An Assessment Of The Quality Of Life Of

HIV/AIDS Patients And Their Families In Ghana

During the Scale Up of Delivery of Antiretroviral

Treatment

J.Amponsah2, C. Machingauta3, B. Ocran2, S. A. Addo1, S. Ahmed2, B.Dornoo1, H. Kazianga5, R.A.Selby2, S. Sory2, M. Over4,

N.A. Addo1, D. deWalque3, J. O.Gyapong2

1NACP -Ghana, 2Research &Development Division-Ghana Health Service, 3World Bank Development Research Group,4Center for Global

Development, 5Oklahoma State University

1

Overview

Background

Hypothesis

Findings

Ghana TAP Survey

Quantitative Analysis

Results

Conclusions

2

Background

Globally,

Africa’s AIDS burden;

67% of all PLWHA in SSA

72% of all AIDS related deaths in 2008(WHO,2010)

Absenteeism, Limited healthcare facilities;

2000-2009 : Average 2 physicians per 10000 people

9 hospital beds per 10000 people (WHO,2010)

3

Background

Country level;

Limited access to ART,

46% estimated coverage in Ghana 2009, 15.6% in 2007 (WHO,2010)

Effect on Households;

Without ART, untrained/constrained family likely to play significant caregiving role

4

Hypothesis

Impact on households and individuals?

Patient : HIV+ individual

Family: Household members residing with HIV+ individual

HIV/AIDS on patient health :Direct & negative

HIV/AIDS on family member health : negative Spillover

ART intake : patient health improves

Family member health ?

We hypothesize that antiretroviral therapy, to the extent that it improves the patient’s health, will also improve the mental well-being of caregivers 5

Findings

6

Our novel empirical findings are that, in comparison to neighbors, family caregivers of AIDS patients;

Are indistinguishable on measures of physical health

Suffer a deficit in mental well-being

Benefit psychologically in relation to the time the patient spends on ART

Ghana TAP Survey

Rand Medical Outcomes Survey Instrument

507 identified patients on ART, 415 family members and 387 neighbors, all 15yrs+

5 month intervals between 2007 and 2008

Patients recruited from health facilities from 9/10 regions in Ghana

7

Ghana TAP Survey

e.g. of Survey Questions:

“How much bodily pain have you generally had during the past 4 weeks ?”

“How often have you felt like crying in the past month”

8 physical and 8 mental health indexes ranging from 0-100 (100 for optimal health)

Cronbach’s Reliability : 0.92

8

Physical and Mental Health IndexesPhysical Health Indexes Mental Health Indexes

Physical Functioning Anxiety

Satisfaction with physical functioning Mental Health Index

Role limitations due to physical health Psychological Wellbeing

Mobility Psychological Distress

Pain Severity Depression/Behavioral Emotional Control

Pain Role limitations due to emotional problems

Effects of pain Positive Affect

Cognitive functioning Feelings of belonging

9

Quantitative Analysis

Bivariate Analysis

Multivariate cross section regressions Controls: HIV Status age, marital status, household

head, education, Greater Accra region

Multivariate panel regression Controls: HIV Status, survey round and individual fixed

effects

Standard errors clustered at health facility level

10

Results

11

Table 1: Physical Health Bivariate Statistics At

Baseline

Neighbor

mean

Family

mean

Patient

mean p1(N&F) p2(F&P) p3(N&P)

Physical

Functioning 91.43 89.62 80.76 0.234 0.000 0.000

Satisfaction with 90.08 89.80 83.28 0.799 0.000 0.000

physical Functioning

Mobility 96.47 94.45 92.86 0.061 0.162 0.001

Effects of Pain 84.32 83.75 79.76 0.430 0.000 0.000

Pain Severity 86.46 87.63 78.44 0.432 0.000 0.000

Pain 90.24 89.85 82.37 0.752 0.000 0.000

Role Limitations

due to 87.96 87.63 73.58 0.862 0.000 0.000

physical health

Role Limitations

(s.f) 86.50 86.44 71.18 0.976 0.000 0.000

Patients report the lowest physical health indexes

12

Table 2: Physical Health Bivariate

Statistics At Follow up

Neighbor

mean

Family

mean

Patient

mean p1 (N&F) p2(F&P) p3(N&P)

Physical Functioning 92.87 92.58 87.34 0.830 0.000 0.000

Satisfaction with 92.97 92.19 87.73 0.422 0.000 0.000

physical Functioning

Mobility 96.15 96.93 95.51 0.441 0.129 0.524

Effects of Pain 86.02 85.58 83.14 0.394 0.000 0.000

Pain Severity 93.95 93.02 88.35 0.405 0.000 0.000

Pain 94.44 93.86 90.81 0.550 0.003 0.001

Role Limitations due to 93.96 92.01 84.70 0.206 0.000 0.000

physical health

Role Limitations (s.f) 92.99 90.66 82.99 0.184 0.000 0.000

No significant difference between family and neighbor physical health

13

Table 3: Mental Health Bivariate Statistics At Baseline

Neighbor

mean

Family

mean

Patient

mean p1 (N&F) p2(F&P) p3(N&P)

