|Year : 2022 | Volume
| Issue : 2 | Page : 103-108
Prevalence of psychological distress and quality of life among people living with HIV/acquired immunodeficiency syndrome at tertiary health-care center in coastal Karnataka, institutional-based cross-sectional study
AR Hariprasada, HN Shruthi, Akshay Phatak
Department of Dermatology and Venerology, Karwar Institute of Medical Sciences, Karnataka, India
|Date of Submission||16-Jan-2022|
|Date of Decision||11-Mar-2022|
|Date of Acceptance||21-Mar-2022|
|Date of Web Publication||26-Aug-2022|
H N Shruthi
G5, Staff Quarters, Karwar Institute of Medical Sciences, Karwar, Karnataka
Source of Support: None, Conflict of Interest: None
Background: With increase in cases of HIV, in addition to the direct effect of HIV, the social stigma causes psychological distress in people living with HIV/AIDS (PLWHA). With improvements in antiretroviral therapy (ART), HIV has become a chronic disease, which increases the incidence of other psychiatric comorbidities. Objectives: To assess the predisposing factors causing psychological distress and to assess the quality of life (QOL) in people living with HIV. Materials and Methods: A total of 380 patients who visited ART center in a Coastal Karnataka tertiary health-care center were included in this study. They were given questionnaires, which included World Health Organization-QOL-Bref, HAM-Depression, MOS-social support survey, perceived stress scale (PSS), and substance abuse. Result: Out of 380, the prevalence of psychological distress in patients with HIV/acquired immunodeficiency syndrome (AIDS) was 30.5%. The mean of the total QOL scores was 78. Prevalence of poor QOL in patients with HIV/AIDS was 1.58%. About 5.8% were mild or moderately depressed. Only 0.5% were found to be with severe depression. There was no statistically significant substance abuse among PLWHA. Conclusion: PLWHA who were in the age group of 30–60 years, illiterate, those with history of alcohol abuse, and having lower QOL scores and high scores in PSS had increased odds of psychological distress. Thus, concerned medical fraternity should collaborate on integrating HIV/AIDS treatment services with mental health services. Future interventions are needed to improve the level of social support and psychological support to the people living with chronic illnesses like HIV/AIDS.
Keywords: Acquired immunodeficiency syndrome, HIV, psychological distress, quality of life, social support
|How to cite this article:|
Hariprasada A R, Shruthi H N, Phatak A. Prevalence of psychological distress and quality of life among people living with HIV/acquired immunodeficiency syndrome at tertiary health-care center in coastal Karnataka, institutional-based cross-sectional study. Clin Dermatol Rev 2022;6:103-8
|How to cite this URL:|
Hariprasada A R, Shruthi H N, Phatak A. Prevalence of psychological distress and quality of life among people living with HIV/acquired immunodeficiency syndrome at tertiary health-care center in coastal Karnataka, institutional-based cross-sectional study. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 25];6:103-8. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/103/354744
| Introduction|| |
Currently, worldwide, 37.7 million people are living with HIV (human immunodeficiency virus). With antiretroviral therapy (ART), the disease progression has been significantly reduced. This, in turn, makes HIV a chronic disease. Despite these improvements, HIV still has a notable impact on quality of life (QOL).
In addition to the direct effect of HIV and the effect of social stigma that causes psychological distress in people living with HIV/AIDS (PLWHA), the ART side effect may additionally be a predisposing factor for the development of these problems. Therefore, the present study attempted to assess the prevalence of psychological distress, substance abuse, and QOL among PLWHA (acquired immunodeficiency syndrome [AIDS]) at ART centre in Coastal Karnataka, India.
| Materials and Methods|| |
This research project was reviewed and approved by the respective Ethics Committee. This study did not involve any intervention. All the information about the participants were kept confidential.
The institution-based cross-sectional questionnaire-based study design was employed to determine the magnitude of and identify factors associated with psychological distress among HIV/AIDS patients at District Hospital, Coastal Karnataka.
All the patients who were visiting the ART Centre at District Hospital during the research period (July–August, 2021), who gave consent to be a part of this study.
