, 
unknown cause helplessness biological, social)  
 
Table 2.1 illustrates the three main HIV-related contexts within which 
unforgiveness may be experienced and the potential psychosocial, behavioural, and 
physiological outcomes of unforgiveness. 
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Critique of the Biopsychosocial Framework of Contexts of Forgiveness in HIV/AIDS  
 The BPS model upon which the BPSFCF has been developed is one of the most 
extensively applied models in healthcare since its conceptualization forty decades ago 
(Wade & Halligan, 2017). This may be due to its alignment with the WHO’s definition of 
and constitutional principle about health as a state of complete physical, mental, and social 
wellbeing and not merely the absence of disease (WHO, 2017c). It may also be that most 
of the models that have attempted to explain the possible determinants of health outcomes 
or vital health behaviours, may critically be broken down into the three components of the 
BPS model – biological, psychological, and social factors. Furthermore, rather than 
focusing biasedly on illness and/or defective health behaviours or determinants, the BPS 
model places an equal emphasis on prevention and health promotion as it does on 
treatment of illnesses (McInerney, 2015). In addition, the model’s extensive application 
may be due to the studies done in various areas that have found and continue to find 
support for the interaction between biological, psychological, and social factors as 
associated with health and illness. These areas include health psychology and medical 
humanities/behavioural medicine to mention a few (e.g., Hatala, 2012; Hyman & Fleisher, 
2011; Melchert, 2013; Wade & Halligan, 2017; Weiner, 2008).  
However, one popular criticism that has been levelled against the BPS model is the 
concern that its social domain leaves out other critical influences on health such as culture, 
religiosity, and large social units like community, society, and nation (Benning, 2015; 
Tavakoli, 2009). Perhaps in response to this, the biopsychosocial-spiritual model was 
proposed to capture the perceived missing spiritual/cultural component of health and 
illness (Hatala, 2012; Taylor, Stotts, Humphreys, Treadwell, & Miaskowski, 2013).  
Quite contrary to these views, it is argued that there seem to be gross 
misrepresentation of the social dimension of the model. As rightly noted by Suls and 
Rothman (2004), the social component of the multidimensional, multi-level BPS model 
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encompasses all system-level/macro-cultural factors beyond the individual. These include 
the family, community, culture, subcultures (e.g., religiosity), society, economy, nation, 
and the broader environment or biosphere within which the individual functions. In their 
review of studies underpinned by the BPS model, Suls and Rothman (2004) noted that the 
under-representation of the model’s social/systems component may be due to the limited 
degree to which all three domains of the model have been integratively explored even 
within the field of health psychology. Often, only the psychological domain has been 
explored (Suls & Rothman, 2004). Thus, it is maintained that the BPS model upon which 
the BPSFCF is situated, is a holistic model that duly considers the role of biological, 
psychological, and social (system-level/macro-cultural) factors in health, illness, and 
healthcare delivery. It is argued that the onus lies on researchers and practitioners to 
understand the range of factors encapsulated within each of the three broad domains of the 
BPS framework and the possible interactions between these.  
 
2.1.3 The Afrocultural Social Ethos Framework 
 The third theoretical framework that underpins the current study is the afrocultural 
social ethos framework (ASEF) by Jagers, Smith, Mock and Dill (1997). Although this 
framework originally sought to explain how culture influences psychosocial functioning in 
urban African American adolescents in the USA, its underlying principles may be 
extended to understand forgiveness coping among PLWHA in Ghana’s typical 
collectivistic societies. According to the ASEF, spirituality, affect, and communalism 
constitute three main worldview factors that are central to the psychosocial experiences of 
African Americans. Spirituality concerns reliance on God’s help, consciousness of the 
presence of deceased loved ones, and respect for the presence of a “spirit” in man. Affect 
describes the typical nature of Africans to acknowledge and sincerely express emotions in 
line with one’s thoughts. Finally, communalism is the worldview that concerns the 
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commitment of Africans to values for interdependence, respect for group goals, and 
acceptance of group responsibilities, particularly among those who are socially involved. 
According to Jagers et al. (1997), much of the psychosocial experiences of African 
Americans center around these three major worldviews, which together form the ASEF. 
 
Critique of the Afrocultural Social Ethos Framework in HIV/AIDS 
 The HIV/AIDS literature suggests that firstly, the components of the ASEF play 
vital roles along the illness and treatment trajectories of HIV/AIDS. For instance, it has 
been reported that religiosity of newly diagnosed HIV/AIDS persons tends to be an 
important determinant of whether they accept their condition (Szaflarski, 2013) or of 
adhere to ARTs following initiation of treatment (Parsons, Cruise, Davenport, & Jones, 
2006). In relation to forgiveness, that this prosocial behaviour is practiced or encouraged 
by many religious bodies in Ghana may mean that the spirituality worldview component 
of the ASEF may be relevant to consider in forgiveness coping with HIV-specific 
offenses. It is possible that religiosity may be a reason for which PLWHA may forgive 
perceived HIV-related offenses (Davis, Hook, & Worthington, 2008; Owen et al., 2011). 
Concerning communalism, reports indicate that people in typically collectivistic societies 
tend to value harmonious social relationships (e.g., Hook et al., 2012). This may suggest 
that PLWHA in Ghana may be likely to receive support from others, which may help them 
to forgive grievances they may hold in relation to their HIV-positive status.   
On the other hand, it is argued in relation to the affect component of the ASEF that 
Africans may not be emotionally expressive in all situations. This may be particularly so 
where expressiveness of thoughts and emotions may jeopardize their personal 
relationships with others or their status within the community. For instance, the continuous 
stigma surrounding HIV may mean that infected persons may not express or disclose their 
status nor their perceived HIV-related offenses easily (Arrey, Bilsen, Lacor, & 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Deschepper, 2016). Dzokoto (2010) has also found that compared to people in largely 
individualistic cultures (e.g., U.S.), Ghanaians may actually pay less attention to their 
emotions and more to their bodies.  
 
2.1.4 Summary of Theoretical Underpinnings 
In summary, the three frameworks underpinning the present study together suggest 
that when an individual appraises a situation as an offense and adopts forgiveness as a way 
of coping, it may manifest in positive health outcomes via direct biological changes in the 
stress response system and/or indirectly through motivation to engage in positive health 
behaviours. In addition, the extent to which an individual may forgive, may be influenced 
by his/her worldviews on spirituality and communalism, which may reflect in their 
religious behaviours and perception of social support. (see Figure 2.2). 
Figure 2.2 illustrates that the SCMF would guide the present study in ascertaining 
the relationship of forgiveness of HIV-specific offenses to PHRQOL and immune health, 
taking participants’ reported offenses and offense severity/hurtfulness as stressful events.  
The BPSFCF in HIV/AIDS would direct the present study into further identifying 
what biopsychosocial conditions (moderators) may change the way forgiveness may be 
associated with the outcomes.   
Finally, the ASEF would help to identify (and control for) some important factors 
that may influence whether or not PLWHA in Ghana may forgive offenses specifically 
related to their positive status. These include religiosity and social support, which may 
stem from the value that Africans place on spirituality and communalism (Jagers et al., 
1997). 
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Figure 2.2: Application of the SCMF, BPSFCF, and ASEF to forgiveness in HIV/AIDS 
(adapted from Temoshok & Wald, 2005) 
 
2.2 Review of Related Literature  
 This section of the thesis seeks to analyse and synthesize the literature on 
forgiveness and HIV/AIDS as related to health. Beginning with its definition and related 
theoretical constructs, an overview of findings on forgiveness and health in general is 
presented. This is followed by a brief overview of PHRQOL in HIV as well as immune 
functioning in HIV. Considering that forgiveness occurs within a complex interaction of 
biopsychosocial factors, key biological, psychological, and social factors in HIV are then 
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reviewed with particular focus on the study outcomes – PHRQOL and CD4 cell count. 
Finally, the section presents a systematic review of forgiveness studies in HIV, with a 
focus on studies reporting health outcomes in relation to this multifaceted construct.  
 
2.2.1 Forgiveness and Related Constructs 
Defining Forgiveness  
 The question of what forgiveness is, is one that has attracted much debate since the 
beginning of forgiveness research (Worthington, 2005). Generally, a consensus seems to 
have been reached on the various ways of coping with offenses that may reduce 
unforgiveness and promote forgiveness but which are distinguished from forgiveness 
(Worthington et al., 2007). These include excusing, condoning, denying, forbearing, and 
reconciliation (Enright & Fitzgibbons, 2000; Worthington, 2005; Worthington et al., 
2007).  
The varying definitions of forgiveness may be attributed to the various dimensions 
of forgiveness (cognitive, emotional, motivational, or behavioural) that researchers may 
consider to be most at play (Worthington, 2005). For instance, while some researchers 
may view the construct mainly in terms of a positive change in motivations (e.g., 
McCullough, Fincham, & Tsang, 2003), others (e.g., DiBlasio, 1998) emphasize primarily 
on the cognitions (e.g., decisions) involved in forgiving. Some researchers also seem to 
conceptualize forgiveness as a complex multidimensional concept that encompasses 
cognitive, emotional-motivational, and behavioural processes (e.g., Davis, Worthington, 
Hook, & Hill, 2013; Enright & Fitzgibbon, 2000; Harris & Thoresen, 2005; Enright, 
1991). For example, Enright and Fitzgibbons (2000) define forgiveness as a freely made 
choice to forgo negative cognitive, emotional, and behavioural responses toward a person 
who caused a hurt, and work toward developing positive cognitive, emotional, and 
behavioural responses. Harris and Thoresen (2005, p. 322) also view forgiveness “not only 
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as the reduction of unforgiveness through reducing the negative thoughts, emotions, 
motivations, and behaviours toward the offender but also as the increase of positive 
emotions and perspectives, such as empathy, hope, or compassion.” In line with these 
latter views, Worthington and Scherer (2004) classify forgiveness into decisional and 
emotional forgiveness. They define decisional forgiveness as change in a person’s 
behavioural intentions toward a transgressor (e.g., intending not to take revenge against or 
avoid the offender). Whereas, emotional forgiveness is defined as replacement of negative 
unforgiving emotions (e.g., bitterness and anger) with positive other-oriented emotions 
(e.g., empathy and love) toward the transgressor (Worthington & Scherer, 2004; 
Worthington et al., 2007).  
According to Worthington et al. (2007), decisional forgiveness may or may not 
lead to the more complete emotional forgiveness stage. Also, some researchers have 
contended that emotional forgiveness has more direct effects or benefits on health, as the 
replacement of more negative with more positive thoughts and emotions involves both 
peripheral and central nervous system changes (Harris & Toresen, 2005; Worthington et 
al., 2007; Toussaint et al., 2012; Griffin, Worthington, Lavelock, Wade, & Hoyt, 2015).  
By and large, researchers at least seem to share a core understanding of forgiveness as a 
prosocial change in people’s experiences following a transgression (McCullough, 
Pargament, & Thoresen, 2000; Worthington, 2005).  
 
Critique of Decisional versus Emotional Forgiveness and Health Benefits  
The multidimensional perspectives on forgiveness indeed appear to provide a more 
comprehensive description of this rather complex human phenomenon. In the least, they 
allow for exploration into questions such as; is a reduction in, or the 
removal/neutralization of unforgiveness, or the experience of emptiness synonymous with 
forgiveness (Davis et al., 2013; Worthington, 2005)? Or is forgiveness a reduction in, and 
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eventual neutralization/removal of negative experiences plus a development of more 
positive cognitions, emotions, and behaviours toward an offender (Worthington et al., 
2007)? A closer consideration of the decisional and emotional forgiveness categorization 
in light of the multidimensional definitions of forgiveness (Harris & Thoresen, 2005; 
Enright & Fitzgibbons, 2000) seems to suggest that these two dimensions capture all these 
processes along a continuum. Although, Worthington et al.’s (2007) definition of 
decisional forgiveness seem not to wholly reflect some important processes/changes that 
may be inherent within this first stage of the forgiveness process. They define decisional 
forgiveness as an intention to forgo negative behavioural responses toward a transgressor 
over a perceived offense (Worthington & Scherer, 2004; Worthington et al., 2007). It is 
argued that this first stage of forgiveness may also encompass important psychological 
changes – reductions or removal– in the negative thoughts and emotions of unforgiveness 
that possibly culminate in a change in behavioural intentions toward an offender (Davis et 
al., 2013; Harris & Toresen, 2005). Again, it is argued that these possible changes (from a 
peak negative to a less negative state in thoughts, emotions and behaviour intentions) that 
may be inherent in the decisional forgiveness stage may mean that decisional forgiveness 
may also have important influences on health.  
 
Offense-Dependent and Offense-Independent Forgiveness  
 Forgiveness always comes into play in the context of offenses. An offense has 
often times been described as a hurt, transgression, wrong doing, or injustice in the 
forgiveness literature (e.g., Worthington, 2005; Exline et al, 2003; Worthington et al., 
2007, Woodyatt et al., 2017). Based on these descriptions, an offence may be defined as a 
wrong doing, whether by direct commission or omission, that causes physical and/or 
psychological suffering to the victim and for which the wrong doer may also in like 
manner suffer, especially if they acknowledge responsibility for the wrong deed.  
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Typically, the construct “forgiveness” is used in the forgiveness literature to refer 
to the state of forgiving a specific offense situation in which both the offense and offender 
have specific characteristics. These include the nature, intensity, duration, and potential 
consequences of the offense and how the offender may be related to the victim 
(Suwartono, Prawasti, & Mullet, 2007; Worthington et al, 2007). Where individuals have 
the disposition, trait, or tendency of forgiving offenses consistently across time, situations, 
and people, this overall disposition has been referred to as forgivingness (Suwartono et 
al.2007; Worthington et al., 2007; Thompson et al., 2005). Based on this distinction, 
forgiveness is often referred to in acute stress situations while forgivingness is made 
reference to in chronic stress situations (Worthington et al. 2007). 
The effects of both state forgiveness and trait forgivingness on health outcomes 
have been studied. Research suggests that because chronic stress takes time to accumulate 
and to have its effects on health, forgivingness, when practiced for a long time across 
situations, tends to associate more often with health compared to forgiveness of particular 
situations (Lawler et al., 2003; Thompson et al., 2005; Worthington et al., 2007). Some 
studies have however, also found that whether as a predictor, criterion, or mechanism 
variable, forgiveness of specific offense situations is associated with health outcomes 
(Harris & Thoresen, 2005; Lawler-Row, 2010; Lawler et al., 2005; Lawler et al., 2003; 
Toussaint et al., 2015; Toussaint & Webb, 2005; Worthington & Scherer, 2004). 
In HIV/AIDS, a number of situations specifically common to those with a positive 
diagnosis may arouse intense and prolonged feelings of anger, sorrow, fear, 
disappointment, resentment, guilt, blame, etc., characteristic of unforgiveness (Temoshok 
& Wald, 2005). As indicated earlier above, these situations include how an individual may 
have acquired the virus (e.g., rape, spouse’s infidelity, promiscuity), as well as post-
acquisition experiences such as stigmatization and rejection by significant others 
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(Temoshok & Wald, 2005). Thus, a change from these negative to positive responses may 
likely have important influences on health.  
 
Intrapersonal, Interpersonal, and Spiritual Contexts of Forgiveness 
 Forgiveness can occur in at least three major contexts; interpersonal, intrapersonal, 
and spiritual contexts (Worthington, 2005; Temoshok & Wald, 2005). The interpersonal 
context of forgiveness is a social/transactional context that involves at least two 
individuals; the offender and the victim, who may need to forgive the former (Hoyt & 
McCullough, 2005). Thus, interpersonal forgiveness involves other-oriented behavioural 
intentions and emotions following a transgression perpetrated by another (Worthington et 
al., 2007; Worthington & Scherer, 2004). The “other” may be an individual person, a 
group/out-group of persons, or a situation external to the individual self, although some 
have conceptualized forgiveness of situations separately from forgiveness of others (e.g., 
Temoshok & Wald, 2005).  
Intrapersonal context of forgiveness is an individual-level context, where 
forgiveness is extended towards one’s own self – self-forgiveness. Extending forgiveness 
towards one’s own self over an offence perpetrated against another (e.g., passing on HIV 
knowingly to a partner) reflects self-forgiveness in interpersonal contexts. Whereas, 
extending forgiveness towards one’s own self for an injustice perpetrated by the individual 
against him/herself, constitute self-forgiveness in intrapersonal contexts (Woodyatt et al., 
2017). Often, this intrapersonal context of self-forgiveness occurs where the hurtful 
situation is perceived to have resulted from violation of one’s personal values. For 
example, an individual who engages in promiscuity may perceive a diagnosis of 
HIV/AIDS as a gross injustice done to him/herself. Woodyatt and colleagues (2017) 
emphasize that whether in intrapersonal or interpersonal contexts, self-forgiveness is 
distinguished from letting one’s self off the hook of responsibility. Thus, they 
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conceptualize self-forgiveness to first include an experience of unforgiveness towards 
one’s own self, which may manifest as internalized guilt, regret, self-hatred, self-
condemnation, and thoughts of punishing one’s self (Hall & Fincham, 2005; Temoshok & 
Wald, 2005; Toussaint & Worthington, 2017; Woodyatt et al., 2017). This is followed by 
accepting responsibility for the offense and then incorporating the offense into a new 
lifestyle via reaffirmation of one’s values and a positive regard towards the self. The goal 
of self-forgiveness is to relieve the self-focused negative emotions and transform one’s 
self-image (Woodyatt et al., 2017).    
Another common context within which forgiveness of offenses has been explored 
is spirituality. Generally, forgiveness in the spiritual context has been conceptualized 
largely as feeling forgiven by God for one’s own transgressions (e.g., Temoshok & Wald, 
2005). Where perceived offensive situations have been thought of as a punishment from 
God, forgiveness has also been explored as changes in attitudes towards God (e.g., a 
current view of God as kind/benevolent/all-knowing rather than unkind/harsh/judgmental) 
(Ironson et al., 2006; 2011).  Toussaint and Webb (2005) proposed that in addition to these 
main contexts of forgiveness, the construct can play out in four other contexts: 
“forgiveness of God”, feeling others’ forgiveness, seeking others’ forgiveness; and 
seeking God’s forgiveness. The authors however highlighted that feeling and seeking 
forgiveness from one’s self has yet to be defined. Similarly, the context of “forgiveness of 
God” seems relatively under defined at present. In typically religious settings, where 
believe in an infallible sovereign God may be dominant, the context of “forgiveness of 
God” may warrant exceptional care in its conceptualisation and measurement.      
 
Culture and Forgiveness  
 The individualism-collectivism categorization is one of the most common ways of 
conceptualizing culture in research studies (Markus & Kitayama, 1991; Oyserman, Coon, 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
& Kemmelmeier, 2002; Triandis, 1999). It is reported that how people understand and 
practice forgiveness may vary across cultures, when culture is broadly organized into 
individualistic and collectivistic societies (Hook et al., 2012). Indeed, as societies grow 
more and more diverse and cultures become more and more complex (Hook et al., 2012; 
Jehoda, 2012), the extent to which whole societies may be collectivistic or individualistic 
may be questionable (Cooper & Denner, 1998). However, as Dzokoto (2010) hinted, there 
is enough evidence to propose significant individualistic-collectivistic differences between 
typical Western and non-Western groups of samples in spite of any within-group 
differences due for example to differences in individual personality or ethnic groups. 
Further, studies comparing forgiveness and health across countries have reported 
differences between Western and non-Western countries that have largely been associated 
with cultural differences in personal and relational orientations (Leach & Parazak, 2015). 
In typical collectivistic countries (e.g., Ghana) it is reported that people may tend to 
prioritize group goals, social harmony, and relational repair above their individual interests 
and wellbeing (Markus & Kitayama, 1991; Oyserman et al., 2002; Triandis, 1999). It has 
also been found that people in such interdependent cultures may be less focused on their 
inner emotions and hence less expressive of such emotions (Dzokoto, 2010). In line with 
these patterns of cultural behaviour, reports further suggest that more of decisions to 
forgive than emotional forgiveness may be reported in generally collectivistic societies 
(Hook et al., 2009; Hook et al., 2012). It is worth exploring however, how such common 
reports of decisional forgiveness may relate to health compared to the potential lower 
reports of emotional forgiveness.  
 
2.2.2 Forgiveness and General Health Outcomes  
Toussaint and colleagues (2015) in their collection of empirical works on 
forgiveness point to important associations between this construct and various aspects of 
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health. These include physiological indicators of health as well as self-reported physical, 
psychological, relational, and spiritual health (Worthington et al., 2007). Physiologically, 
although the evidence is inconclusive, they point to an association between forgiveness 
and central nervous, peripheral nervous, endocrine, and immune system functioning 
(Larkin, Goulet, & Cavanagh, 2015). For example, cortisol reactivity, an indicator of 
stress response, appears to be lower in forgiving individuals and higher in those who 
ruminate about offenses (Larkin et al., 2015).  
Increased reports of forgiveness have also been found to be associated with lower 
self-reported levels of perceived stress (e.g., Toussaint et al., 2016a; 2016b). Lower levels 
of perceived stress in turn associated with decreased mental health symptoms in the 
studies by Toussaint and colleagues (2016a; 2016b). The evidence for the forgiveness–
mental health link has also been reported in reviews of several studies (e.g., Griffin et al., 
2015). This include a recent systematic review and meta-analysis of the impact of 
forgiveness interventions on mental wellbeing (Akhtar & Barlow, 2016). The authors 
concluded that forgiving a variety of real-life interpersonal offenses was effective in 
reducing depression, anger, hostility, stress and distress. 
Although the studies by Toussaint et al. (2016a; 2016b) found no association 
between forgiveness and physical health symptoms, other studies have reported this link 
both in healthy (Cheadle & Toussaint, 2015) and patient populations (Friedberg, Tuvia, & 
Cha, 2015). Among patient populations including those with chronic pain and 
fibromyalgia, cancer, and cardiovascular disorders, the evidence supports the benefits of 
forgiveness in relation to improved illness-related symptoms (Friedberg, et al., 2015; 
Lawler et al., 2003; Lawler et al., 2005; Offenbächer, Dezutter, Vallejo, & Toussaint, 
2015).  
 
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Support has also been found for the benefits of forgiveness on health and wellbeing 
in the context of close relationships. These include married, unmarried, and general family 
relationships (Davis, Green, Reid, Moloney, & Burnette, 2013; Fincham, 2015; Rusbult, 
Hannon, Stocker, & Finkel, 2005). As well, some studies have found forgiveness in terms 
of views about God or deity as a mechanism for improving health and wellbeing (Ironson 
et al., 2006; Ironson et al., 2011).  
Overall, across contexts, disciplines, and populations, the empirical evidence 
seems to provide support for an association between forgiveness and diverse correlates of 
health (Toussaint et al., 2015; Woodyatt et al., 2017; Worthington, 2005). These are 
besides the associations that have been found in the specific area of HIV and AIDS. 
 
2.2.3 The Human Immuno-Deficiency Virus and Immune Functioning 
 The human immunodeficiency virus (HIV) is the virus that causes HIV infection 
and acquired immune deficiency syndrome (AIDS) – the most advanced stage of HIV 
infection (Kharsany & Karim, 2016). Once it enters the human body, the HIV virus acts 
by attacking the cluster of differentiation-4 (CD4) lymphocyte cells, also known as the T-
helper cells. These are the immune or white blood cells responsible for protecting the body 
against infections (Resino et al., 2006). The attack of the virus on the CD4 cells suppresses 
or reduces the number of the cells from a mean normal value of 500 – 1,300 cells/µL to as 
low as <200 cells/µL over time (Resino et al., 2006). It has been established that PLWHA 
who initiate and strictly adhere to ART (before their CD4 level falls to <350 cells/µL) are 
likely to experience better preservation of or increases in their CD4 cell count (U.S. 
Department of Health and Human Services (USDHHS), 2017).  
Generally, the goal of ART is to reduce the number of the HIV virus (viral load) in 
the body (WHO, 2013). Current treatment guidelines also recommend that all persons 
testing positive for HIV must be initiated on ART irrespective of baseline CD4 count 
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(WHO, 2017). However, the CD4 cell count is still widely used to assess patients’ HIV 
stage and in some cases (e.g., Tuberculosis co-infection) to determine ART success or 
otherwise (WHO, 2013; 2017). It is also used to determine initiation of prophylaxis 
(preventive treatment) against opportunistic infections – infections more frequent and 
severe in people with weakened immune systems –  as well as to determine HIV/AIDS 
prognosis (WHO, 2013, 2017). Therefore, CD4 cell count remains an important biomarker 
in HIV/AIDS care (WHO, 2017).  
 
2.2.4 HIV/AIDS and Psychological Health-Related Quality of Life 
One area in HIV/AIDS that seem to have gained much attention following the 
advent of new and effective classes of ART is quality of life (QOL). With the drastic 
change in HIV/AIDS prognosis from a fatal to a long-term manageable condition, QOL is 
currently one of the most important treatment endpoints for PLWHA on ART (Basavaraj, 
2010; European Medicines Agency, 2014; Oguntibeju, 2012; Inungu, 2017; 
WHO/UNAIDS, 2000). Indeed, it is reported that QOL should be considered a primary 
health goal in HIV/AIDS care and research (WHO/UNAIDS, 2000).  
Quality of life concerns the subjective ratings of individuals concerning a wide 
range of aspects of life including health, jobs, education, living conditions, relationships, 
finances, etc. According to the WHO (1998), it can be defined as “individuals' perceptions 
of their position in life in the context of the culture and value systems in which they live 
and in relation to their goals, standards, expectations and concerns.” On their WHOQOL-
BREF measure, the WHO (2012) further classify QOL into four main domains – physical 
health, psychological health, social relationships, and environment.  While most studies 
have investigated all or the health-related domains, it is possible that the effectiveness of 
the ART regimen may improve physical health, and hence, physical health-related QOL 
for the majority of PLWHA taking ART. However, how PLWHA cope with the typical 
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challenges and potential stressors associated with a positive HIV-status may still account 
for important differences in psychological health in this population. For instance, despite 
the advancements in ART, depression and other psychological disorders continue to be 
some of the most reported comorbidities in PLWHA in the region and beyond (Abas, Ali, 
Nakimuli-Mpungu, & Chibanda, 2014; Degroote, Vogelaers, & Vandijck, 2014; Tesfaye, 
& Bune, 2014). Therefore, a focus on the psychological health aspect of the lives of 
PLWHA in relation to forgiveness as a coping mechanism for offenses is in order.   
 
2.2.5 Biopsychosocial Factors, Quality of Life, and Immune Health in HIV  
In seeking to determine whether and how forgiveness may be associated with these 
two HIV/AIDS outcomes; PHRQOL and change in CD4 cell count, it is important that 
other factors capable of affecting the outcomes (and possibly forgiveness) are taken into 
consideration. Therefore, the following sections review key biological, psychological, and 
social factors relevant in HIV/AIDS.  
 
Biological Factors and HIV/AIDS 
 Reports indicate that Beyond the age of 25 years, there is a general decline in the 
function of body organs by 1% each year (Cardoso et al., 2013), suggesting a decline in 
larger body systems such as the immune system. Unsurprisingly, older adults are well 
known to face myriad of health issues including cardiovascular, reproductive, bladder, and 
kidney problems amongst other chronic conditions (Cardoso et al., 2013; Gladyshev & 
Gladyshev, 2012; Strait & Lakatta, 2012). In HIV/AIDS, reports suggest that the 
biological mechanisms underlying the normal aging process may occur at higher rates 
(Oguntibeju, van den Heever, & Schalkwyk, 2007), probably due to the additional 
degrading effects of the virus on immune cells. This suggests that there may be individual 
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differences in health outcomes for older PLWHA (≥40 or 50 years) and those who are 
younger (<40 or 50years) (Cardoso et al., 2013; Kirk & Goetz, 2009; Wing, 2016).  
Indeed, the evidence overwhelmingly suggests that older adults living with 
HIV/AIDS, although they may record lower viral loads, usually record lower levels or 
slower increases in CD4 cell counts, higher mortality rates, and poorer QOL of life 
domains compared to their younger counterparts. This pattern of findings has been 
reported in Western and other non-African countries (Asher et al., 2016; Dehghani et al., 
2017; Monteiro, Canavarro, & Pereira, 2016; Navarro et al., 2008; Vance, Mugavero, 
Willig, Raper, & Saag, 2011; Wellons et al., 2002). Large longitudinal studies conducted 
across various African countries have also reported this finding (Eduardo et al., 2014; 
Fatti, Mothibi, Meintjes, & Grimwood, 2014; Greig, Casas, O’Brien, Mills, & Ford, 
2012). Where studies controlled for baseline factors or compared younger and older adults 
with similar baseline CD4 and viral load, it remained that older adults recorded lower viral 
loads but also, lower CD4 cell counts/increases over time and higher mortality rates (e.g., 
Asher et al., 2016; Fatti et al., 2014). 
Previous studies have explained that the lower CD4 cell counts, higher mortality 
rates, and poorer QOL in older adults with HIV, may be due to other biological factors. 
These include the natural aging process and its associated comorbidities as well as the 
toxicities of ART and other medications that may be harsh on the gradually weakening 
immune systems of older adults (Cordoso et al., 2013; Greig et al., 2012; Kirk & Goetz, 
2009; Wing, 2016). For instance, some studies comparing younger and older adults with 
HIV/AIDS on comorbidities have found that the latter are more likely to have 
comorbidities including high blood pressure, hyperlipidemia, and depression (Tseng, 
2013; Greene 2014). They are also more likely than younger adults with HIV (Tseng et al., 
2013) and the general population (Greene et al., 2014) to be prescribed a greater number 
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of antiretrovirals (ARVs) as well as non-ARV drugs (e.g., gastrointestinal medications) for 
their likely comorbid conditions.  
Another biological factor that may contribute to the poorer outcomes in older 
adults and perhaps the general differences in HIV/AIDS outcomes is sex. It is worth 
noting, that compared to younger adults, older adults in many of the age-related studies 
comprised of more males (e.g., Asher et al., 2016; Eduardo et al., 2014; Fatti et al., 2014; 
Greene et al., 2012; Greig et al., 2012; Navarro et al., 2008; Tseng et al., 2013; Vance et 
al., 2011). However, findings on gender differences in HIV outcomes seem to be 
equivocal. In some studies, no gender differences in CD4 counts were recorded although 
females were more likely to achieve virological suppression (reduced viral loads) (e.g., 
Chen et al., 2017; Kipp et al., 2010; Lee et al., 2015). In other studies, higher CD4 cell 
count for more females than males and viral suppression among fewer females compared 
to males were found (e.g., Cescon et al., 2013; Maskew et al., 2013; Rosin et al., 2013).  
 Previous studies have suggested that inherent biological differences between males 
and females (e.g., early menopause and pregnancy in women) may influence drug 
metabolism, leading to differences in health outcomes (Cardoso et al., 2013; Maskew et 
al., 2013). Yet, the equivocal results found across studies seem to suggest that beyond 
possible inherent biological differences, other social and psychological factors may be 
important in understanding patterns of health outcomes in HIV/AIDS. The subsequent 
section reviews some of these factors.   
 
Social Factors and HIV/AIDS 
 Social factors such as  educational level and marital status may be readily classified 
as non-modifiable determinants of health. However, they may reveal other important 
factors amenable to change. For example, a link between married (compared to non-
married) status and better health outcomes may reflect the importance of social support in 
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the HIV care pathway. This seems logical, as married individuals may obtain support from 
their spouses against life’s pressures. In HIV/AIDS, it may be expected that those with a 
married status may gain spousal support to effectively deal with the challenges that usually 
come with a positive diagnosis. These include the tendency to feel stigmatized and 
isolated by some family and friends and the financial burden involved in attending routine 
HIV clinics, undertaking relevant laboratory tests, and purchasing prescribed non-ARV 
medications. There is also the challenge of remembering to adhere to routine clinic 
schedules as well as to the ART regimen. 
However, the few studies examining the link between marital status and outcomes 
in HIV/AIDS have found conflicting results. In a study that reviewed data of 762,727 
HIV-infected individuals from the US National Longitudinal Mortality Study over a 
period of 11years, an association was found between marital status and HIV/AIDS-related 
mortality (Kposowa, 2013). Compared to married persons, divorced and separated 
individuals were 4.3 times more likely to die of HIV/AIDS. The risk was much greater for 
single/never married persons, who were found to be over 23 times more likely to die of 
HIV/AIDS than their married counterparts. However, when analysed by gender, this 
association was significant among men but not in women, with men being over 7 times 
more likely at risk of mortality (Kposowa, 2013). In a study by Luguterah & Adams 
(2013) conducted among 90 HIV-positive patients in Ghana, it was found that CD4 counts 
rose steadily for all marital groups until after 2years, when it seemed to consistently 
decline for single persons. Overall, no significant difference was found in CD4 changes 
over time as a function of marital status. 
In relation to educational level, again though non-modifiable, several studies have 
identified educational level as an important social determinant of health status and 
outcomes both directly and indirectly. Directly, educational level may play a relevant role 
in how people understand illnesses and their management. Indirectly, it may impact on 
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health through access to other socioeconomic opportunities. Reports indicate that 
educational level may influence HIV/AIDS transmission risk behaviours (Yaya et al., 
2014) and promote better understanding of important aspects of the infection including 
symptoms, role of ART in slowing the disease progression, and the importance of 
adherence in this process (Osei-Yeboah et al., 2017). Furthermore, educational level has 
been found to affect time of presentation for HIV diagnosis at care facilities (Mukolo et 
al., 2013). All these possible consequences of education are pertinent to achieving 
successful outcomes on ART (Mukolo et al., 2013). However, mixed findings have been 
reported by the few studies that have specifically considered the effect of educational level 
on HIV/AIDS outcomes following ART initiation (McMahon, Wanke, Terrin, Skinner, & 
Knox, 2011). In some studies, lower levels of education have been associated with lower 
CD4 counts, higher mortality (McMahon et al., 2011), increased risk of virologic failure 
(McMahon et al., 2011; Ribaudo et al., 2013), and progression of HIV to AIDS (Poorolajal 
et al., 2015). In other studies, no association has been found between level of baseline 
educational attainment and mortality (Cohen, Werner, Gengiah, & Naidoo, 2014; 
Poorolajal et al., 2015). The study by Cohen and colleagues (2014) also found no 
differences in immunologic response, virologic response, or loss to follow-up after 6, 12, 
and 24 months on ART as a result of educational attainment. In Ghana, a retrospective 
data review study among 90 patients receiving ART at the Builsa District hospital 
considered the association between educational level and changes in CD4 cell count over 
time (Luguterah & Adams, 2013). It was found that among the 40 patients who had formal 
education, the average change in CD4 count decreased with increasing educational level 
over the study period. This is in contrast to the findings by McMahon et al. (2011) that 
CD4 counts reduced with lower educational levels. 
 
 
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Psychosocial Factors and HIV/AIDS  
 The management of chronic illnesses in general, has been found to centre around 
key psychosocial factors (Medved Kendrick, 2017; Simoni, Frick, & Huang, 2006). For 
instance, in HIV/AIDS, religiosity plays a vital role throughout the care pathway; from 
diagnosis to self-management of the condition and its treatment (Szaflarski, 2013). 
Depending on how religiosity is adopted – positively or negatively – it may respectively 
influence health outcomes positively or negatively (Medved Kendrick, 2017). Positive 
religious coping involves an increase in religiosity – overt faith-based practices such as 
reading the scriptures – following a challenging situation (Medved Kendrick, 2017). For 
example, individuals newly diagnosed with HIV may dwell on their belief in the power of 
God to develop a high treatment self-efficacy – the belief that one can effectively manage 
the demands of a treatment that he/she is on (Arrey et al., 2016; Simoni et al., 2006). On 
the other hand, negative religious coping reflects the experience of religious struggles 
(e.g., shame and guilt) over behaviours condemned by one’s religious group (e.g., risky 
sexual behaviours). It also includes attributing difficult life experiences to punishment 
from God and developing anger and other negative attitudes towards God (Medved 
Kendrick, 2017; Ironson et al., 2011). Furthermore, it concerns religiosity serving as 
barriers to the uptake of healthcare services such as voluntary testing for HIV and 
initiation on ART (Nunn et al., 2013; Parsons et al., 2006).  
Indeed, research has shown that negative religious coping in PLWHA is associated 
with suboptimal health behaviours and outcomes including poor ART adherence and faster 
disease progression (e.g., Lee, Roberts, & Gibbons, 2013; Lyon et al., 2011; Pargament et 
al., 2005; Parsons et al., 2006). Majority of studies have also found that positive religious 
coping uniquely predicts or moderates better clinical and QOL outcomes throughout the 
HIV/AIDS care trajectory (e.g., Doolittle, Justice, & Fiellin, 2016; Ironson et al., 2006; 
Luguterah & Adams, 2013; Oji et al., 2017; Szaflarski, 2013; Trevino et al., 2010; Utley & 
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Wachholtz, 2011; Vyas, Limneos, Qin, & Mathews, 2014). Only a few studies have found 
no association between religiosity and health in PLWHA (e.g., Lorenz et al., 2005; Cotton 
et al., 2006). 
 Social support, similar to religiosity, is another fundamental coping mechanism in 
HIV/AIDS, particularly following a positive diagnosis (Ironson et al., 2006). A number of 
studies have actually found that social support influences (mediates, partially mediates, 
moderates) the relationship between religiosity and outcomes in HIV/AIDS (Dalmida, 
Koenig, Holstad, & Wirani, 2013; Medved Kendrick, 2017; Steglitz, Ng, Mosha, & 
Kershaw, 2012; Szaflarski, 2013). Other studies have found direct associations between 
social support and HIV/AIDS outcomes. These include psychological health (Asante, 
2012; Seth et al., 2014; Yu et al., 2015), QOL (Abrefa-Gyan, Cornelius, & Okundaye, 
2016; Charkhian et al., 2014), and clinical outcomes such as CD4 cell counts, mortality, 
and morbidity (Bateganya, Amanyeiwe, Roxo, & Dong, 2015; Forouzan et al., 2013; 
Sarfo, Vanderpuye, Addison, & Nyasulu, 2017). Overall, the evidence points to social 
support of varied kinds (material, instrumental, support groups) and from various sources 
(family, friends, other relatives) as an important psychosocial factor in HIV/AIDS. This 
includes evidence from Ghana (Abrefa-Gyan et al., 2016; Asante, 2012; Sarfo et al., 
2017). Although, the magnitude of support reported, varied for different support sources 
across studies. This may be because, social support as a salutatory content of human 
relations, reliably varies with one’s location in the social system (Turner & Turner, 2013). 
Thus, depending on participants’ social status and/or relations with others, they may have 
perceived/received different levels of support. It may however, also reflect cross-cultural 
variations in perceptions of who is more likely to provide support with minimal risk of 
stigmatization and “broadcasting” of one’s HIV-positive status.  
 
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Mental health or psychological wellbeing is another important psychosocial factor 
in HIV/AIDS management and outcomes. Unsurprisingly, a number of studies have 
correlated mental health of PLWHA with other psychosocial and clinical factors. These 
include QOL, perceived/received social support, ART adherence, and immunologic 
function (e.g., Abas et al., 2014; Asante, 2012; Braxton et al., 2007; Dalmida et al., 2009, 
2013; Green, 2014; Ickovics et al., 2001; Tseng, 2013; Seth et al., 2014; Simoni et al., 
2002; Simoni & Ortiz, 2003; Yu et al., 2015). For example, in a study of 59 men and 41 
women initiating ART at a University Hospital in Spain, perceived stress significantly 
predicted CD4 cell count 6 months post ART initiation after baseline demographic and 
treatment factors (age, gender, education, income, duration of ART, ART adherence, CD4 
cell count and viral load) were accounted for (Remor, Penedo, Shen, & Schneiderman, 
2007).  
In Ghana, the study by Asante (2012) of 107 PLWHA receiving treatment at the 
Fevers Unit of the KBTH also found that lower levels of depression and stress were 
significantly associated with higher levels of social support in both men and women with 
HIV/AIDS. It is reported that depression is about the most common mental illness 
prevalent in PLWHA (Bernard, Dabis, & de Rekeneire, 2017). According to Abas and 
colleagues (2014), an estimated 8% of PLWHA in SSA have depression, compared to 
5.5% in the general population.  Findings of a recent systematic review further suggest an 
increasing depression rate of 9% and 32% in PLWHA on ART and in untreated or mixed 
(treated and untreated) HIV-positive populations (Bernard et al., 2017). Overall, a 
systematic review of 104 studies on mental health in PLWHA in SSA has found that all 
studies reported ≥19% prevalence of mental illnesses (Breuer, Myer, Struthers, & Joska, 
2011).   
 
