Nutrition knowledge and practice of dietary diversity among people living with HIV in a resource-limited setting: a multi-center study

Introduction

Human immunodeficiency virus (HIV) is a viral disease caused by a virus, which attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases [1]. It is a single-stranded RNA retrovirus of the lentivirus family, present in the blood and body fluids of infected individuals, which could be transmitted through sexual, parenteral, or vertical routes [1, 2]. In people living with HIV (PLHIV), the virus attacks the body’s immune system, specifically CD4+ cells (often called ‘T cells’), leaving the body susceptible to infections and other diseases [3]. It also affects nutritional status of those individuals, which could lead to poor immune function of the body [4].
Dietary diversity is referred to as the number of different food groups consumed over a reference period (usually 24 hours) [5]. It is widely recognized as a key dimension of diet quality, as consumption of food from a variety of groups has the potential of providing the daily nutrient requirement, especially among PLHIV [6]. Although consumption of a diversified diet cannot cure AIDS or prevent HIV infection, it can help to maintain and improve nutritional status of a HIV-positive person and delay the progression from HIV to AIDS-related diseases as well as sustain healthy levels of physical activity, support optimal quality of life, and optimize benefits of antiretroviral drugs [7-9].
Despite the benefits, diversification of diet is rarely practiced in poor-, low-, and middle-income countries across the globe [10]. Nutritional problems are common in those settings because low-quality monotonous diets are the norm that is predominantly based on grain or tuber-based (starchy) staples, and diets that lack vegetables, fruits, and animal sources [11, 12]. As most HIV infections occur in such settings, individuals have limited dietary quality and quantity, leading to inadequate intake of essential nutrients and energy required for a strong immune system [13]. These may predispose them to various opportunistic infections and further reduce the immune system in a vicious manner. To practice diversification of diet, PLHIV needs to have a good knowledge of nutrition. This was collaborated by Sapp [14], who noted that for individuals to adopt a rational approach towards a diversified diet, they need to have a high level of nutrition knowledge [14]. Having the right knowledge about nutrition will help PLHIV in selecting and consuming healthy foods geared towards improving their health, especially their immunity and preventing opportunistic diseases [15]. In resource-limited settings with the highest burden of HIV, if good nutrition knowledge and practice of dietary diversification do not exist among PLHIV, interventions may be needed to correct them. In order to determine the need for such an intervention, it is important to assess the basic nutritional knowledge and practice of dietary diversity among PLHIV. In Southeast of Nigeria, there are limited studies regarding nutrition knowledge and dietary diversity practice among people living with HIV. Therefore, the aim of this study was to assess the nutrition knowledge and dietary diversity practice among PLHIV in Enugu, Southeast Nigeria.

Material and methods

Study area
The study was conducted in HIV centers of the University of Nigeria Teaching Hospital (UNTH) and Enugu State University Teaching Hospital (ESUTH) in Enugu State, Nigeria. They serve as referral centers for people in Enugu State and other states in Southeast Nigeria. Both tertiary hospitals are involved in the provision of HIV/AIDS prevention, treatment, and care services. Other services they render include prevention of mother-to-child transmission (PMTCT) of HIV, pediatric HIV care and treatment, tuberculosis/HIV care and treatment, laboratory infrastructure obtaining and supply, and human resource capacity building.

Study design
This was a cross-sectional, analytical study, which assessed the knowledge and practice of dietary diversity among people living with HIV in Southeast Nigeria.

Study population
The study population was adults accessing HIV care in the two tertiary hospitals in Enugu State viz ‘HIV clinics’ of UNTH and ESUTH.

Inclusion and exclusion criteria
HIV patients included in the study were those who provided informed consent, were above 18 years of age, and under antiretroviral therapy (ART) for at least 6 months prior to the study. Excluded from the study were pregnant or nursing mothers, patients with other chronic conditions, such as cancer, diabetes mellitus, thyroid disease, hypertension, and those who ate in a festive event a day before the questionnaire was administered. Consumption patterns can be atypical during festive periods, and would unlikely reflect a typical die [5].

Sample size determination
Minimum sample size was determined using a formula for calculating a single-population proportion [16]. Applying the formula, a total of 370 HIV patients were enrolled into the study.

Sampling technique
This entailed the use of simple random sampling by ballot to select the first person provided with questionnaire from the list of patients of the clinic attendance register on each clinic day. Then, systematic random sampling technique was used to select subsequent persons from the attendance register of ART clinic of both hospitals.

