Development and Application of a Life Review Program to Support Mental Health Among Middle‐Aged and Older Adults Living with HIV

1. Introduction

People living with HIV (PLWHIV) face not only medical challenges but also profound psychological and social difficulties. The physiological impact of the virus and the side effects of long-term antiretroviral therapy can contribute to chronic health issues, while stigma, discrimination, and social isolation further exacerbate psychological distress [1,2]. Studies indicate that PLWHIV experience significantly higher rates of depression and anxiety compared to the general population, affecting adherence to antiretroviral therapy and overall health outcomes [3,4].

In Taiwan, although significant progress has been made toward achieving the UNAIDS 90-90-90 targets, mental health services for PLWHIV remain underdeveloped. Reports from the Taiwan Centers for Disease Control [5] highlight that psychological support is a critical unmet need among middle-aged and older PLWHIV, who often experience compounded trauma from life events such as drug addiction, incarceration, hospitalization, and familial rejection.

Therefore, addressing the psychological well-being of PLWHIV is not merely an adjunct to medical treatment but an essential component of holistic HIV care. Given the growing number of middle-aged and older PLWHIV worldwide, there is an urgent need for interventions that are developmentally appropriate, culturally sensitive, and resilience-focused [6,7].

Various interventions have been developed to address the mental health needs of PLWHIV, including cognitive behavioral therapy (CBT), support groups, peer counseling, and digital health applications. Cognitive behavioral interventions have shown effectiveness in reducing depressive symptoms and improving medication adherence among PLWHIV [8,9]. Peer support models, such as the “Positive Peers” intervention, have been associated with enhanced social connectedness and reduced internalized stigma [10]. Additionally, digital interventions, including telemedicine and mobile health (mHealth) programs, have expanded access to psychological services for PLWHIV, especially in resource-limited settings [11,12].

Despite these advancements, most interventions have primarily focused on general adult populations, with limited attention to the unique needs of middle-aged and older PLWHIV. Research indicates that aging PLWHIV face distinct psychosocial challenges, including compounded stigma related to both HIV status and aging, cumulative health burdens, and greater risks of isolation and depression [13,14,15]. Furthermore, existing interventions often overlook culturally sensitive and narrative-based approaches that can facilitate emotional expression, strengthen resilience, and foster self-acceptance—critical elements for long-term psychological well-being in this population.

In Taiwan, integrated psychological services tailored to aging PLWHIV remain scarce. A recent study on mental health services for people living with HIV in Taiwan highlighted a lack of culturally adapted, life-course-sensitive interventions [16]. These gaps underscore the urgent need for innovative, culturally responsive programs that not only address clinical symptoms but also empower middle-aged and older PLWHIV to reconstruct meaning and enhance life satisfaction.

Narrative-based interventions, such as life review therapy, have been recognized as effective strategies for promoting psychological well-being in populations facing chronic illnesses and aging-related challenges. By facilitating the reconstruction of personal meaning and fostering emotional expression, life review interventions can help individuals integrate past experiences, enhance resilience, and restore a sense of self-worth [17,18]. For middle-aged and older PLWHIV, who often contend with cumulative trauma, societal stigma, and social isolation, life review provides an opportunity to reinterpret their life stories positively and to reclaim agency in the face of adversity [19].

Research has demonstrated that life review interventions are associated with reductions in depressive symptoms, improvements in quality of life, and enhanced coping capacities among older adults [20,21]. Despite its demonstrated effectiveness in aging populations, the application of narrative-based approaches among aging PLWHIV remains scarce, particularly within culturally specific contexts such as Taiwan.

This study aims to introduce the development and application of a culturally sensitive life review program designed to support the mental health of middle-aged and older PLWHIV in Taiwan. By describing the program structure and summarizing the participants’ experiential feedback, this study seeks to contribute to the growing field of narrative-based interventions for aging and marginalized populations.

In light of these challenges, there is a pressing need for psychosocial support tools that are both theory-driven and culturally grounded [22,23]. This study presents the development and application of a life review program designed to support the psychological well-being of middle-aged and older adults living with HIV in Taiwan. The program was developed based on Swanson’s Theory of Caring [24], integrating narrative-based reflection and culturally responsive elements to foster emotional processing, self-worth, and social connection. Rather than evaluating intervention efficacy, this study focuses on introducing the structure of the program and illustrating its application through a small pilot implementation with six participants. The purpose is to demonstrate the feasibility and potential relevance of this caring-based tool for long-term supportive care in marginalized aging populations.

2. Methods

2.1. Program Development

The life review program was conceptually developed based on Swanson’s Theory of Caring, which identifies five key caring processes: knowing, being with, doing for, enabling, and maintaining belief. These processes were used to guide the structure, content, and facilitation strategies of the program to ensure that emotional and relational dimensions of care were embedded throughout.

Each of the eight weekly sessions was designed to align with one or more caring processes. For example, “knowing” was operationalized through early sessions involving the exploration of personal histories and life turning points; “being with” was expressed in shared group dialogues that provided space for empathic presence; “doing for” appeared in creative activities such as life mapping and guided storytelling; “enabling” was fostered through strengths-based reflection and future goal setting; and “maintaining belief” was supported by affirming participants’ dignity, hope, and inner resilience, especially in the face of cumulative trauma.

