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Health Related Quality of Life Assessment and Associated Factors Among People on Highly Active Antiretroviral Therapy at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia
ISSN 2155-6113
Journal of AIDS & Clinical Research

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Health Related Quality of Life Assessment and Associated Factors Among People on Highly Active Antiretroviral Therapy at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia

Amare Alemu1*, Aemiro Yenealem2, Amsalu Feleke3 and Solomon Meseret3

1 Department of Midwifery, College of Health Sciences, Mekelle University, P.O.BOX 1871, Mekelle, Ethiopia

2 TB/HIV and ART Clinic, Bahir Dar Felege Hiwot Referral Hospital, P.O.BOX 47, Bahir Dar, Ethiopia

3 Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. BOX 196, Gondar, Ethiopia

*Corresponding Author:
Amare Alemu
Department of Midwifery
College of Health Sciences
Mekelle University, P.O.BOX 1871
Mekelle, Ethiopia
Tel: +251-034-440-6963
Fax: +251-034-441-66-81/40-93-04
E-mail: [email protected]

Received Date: November 12, 2013; Accepted Date: December 16, 2013; Published Date: December 20, 2013

Citation: Alemu A, Yenealem A, Feleke A, Meseret S (2013) Health Related Quality of Life Assessment and Associated Factors Among People on Highly Active Antiretroviral Therapy at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia. J AIDS Clin Res 5:272. doi:10.4172/2155-6113.1000272

Copyright: © 2013 Alemu A, et al.. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Antiretroviral therapy has reduced HIV/AIDS related mortality and more of people living with HIV/ AIDS alive longer. Hence, this study tried to assess the health related quality of life and associated factors among people on highly active antiretroviral therapy at Felege Hiwot Referral Hospital in Bahir Dar, North West Ethiopia.

Methods: Institutional based cross sectional study was conducted among 424 people on highly active antiretroviral therapy at Bahir Dar Felege Hiwot Referral Hospital, North West Ethiopia. Study participants were obtained with a systematic sampling and interviewed to respond for structured pre-tested questionnaires. Clinical variables of highly active antiretroviral therapy were collected from their hospital charts. Data were entered into EPI info version 3.5.1 and analyzed by using SPSS version 20 software for windows. Bivariate and multivariate logistic regression analyses were done.

Result: The proportion of respondents with low health related quality of life in all domains was 56.4%. Unemployment (AOR = 2.32 [95% CI = 1.49, 3.59]), poor adherence (AOR = 3.24 [95% CI = 1.02, 10.32]) and being ambulatory (AOR = 3.19 [95% CI = 1.36, 7.48]) were found to have statistically significant association with health related quality of life.

Conclusion: This study finding stress the need for enhanced support and a better environment for improving the health related quality of life among people living with HIV/AIDS.

Keywords

HIV/AIDS; HAART; HRQoL; Ethiopia

Introduction

Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic is now a global crises, constituents one of the most formidable challenges to development and social progress. Since HIV/AIDS was first discovered, it has taking the lives of 30 million people around the world, around 1.2 million of whom were living in sub-Saharan Africa [1]. Ethiopia is one of the hardest hit countries by HIV/AIDS epidemic and the fifth largest number of people living with the virus, with an estimated overall HIV prevalence rate of 1.4 percent in aged 15 to 49 years [1].

With the development and start of national programme for providing care and free highly active antiretroviral therapy (HAART) to people living with HIV/AIDS, there has been a significant reduction in morbidity and mortality and more of them are surviving with improved quality of life. HAART and other HIV treatments not only keep people alive longer, they also provide a better quality of life, allowing people to return to work and school, take care of their families, and contribute to their communities [2]. During the past two decades, quality of life (QoL) has become an important outcome in medical and psychological research. Increasingly, new evidence supports the importance of including patient’s assessment of health-related quality of life (HRQoL) in clinical studies [3].

As the quality of life for patients on HAART improves, frequent contact with health care providers become difficult, they start missing monthly appointments to obtain antiretroviral drugs. Most patients had returned to their jobs, often requiring stays far from home [3]. The assessments of HRQoL in these patients have become priority, for their wellbeing may be influenced not only by their response to treatment but also by other dimensions including treatment related toxicity. At the same time, psychosocial factors may mediate patients’ self-perception of their health [4]. HIV infection mainly affect on physical, psychological, level of independence, social, environmental and spiritual domains of HRQoL which is varied in term of socio-demographic characteristics and disease related variables [5].

