Abstract
Food insufficiency is associated with suboptimal HIV treatment outcomes. Less is known about psychosocial correlates of food insufficiency among PLWH. This sample includes 1176 adults initiating antiretroviral therapy at HIV clinics in Ethiopia. Logistic regression modeled the association of psychological distress, social support, and HIV-related stigma with food insufficiency. Among respondents, 21.4% reported frequent food insufficiency. Psychological distress [adjusted odds ratio (aOR) 2.61 (95% CI 1.79, 3.82)], low social support [aOR 2.20 (95% CI 1.57, 3.09)] and enacted stigma [aOR 1.69 (95% CI 1.26, 2.25)] were independently associated with food insufficiency. Food insufficiency interventions should address its accompanying psychosocial context.
Keywords: Food insufficiency, HIV, ART, Psychological distress, Social support, Stigma
Introduction
Food insecurity, “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to procure food in socially acceptable ways,” is a significant problem in Sub-Saharan Africa [1]. In Ethiopia specifically, it has been estimated that 35% of the population is food insecure [2]. Food insecurity is more prevalent among people living with HIV/AIDS (PLWH) than the general population and has been associated with worse HIV outcomes, including lower CD4 counts, sub-optimal adherence to antiretroviral therapy (ART), and increased HIV viral load [3, 4].
Food insecurity is associated with poor mental health among PLWH, particularly among those with low levels of social support [5]. Qualitative research with PLWH suggests that HIV-related stigma may contribute to the risk of food insecurity through employment discrimination and social distancing of family, friends, and community members [6].
Food insufficiency, one component of food insecurity, is defined as having an inadequate amount of food and has been associated with moderate or severe food insecurity. Previous estimates of food insufficiency among PLWH in sub-Saharan Africa have varied. A study of pregnant women living with HIV in Uganda found that 7% reported severe food insufficiency and 41% reported moderate food insufficiency within the past 4 weeks [3].
Food insufficiency has been associated with a number of psychosocial factors, including low social support, stigma, and mental health among general populations. Less is known about psychosocial correlates of food insufficiency among PLWH, particularly in sub-Saharan Africa. A greater understanding of the psychosocial context in which food insufficiency occurs among PLWH is critical to developing effective interventions and strategies to prevent or reduce food insufficiency and its consequences among PLWH and may contribute to more effective identification of those at risk of suboptimal HIV treatment outcomes.
The objective of this analysis is to characterize psychosocial correlates of food insufficiency among PLWH initiating ART in Ethiopia. More specifically, this analysis investigates the extent to which psychological distress, low social support, and HIV-related stigma are associated with food insufficiency among PLWH initiating ART in Ethiopia.
Methods
Study Setting
This analysis is based on the multi-level determinants of late ART initiation (LSTART) study, a prospective cohort study of patients initiating ART at HIV clinics in the Oromia region of Ethiopia conducted from June 2012 through April 2013 to examine the correlates of late ART initiation [7]. Participants were recruited from six public-sector HIV clinics that received support from the International Center for AIDS Care and Treatment Program (ICAP) at Columbia University through funding from the President’s Emergency Plan for AIDS Relief (PEPFAR). Individuals were eligible for enrolment if they were: at least 18 years of age, initiated ART between June 2012 and April 2013, and spoke Amharic or Oromiffa. Eligible individuals were referred by providers to the study staff. Study staff administered a structured questionnaire with questions related to psychosocial factors and HIV care. Interviews were conducted within 2 weeks of ART initiation. Informed consent was obtained from all individual participants included in the study. Among the eligible patients referred to the study, 95% consented and completed the interview.
Measures
Past-year Food Insufficiency
Past-year food insufficiency was assessed by asking participants how often their households had trouble satisfying food needs in the past year. Response options included: “never,” “seldom,” “sometimes,” “often,” or “always.” In this analysis, participants responding “never,” “seldom,” and “sometimes,” were categorized as having experienced no or infrequent food insufficiency in the past year. Responses of “often,” or “always,” were categorized as having experienced frequent food insufficiency in the past year.
Psychological Distress
Psychological distress was assessed with the Kessler Psychological Distress Scale (K10), which has been previously validated in Ethiopia. The K10 is a 10-item questionnaire designed to assess psychological distress by asking about anxiety and depressive symptoms in the past 4 weeks. Scores between 10 and 19 were coded as no or low psychological distress, scores between 20 and 29 were categorized as mild or moderate psychological distress, and scores between 30 and 50 were categorized as high psychological distress.