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Adherence to ART and sexual behaviours are also two other psychosocial factors 
that are critical in the treatment endpoints of HIV/AIDS (Du et al., 2015; Sikkema et al., 
2010; USDVA, 2017). Reports indicate that although majority of PLWHA adopt safer 
practices following their HIV-positive diagnosis, some continue to consciously engage in 
high-risk behaviours. These include unprotected sex with HIV-negative persons as well as 
other HIV-positive persons (Du et al., 2015; Sikkema et al., 2010; USDVA, 2017). While 
unprotected sex with HIV-negative persons may facilitate the spread of the infection, 
unprotected sex with other HIV-positive persons, particularly those not on ART, may 
promote poor treatment outcomes via reinfection with different strains of the virus 
(Adedimeji et al., 2015; Molla & Gelagay, 2017). This may in turn promote viral 
resistance to ARVs (USDVA, 2017).  
In Ghana, a cross-sectional survey conducted among 267 HIV-positive individuals 
attending Kumasi South Regional Hospital found high prevalence of sexual risk 
behaviours. Of the 175 who reported having a regular sexual partner, majority had HIV-
negative partners (serodiscordant couples) or partners of unknown HIV status and more 
than half had unprotected anal or vaginal sex. Also, participants taking ARV were 80% 
less likely to have used condoms during their last sexual intercourse. 
Reports similarly indicate that in spite of the current improved ARVs (Colvin, 
2011), an important proportion of PLWHA continue to be non-adherent to ART (Elul et 
al., 2013; Kahana et al., 2015; Rangarajan et al., 2016; Robbins et al., 2014; USDHHS, 
2017). Some studies have defined poor ART adherence as taking less than 95% of ART 
regimen (e.g., Olowookere, Fatiregun, Ladipo, Abioye-Kuteyi, & Adewole, 2016; Seyoum 
& Temesgen, 2017).  
Indeed, there is much evidence to indicate that non-adherence to ART is associated 
with poorer CD4, viral load, and wellbeing outcomes for PLWHA across the globe 
(Bezabhe, Chalmers, Bereznicki, Gee, & Peterson, 2016; Bisson et al., 2008; Kahana et 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
al., 2015; Obirikorang, Selleh, Abledu, & Fofie, 2013; Olowookere, Fatiregun, Ladipo, 
Abioye-Kuteyi, & Adewole, 2016; Seyoum & Temesgen, 2017; Sikkema et al., 2010). 
The studies by Obirikorang et al. (2013) and Olowookere et al. (2016) were conducted 
among 201 PLWHA on ART in the Upper West Regional Hospital of Ghana and among 
318 people initiating ART in Nigeria respectively. Adherence was defined as taking ≥ 
95% of ART within the last 7days (Olowookere et al., 2016) and not missing a single dose 
(Obirikorang et al., 2013). Results of the studies showed a significant positive association 
between adherence to ART and immunological success (Obirikorang et al., 2013, 
Olowookere et al., 2016), with non-adherence increasing the risk of immunological failure 
(Obirikorang et al., 2013). Overall rates of adherence in the last seven days were 63% 
(Olowookere et al., 2016) and 82% (Obirikorang et al., 2013). 
Whether through sexual risk or non-adherent behaviours, PLWHA who 
continuously record lower CD4 cell counts and higher viral loads, or who become resistant 
to ART are at an increased risk of passing on HIV infection to others. Therefore, these 
constitute a significant public health challenge (Robbins et al., 2014; Sikkema et al., 2010; 
USDHHS, 2017). 
 
2.2.6 Summary and Critique of Biopsychosocial Factors in HIV/AIDS 
 In summary, a number of biological, social, and psychosocial factors have been 
found to influence treatment outcomes for PLWHA. These include age, gender, the ART 
regimen, education, social support, religiosity, ART adherence, sexual behaviours, and 
depression among other mental health problems. For some of these factors (e.g., age, ART 
adherence, religiosity, and mental health problems), there seem to be quite consistent 
evidence in support of their association with QOL and/or immune functioning. However, 
the evidence remains equivocal for many of these factors. Also, while a range of 
biological and behavioural factors have been investigated, these seem not to be in direct 
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relation to aspects of the HIV/AIDS experience that may involve emotional wounds. Even 
though mental health issues including depression have been explored quite extensively in 
this area, studies have often not linked this to specific HIV-experiences that may arouse 
these problems. At best, stigma has been explored as a potential source of psychological 
distress in PLWHA. Nonetheless, findings from these studies provide important directions 
concerning key factors to adjust for, in seeking to investigate the relationship between 
forgiveness of specific HIV-related offenses and the outcomes of PHRQOL and change in 
CD4 cell count. The following section reviews the literature on forgiveness as an adaptive 
coping mechanism that may help to offset the negative impact of HIV-related 
unforgiveness, and contribute to the health of PLWHA.  
 
2.2.7 Forgiveness and Health Outcomes in HIV/AIDS: A Systematic Review 
 The three decades of empirical research in forgiveness has appropriately included 
this important population of public health interest – PLWHA. Yet, very few studies 
(Ironson et al., 2011; Owen et al., 2011; Wald & Temoshok, 2004a, b) have readily been 
identified in this area. Therefore, to ascertain the pattern of evidence for the forgiveness-
health link in HIV and AIDS, a systematic review was carried out by the researcher of the 
extant published literature on forgiveness specifically in PLWHA.  
Using the Medical Subject Headings (MeSH) search terms; “forgiv*” and 
“HIV/AIDS”, a search of the databases PsychINFO, MEDLINE, PsycARTICLES, and 
CINAHL Plus was conducted on February 3 2018. A total of 16 articles were retrieved 
from the four databases. A search of the PubMed database also conducted on February 3 
2018 using same search terms extracted a total of 9 articles. A further search of the Journal 
of the International AIDS Society (JIAS), the AIDS and Behaviour Journal, and the 
Abstract Archive of the International AIDS Society (AAIAS) was conducted on February 
7 2018. A total of 17, 33, and 14 papers respectively were retrieved. For all databases 
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searched, search periods were set to between 1985 (around which time empirical study of 
forgiveness begun; Worthington, 2005) and 2018, except for MEDLINE (unidentifiable 
search period option), JIAS (fixed to last 6months), and the AAIAS (fixed to 2001 and 
2016).  
Due to the relatively few papers retrieved from these databases, the scope of the 
search was extended to include other databases and sources. Using the same search terms, 
the African Journal Online and the African Index Medicus databases were searched on 
June 22 2018. No paper was retrieved. Hand searches of the reference sections of retrieved 
articles as well as online searches via Google Scholar citation tool were also conducted. 
Finally, hand searches of the three available handbooks on forgiveness – Handbook of 
Forgiveness (Worthington, 2005), Forgiveness and Health Handbook (Toussaint et al., 
2015), Handbook of the Psychology of Self-Forgiveness (Woodyatt et al., 2017) were 
conducted. Six (6) unique studies (non-duplicates with papers retrieved from the above 
searches) were retrieved from these additional searches.  
Overall, 95 papers were retrieved from these searches. The titles and abstracts of 
all papers were thoroughly appraised for their relevance to the review. The full texts 
(where available) of papers that showed relevance in the abstracts were appraised. All 
levels of appraisal were done in line with a set inclusion criteria. The flowchart in Figure 
3.0 details the number of papers excluded at these levels of the appraisal.  
 
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Figure 2.3: Flow chart of search strategy, appraisal, and extraction of retrieved papers  
(PPT: PowerPoint) 
 
 
 The illustration in Figure 3.0 indicates that following title and abstract appraisal, a 
total of 83 papers were excluded from the extracted 95 papers. No paper was excluded 
following full text appraisal. Papers were excluded if they were duplicate reports or 
participants were not PLWHA. Papers for which full texts could not be obtained and in 
which the abstracts provided insufficient information were also excluded. In line with a set 
inclusion criteria, papers were included in the review if the study assessed forgiveness as 
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an independent, dependent, or mechanism variable self-reported or as experienced by 
PLWHA. Studies were also included if participants were ≥15years old, and if forgiveness 
was specifically assessed/explored in relation to at least one health/treatment outcome 
(assessed by standard scales or as experienced by participants). Health/treatment outcomes 
included wellbeing factors (e.g., QOL, life satisfaction), clinical factors (e.g., recovery, 
physical/mental symptoms, CD4 count, viral load), and critical health-related factors (e.g., 
ART-adherence, social support, and stigma).  
The 12 papers included in the systematic review comprised 4 full text journal 
articles (Chandra et al., 2009; Ironson et al., 2011; Kaldjian, 1998; Martin et al., 2012), 2 
full text dissertations (Gates, 2012; Hua, 2012), 2 conference abstracts (Wald & 
Temoshok, 2004a; Wald & Temoshok, 2004b, in Temoshok & Wald, 2005), 2 dissertation 
abstracts (De La Cruz, 2009; Muhomba, 2008) and 2 power point slides (Owen et al., 
2011; Ridings et al., 2008), which were also conference presentations. Data from these 
studies was first collated into a spreadsheet (see APPENDIX K). The following sections 
review the included studies on forgiveness in PLWHA according to three broad themes; 
critical health-related factors, QOL, and physiological markers. These themes largely 
reflect the variables that forgiveness has been studied in relation to.  
 
Forgiveness and Critical Health-Related Factors in HIV/AIDS 
 Seven of the 12 papers included in the review assessed forgiveness in relation to at 
least one critical health-related psychosocial factor. These were stigma, depression, life 
stressors, satisfaction with health, religious involvement, unprotected sex, medication 
adherence, contraception use and prior resuscitation discussions.  
Muhomba (2008) investigated the relationship between trait forgiveness, 
HIV/AIDS-related stigma, and the state forgiveness process among 112 PLWHA in the 
US. Results of the cross-sectional survey showed that internal stigma, trait forgiveness, 
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and perceived family stigma predicted stage-one state forgiveness, with perceived family 
stigma emerging the strongest predictor of this stage of state forgiveness. The end stage of 
the state forgiveness process was also predicted by trait forgiveness, together with 
ethnicity and sexual orientation.  
In a randomized clinical trial to examine the effects of a forgiveness intervention 
on perceived HIV-related stigma of 57 PLWHA in the US, Hua (2012) found that at six 
months post-intervention, treatment group men reported significantly higher levels of 
dispositional- and self-forgiveness than control group men. Self-forgiveness prior to and 
six months after the intervention significantly accounted for 34% and 28% respectively of 
the variance in HIV-related stigma. Overall, while the forgiveness intervention did not 
significantly reduce HIV-related stigma, self-forgiveness was found to be better than 
forgiveness of others in predicting HIV-related stigma.  
Kaldjian (1998) conducted a study on the role of spiritual beliefs (including 
forgiveness) in end-of-life decisions of 90 hospitalized HIV+ patients. Of the 22 
participants who had had prior resuscitation discussions with their physician, these 
discussions were significantly more likely among those who believed in God’s forgiveness 
and less likely in those who perceived HIV as a punishment from God or in general. 
Furthermore, fear of death was more likely in those who perceived HIV as punishment or 
felt guilty about having HIV and less likely in those who read the Bible frequently or 
attended church regularly.  
The association between forgiveness and contraception use as well as desires to 
have another child was examined in a cross-sectional survey of 96 HIV+ women in the US 
(De La Cruz, 2009). Results of the survey showed that a forgiving disposition was 
significantly associated with various indicators of contraception use for preventing 
pregnancy.   
 
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Two studies have investigated the role of forgiveness in depression among 
PLWHA. Drawing on the traditional stress and coping model, Ridings et al. (2008) 
examined the direct relationship between forgiveness and levels of depression as well as 
the moderating effect of forgiveness on stigma-depression relationship in PLWHA. It 
emerged that higher levels of perceived stigma associated with higher levels of depression. 
However, higher levels of forgiveness associated with lower levels of both depression and 
HIV-related stigma. Forgiveness did not moderate the stigma-depression relationship, a 
finding the authors attributed to their rather small sample size (n=30).    
Wald and Temoshok (2004a) employed the Vignette Similarity Rating Method 
(Wald & Temoshok, 2004a, 2004b) to assess depression among other factors in relation to 
forgiveness across four contexts – self, others, God, and situations. Participants included 
131 HIV+ adults in a US cross-sectional survey. The results indicate that forgiveness 
correlated with fewer depressive symptoms, life stressors, and greater health satisfaction 
more strongly than religious involvement did. Forgiveness remained significantly 
associated after controlling for religious involvement. Perhaps more importantly, the study 
found that forgiveness related to patients' HIV-infection was associated with decreased 
unprotected sex (Wald & Temoshok, 2004a).  Furthermore, of the 91 participants who 
were on ART, feeling unforgiven by important others was associated with significantly 
more missed doses of medication in the previous week (Wald & Temoshok, 2004b). 
 
Forgiveness and Quality of Life in HIV/AIDS 
 Four of the 12 studies included in the systematic review reported findings on QOL. 
Chandra and colleagues (2009) assessed forgiveness as a dimension of QOL in a cross-
sectional survey study to validate the WHO QOL for people with HIV/AIDS-120 measure 
(WHOQOL-HIV 120). The results indicated that females scored significantly higher than 
males only on the forgiveness and blame facet and only on its corresponding religiosity 
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and personal beliefs domain. Compared to older and single women, younger and married 
women also reported higher scores on the forgiveness and blame facet of the WHOQOL-
HIV 120.  
The transactional model of stress and coping underpinned two QOL studies. First, 
Gates (2012) drew on the model to examine how dispositional forgiveness, maladaptive 
coping, and stigma interact to influence QOL. Findings of the cross-sectional correlational 
study indicated that maladaptive coping increased experience of stress-related stigma and 
reduced QOL. However, dispositional forgiveness was associated with lesser use of 
maladaptive coping, which was also associated with QOL.    
Martin and colleagues (2012) also applied the model to study attachment style and 
forgiveness on indicators of QOL in 228 HIV+ adults (72% on ART) in US. Attachment 
anxiety and avoidance, and forgiveness of self and others were related to physical health-
related QOL including pain experience. Among participants who reported attachment 
anxiety, forgiveness of self was associated with improved perceptions of health. Whereas, 
greater forgiveness of others (compared to lower forgiveness of others) was associated 
with more pain. According to the authors, when individuals high in attachment anxiety 
forgive others, they may continue to negatively re-appraise their interactions with 
offenders, due to their defective attachment style. 
The cross-sectional vignette survey of 131 HIV+ US adults (Wald & Temoshok, 
2004a) also assessed forgiveness in relation to QOL. Participants who rated themselves as 
more similar to forgiving vignette characters and less similar to unforgiving vignettes 
reported higher QOL. More importantly, the study found that the size of this association 
was larger than that between religious involvement and QOL. 
 
 
 
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Forgiveness and Immune Functioning Markers in HIV/AIDS 
Finally, two studies were found that determined the association between 
forgiveness and immune functioning markers (preserved or increasing CD4 cell count and 
reducing viral load levels) in PLWHA on ART. While it is admitted that the specific 
mechanisms linking forgiveness to immunological markers in HIV remains to be fully 
understood (Temoshok & Wald, 2005), first, it has been explained that forgiveness can 
increase motivations to engage in positive health behaviours such as adhering to the ART 
regimen (Temoshok & Wald, 2005). Increased adherence to ART typically results in viral 
suppression, which in turn increases the amount of viral-free CD4 cells. Another 
explanation is that there is a direct link between forgiveness via parasympathetic nervous 
system processes that act to counteract chronic sympathetic nervous system mechanisms 
(in response to unforgiveness as a source of prolonged stress) and immunity (Lavelock et 
al., 2015). This latter explanation draws from the broader stress literature that has largely 
found chronic psychological stress such as depression as a neuroimmuno-modulator, 
independent of sociodemographic, behavioural, and disease factors (e.g., Amanor-Boadu 
et al., 2016; Rehm & Konkle-Parker, 2017; Remor, Penedo, Shen, & Schneiderman, 2007; 
Jeon & Kim, 2016). For instance, it has been reported that during autonomic nervous 
system activation, neurotransmitters released by the sympathetic nerve endings (e.g., 
epinephrine) and parasympathetic nerve endings (e.g., acetylcholine) bind to their 
respective receptors on the surface of immune cells, initiating neuroimmune processes 
(Jeon & Kim, 2016). According to Jeon and Kim (2016), chronic arousal of the 
sympathetic nervous system without the normal counteraction by the parasympathetic 
nervous system can activate the immune system with increased levels of pro-inflammatory 
cytokines. Accordingly, studies in HIV have reported significant associations between 
chronic stress situations (e.g., perceived prolonged stress, anxiety, depression, worry, and 
hopelessness) and suppression of immune system markers including decreased CD4 count, 
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T cell proportions, Natural Killer cell count, and lymphocyte proliferation responses 
independent of ART adherence and other biopsychosocial control factors (Amanor-Boadu 
et al., 2016; Rehm & Konkle-Parker; Remor et al., 2007).  
In their study to determine the association between interpersonal forgiveness and 
CD4 cell percentage, Owen and colleagues (2011) found that among a sample of 65 adults 
with HIV/AIDS in the US, greater forgiveness was associated with higher CD4 cell 
percentages. The hierarchical linear regression model with 57 of the sample also revealed 
that forgiveness remained significantly associated with CD4 cell percentages when socio-
demographic factors (age, gender, education, race, and years since HIV+ diagnosis), 
health behaviours (medication adherence, and substance use), and viral load were 
controlled for.  
 Ironson and colleagues (2011) studied the association between scores on the view 
of God Inventory and the outcomes of CD4 count and viral load changes. Data were 
collected on a total of 101 HIV+ persons (80% on ART) in the US every 6 months for 4 
years. Results of the prospective longitudinal study showed that over the period of 4years, 
a positive view of God as forgiving/merciful/benevolent predicted slower disease 
progression. Whereas, a negative view of God as harsh/judgmental/punishing was 
associated with significantly greater loss of CD4 cells, and increases in viral load. These 
results were noted after adjusting for baseline (CD4, viral load, education, ethnicity, age, 
gender, and ART medications) and also, psychosocial factors (church attendance, ART 
adherence, sexual risk behaviour, substance use, mood, coping, and social support. 
Controlling for the psychosocial variables, significant and substantial effects similar to or 
greater than the effect sizes recorded for depression and coping –  two of the most 
predictive psychosocial variables of disease progression to date – were noted. 
 
 
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2.2.8 Summary and Critique of Forgiveness Studies in HIV/AIDS 
 In summary, the systematic review has revealed that so far, a number of variables, 
largely psychosocial, have been studied in relation to forgiveness in PLWHA. Overall, the 
studies reviewed suggest that first, forgiveness seems to play a positive role both in 
clinical (physiological) and patient-reported/behavioural outcomes.   
Secondly, the significant associations found between forgiveness and health 
outcomes in PLWHA lend support to the SCMF and the BPSFCF. Specifically, 
associations were found between forgiveness and variables such as ART adherence, sexual 
risk behaviours, social support, depression, stigma, and QOL (Chandra et al., 2009; Gates, 
2012; Martina et al., 2012; Muhomba, 2008; Ridings et al., 2008; Wald & Temoshok, 
2004a, 2004b). These seem to provide support for the indirect behavioural pathway 
theorized between forgiveness and health outcomes (Temoshok & Wald, 2005). On the 
other hand, the findings that forgiveness predicted preserved/higher CD4 cell count 
(Ironson et al., 2011; Owen et al., 2011) and lower viral load levels (Ironson et al., 2011) 
even after controlling for key behavioural and other psychosocial factors seem to support 
the theorized direct link between these variables via the stress response system (Temoshok 
& Wald, 2005).  
Thirdly, while some studies found that forgiveness moderated the relationship 
between stress-inducing phenomena (stigma and attachment anxiety) and health outcomes 
(Gates, 2012; Martina, 2012), others found no such mechanism effects (Ironson et al., 
2011; Ridings et al., 2009). These mixed findings may be pointing to the fact forgiveness 
is a highly complex and multidimensional coping strategy with a wide range of biological, 
psychological, and social antecedents and consequences (Riek & Mania, 2012). Thus, 
depending on the factors at play (e.g., state vs. trait forgiveness, self, other, or spiritual 
context), forgiveness may possibly have direct effects and/or indirect effects.   
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Ironson and colleagues (2011) reported a finding worth noting; the effect sizes of 
the relationship between negative view of God and both CD4 and viral load changes were 
larger compared to those of the relationship between a positive view of God and the 
outcomes. The stronger effects of the negative versus positive view of God relationship 
with CD4 and viral load seems to suggest that while forgiveness may promote positive 
health outcomes, holding grudge, anger, and other negative attitudes towards God may be 
more debilitating. Secondly, that a negative view of God in particular, proved a stronger 
predictor of CD4 and viral load over and above depression, religiosity, social support, 
ART adherence, sexual risk behaviours, etc. suggest that greater attention may need to be 
paid to the initial stages of the forgiveness process. This is the stage, where negative 
unforgiving responses to a perceived offence may be at its peak, possibly causing the most 
havoc to health. Thus, forgiveness interventions at this stage may better help PLWHA to 
experience reductions in any negative views and feelings they may have about their 
perceived offenders. Furthermore, this finding raises the question of whether a change 
from more negative to less negative or to positive responses may be more influential on 
health outcomes compared to a steady state of positive thoughts and emotions (Harris & 
Thoresen, 2005). In turn, it highlights the benefits of studying forgiveness as a staged 
process. Although, majority of the forgiveness studies in HIV/AIDS have focused largely 
on global dispositional forgiveness. 
The study by Muhomba (2008) was the only study that considered the differential 
impact of the initial and final stages of forgiveness. In support of the process models of 
forgiveness, different sets of predictors were found for each stage (Muhomba, 2008), 
lending support for the decisional forgiveness and emotional forgiveness stages. As 
emphasized by proponents of the process models, the intra-individual prosocial change 
toward a transgressor that ranges from letting go of the negative (decisional forgiveness) 
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to expressions of the positive (emotional forgiveness) is a foundational and undebated 
feature of forgiveness (Freedman et al., 2005; McCullough et al., 2000).  
All three major contexts of forgiveness – intrapersonal, interpersonal, and spiritual 
– have been explored across the forgiveness studies conducted so far in PLWHA. 
Although, this was not clarified in some studies (Chandra et al., 2009; De La Cruz, 2009; 
Muhomba, 2008). Of the four studies that assessed multiple contexts (e.g., Hua, 2012; 
Martin et al., 2012; Wald & Temoshok, 2004a, 2004b), the differential impact of context 
was not examined in three of these studies. Ironson and colleagues (2011) similarly 
reported a limitation to their study over its lack of answer to the question of whether a 
positive or negative view of God is a stronger predictor of disease progression. Perhaps 
instead of being limitations of these studies, analysis within, rather than across contexts, 
may be in line with some propositions that each context of forgiveness entails different 
processes and may have different impacts on health (Hoyt & McCullough, 2005; 
Toussaint & Worthington, 2017). However, Hua (2012) reported that self-forgiveness was 
better than forgiveness of others in predicting HIV-related stigma following a forgiveness 
intervention. This finding may be due to the reason that where comparable, forgiveness of 
others may be more complex to attain, as it may be dependent on a host of idiosyncratic 
motives of the victim about the offender, the offense, and the relationship between 
offender and victim (Hoyt & McCullough, 2005). Self-forgiveness especially within 
intrapersonal contexts, may be dependent more on victim-related factors such as 
personality traits and self-image (Hoyt & McCullough, 2005; Ironson et al., 2011). Thus, 
while self-forgiveness may not be any easier to achieve than forgiveness of others 
(Woodyatt et al., 2017), the dynamics involved may be less complex.   
 A number of methodological shortcomings were noted in the studies reviewed. 
About half of the studies did not report whether, or the percentage of participants on 
treatment. The studies that linked forgiveness to physiological outcomes utilized small 
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sample sizes (e.g., 30 in Ridings et al., 2008 and 57 in Owen et al., 2011). Ironson and 
colleagues’ study (2011) involved a fairly large sample of 101 HIV+ adults. It is not 
certain, the reasons for the small sample sizes. Although this could have accounted for 
some unexpected findings (e.g., Riding et al., 2008). The WHOQOL-HIV-120 and the 
Medical Outcomes Study QOL measure were common QOL measures used in some of the 
studies. While the WHOQOL-HIV-120 measure has been validated in PLWHA across 
cultures (Chandra et al., 2008), its long length (120 items) carries with it a potential 
burden on participants. This may especially be the case, where participants may have to 
complete other self-report measures. Also, none of the studies done so far in PLWHA has 
particularly considered how the typical cultural orientation of the study settings may have 
had bearings on the findings. Furthermore, with the exception of Ironson et al.’s (2011) 
prospective longitudinal design and the RCT by Hua (2012), the studies were 
predominantly cross-sectional. These may be because the scientific study of forgiveness is 
still relatively new. Therefore, in some populations, much of the available research may 
still be pioneering studies for which cross-sectional designs to first explore whether any 
relationships or effects exist, may be necessary. It is imperative that future studies, 
particularly among HIV/AIDS populations for which some evidence of the influence of 
forgiveness has been found, focus on building on this evidence via longitudinal and 
randomized controlled designs across cultures and for different stages and contexts of 
forgiveness.  
 Finally, it is readily noticeable that the extant evidence on the influence of 
forgiveness on HIV/AIDS health outcomes is hugely disproportionately centred in the 
West. Except for Chandra et al.’s (2009) study which was carried out in the largely 
collectivistic society of India, all 11 remaining studies were conducted in the US. This 
disproportion also implies that with the exception of Wald and Temoshok’s (2004a, 
2004b) vignettes, at present no measures of forgiveness may have been particularly 
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validated in PLWHA in non-Western societies. This has implications for future validation 
studies on forgiveness measures in non-Western societies.  
 
2.2.9 Gaps in Forgiveness in HIV/AIDS Studies  
 First and foremost, there exists a huge gap in knowledge of the potential influence 
of forgiveness on health outcomes among PLWHA in generally collectivistic societies 
including Ghana. As unearthed from the systematic review, at present no study has been 
identified to the researcher’s knowledge that has scientifically investigated forgiveness of 
the offenses that HIV-positive individuals in the region may typically experience. Whether 
a change in how PLWHA respond to perceived injustices would impact health outcomes 
has yet to be examined.   
 Secondly, research in the area seem not to have examined forgiveness as related to 
specific HIV-positive offenses experienced by PLWHA. The existing studies have largely 
based on typical offensive situations such as stigma. It is important to understand how 
forgiveness of actually experienced offenses may influence health outcomes for PLWHA.        
 Thirdly, not much is known about the relative influence on HIV/AIDS health 
outcomes of these two core stages/forms of the forgiveness process; decisional forgiveness 
and emotional forgiveness. In typically interdependent cultures like Ghana (Dzokoto, 
2010), it has been reported that people may experience and report more of decisions to 
forgive possibly due to values for maintaining interpersonal harmony and also the less 
attention paid to emotions (Dzokoto, 2010; Hook et al., 2009; Hook et al., 2012). Thus, it 
is important to examine differences between the potential greater decisions to forgive and 
emotional forgiveness in relation to health of PLWHA. Furthermore, in such generally 
interdependent cultures, it may be important to understand how self-forgiveness manifests 
(or does not) in relation to self-inflicted offenses experienced within these societies 
(Woodyatt et al., 2017).   
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 In addition, not much is known about the important factors that may influence the 
forgiveness–health link in PLWHA in generally collectivistic cultures. The evidence 
gathered in the West is inconclusive regarding the intervening mechanisms that may 
influence the forgiveness-health link. While studies have found quite strong associations 
between forgiveness and critical psychosocial factors (e.g., ART adherence, depression, 
sexual behaviours, social support; Wald & Temoshok, 2004a; 2004b), these have not had 
any interaction influence in the few studies that examined the forgiveness-health outcomes 
relationship (Ironson et al., 2011; Owen et al., 2011). As the studies that have examined 
these potential pathways and conditions have involved small sample sizes, replicating 
similar models among larger samples of PLWHA may help to clarify some of these 
inconsistencies in the HIV/AIDS literature.  
Finally, all the studies conducted to date on forgiveness in PLWHA, have solely 
utilized quantitative designs to examine this complex multidimensional phenomenon. 
Indeed, in seeking to replicate the evidence for the forgiveness-health relationship, it is 
imperative to first examine this association using a quantitative approach. However, for at 
least two core reasons, it is crucial to follow the quantitative investigation with an in-depth 
qualitative study on forgiveness from the perspectives of PLWHA in Ghana. First, 
considering that the measures adopted for the quantitative study have largely been 
developed from Western data, triangulation of any findings with narrative data on the 
lived experiences of forgiveness and health among PLWHA in Ghana is in order. 
Secondly, that this may well be the first forgiveness study among PLWHA in Ghana (and 
probably the whole region), a follow-up qualitative study may allow for data-driven 
themes that may provide deeper contextual enhancement to the survey findings. Therefore, 
the present study sought to address the aims and objectives of the study using a mixed 
method study design.  
 
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2.3 Rationale for the Present Study 
 The present study may be the first to contribute to our knowledge of how 
forgiveness as an adaptive coping mechanism may manifest in the health outcomes of 
PLWHA in Ghana and perhaps the wider region of Africa. At present, no evidence base on 
this potential association is available in Ghana nor the wider region, despite the region 
bearing a disproportionate burden of the global HIV/AIDS pandemic.   
Secondly, the study would add to the forgiveness literature on the relative 
importance of decisional and emotional forgiveness in PLWHA in Ghana’s typical 
collectivistic society. Similarly, findings of the study would provide more understanding 
of key behavioural factors that may interact with the potential forgiveness-health 
association.  
In addition, the study would help to address key methodological shortcomings in 
existing studies such as some samples not being on ART. Finally, it may contribute to 
improving treatment experiences for PLWHA in Ghana by informing culturally-sensitive 
forgiveness interventions. At present, PLWHA in the country receive counselling soon 
after a positive HIV diagnosis. However, this is largely focused on encouraging post-
diagnosis self-management behaviours particularly, adherence to ARVs and practice of 
protective behaviours. It appears that not much focus is placed on assessing and 
addressing psychological responses to the potential trauma of receiving a lifelong, highly 
stigmatized, and daily managed condition, coupled with the range of painful modes by 
which individuals may perceive to have acquired the condition.               
Overall, this research was carried out for its potential significant contributions to 
theory and knowledge, and for its possible implications for clinicians, counsellors, public 
health and health psychology practitioners, policy makers, and researchers.   
 
 
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2.4 Operational Definition of Terms 
Adherence: Not missing a single ART dose within the last 7days of completing the survey. 
AIDS: Acquired Immune Deficiency Syndrome is the end stage of HIV infection. 
ART: Antiretroviral therapy refers to the management of HIV/AIDS using antiretroviral 
drugs.  
ARV: Antiretrovirals (ARVs) are the medications/drugs used to treat HIV/AIDS infection. 
CD4 cells: The cluster of differenciation-4 cells are the immune cells attacked by the HIV 
virus when the virus enters the human body. The higher the CD4 count, the healthier the 
immune system. 
Change in CD4 cell count: Difference between first recorded CD4 count and CD4 count 
taken concurrently with forgiveness questionnaire completion at the time of study. 
Decisional forgiveness: Change in a person’s behavioural intentions toward an offender 
(e.g., deciding not to retaliate). 
Disease: An objective description of whether an individual is well or unwell via 
medical/clinical indicators such as CD4 cell levels and viral load levels.  
Emotional forgiveness: Eventual replacement of negative unforgiving emotions (e.g., 
bitterness and anger) with positive emotions (e.g., empathy) toward an offender.  
Forgiveness: forgiveness in this study is defined a freely made choice to forgo negative 
cognitive, emotional, and behavioural responses (e.g., anger, guilt, resentment) toward a 
person who caused a hurt, and work toward developing positive cognitive, emotional, and 
behavioural responses (e.g., empathy, benevolence) (Enright & Fitzgibbon, 2000; 
Toussaint et al., 2012). 
HIV: The human immunodeficiency virus is the virus that causes the HIV infection. 
Health: A complete state of physical, psychological, and social (including spiritual) 
wellbeing, not merely the absence of disease.  
Illness: An individual’s subjective perception of whether he/she is well or unwell. 
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Interpersonal forgiveness: forgiveness of another person who has caused an offense.  
Intrapersonal forgiveness: forgiveness of one’s own self for a perceived self-inflicted 
offense. 
Negative attitudes toward God: These constitute views of God such unkind, due to an 
offense perceived to be a result of the will, permission, or punishment of God. 
Perceived offense: an individual’s consideration of a behaviour as a wrong doing or 
injustice whether perpetrated by self or others and for which the individual feels negative 
painful thoughts, emotions, and behaviour motivations.  
Positive attitudes toward God: These constitute views of God such as caring, regardless of 
an offense perceived to be a result of the will, permission, or punishment of God 
Psychological distress: signs of depression and anxiety indicated by low scores on the 
Kessler Psychological Distress Scale. 
Psychological health-related quality of life: Individuals’ perception of their psychological 
wellbeing as indicated by scores on the psychological health domain of the WHOQOL-
BREF. 
QOL: Individuals’ perception of their wellbeing largely across four life domains – 
physical health, psychological health, social relationships, and their environment.  
Sexual behaviours: Behaviours including multiple sexual partners, condom use, and anal 
sex.  
Spiritual forgiveness context: In this study, positive attitudes toward God constitutes 
forgiveness in the spiritual context. 
Unforgiveness: The delayed negative thoughts, emotions, and behaviours (e.g., retaliatory 
thoughts, hatred, avoidance) experienced toward an offender in response to an offense 
he/she is perceived to have caused.  
 
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CHAPTER THREE 
GENERAL METHODOLOGY 
3.0 Introduction 
 This section of the thesis outlines the strategy or plan of action that lies behind the 
selection and use of the methods that were adopted to collect, analyse, and interpret the 
data for this study. It begins with a brief overview of the philosophical underpinnings of 
the mixed methods approach to this study, narrowing in on the rationale for an explanatory 
mixed methods design. This is followed by a description of the research settings used in 
the study. The chapter closes by highlighting the ethical principles duly considered in 
carrying out this study. 
 
3.1 Research Approaches: A Brief Overview of Philosophical Assumptions 
 A research approach concerns the plans, procedures, and underlying assumptions 
that guide a piece of research through the formulation of the research problem to the 
detailed methods utilized in collecting, analysing, and interpreting data (Creswell, 2014). 
For many decades now, philosophical assumptions about the nature of being or reality 
(ontology) and about how we know what we know and whether what we know is 
trustworthy (epistemology), have guided which research approaches and methods 
researchers have employed in seeking answers to formulated questions. Traditionally, 
researchers have worked either within the quantitative or qualitative research approach as 
two distinct paradigms with incommensurable sets of beliefs and dictates about how social 
reality should be studied (Bryman, 2012).  
 Researchers with worldviews of absolute knowledge and a single reality that can 
be studied objectively and independently of the researcher may align their research 
processes within the positivist scientific paradigm. Accordingly, they may seek to 
establish relationships and/or causality through correlational and experimental 
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methodologies consistent with the quantitative approach (Bryman, 2012; Creswell, 2014). 
On the other hand, researchers may be of the view that reality is subjectively constructed 
and thus multiple, acknowledging the unique experiences of individuals and groups of 
people within a range of contextual factors (e.g., race, gender, politics, culture, historical 
background). Researchers identifying with this worldview may adopt the 
interpretive/relative and/or critical paradigms of the qualitative approach (Bryman, 2012; 
Creswell, 2014). These paradigms include critical constructivism, hermeneutics, feminism, 
and phenomenology. Typical methodological approaches here may include exploring and 
interpreting meanings via interviews, written narratives, participant observations, etc., 
while acknowledging researchers’ own backgrounds as likely influences on the 
interpretation of participants’ meanings of social phenomena.  
 Bryman (2012) has noted that these seemingly parallel paradigmatic approaches 
may suggest that research designs that combine methodologies across both approaches are 
impossible. However, beyond the fact these two approaches each has strengths and 
weaknesses that may be complementary to the other, researchers may actually hold both 
worldviews depending on the nature, aims, and focus of a specific research problem they 
may seek to investigate (Bryman, 2012; Creswell, 2014). Thus, the mixing of methods is 
not only a possible approach, but one recognized over the years as another major research 
approach within the social sciences (Bilinski, Duggleby, Rennie, & 2013; Bryman, 2012; 
Creswell, 2014). 
 
3.1.1 The Mixed Method Approach: Philosophical Underpinnings of the Study 
 The mixed method is an approach to research, where elements of both quantitative 
and qualitative approaches are combined to address different components of a research 
problem. Specifically, Creswell (2014) defines mixed method research as an approach to 
inquiry that involves collecting both quantitative and qualitative data, integrating the two 
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forms of data, and using distinct designs, each of which may involve philosophical 
assumptions and theoretical frameworks.  This approach therefore bothers on a family of 
paradigms within the quantitative-qualitative continuum (e.g., post-modernism, critical 
realism, and pragmatism), with a primary assumption being that either approach in 
isolation is insufficient to unearth comprehensive understanding of the research problem in 
question (Bilinski et al., 2013; Creswell, 2014; Creswell & Plano Clark, 2007).  
The ontological position of the researcher in light of the present study is that first 
of all, HIV/AIDS is a health phenomenon that exists, and which is associated with 
consequences for one’s health outcomes independent of subjective perceptions about the 
disease and its effects. Secondly, the researcher is of the view that notwithstanding its 
objective existence and potential impact, the extent of impact that HIV/AIDS may have on 
health outcomes may be influenced by individuals’ subjective experiences related to the 
infection and its treatment. These include their illness beliefs (e.g., how they contracted 
HIV), treatment beliefs (e.g., whether ARVs are safe), self-management behaviours 
(adherence to ART), and the cultural experiences that shape their perceptions of offenses, 
forgiveness, unforgiveness, health, and wellbeing. Accordingly, the researcher is of the 
epistemological views that first, correlational and other inferential analyses of closed-
ended data from a sample of PLWHA are required to obtain knowledge of the influence of 
forgiveness of HIV-specific offenses on health outcomes. Secondly, to understand the 
possible influence of subjective experiences of HIV/AIDS on the forgiveness-health 
association, it is important to explore and interpret interview data on how PLWHA in 
Ghana experience and make meaning of forgiveness and health.  
 These philosophical positions tie in particularly with the pragmatic worldviews, 
which emphasize on the research problem and what works to provide the best 
understanding of the problem (Creswell, 2014). Thus, rather than being committed to any 
one philosophical stance, pragmatism draws on pluralistic methods, techniques, and 
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procedures across the quantitative-qualitative continuum in support of the mixed method 
research approach (Bilinski et al., 2013; Cameron, 2011; Creswell, 2014).  
 
3.2 Research Design: Explanatory Sequential Mixed Methods Design 
The present study employed the explanatory sequential mixed methods design. It is 
characterized by the collection and analysis of quantitative data (Study 1) followed by the 
collection and analysis of qualitative data (Study 2). Data from the two stages are then 
integrated using findings from the qualitative study mainly to explain that from the 
quantitative study. In the present study, the quantitative phase involved collection of cross-
sectional survey data to explore the forgiveness-health relationship. The subsequent phase 
involved collection of phenomenological interview data to understand how PLWHA 
experienced and made meaning of forgiveness as pertaining to various aspects of their 
lives. Findings from the two phases were then integrated. 
This design was adopted because the main aim of the present study was to 
ascertain the association between forgiveness of HIV-specific offenses and the outcomes 
of PHRQOL and immune markers. Thus, the quantitative method was appropriately 
adopted as the primary and weightier method of inquiry (indicated by the uppercase 
letters, “QUANT”). The complementary qualitative method (indicated by the lowercase 
letters, “qual”) aided the ability of the study to meet its overall aims. Namely, to 
understand any forgiveness-health associations that were uncovered in Study 1 from the 
lived perspective of PLWHA in Ghana’s generally collectivistic cultural societies. Thus, it 
best suited the central aim of the study as a follow up to the primary quantitative method 
to help triangulate, enhance, and most of all, provide cultural contextual explains and 
illustrations of the quantitative findings. 
 
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Figure 4.0 graphically illustrates the explanatory sequential mixed method design 
employed in the present study. The figure indicates that following completion of Study 1 
and Study 2 respectively, findings from the two studies were integrated in a number of 
ways. According to Bryman (2012), quantitative and qualitative research can be combined 
in at least sixteen different ways depending on the purpose for which a mixed methods 
study is undertaken. The present study integrated the two datasets in five main ways: 
sampling, triangulation, illustration, enhancement, and most importantly, explanation. 
 
Figure 3.1: Research process for the two-phase study design adapted from Bilinski et 
al., 2013 
 
In terms of sampling, the study first connected the two sources of data by 
purposefully selecting participants for the qualitative study according to the age categories 
identified in the quantitative survey. Triangulation involved comparing findings from both 
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stages to identify points of convergence and divergence. The qualitative study was also 
used to illustrate – situate the quantitative findings within a cultural context – or as 
described by Bryman (2012), to put flesh on the bones of the dry survey findings. The 
complementary data further helped to augment, build on, or make more sense of the 
survey findings in general, i.e. to enhance the quantitative study. Finally, evidence 
gathered from the qualitative study was drawn on to help explain the nature and directions 
of the associations identified in the survey study.  
 
3.3 Research Setting  
 The study was conducted across the three largest teaching hospitals in Ghana – 
Korle-Bu Teaching Hospital (KBTH), Komfo Anokye Teaching Hospital (KATH), and 
Tamale Teaching Hospital (TTH). These are respectively located in the capital cities of the 
Greater Accra region, Ashanti region, and the Northern region. Thus, although there may 
be some differences across these regions (e.g., slightly more Islamic religion in Tamale), 
they are particularly similar in their diversity of local languages and subcultures as the 
capital cities of their respective regions. At each of these hospitals, there is a unit 
dedicated to the care of PLWHA (KBTH) or to people with sexually transmitted infections 
in general (KATH and TTH). For ethical reasons, the names of the specific units are 
withheld. There is also a more enclosed waiting room at each of these settings, where 
patients who may not be particularly comfortable waiting at the usual out-patient areas 
may wait till their turn is up to be seen by the healthcare personnel.  
 Reports indicate that although HIV/AIDS services have been decentralized across 
district hospitals and clinics in the country, the majority of HIV/AIDS cases are seen in the 
three selected teaching hospitals. This may be because the teaching hospitals expectedly 
have larger diagnostic, treatment, and logistic facilities. However, other reports suggest 
that many HIV-positive individuals in Ghana prefer to be treated at the teaching hospitals, 
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which are not only larger, but may be located farther away from their areas of residence. 
Perhaps, this may be to avoid the possibility and risk of being easily identified by known 
others, who may also be visiting the local hospitals. Thus, these hospitals were selected as 
the settings for this study because of the possible access to PLWHA with diverse 
biographic, psychological, and social (including religious and cultural) backgrounds.  
 
