|Year : 2022 | Volume
| Issue : 3 | Page : 220-225
Predictors of Dietary Diversity among HIV Clients in a Low-resource Tertiary Health Facility in Southeast Nigeria: A Cross-sectional Analytical Study
Ifeyinwa Ezenwosu1, Nwachukwu Ugwunna2, Miriam Ajuba3, Osita Ezenwosu4, Emmanuel Otache1, Ijeoma Ejike3
1 Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria
2 Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Enugu State, Nigeria
3 Department of Community Medicine, Enugu State University College of Medicine, Enugu, Enugu State, Nigeria
4 Department of Pediatrics, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu State, Nigeria
|Date of Submission||04-Sep-2021|
|Date of Decision||18-Jan-2022|
|Date of Acceptance||22-Feb-2022|
|Date of Web Publication||2-Jun-2022|
Department of Paediatrics, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu State
Source of Support: None, Conflict of Interest: None
Background: In a resource-limited setting where nutrient availability is a challenge, it may be necessary to determine factors that affect dietary diversity in people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) as addressing them could lead to better access to diversified diets in this group. Objective: The objective of this study was to determine the factors that influence dietary diversity among HIV clients attending the HIV clinic in a low-resource tertiary health facility. Materials and Methods: An institutional-based cross-sectional study was conducted among HIV clients receiving anti-retroviral therapy in Enugu state, Nigeria. A systematic random sampling technique was employed in selecting the study participants. Bivariate analysis was done using the chi-square test which was further subjected to multivariate logistic regression analyses to determine predictors of dietary diversity. Results: In this study, respondents who earned a family monthly income of 72.5 US dollars and below were 2.6 times less likely to have high dietary diversity (AOR = 0.378, CI = 0.180–0.792) compared to those who earned above 145 dollars. Also, HIV clients on cotrimoxazole prophylaxis were 2.3 times more likely to have high dietary diversity (AOR = 2.304, CI = 1.155–4.598) compared to those who were not on the prophylaxis. Conclusions: High family monthly income and being on cotrimoxazole prophylaxis were predictors of high dietary diversity in People living with HIV/AIDS. Therefore, there is a need to improve the income of PLWHA as well as ensure the ready availability of cotrimoxazole to reduce the rate of opportunistic infections thus leading to better consumption of diversified diets.
Keywords: Dietary diversity, HIV, nutrition, predictors
|How to cite this article:|
Ezenwosu I, Ugwunna N, Ajuba M, Ezenwosu O, Otache E, Ejike I. Predictors of Dietary Diversity among HIV Clients in a Low-resource Tertiary Health Facility in Southeast Nigeria: A Cross-sectional Analytical Study. Int J Med Health Dev 2022;27:220-5
|How to cite this URL:|
Ezenwosu I, Ugwunna N, Ajuba M, Ezenwosu O, Otache E, Ejike I. Predictors of Dietary Diversity among HIV Clients in a Low-resource Tertiary Health Facility in Southeast Nigeria: A Cross-sectional Analytical Study. Int J Med Health Dev [serial online] 2022 [cited 2022 Jul 7];27:220-5. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/220/346434
| Introduction|| |
Globally, approximately 38 million people are living with human immunodeficiency virus (HIV) and approximately 95% of them are adults. The majority of these adults with HIV are living in low- and middle-income countries (LMICs) where sub-Saharan Africa is the most affected region with 68% of people living with HIV/AIDS (PLWHA). In sub-Saharan Africa, Nigeria accounts for a majority of new HIV infections and acquired immunodeficiency syndrome (AIDS)-related deaths each year. Therefore, in Nigeria and other LMICs, HIV presents a major public health challenge that requires revolutionary action in its management to reduce its burden.
One of the important factors in the management of PLWHA is adequate nutrition through diversification of diets., Dietary diversity is referred to as the number of different food groups consumed over a reference time period (usually 24 h). It is widely recognized as a key dimension of diet quality, as consumption of food from variety of food groups has the potential of providing the daily nutrient requirement. Consumption of a diversified diet helps to maintain and improve the nutritional status of a person with HIV/AIDS and delay the progression from HIV to AIDS-related diseases., It also helps in sustaining healthy levels of physical activity, support optimal quality of life and optimize the benefits of antiretroviral drugs., Evidence shows that people living with HIV who are malnourished at the commencement of antiretroviral drugs are 2–6 times more likely to die in the first 6 months than those who are not malnourished. On the contrary, HIV interferes with the ability to access, handle, prepare, eat and utilize food, thus increasing the risk of nutrient deficiency (especially micronutrients) among PLWHA. Hence, as HIV/AIDS increases nutrient demand, PLWHA requires increased nutrients to maintain the same bodyweight as non-infected healthy people.
