Charles M Mwale

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UNIVERSITY OF MALAWI

College of Medicine

The Prevalence Of Psychological Distress And Associated Factors Among People

Living With Aids Attending Antiretroviral Therapy Clinics In Mzuzu, Malawi:

A Cross Sectional Descriptive Study.

By

Charles Masulani Mwale

Bachelor of Science in Nursing

Dissertation submitted in Partial Fulfillment

of the Requirements for the Master of Public Health Degree.

30 November 2006


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CERTIFICATE OF APPROVAL

The thesis of Charles Masulani Mwale is approved by the Thesis Examining Committee

_________________________________________________ (Chairman, Postgraduate Committee)

__________________________________________________ (Supervisor)

_________________________________________________ (Internal Examiner)

__________________________________________(Head of Department)


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Prevalence Of Psychological Distress And Associated Factors Among PLWAs in Mzuzu

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Declaration

I, Charles Masulani-Mwale, declare that this dissertation constitutes my own original

work and has not been presented for any other awards or other purposes at University of

Malawi or any other university. All references and other support have been

acknowledged appropriately.

Name of Student: Charles Masulani Mwale

Signature:

Date: 31 st November 2006


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Acknowledgements:

I am sincerely indebted to the following for their support, encouragement and inputs,

which facilitated this work:

My wife and son, Chisomo for their support, perseverance and understanding my

intermittent presence at home during study periods.

My research supervisors Dr. Rob Stewart, for his technical supervision, financial

support, and guidance during the preparation and write-up of this dissertation; Dr.

Mathanga; Dr Kauye and for their direction during protocol development of this

thesis report.

Research assistants, Messsers Makwakwa, Jonasi, Chaula, Ngambi and Chimaliro

and all research participants for their understanding and co-operation.

The Hospitaller Order of St. John of God, Malawi, for financing my studies.

God almighty, for his sustaining mercies and for raising me to this level.

DEDICATION:


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This dissertation is dedicated to my wife Patricia.


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ABSTRACT:

Background

There are no much statistics of the extent on mental and psychosocial problems among

people living with AIDS (PLWAs) in Malawi. In spite of the lack of the data regarding

psychosocial problems in Malawi, studies of these problems in neighboring countries

show that at least 10% of the general population is affected and the psychosocial

problems are as common as infectious diseases (MOH, 2001). With this backdrop, this

study determined the prevalence of psychological distress and associated factors among

PLWAs attending anti-retroviral (ARV) clinics in Mzuzu.

It is believed that the findings of the study will help to enlighten health care providers

and policy makers on the extent of the problems and guide interventions to ensure that

PLWAs receive a complete and comprehensive health package as recommended by

WHO.

Objectives of the study:

The objective of this study was to determine the prevalence of psychological distress and

associated factors among PLWAs attending ARV clinics in Mzuzu City.

Methods A cross-sectional survey was done among PLWAs attending ARV clinics at Mzuzu

Central and St. Johns hospitals, in Mzuzu. 440 clients were sampled using systematic

sampling. The Self Reporting Questionnaire (SRQ) a measure of psychological

distress, and a questionnaire measuring social demographic and other predictive factors

for psychological distress were administered verbally to the participants. Ethical

clearance, institutional authority and consent for the study were sought from COMREC,

medical directors of the two institutional sites and participants of the study respectively.

SPSS and STATA were used to analyze data to address research objectives of the study.

Findings:

On demographic characteristics of the participants, young age, being female, low

education, joblessness, and poor social economical status were associated with

psychological distress. It was also found that 14.4% of this sub-sample was

psychologically distressed while 4.5% had suicidal feelings. On the clinical part, shorter

duration on ARVs, non-availability of psychological support were some of the factors


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3.2 Study design...........................................................................................................................................30 3.2.1 Validity of the design ......................................................................................................................30 3.2.2 Confounding variables.....................................................................................................................31

3.2.3 Dependent and independent variables: ............................................................................................31 3.3 Study Place.............................................................................................................................................31

3.4 Study Population ...................................................................................................................................31

3.5 Study Period...........................................................................................................................................32

3.6 Sample Size ............................................................................................................................................32

3.7 Data Collection: .....................................................................................................................................33 3.7.1 Instrumentation................................................................................................................................34 3.7.2 Validity of data collection tool ........................................................................................................35 3.8 Data Management and Analysis .........................................................................................................36

3.9 Ethical Considerations..........................................................................................................................37

3.10 Dissemination of the Results...............................................................................................................39

CHAPTER THREE: STUDY FINDINGS.............................................................40

4.0 Introduction:..........................................................................................................................................40

4.1 Sample description:...............................................................................................................................40

4.2 Social demographic characteristics of the participants .......... ........... .......... ........... ........... .......... ......40 AGE..........................................................................................................................................................41 Sex and Marital status...............................................................................................................................41 Educational status .....................................................................................................................................42 Current occupation ...................................................................................................................................42 Social economical state.............................................................................................................................42 VARIABLE..............................................................................................................................................42

4.3 Other social-clinical characteristics of the participants.....................................................................44 HIV staging as recorded on the clients card ............................................................................................44 Duration on ARVs....................................................................................................................................45 Availability of psychological support (confidant) ....................................................................................45 Support with Daily activities ....................................................................................................................46

Disclosure of own HIV status...................................................................................................................46 Attendance to an HIV/AIDS support group .............................................................................................46 VARIABLE..............................................................................................................................................47

4.4 Prevalence of psychological distress: ........... .......... ........... ........... ........... ........... ........... .......... ........... ..47

4.5 Univariate Analysis: ..............................................................................................................................48 4.5.1 Social demographic characteristics of the participants associated with psychological distress: .....48 4.5.2 Other clinical characteristics of the participants associated with psychological distress: ...............50

4.7 Logistic regression: Social-clinical factors adjusted for age, Sex and social-economic status: ......51

4.8 Other significant findings: ....................................................................................................................52


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CHAPTER FOUR: DISCUSSIONS, STUDY IMPLICATIONS,RECOMMENDATIONS AND CONCLUSIONS. .................................................53

5.1 Introduction:..........................................................................................................................................53

5.2 Status of research objectives ................................................................................................................53 5.2.1. Prevalence of psychological distress: .............................................................................................53 5.2.2. Associated factors...........................................................................................................................54

5.3 Logistic regression: Social-clinical factors adjusted for age, Sex and social-economic status: ......60

5.4 Possible limitations of this study:.........................................................................................................60

5.5 Implications and recommendation: .....................................................................................................61 (A) Implications for Health practice and education..................................................................................61 (B) Implications for Research:..................................................................................................................63 (C) Implications for policy: ......................................................................................................................64 (D) Recommendations:.............................................................................................................................65

5.6 Conclusions:...........................................................................................................................................66

REFERENCES: ..................................................................................................67

APPENDIX..........................................................................................................75

I Questionnaire/ Consent Form (English) .................................................................................................75

Consent statement:......................................................................................................................................76 I (B) Consent Form/Questionnaire (Tumbuka/Chichewa)......................................................................82

Section A. Social-Demographic Characteristics ......... ........... ........... .......... ........... ........... ........... ........... ..83

II Study personel: ........................................................................................................................................87

III Budgetary Estimates and Justification ........... .......... ............ .......... .......... ........... .......... ........... ...........87

V. Gannts Chart showing the research period. .......... ........... ........... .......... ........... ........... ........... ...........89

Approval letter from Post graduate committee........................................................................................90

ETHICAL CLEARANCE LETTERS.......................................................................................................91 VI (a) Clearance letter to COMREC.........................................................................................................91 VI (b) Approval letter from COMREC.....................................................................................................92

