Depression literacy among people living with HIV/AIDS in a Nigerian tertiary hospital

Introduction

In 2018, about 38 million people were living with human immunodeficiency virus (HIV) [1]. Sub-Saharan Africa has the highest burden of HIV/acquired immunodeficiency syndrome (AIDS) globally, and the disease is currently the most common cause of death in the region [2]. Almost 10% of the global population of people living with HIV/AIDS (PLWHA) live in Nigeria [3]. Although HIV prevalence among adults in Nigeria is not high (1.5%), but due to its enormous population, it translates to about 1.9 million people [4]. Mental health of PLWHA has received increasing attention in recent years, and depression has been reported to be common among PLWHA. Depression is presently the most common cause of disability in the world [5], and nearly 4.4% of the global population are reported to be living with depression [6]. A recent study by the World Bank showed that one in five Nigerians was depressed, and depression was associated with a lower labor force participation [7]. Mental health and HIV/AIDS are intricately associated [8]. Depression is the most prevalent psychiatric comorbidity linked with HIV infection [9]. HIV and depression have been shown to have a bidirectional relationship, in which depression can increase the risk of getting HIV-infected and be triggered by a diagnosis of HIV infection in people living with the virus [10-13]. Factors associated with developing clinical depression in PLWHA include neurobiological changes connected with the sustained presence of human immunodeficiency virus in the central nervous system (CNS), response to social stigma, coping with the possibility of illness and death, bearing the burden of lifelong antiretroviral therapy and its side-effects, and comorbid illnesses [14, 15]. Depression has been consistently shown to negatively impact HIV-infected patients, significantly decreasing their adherence to antiretroviral treatment, quality of life, treatment outcome, and functionality [16, 17]. The prevalence of depression in PLWHA has been reported to be greater in developing countries compared to developed countries [18]. A study by Chikezie et al. in Nigeria revealed that depression was five times more prevalent among PLWHA compared to general population [19]. The severity of depression was also reported to be greater in PLWHA compared to non-infected populations [19]. The higher tendency for depression among PLWHA points to the need for mental health awareness and improved help-seeking behaviors among these individuals.
Mental health literacy (MHL) has been defined by Jorm and colleagues as “the knowledge and beliefs about mental disorders, which aid their recognition, management, or prevention” [20]. This definition serves as the basis for the premise that the conceptual models used by individuals to understand and explain mental health illnesses, influence their help-seeking behaviors for psychiatric symptoms, preferred treatment options, and stigmatization of patients [21-23]. Therefore, it is important to assess the MHL of PLWHA, since it has been shown to influence varied population’s mental health-related choices, particularly their help-seeking for psychiatric symptoms [21].
MHL of depression among PLWHA is of interest, since depression is about 4-5 times [19, 24] more prevalent in this population compared to the general population. A baseline study on mental health literacy of PLWHA is an important precursor for developing skills that will promote their psychological well-being. Although, there have been previous assessments of mental health literacy among different populations globally [24-28], no study has comprehensively examined the knowledge of depression among PLWHA, indicating the need for the present study. The present study intended to assess knowledge, risk perception, and help-seeking behaviors towards depression among this vulnerable population.

Material and methods

Study design

The study was a cross-sectional descriptive survey carried out in the antiretroviral therapy (ART) clinic of Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH) between February and April 2019. COOUTH is a tertiary healthcare facility, which offers extensive HIV treatment services, and is located in Anambra State, South- Eastern Nigeria.

Study sample

A minimum sample size of 351 was obtained using Raosoft sample size calculator [25], given that an estimated 4,000 people were enrolled in the ART clinic at the time of the study. All registered patients older than 9 years old were eligible to be enrolled in the study. Study participants were randomly selected from the attendance register, and were recruited for the study after the receipt of care to ensure that they did not feel obliged to participate in the survey. Willing participants signed an informed consent form and were recruited. No incentives were given for being part of the research study. The ethical approval for this study was obtained from ethical committee of the Chukwuemeka Ojukwu Odumegwu University Teaching Hospital, while a written informed consent was obtained from all the participants.

Data collection and analysis

Depression literacy questionnaire (D-Lit) developed by Griffith et al. was used in this study [26], and permission to use D-Lit was sought and obtained from the lead developer. The instrument used in the research was organized into three sections: section A sought information on socio- demographics, section B contained questions in D-Lit, while section C comprised open-ended questions on risk perception and preferred source of help. D-Lit items include depression symptoms, management, treatment, and duration as well as differentiation between depression and other mental illnesses. For each respondent, the overall depression literacy scores were calculated as a sum of correct answers ranging from 0 up to a maximum score of 22. Higher scores indicated higher depression literacy. The mean average score obtained in the current study was used as a cut-off to make the tool relevant in the study setting, since the instrument was originally developed for elite athletes [27]. The D-Lit was pre-tested before the survey on 20 patients who were not part of the study population, and had a good internal consistency with a Cronbach α of 0.69. Pre-test data were excluded from the final survey data. Data were analyzed using IBM Statistical Product and Services Solution for Windows, version 21.0. Descriptive analyses were performed to characterize the survey sample. Open-ended responses were grouped based on the similarity of thematic content and frequencies/percentages reported. Kruskal-Wallis and Mann-Whitney tests were carried out to compare independent variables, with statistical significance set at < 0.05.