3.4 Ethical Considerations  
 The study protocol for the two-phase study was first reviewed by recognized 
research ethics institutions; Ethics Committee for Humanities of the University of Ghana 
and the Research and Development Units of all three teaching hospitals and the 37-
Millitary hospital. All participants were informed about the voluntary nature of and 
procedures involved in the study. Written informed consent to voluntarily participate in 
the study were obtained from participants prior to their enrolment in the study.  At the 
quantitative phase of the study, confidentiality of responses and participants’ identity were 
ensured by first of all not indicating any personally identifiable information such as names 
on the questionnaires. For participants who consented to follow-up and as such had their 
telephone numbers written at the back of the questionnaires, data confidentiality and 
identity protection were ensured by the researcher by securely storing the questionnaires in 
a safe place away from the reach of any third parties. Again, to protect participants’ 
identity, majority of the data collection personnel were healthcare professionals already 
working with participants. The few non-healthcare personnel signed an undertaken to not 
disclose participants’ identity under any given circumstance.  
 It was proposed in the protocol that confidentiality and privacy of interview data 
and participants will be ensured by excluding any participant that the researcher may 
happen to know outside of the present study. However, no such situation was encountered 
by the researcher, who conducted all the interviews across the three teaching hospitals. 
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Although, the interview session was cancelled for one participant at the Tamale Teaching 
Hospital. This was because the participant appeared extremely emotional while sharing 
her views on the opening questions, shedding tears a few minutes into the interview. The 
researcher thought it wise to cancel the interview and offered to connect her to a clinical 
psychologist. However, she insisted that she did not need to see the psychologist. The 
researcher nonetheless reminded the participant that she could contact her in case she later 
decided to see the clinical psychologist. The participant was informed that such services 
were highly confidential and would come at no cost to her.   
 Both the survey and interview participants were informed that they could withdraw 
from the study at any time and for any reason without any penalty whatsoever to them. 
They were also given the option of omitting questions they were uncomfortable 
answering. Participants were rewarded for their time in completing the survey measures 
and in participating in the interviews. The risks for participating in this study were no 
greater than the risks associated with daily living. However, participants were advised to 
contact the investigator for the appropriate support in the event that they experience any 
distress related to participating in this study. The findings and implications of the study 
will be communicated with the heads of the Research and HIV/AIDS units of the 
participating hospitals. Any necessary HIV/AIDS care-promoting actions may then be 
followed up by the institutions. This is to further give back to participants for availing 
themselves for the study. 
 
 
 
 
 
 
 
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CHAPTER FOUR 
METHODOLOGY AND RESULTS FOR STUDY ONE 
STUDY 1: ASSOCIATION BETWEEN FORGIVENESS, PSYCHOLOGICAL 
HEALTH-RELATED QUALITY OF LIFE, AND IMMUNE FUNCTIONING IN 
PEOPLE LIVING WITH HIV/AIDS IN GHANA 
 
4.0 Introduction 
 This section of the thesis presents details of the methodology and findings of Study 
1, titled; “Association between forgiveness, psychological health-related quality of life, 
and immune functioning in people living with HIV/AIDS in Ghana”. It also presents a 
summary and brief discussion of the findings.  
 
4.1 Research Questions  
Four main research questions were explored: 
1. What are the differences in scores between decisional and emotional forgiveness 
and between positive and negative attitudes toward God?  
2. What is the relationship between forgiveness (intrapersonal, interpersonal, and 
spiritual) and the outcomes of psychological health-related quality of life 
(PHRQOL) and change in CD4 cell count in PLWHA in Ghana? 
3. How do these key psychosocial factors – ART adherence and sexual risk 
behaviours – influence the relationships in question 2?  
4. What is the relative importance of the forms/stages of each context of forgiveness 
in predicting PHRQOL and change in CD4 when related socio-demographic, 
clinical, and psychosocial factors are controlled for? Specifically, question four 
seeks to investigate: 
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a) What is the relative importance of decisional forgiveness of self and emotional 
forgiveness of self in predicting PHRQOL and change in CD4 count, 
accounting for related control factors?  
b) What is the relative importance of decisional forgiveness of others and 
emotional forgiveness of others, in predicting PHRQOL and change in CD4 
count, accounting for related control factors? 
c) What is the relative importance of positive attitudes towards God and negative 
attitudes towards God in predicting PHRQOL and change in CD4 count, 
accounting for related control factors? 
The sociodemographic, clinical, and psychosocial factors that were controlled for 
(depending on whether they significantly correlated with forgiveness and/or the outcomes) 
included age, gender, educational level, marital status, ART regimen, social support, 
psychological distress, health behaviours, religiosity, and initial CD4 count in the case of 
PHRQOL. 
 
4.2 Research Hypotheses  
 Drawing on the conceptual models underpinning the present study and the 
empirical literature reviewed, the following hypotheses were formulated and tested to 
answer the core research questions of Study 1: 
 
Hypothesis 1: It is hypothesized that participants would report greater decisions to forgive 
self and others than emotional forgiveness of self and others based on some propositions 
and findings by Hook and colleagues (2009; 2012) and also Dzokoto (2010). It is also 
hypothesized that greater positive attitudes towards God than negative attitudes towards 
God would be reported, based on reports that Ghanaians are particularly religious 
(Anderson, 2013).  
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Hypothesis 2: Forgiveness would significantly predict each of the two outcomes: 
a. Intrapersonal forgiveness (decision to forgive self and emotional forgiveness of 
self) would significantly positively predict PHRQOL and change in CD4 count. 
b. Interpersonal forgiveness (decision to forgive other and emotional forgiveness of 
other) would significantly positively predict PHRQOL and change in CD4 count. 
c. Spiritual forgiveness (positive attitudes toward God and negative attitudes toward 
God) would significantly predict PHRQOL and change in CD4 count positively 
and negatively respectively.  
 
Hypothesis 3: Health behaviours (Adherence to ART, number of sexual partners, and 
frequency of condom use) will each have a significant moderating effect on the 
relationship between: 
a. Intrapersonal forgiveness and each of the outcomes of PHRQOL and CD4 cell 
count 
b. Interpersonal forgiveness and each of the outcomes of PHRQOL an CD4 cell count 
c. Spiritual forgiveness and each of the outcomes of PHRQOL and CD4 
d. The strength of the moderation effect will be strongest for ART adherence in all 
cases. 
 
Hypothesis 4: In line with the studies by Ironson et al. (2011) and Owen et al. (2011), it is 
hypothesized that intrapersonal, interpersonal, & spiritual contexts of forgiveness will 
significantly predict PHRQOL & ∆CD4 count controlling for key biopsychosocial factors. 
Specifically, adjusting for related control factors,  
a. Intrapersonal forgiveness would remain a significant positive predictor of 
PHRQOL and change in CD4 count, with decision to forgive self, accounting for a 
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greater proportion of the variance in the outcomes than emotional forgiveness of 
self. 
b. Interpersonal forgiveness would remain a significant positive predictor of 
PHRQOL and change in CD4 count, with decision to forgive others accounting for 
a greater proportion of the variance in the outcomes than emotional forgiveness of 
others. 
c. Spiritual forgiveness would remain a significant predictor of PHRQOL and change 
in CD4 count, with positive attitudes toward God positively accounting for a 
greater proportion of the variance in the outcomes than negative attitudes toward 
God. 
 
4.3 Conceptual Framework Depicting the Hypothesized Model of the Study 
Variables 
 Figure 4.1 depicts the hypothesized model of the relationships between decisional 
forgiveness, emotional forgiveness, attitudes towards God, PHRQOL and change in CD4 
cell count, taking key biopsychosocial control factors into account. The model indicates 
that across all three contexts (self, other, spiritual), a total of 6 predictors/independent 
variables (A) and a total of two outcomes/dependent variables (C) were investigated. Each 
of the moderator variables (B) was expected to influence the conditions under which the 
predictors may have associated with the outcomes. They could strengthen, weaken, or 
reverse the respective IV-DV relationships. As an example, it was expected that adherence 
to the ART regimen would enhance the predicted associations between each of the IVs 
and each of the DVs. That means, increasing adherence would increase the strength (or 
effect size) of the respective associations. Whereas, it was anticipated that there would be 
a buffering interaction effect of sexual risk behaviours on the predicted associations. That 
is, higher sexual risk behaviours would decrease the effect or strength of association of the 
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IVs with the DVs. Finally, the model indicates that a number of sociodemographic, 
clinical, and psychosocial covariates (D) may influence the predictor and/or outcome 
variables.  
 
 
Figure 4.1: Conceptual framework of the association between forgiveness, 
psychological health-related quality of life, and immune function marker.  
 
A: Predictors. B: Moderators. C: Outcomes. D: Control variables. 1To be controlled only 
in PHRQOL analyses. 2To be controlled in CD4 cell count analyses. 
 
4.4 Study Design – Cross-Sectional Survey Design 
 Study 1 employed a cross-sectional survey design, which involves measuring both 
the outcomes and attributes/exposures of a phenomenon in a sample of a population at the 
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same time (Setia, 2016). This design allows for descriptive, correlational, and predictive 
inferences to be drawn from existing differences among participants in relation to the 
study phenomenon (Creswell, 2014; Rovai, Baker, & Ponton, 2014; Setia, 2016). Thus, 
participants are often purposely (rather than randomly) selected based on the inclusion and 
exclusion criteria set for the study (Rovai et al., 2014; Setia, 2016). Although they do not 
establish cause and effect relationships, cross-sectional survey designs can be used to 
collect data from a large number of participants across geographic areas, allowing for 
cross-cultural comparisons of a phenomenon and snapshots of the target population (Setia, 
2016). Thus, this study employed a cross-sectional survey design because it sought to 
examine differences in the outcomes of PHRQOL and CD4 cell counts as a result of 
possible differences in levels of forgiveness among a purposive sample of PLWHA, who 
have ever experienced an offence directly due to their HIV-positive diagnosis. Participants 
were also selected and examined from across three regions in Ghana at approximately the 
same time.   
 
4.4.1 Study Population – People Living with HIV/AIDS 
 People living with HIV/AIDS (PLWHA) receiving ART treatment in Ghana 
constituted the target population for the present study. Since the Korle-Bu, Komfo 
Anokye, and Tamale Teaching Hospitals make up the three largest teaching hospitals in 
Ghana, and treat PLWHA from across the country rather than just within the regions in 
which they are located, participants were selected from the population of PLWHA 
receiving ART from these hospitals.  
 
4.4.2 Sampling Strategy – Maximum Variation Purposive Sampling Technique 
 Participants included in this study needed to possess some unique characteristics 
and experiences to be eligible to participate in the study. These were offenses/injustices 
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they have experienced as a result of their HIV-positive status. Thus, a purposive non-
probability sampling technique was used to select participants based on a set of inclusion 
criteria (Setia, 2016). Purposive sampling is the deliberate choosing of participants on the 
basis of a researcher’s knowledge/judgment of the characteristics of the participants as 
relevant to the purpose of the study (Etikan, Musa, & Alkassim, 2016; Rovai et al., 2014). 
It involves a decision by the researcher about what needs to be known concerning a 
phenomenon, who has the knowledge or experience about it, and who, in addition to the 
knowledge or experience, is available and willing to proficiently provide information 
about the phenomenon (Etikan et al., 2016).  
 Although this technique is limited in terms of generalizations to the whole 
population (Etikan et al., 2016; Rovia et al., 2014), adopting a random sample for this 
study would have made generalizations about the sample difficult. Not all participants may 
have for example, experienced an offense as a result of their HIV-positive status. 
Purposive sampling makes such generalizations to the study sample possible. Also, it 
allows researchers to appropriately target limited resources and workforce at the 
“information-rich cases” (Etikan et al., 2016, p. 2). This was the situation in the present 
study in which both survey and clinical (CD4) data from a large cross-cultural sample was 
collected with limited workforce. Considering that participants in the study differed in age, 
gender, religion, and other socio-demographic variables capable of varying perspectives 
on forgiveness, the sampling technique employed was specifically a maximum variation 
(heterogeneous) purposive sampling method (Etkan et al., 2016).  
 
4.4.3 Inclusion and Exclusion Criteria 
 Setia and Panda (2017) have highlighted that the inclusion and exclusion criteria of 
any research study are mutually exclusive, rather than negative images of the other. Thus, 
while some PLWHA were included in the study for meeting the eligibility criteria, those 
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who met the exclusion criteria were excluded. To be eligible to participate in the present 
study, PLWHA receiving treatment from any of the three research settings met the 
following inclusion criteria. Potential participants who met the exclusion criteria were 
excluded. 
 
Inclusion criteria: 
 People living with HIV/AIDS aged 18years and above 
 Have received ART for at least 12 months prior to the study start date  
 Agree to have clinical data (e.g., ART regimen) collected from their folders 
 Agree, where possible, to undertake (free) CD4 count concurrently with survey 
completion. 
Exclusion Criteria 
 Patients with HIV/AIDS on admission   
 People living with HIV/AIDS with apparent impairments in cognition. 
 Outpatients with severe physical symptoms including TB 
 
4.4.4 Sample Size – Three-Hundred and Twenty-Five People Living with HIV/AIDS 
  The sample size of a study, much like the sampling strategy, is one of the most 
fundamental elements of any research design (Setia & Panda, 2017). Based on the 2016 
estimated number of PWLHA receiving ART in Ghana, and using an electronic sample 
size estimator software (G-Power), the study estimated that 380 PLWHA were needed to 
be included in the study to achieve a medium effect size. A total of 325 PLWHA from 
across the three teaching hospitals participated in the present study, reflecting 86% 
response rate. Of these, 94 were receiving treatment at the Korle-Bu Teaching Hospital, 
105 at the Tamale Teaching Hospital, and 126 at the Komfo Anokye Teaching Hospital. 
 
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4.4.5 Survey Instruments  
 The present study measured a total of 7 independent variables, 2 outcome 
variables, 2 moderating variables, 7 socio-demographic control variables, and 3 clinical 
control variables. Decision to forgive-self, emotional forgiveness-self, Decision to forgive-
other, Emotional forgiveness-other, positive attitudes toward God, and negative attitudes 
toward God constituted the independent variables. The outcome variables included QOL 
(physical health-related QOL and mental health-related QOL) and CD4-cell count. The 
potential intervening variables were ART adherence and sexual behaviours. The socio-
demographic control variables included age, ethnicity, gender, marital status, educational 
status, religiosity/spirituality, and self-construal. Date diagnosed with HIV, time on ART, 
ART regimen, and comorbidity (as well as CD4 for QOL analyses) were the clinical 
control variables. The following instruments were utilized to measure the key variables in 
the study. 
 
Sociodemographic and Clinical Questionnaire: A sociodemographic and clinical 
questionnaire was developed to assess these variables: age, gender, marital status, highest 
education, ethnicity, comorbidities, ART regimen, and CD4 cell count results not more 
than three months old from date of questionnaire administration.  
 
Decision to Forgive (Other): The decision to forgive (other) scale (Davis, Hook, Van 
Tongeren, DeBlaere, Rice, & Worthington, 2015) is a six-item measure that evaluates 
interpersonal forgiveness of a specific offense. Participants rate their agreement with each 
of the items on a 5-point rating scale ranging from 1 = strongly disagree to 5 = strongly 
agree. Higher scores reflect higher decisions to forgive an interpersonal offender. Four 
items directly ask participants if they have forgiven the offender (e.g., I have decided to 
forgive him or her). Two items indirectly ask about decision to release negative emotions 
experienced towards the offender (e.g., I have chosen not to intentionally harbor 
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resentment towards him or her). In line with the definition of forgiveness adopted in this 
study, two items were added by the researcher to indirectly assess forgiveness in terms of 
forgoing negative thoughts (My choice is to release any negative ideas or thoughts I have 
about him or her) and behaviours (I have decided not to take revenge against him or her). 
Thus, the adapted 8-item measure was used to assess participants’ decision to forgive 
others (DTFO). Three studies that examined the psychometric properties of the 6-item 
DTF scale found that scores on the scale showed evidence of reliability, with Cronbach's 
alpha coefficients ranging from .92 to .94, and a 1-week temporal stability coefficient of 
.68 (Davies et al., 2015). Cronbach’s alpha coefficient and exploratory factor analysis 
were assessed for this adapted 8-item DTFO scale. Results of the reliability analysis and 
the factor structure of this scale are reported under the results section of this Chapter.   
 
Decision to Forgive (Self): The decision to forgive (self) scale was adapted from the 8-
item DTFO scale to assess decision to forgive one’s self by replacing “him or her” with 
myself (e.g., I have decided to forgive myself; I have decided not to do anything bad to 
myself; My choice is to release any negative ideas or thoughts I have about myself).  
Participants rate their agreement with each of the items on a 5-point rating scale ranging 
from 1 = strongly disagree to 5 = strongly agree. Higher scores reflect higher decisions to 
forgive an interpersonal offender.  
 
Emotional Forgiveness (Other): The EF (other) scale (Worthington et al., 2007) is an 8-
item scale that assess participants’ emotions towards an offender due to a specific 
interpersonal offense (e.g., I feel love toward him or her; I no longer feel upset when I 
think of him or her). Participants rate their agreement with each of the items on a 5-point 
rating scale ranging from 1 = strongly disagree to 5 = strongly agree. Higher scores reflect 
higher emotional forgiveness. Cronbach’s alpha reliability coefficients have ranged from 
.78 to .81. (Worthinhgton et al., 2007). In a cross-cultural comparison study in China (as a 
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typical collectivistic society) and New Zealand (as a typical individualistic society), Hook 
et al. (2010) found internal consistency reliability to be .61 in China and .83 in New 
Zealand. 
 
Emotional Forgiveness (Self): The 8-item EFO scale was adapted to assess emotional 
forgiveness of self (e.g., I feel love toward myself; I no longer feel upset when I think of 
what I did in the situation). Cronbach’s coefficient and exploratory factor analysis were 
assessed for this 8-item adapted EFS-self and results reported in detail under the results 
section. 
 
Attitudes towards God Scale: The Attitudes toward God scale (Wood et al., 2010) is a 
two-factor 9-item scale. A 5-item factor assesses Positive Attitudes toward God (e.g., I 
feel supported by God). The second four-item factor, referred to as negative attitudes 
toward God (NATG) in this study, assesses Disappointment and Anger with God (e.g., I 
feel angry at God). On each factor, participants rate their responses on a scale of 0 (Not at 
all) to 10 (Extremely), the extent to which they currently experience these attitudes. 
Cronbach’s alpha of .64 to .93 have been reported across six studies (Wood et al., 2010).  
Religious Background and Behaviour Questionnaire: Participants’ religiosity/spirituality 
was measured using the Religious Background and Behaviour Questionnaire (RBBQ). It is 
a 13-item measure developed by Connors and Miller (1993). It consists of one item – 
which of the following best describes you at the present time – that assesses the 
religious/spiritual background/affiliation of participants. The remaining 12 items make up 
two subscales. The God consciousness subscale comprise 6 items that assess how often 
participants have engaged in 6 spiritual/religious behaviours (e.g., thought about God, 
prayed, meditated) in the last one year. Items are scored on an 8-point (0 – 7) Likert scale. 
The remaining 6 items measure whether or not participants currently engage in the 6 
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behaviours on a 3-point (0 – 2) Likert scale. A Cronbach alpha of .82 has been reported on 
the RBBQ (Connors & Miller, 1993).  
 
World Health Organization Quality of Life-BREF: The WHOQOL-BREF (WHO, 1996; 
2012) assesses individuals’ perceptions of their quality of life (QOL). It comprises 26 
items; two single items that measure overall satisfaction with QOL and general health and 
four domains. The four domains measure physical health (7 items, e.g., do you have 
enough energy for everyday life?); psychological health (6 items, e.g., how well are you 
able to concentrate); social relationships (3 items, e.g., how satisfied are you with your 
personal relationships?); and environment (8 items, e.g., how healthy is your physical 
environment?). Responses on each domain are scored on a five-point Likert scale 
following reversal of items 3, 4, and 26. Scores are transformed to a 0 to 100 range 
through summation and calculation of mean scores for each domain in line with the 
WHOQOL-Bref transformation table (WHO, 1996).  A higher total score reflects higher 
QOL across domains. Studies conducted among chronic illness populations including 
those in Ghana, have reported Cronbach alpha scores between 0.81 (Ganu, Boima, Adjei, 
Yendork, Dey, Yorke, et al., 2018) and 0.92 (Skevington & McCrate, 2012) on the 26-
item scale. 
 
Kessler Psychological Distress Scale:The 10-item KPDS measures global psychological 
distress (comprising depression and anxiety symptoms) including significant pathology 
which does not meet formal criteria for a psychiatric illness. It measures symptoms over 
the last 30 days (e.g., in the last 30 days how often did you feel nervous?) Responses are 
rated on a five-point Likert scale ranging from 1 (none of the time) to 5 (all of the time). In 
a study to assess the prevalence and predictors of psychological distress among a sample 
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of patients with tuberculosis, 60% of whom were co-infected with HIV, Cronbach alpha 
was reported to be .92. (Peltzer et al., 2012).  
 
Perceived Social Support-HIV: The PSS-HIV scale (Cortes, Hunt, & McHale, 2014) 
measures the perception of supportive social interaction of PLWHA. It Consists of 12 
items with three subscales; Belonging (e.g., I feel emotionally sheltered by my family), 
Esteem (I can freely express my opinion to my partner or group of friends), and Self-
Development (I think that my friends give me possibility for growth). Responses are rated 
on a five-point Likert scale with higher scores reflecting higher perceived social support. 
Cronbach alpha on the overall scale was reported to be .89 (Cortes et al., 2014).  
 
Adherence Behaviour: Adherence was measured with the single question: “In the last 
seven days, how many times did you miss your HIV medications” (Obirikorang et al., 
2013; Olowookere et al., 2016). 
 
Sexual Risk Behaviours: The Sexual Behaviours subscale of the HIV Risk Behaviour 
Scale (Petry, 2001) was employed to assess sexual risk behaviours in this study. It 
comprises of five items that measure multiple sexual partners behaviour, condom use 
behaviours, and anal sex behaviour within a specified time period (in this study, since 
HIV-related offense was perceived). The multiple sexual partner behaviour item 
(Approximately how many people have you had sex with?) and the anal sex behaviour 
item (How many times have you had anal sex?) are continuous items. Whereas, the 
condom use behaviours (e.g., How often have you used condoms when having sex with 
your regular partners?) are scored on a scale of 0 (None of the time) to 5 (Always). These 
items are reversed and summed up so that higher scores indicate high risk behaviours and 
vice versa. Cronbach’s alpha on the SRBS have ranged from .75 to .80.  
 
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4.4.6 Pilot Study  
 Following institutional approval from the 37-Military Hospital and the three 
Teaching Hospitals, a pilot study was conducted to examine the reliability, content 
validity, and how well the survey instruments would be understood. The preliminary study 
was also intended to help the researcher identify appropriate and standard procedures for 
collecting survey data and following participants up for the qualitative study, while 
ensuring protection of their personal identities. A total of 50 purposively sampled PLWHA 
participated in the pilot study. Participants were selected from across the three teaching 
hospitals as well as the 37-Millitary Hospital in Accra.  
 It emerged at the beginning of the pilot exercise that the instruments should be 
administered either by the researcher or by trained personnel. This was because, 
participants had to complete only the forgiveness questionnaires that were applicable to 
their specific HIV-related offense situation, which could have been confusing for some. 
Also, feedback at the HIV/AIDS units of the hospitals indicated that quite a number of the 
patients had low educational levels, and hence may not be able to fully engage with the 
questions on their own. Thus, particularly at KATH and TTH, personnel were selected and 
thoroughly trained to administer the survey (including the Twi-translated version) in the 
form of an interviewer administered questionnaire. First, selected personnel completed the 
survey. This was followed by a thorough training on how they would explain the 
instructions and administer the questions to participants to ensure standard data collection 
across all settings. Issues of how to approach, recruit, establish rapport, and observe 
ethical principles with potential participants were also addressed during the training. These 
were particularly emphasized and thoroughly explained to the non-health personnel. The 
personnel included HIV/AIDS nurses, counsellors, and a trained psychology graduate. 
Overall, the pilot study allowed the researcher to achieve the following: 
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 Realize the need for and translated the survey instruments and instructions into 
Twi. This was done by a professional who holds a Masters in Ghanaian Language 
(Twi).  
 Modify culturally unpopular word choices on some items (e.g., replacing “blue 
mood” with “feel sad”) based on feedback from both field test participants and 
trained data collection personnel. This was carefully done in order not to 
compromise the meaning of the items or the content of their respective 
subscales/questionnaires.  
 Develop a study procedure that ensured that participants who engaged in the main 
study did not have to queue much longer than other out-patients not involved in the 
study.  
 Develop a follow-up procedure based only on participant’s folder and telephone 
numbers, ensuring confidentiality of responses as well as protection of 
participants’ identity. 
 Establish the reliability of the study variables prior to data collection. The 
Cronbach alpha reliabilities recorded on the pilot data were: .84 for DTFO; .81 for 
DTFS; .70 for EFO; .57 for EFS; .74 for ATG, .61 for SRB; .76 for SS; .71 for 
RBBQ; and .84 for PHRQOL. It was observed on the SRB scale that the anal sex 
item was negatively correlating. This item was dropped, increasing reliability to 
.72. Thus, the SRB had a summed score for the 3 condom use behaviours and a 
single multiple sexual partner behaviour item. 
 
4.4.7 Study Procedure and Data Collection  
 Subsequent to ethical and institutional approval for the study, the researcher and 
trained data collection personnel recruited PLWHA who met the survey study inclusion 
criteria during their routine outpatient visits to the study sites/clinics. Routine clinics at 
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each of the three study sites, were typically held on Mondays, Wednesdays, and Fridays 
but also Thursdays at the KBTH.   
Recruited patients were first informed about the nature and requirements of the 
study. Those who gave written informed consent voluntarily participated in the study. The 
researcher and trained personnel administered the survey and collected clinical data from 
participants’ folders using an average of 1hour per patient. One-on-one administration of 
the survey was carried out in HIV counselling rooms at each of the study site. Participants 
also underwent laboratory tests for their concurrent CD4 test results. In some cases, 
obtaining current CD4 tests were not possible due to the CD4 machines having often 
broken down at the study sites. Participants whose CD4 count could not be taken 
concurrently with the survey due to these challenges on the ground, were excluded from 
the CD4 analysis. For these patients, only PHRQOL was considered as the outcome 
variable. 
Test reports for participants who had their CD4 test done during survey data 
collection were later obtained by their respective survey administrator and matched to 
their survey responses. This was achieved with the help of participants’ folder numbers 
and date the survey was completed, which were recorded on their questionnaires and also, 
blood samples. No other personally identifiable information such as names were recorded 
on the questionnaires. Furthermore, the folder numbers were developed such that they 
could not be identified by third parties as belonging to PLWHA receiving care at any of 
the participating hospitals. Participants were rewarded for their time in the study with fast-
tracked routine care procedures, drinks, and/or transportation.  
 
4.4.8 Data Analysis and Underlying Assumptions 
 The researcher drew on both descriptive and inferential statistics to analyse the 
survey data using SPSS version 21 for Windows (IBM SPSS Inc., Chicago IL, USA). The 
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descriptive statistics were employed to uncover the sociodemographic, clinical, offense 
and forgiveness characteristics of the study participants as well as establish prevalence 
rates of variables such as ART adherence. The inferential statistics were performed to test 
the study hypotheses. They included dependent t-test to test the difference between 
participants’ engagement in decisional versus emotional forgiveness and positive versus 
negative attitudes toward God. Correlational analysis was carried out to identify the inter-
relationships between the study variables. To determine the predictiveness of the types and 
contexts of forgiveness, multivariate regression analyses were conducted. Finally, using 
Hayes (2013) PROCESS moderation model, moderation analyses were conducted to 
examine the moderation effects of three health behaviours on the forgiveness-health 
outcomes associations. Prior to the hypotheses testing, assumptions underlying each of the 
inferential statistics were tested. In general, the assumptions of normality and homogeneity 
of variance of the distribution of the scores were tested to ensure that the study sample 
were similar to the population of PLWHA receiving treatment in Ghana. All analyses were 
considered statistically significant at p ≤ .05.  
 
4.5 Results  
4.5.1 Preliminary Analysis 
 This section of Chapter Four presents findings from Study 1. It begins with a factor 
analysis of the study scales to establish the validity of the scales. This is followed by 
descriptive findings on the sociodemographic, clinical, and HIV-specific offense 
characteristics of the survey participants. The next section presents a report of the inter-
correlations between the core study variables. The final section of this chapter presents 
findings from the hypotheses testing for each of the three contexts – intrapersonal/self, 
interpersonal/other, spiritual/God – within which forgiveness was investigated.  
 
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4.5.1.1 Factor Analysis  
 Factor analysis was first carried out to validate the scales that were used to 
measure the predictor and outcome variables. Particularly for the forgiveness measures, 
which to the best of the researcher’s knowledge have not been used in PLWHA in African 
settings, this preliminary exercise was necessary to ascertain how well the scales 
employed in this study measure their respective constructs. Using principal components 
analysis (PCA, with fixed number of factors and varimax rotation solution), items that 
loaded above .32 were retained. According to Tabachnick and Fidell (2001), a good rule of 
thumb for retaining items is a minimum loading value of .32. Prior to running the PCA, 
underlying assumptions were first checked and met for all scales. First, variables were 
multiple and continuous, and linearly related (confirmed by a significant Bartlett’s Test of 
Sphericity). Sampling was adequate as each analysis involved at least 8 cases per 
variable/item (confirmed by a Kaiser-Meyer-Olkin Measure of Sampling Adequacy value 
of .7 and above) and showed no significant outliers. 
 
Decision to Forgive (Other) Scale 
The decision to forgive scale (DTF, Davis et al., 2015), referred to as decision to 
forgive other (DTFO) in this study, is originally a six-item unidimensional scale that 
measures intentions to forgive another person who has caused a hurt. The first four items 
employ the word “forgive” (e.g., I have made up my mind to forgive him or her). 
However, as well documented in the forgiveness literature that merely using the word 
“forgive” may not necessarily indicate that forgiveness has taken place (Worthington, 
2005; Worthington et al., 2007). The last two items (“My choice is to release any negative 
feelings I have” and “I have chosen not to intentionally harbor resentment towards him or 
her) appropriately assess change in emotions indirectly, which is a constituent of the 
internal actions that usually take place to suggest that one may have actually experienced 
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some form of forgiveness. Considering the definition of forgiveness employed in this 
study as changes from a more negative to a more positive state in cognitions, emotions, 
and behaviours toward an offender (e.g., Enright & Fitzgibbons, 2000). The researcher 
added two additional items to indirectly assess forgiveness in terms of change in 
cognitions (My choice is to release any negative ideas or thoughts I have about him or her) 
and behaviour intentions (I have decided not to take revenge against him or her). The goal 
was to ascertain whether participants’ responses to the first four items with the word 
“forgive”, would be consistent with their responses to these indirect measures of 
forgiveness. This was in consideration of the fact that at present, very little is known about 
how PLWHA in Ghana may conceptualize, understand, and use the word “forgive”.  
Table 4.01 details the factor loadings on the DTFO scale. The table shows that all 
items loaded above 0.5. Similar to the original unidimensional structure of the DTF scale, 
a single factor was extracted suggesting that the additional items fitted well with the scale. 
Also, this may suggest that the items that used the word “forgive” were likely understood 
to mean a decision to forgo negative thoughts, emotions, and behaviours toward another 
offender. The scale also had excellent internal consistency reliability in this study (0.92).  
 
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Table 4.1:  Item Loadings on the Decision to Forgive Other Scale 
Item Number Item Content Item 
Loading 
Factor: Decision to Forgive Other  
1 I have decided to Forgive him or her .83 
2 I made a commitment to forgive him or her .89 
3 I have made up my mind to forgive him or her. .88 
4 My choice is to forgive him or her. .79 
5 My choice is to release any negative feelings I have  .69 
6 I have chosen not to intentionally harbor hatred towards .68 
him or her. 
7 My choice is to release any negative ideas or thoughts I .76 
have about him or her* 
8 I have decided not to take revenge against him or her* .57 
*additional items added 
 
Decision to Forgive (Self) Scale  
The DTFO scale was adapted to assess decision to forgive self (DTFS) by 
replacing the words “him or her” with “myself” (e.g., “I have made up my mind to forgive 
myself”). Item 7 on the DTFO scale (I have decided not to take revenge against him or 
her) was also carefully modified to be more relevant to the context of self-forgiveness 
based on the self-forgiveness literature (Woodyatt et al., 2017). This item was adapted to 
read as; “I have decided not to do anything bad to myself”.  The DTFS scale, which also 
showed high item loadings (.51 to .84) on the extracted single-factor, recorded a high 
internal consistency reliability of 0.85. Table 4.02 presents the factor loadings of the items 
on the DTFS scale. 
 
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Table 4.2: Item Loadings on the Decision to Forgive Self Scale 
Item Number Item Content Item Loading 
Factor: Decision to Forgive Self 
1 I have decided to Forgive myself .57 
2 I made a commitment to forgive myself .76 
3 I have made up my mind to forgive myself. .84 
4 My choice is to forgive myself. .68 
5 My choice is to release any negative feelings I have about .71 
myself 
8 I have chosen not to intentionally harbor hatred towards .51 
myself 
6 My choice is to release any negative ideas or thoughts I .63 
have about myself 
7 I have decided not to do anything bad to myself .51 
 
 
Emotional Forgiveness (Other) Scale 
Table 4.3 presents the factor loadings on the 8-item emotional forgiveness (of 
other) scale (Worthington et al., 2007). Originally, items 1, 4, 6, and 8 constitute the 
Presence of Positive Emotions subscale (e.g., “I care about him/her”). Whereas, items 2, 3, 
5, and 7 constitute the Reduction in Negative Emotions subscale (e.g., “I no longer feel 
upset about the situation”). A rotated solution showed a two-factor structure with items 1, 
4, 6, 8, and also 2, loading onto factor one. Items 3, 5, and 7 loaded onto factor two. The 
scale had a high Cronbach alpha of 0.74, with all items loading above 0.6.  
 
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Table 4.3: Item Loadings on the Emotional Forgiveness of Other Scale 
Item Number Item Content Factor 1 Factor 2 
Loadings Loadings 
Factor 1: Presence of Positive Emotions 
1 I care about him/her/them. .83  
4 I feel sympathy toward him/her/them.  .86  
6 I like him/her/them. .81  
8 I feel love toward him/her/them. .74  
2 I no longer feel upset when I think of him/her/them. .69  
Factor 2: Reduction in Negative Emotions subscale 
3 I’m so annoyed about what he/her/they did to me.  .74 
5 I’m angry about what happened.    .80 
7 I hate what he/she/they did to me.  .78 
 
 
Emotional Forgiveness (Self) Scale 
The EFO scale was adapted to assess emotional forgiveness of self (EFS) by 
carefully replacing the words “him or her” with “myself” (e.g., “I care about myself”), so 
that the meaning of the items were retained. The rotated factor solution on the EFS 
showed a two-factor structure same as the original structure: items 1, 4, 6, and 8 loaded 
onto factor one, while items 2, 3, 5, and 7 loaded onto factor two. As indicated in Table 
4.4, all items loaded above .32 on the scale, which recorded a good internal consistency 
reliability of 0.60.  According to Taris, de Lange, and Kompier (2010), alpha should be a 
minimum of .60 when items are summed up to measure a construct at the group level.   
 
 
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Table 4.4: Item Loadings on the Emotional Forgiveness of Self Scale 
Item Number Item Content Factor 1 Factor 2 
Loadings Loadings 
Factor 1: Emotional Forgiveness of Self 
1 I care about myself .57  
4 I feel sympathy toward myself  .35  
6 I like myself .91  
8 I feel love toward myself .79  
Factor 2: Reduction in Negative Emotions subscale 
2 I no longer feel upset when I think of what I did in  .38 
the situation 
3 I feel guilt and regret for the things I did in the  .86 
situation 
5 I’m angry at myself for what happened.    .67 
7 I hate what I did   .78 
 
Attitudes Toward God Scale 
 Table 4.5 presents the item loadings on the 5-item Positive Attitudes toward God 
scale (PATG) scale and the four-item Disappointment and Anger with God scale (or the 
Negative Attitudes toward God scale, NATG). All PATG items (PA1 to PA5) loaded 
above .60 on the extracted single factor scale. The PATG scale also recorded excellent 
Cronbach alpha reliability of 0.9. Similarly, all NATG items (NA 1 to NA 4) loaded above 
.70 on the extracted single factor scale and recorded a high Cronbach alpha of .83.  
 
 
 
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Table 4.5:  Item Loadings on the PATG and the NATG Scales 
Item Number Item Content Factor 1 Loadings Factor 2 Loadings 
Factor 1: Attitudes Toward God Scale 
PA 1 Trust God to protect and care for you .62  
PA 2 View God as all-powerful and all- .85  
knowing 
PA 3 Feel loved by God  .95  
PA 4 Feel supported by God .91  
PA 5 Feel nurtured or cared for by God  .99  
Factor 1: Negative Attitudes Toward God Scale  
NA 1 Feel angry at God  .86 
NA 2 Feel that God has let you down  .81 
NA 3 View God as unkind   .76 
NA 4 Feel abandoned by God  .84 
 
Psychological Health-Related Quality of Life Domain  
 Table 4.6 shows the factor loadings on the six-item (5, 6, 7, 11, 19, and 26) 
psychological health-related quality of life (PHRQOL) domain of the WHOQOL-BREF. 
All items loaded onto the extracted single factor between .34 on item 26 and .73 on item 5. 
Item 26 was originally culturally-loaded, as it included descriptions such as “blue mood”. 
Specifically, the item read as: “How often do you have negative feelings such as blue 
mood, despair, anxiety, depression?” This item was carefully rephrased in the main study 
to read “How often do you feel sad, disturbed, lose hope, have no interest in things you 
usually enjoy? The scale recorded a good internal consistency reliability of .66 in this 
study. 
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Table 4.6:  Item Loadings on the WHOQOL-BREF Psychological Health Domain 
Item Number Item content Item Loadings 
Factor: Psychological-Health Domain 
5 How much do you enjoy life?  .73 
6 To what extent do you feel your life to be meaningful .66 
7 How well are you able to concentrate? .67 
11 Are you able to accept your bodily appearance? .60 
19 How satisfied are you with yourself? .64 
26 How often do you have negative feelings such as blue .34 
mood, despair, anxiety, depression? 
 
 
Overall, the results of the factor analyses indicate that the scales adopted in the 
present study had similar factor structures to the original scales, with items loading well 
onto these scales. Having established the validity of these scales, descriptive and 
inferential statistics were further tested on the scores obtained on these scales.  
 
4.5.1.2 Descriptive Analysis 
Respondent Background Characteristics  
Following the factor analyses, means, standard deviations, and frequencies were 
calculated to obtain an overview of participants’ background characteristics. Results of the 
descriptive analysis showed that of the 325 PLWHA who responded to the survey, 105 
(32.3%), 94 (28.9%), and 126 (38.8%) respectively, were receiving routine HIV/AIDS 
care at the TTH, KBTH, and KATH. The descriptive analysis also provided an overview 
of Participants’ sociodemographic, clinical, and HIV-related offense characteristics. These 
are respectively reported in Table 4.7. Table 4.8, and Table 4.9.  
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Table 4.7: Sociodemographic characteristics of survey respondents 
 
Characteristic Categories  N % M SD 
Age (yrs)  325 100 42.33 10.34 
 Young adults (18 – 29) 38 11.7 23.63 3.28 
 Middle adults (30 – 49) 210 64.6 40.87 4.87 
 Older adults (>50)  77 23.7 55.53 5.26 
Gender       
 Male  99 30.5   
 Female  226 69.5   
Educational level      
 No education  32 9.8   
 Primary  61 18.8   
 Secondary  137 42.2   
 Post-secondary qualification  95 29.2   
Marital status      
 Single 98 30.2   
 Married/Living as married 147 45.2   
 Separated/Divorced 27 8.0   
 Widowed  54 16.6   
Religion      
 Christian  264 81.2   
 Islam  53 116.3   
 Others  8 2.4   
 
Table 4.7 indicates that respondents comprised largely of females (69.5%) 
compared to their male counterparts (30.5%), and recorded a mean age of 42.3years. There 
were more (64.6%) middle aged adults (30-49years) compared to younger (18-29years) 
and older adults (≥50years). Majority of respondents were married (43.7%), had a 
secondary education (42.2%), and identified with the Christian religion (81.2%).  
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Table 4.8:  Clinical characteristics of survey respondents 
Characteristic Categories  N % M SD 
Duration on ART (m)  325  82.94 (43.75) 
Duration with HIV (m)  325  91.10 (45.63) 
Pre-ART CD4 count  310  286.04 266.80 
Concurrent CD4 count  197  573.12 300.76 
HIV TYPE      
 Type I 305 93.8   
 Type II 6 1.8   
 Type I and II 14 4.3   
Missed ART dose       
 None of the time in past week 255 78.5   
 Only one time in past week 36 11.1   
 Two-three times in past week 22 6.8   
 More than three times 12 3.7   
Medication regimen      
 TDF+3TC+EFV 150 46.2   
 AZT+3TC+NVP 80 24.6   
 AZT+3TC+EFV 61 18.8   
 Others  34 10.4   
Comorbidities   325    
 No comorbidities 289 88.9   
 High blood pressure 18 5.5   
 Diabetes 5  1.5   
 Asthma 3 .9   
 Hepatitis B 3 .9   
 Other 7 2.2   
 
Table 4.8 presents the clinical background of the survey respondents. A greater 
proportion (93.8%) of the respondents had HIV Type I infection. A total of 289 (88.9%) 
respondents reported no known comorbidities. High blood pressure was the most 
frequently reported comorbidity, although this was reported among only 18 (5.5%) of the 
respondents. Close to half (46.2%) of the respondents were taking a first line regimen with 
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the combination; tenofovir (TDF), lamivudine (3TC), and efavirenz (EFV). Adherence – 
not missing any ART dose in the last 7 days prior to completing the survey – was reported 
by 78.5% of participants. An average of 286.04cells/µL was recorded as respondent’s pre-
ART CD4 cell count. The average CD4 cell count concurrently recorded during survey 
completion, was substantially higher than the average pre-ART CD4 count 
(573.12cells/µL: t= -11.23, p<.001). 
 