Cognitive Functioning 84.42 83.83 77.57 0.577 0.000 0.000

Mental Health 85.61 82.77 75.55 0.001 0.000 0.000

Psychological Distress 89.76 86.82 79.26 0.001 0.000 0.000

Depression/Behavioral 89.66 86.86 79.03 0.002 0.000 0.000

emotional control

Anxiety 89.25 85.56 78.86 0.001 0.000 0.000

Psychological Wellbeing 76.61 73.70 67.33 0.007 0.000 0.000

Positive Affect 74.92 71.82 64.93 0.007 0.000 0.000

Feelings of Belonging 80.17 78.62 73.12 0.251 0.000 0.000

Families psychologically burdened at baseline

14

Table 4: Mental Health Bivariate Statistics At

Follow up

Neighbor

mean

Family

mean

Patient

mean p1 (N&F) p2(F&P) p3(N&P)

Cognitive Functioning 86.97 86.52 83.20 0.647 0.001 0.000

Mental Health 85.63 84.94 80.33 0.381 0.000 0.000

Psychological Distress 90.70 89.84 85.05 0.265 0.000 0.000

Depression/Behavioral 90.57 89.50 84.66 0.160 0.000 0.000

emotional control

Anxiety 90.27 89.58 84.89 0.465 0.000 0.000

Psychological

Wellbeing 74.40 74.30 70.02 0.932 0.000 0.000

Positive Affect 72.56 72.80 67.74 0.845 0.000 0.000

Feelings of Belonging 78.92 77.34 75.17 0.272 0.097 0.006

Family psychological burden unobservable at follow up

Evolution of Physical Health75

8085

9095

Mea

n In

dex

1 2Phase

Patients Family of Patient Neighbors

95% CI Patients 95% CI Family 95% CI Neigh

Physical Functioning

Figure 1

15

………………..About 6 Months of ART……………………..

Figure 2

16

78

80

82

84

86

Mean Index

1 2Phase

Patients Family of Patient Neighbors

95% CI Patients 95% CI Family 95% CI Neigh

Effects of Pain

………………..About 6 Months of ART………………………

Evolution of Mental Health75

8085

90

Mea

n In

dex

1 2Phase

Patients Family of Patient Neighbors

95% CI Patients 95% CI Family 95% CI Neigh

Mental Health

Figure 3

17

STATISTICAL SIGNIFICANCE

………………..About 6 Months of ART………………………

18

75

80

85

90

95

Mean Index

1 2Phase

Patients Family of Patient Neighbors

95% CI Patients 95% CI Family 95% CI Neigh

Psychological Distress

Figure 4

STATISTICAL SIGNIFICANCE

………………..About 6 Months of ART………………………

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Table 5: Cross Sectional Analysis of Physical Health at Baseline

Physical

Functioning

Satisfaction

with

Physical

Functioning

Effects

of

Pain

Severity

of pain

Role Limitations

due to

Physical

Health VARIABLES Mobility

Family of Patient -2.642 1.72 -2.726 -1.425 1.374 4.916**

[2.715] [1.428] [2.025] [1.131] [1.802] [2.321]

Patient -8.035** -3.324** -2.014* -2.408** -0.847 -7.584

[3.908] [1.356] [1.038] [1.172] [3.553] [6.232]

Observations 1083 1083 1083 1081 1089 1085

R-squared 0.226 0.149 0.116 0.128 0.13 0.173

*** p<0.01, ** p<0.05, * p<0.1

Robust Standard errors in parentheses

Also controlling for HIV Status age, marital status, household head,

education, Greater Accra region

Physically, patients fare worse than neighbors

Families generally no different from neighbors

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At Baseline:

21

Table 6: Cross Sectional Analysis of Mental Health at Baseline

Cognitive Functioning

Mental

Health

Index1 Psychological Distress 1

Depression-

Behavioral

/Emotional

control

Psychological Wellbeing 1

Positive Affect

Feelings

of Belonging VARIABLES Anxiety

Family of

Patient -0.178 -4.295*** -4.322*** -4.134*** -4.355*** -4.778*** -4.759*** -3.018

[0.926] [1.344] [1.272] [1.227] [1.359] [1.557] [1.484] [2.464]

Patient -2.195 -6.832*** -6.638*** -7.033*** -5.964** -7.393*** -8.199*** -5.064*

[1.945] [2.095] [1.920] [1.883] [2.529] [2.633] [2.767] [2.661]

