Study design
We conducted a quantitative cross-sectional study among adult patients diagnosed with HIV patients across five public health facilities in Blantyre urban, Malawi.
Study setting
The study was conducted at five public health facilities in Blantyre urban: The facilities include Zingwangwa, Limbe, Ndirande, Bangwe, and Chilomoni. These health facilities are normally managed by a clinical officer as the in-charge, nurse, pharmacy technician, psychosocial counselor. The services offered include HIV testing and counselling, ART administration, adherence support services through psychosocial counselling and viral load monitoring.
Study population and sample size estimation
Participants were recruited into the study if they were living with HIV, based on their previous HIV test results obtained in the health passport book, were on ART at least for 3 months, as evidence suggests a 3 months window as a mean time to achieve a biological effect, including viral load suppression, following ART initiation[22], aged 18 years and above. Participants were also recruited if they were attending their out patient clinic within Blantyre urban at the stated government run health facilities and were able to understand the study aims and consent properly. Data were collected from March to August 2018. Participants were recruited consecutively from each health facility. Sample size was calculated using both the Leslie and Kish formula for descriptive studies and for comparing two proportions using sample size calculator in Stata 14. The larger minimum sample size required based on both these methods was taken as the sample size for the study. Based on 90% study power, a precision estimate of 0.05, an estimated disability prevalence of 50%,[10] the sample size of 259 was required.
Ethical considerations
The study was reviewed and approved by the College of Medicine Research Ethics Committee (COMREC), (certificate number P.04/18/2388). Permission to conduct the study was granted by the Director of Health and Social Services (formerly District Health Officer) for Blantyre district. To ensure privacy and confidentiality, codes were used on the questionnaire instead of participants’ names. Informed consent was obtained from participants, and where participants were illiterate a witness was invited to help explain the purpose of the research project during informed consent process. Research assistants were trained on the purpose of the study and all ethical requirements for the study.
Data collection and instrumentation
Data were collected through semi structured interviews using the International Classification of Function, Disability and Health (ICF) checklist. ICF provides a unified, standard language and framework for the description of health and health-related states[23]. The ICF contains a series of over 1,800 codes serving as the uniform terminology and standard to describe and measure an individual's health, disabling conditions, or both within each component of the framework[24]. An alphanumeric system is used in the ICF coding scheme with the letters b, s, d and e denoting the components of Body Functions, Body Structures, Activities and Participation, and Environmental Factors, respectively. Table 1, shows an outline of the ICF checklist with the domains, categories and subcategories that were used in this study. For instance, the column for subcategory level 2 lists examples of some of the subcategories in level 1, but not the full list (see: www.who.int/classifications/icf/training/icfchecklist.pdf). In addition, the checklist has a section for demographic data, including patients’ age, gender, level of education, years of formal education, current occupation, and medical diagnosis, and risk assessment was measured against these factors. The ICF has been reported to be a reliable tool in assessing health, social and environmental challenges faced by persons living with HIV [8],[25]. Table 1 shows the ICF framework indicating the interaction between a health condition, body functions and structure and contextual factors to produce a functional outcome.
Table 1
An outline of the International Classification of Functioning, Disability and Health (ICF) checklist
Domains
|
Subcategory level 1
|
Subcategory level 2
|
Impairments of body
|
b1: Mental
|
Examples of b2 sensory functions:
|
function (b)
|
b2: Sensory
|
b2-10: Seeing
|
|
b3: Voice and speech
|
b2-30: Hearing
|
|
b4: Cardiovascular, hematological and respiratory systems
|
b2-35: Vestibular
|
|
b5: Digestive system
|
b2-80: Pain
|
|
b6: Genitourinary
|
|
|
b7: Neuromuscular-skeletal
|
|
|
b8: Skin and related structures
|
|
Impairments of body
|
s1: Nervous system
|
Examples of s1 nervous system structures:
|
structure (s)
|
s2: Eye and ear
|
s1-10: Brain
|
|
s3: Voice and speech
|
s1-20: Spinal cord and nerves
|
|
s4: Cardiovascular and respiratory
|
|
|
s5: Digestive
|
|
|
s6: Genitourinary
|
|
|
s7: Movement
|
|
Activity limitation
|
d1: Learning and applying knowledge
|
Examples of d4 mobility activities:
|
and participation
|
d2: General tasks and demands
|
d4-30: Lifting and carrying objects
|
restriction (d)
|
d3: Communication
|
d4-40: Fine hand use
|
|
d4: Mobility
|
d4-65: Moving around using equipment
|
|
d5: Self-care
|
d4-70: Using transportation
|
|
d6: Domestic life
|
d4-75: Driving
|
|
d7: Interpersonal relationships
|
|
|
d8: Major life areas
|
|
|
d9: Community and civic life
|
|
|
First qualifier (fq): Extent of activity performance in normal
|
|
|
environment
|
|
|
Second qualifier (sq): Extent of activity without assistance
|
|
Environmental factors (e)
|
e1: Products and technology
|
Examples of e2 natural environment and
|
|
e2: Natural environment and manmade changes
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manmade changes:
|
|
e3: Support and relationships
|
e2-25: Climate
|
|
e4: Attitudes
|
e2-40: Light
|
|
e5: Services systems and policies.
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e2-50: Sound.
|
Data management and analysis
Data were entered into Microsoft excel spreadsheet for cleaning and then exported into STATA version 14 (StataCorp, College Station, TX, USA) for analysis. Data were summarized using proportions for categorical variables while continuous variables were summarized using means and standard deviations. Univariate and multivariate logistic regressions were used to summarize associations and assess risk factors for impairments, activity limitations and participation restriction; this assessment was restricted to factors contained in the ICF tool, these largely included age, employment status, marital status and education status. The Alpha level of significance was set at 0.05.