Studies are documented that good adherence, higher education, high income and CD4+ >200 cells/mm3 had higher quality of life in all domains [6,7]. Multiple fears of AIDS related stigma and discrimination and worries about ability to get married and disclosing their need are also major problems of people living with HIV/AIDS on HAART [8]. The level and extent to which clinical parameters and socio demographic factors influence the HRQoL of people living with HIV/ AIDS on HAART have impact on sickness and complex therapeutic strategies [9]. Thus this study assessed the health related quality of life and associated factors among people on HAART at Felege Hiwot Referral Hospital in Bahir Dar, North West Ethiopia.

Methods

Study design, area and period

An institution-based cross sectional study was conducted among people living with HIV/AIDS on HAART using structured interviews. A total of 424 respondents were recruited from Felege Hiwot Referral Hospital in Bahir Dar, North West Ethiopia. Data were collected between March and May, 2013. At the time of data collection, the hospital ART registration records indicated that about 1,275 people were receiving HAART in the hospital. The hospital provides services to patients from surrounding rural villages and other nearby towns. Most of people who were receiving HAART from the hospital were from their home town, Bahir Dar. Respondents were recruited systematically every third units, from those 1,275 people who were receiving HAART during the data collection period. For the purpose of this study, we defined quality of life as personal evaluation of how things have been going for one self, and health related quality of life as how the individual’s wellbeing may be impacted over time by a disease, a disability, or a disorder.

Sampling

The sample size was calculated using single population proportion formula with estimated proportion of people living with HIV/AIDS with good quality of life is assumed to be 50%, since there were no a research done in the area. Assuming a marginal error of 5% and a 10% non-respondent rate, the estimated sample size was 424.

Data collection

Pre-tested structured questionnaire was prepared by reviewing literatures on the topic of people living with HIV/AIDS health related quality of life [6,7,10]. The questionnaire was first prepared in English and then translated in to Amharic, the local language of patients in the study area. The data were collected using structured intervieweradministered questionnaire. The questionnaires were administered to every third respondents who were attending the hospital during the data collection period, and who met the inclusion criteria. The interview took place while these participants waited for consultation and medication during the routine monthly visits for their drugs. Relevant clinical data such as CD4 count, clinical stage, HAART regimen, and drug adherence status were extracted from participants’ medical charts. In addition, respondents provided demographic information such as age, gender, marital status, and monthly income.

Data quality control

Data were collected by three ART trained nurses who were responsible for in the follow up of people on HAART and worked in the ART units after one day training was given about the objectives and procedures of the data collection by the investigators. Questionnaire was pre-tested to assess clarity, understand ability, flow and consistency, and revised prior to the start of data collection. Data completeness and consistency was checked by the investigators. Data cleaning and editing took place; missed values were statistically handled to help address concerns.

Data analysis

Data were entered using Epi Info version 3.5.1 and exported to, and then analyzed using SPSS version 20. First, descriptive statistics were carried out to explore the socio-demographic characteristics of respondents, and the results were summarised as frequencies and percentages. To determine which factors were associated with health related quality of life to people living with HIV/AIDS, binary and multiple logistic regressions were employed. Variables associated with HRQoL in bivariate analyses were included in the multiple logistic models and P-values less than 0.05 were considered to be statistically significant in all cases.

Ethical consideration

Ethical approval and clearance was taken from institutional review board of Bahir Dar University, College of Medical Sciences. The Regional Health Bureau gave permission to conduct the study in the hospital in the study area. After the purpose of the study was explained, a written informed consent was obtained from study participants before data collection. Study subjects were informed that participating in the study was voluntary and that refusal to participate would not compromise the medical care they received from the hospital. The right to withdraw from the study at any time was also assured. The interviews were conducted in a private room in the hospital to ensure privacy. Coding was used to eliminate names and other personal identification of respondents throughout the study process to ensure participants confidentiality.

Results

Demographic characteristics of study participants

A total of 424 respondents participated in the study. Of 424 HAART HIV infected people, females accounted for 266 (62.7%) and 244 (57.5%) were age less than 30 years. Eighty seven percent participants were urban residents. Half of the study participants 222 (52.4%) were married and 361 (85.1 %) were orthodox religion followers. 282 (66.5%) participants had household size of more than three. More than half 266 (62.7%) were unemployed (Table 1). In this study, clinical stage three 303 (71.5%) was the predominant, 373 (88%) were working in functional status. The mean duration of treatment was 47.5 months (range 2 -120) (Table 2).