In LMICs like Nigeria where nutrient availability is a challenge, it may be necessary to determine factors that affect dietary diversity in PLWHA. Identification of these factors could lead to their address which will possibly ensure better access and consumption of diversified diets in this group. This will ultimately help them to cope in LMIC setting where nutrient availability is limited. Several researchers have studied the effect of socio-demographic and health-related factors on dietary diversity in HIV patients either singly or collectively., Studies done in Rwanda, Ethiopia and Ghana showed that low income, having no formal education, employment status, marital status and age were the socio-demographic factors associated with dietary diversity.,, Regarding health-related factors, some studies reported that duration of anti-retroviral treatment (ART), being on cotrimoxazole and CD4 count were determinants of dietary diversity.,
Despite the highest global burden of HIV existing in Nigeria and evidences showing that dietary diversity and factors affecting dietary diversity could worsen disease outcome in HIV,,,,,,, there is limited study in Nigeria to determine factors that could impact on dietary diversity of PLWHA. Researches on dietary diversity and its influencing factors could help in identification of such factors with possibility of preventing and reducing HIV burden emanating from them. This study, therefore, aimed to determine the predictors of dietary diversity among HIV clients in a low-resource tertiary facility in southeast Nigeria.
| Materials and Methods|| |
This was a facility-based cross-sectional analytical study that was conducted at the University of Nigeria Teaching Hospital (UNTH), Enugu to determine predictors of dietary diversity among HIV clients. The health facility provides HIV care to people living with HIV/AIDS in Enugu state, Nigeria and other neighboring states. The study population was HIV-positive adults aged 18 years and above accessing HIV care at the hospital. Included in the study were those who gave informed consent, whereas excluded were HIV clients who were too sick to participate and those whose previous 24-h meals were unusual such as those who ate at a feast or special occasion a day before data collection. The sample size was determined using a single population proportion formula considering the following; 6.6% as the proportion of respondents with low dietary diversity, 5% level of significance (α) at 95% level of confidence for two-tail test and a marginal error or level of precision (d) = 5%. Including a 10% non-response rate, a total of 185 HIV clients were interviewed. To select eligible study subjects, a systematic random sampling technique was applied using the total number of registered patients in the HIV clinic as a sampling frame.
The socio-demographic and health-related characteristics of the clients were collected using a structured questionnaire adapted from similar studies.,, The dietary diversity questionnaire was adapted from the Food and Agriculture Organization (FAO), which assessed the 24-h dietary recall of the respondents using nine food groups. The client scored 1 for each food group consumed and 0 when each food group was not consumed. Dietary diversity score (DDS) was assigned to each client based on the sum of 9 points and was categorized as low DDS for consumption of 0–4 food groups, whereas ≥5 food groups represented high DDS.
Statistical analysis of the data was performed with the SPSS statistical program version 22. Frequency, mean and standard deviations were calculated for univariate analysis. Chi-square statistical test was used to measure the association between dependent and independent variables at the bivariate level. To determine predictors of dietary diversity, multivariate analysis using logistic regression was done for variables with a P < 0.2 at the bivariate level. The level of statistical significance was set at P < 0.05 for all cross-tabulations and inferential analysis, whereas a 95% confidence interval was used in the data presentation for the regression model.
Ethical clearance was got from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Enugu (Reference number: UNTH/CSA/329/VOL.5). Permission to conduct the study was obtained from the management of the HIV care program in the institution. Written informed consent was also obtained from the respondents before recruitment.
| Results|| |
Sociodemographic characteristics of the respondents
[Table 1] shows the socio-demographic characteristics of the respondents. A total of 185 respondents participated in this study, the majority (72.4%) were females and the mean age of the respondents was 42.5 ± 10.4 years. Approximately half (51.4%) of them were married with only a few (3.8%) having no formal education. A greater proportion of the respondents (47%) were traders by occupation and more than half (64.9%) had a household size of ≤5.
As shown in [Table 2], all the respondents were on ART but the majority had been on it for >44 months, whereas a greater proportion of the respondents (71.9%) were in clinical stage 2. Few of the respondents (13.0%) had opportunistic infections, the commonest being upper respiratory tract infection (45.8%), whereas 24.1% of the clients had drug adverse effects from HAART regimen and the commonest was dizziness.
The practice of dietary diversity among the respondents
A vast majority of the respondents (96.8%) consumed starchy staples, whereas very few (4.9%) ate organ meat [Table 3]. A good number of the respondents (42.7%) had poor dietary diversity [Figure 1] and the mean DDS was 4.8 ± 1.3.
