Analysis of factors contributing to non-adherence to highly active antiretroviral therapy in selected facilities in Namibia: A development of adherence improvement Programme for health professionals
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Date
2023
Authors
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Publisher
University of Namibia
Abstract
Health professionals are faced with challenges of ART non-adherence in patient
enrolled on HAART. This study was aimed at developing a programme to assist health
professionals to improve ART adherence at the facilities in Oshikoto and Kavango
West regions. The study was carried out in four phases i) phase 1: situational analysis
ii) phase 2: conceptual framework development iii) adherence programme
development and iv) programme evaluation. Phase 1 involved carrying out a situational
analysis using a mixed-method design to understand magnitude of adherence problem
in the study area. In the quantitative part of the study a descriptive and analytic cross sectional study was conducted to collect data using structured interview, with HIV infected persons (n=296) under antiretroviral treatment in Oshikoto and Kavango West
regions. Medication adherence was measured with the Adult AIDS Clinical Trial
Group (AACTG) method and the Morisky Medication adherence Scale (MMAS-8) In depth Interviews (IDIs) of health professionals (n=43) and four Focus Group
Discussions (FGDs) with (n=32) individuals who received ART at a primary health
care clinics were conducted at four facilities in the selected regions. Overall adherence
levels was 76 % with AACTG and 36 % with MMAS-8.
Factors contributing to non-adherence were Type of House, Region and Health
Facility, the relationship was a negative one with beta < 0. Other factors were
forgetfulness and regimens missed during the weekends as reported by the MMAS-8.
Determinants of non-adherence using the AACTG adherence were found to be
Confident of regularly taking medicine, Intention to regularly take medicine over the
next year, Treatment support in taking medicine available and Cues to Action with beta
>0.5). ART potency, that is Doses per day, ART Regimen and Dose each time per day
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with beta >0.5). The factors contributing to non-adherence with Morisky scale that
showed strong positive relations with beta <0.5 were the medicinal barriers, perceived
barriers, more likely to get ill than others, concerned about becoming seriously ill and
barriers based on Infection severity. Determinants of non-adherence using the MMAS 8 were benefits of efficacy (r = 0.143, p <0.05), perceived barriers (r = -0.194, p <0.05)
and social support in taking medicine (r = -0.127, p < 0.05).
Four themes emerged of factors influencing non-adherence to antiretroviral therapy,
these were: patient-related factors, health system, therapy-related factors, and condition
related factors. In the qualitative data analysis, health professionals reported reasons
for ART non-adherence. The subthemes included Unemployment and being poor;
forgetfulness; lack of knowledge due to negative beliefs; side-effects, health system
challenges; workload, inadequate training, lack of skills, and poor adherence reporting
systems; stigma. The HAART participants reported several barriers that negatively
influenced their medication experience and adherence. These barriers included the
following subthemes: financial burden; side-effects, psychological factors, such
alcohol use and stigma. The facilitators included social support, treatment support and
positive patient-provide relationship.
In Phase 2, the development of the conceptual framework was based on the theory of
Dickoff et al. (1968) using the findings of the mixed method. Phase 3 addressed the
development of the Adherence Improvement Programme (AIP) for the health
professionals (1). The programme was developed within the concepts of Intervention
mapping framework suggested by Bartholomew et al. (2006), which outlines the
processes of developing a theory-based health promotion programme. Finally, the
programme was evaluated in Phase 4 using the Centre for Disease Control (CDC)
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‘Framework for programme evaluation in public health’ (2). A pool of public health
experts was utilised for this purpose. The AIP has four programme components
consisting of four objectives. Key performance areas based on the intervention
strategies to improve adherence were elaborated under each objective. Tasks to be
performed under each key performance areas were stipulated accompanied by
indicators to measure programme performance
Description
A dissertation submitted in fulfilment of the requirements for the degree of doctorate of philosophy in public health
Keywords
Antiretroviral therapy, Programme for health professionals, Health facilities in Namibia, HAART