VII. Clearance letters. ................................................................................................................................93 VII (A) Clearance letter from Researchers institution ...........................................................................93 VII (b) Clearance letter to Mzuzu Central Hospital ................................................................................94 VII (c) Approval letter From Mzuzu Central Hospital. ............................................................................95 VII (d) Clearance letter to St. Johns Hospital..........................................................................................96 VII (e) Approval letter from St. Johns Hospital. .....................................................................................97


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List of Tables showing:

1. Social-demographic characteristics of the study respondents

2. Clinical characteristics of the study respondents

3. Relationship between social-demographic characteristics of respondents and

psychological distress

4. Relationship between other clinical characteristics of respondents and

psychological distress

5. Significant clinical variables adjusted for age, sex and social-economic status.

6. Personnel involved in the study

7. Study budget of the study

8. Gantts Chart of the study

List of Figures showing:

1. Age categories in percentages

2. Marital state of the study respondents

3. Participants occupational distribution

4. WHOs HIV staging characteristics of respondents

5. Participants duration on ARVs

6. Participants sources of psychological support (in Percentages).


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Acronyms:

HIV/ AIDS: Human Immuno-deficiency Virus/ Acquired

Immunodeficiency Syndrome

WHO: World Health Organization

PLWAs: People living with AIDS

ARV: Antiretroviral

SRQ: Self-Reporting Questionnaire

HIV+: HIV positive

HIV-: HIV negative

COMREC: College of Medicine Research Ethics Committee

DSM-IV: Diagnostic Statistical Manual, Version IV


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CHAPTER ONE: INTRODUCTION

1.1 Introduction

This chapter presents the context of this study. It highlights literature on mental health

and psychological distress and its predictive factors among people living with

HIV/AIDS. It then looks at statement of the problem, rationale, objectives, and provides

an overview of this research study.

1.2 Background

The overall prevalence of HIV among Malawians aged 15-49 years is 12% (NSO & ORC

Macro. 2005). On the other hand, there is little robust data on the extent of mental and

psychosocial problems in Malawi, let alone data on such psychosocial problems among

people living with AIDS (PLWAs) (MOH, 2001). However, prevalence studies of these

problems amongst general population samples in neighboring countries show that at least

10% of the population is affected (MOH, 2001). Currently, HIV interventions focus

primarily on the physical care and not much on the psychological aspects.

Evidence from literature from the West indicates that a significant proportion of people

presenting at general clinics has a psychiatric disorder (Royal College of Physicians,

2003). In sub-Saharan Africa, prevalence studies of these disorders amongst general

population samples show that at least 10% of the population is affected (MOH, 2001). On

the other side, reported prevalence of psychiatric disorder in people presenting with

symptoms explained by chronic illnesses like AIDS, is 1520%; while in patients who

present with medically unexplained symptoms it is approximately 50% (Van Hemert,

Hengeveld, Bolk, Rooijmans & Vandenbroucke, 1993; & Jackson, Fiddler, Kapur, Wells


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Malawi still has one of the alarming HIV prevalence rates, with 12% of adults aged 15-

49 infected with HIV as per 2004 Demographic and Health Survey report (NSO, 2005).

However, UNIADS, (2006) estimated that 14.1 [6.9 21.4]% of adults aged 15 to 49

were ling with AIDS by end 2005 . The prevalence is higher among women than among

men (13 and 10% respectively. The specific prevalence rate also peaks up to 18% for

women, and 20% for men aged 30-34 (NSO, 2005)

Efforts have been put in place in mitigating the impact of HIV in Malawi. These have

included HIV counseling and testing; home based care, prevention of mother to child

transmission of HIV including care for the vulnerable groups like orphans (MOH, 2003).

The addition of anti-retroviral therapy, in AIDS care, has dramatically improved the survival

of PLWAs. In 2002 Malawi started giving the ARVs in its two central hospitals in Lilongwe

and Blantyre and Chiradzulu District Hospital (MOH, 2003). The government has built on

this existing service by rolling out ARV therapy throughout the country in a phased manner.

Government, mission and some private care providers are currently providing the ARVs and

treatment for opportunistic infections in different health institutions in the country. With the

current profile of mental health services, there is no regular attention to mental health needs

of these PLWAs.

With the highlighted statistics above the Malawi National AIDS Commission estimated

that about a million people were living with HIV/AIDS in the country resulting in more

than 50,000 to 70,000 adult and child deaths annually, respectively (MOH, 2003).


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20% across the majority of studies (Atkinson et al 1988; Lipsitz et al 1994; Perkins et al

1994; Stern et al 1992). In other studies the prevalence has ranged from 0% (Fukunishi

& Hosaka, 1997) to 47.8% (Dew et.al, 1997). This variability is likely due to differences

in designs in patient sampling techniques, especially with regard to demographics (sex,

age), disease stage and treatment status, assessment strategies, and co-morbidity of other

psychiatric conditions. Patients with HIV should therefore be routinely assessed and

appropriately treated for depression.

Although it is well documented that women report higher rates of depression than men in

the general population (Blazer et al 1994), most of the prevalence studies of depression in

HIV disease have focused almost exclusively on men. A few studies have examined rates

of depression among samples including both men and women. Rabkin et al (1997)

examined an intravenous drug-using cohort of 121 men (69 with HIV, 52 without HIV)

and 66 women (36 with HIV, 30 without HIV) over 3 years. At baseline assessment, rates

of major depression and dysthymia ranged from 15% (HIV positive men) to 33% (HIV

positive men and positive HIV women). For HIV positive individuals, degree of mood

improvement over time was related to HIV progression (i.e., those who remained

healthier based on CD4 count and illness stage showed mood improvement over time).

In a five-site World Health Organization study including both men and women, of

varying social-economic background, prevalence rates of major depression ranged from

4.0% to 18.4% among HIV symptomatic individuals and 3.0% to 10.9% among

asymptomatic individuals (Maj 1996). In two sites, women had higher depression scores

than men, but complete data on gender differences across all five sites was unavailable.

In one meta-analysis of ten studies comparing prevalence of depressive prevalence


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among infected people and those at risk of being infected by HIV, it was reported that the

frequency of major depressive disorder among the HIV participants was almost twofold

that of the at-risk individuals (Ciesla & Roberts, 2001).

Prevalence rates of major depression among exclusively HIV women have varied widely.

Rates among clinical samples have ranged from 1.9% to 35% (Boland et al 1999; Goggin

et al 1998; McDaniel et al 1995; Taylor et al 1996) and from 30% to 60% among

community samples (Moore et al 1999; Smith et al 1996). The range of prevalence rates

of depression among HIV women is believed to result from differing methodologies

(point versus life-time prevalence rates) and study populations and in some cases the use

of small samples. Larger scale prevalence studies of HIV women are starting to emerge.

Ickovics et al (2001) studied 765 HIV women and reported that 42% had chronic

depressive symptoms and 35% had intermittent depressive symptoms.

1.5.2 Determinants of psychological distress and major depression among PLWAs

As highlighted above, there is evidence that psychological distress and other mental

disorders are common problems and complications of HIV/AIDS among PLWAs.

There are various findings about factors associated with psychological distress and

depression. Some studies have found a relationship between psychological distress

among PLWAs and prior negative events (Moore, Schuman et. Al, 1999) while others

have not (Evans, Lessserman & Perkings, 1995).


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Several social-demographic factors like female gender (Linchtenstein, Laska & Clair

2002), younger age (Clesla et al, 2001) and low social economic status (Moore et al,

1999) were found to increase the risk for psychological distress among PLWAs. Further

to this, depression in Pakistan, where HIV prevalence is less than 2%, was found to be

associated with severe financial and housing problems, few years of education, and

numerous children (Husain, Creed, Tomenson, 2000; & Mumford, Saeed, Ahmad 1997).

