Title: Factors Contributing to Depression in People with HIV Seeking Treatment at Gondar
University Hospital and an Exploration of a Possible Intervention
Student Name:
Committee Chair:
Meheret Endeshaw
Master of Public Health Candidate
SCOPE Fellow
Department of Global Health
University of Washington
Deepa Rao (MA, PhD)
Research Assistant Professor, Global Health
1
Background
The prevalence of HIV/AIDS in Ethiopia is 2.4 (1). This is considered a low level generalized
epidemic (2). However, HIV/AIDS has varying effects in different regions of the country. In 2006,
it was reported that the Amhara region had the highest prevalence of HIV with a cumulative
rural and urban prevalence of 15% and 5.9%— a rate that is 50% higher than the national
prevalence (3). Ethiopia is divided into eleven regions, and as of 2010, the Amhara region has
the highest number of people living with HIV/AIDS at 379,096 (1).
Mental health is highly intertwined with communicable diseases such as HIV (4). Not only do
mental disorders such as schizophrenia and depression put people at a higher risk for
contracting HIV, living with HIV and its accompanying stigmatization can lead to poor mental
health outcomes (5). Depression is the one of the most common mental health disorders people
with HIV experience (6). One meta-analysis looking at the relationship between HIV infection
and risk of depressive disorders found that living with HIV posed a greater risk of having major
depressive disorder (7). Furthermore, co-morbidity of mental illness and HIV lead to poor
healthcare seeking patterns, diagnosis, and treatment (4). In a study investigating the effect of
psychological factors on antiretroviral (ART) uptake, depression was highly associated with poor
ART adherence (8). The interrelatedness of mental health and HIV make it important to
consider adherence interventions that address both issues simultaneously. Especially in
developing countries where mental health facilities are underdeveloped, HIV is an epidemic,
and factors such as poverty exacerbate mental health problems.
Orthodox Christianity is one of the predominant religions in the country. In the Amhara region—
where the current study will take place—43.5% of the residents identify themselves as followers
of the Orthodox Church (9). Gondar is viewed as the epicenter of Orthodox Christianity and
consists of 2,200 churches within the North Gondar Diocese (10). Studies looking at the
utilization of health services in Ethiopia have found that nearly 50% of terminally ill patients turn
to religion for help (11) (12). Additionally, it was found that 24% of patients with TB received
religious related treatments such as holy water before coming to health facilities (13).
Furthermore, Ethiopians in many communities often interpret mental illness as the result of
possession by evil spirits (14). Hence, the most common means of dealing with mental illnesses
consist of religious rituals that involve drinking holy water, exorcism through prayer, traveling to
remote churches in search of a cure, and wearing amulets made by religious leaders.
As these examples show, Ethiopians turn to religion in times of illness. This is because religious
leaders have an important place and because religion is a large part of the Ethiopian identity
(15). Thus, the current study is interested in exploring the contextual relevance combining
medical and religious (Ethiopian Orthodox Church) efforts to better the lives of PLWHA by.
Organizations such as UNICEF have recognized the importance of involving the religious
leaders in places where religion is part of people’s identity. Religious leaders in some areas
want to join the fight against HIV/AIDS because it is a disease that affects people spiritually,
economically, socially, and physically (16). Various communities have utilized religious leaders
to address issues related to HIV/AIDS. For example in Uganda, imams from the Islamic church
are using Koranic information to talk about sexual ethics and integrity during religious sermons.
They also use Koranic verses during counseling sessions (17). In Jimma Ethiopia, a study that
worked with religious leaders from the Orthodox and Muslim communities found that religious
leaders are willing to educate people about HIV/AIDS following training. They also found that
the majority of leaders believed that PLWHA are part of the community and deserved attention
from religious leaders (15).
The interrelatedness of HIV with mental illness and Ethiopians’ faith in the curative power of
religion for various illnesses make it appropriate to find ways of integrating the religious
community with the care of PLWHA to improve their health outcomes. Since depression in
PLWHA has serious ramifications for patients’ adherence to medications, we want to evaluate
2
depressive symptoms in PLWHA receiving ART treatment. Furthermore, we want to identify
factors that might lead to depression in this setting. Studies in other locations have found that
depression in PLWHA is associated with stigma and lack of social support (18). Thus, the
current study will investigate, if stigma and lack of social support are contributing factors for
depression in PLWHA seeking treatment at GUH. The current study also aims to explore the
contextual relevance involving religious leaders to improve health outcomes for PLWHA.