Results

A total of 188 out of 351 questionnaires were completed (response rate, 53.71%). About three-quarters of the respondents were females (74.5%, n = 140) and were mostly between 21-30 years (45.2%, n = 85). A majority of them had tertiary education (55.9%, n = 105), and about half of them were single (49.5%, n = 93). Nearly half of them were employed (47.9%, n = 90), while about a quarter of them were students (22.9%, n = 43) (Table 1).
The mean D-Lit score was 10.54 ± 2.032. About 53.2% of the respondents (n = 100) had depression knowledge scores less than the average score of 10.54. A greater proportion of male respondents reported being at a higher risk of depression (47.9% vs. 39.3%) compared to females. A greater proportion of males than females recommended seeking help from a psychologist (25.0% vs. 16.4%) and counsellor (16.7% vs. 14.3%). These differences did not reach statistical significance. The majority of the respondents reported that they would seek help from their GP (47.9%, n = 90), while less than one-fifth of them opted to seek help from a psychologist (18.6%, n = 35) (Table 2). Depression literacy scores were statistically significantly different among respondents of different gender, educational level, and preferred source of help (Table 3). Approximately three-quarters of the surveyed respondents reported that antidepressants are addictive (71.7%, n = 101). Almost all the respondents reported counselling as effective as cognitive behavioral therapy for depression (95.4%, n = 145). The most frequently recognized symptom of depression by the respondents was loss of confidence and poor self-esteem (88.3%, n = 136).

Discussion

There were more females than males respondents in this study. In Nigeria, HIV infection is more prevalent in females than males across all age group, except for the 35-39 years and 40-44 years age groups [28]. Furthermore, a report from UNAIDS showed that about 68% of adult women living with HIV were on ART, compared to 37% of adult men [29]. More than three-quarters of the respondents were between 21 and 40 years old. Males were more knowledgeable about depression than females. This is in contrast with other studies among other study populations, where females were shown to have a higher knowledge of depression [30-32]. This difference could be attributed to peculiarity of the study population, in which males were underrepresented, and males at ART clinic maybe over-representative of ‘health-conscious’ men. The difference may also be attributed to differences in study instruments. Higher depression literacy in females has been explained by a higher prevalence of the disorder among them [33, 34]. Although women bear a greater burden of depression, it is a significant morbidity and mortality risk for men [29].
The higher prevalence of depression among females has also been attributed to biological predisposition and life events in women’s life, such as childbearing [35, 36]. Another possible reason for higher depression literacy in females is that women are more likely to discuss about depressive symptoms than men [30]. In the present study, education was significantly associated with depression literacy scores. This is consistent with findings from a recent Iranian study, where there was a correlation between level of education and mental health literacy [37]. Higher education translates to increased access to health information, exposure to a bigger social network, and higher chances of learning about mental health [38]. Lower educational levels were linked to decreased help-seeking, less knowledge about mental health, and increased psychological distress for both genders [39-41]. Study findings provide credence to the construct that disease literacy is necessary for treatment engagement [42]. Friends and family are often the preferred sources of help over health professionals for depression [43, 44]. In this study however, a majority of the study sample responded that they would seek help from their primary care physician. Again, this difference may be explained by the peculiarity of their disease, which necessitates routine hospital visits and physician appointments. This underscores the importance of routine depression screening by primary care providers among this vulnerable population. While women are known to experience higher rates of depressive symptoms than men, poor help-seeking behaviors among men pose an important concern [36]. Surprisingly, a greater proportion of males than females reported that they would seek help from a mental health professional (psychologist/psychiatrist). This finding is different from previous studies, where more females than males recommended formal help-seeking for depressed individuals [45, 46]. However, this concurs with findings from a Nigerian study, in which more male teachers recommended mental health professionals for a vignette character with symptoms of depression [47]. A direct comparison between the cited studies above and the present may not be accurate, as the present study sought to know where the participants would seek help for themselves and not for someone else, as in the above-mentioned studies.
More than half of the respondents felt that they were not at risk of getting depressed. A greater proportion of male respondents surveyed felt they were at risk of depression. This finding may not be unrelated to the fact that they were more knowledgeable about depression in this study, and therefore knew that they were in fact at risk of being depressed. One way to mitigate the negative impact of depression on outcomes in PLWHA is improving their depression literacy to promote early detection and help-seeking among this population. Several studies have established the association between HIV infection and depression; however, this is the first attempt to learn what PLWHA know about depression. The relatively small sample size of participants limits the generalizability of the study findings. There is also the possibility of chanced answers. Furthermore, there could be a difference between responders and non-responders leading to a selection bias. Depression knowledge is an essential part of preventing the debilitating effects of depression, which coexist with chronic conditions, such as HIV infection. Integrating mental health literacy tools into HIV care can improve early detection and appropriate referrals in this population.

Conclusions

The PLWHA surveyed had a poor knowledge of depression, and a majority of them reported that they would seek help from their primary care provider. More than half of the participants felt they were not at risk of being depressed. Poor mental health negatively impacts on the quality of life among PLWHA. More studies are needed to understand how coping and social support relate to depression and anxiety in this population to guide the development of appropriate mental health treatment and support services.

Conflict of interest

The authors declare no conflict of interest with respect to the research, authorship, and/or publication of this article.

References