Other factors found to be associated with depression among the PLWAs include

symptomatic and advanced HIV clinical stages (Maj, 1997) & Clesla et al, 2001);

including history of substance abuse and risky sexual practice (Kalichman, 1999).

Other studies also suggest that social support can buffer the effects of psychosocial and

physical stress on individuals (Broadhead et al., 1983; Cohen, Wills, 1985 & William

et.al 2005). Depression among PLWAs is associated with unavailability of antiretroviral

medication and to HIV disease progression even among PLWAs who adhere to

HIV/AIDS medication regimes (Leserman, 2003).

(Fleming et al., 2004) also found that factors independently associated psychological

distress among persons infected either with HIV, HCV or both, are age, unemployment

and injection drug use.

William et. al, 2005 also reports that HIV associated problems with quality of life,

depression and fatigue, among people living with HIV/AIDS, can be primarily explained

by unstable housing, lack of employment, low education and low income.

Fatigue is also an important and debilitating symptom for people with HIV/AIDS

infection (Dwight et al., 2000; Obhrai et al., 2001). Fatigue is also a well-documented


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around 31% of YLDs, with depression contributing 12% of all disability across all age

groups, and 16% in the 15- to 45-year age category.

Further, as people living with HIV/AIDS (PLWAs) live longer, healthrelated quality of

life and the consumption of health and social services have assumed increasing

importance (William et.al 2005). Psychological distress is further associated with poorer

health and greater health service utilization among the PLWAs and those having other

medical illnesses (Simon, Ormel, VonKorff, & Barlow, 1995; Wells, Rogers, Burnam,

Greenfield, & Ware, 1991). Recent research suggests that psychological distress may

similarly affect the quality of life (Kalichman, Heckman, Kochman, Sikkema, &

Bergholte, 2000; Kemppainen, 2001), social support and disclosure status (Kalichman,

DiMarco, Austin, Luke & DiFonzo, 2003), and service utilization (Sambamoorthi,

Walkup, Olfson, & Crystal, 2000) among PLWAs.

1.5.4 HIV/AIDS and Psychological Distress:

Human immunodeficiency virus sero-positive (HIV) individuals may be at an increased

risk of developing psychiatric disorders.

As seen above, in addition to data regarding HIV infection and mental disorders fatigue

and sleep disorders are an important issue for this patient population, with prevalencereports of 30-40% (Robbins, at al, 2004; Sullivan & Dworkin, 2003). The fatigue

syndrome in HIV positive individuals has been found to be associated with distressful

symptoms (Robbins et al., 2004; Sullivan & Dworkin, 2003), pain (Robbins et al., 2004),

depression (Robbins et al., 2004; Sullivan & Dworkin, 2003) and anxiety (Robbins et al.,

2004).


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Another recent epidemiological study assessed a nationally representative sample of

2,864 HIV patients, and found that nearly half screened positive for a psychiatric

disorder, including major depression, dysthymia, and generalized anxiety disorder (Bing

et al 2001). More than one third screened positive for major depression, and more than

one quarter for dysthymia. It should be noted that these rates were based on screening

instruments and significantly exceed clinical interview based diagnostics assessments.

Since mood disturbances are often viewed as one of the most common psychiatric

symptoms reported by HIV individuals, and clinicians, therefore, need to actively

identify those individuals at risk and ensure the availability of appropriate treatments

(Bing et. al. 2001).

Overall, there is compelling evidence that mood disorders are at higher prevalence rates

in HIV individuals than in the general population, and that psychopharmacologic

interventions can improve mood during the course of HIV disease. Conversely, most

psychiatric disorders among HIV individuals are frequently unrecognized and untreated

(Evans et al 1996), and this necessitates the need for urgent action to enhance

comprehensive care for people living with AIDS.

The assessment of mood disorders during HIV disease poses a number of unique

challenges, including that mood disorders can be considered primary or secondary to the

medical illness. Treisman et al (1998) have noted that the primary group may have a

previous history of a mood disorder but have prevalence rates similar to traditional risk

groups, such as homosexual men and injection drug users. Those with mood disorders

secondary to HIV do not necessarily have a prior history or a familial history, and the


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affective disturbance most likely results from viral infection and central nervous system

(CNS) brain involvement.

There is no consistent evidence that depressive symptoms increase as HIV disease

progresses. Although Lyketsos et al (1996) found an increase in depressive symptoms

approximately 1.5 years before the onset of acquired immunodeficiency syndrome

(AIDS), Rabkin et al (1997b) showed that depression did not increase despite worsening

HIV infection over a four-year period. On the other hand, Goggin et al (1997) found that

HIV depressed and non-depressed men did not differ on global neuro-cognitive

impairment, although the depressed individuals exhibited greater memory impairment.

The clinicians must consequently consider the possibility of a spontaneous onset of first

episode as well as a recurrence of depression in a recently diagnosed HIV individual.

Distinguishing between primary and secondary mood disorders among HIV patients

requires a thorough assessment of affective symptoms both current and past and a

comprehensive evaluation of medical and neurologic contributions. For example

depression in Pakistan where HIV prevalence is lower than 2% is no different from other

areas of high HIV (Husain, Creed, Tomenson, 2000; & Mumford, Saeed, Ahmad 1997).

Further to the above difficulty, it has to be noted that diagnosing major depression among

HIV individuals is also complicated by the fact that several symptoms of depression (e.g.,

fatigue, sleep disturbance, and weight loss) are also common symptoms of HIV disease

(Norman et al 1992; Perkins et al 1995).

In addition, depressive symptoms may also mirror symptoms associated with a co-morbid

substance related disorder (Regier and Farmer 1990). Because of these overlapping

physical and psychological symptom features, mood disorders may be under-diagnosed


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and inadequately treated. Thus, a thorough medical and psychiatric assessment is

warranted.

1.6 THE FUTURE:

As a way forward, it appears that it is imperative to provide comprehensive AIDS care to

PLWAs and to improve their coping abilities and quality of life by recognising and

treating concurring mental health problems. Further to this, PLWAs require improved

monitoring of psychotic and anti-retroviral medication. There is need for increased

training and support from experienced mental health professionals, so that primary health

care staff and volunteers could more effectively recognise psychological distress and

other mental health problems, link the PLWAs with HIV clinics, offer appropriate

medication to PLWAs, and help PLWAs stay on prescribed medication (William et. al,

2005). As seen in the interaction between HIV and psychological distress it is evident

that some of the problems faced by PLWAs may be more appropriately addressed

through mechanisms that are non-biological. In the primary health care setting, this may

require additional psychosocial support and programming, as well as interventions aimed

at the psychological distress.

1.7 STATEMENT OF THE PROBLEM AND RATIONALE FOR THE

RESEARCH PROJECT:

Freeman et. al. (2005), argue that a successful HIV/AIDS intervention program must

include the assessment of mental disorders and their appropriate management as part of

the normative service. They add that there is a need to develop appropriate materials and


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models for the delivery of mental healthcare within the parameters of the WHOs 3 by 5

initiative based on the principles of affordability, acceptability and availability. The

integration of mental health into this initiative presents an excellent opportunity to

strengthen the status of mental health in public health services in developing countries. It

provides an important chance to improve the health of people with HIV and to expand

mental health services in general health services (Dew et. al, 1997). Without data on the

prevalence of psychological distress and its associated factors among PLWAs, all the

above statistics will remain unsubstantiated in Malawi unless a study of this nature is

done. It is hoped that achievement of the objectives below will help to bridge this gap and

help provide base line data for planning, program development and evaluation, to

promote the comprehensive care provision for the PLWAs as we rollout the ARVs

services in Malawi.