Assessing depression, factors related with it, and patients’ feelings toward involving religious
leaders will inform the development a contextually appropriate approach to improve the lives
PLWHA.
General Objective
The general objective of this study is to determine factors that are associated with depression
and exploring a contextually relevant approach to ultimately achieve better treatment outcomes
for patients living with HIV/AIDS.
Specific Study Questions
Does stigma predict depression among people with HIV seeking treatment at Gondar University
Hospital clinics?
How do PLWHA view the role of religious leaders in addressing psychosocial factors associated
with HIV?
Conceptual Framework
Correlates of depression include stigma, social support, and demographic factors. This study
will focus on the association between depression and stigma. This understanding coupled with
patients’ feelings towards using religious leaders to improve health outcomes for PLWHA can
facilitate the development of a program that integrates the religious and medical community in
way that improves treatment outcomes (i.e. adherence).
Stigma
Demographic
factors (i.e.
marital status)
Depression
Social Support
(i.e. religious
leaders)
3
Methods
Study Design
This is a mixed methods study (qualitative and quantitative). Depression and stigma of
HIV/AIDS will be evaluated using standardized measures which will produce quantitative data.
The view of patients about the role of religious leaders in this context will be assessed through
semi-structured questions. These semi-structured questions will be analyzed using qualitative
methods
Study Population
Gondar University Hospital (GUH) is located in the town of Gondar in the Amhara Regional
State of Ethiopia. GUH is the region’s premier teaching hospital and is the referral hospital for
the region. With the support of the International Training and Education Center on Health (ITECH), the hospital opened the area’s first ART clinic, which began offering ART services in
March, 2002. Since its inception, 8,049 patients have been enrolled in HIV care and support
programs and 5,333 have been enrolled in ART. There are currently 3,260 patients receiving
ART. The target population for the current study is patients receiving ART treatment at GUH
ART clinic.
Inclusion Criteria
- Patients on ART from the GUH ART clinic who have a routine appointment during the
two months of the study
- Patients that are 18 and up
Exclusion criteria
- Patients less than 18 years of age
- Patients who have not started taking antiretroviral treatment (ART)
- Women starting short-course ART for the sole purposes of prevention of mother-to-child
transmission
Sampling Strategy and Recruitment
The sampling population will be people who are HIV positive and on ART coming for their
routine appointment at Gondar University Hospital ART clinic. Patients who have a routine
appointment in the duration of the study period will be approached by someone who has had
regular contact with the patients’ course of treatment (ex. ART clinic’s nurse, case manager, or
the lead ART physician). Those involved directly in subject recruitment will not be involved the
actual data collection. The approaching party will use the following script and further taking
points if necessary to explain the purpose and procedure of the study to ask the subjects to
participate.
Recruiter: (nurse, case manager, or physician): Glad to see you here for your routine
appointment. I would like to invite you to participate in a research study working to increase
collaboration between religious leaders and medical personnel to improve care for PLWHA. This
study is conducted by researchers from the University of Gondar, and the University of
Washington – in America. You have been selected for inclusion in the study. Your participation
in this study would be entirely voluntary and you can decide to withdraw yourself from the study
procedure at any time. Your participation in this study would involve participating in a recorded
interview. There is no follow-up to this study, and after the one time interview your participation
in the study will have ended. Are you willing to take an hour of your time to participate in this
study? The investigator or I can answer any questions you might have to make your decision
about participating.
4
-
If response is Yes: Thank you so much, I appreciate your willingness to help. Let me
introduce you to the researcher.
If response is No: Thank you so much it is fine that you are choosing to decline the
interview. We respect your decision.
Data Collection Strategy
Socio-demographic information such as religion, source of income, and marital status will be
collected. Depression will be measured using the Patient Health Questionnaire (PHQ-9)
depression scale. This is one of the most widely used scales across cultures and has been used
in Ethiopia to measure the depression in populations such as college students who witness
gender based violence growing (19) up and women in college who experience gender based
violence (20). The instrument will be translated to the native language of the subjects (Amharic)
by a medical translator in Seattle and by the investigator. Then it will be back translated to
ensure that the content is retained. Stigma will be measured using 4 items from the stigma scale
for chronic illness (SSCI) (21). Two questions will assess perceived stigma and two questions
will assess internalized stigma. Patients’ self-reported adherence to HIV/AIDS medication will be
measured with five questions that have been used in other studies (22). Social support and
subjects’ feelings about involving religious leaders in their care will be assessed using semistructured questions. A complete list of all the questions described is attached to the application.