Study instruments and data collection
A pre-tested, semi-structured, interviewer-administered questionnaire developed by researchers was used for data collection. Section one assessed the socio-demographic chara­cteristics of the respondents, while section two evaluated the practice of dietary diversity, which was adapted from the Food and Agriculture Organization (FAO) [8]. Nine food groups consumed over 24 hours were used to determine individual dietary diversity score (IDDS), with score 1 meaning any of each food group was consumed, and score 0 meaning none of each food group was consumed over 24 hours. IDDS was assigned to each person based on the sum of 9 points (from 9 food groups), and then categorized into two groups. High dietary diversity was applied to any score ≥ 5, whereas a score of < 5 was described as low dietary diversity.
Section three consisted of ten questions that were used to assess the nutrition knowledge of the respondents, and the tool was adapted from regional center for quality of healthcare (RCQHC) [6]. A score of 1 was awarded for a correct answer, while a wrong answer was scored 0. Nutrition knowledge was categorized as good knowledge for score > 6 and poor knowledge for any score ≤ 6.

Data analysis
Data were analyzed using international business machi­ne-statistical package social sciences (IBM-SPSS) version 25. Means and standard deviations of numeric variables were calculated, while frequencies and proportions were gene­rated for categorical variables. Chi-square test was used to measure associations between categorical variables and nutrition knowledge. Logistic regression analysis was performed to determine predictors of good nutrition knowledge and dietary diversity for socio-demographic variables with a p-value < 0.2 in χ2 analysis. Level of statistical signifi­cance was set at p-value < 0.05 for all cross-tabulations and inferential analysis; a 95% confidence interval was used in data presentation for regression model.

Ethical consideration
The study was conducted in compliance with ethical guidelines of health research ethics committee of the University of Nigeria Teaching Hospital, Enugu after obtaining ethical clearance (ethical clearance number: UNTH/CSA/329/VOL. 5). Permission to conduct the study was obtained from the management of UNTH and ESUTH HIV treatment centers. All respondents provided written informed consents after they had been properly informed about purpose of the study and assured of confidentiality of volunteered information.

Results

Socio-demographic characteristics
The socio-demographic characteristics of the respondents (Table 1) show that majority (73.8%) of the HIV patients were females. The age range of the respondents was between 20-70 years, with a mean age of 41.1 ± 10.5 years. Also, 49.7% of the respondents were married and 44.6% had secondary education, while 2.4% did not obtain any formal education. Majority of the participants were traders, earned family monthly income of ≤ 30,000 naira, and had a household size of 4-6 with a number of living children above two.
Nutrition knowledge of the respondents
Table 2 shows the nutrition knowledge of the respondents and their correct responses. Majority of the respondents knew that a balanced diet covers all nutrient requirements, poor nutrition leads to poor ability to fight infection, and every time they visit the clinic, their weight should be measured. However, only 45.4% of the patients knew they should drink at least 8 glasses of water daily. The mean overall knowledge score of the respondents was 7.8 ± 1.5. A greater proportion of the respondents (69.7%) had good knowledge, while 30.3% had poor knowledge.
Dietary diversity of HIV patients
Respondents, who consumed different food groups during a 24-hour recall are presented in Figure 1. The most consumed food group was starchy staples (97.3%), while the least consumed food groups were organ meat (3.0%) and eggs (8.6%). In the overall practice of dietary diversity, 60% of the respondents had high dietary diversity, with a mean dietary diversity score of 4.86 ± 1.30.
Factors associated with nutrition knowledge and dietary diversity
Socio-demographic characteristics associated with nutrition knowledge are shown in Table 3. None of the variables showed significant association with nutrition knowledge at bivariate analysis. Table 4 showed that marital status (χ2 = 12.596; p = 0.002), family monthly income (χ2 = 8.52; p = 0.014), and number of children in a household (χ2 = 11.346; p = 0.003) were significantly associated with dietary diversity.
Predictors of nutrition knowledge and dietary diversity
Three socio-demographic variables associated with nutrition knowledge with p < 0.2 were further subjected to multivariate analysis (Table 5). Accomplishing at least a secondary school level (AOR: 0.536; 95% CI: 0.29-0.97) and earning a family income of 31,000-60,000 naira (AOR: 2.118; 95% CI: 1.11-4.06) were found as predictors of good nutrition knowledge. Also, three variables (marital status, family monthly income, and number of children) were found to be associated with dietary diversity, with a p < 0.2. Further analysis showed that having one to two children was the only predictor of high dietary diversity (AOR: 2.090; 95% CI: 1.19-3.67).