1.8 DEFINITION OF TERMS

1.8.1 Psychological distress: This refers to a combination of emotional syndromes,

involving varying mood and vitality levels, characterized by depression, anxiety, and

somatisation (Townsend, 2001)

1.8.2 Depression: This is defined as a lowered mood or loss of interest or pleasure in

all or almost all activities for almost a period of two weeks. There is presence of at least

five of the following: diminished mood; diminished interest in activities; weight loss or

gain; insomnia or hypersominia; psychomotor agitation or retardation; fatigue; feelings of


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worthlessness; inappropriate guilt; diminished ability to think or concrete; and recurrent

thoughts of deaths (APA, 1994).

1.8.3 Mania: The opposite of depression, mania is defined as a psychotic disorder

whose main feature is abnormal elevation of mood; increased energy; and acceleration of

mental and physical activity (Lyttle, J., 1986).

1.8.4 Anxiety: Denotes a vague and uneasy feeling of discomfort or dread accompanied

by an autonomic response; the source is often non-specific or unknown to the individual;

a feeling of apprehension caused by anticipation of danger (APA, 1994).

1.8.5 Somatisation: This refers to a syndrome of multiple somatic symptoms that can

not be explained medically and are associated with psychosocial distress and long termseeking of assistance from health care professionals (APA, 1994).


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1.9 OBJECTIVES OF THE STUDY

1.9.1 Broad Objective

The broad objective of this study was to determine the prevalence of psychological

distress (depression/anxiety/somatisation) and its associated factors among PLWAs in

Mzuzu City.

1.9.2 Specific Objectives

This study aimed at:

a) Determining the prevalence of the psychological distress amongst PLWAs

attending Rainbow (ARV) clinics at St. Johns Hospital and Mzuzu Central

Hospital in Mzuzu city.

b) Establishing risk factors for psychological distress amongst the PLWAs.

1.10 RESEARCH HYPOTHESES

It was hypothesized that:

(a) PLWAs having an advanced HIV disease stage will have more psychological distress

compared to those who are in early stages.

(b) PLWAs who have not started or have just started ART will have more psychological

distress compared to those who been on ART for sometime (>6 months).

(c) PLWAs having no confidant partner to give psychological support will have more

psychological distress compared to those who have.


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(d) PLWAs having no support in their daily activities will have more psychological

distress compared to those having the support.

(e) PLWAs who have not disclosed their sero status will have more psychological

distress compared to those who have disclosed their sero status.

(f) PLWAs not attending to an HIV/AIDS support group will have more psychological

distress compared to those belonging to one.


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CHAPTER TWO: METHODOLOGY

3.1 INTRODUCTION

This chapter explains the study methodology. A cross-sectional study design was used toaddress the study hypothesis raised in section 1.7 of this report.

3.2 STUDY DESIGN

This study was a cross-sectional one. This is a study design whereby measurements of

exposure and effect are made at the same time. It is an easy and an economical design for

investigating exposures that are fixed characteristics of individuals (Beaglehole, 2002).

3.2.1 Validity of the design

On validity of the design: the sample size was large enough to avoid Type II error

(Statistical conclusion validity); there was systematic sampling of research participants toenhance internal validity. The limitation of the design is its difficulty in assessing the

directions for association because it is hard to determine if exposure (explanatory factors)

preceded the effect (psychological distress) in a cross-sectional study like this one

(Beaglehole, 2002). The other limitation was that a formal inter-rater reliability analysis

was not done in the study, however this is not a real problem as the questionnaire was

highly structured.


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3.2.2 Confounding variables

Variables like age, social economic status and gender (Refer Appendix I), which usually

influence dependent and independent variables in a study were considered to rule out their

influence. These were adjusted for during analysis as, explained in section 4.7 of this report.

Systematic sampling of research subjects was also made to control for these.

3.2.3 Dependent and independent variables:

Psychological distress was the main outcome (dependent variable) while demographic

factors (age, sex, socio-economic status) and factors predicted to be associated with

psychological distress (HIV staging, duration on ART, disclosure of sero-status and support

network) were the explanatory factors (independent variables).

3.3 STUDY PLACE

This study was conducted in ARV clinics at Mzuzu Central and St. Johns Hospitals, in

Mzuzu.

3.4 STUDY POPULATION

PLWAs attending Mzuzu Central Hospital and St. Johns ARV clinics in Mzuzu were

sampled using systematic sampling, whereby every third client was requested to

participate in the study. Regarding selection/inclusion criteria, those PLWAs (both male

and females) aged 18 and above were recruited for the study after completing registration

at the clinic.


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3.5 STUDY PERIOD

The study period was nine months. This period incorporated: conceptualizing the research

area; literature review; draft proposal submission to post graduate committee; proposal write

up; initial translation of research instruments; protocol submission to COMREC; training of

research assistants; data collection and analysis; and report writing (Refer to the Gannts

Chart in appendix V).

3.6 SAMPLE SIZE

Sample size was calculated based on prevalence estimates from a recent epidemiological

study which assessed a nationally representative sample of 2864 HIV+ patients, and

found that nearly half screened positive for a psychiatric disorder, including major

depression, dysthymia, and generalized anxiety disorder (Bing, & Treisman,1996).

Therefore, a prevalence of psychological distress of 50% was assumed among PLWAs.Using the formula by Lwanga & Lameshow (1992) for calculating sample size for a cross

sectional survey, sample size was calculated using the formula below:

Estimated sample size = (Z ) 2 PQ

D2

In this case confidence intervals was set at 95% hence Z was 1.96, where Z is the normal

variate corresponding to the level of significance; P is the proportion with the disorder

while Q is the proportion without the disorder (1-p).

Therefore,


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n=(Z ) 2 PQ = (1.96) 2 x .5 x .5 = 0.9604 = 384

D2 .05 x .05 0.0025

To give an allowance for refusal rate, 440 participants were selected by systematic sampling.

Thus every third client attending the Rainbow clinic was recruited for the study and 438

participants had participated in the study. Those individuals who gave written consent,

(Refer questionnaire- Appendix A.) were interviewed for the study.

Currently, about 80 new and 300 subsequent clients attend these ARV clinics per week.

Assuming a refusal/exclusion rate of 10% and screening every third patient, this allowed

data to be collected in a month. This was achieved, as one assistant would interview at least

10 participants per day.

3.7 DATA COLLECTION:The investigator and four assistants (ARV nurses) collected quantitative data at the two

clinics. The assistants initially were given a three days training in the study methodology

and psychological distress as well as its correlates.

Participants were recruited after registering at the ARV clinic. The investigator and four

assistants explained the purpose of the study and sought informed consent from participants.

They verbally administered the survey questionnaire to consenting participants in rooms

that provided privacy. This took 15 to 20 minutes. This was just done at this one point in

time.

The questionnaire had three components: (1) Self-Reporting Questionnaire (SRQ) as the

measure of psychological distress, (2) Demographic information questions, and (3)


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measures of predicted associated factors (HIV/AIDS staging, disclosure, duration on

ARV and social support) [Refer appendix I].

3.7.1 Instrumentation

As described above, the study questionnaire had the three components:, demographic

information, measures of associated factors for psychological distress and the SRQ.

The first component recorded socio-demographic information (age, sex, religion, education,

occupation, marital state, and a proxy of social economic status). A proxy for social

economical status (having a brick and an iron-roofed house) was used because it is

convenient and that people usually do not give accurate information when asked about social

economic status in monetary terms, which would have given a false picture. These were used

as variables for establishing any association between social-demographic variables and

psychological distress.

The second component measured the factors hypothesized by this study to be associated with

psychological distress (HIV stage, duration on ARV, disclosure of sero-status and support

network). The questions for all three components are included in the appendix I . No data was

collected on other medical conditions.