Basic Data analysis plan
Quantitative
All interviews will be conducted in Amharic. The PHQ-9 and the stigma measure will translate to
Amharic with same scaling system. Thus, participant responses to the PHQ-9, stigma scale,
social support questions, and the socio-demographic questions will be interned into quantitative
data analysis software. A regression will be used to assess the relationship between stigma and
depressive symptoms.
Qualitative
Using the interview recordings with subjects, the religion related semi-structured portion of the
interview will be translated and transcribed in English. Participant identifier information will be
removed during the translation and transcription process. Data analysis will begin once
interviews have started. Starting qualitative data analysis at an early stage will help inform future
interviews. Content analysis will be the main form of analysis. This means that investigator will
read and review the transcripts several times and look for concepts and ideas that emerge and
reoccur throughout interviews with patients. Ideas and concepts that emerge will be coded and
categorized.
Sample Size
We used G power to estimate sample size (23). With power set at 80% and a two-sided
significance level (alpha) of 0.05, we will need a sample size of 55 to detect an effect. We used
an effect size (f2) of 0.15 in our calculations, which Cohen defined as a medium effect size (24).
Pilot Study
The study will be piloted with 5 non-patients native Amharic speakers to see if the translated
instruments measure their intended construct.
5
Consent and Institutional Review Board
Risks of participating in this study include accidental breach of confidentiality. Subjects may
experience stress or discomfort at being asked questions of a personal nature regarding their
experience of depressive symptoms and their experiences as PLWHA. Because HIV/AIDS and
mental health issues can be stigmatized conditions, it is possible that subjects may have
negative emotional reactions to some of the questions on the survey. All subjects participating in
this study will have already known their HIV+ status. The co-morbidity of mental health issues is
expected in some patients. All participants who exhibit active suicidal ideation will have follow
up care from a physician.
Once participants agree to participate in this study during the recruitment process, they will be
introduced to the investigator. The investigator will further explain the nature of the study and let
participants know that they can change their mind about their participation at any time during the
interview process. The investigator will answer any questions that a participant may have and
after answering all questions will proceed to the questions. The introductory statement that the
investigator will use is attached to the application.
This study will only be carried out once IRB approval has been received from the University of
Washington and Gondar University.
6
Tentative Timeline
M1 M2
M3
Activity
May June July
Submit proposal for
ethical approval to
X
UW & GUH IRB
Translate
oral
consent
form
content
and
questionnaires
to
Amharic
Develop relationship
with GUH staff & at
the Dioceses
Conduct pilot study
at GUH & make
necessary revisions
to study instruments
& questions
Patient recruitment
and interview with
patients that have
appointments
Ongoing
data
analysis
finish any additional
interviews/data
gathering that needs
to be completed
Translate
&
transcribe interviews
Code
transcribed
qualitative data
Manuscript write up
M4
Aug
M5
M6 M7
Sept Oct Nov
M8 M9 M10
Dec Jan Feb
M11
Mar
M12
April
M13
May
X
X
X
M14
June
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Submit thesis
7
Funding
This research is funded by an ongoing project, Strengthening Care Opportunities through
Partnerships in Ethiopia (SCOPE). SCOPE is collaboration between the University of
Washington Department of Global Health, University of Presbyterian Church in Seattle, and the
University of Gondar in Ethiopia.
Dissemination
Knowing what factors contribute to depression in people living with HIV/AIDS can inform
programming and counseling in this population. Increased understanding of the factors
associated with depression in patients who are HIV+ will help improve service delivery and to
provide additional support to at-risk patients, thereby minimizing the impact of these poor
outcomes and improving quality of life for patients. The Ministry of Health and other
organizations can use these finding to partner with the influential Orthodox Church to better help
patient suffering from HIV and mental health conditions. The results of this research can also be
used to empower religious leaders to be more involved in helping their perishners who may be
experiencing mental health problems. Furthermore, if the involvement of religious leaders in
addressing mental health in PLWHA is successful, this model can be adapted to other religions
in the country. Additionally, the findings of this research can be used to influence policy makers
to develop the most appropriate and effective policies for PLWHA and factors that affect them.
8
Sources
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
National Factsheet. AIDS in Ethiopia Main Indicators 2010- National. Retrieved May 3,
2011 http://www.etharc.org.
USAID Ethiopia HIV/AIDS Health Profile. Retrieved May 2, 2011 from
http://www.usaid.gov/our_work/global_health/aids/Countries/africa/ethiopia.pdf.
AIDS in Ethiopia Technical Report. Amhara HIV/AIDS Prevention & Control
Secretariat: HIV Facts & Figures-Amhara 2006 . Retrieved May 7, 2011 from
http://www.etharc.org.
Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without
mental health. The Lancet 2007;370(9590):859-877.
WHO. World Health Organization Mental Health and Poverty Project: Mental health and
development, targeting people with mental health conditions as a vulnerable group 2010.
Retrieved November 11, 2010 from
www.who.int/entity/mental_health/policy/mhtargeting/en/index.html. In.
Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS Rep
2008;5(4):163-71.
Ciesla J. Meta-Analysis of the Relationship Between HIV Infection and Risk for
Depressive Disorders. In: Roberts J, editor. American Journal of Psychiatry; 2001. p.
725-730.
Gordillo V, del Amo J, Soriano V, Gonzalez-Lahoz J. Sociodemographic and
psychological variables influencing adherence to antiretroviral therapy. AIDS
1999;13(13):1763-9.
Ethiopian Central Statistical Agency (CSA) Population and Housing Census of 2007.
Retrieved May 1, 2011 from
http://www.csa.gov.et/surveys/Population%20and%20Housing%20Census%201994/surv
ey0/index.html.
Berkely Center for Religion, Peace and World Affairs: Georgetown University. A
Discussion with Nigussu Legesse on Efforts of the Ethiopian Orthodox Church. Interview
conducted June 21, 2008. Retrieved from
http://berkleycenter.georgetown.edu/interviews/a-discussion-with-nigussu-legesse-onefforts-of-the-ethiopian-orthodox-church
Tessema B, Biadglegne F, Mulu A, Getachew A, Emmrich F, Sack U. Magnitude and
determinants of nonadherence and nonreadiness to highly active antiretroviral therapy
among people living with HIV/AIDS in Northwest Ethiopia: a cross-sectional study. In:
AIDS Res Ther. England; 2010. p. 2.
Reniers G, Tesfai R. Health services utilization during terminal illness in Addis Ababa,
Ethiopia. In: Health Policy Plan. England; 2009. p. 312-9.
Mesfin MM, Newell JN, Walley JD, Gessessew A, Madeley RJ. Delayed consultation
among pulmonary tuberculosis patients: a cross sectional study of 10 DOTS districts of
Ethiopia. BMC Public Health 2009;9:53.
Alem A. Human rights and psychiatric care in Africa with particular reference to the
Ethiopian situation. In: Acta Psychiatrica Scandinavica; 2000. p. 93-96.
Feiruz S, Mirgissa K. The Role of Religious Leaders in HIV/AIDS Prevention, Control,
and Patient Care and Support: A Pilot Project in Jimma Zone. Northeast African Studies
2000;7(2):59-79.
9
16.
17.
18.
19.
20.
21.
22.
23.
24.
UNCIF. What Religious Leaders Can Do about HIV/AIDS: Action for Children and
Young People. Retrieved May April 22, 2011 from
http://www.unicef.org/adolescence/files/Religious_leaders_Aids.pdf.
Kagimu M, Marum E, Wabwire-Mangen F, Nakyanjo N, Walakira Y, Hogle J.
Evaluation of the effectiveness of AIDS health education interventions in the Muslim
community in Uganda. AIDS Educ Prev 1998;10(3):215-28.
Li L, Lee SJ, Thammawijaya P, Jiraphongsa C, Rotheram-Borus MJ. Stigma, social
support, and depression among people living with HIV in Thailand. AIDS Care
2009;21(8):1007-13.
Nicodimos S, Gelaye BS, Williams MA, Berhane Y. Associations between witnessing
parental violence and experiencing symptoms of depression among college students. East
Afr J Public Health 2009;6(2):184-90.
Gelaye B, Arnold D, Williams MA, Goshu M, Berhane Y. Depressive symptoms among
female college students experiencing gender-based violence in Awassa, Ethiopia. J
Interpers Violence 2009;24(3):464-81.
Rao D, Choi SW, Victorson D, Bode R, Peterman A, Heinemann A, et al. Measuring
stigma across neurological conditions: the development of the stigma scale for chronic
illness (SSCI). Qual Life Res 2009;18(5):585-95.
Rao D, Feldman BJ, Fredericksen RJ, Crane PK, Simoni JM, Kitahata MM, et al. A
Structural Equation Model of HIV-Related Stigma, Depressive Symptoms, and
Medication Adherence. AIDS Behav 2011.
Google search for G power Retreived May 17, 2011 from http://www.psycho.uniduesseldorf.de/aap/projects/gpower/.
Cohen J. A Power Primer Psychological Bulletin 1992;112(1):155-159.
10