Table 4.9: HIV-specific offense characteristics of survey respondents  
Characteristic Categories N % 
Offense context    
 Intrapersonal 91 28.0 
 Interpersonal 191 58.8 
 Spiritual  43 13.2 
Most offensive situation    
 Perceived cause of HIV 171 92.0 
 Experience of HIV  26 8.0 
Offense hurtfulness    
 Very little hurt  23 7.1 
 Little hurt 22 6.8 
 Moderate hurt 31 9.5 
 Large amount of hurt 43 13.2 
 Extreme amount of hurt  206 63.4 
 
Table 4.9 depicts the HIV-specific offense characteristics of the survey 
respondents. Across the three hospitals, a total of 191 (58.8%) PLWAH perceived an HIV-
related offence committed against them by others and hence responded to the interpersonal 
(other) forgiveness survey measures. Ninety-one respondents (28%) perceived that their 
most offensive HIV-related situation was a wrong doing they had committed against 
themselves and hence, completed the self-forgiveness measures. Respondents who 
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reported anger and other negative attitudes toward God over their HIV-positive status 
totalled 43 (13.2%).   
The vast majority (98%) of the respondents indicated that their most offensive 
HIV-related situation had to do with the cause of their HIV-infection. These included self-
emanating causes (intrapersonal offenses) such as previous ungodly lifestyles, 
unfaithfulness to spouse/partner, and not observing protective work habits. Sources of 
interpersonal offenses chiefly related to unfaithfulness of and/or deliberate infection by 
spouses/partners. A few perceived hospital procedures and sodomy/rape as causes of their 
positive status. Family members were also perceived by some respondents as the cause of 
their HIV-infection via witchcraft or post-diagnosis stigmatization and discrimination. In 
the spiritual context, respondents’ most offensive situations concerned God allowing their 
HIV-infection, dealing unfairly with them, or having forsaken them.  Experiences 
surrounding the HIV itself, were also perceived by 26% of respondents as their most 
offensive HIV-related situations. These included the symptoms of the illness and also, the 
time of diagnosis (e.g., at pregnancy, delivery, or death of spouse). A total of 76.6% of 
respondents reported that the hurtfulness of their perceived HIV-offense was large or an 
extreme amount.  
 
4.5.1.3 Means, Normality, and Reliability of Study Variables 
 As part of the preliminary analysis, means, skewness and kurtosis, and internal 
consistency reliabilities of the scales employed in the present study were also tested on the 
main study data. The results of this analysis are summarized in table 4.10.  
  
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Table 4.10:  Summary of means, normality, and reliability of study variables  
Variable N Min Max Mean SD Skewness Kurtosis α 
Decision to forgive self 91 21.0 40.0 32.99 3.25 -1.13 4.51 .85 
Emotional forgiveness of self 91 14.0 36.0 28.25 3.72 -.694 1.70 .60 
Decision to forgive other 191 8.0 40.0 31.21 5.21 -1.68 4.93 .92 
Emotional forgiveness of other  191 8.0 40.0 25.72 5.13 -.84 .87 .74 
Positive attitudes toward God 43 5.2 10.0 9.14 1.40 -1.50 .96 .90 
Negative attitudes toward God 43 1.0 10.0 3.89 2.03 1.48 2.28 .83 
Perceived social support 325 27.0 60.0 43.10 5.80 .16 .21 .79 
Psychological distress 325 10.0 50.0 18.04 7.20 1.52 2.45 .87 
Religiosity 325 7.0 58.0 44.88 8.78 -1.01 1.43 .75 
Condom use behaviour 325 0.0 13.0 3.38 4.69 1.70 2.10 .84 
Quality of life 325 25.0 100.0 71.78 13.42 -.97 1.36 .88 
 
 
Table 4.10 indicates that all scales employed to measure forgiveness and the 
psychosocial variables in the study showed good to high reliability (0.60 to 0.92). The 26-
item QOL scale also showed high internal consistency of .88. On the individual domains, 
α levels of 0.76, 0.74, 0.66, and 0.46 were respectively recorded for the environment, 
physical, psychological, and social relationship domains respectively. The table also 
shows acceptable skewness statistics of less than 2 (.16 - 1.68) for each scale, indicating a 
normal distribution of scores on these scales in relation to the +/-1 to +/-3 range (Field, 
2009; Tabachnick & Fidell, 2007). With the exception of two variables – DTFS and 
DTFO – the kurtosis statistic for scores on the study variables also fell within the 
recognized range of +/-1 to +/-3 (between .21 and 2.45). Regarding the DTFS and DTFO 
variables, which had kurtosis statistics greater than 3, the violations of normality were 
considered to be negligible due to the large sample sizes on these scales (Field, 2009; Hair 
et al., 2010). Thus overall, the assumption of normality for use of parametric tests was 
considered to have been met for the study variables. 
 
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4.5.1.4 Correlation Matrices   
Correlations between socio-demographic, clinical, and study variables 
Table 4.11 presents the Pearson product moment correlation coefficients (r) 
between the background sociodemographic and clinical variables, the forgiveness 
variables (independent variables), and the two outcome or dependent variables in the 
present study; psychological health-related quality of life (PHRQOL) and change in CD4 
count. Prior to the correlation analysis, categorical variables (e.g., gender, marital status, 
educational level, ART regimen, hurtfulness of offense, and condom use behaviours) were 
dummy-coded (see Appendix I). 
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Table 4. 11: Summary of correlations between sociodemographic, clinical, independent, and dependent study variables 
     Variable  1a 2a 3a 4a 5a 6a 7a 8b 9a 10c 11c 12d 13d 14e 15e 16a 17f 
1 Age -                 
2 Gender -.23** -                
3 EducP .03 .11* -               
4 EducS -.23** .06 -.41** -              
5 EducPS .06 -.21** -.31** -.55** -             
6 MStatus .20** -.23** -.06 .00 .08 -            
7 ARTReg .00 .02 .08 .10 -.19** .01 -           
8 1st CD4 -.14* .10 .05 .08 -.06 -.07 .01 -          
9 Hurt .03 .20** .15** .00 -.20** -.20** -.03 .05 -         
10 DTFS .05 -.17 .11 -.05 -.05 .01 .19 -.17 .05 -        
11 EFS -.08 .01 .24* -.06 -.16 .11    .26* .02 .03 .27** -       
12 DTFO .07 -.17* .06 -.15 .13 .06 -.02 -.02 .23** --- --- -      
13 EFO .13 -.20** -.08 -.06 .12 .20** -.07 -.02 -.23 --- --- .59** -     
14 PATG -.04 -.25 .07 -.15 .05 -.05    .10 -.09 -.07 --- --- --- --- -    
15 NATG -.25 .12 -.05 -.07 .09 -.13    .05 .05 -.06 --- --- --- --- -.15 -   
16 PHRQOL .06 -.08 .00 -.05 .04 .13*    .08 -.14* -.12 .30** .29** .24* .23** .31* -.28 -  
17 ∆CD4 .25** .04 .11 -.14 .03 .05 .07 -.56** .07 .34** -.16 .05 -.08 .06 .18 .10     -  
  a: N=325; b: N=310, c: N= 91, d: N=191, e: N= 43, f: N=190 *p<.05; **p<.01; ---correlations across forgiveness contexts not applicable; 
DTFS=decision to forgive self; EFS=emotional forgiveness of self; DTFO=decision to forgive other; EFO=emotional forgiveness of other; 
PATG=positive attitudes toward God; NATG=negative attitudes towards God; EducP=primary education; EducS=Sec. education; EducPS=Postsec. 
education; Mstatus=Married/cohabiting status; ARTReg=ART regimen; Hurt=hurtfulness of offense; PHRQOL= psychological health-related 
quality of life; 1st CD4 = first CD4 count; ∆CD4 = change in CD4 cell count. 
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Table 4.11 shows significant correlations between PHRQOL and these two 
background variables; married/cohabiting status (r= .11, N=325, p<.05) and first CD4 
result (r= -.12, N=310, p<.05). Change in CD4 correlated significantly with age (r= .25, 
N=276, p<.01) and as expected, first CD4 count (r= -.52, N=276, p<.001). Having a 
primary education and being on the TDF, 3TC, EFV regimen correlated significantly with 
emotional forgiveness of self (EFS: r= .24, N=91, p<.05 and r= .26, N=91, p<.05). Other 
significant associations included being female and DTFO (r= -.17, N=191, p<.05) and 
also, (EFO: r= -.20, N=191, p<.01). Furthermore, hurtfulness of offense and being married 
significantly correlated with DTFO (r = .23, N=191, p<.01) and EFO (r= .20, N=191, 
p<.01) respectively.  
 
Correlations between psychosocial variables and study variables 
The Pearson product moment correlation coefficient (r) test was conducted to 
check for associations between respondents’ psychosocial factors and the independent and 
dependent variables. It was also to check for multicollinearity, that is, very strong 
correlations of >.9 among the variables (Field, 2009). Table 4.12 indicates the correlation 
test output/matrix. The table shows that first of all, there is no extreme multi-collinearity 
among the predictor variables (as well as among all other variables). The largest 
correlation co-efficient of .59 (between DTFO and EFO) confirms that extreme 
multicollinearity was not an issue in the present study.  
 
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Table 4.12: Summary of correlations among psychosocial, independent, and dependent study variables 
     Variable  1a 2a 3b                   4  b 5c 6c  7d 8d 9d 10d 11d 12d 13d 14e 
1 DTFS -              
2 EFS .27** -             
3 DTFO --- --- -            
4 EFO --- ---  .59** -           
5 PATG --- --- --- --- -          
6 NATG --- --- --- --- -.15* -         
7 S. support  .12 -.11  .26**  .19**  -.07 -.25 -        
8 P. Distress -.09 -.06 -.14 -.09  -.01   .31*  .06 -       
9 Religiosity  .07  .15  .04  .07 -.14 -.03  .21**  -.08 -      
10 MissART  .12  .17 -.02  .03   .13  .10 -.13*        .02 -.03 -     
11 MSP Bhv -.02  .20 -.17* -.12  .09  .01 -.17** -.15** -.07 .02   -    
12 CU Bhv -.07 -.09 -.14 -.14 .19 -.11 -.11** -.08 -.02 .01 .53**   -   
13 PHRQOL  .30**  .29*  .24*  .23**   .31*    -.28   .12*  -.36**  .06  -.05   .13   -.07    -  
14 ∆CD4  .34** -.16  .05 -.08  .06  .18   .02  -.05 -.09   - .08   .03    .18* .09   - 
   a: N= 91; b: N=191, c: N= 43, d: N=325, ea: N=45, eb = 118, ec=27  *p<.05; **p<.01; ---correlations across forgiveness contexts not applicable; 
DTFS=decision to forgive self; EFS=emotional forgiveness of self; DTFO=decision to forgive other; EFO=emotional forgiveness of other; 
PATG=positive attitudes toward God; NATG=negative attitudes towards Go d; RS=religiosity/spirituality; MissART=Number of times ART was 
missed in the last 7days; SexPple=no. of sexual partners since offence; SexCon=frequency of condom use; PHRQOL= psychological health-related 
quality of life;  ∆CD4 =   change in CD4 cell count (first  CD4 result – CD4 result concurrently taken at time of survey). 
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It can also be observed from Table 4.12 that there was a significant and positive 
correlation between PHRQOL and all the intrapersonal and interpersonal forgiveness 
variables, but only with the positive attitudes toward God (PATG) variable. Specifically, 
there were significant correlations between PHRQOL and decision to forgive self (DTFS, 
r= .30, N=91, p<.01), EFS (r= .29, N=91, p<.05), DTFO (r= .24, N=191, p<.05), EFO (r= 
.23, N=191, p<.01), and PATG (r= .31, N=43, p<.05). Decision to forgive self was the 
only main independent variable that significantly positively correlated with change in CD4 
cell count (r = .34, N=91, p<.01). 
Again, the table indicates that although social support and religiosity/spirituality 
(RS) are also types of coping, only social support correlated significantly positively with 
PHRQOL (r= .12, N=325, p<.05). A closer observation of the results further shows that 
except for DTFO (r=.19), the strength of the correlations between PHRQOL and all 
forgiveness variables were larger (r=.23 to .31) compared to the strength of the PHRQOL-
social support correlation (r=.12).  
Psychological distress as was expected, significantly negatively correlated with 
PHRQOL (r= -.36; N=325, p<.01). Finally, an examination of the correlation matrix in 
Table 4.12 shows that there was a positive correlation between social support and both 
forms of interpersonal forgiveness (DTFO: r= .26, p<.01, and EFO: r= .19, p<.01). 
However, there was no correlation between social support and scores on any of the 
intrapersonal forgiveness scales.  
 
4.5.2 Hypotheses Testing 
 To further investigate whether forgiveness of HIV-specific offenses would predict 
the criterion variables (PHRQOL and CD4), four main hypotheses were tested for each of 
the three contexts of forgiveness – intrapersonal, interpersonal, and spiritual – using 
simple, multiple, and hierarchical regression analyses.  
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 The first hypothesis tested the differences in scores between the forms of 
forgiveness in each context using dependent t-tests. The assumption of normality of 
difference scores was checked prior to carrying out the t-tests, using the Kolmogorov-
Smirnov test and was found tenable. Hypotheses 2, 3, and 4 assessed the importance of the 
forms/stages of forgiveness in predicting the criterion variables. The assumption of 
multicollinearity was examined using the Tolerance and VIF (variance inflation factor) 
values. All Tolerance values were greater than .2 and VIF values were less than 3, 
suggesting that the multicollinearity assumption was met for each regression analysis 
(Rovai et al., 2014). The assumption of independence of observation was also met as the 
Durbin-Watson statistic was between 1.5 and 2.5 (Field, 2009; Rovai et al., 2014) for all 
the regression analyses conducted. Other assumptions for regression analysis including 
normal distribution of residuals, absence of extreme outliers, and linearity were examined 
using the Kolmogorov-Smirnov test with Lillifors significance correction, inspection of 
boxplots, and inspection of scatter plots respectively. All assumptions were duly met.  
 
 4.5.2.1 Hypotheses Testing for Intrapersonal Forgiveness 
H1: Participants would report more decisions to forgive self than emotional forgiveness of 
self.  
 To test H1a, a dependent t-test was conducted to evaluate the differences in scores 
on DTFS and EFS among participants, who reported self-forgiveness (N= 91). Results of 
the test indicated that DTFS (M = 32.99, SD = 3.25) was higher than emotional 
forgiveness of the self (M = 28.25, SD = 3.72), t(90) = 10.68, p<.001. The 95% 
confidence interval for the difference in means ranged from 3.86 to 5.62. Thus, hypothesis 
H1a was supported.  
 
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Cohen’s d was further calculated to determine the magnitude of the difference 
between DTFS scores and EFS scores. Using the Cohen’s d online calculator, information 
on the mean scores, standard deviations, and sample size (n=91) for each group were 
entered (Social Science Statistics, 2018). The results indicated a large effect of 1.36.  
  
 
H2: Intrapersonal forgiveness (DTFS and EFS) will significantly positively predict the 
criterion variables (PHRQOL and change in CD4 cell count). 
 
 Standard multiple linear regression was used to test the significance of DTFS and 
EFS in predicting PHRQOL. Whereas, simple linear regression was used to test the 
predictiveness of change in CD4 count from DTFS as the correlation matrix in Table 4.12 
indicates that only DTFS correlated significantly with change in CD4 cell count. Tables 
4.13 and 4.14 respectively present the regression models for intrapersonal forgiveness 
regressed on PHRQOL and change in CD4 cell count. 
 
Table 4.13: Summary Coefficients of Self-Forgiveness Predicting Psychological 
Health-Related Quality of life 
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant           20.54     14.28    
Emotional forgiveness of self          0.76     0.35            .22     2.17 .033 
Decision to forgive self          0.94     0.40            .24     2.34 .022 
F =6.957, R2 = .137 p<.01  
 
The regression output presented in Table 4.13 indicates that in support of 
hypothesis 2, the model significantly accounted for 13.7% of variance in PHRQOL 
(F(2,88) =6.96, p<.01), with both DTFS (β = .24, p<.05) and EFS (β = .22, p<.05) making 
significant and positive unique contributions to the variation in PHRQOL.  
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Table 4.14: Summary Coefficients of Decision to Forgive Self Predicting Change in 
CD4 Cell Count 
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          -604.65     325.73    
Decision to forgive of self            27.18     9.82            .30     2.77 .007 
N = 43, F(1, 41) =7.66, R2 = .093, p<.01 
 
The results of the simple linear regression model presented in Table 4.14 further 
supported hypothesis 2; DTFS significantly and positively predicted change in CD4 cell 
count (β = .30 p<.01). Overall, the model significantly accounted for 9.3% of the variance 
in this outcome (F(1, 41) = 7.66, p<.01). 
 
H3: Adherence to ART (number of missed doses in the last 7 days) and sexual risk 
behaviours (number of people you have had sex with and frequency of condom use since 
perceived offense) would moderate the relationship between intrapersonal forgiveness 
(DTFS and EFS) and the criterion variables (PHRQOL and CD4 cell change).  
 
 Hayes (2013) PROCESS model 3.0 was used to test the moderating effects of ART 
nonadherence and sexual risk behaviours on the relationship between intrapersonal 
forgiveness and the outcomes. At this stage, multiple sexual partner behaviour was also 
dummy codded into low (0) and high (1) risk behaviours for ease of interpreting any 
significant interaction effect (see Appendix I).  Results of the moderation analysis in 
relation to PHRQOL are reported in Table 4.15 whereas the results in relation to change in 
CD4 count are reported in Table 4.16. 
 
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Table 4.15:  Summary Results of Moderation Analysis on the Intrapersonal 
Forgiveness–Psychological Health-Related Quality of Life Relationship. 
Model B t Sig 
EFS * ART Adherence 2.09 1.93 .06 
EFS * Sex No. of People -.28 -.38 .70 
EFS * Condom Use                 -1.17                              -  1  . 6  2  .10 
DTFS * ART Adherence .66 .49 .63 
DTFS * Sex No. of People .14 .16 .87 
DTFS * Condom Use                  -.35           -.43 .66 
    N=91, *p<.05 
 
Table 4.15 presents results of the moderation analysis on the main effects of EFS 
and DTFS on PHRQOL as the criterion variable. Results of the analysis indicates that 
contrary to H3, health behaviours (number of times ART was missed in the last week, 
number of people one has had sex with since HIV-specific offence occurred, and 
frequency of condom use) had no interaction effect on the relationship between the 
predictors and PHRQOL. 
 
Table 4.16: Summary Result of Moderation Analysis on the Decision to Forgive Self–
Change in CD4 Cell Count Relationship. 
Model B t Sig 
DTFS * ART Adherence                 33.09             .60 .55 
DTFS * Sex No. of People                -16.48  -.57 .57 
DTFS * Condom Use                -40.83 -1.53 .13 
    N = 43, *p<.05 
 
 Table 4.16 presents results of the moderation analysis on the main effect of DTFS 
on change in CD4 cell count as the criterion variable. Results of the analysis indicates that 
contrary to H3, health behaviours (number of times ART was missed in the 7days, number 
of people one has had sex with since HIV-specific offence occurred, and frequency of 
condom use since offense) had no interaction effect on the relationship between DTFS and 
change in CD4 count.  
 
H4: Controlling for related sociodemographic, clinical, and psychosocial factors, 
intrapersonal forgiveness (DTFS and EFS) will remain a significant predictor of PHRQOL 
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and change in CD4 count, with DTFS accounting for a greater proportion of variance in 
the outcomes than EFS.   
 
 A two-step hierarchical multiple linear regression model was employed to test H4. 
Key sociodemographic, clinical, and psychosocial factors that correlated with DTFS, EFS, 
PHRQOL, and/or change in CD4 count (see Tables 4.11 and 4.12) were entered in the first 
step of the model. The predictors were entered in step two to determine whether they 
would remain significant predictors of the outcomes, having ascertained their uncontrolled 
predictive power in H2. Table 4.17 summarizes results for H4 in relation to PHRQOL, 
controlling for marital status, primary education, ART regimen, first CD4 count, social 
support, and psychological distress. These were the factors that significantly correlated 
with EFS and/or PHRQOL.  
Table 4.17: Summary of Final Model of Psychological Health-Related Quality of Life 
Regressed on Self Forgiveness Controlling for Covariates  
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Step 2      
Constant   27.01 16.76  1.61 .11 
Primary education            5.46      3.05 .18 1.79 .08 
ART regimen    2.62      2.50 .10 1.05 .30 
Marital status    1.41      2.44           .06   .58  .56 
First CD4 cell count    -.00        .01          -.05  -.46 .65 
Social support              .50   .22 .22  2.24 .03 
Psychological distress             -.82   .23 -.34 -3.61   .00 
Emotional forgiveness of Self              .60   .36 .18  1.70  .09 
Decision to forgive Self              .57  .40 .25  1.45  .15 
N=88; F = 4.719, R2 = .259, p=.000 for step 1; F = 3.269, R2 = .057, p=.043 for step 2 
     
  
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Table 4.17 presents the final model of the hierarchical multiple regression for the 
association between intrapersonal forgiveness and PHRQOL, controlling for related 
background variables. The control variables were entered first, followed by EFS and 
DTFS in step 2. Results of the regression analysis supports H4; taking all these covariates 
into account, intrapersonal forgiveness remained a significant predictor of PHRQOL (∆R2 
= .057, ∆F(2, 79) = 3.27, p<.05). However, neither DTFS (ß = .15, p>.05, n.s.) nor EFS (ß 
= .13, p = .233, n.s.) made unique significant contributions to the variation in PHRQOL. 
The first model explained approximately 26% of the variation in PHRQOL (R2 = .26, F(6, 
81) = 4.72, p <.001). The introduction of the intrapersonal forgiveness stages in step 2 
increased the predictive power of the final model to 31.6% (R2 = .316, F(8, 79) = 4.55, 
p<.001). Only social support (ß =.22, p<.05) and psychological distress (ß = -.34, p<.01) 
uniquely contributed to the variance in PHRQOL. It was explored further, whether 
entering intrapersonal forgiveness in the first step and the covariates in the second step 
would modify the outcomes. However, results of the final model (R2 = .316, F(8, 79) = 
4.55, p<.001) and the ß values remained unchanged.  
Table 4.18 summarizes results for H4 in relation to change in CD4 cell count, 
controlling for age and condom use, which were the variables that significantly correlated 
with change in CD4 count (none of the background factors correlated significantly with 
DTFS). Time in months between first and recent CD4 count collection was also controlled 
for.  
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Table 4.18: Summary of Final Model of Change in CD4 cell Count Regressed on 
Decision to Forgive Self Controlling for Covariates  
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Beta   
Error 
Step 2      
Constant      -1118.61   357.71    -3.31  .00 
Age          10.69       3.83   .36 2.79    .01 
Condom use        192.89      90.54   .24 2.13    .04 
Time from first CD4 collection            2.31       1.02   .29 2.28    .03 
Decision to forgive self          23.89     10.53   .26    2.27       .03 
N= 43, F = 9.718, p=.000, R2 = .416, for step 1; F = 5.141, R2 = .067, p=.029 for step 2.
        
 The summary model in Table 4.18 is the final hierarchical linear regression model 
of DTFS on change in CD4 count. The table indicates that taking these covariates into 
account, DTFS remained a significant predictor of change in CD4 count (R2 = .07 F(1, 
40)= 5.14, p<.05). The first model explained 42% of the variation in PHRQOL (R2= .42, 
F(3, 41) = 9.72, p <.001). The introduction of DTFS in step 2 increased the predictive 
power of the final model to 48% (R2 = .48, F(4, 40) = 9.31, p<.001). All variables in the 
final model made significant unique contributions to the variation in PHRQOL (age: ß = 
.36, p<.01; condom use behaviour: ß = .24, p<.05; time between first and second CD4 
counts: ß = .29, p<.05; DTFS: ß = .26, p<.05). Overall, H4 was partially supported: 
controlling for covariates, DTFS and EFS together remained a significant predictor of 
PHRQOL, although not unique contributors to the variation in PHRQOL. Only DTFS 
remained a significant and unique predictor of CD4 count change.  
 
4.5.2.2 Hypotheses Testing for Interpersonal Forgiveness 
 The four hypotheses for the present study were tested in relation to interpersonal 
forgiveness (DTFO and EFO). It was posited that: 
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H1: Participants will report more decisions to forgive others than emotional forgiveness of 
others. 
 To test H1 in this context, dependent t-tests were similarly conducted to evaluate 
the differences in scores between DTFO and EFO (N= 191). The results of the dependent 
t-tests indicated that DTFO (M = 31.21, SD = 5.21) was higher than emotional forgiveness 
of others (M = 25.72, SD = 5.13), t(190) = 16.27, p<.001. The 95% confidence interval for 
the difference in means ranged from 4.83 to 6.16.  
Cohen’s d was further calculated to determine the magnitude of the difference 
between DTFO scores and EFO scores. Using Cohen’s d online calculator, information on 
the mean scores, standard deviations, and sample size (n = 191) for each group were 
entered (Social Science Statistics, 2018). The results indicated a large effect of 1.06. 
 
H2: Interpersonal forgiveness (DTFO and EFO) will significantly positively predict 
PHRQOL and change in CD4 cell count. 
 
The correlation matrix in Table 4.12 shows no significant correlations between any 
of the forms/stages of interpersonal forgiveness and change in CD4 cell count. Thus, 
hypothesis two was investigated in relation to only interpersonal forgiveness (DTFO and 
EFO) and PHRQOL. Table 4.19 summarizes the results of the standard multiple linear 
regression model.  
Table 4.19: Summary Results of Coefficients for Interpersonal Forgiveness 
Regressed on Psychological Health-Related Quality of life 
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Step 1      
Constant  47.51 6.35  7.48 .000 
Emotional forgiveness of other   0.38 .24 .14 1.58 .116 
Decision to forgive other           0.42 .24          .15 1.76 .079 
N = 191, R2 = .068, F =6.858, p=.001  
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Table 4.19 indicates that in support of hypothesis 2, the model significantly 
predicted PHRQOL (F(2,188) =6.86, p<.01), accounting for 6.8% of the variance in this 
outcome. Although, individually, neither DTFO (β = .15, p>.05, n.s.)  nor EFO (β = .14, 
p>.05, n.s) made significant unique contributions to the variation in PHRQOL when the 
other was held constant. 
 
H3: Adherence to ART (number of missed doses in the last 7days) and sexual risk 
behaviours (number of people you have had sex with and frequency of condom use) would 
moderate the relationship between interpersonal forgiveness (DTFO, EFO) and PHRQOL. 
 
Hayes PROCESS v3.0 was used to test the moderating effects of ART 
nonadherence and sexual risk behaviours on the relationship between interpersonal 
forgiveness and PHRQOL. Results of the moderation analysis are reported in Table 4.20 
Table 4. 20: Summary Results of Moderation Analysis on the Interpersonal 
Forgiveness–Psychological Health-Related Quality of Life Relationship. 
Model B   T Sig 
EFO * ART Adherence                -.41              -.86 .39 
EFO * Sex No. of People                -.11       -.26 .79 
EFO * Condom Use                -.45            -1.12 .26 
DTFO * ART Adherence                -.83            -1.74 .08 
DTFO * Sex No. of People                -.35       -.77 .44 
DTFO * Condom Use                -.71      -1.82 .07 
N = 191, *p<.05 
 
 The moderation results presented in Table 4.20 shows that contrary to H3 there 
was no significant moderation effect of adherence or any of the sexual risk behaviours on 
the association between interpersonal forgiveness (DTFO and EFO) and PHRQOL.   
 
H4: Controlling for related sociodemographic, clinical, and psychosocial variables, 
interpersonal forgiveness (DTFO and EFO) would remain a significant predictor of the 
criterion variables (PHRQOL and change in CD4 cell count), with DTFO accounting for a 
larger proportion of the variance in the outcomes than EFO.    
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The correlation matrix in Table 4.12 shows no significant correlations between any 
of the forms/stages of interpersonal forgiveness and change in CD4 cell count. Thus, 
hypothesis four was investigated in relation to only interpersonal forgiveness (DTFO and 
EFO) and PHRQOL. Using a two-step hierarchical linear regression model, background 
factors that correlated with interpersonal forgiveness and/or PHRQOL (see Table 4.11 and 
4.12) were entered in step one. These were gender, marital status, first CD4 count, 
hurtfulness of offense, multiple sexual partner behaviour, social support, and 
psychological distress. The predictors – DTFO and EFO – were entered in step two to 
determine whether they would remain significant predictors of the outcomes, having 
ascertained their uncontrolled predictive power in H2. Table 4.21 summarizes results for 
H4 in relation to interpersonal forgiveness. 
Table 4.21: Summary of Final Model Results of Relationship between Interpersonal 
Forgiveness and Psychological Health-Related Quality of Life Controlling 
for Covariates  
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Step 2      
Constant         57.00 10.73  5.31 .00 
Female gender          1.86 2.18 .06   .85 .34 
Married or cohabiting          3.28 2.18 .12  1.51 .13 
Large/extreme hurt .68 2.41 .02   .28 .78 
First CD4 results -.01  .00 -.13 -2.01 .05 
Social support .14 2.41  .17  2.08 .04 
Psychological distress           -.66   .12 -.37 -5.38 .00 
Multiple sex. partner behaviour 2.91      2.16 .10 1.34 .18 
Emotional forgiveness of other .19 .23  .07  .82 .42 
Decision to forgive other .39 .22  .15 1.02 .08 
N = 180; F =7.765 R2 = .240, p=.000 for model 1; R2 = .032, F=3.733, p=.026 for 
model 2 
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The results of the multiple linear regression model reported in Table 4.21 indicates 
that H4 was also partially supported in the interpersonal context. Adjusting for related 
sociodemographic, clinical, and psychosocial covariates, interpersonal forgiveness (DTFO 
and EFO) significantly predicted PHRQOL (F (2, 170) = 3.73, p<.05), although it 
accounted for only 3.2% of the variance in this outcome. The first model explained 24% 
(R2 = .24, F(7, 172) = 7.77, p<.001) of the variation in PHRQOL. The introduction of 
DTFO and EFO in step 2 increased the predictive power of the final model to 27% (R2= 
.27, F(9, 170) = 7.06, p <.001). Neither DTFO (ß = .15, p>.05) nor EFO (ß = .07, p>.05) 
made significant unique contributions to the variance in PHRQOL. Significant predictors 
in the final model were participants’ first recorded CD4 count (ß = -.13, p<.05), social 
support (ß = .17, p<.05), and psychological distress (ß = -.37, p<.001). Overall, H4 was 
partially supported in the interpersonal context: controlling for covariates, DTFS and EFS 
together remained a significant predictor of PHRQOL. However, neither of these variables 
uniquely associated with PHRQOL nor remained significant predictors of CD4 count 
change.  
 
4.5.2.3 Hypotheses Testing for Spiritual Context of Forgiveness  
 The four study hypotheses were tested for the spiritual forgiveness context 
(attitudes toward God), to examine the predictive associations of positive attitudes toward 
God (PATG) and negative attitudes toward God (NATG) with the criterion variables – 
PHRQOL and change in CD4 cell count. It was posited that:  
 
H1: Respondents will report more of positive attitudes toward God (PATG) than negative 
attitudes toward God (NATG). 
 
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 To test H1, a dependent t-test was conducted to evaluate the differences in scores 
on PATG and NATG among participants, who reported changes in attitudes towards God 
(N= 43). The results of the dependent t-test indicated that PATG (M = 9.14, SD = 1.40) 
were significantly higher than NATG (M = 3.89, SD = 2.03), t(42) = 14.16, p<.001. The 
95% confidence interval for the difference in means ranged from 3.86 to 5.62.  Therefore, 
hypothesis 1 was supported for the spiritual forgiveness context. 
 
Cohen’s d was calculated to further determine the magnitude of the difference 
between PATG scores and NATG scores. Using Cohen’s d online calculator, information 
on the mean scores, standard deviations, and sample size (n=43) for each group were 
entered (Social Science Statistics, 2018). The results indicated a large effect size of 3.01 
 
H2: Positive attitudes toward God (PATG) and negative attitudes toward God (NATG) 
will significantly predict the criterion variables (PHRQOL and change in CD4 cell count).   
 
The Pearson correlation (r) results in Table 4.12 shows that there was no 
significant correlation between NATG and both PHRQOL and change in CD4 count. Only 
PATG significantly correlated with PHRQOL but not change in CD4 count. Therefore, H2 
was tested in relation to PATG and PHRQOL. Table 4.22 summarizes the results of the 
standard multiple linear regression model.  
Table 4. 22:  Summary Results of Positive Attitudes toward God Regressed on 
Psychological Health-Related Quality of Life 
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          53.70     10.23    
Positive attitudes towards God           2.34       1.11          .31       2.12  .041 
N= 43, F =4.471, p=.041; R2 = .098 
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 The results presented in Table 4.22 indicates that in support of H2, PATG 
significantly predicted PHRQOL (F(1, 41) =4.47, p<.05). The model accounted for 
approximately 10% of the variance in the outcome. There was a significant and positive 
predictive association between PATG and PHRQOL (β = .31, p<.05).  
H3: Adherence to ART (number of missed doses in the last 7days) and sexual risk 
behaviours (multiple sexual partner behaviours and frequency of condom use) would 
moderate the relationship between spiritual forgiveness (PATG, NATG) and PHRQOL. 
 
Hayes PROCESS v3.0 was used to test the moderating effects of ART adherence 
and sexual risk behaviours on the relationship between PATG and PHRQOL, considering 
that only PATG significantly predicted PHRQOL (see Table 4.12).  
Table 4.23:  Summary Results of Moderation Analysis on the PATG–Psychological 
Health-Related Quality of Life Relationship. 
Model    B         t Sig 
PATG * ART Adherence                   1.92                .75 .45 
PATG * MSP Behaviour                  -2.31       -1.03 .31 
PATG * Condom Use Behaviour                  -1.41               -.64 .52 
N = 43, *p<.05 *MSP = multiple sexual partner 
 
The moderation results presented in Table 4.23 shows that contrary to H3 there 
was no moderation effect of adherence or any of the sexual risk behaviours on the 
association between PATG and PHRQOL. 
 
H4: Controlling for related covariates, spiritual forgiveness (PATG and NATG) would 
remain a significant predictor of the criterion variables (PHRQOL and change in CD4 cell 
count), with PATG accounting for a larger proportion of the variance in the outcomes than 
NATG.    
 
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The correlation matrix in Table 4.12 shows no significant correlations between 
NATG and both outcomes. Thus, hypothesis four was investigated for PATG in relation to 
only PHRQOL, as PATG did not significantly correlate with change in CD4 count. Using 
a two-step hierarchical linear regression model, background factors that correlated with 
PHRQOL were entered in step one (see Table 4.11 and 4.12). These were marital status, 
first CD4 count, social support, and psychological distress. There were no correlations 
between the background factors and PATG. The predictor variable – PATG – was entered 
in step two to determine whether it would remain a significant predictor of PHRQOL, 
having ascertained its uncontrolled predictive power in H2. Table 4.24 summarizes results 
for H4 in relation to PATG. 
Table 4.24: Summary of Final Model Results of Relationship between Positive 
Attitudes Toward God and Psychological Health-Related Quality of Life 
Controlling for Covariates  
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Step 2      
Constant          35.93 10.73  2.21 .03 
Married or cohabiting         -2.38   3.29 -.12     -.73 .47 
First CD4 results  00     .01    00   .03  .98 
Social support  .51    .26   .31 1.97 .06 
Psychological distress           -.22    .25  -.14 -.86  .40 
PATG          2.38 1.13   .32 2.11 .04 
N = 42; F =.870 R2 = .086, p=.491 for model 1; F=4.470 R2 = .101, p=.041 for model 2 
 
The results of the hierarchical multiple linear regression model reported in Table 
4.24 indicates that H4 was also partially supported in the spiritual context: adjusting for 
related covariates, PATG (but not NATG) significantly predicted PHRQOL (F (1, 36) = 
4.47, p<.05), accounting for approximately 10% of the variance in this outcome. Both the 
first and second models failed to significantly explain the variation in PHRQOL (R2 = .09, 
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F = .87, p >.05 and R2 = .19, F=1.66, p>.05 respectively). Although, PATG made 
significant and positive unique contributions to the variance in PHRQOL ( = .32, p<.05), 
providing the only unique significant explanation of the variation in PHRQOL in the final 
model (F=4.470, R2 = .101, p=.041). 
 
4.5.3 Additional Analysis and Findings 
 The main focus and premise of the present study was to ascertain the 
predictive association between forgiveness (across the three contexts) and the outcomes of 
PHRQOL and change in CD4 count controlling for key related background factors. 
However, first, considering that social support significantly correlated with the 
interpersonal forgiveness predictors (DTFO: r=.26, N=191, p<.01 and EFO: r=.12, N=191, 
p<.05) as well as the outcome variable, PHRQOL (r=.12, N=191, p<.05), an additional 
mediation analysis was conducted. The purpose was to determine whether social support 
would mediate the relationship between interpersonal forgiveness and PHRQOL. Using 
Hayes Process Model 3.0, and model number 4 for mediation analysis, the results showed 
that social support did not significantly mediate the DTFO–PHRQOL relationship nor the 
EFO–PHRQOL relationship. The confidence intervals in each of the indirect associations 
changed from a negative to a positive value between the lower and upper bound limits (see 
Appendix G). 
Second, taking into consideration the close links that PHRQOL may have with the 
other domains of QOL, an additional analysis was further carried out to answer the 
questions:   
1. What is the predictive association between forgiveness (in the three contexts) and 
physical health–related QOL (PHYSQOL)? 
2. What is the predictive association between forgiveness (in the three contexts) and 
environment–related quality of life (ENQOL)?   
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It is worthy of mention that due to the very low internal consistency reliability recorded on 
the social relationships domain (.46), this domain was not considered for statistical 
analysis. 
 
Psychometric properties of Physical Health and Environment domains of WHOQOL-
BREF 
A single factor was extracted on the 8-item Environment domain (ENQOL) using 
principal components analysis. All items (8, 9, 12, 13, 14, 23, 24, and 25) loaded above .4 
on the unidimensional scale, which also showed good internal consistency reliability of 
0.76. On the physical health domain (PHYSQOL), the varimax rotated solution showed 
that all but one of the items (item 4: “How much do you need any medical treatment to 
function in your daily life?”) loaded onto one factor. Cronbach alpha was 0.65 on the 7-
item scale. Almost all participants selected “strongly agree” on this item, making reference 
to their ART regimen. Thus, this item was dropped as it showed almost no variation in its 
responses. The final solution showed a single factor scale onto which all 6 remaining items 
(3, 10, 15, 16, 17, and 18) loaded above 0.32. Cronbach alpha on the 6-item PHYSQOL 
was 0.74. 
 
Additional Findings 
Intrapersonal Forgiveness, Physical Health, and Environment Domains of Quality of 
Life 
 Intrapersonal forgiveness failed to significantly predict physical health-related 
quality of life (F(2, 88) =2.07, p>.05). There was no significant association between 
PHYSQOL and DTFS (ß =.19, p>.05) nor EFS (β = .06, p>.05).  
Also, intrapersonal forgiveness failed to significantly explain the variance in 
environment-related quality of life (F(2, 88) = .38, p>05). There was no significant 
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association between ENQOL and DTFS (ß =.04, p>.05) nor EFS (β = .07, p>.05). (See 
Appendix G) 
  
 
Interpersonal Forgiveness, Physical Health and Environment Domains of Quality of 
Life 
 Findings of the standard multiple regression analysis showed that together, 
interpersonal forgiveness (DTFO and EFO) marginally significantly explained 3.2% of the 
variance in physical health-related quality of life (F(2, 188) =3.25, p=.05). There were no 
significant and unique associations between PHYSQOL and DTFS (ß =.19, p>.05) nor 
EFS (β = .06, p>.05).  
Interpersonal forgiveness also failed to significantly explain the variance in 
ENQOL (F(2, 188) = 2.06, p>05). There was no significant association between ENQOL 
and DTFO (ß =.09, p>.05) nor EFO (β = .07, p>.05). (see APPENDIX G) 
 
Spiritual Forgiveness and Physical Health and Environment Domains of Quality of 
Life 
 In the spiritual forgiveness context, PATG and NATG together did not explain any 
significant variance in physical health related quality of life (F(2, 40) =1.50 p>.05). There 
was no significant unique association between PHYSQOL and DTFS (ß =.19, p>.05) or 
EFS (β = .06, p>.05). Similarly, spiritual forgiveness did not explain any significant 
variance in environment-related quality of life (F(2, 40) = .09, p>05). There was no 
significant association between ENQOL and PATG (ß =.01, p>.05) nor EFO (β = -.07, 
p>.05). (See Appendix G) 
Overall, these additional results indicate that there was no predictive association 
between forgiveness and the Physical or Environment domains of the WHOQOL-BREF.  
 