Social Support
Social support was assessed with nine questions using a scale developed by Wortman et al. for the coping and change study, a psychosocial supplement to the Chicago site of the Multicenter AIDS Cohort Study. These questions concerned whether the participant has someone to: (1) talk to if upset or depressed, (2) talk to about an important problem, (3) take care of him/her if he/she had to stay in bed for several weeks, (4) borrow money from, help him/her get to the doctor, or to provide him/her with other small immediate help, (5) borrow money from for a medical emergency, (6) give him/her information or guidance, (7) ask for advice, (8) take care of his/her children if she got sick, and (9) accompany him/her to the clinic if needed [8]. Social support scores ranged from 1 (definitely not) to 5 (definitely). Scores were summed and grouped into quartiles.
Enacted HIV-Related Stigma
Enacted stigma in the past 3 months was measured with nine items selected from the HIV/AIDS Stigma Instrument (HASI-P) subscales (verbal abuse, fear of contagion, and social isolation). Items inquired about how often the participant had experienced rejection due to their HIV status (e.g., You were told that you have no future, You were told that God is punishing you, Someone stopped being your friend), with response options ranging from never (4) to most of the time (1) (Cronbach’s α = 0.99) [9]. Because the reported frequency of occurrence of all items was low, the summary measure was coded as any recent enacted HIV-related stigma versus no recent enacted HIV-related stigma.
Sociodemographic Variables
Sociodemographic variables included sex, age, education, relationship status (defined as having a spouse or partner at the time of study enrollment), urban/rural residence, employment status, number of children and religion, and time between HIV diagnosis and enrollment in care.
Statistical Methods
Univariate analyses were conducted to assess the prevalence of food insufficiency, psychological distress, HIV-related stigma, and social support. Bivariate analyses of the relationship between food insufficiency and social support, enacted stigma, and psychological distress were conducted using Pearson Chi squared tests. A multivariable logistic regression model was used to examine the association of past-year frequent food insufficiency with psychological distress, enacted stigma, and social support. Adjusted analyses controlled for sex, education, relationship status, and urban versus rural living environment. Analyses accounted for clustering by health facility using the cluster command in STATA.
Ethical Considerations
The study was approved by the Institutional Review Boards of the Oromia Regional Health Bureau, Columbia University Medical Center, and the City University of New York. Written, informed consent for the interview and extraction of medical record data was obtained from each patient prior to study enrolment.
Results
Characteristics of Study Population
Of the 1176 participants assessed, approximately one-third (31.7%) of the population was between 18 and 29 years of age. The majority (61.2%) of the sample was female and reported having ever attended school (68.2%). Most (78.0%) lived in an urban environment and were in a relationship (57.1%).
Psychological Distress, HIV-Related Enacted Stigma, and Social Support
The majority (59.2%) of the sample screened positive for moderate or high psychological distress. Approximately one-sixth (16.3%) of the sample reported having experienced any recent HIV-related enacted stigma. Among the nine variables that comprised social support, two thirds (66.7%) of participants reported that they had someone who would accompany them to clinic if they needed assistance. Approximately one third (31.1%) reported they had someone from whom they could borrow money, get help getting to the doctor, or rely on for other small immediate help.
Food Insufficiency
Frequent food insufficiency (i.e., food insufficiency often or always) in the past year was reported by 21.4% of the study population. One percent of the population reported always experiencing food insufficiency and 20.4% reported having often experienced food insufficiency in the past year.
Demographic Characteristics
Sex, education, relationship status, and living environment (urban/rural) were associated with having experienced frequent food insufficiency in the past year. Frequent food insufficiency was more commonly reported among women than men (23.8% vs. 17.8%, p = 0.015) and among individuals who had never attended school compared to individuals who had ever attended school (28.1% vs. 18.4%, p < 0.001). Individuals not in a relationship were more likely to report frequent food insufficiency in the past year compared to those in a relationship (28.4% vs. 16.2%, respectively, p < 0.001). Frequent food insufficiency was also more commonly reported among individuals living in an urban as compared to a rural environment (23.0% vs. 15.4%, respectively, p = 0.008). Food insufficiency was not significantly associated with age, religion, number of children, total household size, time between diagnosis and enrollment in HIV care, or employment status.
