Table Of ContentADDIS ABABA UNIVERSITY
INSTITUTE OF EDUCATIONAL RESEARCH
THE ROLE OF HEALTH EDUCATION IN AIDS
TREATMENT ADHERENCE
ASSESSMENT OF CHALLENGES IN ADDIS ABABA HEALTH CENTERS
Submitted in Partial Fulfillment of the Requirements for Master of
Arts Degree in Educational Research and Development
By: Berhanu Zewdie
Advisor: Wanna Leka (Ph. D)
June, 2013
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TABLE OF CONTENTS Pages
1. INTRODUCTION
1.1 Background to the Study 1
1.2 Problem Statement 4
1.3 Objectives of the Study 5
1.4 Basic Research Questions 6
1.5 Significance of the Study 7
1.6 Basic Assumptions 8
1.7 Conceptual Framework 9
1.8 Delimitation of the Study 12
1.9 Limitations of the study 13
1.10 Ethical Considerations 13
1.11 Operational Definition of Terms 15
2. REVIEW OF RELATED LITERATURE
2.1 Introduction 17
2.2 Defining ART and Adherence 18
2.3 Factors Affecting Adherence to ART 20
2.4 Interventions to ART Adherence 23
2.5Impact of Education on ART Adherence 23
3. RESEARCH METHODOLOGY
3.1 Introduction 26
3.2 Research Design 26
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3.3Research Method 28
3.4Data Collection 31
3.5 Procedures and Processes 37
3.6 Methods of Data Analysis 39
4. MAJOR FINDINGS OF THE STUDY
[
4.1 Introduction 42
4.2 Description of Health Facilities 42
4.3 Demographics of Participants 43
4.4 Contextual Evaluation 49
4.5 Input Evaluation 56
4.6 Process Evaluation 60
4.7 Product Evaluation 62
5. DISCUSSION ON FINDINGS
5.1 Introduction 65
5.2 The problem 65
5.3 The Role of Education on Adherence 66
5.4 Major Strengths and Challenges 66
5.5 Major Strengths 67
5.6 Major Challenges 69
6. CONCLUSION AND RECOMMENDATIONS
6.1 Introduction 75
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6.2 Conclusion 75
6.3 Recommendations 79
i. References
ii. Questionnaires
iii. Annexes
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CHAPTER ONE
INTRODUCTION
1.1 Introduction
This chapter introduces the theme of the study by providing background
information regarding the nature of the problem, its extent and related facts. It also
explains the objectives and the basic research questions of the study. In addition, it
describes the significance, basic assumptions, limitations and delimitation of the
study.
1.2 Background of the Study
With the introduction of the highly active antiretroviral therapy treatment, HlV related
mortality and morbidity have dramatically decreased(WHO, 2006).In line with this, progresses
were made where the fatal disease was effectively changed into a manageable chronic
illness. However, ART is not a cure and it must be taken for life delivered as part of a
comprehensive care to prolong and enhance the quality of life of people living with
HIV/AIDS (WHO, 2004).
As a chronic disease, HIV requires the use of HAART for an undetermined amount of time.
The aim of HAART is to suppress the replication of HIV to the point of reaching
undetectable levels, and its successful outcomes depend largely on medication adherence
(Schonnesson, Williams, Ross, Diamond, and Keel, 2007). Adherence rates vary as a function
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of illness severity and the patient's perception of the effect that their adherence is likely to
have (Godwin-Rabkin and Chesney, 1999).
Adherence to HAART often represents a complex and demanding set of challenges.
Although newer formulations of HAART often require both fewer pills and fewer dosing
times, the behavior can still be a demanding one in light of the other medical,
psychological, sociological and economic burdens that people living with HIV face (Halkitis,
2002).
Some of the potential consequences include viral resistance, antiretroviral regimens that are
no longer effective, progression of HIV disease and increased morbidity and mortality
(UNAIDS, 2009, p.41).That is why helping patients integrate medications into their daily lives
is one of the most crucial and challenging tasks for health care providers. They can improve
their patients' success with adherence when they approach this issue with the understanding
that adherence to HIV/AIDS treatment involves more than simply remembering to take
medications. Rather, it is a complex issue involving social, economic, and psychological
factors (Chesney, 2006).
In Ethiopia, non-adherence as a problem is yet to attract adequate attention as the focus is
now“getting more people on ART as only 34.9% of people living with HIV in need of
treatment are actually accessing it” (UNAIDS, 2008, p. 36). Nevertheless, recent reports and
studies have pointed out the formidable challenge we are facing as a consequence to lack
of adherenceto ART. A study conducted at Yirgalem Hospital in south Ethiopia, for
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instance,indicated “the low level of adherence among patients”. According to this study
there was only 74.2% adherence rate (Markos, Worku& Davey, 2006, p.3).