Variables Frequency Percent
Age (in year)    
    <35 244 57.5
     >36 180 42.5
Sex    
    Male 158 37.3
    Female 266 62.7
 Residence    
    Urban 370 87.3
    Rural 54 12.7
Education status    
   Illiterate 130 30.7
   Primary school              152 35.8
   Secondary school 98 23.1
Higher education   44 10.4
Ethnicity    
   Amhara 406 95.8
   Other* 18 4.2  
Religion    
   Orthodox  361 85.1
   Other** 63 14.9
Marital status    
   Single 76 17.9
   Married 222 52.4
   Divorced or Separated       69 16.3
   Widowed 57 13.4
Relation to head of household    
   Head  204 48.1
   Spouse  183 43.2
   Daughter or son 29 6.8
   Relative  8 1.9
Currently with whom are you living    
   Alone 90 21.2
   Family/Friends 334 78.8
Family Size     
   0-2 142 33.5
   >3 282 66.5
Income (in Ethiopian birr)    
    <500.00 202 47.6
    501-999 102 24.2
    1000-1499 54 12.7
    1500-1999 28 6.6
    >2500 38 8.9
Employment status        
   Employed 158 37.3
   Unemployed 266 62.7
Substance Use    
   Alcohol 90 21.2
   Chat 8 1.9
   Smoking 2 0.5
   Other 2 0.5
   None 322 75.9

Table 1: Socio demographic characteristics of HIV infected people on HAART in Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia, 2013 (n = 424).

Variables Frequency Percent
Duration of treatment (in months)    
   < 36 172 40.6
   >37 252 59.4
WHO Clinical Stage       
  Stage I 41 9.7
  Stage II 67 15.8
  Stage III 303 71.5
  Stage IV 13 3.1
CD4+ cells count/mm3 at start of HAART*    
   <200 284 67.0
   >200 140 33.0
CD4+ cells count/mm3 at time of study*    
   <200 70 16.5
   >200 354 83.5
HAART Regimen    
  First line 403 95
  Second Line 21 5
Adherence status      
  Good 241 56.8
  Poor 158 37.3
  Fair 25 5.9
Functional status    
  Working 373 88.0
  Ambulatory 41 9.7
  Bed-Ridden 10 2.4

Table 2: Clinical characteristics of HIV infected people on HAART at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia, 2013 (n = 424).

Health related quality of life among people on HAART

Each domain of quality of life was included: low, moderate and high HRQoL score; more than half 239 (56.4%) of the participants had low in overall quality of life domain (Table 3). The weighted mean ± SD of total quality of life was 26.07+6.78. The mean score of all domains was low especially on physical functioning domain. Relationship between various domains of the quality of life was assessed by Pearson’s correlation coefficient. All scores of domains were correlated with the total measure of the quality of life significantly (P<0.05). The most significant positive correlation was observed for the social and mental domains (0.84 and 0.88, respectively) (Table 4). There was also better quality of life who had higher CD4+ with long time usage of HAART with (P=0.05) using chi-square. However, there was no association between health of quality and CD4 absolute count during baseline with (P=0.52) using chi-square (Figure 1).

Quality life scores Frequency Percent
Overall HRQoL
Good
Bad

185
239

43.6
56.4
Physical health functioning problem Low
Moderate
High

37
117
270

8.7
27.6
63.7
Role Functioning Problem
Yes
No

70
354

16.5
83.5
Social activities
Low
Moderate
High

164
89
171

38.7
21.0
40.3
Mental Health Domain
Low
Moderate
High

189
102
133

44.6
24.1
31.3
Vitality(Feeling full life & energy)
Low
Moderate
High

175
112
137

41.3
26.4
32.3
Health Distress
Low
Moderate
High

48
93
283

11.3
21.9
66.7
Cognitive functioning
Low
Moderate
High

236
121
67

55.7
28.5
15.8

Table 3: Health-related quality of life of people on HAART at Felege Hiwot Referral Hospital, in Bahir Dar, North West Ethiopia, 2013.

QOL- Domain Mean (SD) Cronbach’s    α Number of items Score range Correlation with the total score
General 1.85 (0.72) 0.7 2 0-8 0.75
Physical 2.55 (0.63) 0.801 6 0-24 0.69
Psychological 2.66 (1.42) 0.881 8 0-32 0.81
Social 6.40 (1.6) 0.64 4 0-16 0.84
Mental 12.6 (2.41) 0.83 6 0-24 0.88
Total 26.06 (6.78) 0.80 26 0-104 0.96

Table 4: Mean (SD) of domains of the quality of life with scales description.

aids-clinical-research-referral

Figure 1: The effect of CD4 count on quality of life among people on HAART at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia, 2013.

Factors associated with health related quality of life among people on HAART

Factors associated with quality of life were assessed for their associations with socio demographic and clinical characteristics of respondents’ variables. While assessing associated factors of health related quality of life among HIV infected people on HAART, we found that age, educational status, marital status, employment status, CD4+ at base line, adherence and functional status were associated with quality of life using binary logistic regression analyses. However, only unemployment (AOR=2.32 [95% CI=1.49, 3.59]), poor adherence (AOR=3.24, [95% CI=1.02, 10.32]), and being ambulatory (AOR=3.19 [95% CI=1.36, 7.48) were remained independent factors of health related quality of life in the multivariate logistic regression analyses (Table 5).