All patients with HIV above 18 years who were willing to answer the questionnaires and were willing to be a part of the study by signing the informed consent were included.
People with existing central nervous system involvement as suggested by case sheets. People with severe illness and not able to answer the questionnaires were excluded.
The sample size was determined by using a single population proportion formula. The assumptions considered will be (Z/2), which is the standardized normal distribution value for the 95% confidence interval (CI) (1.96), the proportion of psychological distress (P) taken as 34% with the marginal error (d) of 5%. Moreover, considering 10% of the nonresponsive rate, the total sample size calculated was 380. Consecutive sampling technique had been employed to recruit study participants.
n = Z2pq/ε2 = (1.96) 2 (0.34)(0.66)/(0.05) 2 = 344
N = n/(1-d) = 344/(1 − 0.1) = 380.
- HIV-QOL-bref by World Health Organization (WHO)
- MOS social support survey
- Perceived stressed scale (PSS)
- Hamilton depression scale (HAM-D).
- The alcohol used disorders identification test (AUDIT)
- Fagerstrom test for nicotine dependence (FTND).
Patients who visited the ART centre to receive treatment were given questionnaires (1–5) along with participant consent form. They were free to answer the questionnaire. To know the extent of substance abuse if present, 6th and 7th questionnaires were provided.
All questionnaires were first prepared in English and then translated into the regional language, Kannada. The tools had been administered by a trained nurse and investigators by face-to-face interview techniques. These include the following:
- Sociodemographic factors: Residence, age, sex, marital status, educational level, and employment status
- HIV-QOL bref by WHO: This questionnaire had been used to assess the standard and QOL leading by the patients. Response categories range from 1 to 5. Summative composite scores were created for QOL (range: 31–155)
- Psychosocial factors:
- Perceived stressed scale: The 10-item PSS had been used to assess the degree to which situations in life were perceived as stressful. The possible response ranges from 0 (never) to 4 (very often). PSS scores were obtained by reversing responses to the four positively stated items and then summing across all items. Individual scores on the PSS could range from 0 to 40, with higher scores indicating higher perceived stressed
- Social support index: Constructed from 19 functional support items and used to measure five dimensions of social support: (1) Emotional support, (2) informational support. (3) Tangible support (the provision of material aid or behavioral assistance), (4) positive social interaction, and (5) affectionate support. Response choices were as follows: 1-none of the time, 2-a little of the time, 3-some of the time, 4-most of the time, and 5-all of the time
- Hamilton depression scale:  this questionnaire was used to assess the extent of depression suffering by the patients. Response categories ranged from 0 to 4 depending on questions, choices had been given. Summative composite scores were created for QOL (range: 0–85) (the higher the score, the higher extent of depression).
- Substance abuse scaling: Assessment of level of substance abuse by the patients
- The AUDIT is a 10-item screening tool developed by the WHO to assess alcohol consumption, drinking behaviors, and alcohol-related problems. Response categories ranged from 0 to 4
- FTND: Used to assess the extent of smoking, contains 6 item screening tools. Score ranges from 0 to 10. Higher the score, higher the extent of smoking.
- ART side effects: Refers to whether the participant experienced any side effects from ART
- CD4 cell count: The patient's recorded was reviewed to obtain recent CD4 cell count. In this study, the CD4 cell count was used to classify the patients into three categories; <200 cells/mm3-severe deficit, 200–499 cells/mm3-moderate deficit, and >500 cells/mm3-mild deficit.
The data had been analyzed using the SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed as frequencies and proportions. Mean, standard deviation, and range had been calculated for all continuous variables including Questionnaires scores. After univariate analysis, the variables, which had significant P values, had been taken for multivariate analysis to adjust for confounding variables. The Chi ratio had been calculated with 95% CI using the binomial logistic regression. The values of P < 0.05 were considered statistically significant.
| Results|| |
Out of 380 participants, the study included 177 (46.6%) males and 203 (53.4%) females. Higher proportions of participants were of the age group 30–45 (43.9%) and 45–60 (46.8%). Over 63.2% (240) were married and 36.8% of people did not have the support from partners. 33.1% (126) of the participants were literates. Regarding their occupation, approximately half of the PLWHA are semi-skilled workers (51.1%). According to CD4 count, majority, 317 (83.4%), had mild deficit. Approximately 4% (15) of PLWHA experienced side effects of ART. About 95.5% (363) were currently nonalcoholic. Similarly, 97.7% (370) were currently nonsmokers [Table 1].
|Table 1: Psychological and social characteristics of the study participants:(original)|
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Out of 380 participants, 116 (30.5%) were found to be having psychological distress. About 1.6% of the study participants had poor QOL.