Discussion

Poor knowledge and practice of nutrition in the face of HIV infection can negatively affect treatment responses and outcomes, especially in resource-poor countries where people often consume a monotonous diet consisting mainly of starchy staples [17]. Nutritional assessment of people living with HIV can provide information on their adequacy of diet, their food habits, and dietary constraints. Furthermore, it can serve as a basis for evidence-based decision-making regarding the need for interventions, such as food support, nutrition education, and counselling [18].
This study showed that majority of the respondents were in the middle age group (range, 30-49 years), which corresponds to productive and economically active years. A greater proportion of them were females, married, and had secondary education as their highest level of education. Furthermore, majority of the patients earned a family monthly income of ≤ 30,000 naira, had a household size of 4-6, and had more than 2 children in a household.
Regarding overall nutrition knowledge, a good proportion of the respondents had a good nutrition knowledge and this compares favorably with some studies on nutritional knowledge of PLHIV [15, 19], but contrasts with others [20, 21]. Therefore, there appears to be an inconsistency in the findings on nutritional knowledge of PLHIV. These differences may be related to the educational status of study population as good knowledge is expected from studies with higher proportions of participants having higher education. Notably, about three-quarter of our respondents had their highest level of education as secondary and above, indicating that they may have the capacity to acquire some knowledge on basic nutrition from other sources of information, such as newspapers, television, radio, magazines, etc. [22].
The study noted that a moderate proportion of the respondents had a good dietary diversity and this was in agreement with other researchers in Nigeria [22] and Kenya [23], but differed from studies done in Ethiopia [24, 25]. This difference in finding may be due to different study settings as the studies [24, 25] were conducted in primary health centers, while the present study was done in tertiary hospitals. In tertiary hospitals, when compared to primary health centers, there is a tendency for patients to have access to an informal form of nutrition education during counselling sessions by a higher cadre of healthcare workers, which may impact their nutrition knowledge and possibly result in good dietary practice [26]. In this study, the most consumed food group was starchy staples, which supports the long-held belief that most resource-poor, low-, and middle-income countries (LMIC) consume foods predominantly based on starchy staples [24-26], and underscores the need for nutritional restructuring away from starchy-based foods in these LMIC. It is worth to note that the findings of the present study and other research [17, 27] showed that the improvement in nutrition knowledge enhances the practice of high dietary diversity, which is associated with a high level of edu­cation. The least consumed food groups were organ meat and milk, which was similar to findings from other studies [24, 25]. This may be due to the cost of these food groups, as organ meats and milk are more expensive than starchy staples; hence, the consumption of them may vary depending on socio-economic status of the respondents [28].
Interestingly, the level of education and family monthly income were the predictors of good nutrition knowledge among HIV patients. Those with a secondary level of edu­cation were 1.8 times less likely to have good nutrition knowledge compared to those with tertiary education. Also, those respondents, who earned a family monthly income of 31,000-60,000 naira were 2.1 times more likely to have good nutrition knowledge compared to their counterparts. This finding is in line with that of other researchers [20, 22]. This shows that as educational level and family monthly income increases, nutrition knowledge also improves. It also may imply that increasing educational attainment allows an individual to acquire more knowledge on basic nutrition from other sources of information [22]. Also, improvement in nutrition knowledge as family monthly income increases may be explained by the fact that low-income earners are faced with challenges of meeting up with family needs, and may not have the time and resources to acquire more nutrition knowledge, unlike those with increased family income who may be eager to improve their diet through the acquisition of more nutrition knowledge [27]. Furthermore, respondents who had one to two children in their households were 2 times more likely to have high dietary diversity compared to those with more than two children. This may imply that a greater number of children in a household result in an increased demand for food, thus, leading to inadequate funds for diversification of diet [29].

Limitations of the study
One of the limitations of this study is recall bias because some of the patients may not fully recount the food groups consumed 24 hours earlier. Also, a 24-hour recall period did not indicate an individual’s habitual diet. However, it provided an assessment of the diet at the population level, and can be used in target interventions and progress monitoring.

Conclusions

HIV individuals in Southeast Nigeria had a moderate level of good nutrition knowledge and practice of dietary diversity. Educational level and family monthly income were the predictors of nutrition knowledge, while the number of children in a household was the predictor of dietary diversity. Therefore, nutrition education should be incorporated into HIV care program by healthcare providers, targeting those with low educational levels and low family monthly income to promote improvement in their nutrition knowledge. Moreover, food assistance program should be introduced and aimed at people living with HIV, who have many children to improve their diet quality.
We also recommend further studies on selective nutrition education among PLHIV with low educational and low income levels to assess their improvement on nutrition knowledge, health status, and quality of life.

Acknowledgements

We would like to thank the management of UNTH and ESUTH centers for providing the gateway into their domain, the patients who participated in this work, and our research assistants for their tireless efforts during data collection.

Conflict of interest

The authors declare no conflict of interest.

References