Factors associated with dietary diversity
Socio-demographic characteristics associated with dietary diversity [Table 4] at the bivariate level showed that only family monthly income was significantly associated with dietary diversity (χ2= 6.062, P = 0.048). In [Table 5], cotrimoxazole prophylaxis was the only health-related variable significantly associated with dietary diversity (χ2= 4.283, P = 0.039).
|Table 4: Socio-demographic factors associated with dietary diversity among HIV clients|
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[Table 6] shows that at multivariate analysis, family monthly income and cotrimoxazole prophylaxis were the predictors of dietary diversity. Thus respondents who earned a family monthly income of 72.5 dollars and below were 2.6 times less likely to have high dietary diversity (AOR = 0.378, CI = 0.180–0.792). Also, clients on cotrimoxazole prophylaxis were 2.3 times more likely to have high dietary diversity (AOR = 2.304, CI = 1.155–4.598).
| Discussions|| |
This study assessed dietary diversity and determined its predictors among HIV clients receiving ART. The findings of this study revealed that a moderate proportion of the respondents had high dietary diversity. This was consistent with studies in Rwanda, Kenya and Uganda, whereas other studies by researchers in Nigeria and Ethiopia reported a lower proportion of respondents with high dietary diversity. The difference between this study and the earlier study in Nigeria may be due to different study settings as the previous study in Nigeria was community-based, whereas this study was facility-based. Patients in health facilities tend to have access to an informal form of nutrition education during counselling which may impact their nutrition knowledge with possible resultant good dietary practice. Differences in study settings may also explain the contrasting finding from Ethiopia as their study was set in an already food-deficit zone with a weak food marketing chain.
Despite the differences in their DDSs, this study and earlier studies,,, similarly noted that the majority of foods consumed by the HIV clients over 24 h was starchy staples, whereas the least consumed food group was organ meat. The consumption of starchy staples by the majority of the respondents may be explained by the fact that in LMICs, consumption of monotonous diets based on starchy staples is the norm. Also, in such a setting, organ meat may not be numerous enough to be readily available and with possible high cost, the people may be facing affordability challenges which may have led to its poor consumption among the respondents.
This study noted family monthly income as a predictor of high dietary diversity among the respondents. Thus, those who earned 72.5 dollars were 2.6 times less likely to have high dietary diversity compared to those who earned >72.5 dollars. The finding corroborated other studies done in Rwanda, Kenya and Ethiopia. Due to several needs that compete for limited finance, people who are low-income earners may be unable to afford the different varieties of nutritious foods and may resort to consumption of undiversified diets that are of low cost and poor nutrient adequacy.
Another predictor of high dietary diversity is being on cotrimoxazole prophylaxis by the HIV clients. This study revealed that respondents on cotrimoxazole prophylaxis were 2.3 times more likely to have high dietary diversity compared to those not on cotrimoxazole prophylaxis. This observation differs from the findings of a study by Woldemariam et al. which reported that those not on cotrimoxazole prophylaxis were more likely to have high dietary diversity. The researchers argued that side effects of the drug such as nausea and vomiting may be responsible for poor consumption of diversified diets among those on cotrimoxazole. In contrast, however, the use of cotrimoxazole prophylaxis has been noted to reduce the risk of opportunistic infection such as oral candidiasis and indirectly promotes the ability of an individual to eat whatever available or desired food thus leading to consumption of diversified diets. This may explain the positive effect of cotrimoxazole prophylaxis on dietary diversity noted in our study.
These findings imply that HIV clients with low income and those not on cotrimoxazole are at risk of macro-and micro-nutrient deficiencies with their consequent negative effects on the immune system. Thus the need for intervention in these groups of HIV clients for better consumption of diversified diets.
One of the limitations of this study is recall bias. Due to the potential difficulty in recalling previously eaten food, the participants may report inaccurate food items as consumed. This bias was minimized by repeating the inquisition of consumed food twice to ensure consistency in response. Another limitation of our study is its cross-sectional study design which will not allow us to infer causality.
| Conclusion|| |
Family monthly income and cotrimoxazole prophylaxis were predictors of high dietary diversity in PLWHA.
The availability and use of cotrimoxazole prophylaxis should be ensured for all patients with HIV to reduce the rate of opportunistic infections thus leading to better consumption of diversified diets. Also, the government and stakeholders involved in the HIV program may need to create special jobs for PLWHA to ensure sustainable income that will enable dietary diversification.
We thank the HIV management center of UNTH for providing the gateway for us into their domain, the clients who participated in this work and our research assistants for their tireless efforts during the data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]