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3.7.2 Validity of data collection tool

The SRQ is a brief measure of psychiatric symptoms designed by the WHO to be used

across cultures (WHO, 2004). It has been validated and used in a variety of settings

including Zimbabwe, Swaziland, Kenya, Sudan and South Africa and Malawi (Gueness,

1992; Hardiong, 1976; Kigamwa, 1991; & Carta, Carpiniello, Dazzan, & Reda, 2000).

The SRQ is scored out of 20. A cut off point of 7/8 has shown good sensitivity and

specificity in previous studies in Africa (Ibid). Recently, the SRQ was back-translated,

then validated against SCID major depressive episode in mothers of infants attending for

measles vaccination in Thyolo District Hospital-Malawi. At a cut-off of 7/8 the SRQ

detected current major depressive episode with sensitivity 68 %, specificity 77%, and

positive predictive value 33%, and any depression (current major or minor depressive

episode) with sensitivity 59%, specificity 85%, and positive predictive value 64%

(personal communication with Stewart et. al. 2005). This study therefore adopted this

7/8 cutoff-point because it had demonstrated good epidemiological indices above (e.g.

high specificity e.t.c.).

For interpretation sake in this study, the dependent variable, SRQ score was

transformed or Recorded into a dichotomous variable for easy analysis. Thus, those

scoring 8 or above were designated as cases (psychologically distressed) and those

scoring 7 or less as non- distressed. The cut off point was chosen because it gave good

indices in the validation study in Thyolo {Stewart et. al. 2005}

The SRQ all 20 items reflect the concept/ symptomatology of psychological distress, thus

it actually measured what it was supposed to measure {Validity of the tool} (Polit &

Hungler, 1989). This tool has the highest probability of yielding similar results even if


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used by different researchers because of the highest degree of consistency with which the

SRQ measures the distress (reliability of the tool) {Polit & Hungler, 1989}. The only

problem is the low sensitivity at the cut-off point. 70%+ would have been much better

than the 59.

The other limitation was that a formal inter-rater reliability analysis was not done in the

study, however the questionnaire was highly structured.

3.8 Data Management and Analysis

As mentioned above, psychological distress was the main outcome (dependent variable)

while factors predicted to be associated with psychological distress (HIV staging, duration

on ART, disclosure of sero-status and support network) were the explanatory (independent

variables) for this study.

The collected data was coded on a computer, cleaned and analyzed using SPSS (SPSS

inc, 2001) and STATA ( STATA-Corp, 2005).

The prevalence of psychological distress amongst PLWAs attending ARV clinics was

calculated from the SRQ scores. Cases were defined as those scoring 8 or above on the SRQ.

Total number of cases, was divided by total number of subjects to give the prevalence.


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It was then determined which demographic and factors predicted to be significantly

associated with psychological distress. The variables were categorized and/or

dichotomized where necessary.

Inferential data analysis using Pearsons Chi-squared test with SPSS was used to examine

the association between psychological distress and these variables. The significance of

association was determined at a significance level of 0.05. To check for confounding and

interactions between those factors significantly associated with psychological distress,

adjusted odds ratios for each significantly associated variable was computed with

STATA.

3.9 ETHICAL CONSIDERATIONS

HIV/AIDS issues are very sensitive. Therefore, in studies involving PLWAs, issues of

respect and confidentiality are particularly important. As described below, great care was

taken to ensure that clinic attenders were treated with sensitivity, their right to refuse was

made clear, and that the interviews were taken in privacy.

Permission to carry out the study was sought from the medical directors of Mzuzu

Central and St. Johns hospitals (Refer Appendix VI ). Ethical approval for the study was

sought from the College of Medicine Research Ethics Committee (Refer Appendix VI ),

while written consent was sought from all participants before the interview (Refer

Appendix I).


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3.9.1 Risks to participants: There were no invasive procedures involved in the study.

Since participants were asked questions about their health and feelings during the

interview, psychologically they would feel uncomfortable with some questions perceived

to be personal. To prevent that the participants were informed that they were at liberty to

decline to answer such questions without giving reasons for their refusal. To avoid

stigmatization and long waiting periods, the study was integrated within the clinic

schedule.

3.9.2 Implications of the study: There was no harmful effect upon the participants in the

study, other than their visit taking an additional 20-30 minutes. The only beneficial

exception is that participants found with life threatening depressive disorder and suicide

were referred for a psychiatric assessment and management St. John of God Mental

Health Services in Mzuzu.

3.9.3 Confidentiality: All information given here was kept confidential. Names were

anonymized by the use of codes on the questionnaires and have not been included in this

report. Further, all interviews were carried in privacy. Consent forms and questionnaires

were always locked in a cabinet, to ensure access only to the investigator. The cabinet was in

the office of the investigator whose keys are only accessible by the investigator.


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3.9.4 Participation was voluntary: Participation was entirely voluntary and participants

had a free choice to participate and were free to withdraw at any time from the study

without giving reasons for doing so nor detriment to self nor rendered care at clinic.

The study consent was obtained in writing, whereby the consent form was read to the

sampled participants and they were asked to sign if they agreed before the interview took

place.

3.10 DISSEMINATION OF THE RESULTS

Dissemination of these research findings was done at local COMREC research

dissemination conferences and may be submitted for publishing in the East and Southern

Journal of psychiatry and in the Malawi medical journals. Copies of the same will also be

sent to St. John of God College and College of Medicine libraries. Further, a

dissemination seminar/workshop will be conducted with health services providers and

other stakeholders in Mzuzu City.


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CHAPTER THREE: STUDY FINDINGS

4.0 INTRODUCTION:

This chapter presents the findings of this study. Based on the analysis of the data

collected it identifies the characteristics of the study participants, determines the

associated social demographic as well as social-clinical factors for psychological distress,

gives the adjusted ratios for those variables with significant relationship showing the

psychological distress. The valid percentages are reported to avoid contaminating the

results by the missing variables.

4.1 SAMPLE DESCRIPTION:

Of the 440 PLWAs who were sampled for the study, 438 participated in the study (only

two declined giving a 99.5% response rate); 397 had complete data sets, with missing

data on one or two variables. However, there were no significant differences in

characteristics between the 397 and the 438.

4.2 SOCIAL DEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS

The section below describes the social and demographic characteristics of the study

participants. Only valid percentages are reported to avoid effect by missing data. As

mentioned above, only valid percentages are reported to avoid contaminating the results

by the missing variables.


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AGEThe mean age range was the third category, which was 31-40 years. This sample had

40.4% (177 participants) in the 31-40 year category with only 2.3 % aged less than 20

years (refer Figure 1 below).

2.3

24.4

40.4

25.6

7.3

0

10

20

30

40

50

Fig 1: Showing age categories in percentages

20 & belo w

21-30 years

31-40 years

41-50 years

>50 years

Sex and Marital status

The majority of participants were women 69.1 % (299). (Refer Table 1 Below). On

marital status distribution, 57.8% (253) of the participants were married; while 31.3%

were widowed, separated or divorced; and the remaining 5% had never been married

(Refer Fig. 2).

115

48

22

253

Married Never married Widowed Separated/div

Fig 2: Showing marital state of the study participants


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Educational status

On the participants level of education, 195 participants (44.5%) had attended at least

primary education; 220 (50.2%), secondary; while only 10 (2.3%) had done their

university education (Refer Table 1 Below).

.

Current occupation

A large percentage of the participants were unemployed (Refer Fig. 3 below).