In another study in five East African countries including Ethiopia, very low adherence level
was found in health facilities (Johnson & Witt, 2007). This study also identified the kinds of
interventions that have been put in place to address the challenge of non-adherence. These
include Patient education/counseling before and after ARVs, providing care and support to
patients, Systematic monitoring at the clinic, social support, use of community-based health
workers, fast-track services at the health care facility, use of reminder devices,
reimbursement of travel expenses and so on (Johnson& Witt et al, 2007).
In much of the literature, it was indicated that a well-designed continuous adherence
education is the most feasible, applicable and effective method that can significantly
improves clients’behavior for adherence (WHO, 2003). This seems to be an accepted
principle in Ethiopia too where health facilities focus on providing ongoing counseling and
information for their ART clients (Ministry of Health, 2005, p. 64). In doing so, the Ethiopian
Ministry of Health (MOH) have trained and deployed adherence counselors who were
supposed to educate and follow up ART clients (MOH, 2005).
So here comes the puzzle. If the education intervention is the primary method for improving
adherence, how is it working as a strategy in our health facilities? Has it been effective in
bringing the desired result? What is the reason behind the low level of adherence reported
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to be then? On the other hand, could there be gaps in the education process that could
affect its effectiveness?
The main purpose of this study was to come up with possible answers to these key
questions. Consequently, the result of the study is expected to indicate the role of education
in tackling the challenge and locate where the problem lies. The study attempted to uncover
if there were gaps or challenges in the process of the education intervention and based on
the findings tried to forward suggestions for the future.
1.3 Statement of the Problem
As pointed out earlier, inadequate adherence to ART treatment is associated with a host of
consequences including detectable viral loads, declining immune system, disease
progression, episodes of opportunistic infections and long term resistance of the virus to the
treatment. However, lack of optimal adherence level is a huge problem among patients
globally (WHO, 2003).
A number of rigorous reviews have found that, in developed countries, adherence among
patients suffering chronic diseases averages only 50% even if it varies between 37% and
83% depending on the demographic characteristics of patient populations. This represents a
tremendous challenge to population health efforts where success is determined primarily by
adherence to long-term therapies. The magnitude and impact of poor adherence in
developing countries is assumed to be even higher given the paucity of health resources
and inequities in access to health care (WHO, 2003).
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This problem is evident in Ethiopia as well. In fact, the level of adherence to ART in the
country is one of the lowest. A report by Federal Ministry of Health indicated that the
national average adherence rate was around 74% even though there are some variations in
the degree of the problem from region to region (MOH, 2005, p.22). This report also
indicated that, the level is even considerably lower in the capital Addis Ababa (71.4%)
despite the relatively better accessibility to the treatment services compared to rural areas
(MOH, 2005).
Why the adherence level is low? A number of factors could be listed out here. Among them
lack of adequate information by the client is one. That is why many health institutions focus
on educating their clients before, during and after the start of the actual treatment. The
same is true in Ethiopia where health providers give regular education and counseling to
their patients.
Normally, we assume that if the patients understand the significance of adherence they
would have better level of adherence even if it could not avoid the problem altogether.
Therefore, if we can improve the effectiveness of the education, we could increase the
likelihood that clients would develop desired behaviors and thereby decreasing non
adherence rate. That is why this study is curious to understand the process of patient
education in selected health facilities. This would enable us to see if there are gaps in it that
would be fixed to improve its effectiveness for the future.
The main purpose of this study is to understand the role of health education as an
intervention for ART adherence and assess its effectiveness in the health facilities included
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here. The aim is to identify major gaps or challenges and forward recommended actions
that can be done to minimize them.
1.4 Objective of the Study
1.3.1 General Objective
The overall objective of this study is to assess the role of health education in promoting
ART adherence and explore if there were challenges in the process of education of
patients which could affect the level of adherence among them.
1.3.2 Specific Objectives
The specific objectives of the study were the following:
A. To identify and understand the role of health education in ART adherence.
B. To assess if there were challenges and identify major gaps in the health
education for ART adherence.
C. To suggest possible solutions that could increase the effectiveness of adherence
education for the future.
1.5 Basic Research Questions
As indicated earlier, the main objective of this study was to assess the role of health
education in promoting adherence to ART and identify challenges that constrain the
effectiveness of this education in the selected health centers.
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