Regarding social support, 15% (57) participants had social support all the time, 35.3% (134) had social support most of the time, 31.1% (118) had social support some of the time, 14.7% (56) participants had social support little of the time. 4% (15) participants had social support none of the time.
Regarding depression, 5.8% (22) were mild or moderately depressed. Only 0.5% were found to be with severe depression.
Majority of participants were experiencing moderate stress (58.9%). Regarding nicotine dependency, 14 (3.7%) participants were highly dependent on nicotine. Over 2.1% (8) participants were found to have alcohol dependency [Table 2].
|Table 2: Association of psychological distress in people living with human immunodeficiency virus with different variables (original)|
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Prevalence of psychological distress in patients with HIV/AIDS is 30.5%. Psychological distress in PLHIV/AIDS is significantly associated with old age (P = 0.017), illiteracy (P = 0.019), and side effect of ART (P = 0.011), which indicates that younger age people who were literates have less chances of getting psychological diseases. Psychological distress is lesser in people with good quality of living and social support. The extent of depression (P = 0.024), perceived stress (P < 0.001), and alcohol use (0.034) had direct association with psychological distress and QOL of the HIV/AIDS Patients. CD4 count had lesser impact on psychological distress (P = 0.052).
In the QOL assessment, the mean of the total QOL scores was 78. Prevalence of poor QOL in patients with HIV/AIDS is 1.58%. There was a statistically significant association between QOL and severe depression (P < 0.001) and side effects experienced due to ART (P < 0.001). This depicts that the PLWHA with depression and experiencing side effects of ART had more chances of getting poor QOL. There was a statistically significant association between QOL and good social support (P = 0.007).
According to MOS scores, PLWHA who were living with partner had good social support (P < 0.001). In addition, people who were getting good social support had experienced low stress (P < 0.001). Any person living with HIV/AIDS who did not get any social support had 12.261 times (odds ratio [OR] = 12.261 with P = 0.026) more chances of getting psychological distress as compared to anyone who got social support.
Regarding the HAM-D assessment, there was a statistically significant association between depression and side effects experiencing due to ART (P < 0.001), this shows that the side effects of ART can cause depression. There was a significant association between depression and nicotine dependency (P = 0.005); nicotine dependency had increased the chances of depression in PLWHA.
In the PSS, there were 61% of the participants experienced moderate to severe stress. There was a significant association between stress and unemployment in the PLWHA (P < 0.001). Participants with skilled work experience less perceived stress compared to unemployed and semi-skilled person [Graph 1].
CD4 count had no significant association with QOL (P = 0.876), perceived stress (P = 0.061), and depression (P = 0.689).
| Discussion|| |
Majority of participants were middle aged (90%), which is in accordance with the previous studies where majority of patients belongs to 35–45 years. Majority of the participants were females, as in accordance with previous studies.
The prevalence of psychological distress in our study was 30.5%, there was wide variation in the prevalence of psychological distress among previous studies.
A study done by Basha et al. in 2019 showed the prevalence of psychological distress among PLWHA was 7.8%. In a similar study done in Athena, Amsterdam had a prevalence of 9.7%. In contrast to the previous studies, the study done by Kamath et al. in 2014, the prevalence of psychological distress was 68.3%, according to the GHQ12 scale. The wide variability among previous studies can be attributed to the different types of questionnaires used and also due to regional and cultural variation across the world. As in our study, we have used the standard WHO QOL-bref questionnaire.
