Health-related Quality of Life Among People Who Inject Drugs on Methadone Assisted Treatment in Zanzibar, Tanzania

Background: The burden of drug use is growing rapidly in Low- and Middle-Income countries (LMICs) with access to coastlines and most major cities;Tanzania is not exception. Methadone Assisted Treatment (MAT) has a potential to reduce addiction and therefore health and quality of lives. MAT is known to improve health related quality of life and it is essential in addressing a number of drug use related challenges among People Who Inject Drugs (PWIDS). Evidence on the proles of Health Related Quality of Life (HRQOL) among PWIDS who are in treatment programmes particualry MAT services, is scanty in Zanzibar, Tanzania, Objectives: To determine HRQOL and associated factors among PWIDS receiving MAT Services in Zanzibar, Tanzania. Methods: This was a cross-sectional study conducted in Unguja, Zanzibar from July to August 2019. A total of 376 PWIDS attending Kidongo Chekundu MAT clinic were randomly selected and enrolled in the study. Data were electronically collected using Open Data Kit (ODK) programme during face-to-face interviews with PWIDS HRQOL was measured using the WHO's Quality of Life questionnaire Descriptive and binary logistic regression analyses were used to describe and determine factors independently associated with HRQOL. Results: Of the 376 PWIDS enrolled in this study, Vast majority (92.6%) were male. The mean age of participants at enrollment was 39 (± standard deviation (SD) 8.9). Slightly more than one third (45.5%) were single, 56.4% have a secondary school education level. Slightly more than two third (82.7%) were employed, 42% reported living at Magharibi B districts. High proportion were on MAT services for more than one year (70.2%); had good adherence to MAT services (79%), and were receving 50 – 99 mg of methadodone dose per day (51.1%).The majority of PWIDS (82%) had of high HRQOL. Employed PWIDS [AOR=5.36; 95%CI (1.51, 19.04); PWIDS who were in the middle wealth quintile


Background
The burden of drug use is growing rapidly in LMIC with access to coastlines and other major cities,Tanzania is not exception. Geographical locations and regions with a growing burden of drug use in Tanzania include regions of Zanzibar, Dar es salaam, Tanga, and Arusha (1). Opioid addiction, especially heroin is a major drug problem in Zanzibar. This is due to the fact that, for many years Zanzibar has been an important sea route of the heroin smuggled from Asia to Europe and North America. As a result, it is available in streets at a very low price (around 1$ TZS2,300/=) per unit, a lower price and easily accessed compared to alcohol, owing to religious and traditional beliefs in Zanzibar (2)(3)(4)(5). Such easy access has led to an increasing number of PWIDS in Zanzibar i.e. about 3200 in 2019, resulting to high burden of drug related problems including blood borne infections such as HIV (11.3%) and Viral Hepatitis(HCV − 25% and HBV − 5.9) compared to the general population [(blood transfusion donors up to 2.4% for HBV) and those enrolling to armed forces and therefore tested up to 3.4% in HBV)] in Zanzibar. (4, 6, 7). Strada et al.; 2019 reported substantially lower HRQOL in OST patients, especially in their mental HRQOL. MAT services can support further improvement, particularly with regard to mental health services among PWIDs. Clinicians may consider the use of patient-reported outcome measures to identify patients' subjective physical and psychological needs. It has also recommended that further research is needed to determine if employment is a cause or consequence of improved HRQOL (8). Moreover, Fiona et al.; (2018) reports lower QOL in the physical health and psychological domains among clients in Hong Kong (9) In addition, intravenous drug use (IDU) reported to increase the risk of HIV and Hepatitis infections through a number of high risk practices and behaviors. These include needle sharing, blood contamination and sharing, and other risky sexual behaviours (10,11) which are among the important drivers of such epidemics and increasing among PWIDS globally. The World Health Organization (WHO) recommended the use of methadone for the purpose of reducing incidence of HIV and co-infections associated with HIV such as Hepatitis, Tuberculosis, and other blood born infections (4,6,7,12), with proven effects on both physical and mental health (4). To address the growing burden of drug use and the effects thereof, Tanzania introduced Methadone Assisted Therapy (MAT) as a harm reduction stretagy in 2011. This has been proven effective in reducing the prevalence of opioid addiction (4,13).
Similar efforts have been reciprocated in Zanzibar in February 2015 whereby the rst MAT clinic was established at Kidongo Chekundu.
The coverage of HIV and HCV prevention, treatment and care services against drug use for PWIDS remain low in Zanzibar which create a demand to improve these services (10). Owing to socio-demographic disadvantages, and addiction challenges, PWIDS are often involved in crime and other illegal behaviours (14). All these put Health Related Quality of Life (HRQOL) at jeopardy and therefore, impair the effectiveness of any intervention in their health. There is limited data on HRQOL among PWIDS who are on MAT services in Zanzibar. This study aimed at examining HRQOL and its associated factors among PWIDS who attend MAT clinic in Zanzibar, Tanzania.