Cultural sensitivity was also a core design principle. The program incorporated local language references, respect for collectivist cultural values, and age-appropriate metaphors relevant to Taiwanese PLWHIV. Session themes included self-introduction, personal strengths, life struggles, emotional expression, and envisioning the future. Sensory elements such as music, essential oils, photographs, and symbolic objects were integrated to promote memory recall and emotional engagement. (Table 1)

2.2. Research Design Justification

This study employed a qualitative, exploratory design aimed at understanding the subjective psychological experiences of middle-aged and older adults living with HIV following their participation in a life review intervention. As the primary objective was to explore emotional meaning-making, resilience, and perceived transformation, the study did not include standardized pre- and post-intervention psychological assessments. Instead, rich narrative data were collected through in-depth interviews and participant observation. This design is particularly appropriate for pilot-stage research in underexplored populations, such as aging PLWHIV in Taiwan, where limited evidence exists regarding culturally grounded narrative-based interventions.

2.3. Participants and Setting

Participants were recruited from two long-term care facilities in central Taiwan that provided specialized services for people living with HIV. Inclusion criteria were: (1) aged 45 years or older, (2) confirmed diagnosis of HIV, (3) ability to provide informed consent, and (4) willingness to participate in weekly sessions. A total of six participants were enrolled. Participants were referred by facility directors and social workers, who identified individuals perceived as emotionally distressed, socially withdrawn, or psychologically vulnerable based on their professional judgment and long-term interactions. Although no standardized psychological assessments were conducted prior to participation, purposive sampling focused on individuals who were likely to benefit from a reflective and supportive intervention. Table 2 presents the detailed demographic characteristics of each participant.

2.4. Ethical Considerations

This study adheres to the principles of the Declaration of Helsinki and has received approval from the National Cheng Kung University Ethics Review Committee (Approval Number: NCKU-IRB-113-101). All participants signed informed consent forms before the commencement of the study, understanding its objectives, procedures, and their rights. The Declaration of Helsinki is a set of ethical principles for medical research involving human subjects, developed by the World Medical Association in 1964 and most recently amended in 2013 [25].

2.5. Data Collection

Data were collected through semi-structured interviews conducted at baseline and after the completion of the program, as well as through participant observations during the sessions. Interviews explored participants’ emotional experiences, perceived changes, and reflections on the intervention. All interviews were audio-recorded with consent and transcribed verbatim for analysis. Field notes were also maintained to capture non-verbal cues and group dynamics during sessions.

2.6. Data Analysis

A qualitative content analysis approach was employed to examine the interview transcripts and observation notes. Thematic analysis was conducted to identify recurring patterns, themes, and emotional responses. Coding was performed independently by two researchers to enhance reliability, and discrepancies were resolved through discussion. Key themes were organized to reflect the core emotional and psychological changes experienced by participants during the program.

2.7. Rigor

We evaluated the rigor and trustworthiness of this study based on the four criteria for qualitative research accuracy proposed by Guba and Lincoln [26]: (1) Credibility: The researchers have extensive experience in studying PLWH’s mental health and have received certification from the Taiwan Ministry of Health and Welfare on HIV prevention knowledge and protective measures (Long-Term Care Professionals Digital Learning, Certificate No. 20220803018). Additionally, the researchers underwent comprehensive training in qualitative research and possessed expertise in interviews and qualitative analysis. Regular discussions with qualitative research experts were also an essential part of the research process. (2) Transferability: The interview content was accurately and faithfully transcribed verbatim to ensure it could be properly presented in this study. The transcripts were returned to the participants for verification and correction. (3) Dependability: We invited two professionals with extensive experience in qualitative research and HIV studies to review and revise the categorization of the research findings. (4) Confirmability: The researchers maintained all reflective field notes and data analysis records for future validation and reference. In the final stage of the study, participants were given the opportunity to review and confirm the research findings.

3. Results

3.1. Participants’ Emotional Engagement During the Life Review Sessions

During the eight-week program, participants frequently described the emotional intensity of reflecting on their past experiences. Many were visibly moved during sessions and described the life review activities as both challenging and healing.

“When I talked about my past, I finally cried. I didn’t expect it, but it felt like something loosened inside me.” (Participant 3)

“The smell of the essential oils and the music brought up memories I had not thought about in years.” (Participant 5)

The integration of sensory elements and structured guidance supported access to suppressed emotions.

The caring environment allowed participants to feel emotionally safe. P1 stated, “It was the first time I could speak about my regrets without being judged.” P6 added, “I usually hide my feelings, but here, I felt it was okay to be vulnerable.” These responses suggest that the program, grounded in Swanson’s “knowing” and “being with” processes, facilitated meaningful emotional expression and self-recognition.

