Quality of Life Among People Living with HIV in Jimma, Ethiopia: the Role of Mental Health, Food and Nutrition
Publikation: Bog/antologi/afhandling/rapport › Ph.d.-afhandling › Forskning
Markos Tesfaye Woldeyohannes
Background: The availability of antiretroviral treatment (ART) for people living with HIV (PLHIV) in sub-Saharan has led to greatly improved survival over the last decade. However, PLHIV in low-income country settings continue to experience a variety of socio-economic, social and health issues which might affect their quality of life. Among others, food insecurity is a common problem among PLHIV, and HIV programs in lowincome settings often provide food support and nutritional counselling. However, the effect of nutritional intervention on quality of life of PLHIV has not been adequately investigated. Furthermore, food insecurity has been linked to poor mental health. Poor mental health is in turn associated with poor quality of life. The potential relationship among food security, mental health and quality of life needs to be investigated so as to inform programs aimed to address quality of life of PLHIV in low-income settings. On the other hand, the assessment of quality of life among PLHIV in Africa requires tools to be adapted to ensure cultural validity in the setting. Objectives: The primary objective of this project was to investigate the effect of lipidbased nutrient supplements (LNS) on the quality of life of PLHIV initiating ART. The secondary objectives were to conduct cultural adaptation of the short version of World Health Organization Quality of Life assessment tool for HIV (WHOQOL-HIV BREF), and to investigate the independent association of food insecurity and mental health with quality of life of PLHIV. Methods: Aspects of quality of life relevant in Ethiopian context were incorporated into the WHOQOL-HIV BREF. Semantic equivalence of the tool was achieved through translation and back-translation. Cognitive interviewing was carried out to test the relevance and meaning of items in context. After pilot testing on 100 PLHIV on treatment and testing for known-group validity, a new tool namely, WHOQOL-HIVBREF- ETH was produced. The new tool was then tested for construct validity on 348 PLHIV using confirmatory factor analysis. Data on quality of life, mental health, and level of food insecurity from 348 PLHIV initiating ART at three health facilities in Jimma zone, southwest Ethiopia was collected. Using multiple linear regression, the independent associations of poor mental health and food insecurity with quality of life were investigated. Data from a sub-sample of the 348 PLHIV who had BMI>17 kg/m2 (n=282), and who were enrolled in the nutritional intervention trial, were analyzed to assess the effects of three months of supplementation upon quality of life. Nutritional supplementation was given either during the first three months or during the fourth to sixth months after initiation of ART. Comparison of quality of life at the six month assessment time point was made using mixed linear regression to investigate whether timing of supplementation had different effects on quality of life. Results: Problems encountered in the semantic, item and measurement equivalences of WHOQOL-HIV-BREF, which might limit its use in clinical settings, were addressed through a rigorous adaptation process. The Ethiopian version, WHOQOL-HIV-BREFETH, demonstrated an excellent known groups validity in all domains for asymptomatic PLHIV and advanced HIV. Furthermore, the WHOQOL-HIV-BREF-ETH includes aspects of quality of life in social and environment domains that were not represented within the original tool. Confirmatory factor analysis fit indices were close to, although not within, the recommended range. Analysis of the baseline data showed that both moderate (β= -2.52, 95% CI:-5.55; 0.51) and severe (β=-3.24, 95% CI:-6.19; -0.29) food insecurity were associated with lower quality of life. A higher burden of symptoms of common mental disorders was associated with lower quality of life (β=-1.72, 95% CI: -1.94; -1.49). In addition, advanced HIV disease (β=-3.80, 95% CI: -6.18; -1.42), and having mild malnutrition (BMI=17.0-18.5 kg/m2) were associated with lower quality of life scores (β=-3.45, 95% CI: -6.18; -0.71). Furthermore, severe food insecurity (β=2.40, 95% CI: 1.05; 3.74) had a significantly stronger association with symptoms of common mental disorders than moderate food insecurity (β=2.31, 95% CI: 0.92; 3.71, p=0.001). After three months, participants who received LNS during the first three months following ART initiation showed better quality of life than those who only received ART without LNS [β=6.2, 95% CI: 2.9: 9.6]. At the six month assessment, there was no difference in total quality of life score between the early and delayed supplementation groups [β=3.0, 95% confidence interval: -0.4: 6.4]. However, at the six month assessment, the early supplementation group showed higher scores on the social and spirituality domains than the delayed group. Conclusions: Access to adequate food and nutrition is an important aspect of quality of life among PLHIV in low-income settings. Supplementation with LNS for PLHIV initiating ART has a beneficial effect on quality of life in the short term. Food insecurity and poor mental health are independently associated with lower quality of life among PLHIV. Food support in HIV programs need to consider the food security status of PLHIV in addition to their nutritional status. The long-term effects of early supplementation with LNS on quality of life need further investigation. Future studies are needed to establish causal association between food insecurity and poor mental health among PLHIV.
|Forlag||Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen|
|Status||Udgivet - 2016|
CURIS 2017 NEXS 082