Study setting and design
This was a cross-sectional study conducted from 5th July to 2nd August 2019 at Kidongo Chekundu MAT Clinic in the Urban district of Unguja Island in Zanzibar. This is the only clinic which currently provides comprehensive MAT services to PWIDS in Zanzibar. More than 500 PWIDS attend and receive care every day in this facility. While there are about 3,200 documented PWIDS in Zanzibar the prevalence of HIV and HCV is high (11.3% and 25% respectively) (15,16). The study uses the WHO's Quality of Life (WHOQol) tool to respond to the study objectives (17,18).

Study population and enrollment procedures
This study included PWIDS who are receiving methadone services for at least 6 months at Kidongo Chekundu MAT clinic in Unguja. At least 98.7% (376/381) of the estimated PWIDS attending MAT clinic were randomly selected from the clinic register on a daily basis. We recruited all clients who attend MAT clinic during the study period. About 30 clients were randomly selected each day for 15 days until the required sample was reached.

Variables and outcome measures
The main oucome variable in this study was the HRQOL. This was measured using the WHOQol questionnaire. This 26-items instrument has two main questions assessing the overall HRQOL and the four domains assessing different individual aspects of HRQOL. These domains were physical health, psychological health, Social relationship and environmental health. The overall HRQOL was measured by looking at an individual's overall satisfaction with life and a general sense of personal well-being. The tool is crutial for use in diverse cultural settings (17,18).
Independent variables included socio-demographic and economic characteristics, feeding and dietary intake, adherence to MAT, methadone dosage, duration in MAT treatment. We measured socio demographic characteristics (age, sex, marital status, education, etc) using the Tanzania Demographic and Health Survey (TDHS) individual questionnaires. Educational level was categorised into primary, no education, primary level, secondary level and more than secondary level. Age (in years) were divided into four categories i.e < 25, 25-34, 35-44 and 45+.
The weigthed wealth index was used to consider the household assets ownership, housing characteristics, fuel for lighting and cooking, type of toilet, source of water, and feeding characteristics. The variables were dichotomized and we used the Principal Component Analysis (PCA) to reduce 31 items to 14 in components one to three loaded before the hinge of the scree plot. Their factor loadings were used as item weights and totalled to yield the total wealth index for each household. This was then divided into quintiles designating lowest, low, middle, high, and highest quantiles of the wealth index (19,20).
The employment status was measured based on participants self-reported type of job. Employed participants included those who reported currently being under formal or informal employment, selfemployed included street workers, and daladala driver. Those who reported not involved in any income generating activities were coded as unemployed.
The dietary intake was assessed based on the Individual Dietary Diversity Score (IDDS) which measure varieties of food items consumed by individuals a previous day and night. Dietary Diversity Scores were calculated by taking the sum of foods group consumed in the day that preceded the interview. Dietary diversity scores below three were considered low dietary intake, otherwise high (21,22). This tools is useful proxy indicator of nutrient adequacy of marginalized populations including rural elderly people in Sri lanka as indeed, the performance of the indicators is improved when considering the quantities of food consumed (23).

Data analysis
Data were checked for completeness and consistency, cleaned and analysed using STATA software version 15 (Stata Corp. LP, College Station, United States of America). Respective descriptive analysis was used to summarize both categorical and numerical data. Logistic Regression analyses were used to determine factors associated with quality of life among PWIDS attending MAT clinic. The binary associations in the logistic regression model that reached p < 0.2 were subjected to a multiple logistic regression model.

Socio-demographic characteristics of the participants
In total, 376 out of 381 PWIDS were enrolled in this study, yielding a 98.7% response rate. Most of them were males (92.6%). The mean age (± standard deviation (SD) of participants at enrollment was 39 (±8.9) years. Of the 376 participants, 45.5% were single, 56.4% had secondary education, 82.7% were employed, and 34% with above low wealth index. Table 1 shows these results.   Health-related quality of life among study participants