Variables Quality of Life  
Poor Good COR (95% CI) AOR (95% CI)
Age
<
35
>36

125
114

119
66

1
1.64 (1.12, 2.44)

1.54 (0.98, 2.44)
Educational status Illiterate
Primary
Secondary
Higher

87
78
55
19

43
74
43
25

2.66 (1.32, 5.36)
1.39 (0.71, 2.73)
1.68 (0.82, 3.45)
1
1.33 (0.61, 2.90)
Employed status Employed
Unemployed

73
166

85
100

1
1.99 (1.29, 2.88)

1
2.32 (1.49, 3.59)
Income in ETB <500.00
501-999
1000-1499
1500-1999
>
2000.00

125
58
26
14
16

77
44
28
14
22

2.23 (1.104, 4.512)
1.81 (0.85, 3.85)
1.28 (0.55, 2.95)
1.37 (0.51, 3.67)
1
0.84 (0.40, 1.73)
Adherence        
Good 120 121 1 1
    Fair 98 60 1.65 (1.09, 2.48) 1.54 (1.00, 2.36)
    Poor 21 4 5.29 (1.76, 15.88) 3.24 (1.01, 10.32)
Functional status        
   Working 198 175 1 1
   Ambulatory 33 8 1.25 (1.64, 8.10) 0.16 (1.36, 7.49)
   Bed-ridden 8 2 3.59 (0.74, 16.87) 3.19 (1.49, 5.04)

Table 5: Factors associated with health related quality of life for people on HAART at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia, 2013.

Discussion

This study assessed the health related quality of life and associated factors among people on highly active antiretroviral therapy at Felege Hiwot Referral Hospital in Bahir Dar, North West Ethiopia. In this study, more than half (56.4%) of respondents had low quality of life scores in all domains of health related quality of life. This finding is not comparable with study conducted in Norway [11]; however it is concordant with the study conducted in Bangladesh [7]. This difference may be due to the study design, demographic characteristics and economic affairs.

The result of this study showed that unemployment status of respondents was associated with health related quality of life. Unemployed respondents were 2.3 times more likely risk to have poor health related quality of life than their counterparts (AOR=2.32 [95% CI=1.49, 3.59]). This finding is consistent with study conducted in Ethiopia [12]. This might be due to respondent’s poor daily food consumption because almost half 202 (47%) of respondents in this study had low monthly income (<500 ETB).

In this study, drug adherence of people on HAART was found to be a significant predictor of poor health related quality of life. People who had poor drug adherence were 3.2 times more likely to be risk to poor QoL than good drug adherence (AOR=3.24 [95% CI=1.02, 10.32]). This finding is similar with study conducted in Thailand and different African countries [13-15]. This could be explained that since drug adherence is associated with CD4 counts, and this CD4 number depend on drug adherence so that poor drug adherence leads to poor QoL of people.

Functional status of the respondents was significantly associated with their QoL. Ambulatory people were 3.2 times more likely to have poor QoL than working ones (AOR=3.19 [95% CI=1.36, 7.48]). This finding is similar with study conducted in different African countries [14-16]. This might be due to people’s poor daily living activities that lead them into poor income generating and finally this could affect their health related quality of life. In this study, age, educational status, marital status, and CD4 count were not significantly associated with health related quality of life among HIV infected people on HAART.

The study had some limitations; only focuses on HAART, since there are many social factors that may alter people’s health related quality of life on HAART. This study was cross-sectional and could not establish the circumstances resulting in low health related quality of life; we recommend more studies be conducted to answer these questions. Given this, further research involving qualitative methods could overcome this limitation.

Conclusion

This study found that more than half of HIV positive people on HAART had poor health related quality of life in almost all quality scores. Employment status, drug adherence, and functional status of respondents were significantly associated with health related quality of life among HIV infected people on HAART. Establishing improved drug adherence services for all people receiving HAART so that they could have a better knowledge on the importance of good drug adherence will help to increase their quality of life.

Acknowledgements

This research was funded by Bahir Dar University, College of Medical Sciences Grants for Graduate Research. Therefore, we are grateful to Bahir Dar University, College of Medical Sciences for their financial support. We thank all health care providers of Felege Hiwot Referral Hospital for their facilitation during training of data collectors and data collection period. We would also like to thank all data collectors, supervisor and research participants who took part in this study without whom this research would not have been realized.

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