The prevalence of psychological distress was calculated using the score of the psychological domain, which was 30.5%. Psychological distress showed a statistically significant correlation with severe depression, alcohol dependency and severe perceived stress and positive correlation with good social support in multivariate statistical analysis with binary regression. However, there was no statistically significant association with regard to gender. The previous studies showed significant preponderance in the female gender.
In our study, there was a significant association between illiteracy and psychological distress, which is in accordance with a previous study by Basha et al. Participants with better education had the lesser extent of psychological distress. Association may be due to lack of knowledge and awareness, which will lead to delay in diagnosis and management of psychological distress. There was a significant association between psychological distress and alcohol consumption; this is again in accordance with studies conducted in the Netherlands, Uganda, and Gondar. Association between alcohol and psychological distress may be attributed to the effect that alcohol causes on different parts of the brain. This is responsible for memory, decision, and judgment, all of which could lead to increase in psychological distress.
In our study, there were good QOL scores in social, environmental, and level of independence domains but poor scores in psychological and physical domains. Which is in contrast to the study done in 2019 by Sarkar et al. where they found that there were good QOL scores in physical, psychological, and environmental domains but poor social domain scores. The mean scores of physical, psychological, social relationship, and environmental domains in our study were 55, 65, 70, and 75, whereas mean scores in the study of Sarkar et al. are 56, 63, 48, and 51, respectively. This shows that there is a significant difference in social and environmental QOL scores with respect to our study. This may be attributed to the regional and cultural variation between these studies.
Our study showed that good QOL decreases the probability of depression in PLWHA, which is in accordance with a study done in 2019 by Shriharsha and Rentala.
Any person living with HIV/AIDS who got no social support has 12.261 times (OR = 12.261 with P = 0.026) more chances of getting a psychological distress as compared to anyone who got social support. This shows that good social support decreases the incidence of psychological distress. There was a statistically significant association between good social support and low perceived stress and lower nicotine dependency. This may be attributed to the effect of stress hormones that trigger a fight or flight response. This, in turn, decreases social harmony and support. There were no previous studies regarding social support and perceived stress to compare the results.
The association between Perceived stress and occupational status may be attributed to the heavy workload, tight deadlines, and work responsibilities, which can be the reason for stress and anxiety.
There was a significant association between depression and Nicotine dependency. Association of nicotine dependency and depression may be attributed to the effect that nicotine stimulates the release of dopamine in the brain. Dopamine is involved in positive feelings. It is often low in depressed people, who may use nicotine to temporarily increase their dopamine supply.
The strength of this study is the fact that it has enrolled a statistically significant number of study participants. This helps to ensure the representativeness of the study results throughout the PLWHA. In addition, we measured various variables that affect psychological distress, such as perceived stress, social support, and QOL. We also measured the QOL and its association with many variables like psychological distress. We evaluated the QOL under different domains. This study also tried to interpret the importance of social support in QOL and its association with alcohol and nicotine abuse. There were no previous studies regarding social support, this study tried to evaluate social support among PLWHA.
However, the results of this study should be considered with the following methodological limitations in mind: One of the drawbacks of this study could be memory bias, but we tried to minimize it, by including questions of recent past (2 weeks). In addition, we evaluated substance abuse only under alcohol and nicotine dependency, but without considering the substance abuse like various pain medications and illegal drugs, might have resulted in an underestimation of the strength of association with the outcomes.
| Conclusion|| |
The prevalence of psychological distress was high as compared to other studies. As the problem is relatively high, it has affected the QOL of PLWHA and their families. Being old age, illiterate, alcohol abuse, and having lower QOL scores and high scores in PSS increased the odds of psychological distress. Thus, concerned medical fraternity should collaborate on integrating HIV/AIDS treatment services with mental health services. Behavioral change intervention is mandatory to reduce risk behavior like alcohol and nicotine usage.
Our findings also imply that future interventions are needed to improve the level of social support and psychological support to the people living with chronic illnesses like HIV/AIDS. This, in turn, improves the QOL among HIV/AIDS. Further studies are needed to evaluate the different aspects of psychological distress, social support, and stress management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
ICMR funded under the STS program.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]