Level of HRQoL
We measured four domains of Quality of life using a standardized tool (18). These include physical health status, Psychological health, Social life and Personal relationships. Evidence from this study shows that more than 80% of PWIDS reported above-average good physical health status. This may be explained by the fact that MAT services are helpful to render PWIDS able to perform their duties and feel able to work (8, 24). Majority of PWIDS do have the capacity for work but also able to perform daily living activities compared to the time where they were on heroin dependence (25,28). This achievement might due to good quality and timely psychosocial support provided to PWIDS.
The majority (73%) of participants reported above-average good psychological health (very much and an extremely). However, in many of the related studies MAT patients performed signi cantly worse than matched controls with no history of opioid use on measures of psychological situations (26-28). Nevertheless, it is unclear if the observed differences are because of MAT or because of long-term use of opioids in general. The ndings from a study on effects of MAT for opioid use disorder on functional outcomes revealed that, although healthy controls are usually matched to patients on demographics and other characteristics, these individuals clearly differ in substance abuse history and may differ in unreported psychological, psychiatric, and family history characteristics that contribute to poor function. Quality of evidence for most outcomes was low or very low (26).
In the social relationship domain, except for sexual activities; a vast majority (80.6%) of PWIDS reported above-average satisfaction with the sexual activities and their personal relationship and social support. In addition, most of them do satisfy with social support from their friend but also, they do satisfy with their personal relationship which is different from the time of their heroin dependence. These situations are supported by the study conducted on HRQoL in individual Transferred from a NEP and starting OST conducted in Sweeden which state that Despite having a high degree of problems due to using of illicit substances, signs of severe psychiatric symptomatology, and social problems, patients were retained in treatment to a high degree at 12-month follow-up (29). These might due to different social and recreational services and support provided from NGOs where do they enrol before referred to comprehensive MAT services.
More than two thirds of participants reported above-average good satisfaction with environmental health.
About 18% of participants reported good environmental health status (opportunities for recreation/leisure and do not have enough money to meet their need) above average level (good and very good). Being in MAT service provide an opportunity for the client to access reliable health-related information and skills, but also have freedom, physical safety and security (30,31). It was observed and evident that the level of trust worth among PWIDS who were on MAT services is increasing over time (32). This has been noticed as many of the family members report to meet with social workers and psychologist at the clinic for the purpose of discussing the best way as they want to offer capital for the business to their loved clients so as to help them in raising income to support their daily life.

Factors associated with HRQoL
Employment and wealth indexes were the only factors that were independently associated with normal HRQOL among PWIDS at KCMAT clinic. PWIDS who were unemployed were more likely to be associated with low HRQOL compared to employed PWIDS. Being unemployed increases chances of PWIDS to low HRQOL. Similar ndings are reported for the association between poverty and quality of life among PWIDS (17). Employed individuals have a chance to plan for their daily life and can able to buy or borrow property with high security in repaid back compared to those who are not in employment. Unemployment and the nancial problems resulted from the addicts' lack of role in the family and society which reduces the quality of life in the addicts (17,33). Evidence generated from this study is consistent with the one conducted in Muhimbili MAT clinic which assessed HRQOL among clients (28).
PWIDS in the wealthier quintiles were more likely to have better HRQOL compared to those in the poorest quintile in this study. Economic status is the one among the most important factors in a day to day life of any person (17). PWIDS are not exempted and have high demand as other population in the world. Better economic situation improves the life of an individual. This will facilitate the improvement of getting necessary services that can also improve the overall health. This includes safe water, food, health services, and education. Owning some important properties is an indicator of how wealthier a person can be and can also facilitate and improve the quality of life thereof (22,33,34).

Limitations
This study included only participants who inject drugs (heroin injectors) who were on MAT services for atleast six months and exclude non injectors who were in the services.

Declarations
We thank the management of Kidongo chekundu hospital through MAT clinic for supporting and accepting their participation in this study, we also thank the medical records and staff for their participation in data collection. Last but not the list we gratefully acknowledged the clients for their paticipation in providing consent and infrmation which enabled us to perform this study.
Authors' contributions SHH and BFS designed the study. SHH, NR,OM, BFS,DJD,AUK, and FJK participated in data collection.
SHH, DJD, CM and BFS, analysed the data and drafted the manuscript. All authors contributed in the nal draft of manuscript and gave nal approval to the manuscript.

None
Availability of data and materials Due to ongoing analyses, the supporting data are available from the corresponding author on a reasonable request.

Ethics approval and consent to particpants
The study tools and the proposal were approved by the Independent Review Board (IRB) of the Muhimbili University of Health and Allied Sciences through refrence number DA.287/298/01A and Zanzibar Health Research Committee (ZAHREC) through reference number ZAHREC/02/July/2019/49. In addition, participants provided with the informed consent form to read and understand and nal were requested to sign to ensure their readiness in participating in the study. An opportunity to withdraw from the study at any given time without any rami cation in their care are provided to them. Moreover, respondents were assured that the information provided to this study was con dential. The ndings will be used for decision-making and academic purposes and no individual information be published along with the results.

Consent for publication
Not applicable