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4.6 Summary of Study One Findings  
Study one primarily aimed at investigating the association between forgiveness of 
HIV-specific offenses (as a predictor/independent variable) and two main outcome 
variables across three contexts – self, other, and spiritual. The outcome variables were 
psychological health-related quality of life (PHRQOL) and change in CD4 cell count. 
Following preliminary analyses, the main objective of the study to determine whether 
forgiveness would significantly predict the two outcomes in both unadjusted and adjusted 
analyses was tested.  In unadjusted analyses, covariates were not controlled for. Whereas 
in adjusted analyses covariates that significantly correlated with a predictor and/or 
outcome variable were controlled for. The mediation effect of social support on the 
interpersonal forgiveness-PHRQOL relationship as well as the association between 
forgiveness and other QOL domains were additionally investigated.  
Results of the preliminary analyses showed that over a third of the respondents 
experienced large to extreme amounts of hurt over their perceived most offensive 
situation. The most offensive situation for the majority of the participants was who/what 
they believed caused their HIV infection. These included themselves and other people, 
particularly sexual partners. Some also attributed their perceived offense to God as having 
allowed it. Five of the six predictor variables examined across the three forgiveness 
contexts significantly correlated with PHRQOL. These were decision to forgive self 
(DTFS), emotional forgiveness of self (EFS), decision to forgive other (DTFO), emotional 
forgiveness of other (EFO), and positive attitudes toward God (PATG). Only DTFS 
correlated significantly with change in CD4 cell count.  
Regression analyses further revealed associations between forgiveness and the two 
outcome variables, with important differences in the nature of the associations between the 
different forms/stages and contexts of forgiveness and the two outcomes. In particular, 
DTFS significantly uniquely predicted change in CD4 cell count. Together, DTFS and 
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EFS explained a significant proportion of variance in PHRQOL, although neither made 
unique significant predictions of this outcome when covariates were controlled for. Also, 
PATG significantly uniquely predicted PHRQOL. Both DTFO and EFO together 
explained a significant proportion of the variance in PHRQOL, although neither made 
unique significant predictions of this outcome. The following sections present a brief 
discussion of the findings from Study 1. 
 
4.7 Brief Discussion of Study 1 Findings 
Decisional versus Emotional Forgiveness  
The first finding of this study was that participants reported more of decisions to 
forgive the self than emotional forgiveness of self (in the intrapersonal context) and more 
of decisions to forgive another offender than emotional forgiveness of another (in the 
interpersonal context). In the interpersonal context, this finding may indicate that PLWHA 
may be more ready to decide to forgive perceived offenders than they may be to 
experience positive emotions. Hook and colleagues (2009; 2011) found that individuals 
high on collectivistic worldviews seem to show a greater tendency to respond to 
(interpersonal) offenses with decisional forgiveness than emotional forgiveness. 
According to them, the priority that individuals in collectivistic cultures seem to place on 
maintaining interpersonal/social harmony may explain why they may be quick to decide to 
let go of offenses. On the other hand, as noted by Worthington (2005), some researchers 
have reported that decisional forgiveness may be easier to experience and attain than 
emotional forgiveness. However, the findings may also support the proposition that 
indeed, decisional forgiveness precedes emotional forgiveness in the process of 
forgiveness coping with offenses (Worthington & Scherer, 2004; Worthington et al., 
2007). Hence, while PLWHA may have fully or strongly decided to forgive, it is possible 
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that they may not yet have completely replaced their negative emotions with more positive 
emotions toward the perceived offender.  
 More interestingly, that these differences were observed in the intrapersonal 
context may suggest the possibility of deciding to forgive one’s self and eventually 
experiencing positive emotions toward the self. For example, in line with the definition of 
self-forgiveness by Hall and Fincham (2005), it may be possible that people who perceive 
self-inflicted offenses may decide not to retaliate against the self via active self-punishing 
or passive self-neglecting behaviours. They define self-forgiveness to include decreased 
motivation to retaliate against the self, including punishing the self, engaging in self-
destructive behaviours, etc., and increased motivation to act benevolently towards the self. 
Indeed, the terms “decisional forgiveness of self” and “emotional forgiveness of self” may 
not have been explicitly expressed in the self-forgiveness literature. However, that self-
forgiveness has been recognized to entail release of negative self-directed emotions and 
behavioural motivations and fostering of positive ones (Woodyatt et al., 2017), seem to 
provide some support for the significant difference found between DTFS and EFS in this 
study. 
 
Decision to Forgive self and Immune Functioning 
 One of the major findings of the present study was that decision to forgive the self, 
predicted immune function – change in CD4 cell count. Controlling for related covariates, 
DTFS remained a significant predictor of immune functioning, whereas, there was no 
significant association between EFS and this outcome. This finding is in contradiction to 
reports in favour of emotional forgiveness as more beneficial to health outcomes (e.g., 
Worthington et al., 2007; Worthington & Scherer, 2004; Toussaint & Worthington, 2017). 
However, it lends support to the proposition that although there may be additional health 
benefits of developing positive emotional states, “the health benefits of forgiveness should 
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include the health benefits of unforgiveness reduction” (Harris & Thoresen, 2005, p. 322). 
As initially argued above, decisional forgiveness may involve more than making a 
decision not to retaliate in response to an offense. It may also involve some level of 
changes from a higher to a lower state of unforgiveness, possibly leading to that decision 
to forgo any negative behaviours toward the offender (Worthington et al., 2007).  
Indeed, a closer consideration of the items on the DTFS scale (e.g., “I have decided 
not to intentionally harbor hatred towards myself” and “My choice is to release any 
negative ideas or thoughts I have about myself”), seem to lend some support to this 
argument. These items suggest that deciding to forgive includes a decision not only to 
forgo retaliatory/avoidant behaviours, but also, the negative feelings and thoughts that may 
lend unforgiveness its negative link to health (Harris & Thoresen, 2005). Therefore, while 
these findings are in no way suggestive of a causal link between decisional forgiveness of 
self and immune functioning, they suggest the possibility that the processes inherent in 
letting go at the decisional forgiveness stage, may entail important links to immune health.  
 
Intrapersonal Forgiveness, Interpersonal Forgiveness, and Psychological Health-
Related Quality of Life 
The present study found that self-forgiveness (DTFS and EFS) and other-
forgiveness (DTFO and EFO) explained significant proportions of the variance in 
psychological health-related quality of life even after controlling for important 
sociodemographic, clinical, and psychosocial factors including social support and 
psychological distress. This finding supports the myriad of studies that have found support 
for the association between forgiveness and health across illness populations (e.g., Akhtar 
& Barlow, 2016; Harris & Toressen, 2005; Lawler et al., 2005; Toussaint & Web, 2005; 
Woodyatt et al., 2017; Toussaint & Worthington, 2017). In the intrapersonal context, both 
DTFS and EFS also made unique significant contributions to the variation in PHRQOL in 
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unadjusted analysis. Decision to forgive others (DTFO) and EFO were however, not 
uniquely associated with PHRQOL even in the unadjusted analysis. This inconsistency 
rather seems to underscore previous findings in HIV/AIDS and other patient populations 
that have found support for intrapersonal forgiveness as a better predictor of health than 
interpersonal forgiveness (e.g., Bassett et al., 2016; Hua, 2012).  
Another finding was that adjusting for background factors, health behaviours, and 
other psychosocial factors, the different stages of intrapersonal and interpersonal 
forgiveness did not uniquely predict PHRQOL. Although, social support and 
psychological distress largely remained significant predictors. This finding may be 
attributed to the fact, PHRQOL is a complex experience that aside forgiveness, could be 
affected by various inter-related factors. For instance, the inter-correlations in Table 4.12 
indicate that higher levels of forgiveness were associated with higher social support for 
PLWHA who had experienced interpersonal offenses. Thus, clearly distinct associations 
between forgiveness and PHRQOL may require for example, experimental methods to 
ascertain. A number of methodological differences between the present study and similar 
previous studies (e.g., Owen et al., 2011; Wald & Temoshok, 2004a) may also have 
accounted for the absence of unique associations that were noted in this study. 
First of all, it is worth noting that the factors controlled in the studies by Owen and 
colleagues (2011) and Temoshok and Wald (2004a) excluded these two important HIV-
related factors – social support and psychological distress. Secondly, forgiveness has 
largely been considered in the few HIV studies and majority of other forgiveness-health 
studies as a global construct (Harris & Thoresen, 2005). The present study investigated 
forgiveness as a process that may occur in two main stages – decisional and emotional 
stages. Furthermore, reports indicate that state forgiveness of specific offenses may be less 
predictive of health than dispositional forgiveness (Lawler et al., 2003; Lawler, et al., 
2005; Thompson et al., 2005; Worthington et al., 2007). In the present study, it was 
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pertinent to assess state forgiveness, considering the specific nature of the offense in 
question.  It is possible that among participants who self-reported unforgiveness, this 
negative stress response may not yet have fully manifested across different aspects of their 
lives (Toussaint et al., 2016a, b). Finally, it may also be that the adapted forgiveness 
measures employed in this study may have contributed to the unique contributions of the 
forgiveness stages not showing significant associations with PHRQOL. However, since no 
studies have yet been identified that employed the original versions of the scales with 
PLWHA, it may be difficult to compare and ascertain this assumption. Besides, the 
validation procedures showed good construct validity and internal consistency reliability 
of the scales. For example, internal consistency reliability was excellent (.92) on the 
DTFO scale and even slightly higher than on the original 6-item scale (.90). Furthermore, 
similar other- to self-forgiveness definitions and measures have been previously reported 
(Woodyatt et al., 2017). Nonetheless, it is important that any findings at this stage remain 
exceptionally tentative.    
 
Positive Attitudes toward God and Psychological Health-Related Quality of Life 
The present study found that in the spiritual context, positive attitudes toward God 
were reported significantly more than negative attitudes toward God. Similar results were 
found in the study by Ironson and colleagues (2011) in which participants reported more 
positive than negative views of God. When examined in relation to PHRQOL, the study 
found that PATG (but not NATG) significantly predicted PHRQOL and remained a 
significant predictor after variances from related covariates were removed. Again, this 
finding is in support of that by Ironson et al. (2011) and suggests that viewing God as 
benevolent, all knowing, all powerful, caring, and nurturing, may have important bearings 
on how PLWHA perceive their psychological health. In line with the theorization by 
Temoshok and Wald (2005), it is possible that participants’ PATG may have offered them 
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with strength to accept their HIV status and to engage in positive health promoting 
behaviours essential to psychological health (e.g., maintaining social relationships, and 
seeking/accepting social support). As mentioned above, both DTFO and EFO positively 
correlated with social support in the interpersonal context. It may also be that PATG 
allows PLWHA to reframe their HIV positive status as an opportunity for growth and a 
greater God-given purpose in life (Ironson et al., 2011).  
That NATG failed to significantly correlate with health outcomes in the present 
study may be that the generally religious nature of Ghanaians (Anderson, 2013) and the 
study sample for that matter, may have influenced the extent to which participants 
expressed their negative emotions and thoughts about God. It may be that participants, 
who reported NATG did so with some reservations or caution to avoid a situation of 
charging God with wrongdoing. Thus, participants’ responses about their NATG may not 
have been a true reflection of their perceived health status. Nonetheless, very few 
participants actually reported any negative attitudes toward God. This may also have 
accounted for the no association between NATG and the outcomes. 
 
Conclusion to Study 1  
In conclusion, Study 1, which sought to determine the association between 
forgiveness across three contexts and psychological and immune health in PLWHA has 
found support particularly for PATG and DTFS as unique predictors of psychological 
health and immune health respectively.  These findings in a number of ways correspond 
with existing findings and theorizations on forgiveness. In addition, findings from the 
present study highlight other interesting insights into this complex phenomenon such as 
decisional forgiveness not only being more reported, but also, being more predictive than 
emotional forgiveness in the self-context.  
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CHAPTER FIVE 
METHODOLOGY AND RESULTS FOR STUDY TWO 
 
STUDY 2: LIVED EXPERIENCES OF FORGIVENESS OF HIV-RELATED 
OFFENCES AMONG PEOPLE LIVING WITH HIV/AIDS IN GHANA 
 
5.0 Introduction 
This section of the thesis presents details of the methodology and findings of Study 2 
titled; “Lived Experiences of Forgiveness of HIV-Related Offences among People Living 
with HIV/AIDS in Ghana”. It also presents a summary and brief discussion of the 
findings.  
 
5.1 Research Questions  
Following Study 1, an in-depth qualitative phenomenology study, which adopted 
interpretative phenomenological analysis (IPA) was employed to answer two main 
research questions: 
1. What are the lived experiences of forgiveness of HIV-specific offenses among 
PLWHA in Ghana? 
a. How do PLWHA in Ghana conceptualize and relate to the constructs of self-
forgiveness, other-forgiveness, and change in attitudes towards God? 
b. What is it like, to forgive an offence specifically due to one’s HIV-positive 
status?  
c. What factors facilitate or hinder forgiveness of perceived HIV-specific 
offenses? 
 
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2. What does it mean to PLWHA in Ghana to have been diagnosed with HIV, 
experience an offence specifically due to their positive status, and to have forgiven 
(or not forgiven) the offender? 
a. How do PLWHA in Ghana perceive the influence of forgiveness (or its 
converse) of HIV-specific offenses on their health? 
b. What are PLWHA’s perceived role of forgiveness (or unforgiveness) on other 
aspects of their lives including social relationships? 
 
5.2 Study Design – Interpretative Phenomenology 
 Study 2 employed an interpretative phenomenological design to basically 
understand two main issues: 1) the perceptions of PLWHA in Ghana regarding their 
forgiveness (or otherwise) of offenses experienced directly in relation to their HIV-
positive status and 2) the meaning participants make of their HIV-specific forgiveness 
experiences (Creswell, 2014; Smith & Osborn, 2004; Tuffour, 2017).  
Phenomenology is a qualitative research design concerned with the essence 
(structure and meaning) of lived human experiences about a phenomenon (Creswell, 2014; 
Eatough & Smith, 2008; Smith & Osborn, 2004; Tuffour, 2017). Its goal is to examine in 
detail, the personal and social world experiences of phenomena that people have lived 
through and the meaning they make of these experiences (Creswell, 2014; Smith & 
Osborn, 2004). While there are purely descriptive types of phenomenology, in this study, 
the double-hermeneutic approach that distinguishes the IPA method was employed 
(Creswell, 2014; Eatough & Smith, 2008; Smith & Osborn, 2004; Tuffour, 2017). The 
concept of double-hermeneutics describes the role of the researcher in skilfully drawing 
out a second deeper meaning or interpretation of participants’ own sense-making of their 
lived-through experiences (Eatough & Smith, 2008; Smith & Osborn, 2004; Tuffour, 
2017). It has been argued that it is impossible for researchers to report participants’ 
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descriptions without describing or expressing them from their interpretative lens (Tuffour, 
2017) – the perspective informed among other things, by researchers’ experiences, 
knowledge, beliefs, and historical backgrounds and from which they may interpret any 
given phenomenon. Thus, phenomenology, specifically the IPA method, was adopted in 
Study 2 to guide the data collection and analysis to be able to bring out not only 
participants’ descriptions of their lived experiences, but also, the meaning they make of 
these experiences as well as what these could mean from the researcher’s interpretative 
lens in line with the overall study goals.  
 
5.2.1 Rationale for Study 2  
 The purpose of study 2 was first of all to understand in further detail, how 
forgiveness of HIV-specific offenses impact health and wellbeing from the perspectives 
and interpretations of PLWHA in Ghana. At present, a thorough review of the forgiveness 
and HIV literature suggests that the existential accounts of this population in Ghana and 
most likely the whole region have yet to be systematically explored. Secondly, Study 2 
was intended to identify and extend culturally-relevant contexts of meaning/explanations 
to the findings from Study 1. Finally, Study 2 was carried out for purposes of triangulation 
as the theories, literature, and measures that informed Study 1 have largely been developed 
based on Western literature and data.  
 
5.2.2 Participants and Sampling Procedure –Purposive sampling   
 Fifteen participants from Study 1 were selected again using the purposive sampling 
technique (Bilinski et al., 2013). The purpose of this sampling technique was to allow for 
an in-depth exploration of forgiveness from PLWHA across all the adult age groups that 
were represented in the survey (young adults: 18-30years, middle adults: 31-49years, and 
older adults: ≥ 50years). This was also to increase the chances that information on the 
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phenomenon in focus would be elicited from perinatally infected PLWHA. These are 
PLWHA who acquired the HIV infection from an infected mother during the perinatal 
period. It was anticipated that they may have unique experiences from those who may 
have been infected via external factors/behaviours. Thus, this sampling method, which 
combined purposeful and probability sampling techniques was not only appropriate, but 
also, informationally representative (Bilinski et al., 2013).  
Participants from each of the study sites, who had agreed to the follow-up 
qualitative study, were first stratified by age. Stratification was achieved by writing 
participants’ folder numbers on sheets of paper and placing each paper in a respective age 
category-labelled box by hospital. Participants were then purposively selected to allow for 
gaining rich descriptions necessary to throw more light on the quantitative findings. Of the 
15 participants selected, 3 were receiving treatment from the Korle-Bu Teaching Hospital, 
7 from the Tamale Teaching Hospital, and 5 from the Komfo-Anokye Teaching Hospital. 
This sample size is in support of the views of Pietkiewicz and Smith (2012). They 
emphasize that sample size in descriptive-interpretive studies may range from 1 to 15 or 
more depending on a number of factors such as the depth of analysis a researcher intends 
to do both within and across cases in line with the objectives of the study.   
 
5.2.3 Inclusion and Exclusion Criteria 
As all participants in Study 2 had participated in Study 1, they automatically 
fulfilled the following inclusion and exclusion criteria: 
1. Adults with HIV/AIDS aged 18 years and above 
2. Ever experienced an offense directly related to their HIV-positive status  
3. Have been taking ART for at least one year.  
4. Participants were excluded if they showed any signs of distress related to the 
interview questions. 
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5.2.4 Data Collection Instruments – Semi-structured Interview Schedule 
 This phenomenology study relied on semi-structured interviews to obtain 
descriptions necessary to answer the research questions for Study 2. A semi-structured 
interview schedule (Appendix G) was developed that focused on eliciting participants’ 
descriptions and sense making of the phenomenon under investigation from their own 
thoughts, emotions, and behaviours (Smith & Osborn, 2004).  
 The purpose of the interview schedule was to serve as a guide for the researcher to 
gather as much in-depth information as possible and to flexibly dialogue with participants, 
asking interview questions and prompts in a way that made the conversation flow. That is, 
the researcher did not ask the interview questions strictly in the order in which it was 
drafted but rather flexibly in accordance with how individual participants narrated their 
responses to each question. Furthermore, while it provided some standard structure to the 
questions asked of participants, it allowed the researcher to probe further into arising 
issues as the interviews progressed, resulting in deeper descriptions of the phenomenon 
under investigation and their sense making of it (Harding, 2013).  
Essentially, the interview schedule asked participants to describe their HIV-related 
offense experiences. This was necessary to situate the forgiveness questions in the 
appropriate context. Participants were also asked to describe their forgiveness experiences 
and what these experiences meant to them. Well-structured prompts were used to guide 
the conversation to generate   descriptions of all aspects of their experiences. The 
interview questions were revised as appropriate for participants who reported 
unforgiveness of any HIV-specific offense they had experienced.  
 
5.2.5 Pilot Study 
 A small number of 4 participants were selected separate from those included in the 
main qualitative study to test the appropriateness and level of understanding of the 
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interview questions. The pilot study was also conducted to test the suitability of the order 
in which the interview schedule had been designed to allow for a good flow of the 
interaction between the researcher and participants during the main study (Harding, 2013). 
Pilot participants included PLWHA receiving care at the Tamale (n=2) and Komfo 
Anokye (n=2) Teaching Hospitals. The researcher’s observations about the pilot 
interviews as well as participants’ feedback highlighted the need for a translation of the 
schedule into the most common local language – Twi. This was done by a professional 
with Master’s degree in Ghanaian languages. Also, the pilot phone interviews greatly 
equipped the researcher with knowledge about how to handle any phone interviews that 
became necessary in the main study. 
 
5.2.6 Study Procedure 
 Following analysis of data from Study 1, participants who consented to follow-up 
were selected from each of the hospitals to participate in Study 2. Participants were 
contacted through the telephone numbers they consensually provided during the survey. 
Prior to commencing each interview, participants’ questions and concerns (e.g., whether 
the recordings included a video recording) were thoroughly addressed. All participants 
gave written informed consent to participate in the study and also gave permission for the 
interviews to be audio recorded prior to the interviews.  
 With the exception of two participants in Tamale and one in Kumasi, all interviews 
were conducted face-to-face by the researcher, using the interview schedule as a guide. 
The other three interviews were conducted by the researcher by phone. Verbal informed 
consent was recorded for phone interview participants. The primary reasons for the phone 
interviews were participants’ inability to travel to the study site/hospital during the period 
of the study. One of the participants however indicated a reluctance, fear, and lack of 
confidence in going into public ever since she was diagnosed with HIV, and as such, was 
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reluctant to come to the study site for a face-to-face interview. To ensure similar interview 
experiences irrespective of the interview mode, the researcher conducted the phone 
interviews in a quiet and locked office at each of the sites, in order to minimize 
disruptions. The researcher also used careful listening, frequent repetitions, and summaries 
of participants’ narratives to ensure that no details were lost over the phone (and also with 
face-to-face participants). The face-to-face interviews were conducted at the study sites, 
also in offices that helped to ensure that participants’ narratives remained confidential. 
Field notes were taken during both face-to-face and phone interviews for cross-checking 
of participants’ narratives during the analysis. Each interview lasted between 
approximately 30-60minutes. Each participant received a token of appreciation for their 
time in participating in the interview. 
 
5.2.7 Analytic Strategy –Interpretative Phenomenological Analysis 
 Following the interview data collection, the audio recordings in Twi were first 
translated and transcribed verbatim in English by a professional translator, who holds a 
Master’s degree in Ghanaian Language. These transcripts were reviewed along with the 
audio recordings by the researcher and a second independent person to ensure that the 
transcripts were accurate within the context of participants’ narratives. The second 
independent person was a PhD candidate outside of the area of psychology who received 
training in the area under investigation. All other audio recordings were also transcribed 
verbatim by the researcher and the second independent person. The verbatim transcription 
helped to capture as much as possible, every single description of participants’ 
experiences.   
Interpretative phenomenological analysis (IPA) was used to analyse the data. The 
core tenets of IPA is that researchers interpret how participants make sense of their lived 
experiences of a phenomenon (Smith & Osborn, 2004; Eatough & Smith, 2008). 
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Typically, IPA is characterized by data-driven inductive process of coding. This type of 
coding emphasizes detailed ideographic study of people through the generation of codes 
on the direct basis of the emerging information from participants. This means, without 
prior hypotheses or predetermined codes (Pietkiewicz & Smith, 2012). This bottom-up 
method of analysis is suitably oriented to the goals of phenomenology (Tuffour, 2017). 
Indeed, that Study 2 was conducted to help explain the Study 1 findings means that the 
objectives and hence research questions of Study 2, may have reflected that of Study 1. 
However, these data analysis steps directed by Smith and Osborn (2004) were followed to 
stay close to the strengths of the IPA method: 
1. Each transcript was thoroughly read and reread several times along with the audio 
recordings. This allowed the coders to immerse themselves within each data 
item/transcript.  
2. The coders independently coded each line of each transcript so that thorough data-
driven codes were generated per data item. NVivo version 11 qualitative data 
analysis software was used for the coding.  
3. Following coding, the researcher and the second independent person reviewed the 
codes together with a third person. Where there were disparities in the codes, these 
were discussed and the views of the third person helped to come to an agreement 
that most closely reflected participants’ personal descriptions.  
4. Emergent themes were then developed within each transcript. This process of 
coding followed by theme development was repeated for all transcripts.   
5.  Superordinate themes based on similar patterns of emergent themes identified 
within each data item and across the dataset were extracted. These were then 
reviewed (together with the third person) to check for how well the superordinate 
themes, emergent themes and subthemes coherently interrelated as well as 
reflected the descriptive overviews and deeper meanings of participants’ accounts.  
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6. Superordinate themes, themes, and subthemes identified, were reported (Chapter 
Five) with supporting extracts from participants’ narratives. The researcher’s 
interpretation of what these overarching patterns in the data mean were also 
discussed in line with the objectives of the study.  
This descriptive-interpretative method of data analysis differs from thematic analysis 
in that it focuses on inductive coding whereas the latter can employ inductive coding, 
deductive coding or both (hybrid method).  Secondly, in IPA, themes are developed 
for each data item (individual transcript) and then across the whole data set (all 
transcripts). In thematic analysis however, themes are typically generated across the 
dataset (Creswell, 2014). 
 
5.3 Trustworthiness of Data Analysis and Findings  
 A number of strategies were adopted to ascertain the trustworthiness – 
confirmability, dependability, credibility, and transferability – of the qualitative study 
findings. First, prior to initiating the analysis, the researcher and the second transcriber and 
coder reflected (separately) on and noted down their assumptions about the nature and 
meaning of forgiveness. In addition, each noted down her background (e.g., Christian and 
healthcare researcher), significant life experiences of forgiveness, as well as her values 
and expectations when it comes to forgiveness of offenses. The purpose of this reflective 
exercise was to ensure confirmability of the qualitative findings as it ensured that the 
codes as well as interpretation of the themes reflected participants’ experiential realities, 
rather than a fictional non-existent reality or a biased reality of the researcher. Also, to 
further ensure that the findings were confirmable, the researcher drew on relevant 
psychological theories and principles to appropriately guide interpretation of the themes 
generated from the data.  
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Secondly, to ascertain the credibility of the findings, the interviews were 
transcribed and coded by the researcher and a second independent person, and the codes 
and themes were reviewed together with a third neutral person. To establish transferability 
of the findings, thick descriptions of the study participants’ background information 
including the hospitals they were selected from, the target(s) of their perceived offense, 
whether or not they had forgiven the perceived offense, their age, and gender were 
provided (under the results section below). Finally, the dependability of the qualitative 
findings was ensured through peer review by the 3rd independent person of the final 
themes and interpretations alongside the raw data transcripts. Dependability was also 
established by supporting the final themes with verbatim quotes from participants’ 
narratives.  
 
5.4 Results  
5.4.1 Introduction 
This section reports findings of the interpretative phenomenological analysis conducted to 
make meaning of the descriptive and explanatory themes from participants’ lived 
experiences of the phenomenon of forgiveness (of HIV-specific offenses). It begins with a 
basic description of the interview participants’ background characteristics followed by a 
report of the three superordinate themes and their respective themes and subthemes that 
were identified. At the end of each theme, the researcher’s interpretation of the findings is 
highlighted. The section closes with a table summarizing the list of themes and subthemes 
identified and example supportive quotes.  
 
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5.4.2 Characteristics of Interview Participants 
 Table 5.1 summarizes relevant characteristics of Study 2 participants.  
Table 5.1: Background Characteristics of Interview Participants 
Part. Hospital Gender Age Offense Target(s) Forgiveness Status 
ID Group 
1 TTH F MA Ex-boyfriend (Deceased)1 Forgiven  
2 TTH M OA Self (Possible past lifestyle)2 Forgiven  
3 TTH F MA Ex-friend (Deceased)1 Not forgiven  
4 TTH M OA Ex-wife (Deceased)/Relatives1 Forgiven and Not Forgiven 
5 TTH F MA Self and Ex-husband (deceased)1,2 Forgiven  
6 TTH F MA Self and Husband (Alive)1 Forgiven  
7 TTH M OA Self (Previous lifestyle)2 Forgiven  
8 KA F YA Ex-boyfriend (Alive)1 Forgiven  
9 KA F MA Self (Possible past lifestyle)2 Forgiven  
10 KA F MA Husband (Alive)1 Forgiven  
11 KA F OA Husband (Alive)1 Forgiven  
12 KA F YA Stepmother1 Forgiven 
13 KB M MA Self (Previous lifestyle)2 Forgiven? 
14 KB F OA Ex-husband (Deceased)1 Forgiven  
15 KB F YA God and ex-partner3 Not forgiven  
1Interpersonal context 2Intrapersonal context 3Spiritual Context YA: Young adult, MA: 
Middle adult, OA: Older adult 
 
Table 5.1 summarizes the demographic and forgiveness background characteristics 
of the interview study participants. More women (n=11) than men were involved in the 
interview study, reflecting the larger proportion of women to men in the HIV population in 
Ghana. Majority (10) of the study participants reported that the offense they perceived was 
directed at other people, primarily, spouses or partners but also relatives. Four of the 
participants perceived themselves as the targets of their offenses. Two females reported 
both themselves and their ex- and living-husbands as the targets of their offenses. Only 
one person attributed her anger to God, and in addition, felt offended at her ex-partner. 
 
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Forgiveness was reported among 13 participants. Two female participants reported 
not having forgiven any of their perceived targets or sources of their HIV-related offenses. 
One male participant reported having forgiven his perceived source – late wife – of his 
HIV-positive status but not his relatives who continue to display stigmatizing and 
discriminatory attitudes towards him and HIV in general.  
 
5.4.3 Superordinate Themes, Themes, and Subthemes 
 Three superordinate themes were identified from participants’ narratives as HIV-
Specific Offense Experiences, Experiences of the Forgiveness Process, and Implications 
of Forgiveness. Six themes were identified from participants’ descriptions and sense 
making of forgiveness experiences as related to their perceived HIV-specific offenses. 
These were: Offense Nature; Offense Responses; Personal Actions and Changes; Realities, 
Conditions, and Rationalization; Restoration, Development and Preservation; and Focused 
Life. The meaning of the themes and their respective subthemes are reported below in line 
with the research questions for Study 2.  
 
5.4.4 Superordinate Theme A: HIV-Specific Offense Experiences  
This superordinate theme describes the range of HIV-positive-related situations 
that were experienced by participants as offensive and their responses to these situations. 
Two themes emerged under this superordinate theme: Offense Nature and Offense 
Responses. It was within the context of these offenses and responses that participants 
situated their experiences of forgiveness in HIV. 
 
5.4.4.1 Theme 1: Offense Nature  
This theme describes the range and characteristics of situations perceived by participants 
as offensive experiences directly related to their HIV-positive status. Three subthemes 
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emerged under this theme as Causes of HIV, Negative Attitudes, and Illness and 
Treatment Demands. 
 
Causes of HIV 
This subtheme describes participants’ perceived modes of acquiring the HIV 
infection. That is, how or from whom they got HIV. Modes of acquiring the infection were 
the most commonly perceived sources of offense related to participants’ HIV-positive 
status. Sexual partners, whether alive or deceased, were mostly mentioned as causes of 
participants’ HIV infection and hence the source of their perceived offenses as indicated in 
the extracts below:  
“I got infected by my late wife…I was always annoyed when I saw the mother. I 
didn’t find it easy at all. I got sick for like 8years” (Participant 4) 
 
 
“My husband was diagnosed first after he had been sick for about two years. Even 
he, he didn’t know oo…and then me too, I came to check and they said there are 
some of the virus in my blood. When I learnt about it, it hurt me very badly” 
(Participant 10) 
 
According to one participant, she got (sexually) infected by a (deceased) man who she had 
earlier believed was going to get her a job: 
That time I just completed school and I needed a job… and that person was 
sending me to workshop, this HIV workshop… and he wanted to give me a job. So I 
thought it was, he was a good person, a good Samaritan…but through that…I’m 
infected person… Oh yes he knew about it [his HIV positive status]” (Participant 
3). 
 
Participants also reported past sexual behaviours as mistakes they made which may have 
caused their HIV-infection. It appeared that some participants perceived these mistakes as 
injustices they had committed against themselves. As narrated by one participant:  
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“I felt that, I felt I had, I had not lived a life that I ought to have lived. So I failed 
myself. So I put the blame squarely on my own self.” (Participant 7) 
 
One participant felt offended with herself for not having pursued her life goals but rather, 
going into marriage under the influence of her father and getting infected by her late 
husband [P5]. 
“…they [father] used to say that you should marry, you should marry. And now I 
marry and I get HIV. At that time, I had gotten police in Accra…yes, yes, but I got 
married and I didn’t go again. If I had gone, like by now maybe koraa like I’m not 
here.” (Participant 5) 
 
Similarly, another female participant’s perceived offense was not only toward her husband 
for living an immoral life and infecting her with HIV through that. But also toward herself 
for not leaving the marriage despite her husband’s immoral behaviours. She reported that: 
“At times, I used to curse myself. I would ask myself how did I even come in 
contact with this person that is not morally sound? Or even when there was some 
issue in the marriage, why didn’t I use that and leave. At times, when you say that 
it shall be well, it shall be well, it is not well…I will advise others that they should 
not keep saying it shall be well but take to their heels when they suspect that kind 
of behaviour.” (Participant 6)  
 
The participant, who reported anger toward God narrated that: 
“I felt so angry at God. I was crying and asking God, why, why, why? In fact, I 
stopped praying and even going to church. Because I felt that He doesn’t hear my 
prayers or even care about me so what’s the point in going?” (Participant 15) 
 
Negative attitudes 
 The second subtheme that emerged concerns the negative attitudes that 
participants had experienced from others as a result of their HIV-positive status. It 
emerged that experiences of rejection, discrimination, isolation, and other stigmatizing 
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attitudes as a result of one’s HIV-positive status were very painful offenses. Often, these 
negative behaviours were carried out by family members, who had knowledge of 
participants’ HIV-positive status. In support of this finding, one participant narrated his 
ordeal in this manner: 
“…they [family members] don’t associate me whatever they are doing in the 
house…they don’t even mind me to be somebody…they are still stigmatizing me 
because of the HIV…in the morning I have to force and greet them but they cannot 
greet me…even I go and use the bathroom, and quickly, they will go and scrub the 
place.” (Participant 4) 
 
The young lady who acquired the infection perinatally (mother deceased), also narrated 
her experiences of stigmatization and discrimination as a result of her positive status as: 
“At first, even me I didn’t know. My father used to take me to the hospital. I didn’t 
know. So, it was one day “bi” that I asked the nurses and they told me. So, at first, 
I didn’t understand, like I used to wonder why my stepmother didn’t want me to 
come close to her. She used to isolate herself from me.  She’ll warn my younger 
[step] siblings not to come close to me otherwise they’ll get sick. She even used to 
tell other people in the house that I have HIV. When I use a cup, she won’t touch it, 
3h333…so at first “de3”, I used to hurt a lot, a lot.” (Participant 12) 
 
For the lady who felt angry at God, her fiancé rejecting her for testing positive to HIV, 
while he tested negative prior to their marriage, was the most painful of all her perceived 
HIV-related offenses. She narrated her experience as: 
“the most painful thing was the guy disappointing me. Because I never thought he 
could do that. I thought he would stand by me no matter the situation. Because if it 
were me, I would stand by him…the wedding calling off was more painful than 
finding out I was pregnant and he not taking any responsibility towards the child.” 
(Participant 14) 
 
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Illness and Treatment Demands 
Finally, the illness and treatment demands of the HIV infection itself were also 
reported as other offensive experiences by the participant who acquired the infection via 
mother-to-child transmission [P12]. She explained that she felt hurt for having to endure 
the visible symptoms (rashes) of the infection as well as take medication every single day 
without missing any. Also, the financial difficulties she continuous to experience in 
meeting up with routine clinic visits and laboratory tests, causes her great pain/hurt. 
According to her: 
“Sometimes I have to walk all the way to Atonsu Junction before I can take car to 
G [KATH]. Even at first, they used to share some things for us where I was 
initially going, like soaps and stuff like that. But here they don’t give us anything. I 
struggle a lot. When I come and I have to do labs, I often don’t have money. So it 
makes me hurt a lot. It makes me hurt a lot. And the drug too, you have to take it 
every single day. Even you can’t miss it even one day “koraa”.” (Participant 12).  
 
Similar financial challenges in meeting the costs of the routine laboratory tests were 
reported by other participants including participants 9 and 10. Although, these experiences 
were not reported as offensive as was the case in participant 12. For instance, one married 
non-working woman reported that: 
“But the medication at times I don’t take it o, hmmm. You see, this medication, 
when you take it you feel hungry. And now, times are hard for me. So at times, if I 
see that I won’t get food to eat, I don’t take it.” 
 
Another married woman also shared that: 
“…the labs, “33n”, the labs, please, tell them to help us. It’s too expensive. Even 
today, I have to do some labs, but I can’t. So I’ll go and see if I can come later to 
do it. At first, everything used to be free but now, it’s only the medication that is 
free.” (Participant 9) 
 
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These emerging HIV-related offense experiences seem to point out a number of 
important issues. First, there seem to be a major challenge with disclosing a positive HIV 
diagnosis or status to young people who acquired the infection via vertical (mother-to-
child) transmission. The narratives by the young lady who got to know of her positive 
status from her nurses raises the difficult question of when, who and how to break the 
news of a positive HIV status to children and young adults infected perinatally? It appears 
that parents or surviving guardians of these young adults may not have the requisite 
information, skills, and confidence to break such news to their children. It may also be that 
parents lack the appropriate coping strategies they may need to effectively deal with the 
many potential ways in which their young ones may respond to such news. These may 
include anger, isolation, depression, and even suicidal thoughts and attempts. Whatever 
the reasons may be, the core and glaring public health problem inherent in this lack of or 
delayed information is that young people may become sexually active without any 
knowledge of the risk they pose to others and even themselves (in terms of HIV re-
infection).  
A second issue emerging from these narratives concerns the perception of financial 
challenges in meeting the treatment demands as a source of offense for the young lady 
who was perinatally infected. While other participants complained of such economic 
difficulties in relation to their treatment, these were not perceived as offenses.  Perhaps, 
for young people who acquired the infection out of no direct fault of theirs, it may be 
crucial to remove financial and similar barriers, to help promote adherence to treatment 
recommendations. It appears that they may hold the view of “why do I have to suffer to 
manage something I did not call for?”  
Participants’ narratives about the most common type of HIV-related offense – who 
or what caused HIV – also seem to reiterate the importance of continuous HIV education 
and voluntary testing. It appears that most participants, including those who had lost their 
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spouses or partners were not expecting a diagnosis of HIV. This raises a concern over how 
informed people are, about the signs and symptoms of HIV infection along the various 
stages of the condition.  
Also, the sexual partner-related offenses seem to suggest a sense of helplessness 
among couples whose spouses may engage in risky sexual behaviours that place them at 
risk of infection. As hinted by participant 6, looking on such behaviours and hoping it is 
well does not make it well. This may suggest an area that needs to be paid attention to in 
HIV/AIDS education – equipping married couples in particular with practical information 
and ways of protecting themselves in such cases of infidelity and other risk behaviours.  
 
5.4.4.2 Theme 2: Offense Responses 
This subtheme describes a range of cognitive, emotional, and behavioural 
responses that participants experienced in response to their HIV-positive diagnosis. These 
responses largely fell under two main subthemes: Immediate Responses and Delayed 
Responses. 
 
Immediate Responses  
All participants reported experiencing one or more immediate reactions in response 
to their perceived offenses.  Particularly for those who linked their perceived offense to the 
source of their HIV infection, immediate responses to a positive diagnosis included shock, 
anger, confusion, crying, sleepless nights, rumination, questioning of the self, and suicidal 
thoughts.  
“In fact, I was shocked. I was shocked. Yeah, I was very shocked.” (Participant 
13) 
 
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“You know, as for that time, at the beginning, you think a lot. At times, you’ll wake 
up in the night and be thinking and wondering where this thing came from.” 
(Participant 6) 
 
 
Particularly for participants who least expected a positive HIV diagnosis and those who 
perceived that their partners intentionally infected them or failed to protect them even 
though they (partners) were aware of their positive status, immediate responses to their 
diagnosis included fainting and also, the desire to commit suicide. 
 
