Study area and period-the study was conducted in Jimma Zone public hospitals, Southwest Ethiopia. Jimma zone is located 357 Kms Southwest of Addis Ababa. Jimma zone is found in a region that accounted for the highest number of HIV infected people from Ethiopia. It is found near Gambella region, a region that accounted for the highest prevalence rate of HIV from Ethiopia[3]. The study was taken place in four public hospitals called Jimma University Medical Center (JUMC), Shenen Gibe hospital (SGH), Agaro hospital (AH) and Limu Genet hospital (LGH). These were selected due to the provision of ART services for a long period of time, have many patients on ART and their electronic medical records. These health institutions serve a catchment area of 3 million people with about 11,500 PLWHA were on follow up HIV chronic care during the study. The study was done from March 10-April 30- 2018.
Study design
Institution based unmatched case control study design was employed.
Population
Definition of cases and controls
Quality of Life was defined by World Health Organization (WHO) short form instrument (WHOQOL-HIV BREF) items. The instrument comprises socio demographics, wealth index, clinical, social support variables, and perceived stigma assessing questions. WHOQOL-HIV BREF contains 31 items distributed into 6 domains: physical, social relationships, level of independence, and spirituality domains each with 4 items and psychological and environmental domains with 5 and 8 items, respectively. The individual items are rated on a 5-point likert scale where 1 indicates low/negative perceptions and 5 indicate high/positive perceptions. The remaining two items measure overall perceived quality of life and general health perception of people living with HIV [30,35-37].
Case: Based on the WHOQOL-HIV BREF items, an individual patient living with HIV aged ≥15 years enrolled in to HAART care with poor quality of life was below the mean score of WHOQOL-HIV BREF items.
Control: An individual patient living with HIV and aged ≥15 years enrolled to HAART care with defined good quality of life above the mean score of WHOQOL-HIV BREF) items.
Sample size Determination and sampling technique
The sample size was calculated by using statistical EPI info 7.1.1 software package by considering the percent of controls exposed of the psychosocial factor (having less social support) among controls is 12% and among cases 27.1% with AOR of 2.73 by considering the following parameters: 95% Confidence Level, 80% power, a case to control ratio of 1:3 accordingly, the final sample size, required was 300(75 cases and 225- controls). Therefore, the largest sample size was taken by considering all objectives which gives more representative sample [31](Table1).
Simple random sampling technique was employed to select cases and controls. Screening was conducted in order to identify eligible and non-eligible study participants, as a case and controls by the facilitator from each hospital. The screening criteria were taken from WHOQOL Brief tool composed of six components and mean score was considered as a cut of point to classify respondents. Non respondents were replaced by the next cases/controls.
Data collection Instruments and procedures
Interviewer administered structured questionnaire was used as a data collection tool that was adapted according to local context and objectives of the study[14,20,21]. The questionnaires contain screening part that contain six dimensions of WHO quality of life assessment tool which includes measuring physical dimension, psychological dimension, level of independence, social relations, environmental and religious/spiritual/personal belief which helps identify advanced disease state with recurrent infections.
Data collection procedure
Face to face interview using short interviewer administered structured questionnaire was employed to identify (to screen) eligible and none eligible participants as well as to classify those eligible clients as cases and controls by facilitators in JUMC and one in the rest hospitals in a private room while waiting for ART services during the study period. After screening of cases and controls, respondents were sent to two data collection rooms then face to face interview was implemented to collect information.
Data collection task was handled by two selected ART nurses in each hospital working in ART clinics. One supervisor was assigned to each site to oversee the process. Data on patients characteristics was collected (Socio-demographic and economic, behavioral and psychosocial data was also interviewed). The principal investigator supervised every aspect of the data collection process along with supervisors and the ART nurses mentored shouldering the regular data collection task. The filled questionnaire was gathered to/by the principal investigator and/or the supervisor on daily basis.
Operational definitions and definition of terms
For the purpose of this study, i defined quality of life as personal evaluation of how things have been going for one self, and as how the individual‘s wellbeing may be impacted over time by a disease, a disability, or a disorder.
Good quality of life –an individual patient on ART and whose quality of life measured score above the mean value at 50% after transformation.
Poor quality of life –an individual patient on ART and whose quality of life measured score is below mean-value at 50% after transformation.
Stigma: is a perceived negative attribute that cause someone to devalue or think less of the whole person which is measured using mean as a cut of point. Stigmatized those with higher score value above mean and not stigmatized for below mean value[36].
Depression = depression is a mental disorder representing with loss of pleasure or interest, feelings of low self-esteem or guilty, depressed mood, disturbed appetite or sleep, lack of concentration or low energy. Depression was measured using Beck depression inventory (BDI-13score) by PCA considering its internal consistency and reliability with a (Crombach‘s Alpha 0.935) which is above o.7. It was measured using ordered scale from zero to three where the lower indicates minimal and the higher value indicated severe depression[37].
Wealth quintiles: Wealth index is a composite measure of the cumulative living standard of households and was calculated using easy-to collect data on ownership of household assets. Wealth index was generated by using statistical procedure called principal components analysis (PCA) and was categorized in to three quintiles ranked from 1st quintile (poorest), 2nd quintile (middle), 3rd quintile (wealthiest), taken from previously used Ethiopian demographic Health Survey 2016[38].
Satisfaction from the overall support was measured as dissatisfied, somehow satisfied and very satisfied.
Presence of psychosocial support was measured using yes no response for each category.
Data processing and analysis
Collected data were first checked manually for completeness and consistency by supervisors during the time of data collection and rechecked again at office by the principal investigator before data entry. Then, data was entered into Epi Data version 3.1 and exported to SPSS version 20 for analysis. Quality of life was measured using mean of WHOQOL-HIV BREF items tool [14,20-21,37].
Then, the higher total score denotes higher/good quality of life and the lower score denote low/poor quality of life. Descriptive statistics was done for socio demographic characteristics, behavioral, and psychosocial variables in terms of mean with standard deviations and range values for numerical data as opposed to percentage and frequency tables for categorical data. Principal component analysis for wealth index, stigma and depression score. Cronbach‘s alpha was used to test for internal consistency and reliability of PCA and accepted above 0.7 and depression score was accepted at scale-reliability of 0.935. Bivariate analysis and multivariate logistic regressions were used and association was declared using AOR at 95% CI. The final model was constructed using backward logistic regression method. Model fitness was checked by Hosmer and Lemeshow test statistics and overall classification accuracy test.
Data quality management
The principal investigator used a pre-tested questionnaire prior to actual data collection and amendments were made. Local language was used to get valid data. Data collectors and supervisors were given training on the data collection tool contents, how to collect data and to make the question items understood uniformly. In the actual data collection process, the principal investigator strictly ensured that the collected data fulfills the expected procedures and kept every question responded properly by the respondent through spot checking. When data collectors face problem during interview, supervisors as well as the principal investigator actively supported them. Data editing, coding and entry was made which then, data cleaning was taken place to check for the consistency of data and identify errors that occur during data collection or coding process.
Ethical Approval and Consent to Participate
Ethical Clearance was obtained from Jimma University Research Ethics Review Committee.
Formal written letter was obtained from Population and Family health department, to Jimma
zone health office and respective hospitals. Permission was obtained from the facilities and written informed consent was obtained from all informants including guardians whose child was under age of 18 years. The interview procedures were conducted completely in a private room. The informants were ensured that all data would be kept confidential by using codes to identify participants and were also clearly informed about their right to refuse to participate in the study or withdraw at any time during the interview session.