3.2. Social Connection and Peer Sharing as Emergent Processes

As the group sessions progressed, participants increasingly engaged with one another, forming bonds through shared storytelling. Early hesitancy gave way to openness, as noted by Participant 2:

“I didn’t want to talk at first, but listening to others made me feel brave enough to speak.” This mutual encouragement fostered solidarity among the group.” (Participant 2)

“When others nodded while I was sharing, I felt understood. I wasn’t the only one with pain.” (Participant 4)

“We laughed and cried together. It reminded me that we’re all human, no matter what we’ve been through.” (Participant 6)

“Even if we came from different backgrounds, our struggles made us similar. I didn’t expect to feel connected like this.” (Participant 5)

The peer connections reflect the “being with” and “doing for” aspects of Swanson’s framework, as participants supported one another through empathetic listening and shared presence.

3.3. Reframing Life Narratives and Renewed Perspective

In the final sessions, participants demonstrated narrative shifts in how they perceived their lives. The letter-writing activity and future-focused discussions helped them reframe negative self-perceptions.

“I always thought my life was a failure, but now I see how strong I’ve been to survive.” (Participant 3)

“If I could go back and talk to my younger self, I’d say: Don’t give up—you’ll make it.” (Participant 2)

“I felt like I had no value before, but after all these sessions, I realize I still have stories worth telling.” (Participant 6)

Others expressed renewed hope and a desire to reclaim purpose.

“Before this program, I didn’t think the future mattered,” (Participant 5)

“But now I have plans. I want to see my niece grow up. Even though I’m getting older, I don’t want to give up on myself again,” (Participant 1)

These expressions demonstrate the power of narrative-based reflection to cultivate meaning and reframe identity, aligning with the “maintaining belief” and “enabling” caring processes.

4. Discussion

This study introduced the development and pilot application of a life review program grounded in Swanson’s Theory of Caring, specifically tailored to the psychological support needs of middle-aged and older adults living with HIV in Taiwan. The program was not intended to evaluate clinical efficacy, but to present a theoretically grounded and culturally sensitive intervention structure, and to document participants’ responses as an initial demonstration of its applicability.

By centering the program on Swanson’s five caring processes—knowing, being with, doing for, enabling, and maintaining belief—the intervention was able to create a relational and emotionally supportive space. Participants’ responses demonstrated that the structured narrative reflection not only triggered deep emotional engagement, but also enabled meaning-making and increased self-acceptance. This is consistent with prior studies affirming the potential of life review therapy to foster emotional integration and identity coherence among older adults living with HIV [27,28].

The cultural relevance of the program was also critical to its reception. Incorporating sensory elements, culturally familiar metaphors, and localized storytelling helped reduce emotional barriers and foster group cohesion. As reflected in the participants’ comments, shared experiences and mutual storytelling facilitated a sense of connection and collective healing, echoing the “being with” and “doing for” elements of Swanson’s framework. These findings align with the growing recognition that psychosocial care for aging PLWHIV must go beyond symptom reduction and instead prioritize empowerment, community, and cultural identity [29].

Notably, many participants reported a reframing of their life narratives—from stories of loss and shame to ones of survival and hope. Activities such as letter-writing and goal visualization allowed participants to reimagine their futures, reflecting Swanson’s “maintaining belief” component and affirming previous evidence on narrative reconstruction and life review therapy’s potential to improve resilience [30,31].

While these findings are promising, several limitations must be acknowledged. This pilot was conducted with only six participants, limiting generalizability. The absence of formal pre- and post-intervention psychological assessments means the program’s outcomes were documented through qualitative feedback only. However, the objective of this phase was to present the design and experiential value of the program from the user’s perspective—not to establish outcome efficacy.

Future studies should consider adopting a mixed-methods approach to quantitatively evaluate psychosocial outcomes while preserving the depth of narrative data. Tools such as PHQ-9 and WHOQOL-HIV BREF could complement interview-based insights and enhance scientific rigor [32,33]. Moreover, this program can serve as a template for adaptation to other marginalized populations, including individuals aging with other chronic conditions or those in culturally diverse care settings. Future studies may consider incorporating standardized psychological screening tools such as the PHQ-9 or WHOQOL-HIV BREF to complement observational referral methods and enhance the rigor of participant selection.

5. Conclusions

This study presented the design and pilot application of a culturally sensitive life review program informed by Swanson’s Theory of Caring, tailored to the needs of middle-aged and older adults living with HIV in Taiwan. By aligning each session with caring processes such as knowing, being with, doing for, enabling, and maintaining belief, the program offered a compassionate framework that enabled participants to reflect on their life histories, express emotions, and reconstruct personal meaning in a supportive group setting. Rather than measuring intervention efficacy, this study emphasized user experiences and implementation feasibility. Thematic analysis of participants’ responses revealed emotional engagement, enhanced social connection, and renewed life perspectives—demonstrating the potential of narrative-based, caring-centered tools to address psychological well-being among aging PLWHIV. These findings reinforce the relevance of integrating caring theory into psychosocial program design, particularly when working with populations facing compounded trauma, stigma, and social isolation. While limited by small sample size and the absence of quantitative outcome data, this pilot offers a practical foundation for future development. The program may be adapted and expanded for other marginalized or chronically ill aging populations. Future studies are encouraged to apply mixed-method approaches that combine qualitative depth with standardized measures to further evaluate the effectiveness and scalability of this model.