1 7 4

1 3

1 1

1 4 4

9 0

0 50 100 150 200

Unemployed

Laborer

Student

Business

Skilled

Fig 3: Showing paticipants' Occupational distribution

Social economical state

A proxy variable of social economical status (Acquisition of a brick and an iron-thatched

house) showed that 56.2% of the participants (241) had a better status (Refer Table 1

Below)

Table 1: Showing social demographic characteristics of respondents

VARIABLE CATEGORIES FREQUENCY %

Age (Recorded)


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21-30 years 107 24.4

31-40 years 177 40.4

31-40 years 112 25.6

>50 years 32 7.3

Gender Male 134 30.6

Female 299 68.3

Marital status Married 253 57.8

Never married 22 5

Widowed 115 26.3

Separated/divorced 48 11

Education Never educated 13 3

Primary 195 44.5

Secondary 220 50.2

University + 10 2.3

Occupation (R) Unemployed 184 42.2

Employed 254 57.8

SES (R) Poor 188 42.9

Rich 241 55


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4.3 OTHER SOCIAL-CLINICAL CHARACTERISTICS OF THE

PARTICIPANTS.

HIV staging as recorded on the clients card

303 participants (69.2%) in this study were in their third clinical stage of HIV using

WHO guidelines (Refer Fig 4 below). The Characteristics of each stage are as in

Appendix X III

Fig. 4: Showing the WHOs Staging characteristics of the participants

HIV Staging (on card).

4.03.02.01.0

HIV Staging (on card).

F r e q u e n c y

400

300

200

100

0

Std. Dev =.55

Mean =3.0

N =428.00


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Duration on ARVs

More than half of this sample population had been on the ARVs for more than six months

(Refer Fig 5 Below).

243

165

27

2 0

50

100

150

200

250

>6months


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5.7

3.2

12.2

18.2

18.2

0 2 4 6 8 10 12 14 16 18 20

None

Church & other

Uncle/in-law

Brother/sis/nephwe

Parent

Spouse

Fig 6: Showing Paticipants' sources of Psychological support (in percentages)

Support with Daily activities

There was no large difference between participants who had no support with their daily

activities and who had (47.9% versus 52% (Refer Table 2 Below).

Disclosure of own HIV status

Unlike previous trends in Malawians behaviors of not disclosing their positive status,

more people in this sample (96%) had reported to disclose their sero-status to somebody

(Refer table 2 below).

Attendance to an HIV/AIDS support group

Only 34% of the participants had attended the HIV/AIDS support group in this sub-

population (Refer Table 2).


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Table 2: Showing clinical characteristics of respondents VARIABLE CATEGORIES COUNT %

HIV staging Stage 1 1 .2

Stage 2 55 12.6

Stage 3 303 69.2

Stage 4 69 15.8

Duration on ARV Stopped by side effects 2 .5

Not started 27 6.2

6m 243 55.5

Psychological support Parent 79 18

Spouse 191 43.6

Other/none 170 38.4

Support for daily activities Not available 207 47.3

Available 229 52.3

Disclosure of own status Not disclosed 15 3.4

Disclosed 415 94.7

Support group Not attended 284 64.8

Attended 147 33.6

4.4 PREVALENCE OF PSYCHOLOGICAL DISTRESS:

The prevalence rate of psychological distress in this study was 14.4%. Of the total 438

participants who had completed the SRQ in the study, 63 had scored more than the laid-


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down cut-off point of 8. Therefore, the prevalence of psychological distress was found by

dividing the 63 cases by 438 ARV clinic attenders and multiplied by 100. That is to say that

14.4% of this sub-sample had scored above the threshold of eight on the SRQ (were

psychologically distressed). Using the suicidal item on SRQ, 4.5 % of the participants

had suicidal feelings.

4.5 UNIVARIATE ANALYSIS:

To test for the associations, univariate analysis using Chi-Squared test and Pearsons

correlation were done. Following statistical tabulation of social-demographic factors and

psychological distress, it was found out that the following were related as detailed on the

table 3 below:

4.5.1 Social demographic characteristics of the participants associated withpsychological distress:

To establish association between social-demographic factors and psychological distress,

some of the variables were recorded or dichotomized as appropriate. A 2 by 2 table

generated by SPSS and its chi-square value were computed at significance level of

=0.05. Chi-test ( 2 at P or =0.05) and Correlation coefficient ( r ) were used to

establish the association and direction of association of the variables (Refer Table 3).

AGE: Age was recorded into a dichotomous variable (younger and older). Younger

people were more distressed than the elderly population (r=-0.164; 2=17.89; P= 0.001).

Gender: Females were more distressed than the men (r=0.103; 2 4.5=; P=0.03).


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Secondary 44.1 6.2University + 2.1 0.2

Occupation (R) Unemployed 32.6 53.0 20.21 0.003 -0.09Employed 7.1 7.3

SES (R) Poor (No) 34.5 9.3 11.60 0.001 -0.16Rich (Yes) 50.8 5.4

4.5.2 Other clinical characteristics of the participants associated with psychologicaldistress:

Duration on ARVs: Participants who had been on ARVs for less than six months or

none at all were more distressed than those who had been getting the life prolonging

drugs for more than six months (r=-0.12; 2=27.5; P= 0.000).

Availability of psychological support: Participants who had no confidant to provide

psychological support, especially those without parents or spouses, were more distressed

than those who had more direct psychological support (r= -0.07; 2= 17.63; P= 0.024).

The relationship between staging and psychological distress was not statistically

significant. However, looking at magnitude and directional relationship by correlation

coefficient, people who were in their late/advanced AIDS clinical stages were more

distressed than those in their early stages (r=-0.03; 2=0.75; P= 0.86). Support for daily

activities; Disclosure of own HIV sero-status; and Attendance to an HIV/ AIDS support

did not show a statistical significant relationship with psychological distress (Refer Table

4 Below).


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Table 4: Showing relationship between the other clinical variables and psychological

distress.

Variable Categories %SRQ- %SRQ+ 2 P r

HIV staging Stage 1 0.2 0 0.75 0.86 -0.03Stage 2 10.7 2.1Stage 3 61.2 9.6Stage 4 14.3 1.9

Duration on ARV Stopped by side

effects

0.5 0 27.5 0.000 -0.12

Not stated 3.2 3.06m 49.0 6.6

Psychologicalsupport

Parent 13.8 4.4 17.6 0.02 -0.07

Spouse 39.3 4.6 None /Other 46.9 91.0

Support for dailyactivities

Not available 39.7 7.8 1.57 0.21 -0.06

Available 46.1 6.4

Disclosure of ownstatus

Not disclosed 2.6 0.9 1.88 0.169 -0.06

Disclosed 83.0 13.5Support group Not attended 56.4 9.5 0.002 0.96 -.002

Attended 29.2 4.9

4.7 LOGISTIC REGRESSION: SOCIAL-CLINICAL FACTORS ADJUSTED FOR

AGE, SEX AND SOCIAL-ECONOMIC STATUS:

Outcome of adjusted odds ratios (prevalence ratios in cross-sectional studies) at 95%

confidence intervals, for the two significant clinical predictors (Duration on ARVs and

availability of psychological support), was negligible and did not give any statistically

significant interaction or confounding brought by age (old compared to younger), sex (males


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CHAPTER FOUR: DISCUSSIONS, STUDY IMPLICATIONS,RECOMMENDATIONS AND CONCLUSIONS.

5.1 INTRODUCTION:

This chapter interprets and discusses the findings in the preceding chapter of the study

with reference to existing knowledge; reflects on the studys implication on practice,

research and education. It also considers strengths and limitations of these study findings;

and finalizes with recommendations and conclusions for the study.