Observations 1082 1082 1082 1082 1082 1082 1082 1082

R-squared 0.140 0.194 0.180 0.193 0.138 0.154 0.157 0.126

*** p<0.01,

** p<0.05, * p<0.1

Robust Standard errors in parentheses, age controls included

Also controlling for HIV Status age, marital status, household head, education, Greater Accra region

Mentally, patients and family members not as healthy as neighbors

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Table 7: Panel Regression, Individual Fixed effects –Physical Health

Physical

Functioning

Satisfaction. with

Physical

Functioning

Effects of

Pain

Severity

of pain

Role

Limitations

VARIABLES Mobility

due to Physical

Health

Follow up 1.997*** 2.765*** -0.676 1.787*** 8.186*** 6.806***

[0.379] [0.755] [0.798] [0.181] [0.536] [1.298]

Family at

Follow up 1.504 -1.095 3.800** -0.00548 -2.815 -4.883**

[3.156] [0.973] [1.574] [1.623] [1.745] [1.93]

Patient at

Follow -up 5.410*** 2.233** 2.005 0.894 -0.797 5.241

[1.954] [0.932] [1.506] [0.743] [1.818] [3.473]

Constant 48.97*** 98.50*** 129.8*** 81.98*** 53.13*** 87.72***

[12.49] [2.284] [2.424] [4.555] [12.45] [8.539]

Observations 2292 2292 2292 2290 2298 2294

R-squared 0.148 0.125 0.104 0.101 0.17 0.142

unique

observations 1200 1200 1200 1200 1200 1200 *** p<0.01, **

p<0.05, * p<0.1

Robust Standard errors in parentheses, age controls included

Standard Errors clustered at Health Facility level

23

Family members improve more than neighbors in ‘Mobility’ and less in ‘Role Limitations’

Additional improvement for Patients in ‘Physical functioning’ and ‘Satisfaction with Physical Functioning’

At Follow up:

24

Table 8 : Panel Regression, Individual Fixed Effects – Mental Health

Depression- Behavioral /Emotional

control

Cognitive Functioning

Mental Health

Index1 Psychological Distress 1

Psychological Wellbeing 1

Positive Affect

Feelings of Belonging VARIABLES Anxiety

Follow up

3.544*** 0.869** 1.952*** 1.614*** 2.520*** -1.690** -1.907*** -0.589

[0.998] [0.437] [0.361] [0.38] [0.354] [0.674] [0.59] [0.896]

Family (Follow up) 0.223 0.132 0.148 -0.312 0.813 0.754 1.18 -2.447

[0.684] [1.712] [1.763] [1.824] [1.59] [1.377] [1.3] [2.422]

Patient at

Follow -up 1.386** 2.982* 2.651** 3.510** 1.316 3.821* 4.096* 2.806

[0.531] [1.598] [1.309] [1.596] [1.049] [2.259] [2.22] [3.002]

Female Patient at Follow up 0.818 1.526* 1.819* 1.024 3.023** 1.157 1.49 -0.555

[1.487] [0.907] [0.963] [1.02] [1.274] [1.208] [1.36] [1.644]

Female Family

(Follow up) -0.0136 2.083*** 1.906*** 2.273*** 2.076*** 2.210*** 2.254*** 3.014***

[0.835] [0.576] [0.696] [0.659] [0.605] [0.661] [0.65] [0.871]

Constant

31.08*** 71.39*** 73.21*** 74.14*** 50.70*** 72.82*** 76.80*** 45.44***

[2.894] [1.508] [1.86] [2.214] [1.93] [3.025] [4.09] [3.82]

Observations 2291 2291 2291 2291 2291 2291 2291 2291 R-squared

0.143 0.112 0.138 0.13 0.132 0.071 0.07 0.085

Unique

Observations 1199 1199 1199 1199 1199 1199 1199 1199

*** p<0.01, ** p<0.05, * p<0.1

Additional improvement for female family compared to male family in 7 indexes

Additional improvement for Patients in 6 of the 8 indexes

Suggests psychological burden for patients at baseline, that wears off with ART

25

At Follow up:

Conclusions

26

As expected, time on ART alleviates the deficits in mental and physical well-being suffered by AIDS patients relative to their families and neighbors

Conclusions

27

In comparison to neighbors, family caregivers of AIDS patients;

Are indistinguishable on measures of physical health

Suffer a deficit in mental well-being

Benefit psychologically in relation to the time the patient spends on ART

Acknowledgements

We are grateful for funding from the Dutch Government via the Bank Netherlands Partnership Program (BNPP) , and the Hewlett Foundation for grant support through Trust Fund TF070424 given to the World Bank.

Mead Over acknowledges the support of a grant to the Center for Global Development from the Bill and Melinda Gates Foundation

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