“Something nobody looked for but it happened all of a sudden... I cried the whole 
day, like one whole week non-stop. I cried. I was so miserable, I didn’t eat, 
nothing...In fact, I nearly killed myself. I nearly [stretched] killed myself. Hmmm 
[chukles]. (Participant 15) 
 
“Hmmm, when I started falling ill, me my mind was not even there that it is this 
thing. The day we went to the clinic…when they told me, I fainted. I refused to eat 
and to take the drugs…I wanted to die. I would just sit in the room and cry all 
day…Me I know that he [deceased partner] knew [about HIV positive status]. 
Because he used to say some things...“this sickness that I’m having I don’t want 
you to get some”. And when he died too, one nurse who knew him very well told 
me that...[Name] did you know that this and this.” (Participant1) 
 
Delayed Responses 
Participants’ descriptions of their offense experiences also seemed to indicate that 
some responses endured longer than others. Common delayed responses included going 
days without eating well and refusing to take care of one’s self. The extracts below reflect 
these immediate and delayed responses: 
“I cried the whole day. Like one whole week crying non-stop. I cried. I was so 
miserable.” (Participant 15)  
 
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 “Before God and man, my heart skipped when I got to know it. I was really 
shocked and for about a week I was not eating well. I decided to take medicine 
“koraa” and die.” (Participant 11) 
 
There was also a delayed response of continued fear among some participants, including 
the fear of other people discovering their HIV positive status and also, the fear of infecting 
loved ones. Prolonged fear and some of its associated challenges on participants’ lives are 
reflected in the responses of these two participants: 
“…when I started my medication…when am coming to collect the medicine, I don’t 
want even anybody to see, I will hide for everybody to go before I will enter and 
collect my medicine. I was so afraid that people will know I have this sickness.”  
(Participant 1) 
 
“I can’t even ride a motorbike now…all my secret [HIV positive status] is going to 
reveal... I want to have another child. I have only one. Hmmmm…but I’m afraid 
that my secret will come out” (Participant 3) 
 
However, one participant who attributed her HIV positive status to a spiritual cause 
perceived no such fear of infecting her current partner. She believed that the spiritual 
origin of her condition means there is no way she can pass it on to others even if she 
wasn’t taking the medication.  
“You know, so long as they say it’s spiritual, I don’t believe that I’ll infect him 
[partner]. And me, I believe it is spiritual, like they bought it for me… You 
understand? “3h3”. So…even if I wasn’t taking the drug then [when pregnant], my 
son would not have gotten it. Yeah.” (Participant 15) 
 
It can be deduced from these subthemes (Immediate Responses and Delayed 
Responses) that first of all, in spite of the unprecedented advancements in HIV/AIDS 
treatment and care, a positive diagnosis is one that the majority of people do not take 
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lightly. Secondly, while a positive diagnosis may be followed by a typical period of 
mourning and offense perception, not all people are able to move on from this stage. 
Although, it appears that the intensity and duration of this period may be dependent on the 
circumstances surrounding one’s diagnosis. The power of individual differences in coping 
also seems to permeate through these narratives. For example, in the case of participant 14 
and also participant 1, although they fainted at diagnosis because they least expected HIV 
and also entertained suicidal thoughts at some point, both currently report having forgiven 
and moved on with their lives. Participants 14 is now a Model of Hope who publicly 
declares her status to support others without any fear. In contrast, participants 3 and 15 
who shared similar experiences seem to find themselves entrenched in cycles of 
rumination, experience of emotional pain, and an almost complete standstill in life. They 
also respectively seem entrenched in fear of others discovering their status and the fear of 
being rejected again after disclosing their positive status, holding implications for their 
partners being as risk of HIV infection. 
 
5.4.5 Superordinate Theme B: Experiences of the Forgiveness Process 
Participants were asked what it is to, what it is like, and what it feels like to forgive 
the offenses they reported in relation to their HIV positive status. The superordinate theme 
of Experiences of the Forgiveness Process describes participants’ lived accounts of what 
forgiveness entails, how it feels to forgive, and what facilitates or hinders forgiveness of 
HIV-related offenses. Two themes emerged: 1) Personal Actions and Changes and 2) 
Realities, Conditions, and Rationalization.  
 
5.4.5.1 Theme 1: Personal Actions and Changes 
The theme Personal Actions and Changes describes the individual and inner actions 
participants experienced in overcoming the offenses they perceived in relation to their 
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positive status. It also encompasses the emotional and cognitive changes that were 
experienced following these actions. Under this theme, participants’ narratives largely fell 
into two subthemes: Internal and External Actions and Psychological Changes.  
 
Internal and External Actions 
This subtheme defines the two main types of actions – internal and external – that 
participants used to describe their experiences of forgiveness.  
 
Internal actions 
First, participants described forgiveness as “eliminatory” actions that take place 
within the offended or victim. Chiefly, forgiveness was described as “to let go”, “to 
remove hatred from the heart”, “to remove the hurt from your heart and mind”, “to not 
retaliate”, “to take bad things you used to think about the person out of your heart 
completely”. 
“Forgiveness means to just let it go forever of the hurt or pain. You erase the 
situation from your mind and just say it, this situation was so but not so because of 
the person.” (Participant 6) 
 
“You have said you have forgiven. So, let it go. So, it means that you let it go and 
then you’re free in whatever you do. Because if you do not let it go, it will continue 
to hinder your progress…” (Participant 7) 
 
These internal actions were in relation to both the pain of having experienced the offense 
and the negative thoughts, emotions, and behavioural intentions that were experienced 
toward the offender as indicated in the extracts below: 
 “To forgive from your heart means all pain or hurt has left from within your heart 
so it shouldn’t happen that you’ll hurt over it again. Even if I remember, or she 
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does something to hurt me again, I wouldn’t retaliate nor feel hurt.” (participant 
12)  
 
“I was so hurt. I told my dad I will curse the boy. But... I decided to forgive him 
and I took it out of my mind.” (Participant 8) 
 
Other ways in which participants described forgiveness included; to accept mistakes and 
receive God’s forgiveness, thinking positive thoughts about the offender, and to forget 
about the offense and who or what caused it.  
“Forgiveness means forgetting about it. Forgiveness means leaving it to God.” 
(Participant 13) 
 
“Now, I’ve forgotten about it. I don’t think about it anymore. Both me and my wife, 
we don’t think about it. I have accepted my past mistakes. I’ve asked God for 
forgiveness” (Participant 2) 
 
Interestingly, most of the participants whose description of forgiveness included forgetting 
clarified that where forgiveness has taken place, even when one remembers, such 
memories would not be accompanied by feeling hurt, continuously attributing the offense 
to the offender, or experiencing negative thoughts and attitudes toward the offender. These 
extracts buttress this finding:  
“The memories will come to your mind but when they do, you should think positive 
about the person and not negative.” (Participant 6) 
 
“Forgiveness is not to forget per se, but not to keep it within you and so that you 
continue to be pondering over the same issue.” (Participant 7) 
 
Only one participant, who believed that forgiveness is of God reported that he avoided 
trying to remember the offense as it aroused hurt and regret. Although he reported having 
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forgiven himself, he emphasized that it (forgiveness) was basically trying to forget the past 
as he was uncertain whether or not God may have forgiven him. According to him: 
“Forgiveness is leaving it to God. Because, whether you forgive or not, it’s only 
God who can forgive so you leave it to God and move on.” (Participant 13) 
 
Quite contrarily, another participant who reported having offended himself confidently 
reported having forgiven himself, saying that: 
“I believe in God’s forgiveness. I believe that God forgives us when we ask for 
forgiveness. I mean, the Bible is clear on that… It is only a deviant person who 
would not, who would find it hard to believe in God’s forgiveness.” (Participant 
7).  
 
External actions 
Besides these internal actions, it emerged from participants’ narratives that 
forgiveness was also experienced in the form of external actions – having good or pleasant 
relationships with the offender. These actions appeared to be an almost inextricable 
element of the internal actions reported. For example, participants indicated that: 
“It cannot be forgiveness if you say you’ve let the hurt go but cannot get close to 
or relate with the person if the person is in your vicinity.” (Participant 6) 
 
“You have to be able to talk to the person, laugh with the person, do things with 
the person. Otherwise, then it means you have not forgiven. It means the pain is 
still in your heart.” (Participant 14) 
 
Among those whose perceived offenders were their deceased spouses, some hinted that 
they would have continued living with them if they were alive. For example: 
“If I forgive him, I have to continue living with him. The thing [HIV] was in him 
and he gave it to me. I don’t know whether the next person I go in for, I may infect 
him. So, I have to stay with him and for us to protect ourselves…and we’ll focus on 
taking the drugs as prescribed and we’ll live in peace.” (Participant 14) 
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“I still pray for a good resting place for him…If he had tested [for HIV] earlier, 
like by now, he too he’ll be here and we all will be taking the medication and 
managing this sickness small small.” (Participant 5) 
 
One participant provided an interesting exposition on whether these external positive 
behaviours toward HIV-specific offenders were synonymous to reconciliation. She 
narrated that: 
“You’ve not quarrelled or fought (with the offender). That you were having pain 
does not mean you weren’t on good terms with the person, so you won’t call it 
reconciliation” (Participant 6) 
 
Indeed, some participants clarified that it may be possible to put up positive behaviours 
toward the offender while harbouring the pain. However, according to them, such cases 
are not the same as forgiveness. As one participant highlighted: 
“When you say that you have forgiven the person, it means you have taken 
everything out of your heart…it is possible…[to] pretend to be fine with the 
person. Some people do that, “333nn” [yes], some people are able to do that. But 
then that means you haven’t forgiven the person…It means the pain is still in your 
heart.” (Participant 14) 
 
Psychological Changes 
This subtheme refers to the changes in participants’ feelings and thoughts about the 
offense and offender after letting go. Most commonly, participants described that to 
forgive is to feel free in the mind.  
“Physically, mentally, in your everything. You will be free... You are no more a 
slave. But if you and somebody have a grudge “ahh”, you are like a slave oo…you 
see, the moment you see the person [chuckles] you will not be free. You will not be 
free.” (Participant 2) 
 
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“It [forgiveness] makes you take negative thoughts out of your mind. So, your mind 
will be free” (Participant 13) 
 
 
These experiences were also echoed by the participant who reported still feeling angry at 
God and her ex-partner, in narrating what it may feel like to eventually forgive:  
“It would feel good to let the hurt go. forgiveness feels like your heart is clean. 
You’re free. Your mind is free. You don’t think about it again. You know longer 
have that mind-set for the person again that he wronged you some time ago.” 
(Participant 15) 
 
Other expressions used to describe what it feels like to forgive included: thinking positive, 
feeling happy, joy, and at peace, feeling as if a burden has been lifted off you, and having 
no worries or hurts. Participants also reported that where forgiveness has not yet taken 
place, anxious and disturbing responses to the offender may rather be experienced. 
 “it [unforgiveness] won’t give you peace…to forgive is like a great burden has 
been lifted off me” (Participant 14)  
 
“I felt happy, I felt joy…It feels like all is well.” (Participant 13) 
 
Participants’ experiences of forgiveness as internal and external actions 
accompanied by positive emotions indicates an awareness of the influence of forgiveness 
on emotion regulation. Although, it appears that the positive emotions that participants 
expressed seem to be in relation to themselves and their own personal feeling of 
wellbeing. In relation to others (offenders), participants reported more of external positive 
behaviours that seem to be a reflection of inner positive affect towards others. This is seen 
in how participants clarified that to still feel hurt or pain should the offense experience be 
brought be mind, qualifies persistent unforgiveness rather than forgiveness. Thus, while 
PLWHA may be aware of their emotional states of equanimity from forgiveness, in 
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relation to expressing emotions toward others, they may more likely do so in terms of 
actions and bodily behaviours including talking and relating well with the offender.  
It also appears that in the context of PLWHA in Ghana, forgiveness may be 
expressed in other terms that may suggest that forgiveness has not completely taken place. 
For instance, quite a number of the participants mentioned forgetting. However, further 
probing revealed that forgetting also meant to let go without experiencing any negative 
emotions toward the offender even upon recall of the offense, which is more reflective of 
at least a neutral state in the forgiveness process.  
 
5.4.5.2 Theme 2: Realities, Conditions, And Rationalization   
The theme Realities, Conditions, and Rationalization reflects the antecedents of 
and barriers to forgiveness that were reported respectively among participants who had 
forgiven and those who had not. Three subthemes emerged from participants’ narratives in 
relation to this theme. The first subtheme – Existential Factors – describes the real or 
existing factors which facilitated forgiveness of participants’ perceived HIV-related 
offenses. The second subtheme, Possible Conditions, describes those factors that 
participants indicated could help them eventually forgive. Continuous Offenses and 
Personal Resolution emerged as the third subtheme, and describes, among those who still 
held grievances, the reasons for which they had not forgiven.  
 
Existential Factors  
The existing factors that participants perceived to have helped in their forgiveness 
experiences fell under four main categories; religious realities, social factors, personal 
factors, and medical factors.  
 
 
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Religious realities 
Chiefly, participants reported that their faith in God, believe in God’s word about 
forgiveness, and prayers to God for help, gave them the strength to experience and extend 
forgiveness to their perceived offenders. These extracts indicate some of these religious 
experiences: 
“…had to ask God to help me take the pain out of me and change my mind and 
have a new mind to live life. And after that truly, the pain left my heart.” 
(Participant 14) 
 
“God says you should forgive those who offend you so He would also forgive you. 
So I’ve forgiven her.” (Participant 12) 
 
One interesting religion-related phenomenon that appeared to have helped some 
participants let go of their offenses is what the researcher terms as Double Attribution. 
Namely, while majority of participants primarily attributed their perceived offense to other 
people or themselves, they indicated, in addition, that they believed God gave them the 
condition or allowed their infection with HIV. Example extracts reflecting this 
phenomenon are: 
 “I feel…it is God who want me to be HIV-positive…” (Participant 4) 
 
 “I don’t think about it, because I know God gave it to me. And so far as God gave 
it to me, I don’t need to think about it but remove everything from my mind and be 
free and happy.” (Participant 12) 
 
For some participants, double attribution was made with the belief that God had a purpose 
for their lives because they believed that He could have prevented them from getting HIV. 
Two participants narrated their double attributions as: 
 “…there are so many women around and men around who do prostitution and a 
lot of…bad, bad things…but at the end they’ll come and do HIV test and they’re 
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negative…so I feel…it is God who want me to be HIV-positive so that when I’m 
positive I’ll get a lot of experience. Whoever is diagnosed HIV positive then I’ll 
stand as a statue to even testify to the person to have hope and continue with the 
drug without running away.” (Participant 4) 
 
“[to have been offended at myself and to have forgiven myself] means that trouble 
has come, and the trouble that has come, God could have stopped it from coming. 
But if He allowed it to come, He knows the reason. It may be to increase your faith. 
So, glory be to God. We move on…because there are more people that are 
mingling around but they are free.” (Participant 13) 
  
Although the participants who had not yet forgiven also indicated that God allowed them 
to get it, this was reported more in a tone of pain and blame rather than with the indication 
that God is All-Powerful, All-Knowing, and Sovereign as hinted by other participants who 
made a double attribution of their positive status to God. For instance, Participant 3 
indicated that: 
“He [deceased offender] has done this and is gone. So, I’ll also do the same and 
when we both get there, we’ll both answer to God. If God didn’t want this to 
happen, it wouldn’t have happened.” (Participant 3) 
 
 The finding that people drew on their religious believes to help them forgive, 
though not surprising, appears to reveal very interesting insights.  Particularly, those who 
made a double attribution of their HIV-positive status to God, but rather than react in 
anger, acknowledged He knows what He is doing, seemed to have experienced an 
outstanding sense of purpose to their lives. This was in sharp contrast to the experiences of 
the participant, who reported anger toward God and would only let go if God turned things 
around for her. This further suggests that while leaving a perceived offense to God may 
not be forgiveness, it may arouse a deep sense of purpose that may diminish any value or 
reason for holding on to grudges.  
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Social factors  
It emerged from participants’ narratives that social support and social comparisons 
promoted their forgiveness experiences. Participants received both emotional and 
informational support from family members in particular, and also from healthcare 
providers including counsellors and Models of Hope. They reported that the support of 
others helped them to accept their status and to decide to let go of their perceived offenses. 
For example:  
“My husband also supported me. He was the main person. Rather than causing me 
distress, he is the one who is encouraging me. So why don’t I let it go?” 
(Participant 9) 
 
“My younger brother is pharmacist, one is medical assistant…my wife also 
accepted me although she tested negative. So…that helped me to forgive myself.” 
(Participant 7) 
 
Also, making social comparisons to HIV-positive children, other HIV-positive adults 
perceived to be of equal or higher social status, and to the nature of other health conditions 
(e.g., high blood pressure), also seemed to have helped participants to let go of their hurt. 
“I told myself that even if children less than 5years of age that I see at the clinic 
have it, then I an older person, if I have to get, I’ll get. So, I advised and consoled 
myself that I have to continue taking the drugs.” (Participant 8) 
 
“…a lot of people are here [HIV/AIDS clinic], even some are in their cars who 
have this condition. He [husband] showed me one [nursing] sister who has it who 
is thick tall. So that encouraged me to take it out of my mind.” (Participant 10)  
 
Personal factors  
Another forgiveness-promoting factor was engaging in self-talk/questioning, which 
also seemed to be linked with other phenomena that were also mentioned as having 
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promoted forgiveness. These included accepting HIV-positive status, accepting the 
offensive situation, and engaging in healthy behaviours that made participants regain their 
strength. For instance, some narrated that: 
“I’ll just ask myself that ah, if it is so and you’re still okay, what is it about? So 
just forget about it and live normal…I’ll just ask myself what if it was the other 
way round? Wouldn’t you have accepted it?” (Participant 6) 
 
“When I started the drug and I started picking up and I talked to myself that this is 
not anything. I should accept it like a normal err sickness like headache and other 
this thing and forget what has happened...” (Participant 4) 
 
Medical factors 
Finally, it emerged, interestingly, that the HIV medication and its effects helped 
participants to let go of grudges and emotional pain related to their HIV infection. Some 
participants emphasized that they forgave because after sometime on the medication they 
did not only realize they were still alive, but also noticed that they were regaining their 
strength and usual self/body appearance. 
“When I was hurting, I couldn’t do anything…But when I discovered the drug and 
forgave him, I have strength to go about my daily activities” (participant 14) 
 
 “When I started taking the medicines, I got back to how I looked, then all the 
worry [rumination] left.” (Participant 8)  
 
Adherence to ART has long been identified as a health behaviour that promotes the 
lifespan of PLWHA. However, that it emerged as one reason for which participants 
forgave their perceived HIV-related offenses is an interesting finding that lends more 
support to the importance of ART in HIV/AIDS care. Beyond this insight however, this 
finding seems to suggest that the perceived consequences of an offense may indeed, 
contribute to the depth of unforgiveness experienced. It seemed that the probable fear of 
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death, wastage (extreme loss of weight from HIV infection), or an already ended life may 
have contributed to participants’ perceived offenses as well as their immediate and 
delayed responses. Hence, it sounds logical that discovering that they may not go through 
these experiences as long as they take the ART helped most to forgive their perceived 
offenders.    
 
Possible Conditions 
The subtheme, Possible Conditions, describes those factors which one of the 
participants who had not yet forgiven, hoped to come by someday and which she reported 
may help her to forgive. These included finding love/marriage, a job, and a cure for HIV. 
For this participant, until she is declared HIV negative, she may not be able to forgive. She 
rationalized that: 
 
“…until this HIV leaves my body, I will not be okay, yeah. I won’t be okay…I’ll see 
God differently when the pain is no longer in my heart, yeah, as for that one 
“de3”… And it’s because He [God] will let everything fall into place. He will give 
me love, He will give me marriage, He will let me have a job, yeah. Even if it’s not 
marriage per se, someone who’s there for me, who I can confidently tell him I’m 
going to here and come cos there’ll be no long questions…if I’m taking this meds, 
he’ll know its meds I’m taking without asking me any plenty questions…hmmm…” 
(Participant 15) 
 
Continuous Offenses and Personal Resolution  
This subtheme – Continuous Offenses and Personal Resolution – concerns how 
participants who had not yet forgiven their perceived offenders, also rationalized their 
unforgiveness. According to one participant, whose family members were still 
stigmatizing and discriminating against him, he could only forgive them if they 
discontinue those behaviours. He reasoned that:  
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“errr…there are some areas still I haven’t forgiven. Because err…they 
[family/relatives] still not trying to understand HIV…they don’t associate me 
whatever they are doing in the house…they don’t even mind me to be 
somebody…that is the reason I cannot forgive them…they are still stigmatizing me 
because of the HIV…in the morning I have to force and greet them but they cannot 
greet me…so for those people de3 I cannot forgive them. Until they also 
understand way of life and change their behaviour. That will make me to forgive 
them…if they change and do the right thing that is when the forgiveness will 
come…God sef will not forgive them because they doing it intentionally” 
(Participant 4) 
 
For the participant who reported not having forgiven the deceased ex-friend who infected 
her, forgiveness of this (deceased) person seemed to be a situation that may never happen 
under any circumstance. This is because she had made a personal resolution that nothing 
could make her forgive him, as she perceives that he knew his status, yet intentionally 
infected her with HIV when she was vulnerable – looking for a job. Indeed, it appeared 
that this participant was fully aware of the many negative ways in which unforgiveness of 
her ex-friend’s betrayal were affecting her life. For example, she narrated that: 
“I can’t remember things. Even work information or when I dream, I can’t 
remember. I’m always thinking and it is affecting my work. When I count money, 
it’s more or less the right amount. When I even attend workshop, I can’t remember 
anything the moment I leave there. I was not like this before…as if I’m no body.” 
(Participant 3) 
 
However, she held onto her personal resolution to not forgive, narrating that: 
“Even today and they say the treatment has just come… even today if they cure it 
(HIV/AIDS) “33nn”, I can’t forgive.” (Participant 3) 
 
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5.4.6 Superordinate Theme C: Implications of Forgiveness 
Finally, when asked what it meant to them to have forgiven the offenses they had 
experienced as a result of their HIV-positive status, participants’ narratives indicated two 
themes. These are; Restoration, Development, and Preservation and also, Focused Life.  
 
5.4.6.1 Theme 1: Restoration, Development, and Preservation 
The theme: Restoration, Development, and Preservation illustrates the range of impact that 
participants believe forgiveness has had on various important aspects of their lives. Three 
subthemes identified in relation to this theme were; Restoration of Health and Body 
Image, Self-Development, and Preservation of Social Relationships and Structures. 
 
Restoration of health and body image 
 Restoration of physical health, mental health, and body appearance/image was one 
subtheme that cut across participants’ narratives regarding what forgiveness meant to 
them. Participants indicated that having forgiven, they eat and sleep well, exercise, think 
more positively, and do not worry or ruminate about the situation. This meant that 
physically, they felt fit while mentally they experienced sound mind, social inclusion, 
peace, and other positive cognitive and emotional states.  
“Forgiveness gives us a lot of things. Physically, you’ll be fit, strong, free in your 
mind, you can eat well, you’ll be happy…you’ll live longer. Will let you pray and 
accept any faults…God will also forgive and put His blessings on the 
medicines…unforgiveness does not let people concentrate their minds on what they 
are advised to do to live longer. So it kills them off because of negligence.” 
(Participant 2) 
 
“Forgiveness helps your mental health. When there is something like 
unforgiveness in your mind, it heats up your mind all the time. Always, your mind 
will be so hot. But when there is nothing in the mind, it makes the mind feel cool. It 
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helps you to sleep. Otherwise you’ll keep doing hmmm…hmmm…hmmm when 
you’re sleeping. You’ll have no peace in your mind.” (Participant 14) 
 
Restoration of physical appearance/body image was mentioned chiefly by the female 
participants and also one male participant. According to them, they observed that for as 
long as the pain was in them, they were losing weight or growing lean, looked 
unattractive, and even felt that others could obviously tell that something was wrong with 
them. Some had also observed that their body complexion and general body image or 
appearance returned to normal after they let go of the pain and focused on taking the 
medication. 
“…you could see that you were, you’ll be growing lean and like you don’t feel 
happy at all. Like somebody can even see it on your face….so, physically, your 
body appearance will not be attractive, psychologically, you may be withdrawn 
from society.” (Participant 6) 
 
“I can even see myself that my body has changed. I’ve become fine. But when you 
harbour the pain within you, it can “eat” further into you. Even when someone 
sees you, the person can see that there’s something wrong with you. You’ll grow 
lean and look unattractive.” (Participant 14) 
 
These observations were reiterated by the female participant, who still felt angry at God 
and her ex-partner. When asked what it meant to her to still feel the hurt, she confirmed 
that:  
 “At first, let’s say, I was much prettier than now. Yeah. I was even fairer than 
now. But now I’ve changed. Everything has changed towards me because of my 
thinking and I’m not happy. Within me, I don’t, I don’t, I’m not happy but I just 
pretend to be...hmmm [chukles].” (Participant 15) 
 
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Self -development 
A second subtheme that emerged concerning what forgiveness meant to 
participants was that of self-development, particularly, for those who reported having 
forgiven themselves. This subtheme describes participants’ efforts at rebuilding or re-
establishing their self-image and values after letting go their offensive past. According to 
some participants, having forgiven meant they had stopped blaming themselves, making 
comparisons to, feeling inferior to, or feeling different from others. Rather, they now 
valued themselves as one participant indicated: 
“Initially, I felt hurt, I felt dejected. When I sit with people, I felt that I’m not, I 
mean, I’m a different person. But now I don’t see that. I have forgiven myself in 
that there’s nothing that maybe “X” can do that I cannot do provided it’s not 
physical work that I will say “X” is stronger than me.” (participant 7) 
 
One participant also highlighted the importance to the self-image of PLWHA in relation to 
eating well, exercising, and making personal hygiene a way of life. According to him: 
“When you eat well, and also you exercise, “33”, exercise, you’ll see that you’ll be 
fine. “3h333”. You see, and also you make personal hygiene a way of life. That 
will even make people to not discriminate you but rather they’ll accept you as a 
human being”. (participant 4) 
 
Preservation of Social Relationships and Structures 
Another aspect of life for which forgiveness seemed to hold much meaning for 
participants was that of restoring and maintaining of social relationships. This was the case 
both for participants, whose perceived offenders were still alive and those whose 
perceived offenders were deceased: 
“I’ve forgiven them [late husband’s relatives]. So now we are free. Now when I 
see my husband’s relatives I greet them and they too they greet me. Even my 
children can go there. And for me, it is very important. Because you know, we 
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Muslims, it is important that your children have fathers from their father’s side. So 
that tomorrow if I’m not around, “3h333”” (Participant 5)  
 
 “When I forgave my wife and the family, I no longer think about bad things to do 
to them. Now we are very close, very, very close. The mother, the father, when they 
see me, they’ll stop and we’ll talk for a long time. So, it has helped me, even the 
people in my community “sef”, at first, they used to point at me, but when I forgave 
and started talking to them, now when people see me they’ll be calling my 
name...they are all free with me” (Participant 4) 
 
Preservation of marriage was also mentioned as an outcome of forgiveness that held great 
meaning to participants. It seemed particularly important to one participant, who perceived 
having gotten infected through her husband’s immoral behaviours. According to her: 
“It means a lot to have forgiven. If pain was in me, I would by now maybe have 
even let go of the marriage….and maybe would have caused more harm than 
good…it has helped my family because my children they still have their father as a 
father…it has helped to keep them not in a broken home…you know…we the 
Northerners, we are not found of leaving marriages.” (Participant 6)  
 
One male participant also reiterated that: 
“Unforgiveness can break marriages among couples who discover that they have 
[HIV] and keep blaming one or the other. This one will say it was you, the other 
too will say it was you. You’ll see “nor”, the marriage is over.” (Participant 2) 
 
5.4.6.2 Theme 2: Focused Life 
Finally, also in relation to the sense participants made of forgiveness of their 
perceived HIV-related offenses, the theme: Focused Life emerged. It pertains to how 
participants focused on living life after letting go of their perceived HIV-related offenses. 
As participant 13 noted, life after forgiveness was perceived as a new life. The subthemes 
that emerged under the Focused Life theme were Life Promoting Behaviours and Focusing 
Ahead.  
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Life-Promoting Behaviours 
This subtheme concerns both the passive and active behaviours that participants 
reported focusing on, after letting go of their pain, and which reflect a desire or interest to 
want to continue living life. Participants’ narratives suggested that these behaviours were 
both passive and active. 
 
Passive behaviours 
These are behaviours that indicated a desire to live, to move on, or to start afresh. 
They included forgoing suicidal attempts and thoughts, ceasing behaviours like crying, 
guarding against worry and rumination, endeavouring to think positively, and guarding 
against going back into one’s past life. For instance, some participants reported that: 
 “Initially when I wanted to die, I refused the medications so I could die…but now 
that I have forgiven him, I don’t want to kill myself anymore” (Participant 1) 
 
“I must prevent or avoid anything that could make the pain or hurt to come 
again.” (Participant 12) 
 
Active behaviours 
With respect to active behaviours, participants reported that forgiving their 
perceived offenders helped them to take their medication. For instance, participant 9, who 
initially denied a positive HIV-diagnosis (from routine antenatal screening) and refused 
taking the medications until she lost her new-born baby reported that:  
“If I miss it (ART) then that means I want to die. I have never missed it.” 
(Participant 9) 
 
 
The young lady who initially faced gross stigmatization and discrimination at the hands of 
her stepmother also reported that: 
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“If I had not forgiven…I would not have been serious about taking my medication 
because I would have thought that with what is happening, I’m better off dying and 
if that’s the case what am I taking the medications for?” (Participant 12) 
 
 
When asked how forgiveness helped them to take their medication, participants explained 
that forgiveness gave them enough time and a sound mind with which they were able to 
remember to take their medication as indicated in this sample extract: 
“If I had not forgiven, I may not even be taking the medicines. Because through 
thinking a lot and the pain in me, I may easily forget to take it or to even attend the 
clinics.” (Participant 14). 
 
Another participant linked medication adherence to obedience to God, narrating that: 
“Because the word of God is truth and you have to be obedient to every good 
words that can help you. So, if they say to take this for it to help you and you 
disobey it, you are disobeying God. Because God gives them wisdom and 
knowledge to bring all those things together. So, if you obey them, God will help 
you to keep with it.” (Participant 13) 
 
Other active behaviours that indicated an interest in living life was reflected in efforts of 
the majority of participants to directly protect others from acquiring the infection as well 
as protect themselves from getting re-infected. These sample extracts lend support to this 
finding: 
“If like the pain was still in me “a”, like I will not have bothered to protect him 
[boyfriend]. Because I would have said, someone gave it to me so I’m also giving it 
to someone so that we all die together.” (Participant 12) 
 
“I’m very keen about protecting others be it outsider or whoever. Wherever maybe 
a drop of my blood touches, I make sure that I go and bury it before anybody can 
get in contact with it.” (Participant 6) 
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Participants also indicated a willingness to indirectly protect and support others (both 
family and non-family) through educating them on issues around HIV/AIDS and 
forgiveness. These included issues on transmission risks factors, signs and symptoms, 
protective and self-management behaviours, and forgiveness. These sample extracts lend 
support to this finding: 
“You see, even, when I see people and they seem to show some signs and symptoms 
that look like it is this condition, usually, I advise them to go and test. I encourage 
them that now, this condition is no longer scary. Other conditions like pressure 
can kill you instantly…but this condition does not kill suddenly.” (Participant 11) 
 
“…the forgiveness I’ve had, I can use it to educate others who find themselves in 
this situation, who can also become like me and help others.” (Participant 14)  
 
 
According to one participant, she saved her friend’s life (from HIV), narrating that: 
“...he [ex-boyfriend] wanted to date my friend and I warned her not to. She 
thought I didn’t like her, because I didn’t tell her the reason. She listened. The guy 
went out with another lady who is now dead. So my friend came to thank me that I 
saved her life.” (Participant 8) 
 
 
On the contrary, the participant who reported still experiencing pain and anger toward God 
and her ex-fiancé, reported engaging in health risk behaviours sometimes. She indicated 
that: 
“I didn’t imagine him treating me this way, you see?...sometimes I just do some 
things just to forget some things. I just do some crazy things to forget some things. 
Like parting, having sex, yeah.” (Participant 15)  
 
“…at some point, I stopped taking the medication for like one year. Because they 
[pastors] were doing things for me, deliverance, concoctions, Yeah. And you know, 
I didn’t want to mix the two therapies. But now I take the medicine because I still 
tested positive after the one year.” (Participant 15) 
 
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When asked the risks she perceived in having sex to forget her pain, she replied that: 
“I won’t infect him [new partner] because they say the virus are not as many now 
as before…also, the pastors say it’s spiritual…You know, so long as they say it’s 
spiritual, I don’t believe that I’ll infect him [partner]. And me, I believe it is 
spiritual, like they’ve done it purposely for me…You understand? “3h3””  
 
Focusing Ahead 
Finally, this subtheme – Focusing Ahead – emerged from participants’ narratives 
concerning the important things/pursuits in life that they decided to focus on, after 
forgiving their perceived HIV-related offenses. These things included learning a vocation, 
starting their own business, starting a new career, or having the ability to go to work and 
return each day: 
“To me, forgiveness means, leave past and move to the future or new life and the 
past becomes a check for you to constantly examine whether you’re going back 
into the past.” (Participant 13) 
 
“It was very helpful that I forgave [husband]. Because if I was thinking about it 
everyday, I don’t think I would have looked fine or been able to concentrate on my 
work and other important things in life. So it’s very good I took it out of mind.” 
(Participant 10) 
 
“What is important to me now, is to get the strength every morning to go to work. 
So, it’s [forgiveness] helped me, its helped me in diverse ways.” (participant 8) 
 
The main concern or interest of other participants was to be able to focus on taking their 
medication to look well, ensure that their infected children took their medication to remain 
strong, and their uninfected children remain protected. Similar to this, the focus of others 
was on being able take care of their whole families, for God to protect them, and for their 
children and others to never have to go through their experiences with HIV: 
 
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“Forgiveness gives you free mind to think about other things. Helps you think 
about important things that are waiting for you. For example, when I wake up, 
everyday, I make sure my children, the boys, take the medicine so that they grow 
and don’t get sick. And those who don’t have it, I make sure they don’t get it.” 
(Participant 5) 
 
“…I’ve forgotten everything. What matters is that we’ll wake up to another day 
and God will protect me and my kids and husband…that I wouldn’t watch my 
daughter to become like me.” (Participant 9) 
 
Overall, the expressions of this participant seem to sum up this subtheme of forgiving and 
forging ahead irrespective of the HIV-related offenses one may have experienced: 
“I don’t blame myself anymore. Life must go on. You can’t continue to live in the 
past. You have to make do with what is available...Because if you do not let it go, it 
will continue to hinder your progress…I mean, it will not even help you to think of 
what next to do. You’ll be, you’ll be stagnated. You see? Or what you 
psychologists say, fixated. I don’t want to be fixated [laughs]. So, I have to move 
on. I feel fine. It [forgiveness] has benefited me a lot…I take my medications 
regularly. If I travel, it’s in my bag. Forgiving myself has helped me to rather think 
of what next to do rather than think what went wrong.” (Participant 7) 
 
5.4.7 Summary 
Table 5.2 summarizes the superordinate themes, main themes, and subthemes that 
emerged from Study 2. The table indicates that of the six main themes that emerged, the 
first two pertains to participants’ experiences with their perceived offences, which were 
directly related to their HIV-positive status. Themes three and four concern participants’ 
experiences with forgiveness (or otherwise) of these offenses. The fifth and final themes 
highlight participant’s sense making of their forgiveness experiences as related 
specifically to their perceived HIV-related offense. 
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Table 5.2:  Summary of Themes, Subthemes and Supporting Quotes 
Theme Subtheme Supporting Quote 
Superordinate Theme 1: HIV-Specific Offense Experiences 
1. Offense Causes of HIV “I felt that, I felt I had, I had not lived a life that I ought 
Nature  to have lived. So I failed myself. So I put the blame 
 squarely on my own self.” [P7] 
 Negative Attitudes “…they [family members] don’t associate me whatever 
they are doing in the house…they don’t even mind me to 
be somebody…they are still stigmatizing me because of 
the HIV…” [P4 
Illness and Treatment “When I come and I have to do labs, I often don’t have 
Demands money. So it makes me hurt a lot…And the drug too, you 
have to take it every single day. Even you can’t miss it 
even one day koraa.” [P12] 
2. Offense Immediate Responses  “I fainted. I fainted. Because as for HIV, I never dreamt 
Responses that I would get HIV. I fainted. I decided that I would kill 
myself.” [P14] 
Delayed Responses “I can’t even ride a motorbike... I want to have another 
child. I have only one. Hmmm…but I’m afraid that my 
secret will come out” [P3] 
Superordinate theme 2: Experiences of the Forgiveness Process 
3. Personal Internal and External “Forgiveness means to just let it go forever of the hurt or 
Actions and Actions pain. You erase the situation from your mind and just say 
Changes it, this situation was so but not so because of the person.” 
[P6] 
Psychological “it [unforgiveness] won’t give you peace…to forgive is 
Changes like a great burden has been lifted off me” [P14] 
4. Realities, Existential Factors  “…I’ll say it is God. So, it is religion that has also helped 
Conditions, and me.” [P6] 
Rationalization  Possible Conditions “I’ll see God differently when the pain is no longer in my 
heart, yeah, as for that one “de3”… And it’s because He 
[God] will let everything fall into place. He will give me 
love, He will give me marriage, He will let me have a job, 
yeah… [P15] 
Continuous Offenses  “Even today and they say the treatment has just come… 
and Personal even today if they cure it (HIV/AIDS) 33nn, I can’t 
Resolution forgive.” [P3] 
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Table 5.2 continued: Summary of Themes, Subthemes, and Supporting Quotes 
Main Theme Subtheme Supporting Quote 
Superordinate theme 3: Implications of Forgiveness  
5. Restoration, Restoration “I can even see myself that my body has changed. I’ve become 
Development, of Health and fine. But when you harbour the pain within you, it can “eat” 
and Body Image further into you. Even when someone sees you, the person can 
Preservation see that there’s something wrong with you. You’ll grow lean and 
look unattractive.” [P14] 
Self- “I have forgiven myself. Life must go on. I mean, I don’t blame 
Development myself anymore. Initially, I felt hurt, at that time I felt, I felt 
dejected. When I sit with people I feel that I am not, I mean, I’m 
a different person. But now I don’t see that. I have forgiven 
myself in the sense that there’s nothing that “X” can do and I 
cannot do…So it has helped me. It has helped me. I don’t 
compare myself to others anymore, I just focus on what I can do 
best.” [P7] 
Preservation “I’ve forgiven them [late husband’s relatives]. So now we are 
of social free. Now when I see my husband’s relatives I greet them and 
relationships they too they greet me. Even my children can go there. And for 
& structures me, it is very important. Because you know, we Muslims, it is 
important that your children have fathers from their father’s 
side. So that tomorrow if I’m not around, 3h333” (Participant 5)  
6. Focused Life “If I had not forgiven…I would not have been serious about 
Life Promoting taking my medication because I would have thought that with 
Behaviours what is happening, I’m better off dying and if that’s the case 
what am I taking the medications for?” [P12]  
Focusing “If every day I was thinking about it [that my husband gave it to 
Ahead me], I don’t think I would have been able to concentrate on my 
work and other important things in life. So, it’s very good I took 
it out of me.” [P10] 
 
 
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5.4.8 Brief Discussion of Study 2 Findings 
Intrapersonal, Interpersonal, and Spiritual Contexts of Forgiveness 
 Study two first of all sought to explore what have been the lived-through 
experiences of PLWHA in Ghana, regarding their forgiveness of offenses which they may 
have perceived as a result of their HIV-positive status. In line with the three main reported 
contexts of forgiveness of offenses – intrapersonal, interpersonal, and spiritual – 
participants attributed their perceived offenses to others (sexual partners and stigmatizing 
family members), themselves, and God (Bassett et al., 2016; Temoshok & Wald, 2005; 
Worthington, 2005). It emerged that the demands of the illness and its treatment may also 
be perceived as an offensive/unjust experience. This seems to support the concept of 
forgiveness of situations and whole institutions, including the healthcare system 
(Temoshok & Wald, 2005). Although similar financial challenges in meeting the treatment 
demands of HIV were experienced by other participants, these were not perceived as 
offenses as in the case of the young lady who acquired the infection via vertical 
transmission. This may suggest that for young adults with HIV, who acquired the infection 
via mother-to-child transmission, facing system-level difficulties with accessing routine 
care may arouse painful feelings of unforgiveness. It is possible that such young adults 
may perceive their positive status as entirely no fault of theirs and hence an injustice that 
they should struggle to manage it. 
 
Psychological Responses to Perceived HIV-Related Offenses 
 The nature of participants’ responses to the reported offenses seemed to cut across 
for all three contexts. However, for those who had been offended by others, it appeared 
that the perceived intentions of the offender seemed to influence their willingness to 
forgive. For instance, most of the participants who perceived that they were intentionally 
infected, rejected, or stigmatized by their respective offenders, reported experiencing 
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extreme amounts of hurt. For some of these participants, responses to their hurts included 
fainting, weeping for an extended period of time, starvation, initial refusal of antiretroviral 
therapy (ART), and suicidal thoughts. Also, three of four such participants reported not 
having forgiven their offenders. This finding seems to align with the injustice-gap concept, 
which suggests that negative offender characteristics may widen the injustice gap 
perceived by the victim, increasing unforgiveness (Davis et al., 2013; Hook et al., 2016; 
Worthington & Scherer, 2007). These characteristics include the offender committing the 
offense intentionally or continuously, not taking responsibility, or not apologizing for the 
offense.  
 
Experiences of Decisional and Emotional Forgiveness 
 Thirteen of the fifteen interview participants indicated having forgiven at least one 
of the targets of their perceived offense. First of all, participants’ descriptions of 
forgiveness as an internal action is in direct support of what has been reported that the 
phenomenon occurs within the victim and can be generally independent of the offender 
(Worthington & Scherer, 2004; Staub, 2005). As Worthington (2005) puts it, forgiveness 
occurs within the skin of the offended.  
 Secondly, participant’s descriptions that forgiveness included letting go of the 
offensive situation and pain, taking the offense out of or erasing the offense from your 
mind, forgoing retaliation and bad plans against the offender, etc. seems to suggest that in 
the least, participants had experienced decisional forgiveness (Davis et al., 2015; 
Worthington & Scherer, 2007). In addition, these experiences lend support to the 
proposition that (decisional) forgiveness includes a reduction in negative emotions (Harris 
& Thoresen, 2005; Worthington & Scherer, 2007).  
 