5.2 STATUS OF RESEARCH OBJECTIVES

5.2.1. Prevalence of psychological distress:

Prevalence of psychological distress was 14.4%. This compares well, though on a lower

side, with the 30% found among the mothers of malnourished children in Thyolo (Stewart

et.al, 2005). The difference may be due to the cut-off point which would necessitate that

future studies be carried using a cutoff-point with best indices in this population, since the

former study PPV was relatively low (33%). The prevalence was however, within the

reported 15-20% prevalence of similar psychiatric disorders in other studies in the west

(Atkinson et al 1988; Lipsitz et al 1994; Perkins et al 1994 and Stern et al, 1992).

On another note, however, this reveals the magnitude of psychological distress, which is

prevalent not only in our ARV clinics but also in general Primary health care clinics, and that

go undiagnosed and unmanaged. With the mental health service profile for the country and

the current deficient ARV package, the PLWAs are not granted the holistic care to achieve

their maximum quality of life.


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5.2.2. Associated factors

Social demographic characteristics of the participants associated with psychologicaldistress:

Following statistical tabulation of social-demographic factors and psychological distress,

it was found out that the following were related as per details on the table below:

This study investigated the impact demographic factors on psychological distress among

the PLWAs and the following were the findings for the section:

AGE: In this population, younger people were more distressed than the elderly

population. This is consistent with other findings by Clesila & Roberts (2001) who found

age to be negatively associated with severe emotional distress among HIV/AIDS patients.

Young people may also be more distressed because of the perceived pending out come of

their HIV status which would result into death or troubled future (Hay & Cuningham,

200). Further to this they may not have developed experience in handling distress in

situations nor copping skills/ styles which were predictive of clinical diagnosis of major

depression in one study (Olley et. al., 2004).

Gender: Females were more distressed than the men (r=0.103; 2

4.5=; P=0.033). Since

it is not known about the factors that determine attendance at the hospital clinic,

attendance may be determined by the ability to access the services. It is, however

reported in one population based study that depression among women is usually

untreated in a general clinic (Husain et. al, 2000). This may be the indication of such


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untreated distress in our ARV clinics where patients present with this chronic and severe

illness.

Being an ARV clinic, the situation is not similar to that in Kenya where researchers

found no gender difference in the prevalence of psychiatric morbidity in patients

attending general hospital outpatient clinics (Dhadphale & Ellison, 1992, & Dhadphale

et.al, 1993). They suggested that depression might in fact be more common in women

than men but there is a culturally defined attitude of acceptance of discomfort and pain by

women, which militates against women seeking medical treatment. The differences in

health care seeking behaviors between Malawians and Kenyans may explain this

difference.

Marital status: The relationship between marital state and psychological distress was

not statistically significant despite the fact that participants who were either married,

divorced or widowed were more distressed than the married ones. This finding may add

on the gap in information since there was also no data found in reviewed literature on the

relationship between marital state and psychological distress among PLWAs. However

the directional relationship between the two variables would be explained by the possible

distress prevalent among PLWAs who had no confidant partner as shown below. Widows

and separated participants may not have anyone to share their worries with nor anyone to

give encouragement unlike those who were happily married and ultimately supported

socially as well as psychologically.


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Education: The less educated people were more distressed than the educated population.

This adds on the data that was found in Pakistan that depression is associated with few

years of education, severe financial problems, numerous children and housing problems,

(Husain et. al, 2000). This could also be explained by ability of the learned people to

understand of information of encouragement that is given in clinics as well as the media

that PLWAs would still live longer provided the health tips.

Occupation: The people who were not working were more distressed than the ones who

had an employment of some kind as per study findings above. These findings add to the

existing evidence reported by Fleming et al. (2004) & William et. al (2005) that

unemployment predicts psychological distress and that fatigue and depression are

associated with lack of employment among PLWAs respectively.

This possibly due to the fact that working PLWAs are assured of an income that wouldenable them AIDS care and the ARVs. In addition, this may be fruition on the work-place

AIDS policies that government is promoting in the country to alleviate the plight of

PLWAs in different workplaces.

Social-economical status: Studies have shown that emotional distress and poor social

economic state affect peoples ability to cope with HIV infection (Grassie, Righi,

Sighinolfi, Makoui, & Ghinelli, 1998) and the findings of this study suggest this is true

for distressed PLWAs in our ARV clinics. These correlates with this study finding where

by participants with low social economic status were more distressed than those who had

a higher social-economical status. Further to the above studies, depression alone in

Pakistan, where HIV was almost non-existent, was associated with severe financial and


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housing problems, few years of education, and numerous children (Mumford et. al,

2000).

These findings add on the prior evidence on the role of gender, education, sex, and social

economic status in the emotion wellness among people infected by HIV/AIDS.

Other clinical characteristics associated with psychological distress and status of research hypotheses:

This section discusses the status of the studys research hypotheses and findings on the

relationship between the distress and social clinical factors that are reported to predict

psychological distress.

HIV staging: Unlike most studies in the west, and despite the fact that people who were

in their late/advanced AIDS clinical stages were more distressed than those in their early

stages this directional relationship, this was not statistically significant. In this case werejected the alternative hypothesis for this study. This could explained by the fact that the

staging that were captured during this study were not the recent clinical staging but the

one the PLWAs got when they initially given the diagnosis (staging) and/or being

referred for the ART. Further, this may explain the differences between these study

findings and those in reported by other studies where staging and CD-4 count was

associated with emotional distress (Maj, 1997 & Clesila & Roberts, 2001). For some

participants in this study, some significant improvements had already occurred and this

could mask the AIDS impact on their psychological wellness, since they had improved

from the time of first diagnosis to the time of data collection.


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Duration on ARVs: As shown above, there was no significant difference between

participants who had been on ARVs for less than six and those who had been getting the

life prolonging drugs for more than six months. In this situation we failed to reject the

null hypothesis and reject the alternative hypothesis for this study. The finding may be as

a result of elevated anxiety and distress that is reported to have increase with the HIV

diagnosis and onset of HIV related symptoms respectively (Brown et. Al, 1992 & Kelly

et. Al., 1993). With advent of ARVs and as individuals take the ARVs with time, they

tend to get more hope and the distress levels go down. This is also in consistence with

reports by Burack, Barret & Stall (1993) who reported the relationship between HIV

disease staging among HIV positive gay men over a 5.5-year follow-up.

Availability of psychological support: The findings of this study also suggest that

PLWAs with a confidant do experience more of this buffer as the participants who had noconfidant to provide psychological support, especially those without spouses, were more

distressed than those who had more direct psychological support. With this statistically

significant relationship we rejected the null hypothesis and accepted the alternative

hypothesis for this study. Other studies also suggest that psychosocial support can buffer

the effects of psychosocial and physical stress on individuals (Broadhead et al., 1983;

Cohen & Wills, 1985).

Further to that, understanding that parents and spouses were giving support to their

relatives living with the virus extend our understanding of other people in need of

information about prevention of depression by support PLWAs psychologically like

church groups and other service providers. Further to this, several studies show that lack


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of social support particularly from the spouse or partner is a well-established predictor for

mental health problems, especially when levels of stressful life events are high (Cutrona,

1984; & Paykel, Emms, Fletcher, & Rassaby, 1990). This is reported in the west, where

most research on the prevalence of psychological distress among HIV+ individuals has

been done,.

Support for daily activities: On this factor (variable), we failed to reject the null

hypothesis for rejection of the alternative hypothesis for this study. This is against other

study findings that found that HIV/AIDS was accompanied by substantial impairment in

role as well as physical functioning (OKeefe & Wood, 1996). It would be expected that

support to PLWAs with their daily activities would alleviate the levels of their distress as

was found by Watchtel et. al, 1992). This finding could either be explained by the

discontentment that the PLWAs had from the support they get from the people they

expect to get the support from. On the other hand this may be a manifestation of the lack

of support for these people, which could be as result of prevalent stigma, and

discrimination that may be residual in our societies against the PLWAs.