Psychosocial Characteristics
In bivariate Chi squared analyses, greater psychological distress, lower social support, and having experienced enacted HIV-related stigma were significantly associated with having experienced frequent food insufficiency in the past year. Among participants who reported no or low psychological distress, 11.7% reported frequent food insufficiency. However, the prevalence of frequent food insufficiency was 23.1% for those experiencing moderate levels of psychological distress and 33.2% for those experiencing high levels of psychological distress (p < 0.001). Greater social support was inversely related to prevalence of frequent food insufficiency. Among those in the top quartile of social support, 14.4% reported frequent food insufficiency, compared to 35.7% in the lowest quartile of social support (p < 0.001). Finally, having experienced recent enacted HIV-related stigma was significantly associated with reporting frequent food insufficiency in the past year (31.4% vs. 19.6%, p < 0.001).
Multivariable Regression Analyses
As seen in Table 1, in adjusted regression analyses, individuals who reported moderate or high levels of psychological distress had greater odds of reporting frequent food insufficiency in the past year compared to those with no or low levels of psychological distress [adjusted odds ratio (aOR) 2.61, (95% confidence interval (CI) 1.79, 3.82)]. Low social support [aOR 2.20 (95% CI 1.57, 3.09)] and having experienced enacted HIV-related stigma [aOR 1.69 (95% CI 1.26, 2.25)] were also associated with greater odds of frequent food insufficiency in the past year.
Table 1.
Bivariate and multivariable associations between past-year frequent food insufficiency and psychosocial characteristics among individuals initiating ART in Oromia, Ethiopia
| Frequent food insufficiency, n (%) | No or infrequent food insufficiency, n (%) | Frequent food insufficiency bivariate OR (95% CI) | Frequent food insufficiency multivariable OR (95% CI)* | |
|---|---|---|---|---|
| Psychological distress | ||||
| Low/none | 56 (11.7) | 422 (88.3) | 1.00 | 1.00 |
| Moderate or high | 195 (28.1) | 498 (71.9) | 2.95 (1.91, 4.57) | 2.61 (1.79, 3.82) |
| Social support | ||||
| High (top 25%) | 41 (14.4) | 243 (85.6) | 1.00 | 1.00 |
| Medium–high | 49 (16.8) | 242 (83.2) | 1.20 (0.81, 1.79) | 1.21 (0.87, 1.69) |
| Medium–low | 56 (18.4) | 248 (81.6) | 1.34 (1.01, 1.78) | 1.18 (0.81, 1.73) |
| Low (bottom 25%) | 106 (35.7) | 191 (64.3) | 3.29 (2.45, 4.41) | 2.20 (1.57, 3.09) |
| Enacted HIV-related stigma | ||||
| No | 192 (19.6) | 788 (80.4) | 1.00 | 1.00 |
| Yes | 60 (31.4) | 131 (68.6) | 1.88 (1.26, 2.82) | 1.69 (1.26, 2.25) |
Multivariable model includes all psychosocial characteristics assessed (i.e., psychological distress, social support, and enacted HIV-related stigma) and is adjusted for sex, education level, relationship status, living environment, and study site
Discussion
Just over one fifth of the study population reported having experienced food insufficiency often or always in the past year. Previous estimates of food insufficiency among PLWH in sub-Saharan Africa have varied. Caution is warranted when making direct comparisons of the prevalence of food insufficiency across studies due to differences in measurement of food insufficiency, populations studied, and geographic settings.
Psychological distress was associated with recent food insufficiency in bivariate and multivariable models. These findings are consistent with research with PLWH in Uganda which found that food insecurity was associated with significantly worse mental health [10]. The directionality of the relationship between food insufficiency and psychological distress remains unclear. It is possible that stress and anxiety related to food insufficiency lead to greater psychological distress among PLWH. Evidence from high-income settings provides preliminary support for such a pathway. For example, a prospective cohort study of individuals co-infected with HIV and Hepatitis C in the United States found that moderate and severe food insecurity were significant risk factors for subsequent depressive symptoms [11].
It is also possible that psychological distress increases one’s risk of subsequent food insufficiency. For example, psychological distress may act as a barrier to accessing existing nutritional support services [1]. Furthermore, depression may impede access to care, subsequently worsening patients’ disease course and making them less likely to initiate ART in a timely manner, which could also contribute to worsening food insufficiency. Longitudinal studies are needed to assess the directionality of the relationship between food insufficiency and psychological distress.