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Beyond these internal actions, majority of participants emphasized that their 
forgiveness experiences included external actions of maintaining good relationships with 
the offender. This may imply that besides their decisions to forgo unforgiveness, 
participants also experienced positive emotions toward the offender characteristic of 
emotional forgiveness. As some participants narrated, it (the experience) cannot pass as 
forgiveness without these external acts of goodwill toward the offender. While this may 
raise the question of whether participants largely experienced decisional forgiveness 
accompanied by reconciliation rather than experienced emotional forgiveness. It may be 
argued that participants did experience both decisional and emotional forgiveness, which 
together translated into positive acts toward the offender be it self or others. Two main 
issues that emerged from participants’ narratives may lend support to their likely 
experience of emotional forgiveness. First are the psychological changes they experienced 
following their decisions to forgo the negative thoughts, emotions, and behavioural 
intentions they had experienced toward the offender. As some narrated, to forgive is to 
feel happy, joy, peace of mind, free in mind, relieved, fine with one’s self, think positive 
thoughts, have love for the offender, etc. All of which indicate not only the absence of 
negative emotions, but also, the presence of positive emotions. Second, participants 
highlighted that where one feels hurt or continues to apportion blame upon recall of the 
offense, then forgiveness has not yet taken place. Furthermore, some participants clarified 
that having good relationships with the offender while harbouring negative emotions 
within is also not forgiveness. This indicates that participants appeared to be aware of the 
importance of developing positive emotions for the offender as part of forgiveness. Thus, 
in support of the theoretical framework of the present study, it can be said that overall, 
participants’ experiences included both decisional and emotional forgiveness.  
 
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Experiences of Emotional Forgiveness versus Reconciliation 
One interesting question that may be raised still in regards to participants’ positive 
external behaviours, is how distinct these behaviours are from reconciliation. In other 
words, whether these behaviours were portrayed more out of duty to maintain good 
relationships rather than a desire to experience inner emotional wellbeing? Hook and 
colleagues (2009; 2012) have reported that collectivistic worldviews influence 
understanding of forgiveness as interpersonal processes that focus on a decision to forgive 
(more than a desire to regulate personal emotions or experience emotional forgiveness). 
And that this decision to forgive is motivated by collectivistic values for maintaining 
social harmony, for reconciliation, and for relational repair. Thus, one may argue that 
participants’ positive behaviours may be more a reflection of reconciliation than emotional 
forgiveness, in order to maintain social harmony or repair strained relationships with their 
offenders and/or families of their offenders. The insight gleaned from one participant’s 
narratives seem to suggest otherwise. As she indicated, these positive or loving behaviours 
do not qualify as reconciliation since the hurt, pain, or offense experienced by the victim 
does not suggest quarrelling, fighting, or not being on good terms with the offender.  
In support of this view, Staub (2005) emphasized that although forgiveness and 
reconciliation overlap, an essential feature of reconciliation is mutuality – the mutual 
acceptance by both the victim and offender of each other. In the specific case of PLWHA, 
perceiving an offense/injustice in relation to one’s HIV positive status may not in all 
instances imply a conflict or mutual disagreement between the offended and offender. 
Again, in the specific case of HIV/AIDS, the infectious nature of the condition may mean 
that offended persons may genuinely desire to continue intimate relationships with their 
offenders, who may already know their status. This was reflected in some participants still 
living with their perceived offenders and the willingness of those who had lost their 
partners to continue the relationship had their partners been alive. In addition, because the 
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need to feel accepted appears particularly important for PLWHA, individuals may tend to 
genuinely forgive and relate well with their offenders in hope that the latter would 
eventually turn around and treat them well (e.g. in cases of stigmatization and 
discrimination). Perhaps, this may explain why the young lady tolerated her stepmother’s 
negative attitudes toward her till such behaviours ceased. 
Therefore, while it is acknowledged that decisional forgiveness may have been 
more readily reported by participants, overall, the following key findings seem to support 
their likely experience of emotional forgiveness in addition. First, the understanding that 
extension of positive behaviours while still harbouring pain is not forgiveness. Second, the 
understanding that painful rumination – recalling offense to mind and experiencing 
hurt/pain in response – is not forgiveness. And third, and perhaps most importantly, the 
internal positive psychological changes participants reported which were more of 
emotional experiences, suggesting an effort to emotionally feel better within themselves 
about the offense and offender. 
On another dimension, this finding of participants associating their forgiveness 
experiences with positive cognitive (e.g., free mind) and emotional (e.g., joy, relieve, 
peace) experiences, may seem to be contradictory to the findings by Dzokoto (2010). 
However, a closer observation of participants’ narratives indicates that not all positive 
emotions associated with the experience of forgiveness, did participants consciously 
express. Most of the emotions that participants seemed aware of, and which were 
expressed, were personal self-directed emotions (e.g., feeling happy, joy, relieved, at 
peace). Regarding positive emotions toward offenders, it appears that participants 
expressed these more in terms of bodily actions (e.g., talking, laughing, and associating 
with the offender). It may be that in this context, as far as an external offender is 
concerned, people may not consciously express their other-oriented emotions in the form 
of empathy, compassion, etc. as suggested by Worthington et al. (2007). However, 
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forgiveness may be realised by the absence of ill feeling upon unintentional recall of the 
offense, by actions of goodwill for the offender, and by the experience of positive personal 
emotions of wellbeing.   
 
Experiences of Forgiveness and Quality of Life 
 Participants’ sense making of their forgiveness experiences generated a number of 
rich insights. First of all, participants who reported forgiveness considered this 
phenomenon to have been very beneficial to their lives. Physically, participants 
understood their forgiveness of HIV-related offenses as a phenomenon that had improved 
their physical fitness via better eating, sleeping, exercising and other positive self-
management behaviours. Psychologically, forgiving HIV-related offenses held meaning 
for participants’ emotional wellbeing as they thought positively, worried less, slept 
soundly, and felt happy, relived, less depressed, free in mind, and at peace. It also emerged 
that forgiving these specific offenses meant social inclusion rather than exclusion as well 
as continuance of marital and family bonds/relationships. That religion/ spirituality was 
relied on massively in coping with HIV-related offenses via forgiveness, also suggests that 
the forgiveness process drew participants closer to God. Indeed, some participants 
affirmed that the process of forgiveness of these offenses had increased their faith in and 
reliance on God. All these findings are in support of similar studies conducted so far in 
PLWHA (Ironson et al. 2011; Owen et al., 2011; Ridings et al., 2008; Wald & Temoshok, 
2004a, b). They also lend support to previous reports and findings that forgiveness 
generally has physical, mental, relational, and spiritual benefits. (e.g., Toussaint et al., 
2015; Woodyatt et al., 2017; Worthington, 2005). Furthermore, the finding that self-
forgiveness meant ceasing self-blame and comparisons, revaluing one’s self, positive self-
challenge and development, and increased self-efficacy aligns with the self-forgiveness 
literature (Woodyatt et al., 2017).  
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Experiences of Forgiveness and Health Behaviours 
 Temoshok and Wald (2005) theorized that one pathway by which forgiveness of 
HIV-specific offenses may have its influence on health outcomes is via motivation to carry 
out health-promoting behaviours. As they had earlier found, forgiveness was associated 
with less unprotected sex, while feeling unforgiven was associated with more missed 
doses of ART (Wald & Temoshok, 2004a,b). Similar to their findings, majority of 
interview participants indicated that forgiveness helped them to take their medication and 
to also protect others from becoming infected. Some explained that forgiveness reduced 
excessive thinking/worrying and forgetfulness, giving them a sound mind to remember to 
take their medications. Others explained that they no longer wanted to take their lives or 
that they desired to continue living having let go, and hence the need to take their 
medication. Yet still, this pro-health behaviour was perceived to mean obedience to God, 
and hence, an instruction that should not be violated. With regards to protecting others, 
participants reported that forgiveness motivated them to practice safe sex with their sexual 
partners. It also motivated them to protect their families and other people via direct 
behaviours such as not sharing tooth brush and treating cuts carefully. Indirect protective 
behaviours included educating family and others on HIV/AIDS. As some explained, 
should they have still been experiencing the hurt, they would have cared less about others 
also acquiring the infection. Unfortunately, one participant who had not forgiven reported 
that she sometimes did some things out of unhappiness, including having unprotected sex, 
highlighting the potential for unforgiveness to promote risk behaviours of public health 
concern.  
 
Experiences of Forgiveness and Body Image Perception  
 Perhaps, an important addition to the literature of the present phenomenology 
study, is the finding that forgiveness in the case of PLWHA, may improve body image 
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perception. Particularly among the females, it was reported that as long as they were 
hurting, they were growing lean, did not look/appear fine, and most likely appeared to 
others to have something bothering them. They however noticed differences in these areas 
after forgiving. Indeed, it may be argued that this pattern of finding may be linked to 
participants not adhering to their ART when hurting over their perceived offenses. 
However, the reports of the two female participants, who had still not forgiven their 
offenders may suggest otherwise. This is because, they reported adherence to their 
medication, yet highlighted that they had changed drastically in appearance/body image to 
the extent one avoided social functions as she felt she didn’t look good even when she 
dressed up. According to one of these two participants, whether she forgives or not, she 
would adhere to the medication as she had come to believe that it is currently the only 
thing that helps the condition medically. Considering that majority of the participants, who 
reported forgiveness also reported adherence as a result, this study seems to have found 
that perhaps, as long as PLWHA desire to continue living, they may adhere to their ART, 
whether they have forgiven their perceived offenders or not. However, those who 
experience forgiveness may have more positive perceptions about their body image, 
compared to those who continue to harbor unforgiveness.  
 
Experiences of Forgiveness, Social Support, and Religiosity 
 A range of antecedents of forgiveness including personal (e.g., self-talk), spiritual 
(e.g., faith in God), and social (e.g., social comparisons) antecedents emerged from 
participants’ narratives. In support of the Afrocultural Social Ethos Framework (Jagers et 
al., 1997), religiosity as well as personal beliefs in God and social support emerged as two 
of the most commonly reported antecedents of forgiveness.   
Most participants indicated that the support and acceptance of their families (e.g., 
spouses, parents, children, and siblings) helped them to let go of their hurt. Support was 
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also received from participants’ healthcare providers and models of hope, who are HIV-
positive patients dedicated to supporting newly diagnosed patients and creating HIV 
awareness.  
Secondly, majority of participants reported that God or their faith in God helped 
them to forgive their perceived HIV-related offenses. A related antecedent that 
interestingly emerged, is the concept which the researcher termed Double Attribution. It 
was noted that even among participants who perceived others or themselves as the source 
of their HIV-related offence, attributions were also made to God as having caused or 
allowed their infection with HIV. Perhaps, participants found more solace in and purpose 
to their lives in attributing their perceived offense to God or a God-determined destiny, 
which may have contributed to their reports of forgiveness. These findings may imply that 
indeed, Africans value the worldviews of spirituality and communalism, and are likely to 
rely on these not only to manage illnesses, but also, to cope with illness-related offenses. 
Nonetheless, there may be important differences in how individuals adopt and 
apply these and other coping resources such that for some people, these coping 
mechanisms may have a negative health influence. In the present study, the female 
participant who reported anger toward God and her ex-partner strongly believed that her 
HIV positive status was spiritually caused or bought for her. Thus, she believed having 
unprotected sex would not place her current sexual partner at risk of HIV infection. Again, 
she believed that even if she had not taken ART during pregnancy, her child would not 
have become infected. This may imply that spiritual worldviews, depending on how they 
are adopted, may also facilitate health risk behaviours and pose public health challenges.   
 Overall, the phenomenological qualitative inquiry in study two showed that 
participants who reported forgiveness also reported perceived improved physical health, 
psychological health, social inclusion and ties, spiritual closeness and purpose, and more 
attractive body image. Those who reported forgiveness also indicated a focus on positive 
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health behaviours and pursuits important to them in life. However, the few who reported 
unforgiveness reported negative and debilitating experiences in almost all of these areas of 
their lives. These findings lend support to the propositions of the Stress and Coping Model 
of Forgiveness, that as an emotion-focused coping strategy, forgiveness may reduce the 
stress/burden of unforgiveness from perceived offenses/injustices and bring about 
improvement in health and other important aspects of life (Lavelock et al., 2015; Strelan & 
Covic, 2006; Toussaint & Worthington, 2017; Worthington, 2006; Worthington & 
Scherer, 2004).    
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CHAPTER SIX 
GENERAL DISCUSSION 
6.0 Introduction 
The present chapter is the final chapter of this thesis. It presents an integrated 
discussion of the findings from studies one and two, beginning with an overview of the 
thesis. The implications of the integrated findings for theory, policy, and clinical practice 
are presented. The public health as well as health psychology implications of the study are 
also highlighted. These are followed by the limitations of the study and their implications 
for future research. Finally, the chapter highlights the contributions of this study to 
science, concluding with an overarching message from the thesis. 
 
6.1 Overview of the Thesis 
This study aimed at investigating the impact on health of forgiveness of HIV-
related offenses in people living with HIV/AIDS in Ghana. An explanatory sequential 
mixed-method design comprising of two related studies was employed to achieve this aim.  
Study one was a cross-sectional survey of 325 PLWHA receiving treatment across the 
Korle-Bu, Komfo Anokye, and Tamale Teaching Hospitals. Standardized questionnaires 
and clinical data were used to assess the association between forgiveness and the outcomes 
of PHRQOL and change in CD4 cell count across three contexts – intrapersonal, 
interpersonal, and spiritual. Study two was a follow-up in-depth phenomenological inquiry 
into the lived experiences of forgiveness of HIV-related offenses among 15 of the 325 
survey participants using a semi-structured interview guide. Multivariate regression 
analysis and interpretative phenomenological analysis were used to analyse data from 
study one and study two respectively.   
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6.2 Summary of Findings  
 Study one found that forgiving the self and positive attitudes toward God 
significantly predicted PHRQOL, with PATG remaining a significant predictor when 
related covariates were accounted for. Decision to forgive self (DTFS) significantly 
predicted change in CD4 cell count both before and after controlling for the effects of 
significant covariates. Decisions to forgive were reported significantly more than 
emotional forgiveness in both the intrapersonal and interpersonal contexts. Likewise, 
significantly higher PATG than NATG were reported. The study found no moderating 
effects of health behaviours (ART adherence, multiple sexual partners, and frequency of 
condom use). In additional analysis, the study also found no mediating effects of social 
support, religiosity/spirituality, and psychological distress on the forgiveness-health 
relationships. With no allusion, whatsoever to forgiveness as a cause of PHRQOL or CD4 
count difference, these findings suggest that there is an important link between forgiving 
HIV-related offenses particularly in the self and spiritual contexts, and both psychological 
and physiological markers of wellbeing. In relation to PHRQOL, the findings indicate that 
the forgiveness-health link in HIV may be observed across contexts, but particularly, 
among PLWHA who are able to replace their hurts and negative attitudes toward God with 
more positive attitudes. The study’s support for DFTS in relation to change in CD4 count 
is an interesting finding that seems to highlight the importance of reduction in 
unforgiveness on the health of PLWHA in typical collectivistic societies.  
 In study two, it was found consistent with the three contexts in Study 1 that 
forgiveness was largely experienced within the context of offenses committed by others 
against participants, by participants against themselves, or both. One person reported 
being angry toward God and another participant reported that the demands of the illness 
and its treatment (e.g., periodic labs and strict adherence recommendations) was a source 
of offense. Secondly, forgiveness was experienced both as an internal action to remove 
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unforgiveness from within one’s heart and mind and an external action of good 
relationships with the perceived offender. Forgiveness was also reported to be 
accompanied by psychological changes such as feeling free in the mind, relieved, happy, 
at peace, and also experiencing love for the offender. Even among participants, who 
reported self-forgiveness, it emerged that forgiveness included feelings of competency, 
adequacy, and positive self-regard. These emotional experiences appeared to be 
confirmation that the complete form of this prosocial behaviour – emotional forgiveness – 
had taken place, as participants reported that experiencing hurt or pain upon recall of the 
offense would indicate that one has not forgiven. Participants further narrated that 
extension of positive behaviours toward an offender while still experiencing pain – a 
description more suggestive of forbearance – is not forgiveness. This is in support of the 
general consensus reached among researchers that forgiveness is distinct from other ways 
of coping with offenses including forbearance and reconciliation (Worthington, 2005). In 
addition, the positive emotional changes participants experienced, in support of the 
significant differences found between decisions to forgive and emotional forgiveness in 
study one, suggest that participants’ experiences of forgiveness included both decisional 
and emotional forgiveness (Worthington & Scherer, 2004).  
 
6.2.1 Study One – Study Two Points of Convergence 
Overall, the findings from Studies One and Two appear to converge in four main 
ways. First, the survey found a link between intrapersonal forgiveness (DTFS and EFS) 
and PATG as predictors and PHRQOL as an outcome. A significant association was also 
found between DTFS and change in CD4 count. These findings were supported by 
participants’ experiences of positive physical and psychological health as well as attractive 
body image after forgiving offenses they had perceived directly as a result of their HIV 
infection. Participants reported looking and feeling well, being able to eat, sleep, 
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concentrate, feeling happy, relieved, at peace, and feeling socially included. The 
debilitating physical and psychological health experiences of the few who had utterly not 
forgiven those they perceived to have infected them also lend support to the forgiveness-
health link found in Study One. For example, these participants reported feeling unhappy, 
miserable, forgetful, as well as looking different (less attractive) in their physical/body 
appearance compared to the period before the offense. Their narratives also revealed 
experiences of social isolation, lack of self-confidence and self-esteem, as well as 
prolonged and disruptive fear of others discovering their positive status. 
Secondly, both Studies support the decisional-emotional stages of the forgiveness 
process. In Study One, a significant difference was observed between decisional and 
emotional forgiveness of both self and others. In Study Two, participants’ descriptions of 
forgiveness, for example, as letting go and removing hatred suggests their experience of 
decisional forgiveness. That participants experienced personal positive emotions of 
wellbeing after letting go coupled with their willingness to relate well with the offender, 
also suggest replacement of any negative emotions with more positive ones. Participants’ 
understanding that extending positive behaviours while still harbouring negative emotions 
toward the offender is more of pretence than forgiveness further support their experience 
of emotional forgiveness. 
Third, findings from both Studies, together, lend support to the three theories that 
underpinned the present study. Namely, both studies found a positive influence of 
forgiveness on psychological and immunological/physical health in support of the SCMF. 
In support of the direct stress response pathway proposed by the BPSFCF as linking 
forgiveness to health, Study 1 found no significant moderation influence of ART 
adherence on the associations between forgiveness and the health outcomes. On the other 
hand, in Study 2, participants reported that forgiving their perceived offenders motivated 
them to adhere to their ART regimen, supporting the behavioural pathway proposed by the 
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BPSFCF. It is interesting to note here that some participants also reported that they 
decided to forgive, after they discovered ART and observed its effects on their health. This 
novel finding which suggests that there may be a bidirectional association between 
forgiveness and ART adherence, seems to lend support to the significant association that 
was found between DTFS and change in CD4 cell count in Study One. Again, in support 
of the ASEF, social support emerged as a significant correlate of DTFO, EFO and 
PHRQOL in Study One. In Study Two, social support and religiosity/spirituality 
comprised two of the most commonly reported antecedents of forgiveness that emerged. 
Whether from family, models of hope, or healthcare professionals, social support seemed 
to have helped participants to first come to terms with their HIV-positive status and to also 
forgive their perceived offenders. In support of the finding that PATG significantly 
predicted PHRQOL after adjusting for covariates, it also emerged from Study Two that 
majority of participants seemed to make some attributions to God regarding their 
perceived cause of their HIV infection irrespective of their initial target of offense. This 
phenomenon, which was termed Double Attribution, may also explain why no association 
was found between NATG and the study outcomes as almost all participants seemed to 
make positive attributions of their HIV-related experiences to God. For some participants, 
these attributions were made with the belief that God had a purpose for their lives (e.g., to 
support newly diagnosed persons), possibly helping them to forgive their perceived 
offenders.   
Finally, the findings from Study One and Study Two complementarily support 
previous findings in the forgiveness-HIV health literature as well as the general 
forgiveness-health literature (e.g., Ironson et al., 2011; Owen et al., 2011; Ridings et al., 
2008; Toussaint et al., 2015; Wald & Temoshok, 2004a, b). 
 
 
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6.2.2 Study One – Study Two Points of Divergence 
 The findings from Studies One and Two showed some interesting divergence 
worth noting. First, none of the health behaviours (Adherence to ART and sexual risk 
behaviours) moderated any of the study relationships as had been predicted in Study One. 
This was in line with the study by Ironson et al., (2011), who found no mechanism effects 
of health behaviours on the relationship between spiritual context of forgiveness and 
health outcomes.  However, this finding was contrary to that by Wald and Temoshok 
(2004b), who found significant associations between forgiveness and these health 
behaviours. The qualitative study on the other hand, showed that forgiveness held meaning 
for participants’ health behaviours, in line with the study by Wald and Temoshok (2004a). 
According to participants, forgiving gave them a free and sound mind to remember to take 
their medication. It was also an indication that they desired to continue living life, as well 
as an indication that they were obeying God. More importantly, the finding that once 
PLWHA decide to continue living rather than end their lives, they would take their 
medication irrespective of whether they may have forgiven any perceived offenses, lends 
some explanation to why ART adherence was not a significant moderator in Study 1. 
According to participants, whether they had forgiven or not, adherence to ART was 
important to sustain their lives and prevent visible HIV symptoms. With regards to sexual 
behaviours, participants who reported forgiveness in Study Two also reported willingness 
and actual efforts to protect others through both direct and indirect behaviours. These 
included engaging in protected sex with partners and educating family and others on 
HIV/AIDS. Interesting, of those who had not forgiven, nuances in their emotional 
responses and behaviours may explain why sexual behaviours did not significantly 
moderate the forgiveness-health associations in Study One. First, it was noted that the 
participant who reported anger toward God and her ex-partner also reported that she 
sometimes engaged in risky behaviours such as engaging in unprotected sex. However, the 
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other participant who reported deep anger toward the deceased man who had intentionally 
infected her reported an intense fear of others discovering her HIV-positive status. This 
intense fear meant that she avoided any situation that could lead to others discovering her 
positive status. For example, she avoided having more children although she longed for 
that. She also refrained from riding motor bikes to avoid any injuries that could warrant 
medical examinations. This means she would most likely also avoid any behaviours (e.g., 
unprotected sex) that could lead to others discovering her positive status. Hence, it can be 
deduced from her case that while forgiveness may motivate protective behaviours, 
unforgiveness may not necessarily promote engagement in risk behaviours due for 
example, to such emotional responses as fear of others discovering one’s HIV positive 
status.  
A second point of divergence in the two study findings was that while DTFS 
significantly predicted change in CD4 cell count, forgiveness of others and attitudes 
toward God failed to significantly predict this outcome. Again, participants’ narratives 
reveal some possible reasons; it was noted that a number of interpersonal offender 
characteristics may have caused participants to forgive some perceived offenders while 
still holding grudge against others. This was typical in the case of the participant who had 
forgiven his late wife and in-laws but was holding grudge against his family members who 
were still stigmatizing against him. Lack of sincere apology from the offender (e.g., in the 
case of participant 15) and intentional infection with HIV (e.g., in the case of participant 
3) also emerged as situations that may account for why interpersonal forgiveness may be 
less predictive of health than intrapersonal forgiveness. The very small size of the sample 
that had both pre-and-post measures of CD4 count and reported attitudes toward God, may 
have also accounted for ATG not significantly predicting CD4 count change.  
 Third, in Study Two, participants reported personal emotional changes when they 
forgave. As well, they reported extending positive acts of goodwill (e.g., talking to and 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
greeting the perceived offender) as part of their forgiveness experiences. While majority 
did not explicitly or consciously report experiencing positive offender-oriented emotions 
toward the offender, their understanding that extending positive behaviours while still 
harbouring negative emotions is not forgiveness, suggests their experience of emotional 
forgiveness. Nonetheless, in Study One, emotional forgiveness of both self and others was 
not predictive of the study outcomes particularly when cofounding factors were taken into 
account. Indeed, this divergence could be solely because participants experienced 
significantly greater decisional forgiveness than emotional forgiveness as observed in 
Study One. However, it may also stem from the finding that within our generally 
collectivistic cultural context, people may be more conscious of their actions when it 
comes to others than they may be of their emotions toward others. As noted in Study Two, 
participants expressed their offender-oriented positive emotions more in terms of their 
positive behaviours toward their perceived offenders and less in terms of the typical 
emotions that the Emotional Forgiveness Scale measures (e.g., empathy, compassion, 
altruistic love, and benevolence). Hence, the less predictiveness of emotional forgiveness 
compared to decisional forgiveness in Study One could have been because participants 
related better with the items of the Decision to Forgive Scale than those of the EFS, which 
excludes items on positive behaviours that stem from the experience of positive offender-
oriented emotions.  
Finally, in Study Two, participants’ religious beliefs (including their double/re-
attribution of their HIV-related offense experiences to the will of God), emerged as an 
important driver of their forgiveness experiences. Participants who reported forgiveness 
also reported positive transformations in their physical and mental health as well as their 
social lives (e.g., better relationships with perceived offenders and others). Conversely, 
participants who indicated anger toward God reported debilitating physical health, mental 
health, and social experiences. Yet, in Study One, religiosity did not significantly correlate 
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with any of the forgiveness variables neither did it correlate with the outcome variables, 
particularly, PHRQOL. Furthermore, NATG did not significantly predict any of the study 
outcomes as had been hypothesized. Drawing on the findings from Study Two, it is 
possible that participants who scored lower on the forgiveness scales in Study One, scored 
as high on the religiosity questionnaire as those who indicated high forgiveness because of 
the potential double attribution of their offence experiences to the will of God. Again, this 
concept of double attribution may have accounted for the averagely low scores on the 
NATG scale and perhaps the insignificant association between this variable and the 
outcome variables.  
Overall, the qualitative findings that forgiveness is to let go or remove hurt/hatred, 
extend positive behaviours of goodwill toward the offender, and feel personal positive 
emotions within lend support to the quantitative study findings. These internal and 
external actions that comprised participants’ experiences of forgiveness meant good 
mental health – free, sound, relived, and peaceful mind. Experiences of forgiveness also 
meant a physically fit and more attractive body. Indeed, no association was found between 
forgiveness and the physical health domain of QOL in the additional analyses in Study 
One. However, that DTFS significantly predicted change in CD4 count may suggest that 
in line with previous studies, the physical/somatic effect of forgiveness may take a long 
time to manifest. As well, they meant motivations to continue living and focusing on 
aspects of life important to them including protecting others from the infection. Again, that 
those who reported unforgiveness experiences also reported various psychological and 
somatic problems (e.g., loss of concentration, unhappiness, poor body image), lend 
support to the positive associations found between forgiveness and health outcomes in the 
quantitative study and in previous studies (e.g., Ironson et al., 2011; Owen et al., 2011; 
Wald & Temoshok, 2004a, b).  
 
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6.3 Revised Model 
Figure 6.0 depicts the revised model for the study, illustrating the forgiveness 
variables that had significant effects on the outcome variables. Specifically, the model 
highlights DTFS and EFS as significant predictors of PHRQOL in unadjusted analyses. It 
also indicates that PATG and DTFS were significant predictors of PHRQOL and change 
in CD4 cell count respectively in both unadjusted and adjusted analyses.  
 
 
Figure 6.1: Revised model of the relationship between forgiveness and the outcomes of 
PHRQOL and change in CD4 count.  
 
Figure 6.1 shows that the findings of the present study lend support to previous 
findings linking different contexts and stages of forgiveness to both patient-reported and 
clinical outcomes among people living with HIV/AIDS (e.g., Ironson et al., 2011; Martina 
et al., 2012; Muhomba et al., 2008; Wald & Temoshok, 2004a). The study findings also 
provide support for the SCMF, the ASEF, and the BPSFCF.  
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6.4. Contributions of the Present Study 
One clear observation made prior to the commencement of this study was both the 
verbalized and non-verbalized question of “how on earth can forgiveness have anything to 
do with scientific research let alone health outcomes in people living with HIV?”. This 
mixed method study has shown that not only do PLWHA often experience large to 
extreme amounts of offenses or injustices directly as a result of their HIV-positive status. 
But also, the more one forgives these offenses, the greater the likelihood that they may 
experience better self-reported as well as clinically measured health outcomes. 
Specifically, the study has made key contributions to theory, knowledge, and research. 
 
6.4.1 Contributions to Knowledge 
 This is the first study, to the best of the knowledge of the researcher, that has 
explored stages of the forgiveness process in relation to both self-reported and clinical 
health outcomes, showing that different stages of the forgiveness process may predict 
health outcomes differently across intrapersonal, interpersonal, and spiritual contexts of 
the experience of unforgiveness of HIV-specific offenses. Importantly, the study has 
shown that reductions in unforgiveness typically inherent in the decisional forgiveness 
stage, may have important links to psychological and immunological health particularly in 
the context of self-forgiveness.  
Again, to the best of the knowledge of the researcher, this study may be the first to 
have scientifically investigated the phenomenon of forgiveness from a biological as well 
as psychosocial perspective. Existing studies in HIV/AIDS have either looked at 
forgiveness in relation to stigma, QOL, other psychosocial factors or purely in relation to 
physiological markers. Thus, this study most likely marks the first in Ghana and perhaps 
the region of Africa and beyond (based on the systematic review findings) to contribute to 
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the scientific literature on forgiveness of HIV-specific offenses in relation to self-reported 
and clinical outcomes.  
The benefits of forgiveness seem to cut across in the literature as physical, 
psychological, social/relational, and spiritual health and wellbeing. Together, findings 
from the present study lend support for the health benefits of forgiveness in all these areas. 
Thus, this study has contributed to knowledge of the possible role of forgiveness among 
PLWHA in Ghana.  
 
6.4.2 Contributions to Research 
The findings of the systematic review of forgiveness studies in PLWHA as related 
to health showed that all studies in the area have so far employed quantitative research 
methods. Therefore, this study may be the first to have employed a mixed method design 
to ascertain the forgiveness-health link in PLWHA in typically collectivistic societies and 
to unearth what it is like and means to forgive HIV-specific offenses. Using this design, 
other behaviours and factors that may link forgiveness to health including a renewed 
desire to live a focused life were identified.   
The study also seems to have noticed that particularly among women, forgiveness 
may promote a sense of positive or attractive body image. This is an important finding that 
may provide directions for further wellbeing research in HIV/AIDS, considering that some 
PLWHA have expressed concerns about their weight and other issues related to body 
image. It may also provide directions for researchers in the area of body image in general, 
to explore whether deep-seated hurts and unforgiveness may be a contributing factor 
among people with negative body image perceptions and vice versa.  
Finally, the study has made contributions to scientific theory and methodology in 
drawing out core implications that relate to 1) the definition and extent of impact of 
decisional forgiveness on health, 2) the seemingly fine lines between decisional 
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forgiveness, emotional forgiveness, and reconciliation, and 3) the validation of the 
WHOQOL-BREF in PLWHA in Ghana.  
 
6.4.3 Theoretical Contributions and Implications 
 This study found that in unadjusted analysis, DTFS slightly predicted PHRQOL 
over EFS and remained a significant predictor of change in CD4 count when covariates 
were accounted for. Whereas, there was no significant relationship between emotional 
forgiveness whether of self or others and immunological function, although it has been 
theorized that emotional forgiveness may have more health benefits than decisional 
forgiveness (Worthington and Scherer, 2004). Thus, the present study holds implications 
for further consideration of the extent of impact that reduction in unforgiveness may have 
on health compared to a stable state of positive emotions. It may be that the theory of 
emotional forgiveness having more health benefits may be realized more in certain offense 
contexts or sub-populations or that the emotional forgiveness scale may not be measuring 
some cultural contextual emotional experiences (e.g., offender-oriented positive 
behaviours due to positive emotions of forgiveness).  
In relation to the above point, the support found in this study for the link between 
decisions to forgive (especially in the self-forgiveness context) and health, holds 
implications for clarifying the definition of decisional forgiveness in ways that draw out 
the core process of unforgiveness reduction that may be inherent in this stage. A proposed 
definition is offered based on the findings of the present study as: decisional forgiveness is 
the reduction in or removal of negative thoughts and emotions about an offender that 
reflects in a decision to forgo negative behaviours toward the offender and possible 
extension of actual positive behaviours. It is reiterated that before an offended person may 
decide to forgo any intentions to behave in negative ways toward an offender, the 
individual may have most likely experienced some reduction in their negative thoughts 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
and emotions about the offense/offender. It may be this initial change from a peak level of 
hurting to a lesser hurting state that actually drives the decision to let go of negative 
retaliatory/avoidant behaviours, and which possibly lends this stage of forgiveness its role 
in health. 
Also, the study shows that a revisit of the collectivism-forgiveness-reconciliation 
links may be essential in clarifying positive behaviours that may stem from decisional 
and/or emotional forgiveness and those that may be portrayed solely as reconciliatory 
tools for social harmony. In typical collectivistic societies or among people with 
interdependent worldviews especially, it may be particularly important to tease out 
extension of positive behaviours due to forgiveness from mutual reconciliatory behaviours 
in response to two-way conflicts.   
 
6.5 Practical Implications of the Study 
6.5.1 Implications for Clinical Practice 
Clinically, there is the need to develop culturally relevant, easy to grasp 
forgiveness interventions that would help both newly diagnosed and PLWHA to let go of 
any injustices or hurts they may be struggling with, as findings of this study in support of 
previous findings, suggest that forgiveness may help promote positive health outcomes on 
treatment. 
Also, it may be relevant to display evidence-based informational materials at 
HIV/AIDS clinics that creatively draw attention to key evidence-based issues on 
forgiveness in HIV/AIDS and where to obtain support with these issues. For instance, 
there could be a poster on the two most common sources of HIV-related offenses 
identified in the study – who/what caused HIV and the stigmatizing, discriminatory, and 
rejection attitudes of family and other significant others. Again, informational materials 
(e.g., posters) providing clear comparisons on what constitute unforgiveness versus 
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forgiveness and the possible consequences of these phenomena. Quotes from the 
qualitative study could further be utilized as callouts on the posters to buttress these 
messages, as evidence supports patient reports as a helpful tool in health communication. 
 
6.5.2 Implications for Policy 
The policy implications of the findings of this study is the need for what I would 
term a “Policy of Right to Know”. There is the need for a policy that ensures that in the 
least, people with a diagnosis of HIV/AIDS in Ghana are aware of the potential role that 
forgiveness of HIV-specific offenses may play in their health outcomes. Currently, 
HIV/AIDS counselling is chiefly centered on adherence. While this is extremely helpful, it 
emerged from the qualitative study that PLWHA may take their medication even if 
emotionally hurting, where they wish to stay alive. However, this prolonged hurting may 
cause damage in various other ways including loss of self-esteem, poor body image 
perception, lack of concentration, social isolation, chronic fear of others discovering one’s 
status, and deep-seated unhappiness among other consequences. It may help to present 
PLWHA an opportunity to know about these debilitating experiences of unforgiveness and 
the positive experiences of forgiveness that held meaning for participants’ physical, 
psychological, social (including career), and spiritual wellbeing. These included having a 
fit and attractive body/ appearance, a relieved, free, and peaceful mind, joyful heart, 
preserved social relationships and bonds, and a renewed focus on personal achievements 
and that of others.  
Therefore, there is a need for a policy that 1) mandates evidence-based assessment 
for perceived offenses, responses to, and current ways of coping with offenses for all 
PLWHA as part of routine HIV/AIDS care protocols, 2) specifies awareness creation 
about possible effects of unforgiveness and forgiveness for all screened persons, and 3) 
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specifies a clear intervention support pathway for screened persons at high risk of 
unforgiveness and emotional breakdown.   
 
6.5.3 Public Health Implications of the Study 
 This study has identified four interesting situations that may be of significant 
public health interest. First, it emerged from the phenomenological inquiry that 
forgiveness of HIV-related offenses made participants adhere to their ART, partly because 
forgiveness gave them a sound mind that helped them to remember to take the 
medications. This means that in seeking to promote adherence and in-turn reduce incidents 
of secondary infection and development of newer and resistant viral strains, HIV-related 
offenses need to be explored and appropriate support provided to aid forgiveness of these 
offenses.  
Secondly, it emerged from the qualitative study that unforgiveness of HIV-related 
offenses may lead to behaviours that may impede public health efforts at curbing 
secondary transmission of HIV and preventing re-infection, risk of resistance, and 
treatment failure in PLWHA on ART. Participants revealed that if they had not forgiven 
their HIV-related offenses, they would have cared less about others acquiring the infection 
from them. One participant who was still experiencing pain and anger toward God and her 
ex-fiancé reported that she sometimes did crazy things like partying and having sex as she 
was so unhappy within. On the contrary, participants who reported having forgiven 
indicated a strong focus on protecting both family and non-family members from 
acquiring the infection through a number of practical ways.  
Similar to the problem of unforgiveness linking to sexual risk behaviours, the study 
found that one’s belief about their HIV as being spiritually caused, may promote HIV 
transmission risk behaviours. As reported by one participant, that her HIV was spiritually 
bought for her means that it is impossible for her to transmit the virus to her sexual partner 
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whom she had not yet disclosed her status to, even if she fails to use a condom or stops 
taking her medication. Again, she believed that she could not have transmitted the 
infection to her son even if she was not on the medication during her pregnancy. These 
findings imply that including clear guidelines in existing HIV counselling protocols for 
probing into participants’ beliefs and feelings (of hurt or perceived injustices) about their 
HIV may in the long run, help to prevent HIV-transmission risk behaviours. Currently, 
HIV/AIDS counselling typically seems to align with the one-size-fits all approach. 
However, this approach may mean that perceived offenses and misplaced beliefs that may 
have implications for increased transmission of HIV infection may go unnoticed and 
unaddressed.  
Finally, the findings of this study hold important implications for ongoing 
HIV/AIDS education. Among PLWHA who reported having forgiven, an overwhelming 
proportion reported that they educated their families and also non-family members about 
HIV/AIDS. These included education about transmission risks, signs and symptoms, and 
voluntary testing. While most participants were careful not to disclose their HIV positive 
status in the course of educating others, that they propagated these important facts about 
the infection is an important practice worth supporting. The implication for public health 
organizations therefore, is to ensure that PLWHA who attend routine clinics gain the right 
understanding about HIV to ensure propagation of the right information. For instance, 
simple pamphlets with well-presented current information about HIV may be made freely 
available at HIV clinics for PLWHA to pick and share with others. To prevent the 
individuals from being stigmatized however, it may be necessary that these pamphlets also 
contain information on other key chronic conditions.  
 
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6.5.4 Implications for Health Psychology Practice in Ghana 
The public health implications and the findings of the study at large, hold several 
implications for the discipline of Health Psychology, which is the branch of psychology 
that focuses on applying psychological principles and theory to promoting health, 
preventing illness, and improving healthcare systems. First, there is the need for expert 
contributions from health psychologists via collaborations with public health practitioners 
and organizations to raise awareness among the population of PLWHA of the links found 
between forgiveness of HIV-specific offenses and health. A core interest of health 
psychologists is health information dissemination via tailored, evidence-based, and 
culturally-relevant communication channels.  
Secondly, health psychologists collaborate with clinical healthcare providers to 
develop culturally relevant forgiveness interventions or adapt existing ones and make them 
suitable for use with target populations. It is important that health psychologists 
collaborate with HIV/AIDS care providers to develop forgiveness interventions that take 
into consideration the typical spiritual orientation of PLWHA in Ghana and the double 
attributions that they may make as a result. Furthermore, it is important that the 
interventions recognize the role of social support on one hand, as a facilitator for 
acceptance of HIV positive status and also of forgiveness. And on the other hand, the fear 
of PLWHA that the more people (including significant others) are aware of their status, 
the less safe their “secret” and the greater the perceived risks of being stigmatized. 
Finally, the study holds implications for the development of health psychology-
based training packages and protocols for counsellors and other healthcare providers 
involved in HIV/AIDS care delivery. The focus of such training would be to support 
healthcare providers with up-to-date approaches for assessing and addressing common as 
well as more difficult emotional and behaviour issues including perceived offenses, 
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forgiveness, and related behaviours, that may interfere with clinical treatment goals for 
PLWHA in Ghana.  
 
6.6 Limitations of the Study 
The present study is without limitations, despite the careful efforts at minimizing 
biases and contamination. First, an ideal design for the study would have been a 
longitudinal design that assessed participants’ thoughts, emotions, and behaviour 
intentions right at diagnosis together with other pre-ART baseline measures, with 
prospective post-ART assessments at fixed time periods for all participants. For a number 
of pragmatic reasons, a cross-sectional design was employed, in which not all participants 
had baseline and/or survey-concurrent clinical measures, concurrent clinical measures 
were taken within a period, and retrospective reports of offenses and forgiveness may have 
introduced recall bias. In an effort to address some of these shortcomings, time period 
between first and concurrent ART measures was controlled for in all CD4 analyses. 
The involvement of trained healthcare personnel already known to participants in 
the data collection may have introduced some level of social desirability bias. However, 
the researcher conducted all the interviews in study two in an attempt to overcome this 
shortcoming.  
Also, as only out-patients were included in the study, these were usually in one 
queue or another at the outpatient departments. It is possible that some respondents, not 
willing to lose their spots in queues, may have been acquiescent in their responses. 
Although, the qualitative interviews were conducted at participants’ preferred times and 
hence, were in-depth, ensuring that rich insights into the study phenomenon were 
uncovered. 
Finally, there were some methodological limitations to the study. These related to 
the relatively small sample sizes involved in the PATG-PHRQOL analysis and also the 
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DTFS-change in CD4 analysis. Although it may be argued that findings from studies with 
small clinical samples hold clinical relevance, there are implications for future studies to 
endeavour to involve larger samples.  Also, although the survey measures employed were 
validated and showed good to excellent internal consistency reliabilities, confirmatory 
validation studies with larger and similar as well as dissimilar populations may provide 
more support for their validity.   
 