Disclosure of sero-status and attendance to a support group: The other surprising

finding was when it was found out that there was no statistically significant difference

between participants who did not disclose their sero-status nor indicated to have attended

any HIV/AIDS support groups were more distressed than those who had. For these two

variables we also failed to reject the null hypothesis and therefore rejected the last two

alternative hypotheses for this study.


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As said above, this may be attributed to anxiety that PLWAs may have in disclosing their

status let alone attend an AIDS support group for fear of being stigmatized and at last

discriminated against in the communities. It may also be due to the PLWAs ambivalent

opinions or due to novel beliefs they may have over the benefit of the disclosure or the

support group.

5.3 LOGISTIC REGRESSION: SOCIAL-CLINICAL FACTORS ADJUSTED FOR

AGE, SEX AND SOCIAL-ECONOMIC STATUS:

Outcome of adjusted odds ratios (prevalence ration in cross-sectional studies) at 95%

confidence intervals did not give any statistically significant interaction or confounding

brought by age, sex and social-economic status in the relationships as shown in the table

below:

5.4 POSSIBLE LIMITATIONS OF THIS STUDY:

The main limitations of the study are:

a) Generalisability : the findings of this study may not be generalisable to other settings

as it is only focused in Mzuzu, which is in the northern region of Malawi. Further

this is a specific group of people with a chronic illness (AIDS) and getting ARVs.

b) Causation : It would be very difficult to determine the causal inference on whether

HIV/AIDS preceded the psychological distress as the data was collected at one

point in time. This is because the study was a cross-sectional one, and not a

longitudinal study.


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c) Validity of the measurement tool: The study tool does not measure specific mental

disorders but symptoms of psychiatric morbidity; hence the prevalence herein does

not specify the prevalence of a specific mental disorder. Further SRQ does not

discriminate against other causes of distress and other mental disorders, however it

was used since it the only validated and convenient tool for estimating mental health

problems in Malawi.

d) The other limitation was that a formal inter-rater reliability analysis was not done

in the study. This could have been done, however the questionnaire was highly

structured.

5.5 IMPLICATIONS AND RECOMMENDATION:

With information in the study findings and discussion above, several implications and

recommendation for service providers and policy makers in Malawi and other developing

countries are presented in his section as follows:

(A) Implications for Health practice and education

First, a successful HIV/AIDS intervention program must include the assessment of

mental disorders and their appropriate management as part of the normative service for

PLWAs. There is a need to develop appropriate materials and models for the delivery of


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mental healthcare within the parameters of the 3 by 5 initiative based on the principles

of affordability, acceptability and availability.

The frontline AIDS care providers should be the existing primary healthcare workers and

counselors who have been given additional in-service training in mental health and

relevant materials although caution is needed so that too many functions are not

expected of the same individuals. If this worsens then enhancing referral measures for

patients with mental health problems would improve the situation. Additional skilled

personnel may be essential in certain situations.

Secondly, it is clear that the same problems concerning the detection and treatment of

mental disorders among the physically ill occur in Malawi, as is the case in the West. It is

very likely that the psychological disorders that accompany physical illness are not very

uncommon in our society. They ultimately increase the degree of impairment of daily

function especially among the PLWAs (Wells et. al, 1989) and this may have serious

consequences if it results in a decline in family income and consequent lack of provision

for the rest of the family. The treatment of such problems should therefore be regarded as

a very important aspect of HIV care (Patel, 2003).

Thirdly, whenever possible, an established relationship with local mental health service

providers should be encouraged, to promote a collaborative model of care that includes

supportive supervision and the in-service training, in mental health care, for the AIDS

care workers as well as clearly defined referral pathways to specialist mental health


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services (Freeman, 2005). This would promote integration of mental health in AIDS

programs that help to advance quality of life among the PLWAs.

Fourthly, it appears that the PLWAs who have HIV have numerous psychological

symptoms as well as somatic ones and they would be given a comprehensive care

considerably if they had their mental status examination done promptly and treated for

the underlying mental health problem (OMalley et. al, 1999). This could be considered

on top of the ARVs to ensure a comprehensive management of their co-occurring health

problems.

Lastly, the rate of probable depressive disorder among the women ARV treatment in our

sample was not markedly raised as it was with men but the level of depression generally

among women is high. This means that satisfactory assessment and treatment of

depressive disorders in women is needed at a primary care level or, possibly in the

general population as there may be cultural reasons why they do not present for

treatment. Such treatment is very important if we are to address the burden of depressive

disorder in the developing world (WHO, 1996).

(B) Implications for Research:

This study only investigated the relationship between psychological distress and HIV

among participants aged 18 and above for ethical reasons. Further to this limitation in

focusing on general population most reported data shows that depressive symptoms are


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associated with increased mortality in HIV- older women (Ickovics et. al., 2001) and

influence disease progression among HIV- men (Leserman et. al., 2002). This situation

highlights the need for more such controlled studies among other age groups. Future

studies should consider exploring other groups at increased risk, such as adolescents and

children (Evans et al 2002),

The third implication is the need to support research on mental health and HIV/AIDS.

Since over 90% of the burden of HIV/AIDS is in developing countries, and that little

research in this area emerges from these countries (Freeman, 2005), it is recommended

that the immediate priorities for research must be linked to the new treatment programs

for PLWAs. There is therefore need to conduct larger studies to look at the prevalence of

specific mental disorders not only among the PLWAs but also in the general population.

Future studies should also establish effect and/or presence of the psychological distress at a

time when one is given a positive sero-status in our VCT centers. This study did not explore

this very important variable.

(C) Implications for policy:

Advocacy is needed from a range of stakeholders to highlight the role of mental health in

HIV/AIDS treatment programs. Sadly, our HIV/AIDS policy hardly highlights the need

for such mental health perspectives in the HIV programs that are being rolled out in rural

areas (MOH, 2003). There is need for the government to put in place measures for

providing in-service training on mental health to its workers involved in HIV/AIDS care.


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Implementation of AIDS treatment programs must also include effective alleviation of

psychiatric symptoms and promote the emotional well-being of people living with

HIV/AIDS (Freeman, 2005). Moreover, people accessing HIV/AIDS services must be

given opportunity to access mental health services. Enhancing referrals to mental health

facilities can help in situations where these mental health services are not prioritized by

agencies implementing AIDS treatment programs.

(D) Recommendations:

From the above discussion it is evident that:

i) Health care providers and policy makers should be sensitive to the fact that people

who are infected with HIV do experience a variety of other psychological

problems as well as increased depression and fatigue. However, these debilitating

issues may not be addressed by physical drugs but more appropriately through

therapies that are also non-biological. In the health care setting, this may require

additional psychosocial support and programming, as well as interventions aimed

at reducing fatigue and depression (such as relaxation exercise, group as well as

individual counseling, perhaps anti-depressive medications, and so on).

ii) The study data suggest that improving patients socio-economic status may also

result in improved quality of life. This adds to the need for economically

empowering needy PLWAs (Braitstein et. al. 2005)

iii) The study findings further affirm the importance of recognizing and treating

psychological disorders in PLWAs, to improve their quality of life. Given that a

good percentage of PLWAs use ARV clinics and most PLWAs are distressed, the


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findings (an underestimate of the true prevalence of depression) support a greater

ARV providers role in treating psychological distress among PLWAs. Studies

indicate depression alone diminishes HIV/AIDS treatment effectiveness partly by

reducing the ability of the PLWAs to stay on their medication (DiMatteo, Lepper,

& Croghan, 2000). This study enlightens the providers that the PLWAs require

improved monitoring antiretroviral medication. There is also an

Documents

Charles M Mwale