Interventions that simultaneously address food insufficiency and mental health should be developed, implemented, and evaluated with PLWH in low-resource settings. While limited, evidence suggests that interventions that focus on food insecurity alone may be insufficient to improve the mental health of PLWH. An impact evaluation of a food assistance program with PLWH in Uganda found that while the intervention was associated with reduced food insecurity, it was not significantly associated with reduced anxiety related to food insecurity or with improved mental health-related quality of life [12]. The effectiveness of interventions that address both food insufficiency and mental health warrant investigation. Individuals who report food insufficiency should be screened for psychological distress and referred for further evaluation and intervention to address any mental health problems present.
Consistent with other studies, this study found that low levels of social support were associated with increased odds of food insufficiency. Food procurement is often a social process, and those without a strong social network may have a more difficult time accessing adequate supplies of food. Other studies have also shown that social support can buffer the impact of food insecurity on depression, and have suggested that interventions simultaneously targeting improving access to food and increasing social support may have synergistic benefits on both mental health and HIV outcomes on PLHIV in low-resource settings [5].
Having experienced enacted HIV-related stigma was also associated with food insufficiency, even adjusted for psychological distress and social support. This is consistent with previous research in sub-Saharan Africa that has suggested a relationship between HIV-related stigma and food insecurity [13]. It is possible that experiences of enacted HIV-related stigma serve to discourage individuals from participating in programs that are or could be seen to be associated with HIV, including nutrition supplementation or other interventions to prevent or reduce food insufficiency among PLWH. Additional research on the relationship between HIV-related stigma and food insufficiency, including the context in which HIV-related stigma and food insufficiency may be related, is warranted.
This study has limitations worth noting. Since it took place in the Oromia region of Ethiopia, findings may not be generalizable to PLWH in other regions of Ethiopia or of sub-Saharan Africa. Furthermore, all participants were initiating ART at the time of data collection. The relationship between psychosocial factors and food insufficiency may differ at other points in the HIV care cascade. For example, we may have underestimated the true prevalence of frequent food insufficiency among PLWH in our study population since people who experience frequent food insufficiency may be less likely to survive until ART initiation. With regard to the associations discussed, because the data are cross-sectional, their temporal order cannot be assessed. Further, while this analysis investigated the relationship between some components of socioeconomic status (i.e., education, employment status) and food insufficiency, other dimensions of socioeconomic status (i.e., income, housing stability), were not measured. It is possible that unmeasured components of socioeconomic status confound the relationship between food insufficiency and the psychosocial factors examined.
Food insufficiency was commonly reported and significantly associated with psychological distress, low social support, and having experienced enacted HIV-related stigma among PLWH in Ethiopia. Future studies should seek to develop and evaluate interventions to simultaneously address food insufficiency and accompanying psychosocial needs. For example, combined interventions that simultaneously address food insufficiency and mental health among PLWH should be developed and evaluated. Nutritional supplementation programs should consider incorporating mental health screening and referral for treatment into their programming. Longitudinal studies are needed to gain additional understanding of the temporal relationships and potential causal mechanisms linking psychosocial factors and food insufficiency among PLWH in low-resource settings. Furthermore, given that food insufficiency has been associated with sub-optimal HIV treatment outcomes, future research should examine to what extent psychological distress, low social support, and enacted stigma mediate or moderate the relationship between food insecurity and HIV treatment outcomes. Such information could be used to better identify those at risk for suboptimal HIV treatment outcomes and inform interventions to better support these patients.
Acknowledgements
The authors gratefully acknowledge the study participants and clinic and research staff who collected the data.
Funding
The project was supported by a research grant from the US National Institute of Mental Health (R01MH089831). Dr. Parcesepe was also supported by Award Number T32 MH019139 (Principal Investigator, Theodorus Sandfort, PhD) from the National Institute of Mental Health. All the clinics included in this study received support from ICAP at Columbia University through funding from the President’s Emergency Plan for AIDS Relief.
Footnotes
Conflict of interest The authors declare that they have no conflict of interest.
Ethical Approval The study was approved by the Institutional Review Boards of the Oromia Regional Health Bureau, Columbia University Medical Center and the City University of New York. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Boards of these institutions and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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