6.7 Recommendations for Future Research 
It is proposed that further research into this study consider a longitudinal 
prospective design that investigates offenses, unforgiveness, stages of forgiveness, and 
clinical variables right from diagnosis. Different clinical endpoints, forgiveness-related 
constructs (e.g., forbearance, resilience, reconciliation), mechanism variables (e.g., sense 
of purpose in life), as well as a sampling procedure that allows for inclusion of large 
samples for all contexts of forgiveness may be worth considering. A randomized 
controlled trial of a forgiveness intervention to ascertain whether increasing forgiveness 
would lead to positive health outcomes for PLWHA in Ghana compared to controls, also 
is much recommended. 
Finally, a large confirmatory validation study among PLWHA in Ghana of the 
forgiveness measures used as well as the WHOQOL-BREF measure is recommended 
(considering that there was no significant association found between forgiveness and the 
other domains of QOL). Also, a cross-cultural validation of Wald and Temoshok’s (2004a, 
b) forgiveness vignette measure may help to assess different contexts of forgiveness in less 
time, helping to reduce the burden on participants that assessing of multi-context 
forgiveness using standard questionnaires may place on them. This may be especially 
useful for use in clinical settings, where participants may not have much time to spare.   
 
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6.8 Conclusion 
 In conclusion, the present study aimed at investigating the link between 
forgiveness of offenses directly related to one’s HIV-positive status and two health 
outcomes – psychological health-related quality of life and change in CD4 cell count. 
Employing an explanatory mixed method design, cross-sectional survey data was first 
collected on three contexts of forgiveness – intrapersonal, interpersonal, and spiritual – 
from a total of 325 people living with HIV/AIDS. Participants were outpatients receiving 
antiretroviral therapy across the Korle-Bu, Komfo Anokye, and Tamale Teaching 
Hospitals. In support of some of the study’s hypotheses, difference tests, regression 
analyses, and moderation analyses revealed that deciding to let go of an HIV-related 
offense, whether towards one’s self or another, was engaged in more readily than feeling 
positive emotions toward the offender. Also, deciding to forgive one’s self as well as 
feeling positive emotions toward the self, predicted higher psychological health-related 
quality of life but only in unadjusted analyses. Interestingly, in both unadjusted analyses 
and adjusted analyses, when significant confounders were taken into account, deciding to 
forgive one’s self and positive attitudes toward God significantly predicted increased 
change in CD4 cell count and higher psychological health-related quality of life 
respectively. Interpersonal forgiveness (decision to forgive others and emotional 
forgiveness of others) did not predict any of the two outcome variables, neither did health 
behaviours moderate any of the associations identified between forgiveness in all three 
contexts and the outcomes.  
 To better explain the survey findings, a follow-up phenomenological study on the 
lived experiences of forgiveness of HIV-related offenses among 15 of the survey 
participants using a semi-structured interview guide was conducted. Interview data were 
analysed using interpretative phenomenological analysis. Six main themes emerged that 
expounded on the survey findings. Mainly, it was found that forgiveness was experienced 
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as internal actions of letting go or removing unforgiveness from within the heart of the 
offended, as external actions of extending goodwill toward the offender, and as positive 
psychological changes within the offender. Participants, who reported forgiveness also 
reported improved psychological experiences as well as improved physical fitness, 
attractive body image, increased self-efficacy and -value, and better social ties. Whereas, 
the few who reported unforgiveness reported gross experiences including unhappiness, 
prolonged fear, lack of self-esteem, unattractive body image, social isolation, and also 
engagement in unprotected sex at times. Religiosity/Spirituality including double 
attribution and also, social support were commonly reported facilitators of forgiveness, 
which held meaning for engaging in positive health behaviours, protecting others from 
infection with HIV, and for a living a new and focused life.   
 Overall, findings of the present study complementarily lend support to the Stress 
and Coping Model of Forgiveness, the Biopsychosocial Contexts of Framework of 
Forgiveness in HIV, and the Afrocultural Social Ethos Framework. Namely, among 
PLWHA in Ghana, forgiveness as an emotion- and adaptive-focused coping strategy for 
perceived HIV-related offenses may hold benefits for psychological and immunological 
health either directly (as suggested by findings in Study 1) or through positive health 
behaviours (as indicated in Study 2 findings). And that among other factors, values for 
communalism and spirituality may facilitate forgiveness experiences through social 
support and religious behaviours and practices, as well as purposeful attributions of 
offense-experiences to the will/doing of God.   
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APPENDICES 
Appendix A: UG-ECH Ethical Clearance 
 
 
 
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Appendix B: 37 Military Hospital IRB 
 
 
 
 
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Appendix C: Tamale Teaching Hospital IRB 
 
 
 
 
 
 
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Appendix D: Komfo Anokye Teaching Hospital IRB 
 
 
 
 
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Appendix E: Korle Bu Teaching Hospital IRB 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix F: Information and Consent Form 
               UNIVERSITY OF GHANA 
Official Use only 
Protocol number 
 
  
Ethics Committee for Humanities (ECH) 
 
PROTOCOL CONSENT FORM  
 
Section A- BACKGROUND 
INFORMATION 
 
Title of Study :       Forgiveness in People Living with HIV/AIDs in Ghana: An Exploration of its 
 Influence on   on Quality of Life and Immune Functioning Markers 
Principal Judith Ansaa Osae-Larbi 
Investigator: 
 
Certified  
Protocol 
Number 
 
Section B– CONSENT TO PARTICIPATE IN 
RESEARCH 
 
General Information about Research 
 The purpose of this research study is to understand how forgiveness may be 
relevant to the health and everyday lives of people living with HIV/AIDS. You are 
being asked to participate in this study because you are 18 years of age or older.  
 In this study, you will be asked to complete a survey which will last about 45 -
60minutes. 
 The survey will ask some questions about how you manage an offence, your views 
on different aspects of your life such, and some demographic questions such as 
your age.  
 This study is in two parts. Therefore, you may be contacted to participate in a 
follow-up interview as part of this research, however, you do not have to 
participate if you do not wish to. You will only be contacted if you agree to 
participate and you may also withdraw from the follow-up study at any time 
without any penalty.  
Benefits/Risk of the study 
 You may not get any direct benefit from participating in this study. However, the 
information we learn from people in this study may help us to better provide 
people living with HIV/AIDS in Ghana with appropriate counseling and support.  
The risks for participating in this study are no greater than the risks associated with 
daily living. However, should participating in this study cause you to feel 
uncomfortable in any way, you can skip any question that you may not be 
comfortable answering. You can also contact the researcher for an appropriate 
psychological support, should you experience any discomfort as a result of 
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participating in this study. Also, you may stop participating in the study or refuse 
to participate in the study altogether. Because a breach of confidentiality could be a 
potential risk, you will not be asked to provide your name. Instead, a coding 
process with a study ID will be used to lessen this risk.  
Confidentiality  
 The data collected in this study will not be personally identifiable, as no name or 
birth date will be matched to your responses. Only your folder numbers will be 
matched to your responses. Data are being collected only for research purposes, 
identified only by an anonymous study ID number based on folder numbers. All 
information will be kept in password protected electronic files. Electronic files of 
the study data will be kept indefinitely. Access to all data will be limited to the 
researcher.  
 The answers you provide in this study will not be passed on to anyone.  
 What we find from this study may be presented at meetings or published in papers, 
but your name will not ever be used in these presentations or papers.  
Compensation  
 You will be given some refreshments as a reward for your participation in this 
study.  
Withdrawal from Study 
 You do not have to participate in this study. Participation in this study is voluntary. 
If you choose to participate, you may stop at any time without any penalty, loss of 
healthcare services, or loss of any benefits to which you are otherwise entitled. To 
withdraw all of your information or parts of your information from the study, you 
can contact the researcher at any time before completion of the study.  
Contact for Additional Information  
 Should you have any questions, complaints, or concerns about the research and 
your participation in it, contact the researcher: 
 
            Judith Osae-Larbi 
Department of Psychology 
School of Social Sciences 
College of Humanities 
P.O.Box 84. Legon-Accra 
Phone: (+233) 050 404 9955 
Email: jaosae-larbi@st.ug.edu.gh  
 
 If you have any questions about your rights as a research participant in this study 
you may contact the Administrator of the Ethics Committee for Humanities, 
ISSER, University of Ghana at ech@isser.edu.gh / ech@ug.edu.gh  or 00233- 303-
933-866. 
 
 
 
 
 
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Section C- VOLUNTEER AGREEMENT 
 
"I have read or have had someone read all of the above, asked questions, received 
answers regarding participation in this study, and am willing to give consent for me, 
my child/ward to participate in this study. I will not have waived any of my rights by 
signing this consent form. Upon signing this consent form, I will receive a copy for 
my personal records." 
 
 
________________________________________________ 
Name of Volunteer 
 
 
_________________________________________               _______________________ 
Signature or mark of volunteer                                     Date    
 
 
If volunteers cannot read the form themselves, a witness must sign here:  
I was present while the benefits, risks and procedures were read to the volunteer. All 
questions were answered and the volunteer has agreed to take part in the research.  
 
 
_________________________________________________ 
Name of witness 
 
 
_________________________________________  _______________________   
Signature of witness                                       Date 
 
 
I certify that the nature and purpose, the potential benefits, and possible risks associated 
with participating in this research have been explained to the above individual.  
 
 
__________________________________________________  
Name of Person who Obtained Consent 
 
 
___________________________________         ______________________ 
Signature of Person Who Obtained Consent                                  Date   
 
 
 
 
 
 
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Appendix G: Study 1 Survey Measures 
 
Questionnaire ID……………………..      Date………………   Admin ID…………….. 
Thank you for agreeing to participate in this study. Please note that your name will NOT 
be written on this questionnaire. All the answers you provide will be kept strictly 
confidential and only used for academic purposes.   
SECTION A 
For each question, please circle the option that participants report best describes them 
Sex 1. 1. Male          2. Female 
Age (years)                                 
Highest education attained 1. Primary       2. Secondary       3. Post-secondary Certificate       
4.     Post-secondary Diploma      5. Degree    6. Masters   7. PHD 
Marital status 1.     Single                2. Married            3. Living as married               
4.     Separated         5. Divorce             6. Widowed 
Native language (e.g., Akan) Please write  
Religious affiliation  1.   Christian     2. Islam    3. Traditional    4. None     5. Not sure 
In the 7 days, how many times did   you1 . 1. None of the time     2. Only one time     3. Two - three times                                                
miss your HIV medication?  4. More than three times 
 
 
SECTION B 
Please provide the following information from the participant’s folder 
1. Are you currently on HIV medication? (please circle)        Yes                       No        
2. Since when have you been on HIV medication?  ______(dd)______(mm)_____(yr) 
3. What HIV medication(s) are you currently on? 
_________________________________________ 
4. When were you first diagnosed with HIV? _______(dd)_______(mm)_______(yr)     
5. What is your HIV Type? _____________________________            
6. What was your first CD4 count test result before you started taking ART? 
_________________ 
7. When did you take your first CD4-cell count test? _______(dd)_______(mm)_______(yr) 
8. What is your most recent CD4 count test result? ______________________ 
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9. When did you take your most recent CD4-cell count test?   A) Today    
B)___(dd)___(mm)____(yr) 
10. Participant’s known comorbidities (Please write down ALL known comorbidities)  
___________________________________________________________________________ 
___________________________________________________________________________ 
 
 
SECTION C 
 
Please recall and write down a description of what offended you most about your HIV-
positive status. After writing your most offensive HIV-specific situation, indicate the 
hurtfulness of the offense, time since the offense occurred, and who you feel offended you 
(Please do not write their names, only their relationship to you e.g., partner). If you have 
more than one target, state all. Please note: if you have more than one HIV-specific situation 
that offended you, please remember and write down the one situation that you consider to 
have offended you most. 
 
My most offensive or hurtful HIV/AIDS-related situation: _________________________ 
___________________________________________________________________________ 
___________________________________________________________________________ 
 
Hurtfulness of offense: Please rate the hurtfulness of the offense, using the scale below. 
Circle your answer.  
        1                               2                               3                            4                                  5  
Very little hurt                                                                               Large amount of hurt 
 
Time since the offense or hurt: Please estimate the time in months since the offense 
occurred.  
The offense occurred ________________ months ago 
 
Target(s) of offense or hurt (e.g., my husband/wife, my boyfriend/girlfriend, myself, a 
hospital, a patient, a nurse, a stranger etc.): ______________________________________ 
 
 
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SECTIONS D – F 
 
Please answer the questions in ALL the sections that APPLY to your specific offense 
situation 
 If the target of your offense/hurt includes yourself, please go to Section D 
 If the target of your offense/hurt includes another person, group of persons, or 
institution please go to Section E 
 If you feel that God allowed what happened in the situation you just described, please 
go to Section F 
 
SECTION D: WHEN THE TARGET OF YOUR OFFENSE INCLUDES 
YOURSELF 
As you think about this offense situation you just described, please rate your agreement with 
each of the statements in this section based on how you currently feel using 5-point ratings 
ranging from 1 = strongly disagree to 5 = strongly agree.  Please tick the appropriate box for 
each statement. 
 Strongly Disagree Agree and   Agree Strongly 
Disagree disagree      agree 
equally 
1. I have decided to forgive myself.       
2. I made a commitment to forgive myself.       
3. I have made up my mind to forgive myself.       
4. My choice is to forgive myself.       
5. My choice is to release any negative feelings I        
have about myself.  
6. My choice is to release any negative ideas or          
thoughts I have about myself. 
7. I have decided not to do anything bad to myself.     
8. I have chosen not to intentionally harbor hatred      
towards myself.  
9. I care about myself.      
10. I no longer feel upset when I think of what I      
did   in the situation. 
11. I feel guilt and regret for the things I did in                        
the situation 
12. I feel sympathy toward myself       
 
 
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SECTION D Continued 
 Strongly Disagree Agree and  Agree Strongly 
Disagree disagree agree 
equally 
13. I’m angry at myself for what happened        
14. I like myself      
15. I hate what I did in the situation      
16. I feel love toward myself      
 
SECTION E: WHEN THE TARGET OF YOUR OFFENSE INCLUDES OTHERS  
As you think about this offense situation you just described, please rate your agreement with 
each of the statements in this section based on how you currently feel using 5-point ratings 
ranging from 1 = strongly disagree to 5 = strongly agree.  Please tick the appropriate box for 
each statement. 
 Strongly Disagree Agree and  Agree Strongly 
Disagree disagree     agree 
equally 
1. I have decided to forgive him/her/them      
2. I made a commitment to forgive him/her/them     
3. I have made up my mind to forgive      
him/her/them 
4. My choice is to forgive him/her/institution.       
5. My choice is to release any negative feelings I       
have about him/her/them  
6. My choice if to release any negative ideas or      
thoughts I have about him/her/them 
7. I have decided not to take revenge against      
him/her/them 
8. I have chosen not to intentionally harbor      
hatred towards him/her/them  
9. I care about him/her/them      
10. I no longer feel upset when I think of      
him/her/ them 
11. I’m so annoyed about what he/her/they did to      
me. 
12. I feel sympathy toward him/her/them.       
13. I’m angry about what happened.        
 
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SECTION E Continued 
 Strongly Disagree Agree and   Agree Strongly 
Disagree disagree agree 
equally 
14. I like him/her/them.      
15. I hate what he/she/they did to me.      
16. I feel love toward him/her/them.      
 
SECTION F: WHEN YOU BELIEVE THAT GOD ALLOWED THE SITUATION 
As you think about this offense situation you just described, please rate your agreement 
with each of the statements based on how you currently feel in this section on a scale of 0 
(Not at all) to 10 (Extremely). Please tick the appropriate box for each statement. 
                                                                                   
To what extent do you currently:  
                                                Not at all                                                                    Extremely                                                                                         
 0 1 2 3 4 5 6 7 8 9 10 
1. Trust God to protect and care for you            
2. Feel angry at God            
3. Feel that God has let you down            
4. View God as unkind             
5. View God as all-powerful and all-            
knowing 
6. Feel loved by God            
7. Feel supported by God            
8. Feel nurtured or cared for by God            
9. Feel abandoned by God            
 
 
 
 
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SECTIONS G – K 
 
 FOR ALL PARTICIPANTS: Please answer the questions in sections G – K 
 
 
SECTION G 
The statements in this section measure various situations we may find ourselves in. For each 
statement, indicate on a scale of 1 (Strongly disagree) to 5 (Strongly agree), the extent to 
which you agree with it. Please write the number beside the statement.  
1 = Strongly  2 = Disagree 3 = Agree and disagree 4 = Agree 5 = Strongly agree 
Disagree equally 
 
1. I can freely express my opinion to my partner or group of friends. _____ 
2. I feel I can count on my closest friends or partner when I need to be listened to. _____ 
3. I feel emotionally sheltered by my family._____ 
4. If I ask for it, my friends can give me good advice for my personal development._____ 
5. To be part of a group of friends allows me to know myself better._____ 
6. I think that my friends give me possibilities for growth._____ 
7. If I want to talk to somebody, I can turn to a friend/or my partner and he/she will listen to 
me._____ 
8. Most of the time, solutions presented by my group of friends are useful for problems I may 
face._____ 
9. If I have problems, my friends/partner would help me._____ 
10. If something is for my own good, my family will support me._____ 
11. Among my friends conflicts are promptly resolved._____ 
12. My friends have been able to give affection when I needed it._____ 
 
 
SECTION H 
 
The questions under this section concern how you have been feeling over the past 30 days. 
Please circle the number to the right of each question that best represents or describes how 
you have been.   
During the last 30days, 1. None of 2. A little of 3. Some of 4. Most of 5. All of the 
the time the time the time the time time 
1. about how often did you feel tired out for no      
good reason?       1        2        3       4        5 
 
 
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SECTION H Continued 
During the last 30 days, 1. None of 2. A little      3. Some of 4. Most of 5. All of     
the time of the time the time the time the time 
2. about how often did you feel nervous?      
      1       2        3      4       5 
3. about how often did you feel so nervous       
that nothing could calm you down?       1        2        3       4        5 
4. about how often did you feel hopeless?      
      1        2        3       4        5 
5. about how often did you feel restless or       
fidgety?       1        2        3       4        5 
6. about how often did you feel so restless         
you could not sit still?       1        2        3       4        5 
7. about how often did you feel depressed?     
      1        2        3       4        5 
8. about how often did you feel that        
everything was an effort?       1        2        3       4        5 
9. about how often did you feel so sad that       
nothing could cheer you up?       1        2        3       4        5 
10. about how often did you feel      
worthless?       1        2        3       4        5 
 
 
SECTION I 
The following questions ask how you feel about your quality of life, health, or other areas of 
your life. For each question, please choose the answer that appears most appropriate by 
circling the corresponding number to that answer. If you are unsure about which response to 
give to a question, the first response you think of is often the best one. Please keep in mind 
your standards, hopes, pleasures and concerns. We ask that you think about your life in the 
last four weeks.  
  Very Poor Poor Neither poor      Good Very good 
nor good 
1.  How would you rate your      
quality    of life?       1        2        3       4        5 
 
 
  Very Dissatisfied Neither satisfied Satisfied Very 
dissatisfied nor dissatisfied satisfied 
2. How satisfied are you with      
your health?       1         2        3       4        5 
 
 
 
 
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SECTION I Continued 
 
  Not at all A little A moderate Very much An extreme 
amount amount 
3. To what extent do you feel that      
physical pain prevents you from       1        2        3       4        5 
doing what you need to do? 
4.  How much do you need any      
medical treatment to function       1        2        3       4        5 
in your daily life? 
5.  How much do you enjoy life?        1        2        3       4        5 
6. To what extent do you feel your      
life to be meaningful       1        2        3       4        5 
 
 
  Not at all A little A moderate Very much Extremely 
amount 
7. How well are you able to      
concentrate?       1        2        3       4        5 
8. How safe do you feel in your      
daily life?       1        2        3       4        5 
9.  How healthy is your physical      
environment?       1        2        3       4        5 
 
 
  Not at all A little Moderately Mostly Completely 
10 Do you have enough energy for      
everyday life?       1        2        3       4        5 
11 Are you able to accept your      
bodily appearance?       1        2        3       4        5 
12  Have you enough money to      
meet your needs?       1        2        3       4        5 
13 How available to you is the      
information that you need in       1        2        3       4        5 
your day-to-day life? 
 
14 To what extent do you have the      
opportunity for leisure       1        2        3       4        5 
activities?  
 
  Very poor Poor Neither poor Good Very good 
nor good 
15 How well are you able to get      
around?       1        2        3       4        5 
SECTION I Continued 
  Very Dissatisfied Neither Satisfied Very 
dissatisfied satisfied nor satisfied 
dissatisfied 
16 How satisfied are you with your      
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sleep?       1        2        3       4        5 
17 How satisfied are you with      
your ability to perform your       1        2        3       4        5 
daily living activities? 
18 How satisfied are you with      
your capacity for work?       1        2        3       4        5 
19 How satisfied are you with      
yourself?       1        2        3       4        5 
20 How satisfied are you with your      
personal relationships?       1        2        3       4        5 
21 How satisfied are you with      
your sex life?       1        2        3       4        5 
22 How satisfied are you with the      
support you get from your       1        2        3       4        5 
friends? 
23 How satisfied are you with the      
conditions of your living place?       1        2        3       4        5 
24 How satisfied are you with your      
access to health services?       1        2        3       4        5 
25 How satisfied are you with      
your transport?       1        2        3       4        5 
 
  Never  Occasionally Quite often Very oftenA lways 
26 How often do you feel sad,      
disturbed, lose hope, have no       1        2        3       4        5 
interest in things you usually 
enjoy? 
 
 
 
 
 
SECTION J 
 
The questions below measure a variety of behaviours.  Please indicate the extent to which 
you may have ever engaged in any of the behaviours since the offense you described above 
in Section A occurred. Rate your responses from 0 (None of the time) to 5 (All of the time) 
or NA if not applicable. 
1.     Approximately how many people have you had sex with? _____ 
2.     How often have you used condoms when having sex with your regular partners? _____ 
3.     How often have you used condoms when having sex with casual partners? _____ 
4.    How often have you used condoms paying for, or being paid for, sex with money? ____ 
5.    How many times have you had anal sex? _____ 
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SECTION K 
 
The questions in this section measure religious practices. For each question, please check the 
option or circle the number that best describes you.   
1. Which of the following best describes you at the present time (Please circle one option) 
a. Atheist (I do not believe in God) 
b. Agnostic (I believe we can’t really know about God) 
c. Unsure (I don’t know what to believe about God) 
d. Spiritual (I believe in God, but I’m not religious) 
e. Religious (I believe in God and practice religion) 
 
2. In the past year, how often have you done the following? (Circle one number for each line) 
 Never  Rarely  Once a Twice a Once a Twice a Almost More than 
month month week week daily once a day 
a. Thought about God  1 2 3 4 5 6 7 8 
b. Prayed 1 2 3 4 5 6 7 8 
c. Meditated 1 2 3 4 5 6 7 8 
d. Attended worship 1 2 3 4 5 6 7 8 
service 
e. Read/studied scriptures 1 2 3 4 5 6 7 8 
or holy writings 
f. Had direct experiences 1 2 3 4 5 6 7 8 
of God 
 
3. Have you ever in your life done the following? (Circle one number for each line) 
 Never Yes, in the past but not now Yes, and I still do 
a. Believed in God? 1 2 3 
b. Prayed? 1 2 3 
c. Meditated? 1 2 3 
d. Attended worship services 1 2 3 
regularly? 
e. Read scriptures or holy writings 1 2 3 
regularly? 
f. Had direct experiences of God? 1 2 3 
 
Follow-Up Interview Study 
In the near future, we will conduct a follow-up interview study with some of the participants who will 
take part in this survey research. This is to gain deeper understanding of how people living with 
HIV/AIDS deal with offenses specifically related to their HIV-positive status. Please indicate your 
interest or not in participating in the follow-up interview study by ticking the appropriate box below.  
Please note:  Participation in the interview study is also voluntary, any information provided will be 
kept highly confidential and participants’ identity will be strictly protected.  
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           Yes I am interested in the interview study. You may contact me and give me more  
 
           information about the study.  My telephone number: ________________________________ 
           No I am not interested in the interview study and would not like to be contacted about it. 
THANK YOU FOR YOUR HELP! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix H: Study 2 Interview Guide  
Research Question Interview Questions 
RQ 1: 1) What it is like to receive a diagnosis of HIV/AIDS? 
What are the HIV- Prompts: 
specific offense  When did you find out that you have HIV and how do you think 
experiences of you got it? 
PLWHA?  What came to mind, how did you feel, or what did you do when 
 you were first diagnosed? 
  
 2) What has been your experience of living with HIV/AIDS? 
Objective:             [Positive?,  Negative?] 
Build rapport and  
understanding the [IF NEGATIVE EXPEREINCES REPORTED FROM Q1 AND Q2] 
HIV-specific offense  
context of 3) What situations related to you being HIV-positive, would you 
forgiveness consider as offensive experiences and why? 
 
4) What has been your most offensive HIV-related situation?  
Prompts: 
 What caused you the most pain when it comes to your HIV-
positive status and why? 
 What is it like, to feel offended because of your HIV-positive 
status?  
 
RQ 2:  5) Looking back from when you experienced this offense, how 
What are the lived- would you describe the way you feel now?  
through experiences Prompts: 
of forgiveness of  Still feel offended like initially? 
HIV-specific   Completely no more of such feelings/thoughts/behaviours?  
offenses?  Some of those gone and some still there? 
  
  6) What do these changes mean to you? 
Prompts: 
 Would you say these changes you have experienced mean you have 
forgiven the one who offended you most? Why? 
 What about when you experience these changes but avoid the 
person? 
 What about when you relate well with the person but feel offended 
within? 
  
 
 
 
 
 
 
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Appendix H Continued 
  
[IF PARTICIPANT INDICATES FORGIVENESS FROM Q5 AND Q6] 
 
7) What to you is forgiveness? 
 
8) What is it like, to forgive the person or situation that offended you 
most in relation to your HIV-positive status?  
Prompts: 
 How do you tell that you have forgiven? 
 How does it feel like to forgive this offender? 
 How did you move from feeling offended to forgiving the offender? 
 
RQ3: What does 9) What does it mean to you to forgive the person or situation that 
forgiveness of offended you most when it comes to your HIV-positive status?  
HIV-specific Prompts 
offenses mean to  How has forgiving your most offensive HIV-related experience 
PLWHA? influenced your life? 
  Positive? Negative? 
 
Understanding  [IF PARTICIPANT INDICATES UNFORGIVENESS IN RESPONSE TO Q5 
experiences of AND Q6]  
unforgiveness of  
HIV-specific 1) How does it feel like to presently be offended over the situation? 
offenses  
2) Why do you think you feel just as offended as when the situation first 
happened? 
 
3) What does it mean to you to be feeling offended currently? 
4) [Justified, burdened, satisfied?] 
 
5) What do you think a change or reduction in how offended you 
currently feel would mean to you? 
Prompts 
 Would forgiving be beneficial to any aspects of your life? If so how? 
 Would forgiving have negative effects on any aspect of your life? If 
so how? 
 
6) What do you think may bring about any change or reduction in how 
hurt you currently feel? 
 
 
 
 
 
 
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Appendix I: Dummy-Coded Categorical Variables 
 
1. Gender (1: Male, 2: Female) 
Dummy codes:  
Male = 0 
Female = 1 
 
2. Education (1: No education, 2: Primary education, 3: secondary education, 4: all 
post-secondary education). 
Dummy codes: 
Primary education Secondary education Postsecondary education 
1 = 0 1 = 0 1 = 0 
2 = 1 2 = 0 2 = 0 
3 = 0 3 = 1 3 = 0 
4 = 0 4 = 0 4 = 1 
 
3. Marital status (1: unmarried status including single, divorced, separated, 2: 
married or cohabiting status) 
Dummy codes:  
Single, divorced, separated = 0 
Married, cohabiting = 1 
 
4. ART Regimen (1: TDF, 3TC, EFV, 2: others) 
Dummy codes:  
All others =0 
TDF, 3TC, EFV = 1 
 
5. Hurtfulness of offense (1: Little to moderate hurt, 2: Large to extreme) 
Dummy codes:  
Little to moderate = 0 
Large to extreme = 1 
 
 
6. Condom use behaviours [0: use condoms always or practice abstinence (low risk 
behaviour) – 5: use condoms some or none of the time (high risk behaviour)] 
Dummy codes: 
Low risk condom behaviour (mean score of 0) = 0 
High risk condom behaviour (mean score ≥1) = 1 
 
7. Multiple sexual partner behaviours  
Dummy codes: 
Low risk behaviour (≤ 1) = 0 
High risk behaviour (> 1) = 1 
 
ADHERENCE? 
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Appendix J: Regression Outputs from Additional QOL Findings 
 
Intrapersonal Forgiveness, Physical Health, and Environment Domains of Quality of 
Life 
Summary Results of Intrapersonal Forgiveness Regressed on Physical Health Domain of 
Quality of Life 
Model Unstandardized  Standardized t Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          43.00     15.95      2.70  .008 
Emotional forgiveness of self           0.20         .39          .06       .52  .607 
Decision to forgive self           0.79         .45          .19     1.76  .082 
N= 91, F =2.074, p=.132; R2 = .045 
 
 
Summary Results of Intrapersonal Forgiveness Regressed on Environmental Domain of 
Quality of Life 
Model Unstandardized  Standardized T Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          51.38     14.16      3.63  .000 
Emotional forgiveness of self           0.23         .35          .07       .65  .518 
Decision to forgive self           0.15         .40          .04       .39  .699 
N= 91, F =.382, p=.684; R2 = .009 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Interpersonal Forgiveness and Physical health and Environment domains of Quality of 
Life 
Summary Results of Intrapersonal Forgiveness Regressed on Physical Health Domain of 
Quality of Life 
Model Unstandardize  Standardized T Sig 
d Coefficients Coefficient 
 B Std. Error Beta   
Constant          56.12       6.92      8.17  .008 
Emotional forgiveness of other           0.46         .26          .16     1.74  .083 
Decision to forgive other           0.11         .26          .04       .43  .671 
N= 191, F =3.15, p=.045; R2 = .032   
 
Summary Results of Intrapersonal Forgiveness Regressed on Environmental Domain of 
Quality of Life 
Model Unstandardized  Standardized T Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          48.22       6.67      7.23  .000 
Emotional Forgiveness of self           0.21         .25          .07       .83  .409 
Decision to forgive self           0.25         .25          .09     1.00   .317 
N= 191, F =2.064, p=.130; R2 = .021 
 
Spiritual Forgiveness and Physical Health and Environment Domains of Quality of 
Life 
Summary Results of Spiritual Forgiveness Regressed on Physical Health Domain of 
Quality of Life 
Model Unstandardize  Standardized T Sig 
d Coefficients Coefficient 
 B Std. Error Beta   
Constant          67.96       14.46      4.70  .008 
Positive attitudes toward God           1.30         1.53          .13       .85  .402 
Negative attitudes toward God          -1.08           .79         -.21    -1.37  .179 
N= 43, F =1.596, p=.236; R2 = .070 
 
 
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Summary Results of Spiritual Forgiveness Regressed on Environmental Domain of 
Quality of Life 
Model Unstandardized  Standardized T Sig 
Coefficients Coefficient 
 B Std. Error Beta   
Constant          64.98       16.12      4.03  .000 
Emotional forgiveness of Self           0.08         1.70          .01       .05  .961 
Decision to forgive self          -0.37           .88         -.07       .68   .317 
N= 43, F =.093, p=.911; R2 = .005 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Appendix K: Spreadsheet of Data Collated from Systematic Review Papers 
 
FIRST STUDY THEORY DESIGN VARIABLES     ANALYSIS KEY AUTHOR 
AUTHOR  OBJECTIVES AND & FORGIV. FINDINGS EXPLANA- 
SAMPLE MEASURES TIONS 
Chandra et Examined None  Cross- IV: Gender Chi-square, Women Possible higher 
al. 2009  gender sectional DV: QOL student t- reported greater secondary 
differences in cohort (Inc. Fg), CD4 test, item Fg on Fg & transmission 
QOL among survey count, ART analysis blame facet of among women 
HIV1-PLWHA  use,  WHOQOLHIV- as many forgive 
using the locally 109 HIV+ Fg and blame 120 unfaithful and 
validated people facet on  at risk husbands 
version of the (M=50). Spiritual/ Younger & 
WHOQOLHIV Mage= Religious and married women 
120 29.83(5.22). personal reported greater 
14 on ART beliefs domain Fg.  
excluded of the 
from study WHOQOL120 
 
Gates, Examined how Lazarus & Cross- IV: Structural 1) Maladaptive DF works 
2003 the constructs of Folkman sectional Dispositional regression coping fully through coping 
dispositional Transactional correlational Fg (DF) modelling mediated DF to alter 
forgiveness, model of design  and perceived perceptions of 
maladaptive stress and  DV: Stigma, stigma assoc. stigmatization. 
coping, and coping 277 HIV+ QOL and between DF DF indirectly 
stigma relate to people (M=  and QOL. DF influences 
one another to 138). Mean MV: COPE assoc. with attitudes related 
influence age: 41.6 scale lesser use of to QOL.  
psychosocial (SD=8.4)  maladaptive  
QOL indicators. ART: not Heartland coping (MC). More cross-
mentioned Forgiveness MC increased cultural More 
Scale experience of validation 
 stress-related evidence 
 stigma and needed. 
reduced QOL. 
Ironson et Examined None  Prospective IVs: Positive Hierarchical After 4yrs and Individuals 
al. 2011 association longitudinal View of God Linear after controlling with negative 
between study and negative Modeling for MVs: view of God, 
negative/positive  View of God (HLM)  may be 
view of God and 101 HIV+  Greater PVG = encouraged to 
CD4 count people DVs: CD4 cell higher CD4 and seek a 
changes and VL (M=63%) and VL lower VL. supportive 
changes seen every 6 changes  Greater NVG = context for 
months for 4 MVs: Mood, lower CD4 and spiritual growth 
years. 80% SS, ARTA, higher VL  and support.  
on ART at SRB, SU,   
study entry.   
View of God 
Inventory 
 
*Fg=forgiveness 
 
252 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Appendix K Continued 
FIRST STUDY THEORY DESIGN VARIABLES     ANALYSIS KEY AUTHOR 
AUTHOR  OBJECTIVES AND & FORGIV. FINDINGS EXPLANA- 
SAMPLE MEASURES TIONS 
Kaldjian et Spiritual/ None   S/R beliefs  81% of Spiritual 
al. 1998 Religious Descriptive and practices Pearson’s believed in beliefs may 
beliefs and CS survey  Chi-Square God's Fg. Prior either enhance 
practices of  Death, test resuscitation or diminish an 
HIV+ patients 90 inpatient Suicide, and discussions HIV-positive 
that affect their HIV+ end of life more likely in patient’s 
approach to patients decisions those who ability to 
end-of-life (M= 54), including believed in discuss end-
decisions.  Mage earlier God’s Fg. Fear of-life 
=34yrs  resuscitation of death more decisions 
discussions likely in those  
with who perceived 
physician HIV as 
 punishment or 
A 100-item felt guilty 
questionnaire about having 
HIV.  
Martina et Examined the Lazarus &  IV: Pearson r Self-Fg & In HIV+ 
al. 2012 main and Folkman CS design Attachment and Other-Fg corr. adults, 
interactive Transactio  style Hierarchical with all QOL whether a 
effects of nal model 288 (HIV+  multiple domains. Only Forgiveness 
attachment style of stress adults M= DV: QOL regression self-Fg intervention 
and forgiveness and coping 147) domains (HMR) predicted pain outcome 
on indicators of Mage=41.7  & role fxn. would 
quality of life of (SD=8.62) MV: >attachment promote 
HIV
adults 72% on Forgiveness anxiety: health may be 
ART 49% of self >Other-Fg  and dependent on 
with AIDS  >QOL-Pain, attachment 
diagnosis  Heartland >Self-Fg > style. 
Forgiveness improved 
Scale- health. 
Muhomba, Relationship bet   Stage 1 and 3 Multiple Internal African 
2008 HIV/AIDS- None  CS survey state regression stigma, trait Americans 
related stigma 112 HIV+ forgiveness analysis  Fg, and reported more 
and the process patients Perceived perceived HIV/AIDS-
of forgiveness family stigma, family stigma related stigma 
from the perceived assoc. Stage-1 and less Fg. 
perspective of society State Fg. Trait which may 
individuals stigma, Fg., ethnicity, imply a need 
living with internal and sexual for more 
HIV/AIDS. stigma, trait orientation evidence 
forgiveness, predicted gathering on 
ethnicity, Stage-3 State Fg. and 
sexual Fg. Perceived potential 
orientation family stigma HIV-related 
mediated stressors in 
societal stigma African 
and Stage-1 populations 
State Fg 
*Fg= forgiveness 
 
253 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Appendix K Continued 
FIRST STUDY THEORY DESIGN VARIABLES     ANALYSIS KEY AUTHOR 
AUTHOR  OBJECTIVES AND & FORGIV. FINDINGS EXPLANA- 
SAMPLE MEASURES TIONS 
De La Explores 1) The Cross-   a forgiving Important to 
Cruze, Correlates of Fertility sectional IV: Current Multivariate disposition, apply TDIB 
2009 desire for another Decision- survey?  parenting analysis parity, child- framework 
child 2) Making  experiences related stress, in fertility 
Predictors of model, or 96 Inc. Fg. and past 30 related issues 
contraceptive use Traits- predomi-  day alcohol 
and consistency Desires- nantly DV: Child use were sig. 
between Intentions- black bearing associated 
contraceptive Behavior sample desires and with various 
practices and (TDIB) of HIV+ contraceptive indicators of 
fertility desires framework women (44 use contraceptive 
sexually use to prevent 
active) pregnancy 
Wald & Examined   IVs: Religious  Fg. Spiritual 
Temoshok, association bet None CS vignette involvement Not Correlated factors 
2004a religious mentioned survey and specified with fewer conferred 
involvement and in abstract  Forgiveness depressive benefits both 
forgiveness and 131 HIV+  symptoms, on the 
QOL, life stress, adult DVs: QOL, life stressors. individual's 
health patients in life stress, Higher QOL mental 
behaviours, and an Inner- health more than health and 
depression city HIV behaviours, religious on the well-
clinic, and involvement being of 
M=56% depression in each case. society, as 
Mage=42.4 Fg associated indicated by 
yrs 91% with decreased 
African decreased transmission 
American unprotected risk. 
sex 
        
Wald & Examined None CS vignette Forgiveness Not Feeling Because near 
Temoshok, associations mentioned survey (feeling specified unforgiven by perfect 
2004b between feeling in abstract   forgiven/ important adherence is 
forgiven/unforgiv 91 unforgiven) others was required for 
en and ART PLWHA  associated successful 
adherence on ART ART with HIV 
(sub- adherence significantly treatment, 
sample of  more missed participants 
Wald & Vignette doses of feeling 
Temoshok, Similarity medication in unforgiven 
2004a) Rating the previous are at an 
method week. increased 
risk of 
treatment 
failure and 
faster disease 
progression. 
*Fg= forgiveness 
 
254 
 
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Forgiveness in HIV, Psychological Health, and Immune Functioning 
Appendix K Continued  
 
FIRST STUDY THEORY DESIGN VARIABLES     ANALYSIS KEY FINDINGS AUTHOR 
AUTHOR  OBJECTIVES AND & FORGIV. EXPLANA- 
SAMPLE MEASURES TIONS 
Owen et Explores the    Bivariate  Forgiving 
al. 2011 relationship of None CS survey? IV: (Pearson's Greater others may be 
forgiveness and specified  Forgiveness correlation) forgiveness was beneficial for 
immune 64 PLWHA  and significantly health among 
markers (CD4 (57 for HLR) DV: CD4 cell Hierarchical associated with PLWHA. 
cell%) in Mage=44.68 percentages Linear higher of CD4 2)Supports the 
PLWH (9.97), 81%  regression cell % (r=.256, inclusion of 
non-white MV: Gender, p=.042) 2) forgiveness in 
race, age, Association interventions 
years HIV+, remained for PLWH 
education, significant after 
medication controlling for 
adherence, sociodemographic 
substance use, variables, health 
VL behaviours, and 
 VL (β= .263, p= 
Eright .034) 
Forgiveness 
Inventory 
Ridings et Predict that Lazarus and    ) Higher levels of 1) Nonmode-
al. 2008 forgiveness, as Folkman's Questionnaire IVs: HIV- Univariate, perceived stigma rating effect of 
an adaptive stress and development related Bivariate, assoc with higher Fg. on the 
coping coping system Stigma, Linear levels of depress., HIV-related 
strategy, will model survey Forgiveness regression 2) Higher levels stigma and 
be associated   of Fg. assoc. with depression link 
with  lower  DV: lower levels of could be due to 
levels of Depression depress., 3) small sample 
depression and  Higher levels of size  
will also MV: Fg. assoc. with,  2) Learning 
moderate the Forgiveness lower levels of and applying 
relationship  HIV-related Fg. coping 
between Heartland stigma . 4) Fg. did techniques may 
perceived HIV- Forgiveness not moderate the help reduce 
related stigma Scale relationship depress. and 
and depression between Stigma HIV-related 
and depression. stigma 
Hua, 2012 Forgiveness Lazarus and RCT IV: T-tests, Overall, Fg HIV-related 
intervention on Folkman  Forgiveness ANOVA, intervention not stigma is likely 
self- and other- transactional 57 HIV+  Multiple effective in more complex 
forgiveness model of adults DV: HIV- regression reducing overall than originally 
stress and related Stigma analysis HIV-related conceptualized.  
coping stigma. Yet, self-  
Fg was better More improved 
predictor of HIV- interventions 
related stigma need. 
than Other-Fg.  
255