FOOD SECURITY AND ANTIRETROVIRAL THERAPY ADHERENCE AMONG PEOPLE LIVING ...

302 Pages·2016·2.14 MB·English

FOOD SECURITY AND ANTIRETROVIRAL THERAPY ADHERENCE AMONG PEOPLE
LIVING WITH HIV IN LUNDAZI DISTRICT, ZAMBIA: A PILOT STUDY

Rainier DeVera Masa

A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill
in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of
Social Work.

Chapel Hill
2016

Approved by:

Gina A.N. Chowa

Kathleen A. Rounds

Kavita Singh Ongechi

Shenyang Guo

Michael Sherraden
© 2016
Rainier DeVera Masa
ALL RIGHTS RESERVED

ii
ABSTRACT
Rainier DeVera Masa: Food Security and Antiretroviral Therapy Adherence
among People Living with HIV in Lundazi District, Zambia: A Pilot Study
(Under the direction of Gina A.N. Chowa)
Food security, or adequate access to food at all times, is critical to the health and well-
being of people living with HIV (PLHIV). Research has shown that food insecurity is associated
with suboptimal adherence to antiretroviral therapy (ART). Nonadherence, in turn, predicts
adverse health outcomes, including higher risk of mortality. However, evidence remains limited
on the prevalence, correlates and effects of food insecurity on treatment adherence, as well as
appropriate strategies to improve food security in rural and resource-limited settings. This
dissertation aims to: 1) expand the literature on food insecurity and ART adherence in resource-
limited settings, particularly in rural communities; and 2) examine the effectiveness of an
income-generating strategy to increase food security and treatment adherence among PLHIV in
Lundazi District, Eastern Province, Zambia. The study sample included 101 PLHIV who were
attending two health facilities in Lundazi District and participating in a pilot integrated HIV and
livelihood program. Consistent with prior research, food insecurity was highly prevalent among
the study sample. Ninety-three and 95 percent of the sample were food insecure at baseline and
follow-up, respectively. In addition, at least 70% of the sample was severely food-insecure at
both time points. In this rural sample of PLHIV, food insecurity was predicted by lack of
economic security in the household. Lower income, fewer assets, and having debts were
significantly associated with food insecurity. Results also indicated an inverse, albeit not
statistically significant, association between food insecurity and treatment adherence. Food-
insecure PLHIV were less likely to achieve optimal treatment adherence contrasted with food-
secure PLHIV. Finally, participation in a livelihood program contributed to statistically
iii
significant increase in food security, as well as positive effect on treatment adherence. Findings
suggest that food security can be improved using a promising intervention that targets
underlying social and economic determinants of food insecurity among PLHIV. Implications of
findings for social work policy, practice, and research, as well as key study limitations, are
discussed.

iv
In loving memory of my father, Generoso Montecillo Masa.

v
ACKNOWLEDGEMENTS
Foremost, I express my sincerest gratitude to my advisor and mentor, Dr. Gina Chowa
for the generous and continuous support of my dissertation research. She represents the kind of
scholar I hope to be. Her guidance, enthusiasm, encouragement, and immense knowledge
assisted and motivated me in all stages of my dissertation and scholarly training. Her support
was instrumental in making my dissertation topic a reality – from a concept developed in our
offices in Chapel Hill to an actual project implemented in Lundazi District in Zambia. It was no
easy task to complete a dissertation topic conducted in a project setting nearly 8,000 miles away
from Chapel Hill. This dissertation would not have happened without her generosity and
backing. I could not have imagined a better advisor and mentor for my doctoral studies. I also
thank my dissertation committee: Dr. Kathleen Rounds, Dr. Kavita Singh Ongechi, Dr.
Shenyang Guo, and Dr. Michael Sherraden, for their encouragement and support, insightful
comments, and challenging inquiries. Also, this dissertation would not have been possible
without financial support from UNC School of Social Work and the Armfield-Reeves Innovation
Fund.
My tremendous gratitude goes to Victor Nyirenda for overseeing research activities in
Lundazi. I am truly grateful for all his support in making this dissertation a reality. I thank all
the interviewers, treatment supporters, and clinicians at Lumezi Mission Hospital and Lundazi
District Hospital for their vital contributions to this project. Most importantly, I express my
gratitude to all individuals who consented and participated in this study. Every one of them
continues to inspire me to search for meaningful solutions to ensure that people living with HIV
in resource-limited settings are surviving and thriving.

vi
Last but not the least, I am grateful to my family and friends: my spouse, life partner and
best friend, Matthew Wescom, for the enduring support and encouragement; my mother, Lucia
Masa, an educator herself, for instilling in me from an early age the value of learning and for
supporting and believing in me; my very good friend and de facto mentor, Dr. Richard Ferrigno,
for opening my eyes to immense possibilities and guiding and encouraging me to pursue
graduate studies; my parents-in-law, Gary and Faith Wescom for the support and
encouragement; and all my family and friends in the Philippines, Chapel Hill, St. Louis, and
Zambia for all their support along the way.

vii
TABLE OF CONTENTS
LIST OF TABLES ............................................................................................................................ xi
LIST OF FIGURES ....................................................................................................................... xiii
LIST OF ABBREVIATIONS .......................................................................................................... xiv
INTRODUCTION ............................................................................................................................. 1
CHAPTER 1: BACKGROUND AND SIGNIFICANCE..................................................................... 6
Food Insecurity and HIV/AIDS in sub-Saharan Africa ...................................................... 6
Interaction of food insecurity and HIV/AIDS in SSA: A reciprocal link ................. 7
Definition of food insecurity .................................................................................. 12
Importance of food and nutrition for PLHIV ........................................................ 15
Summary ................................................................................................................ 17
Food Insecurity and Antiretroviral Therapy Adherence in sub-Saharan Africa ............... 18
Definition of adherence. ........................................................................................ 19
ART adherence in SSA .......................................................................................... 20
Food insecurity as a barrier to ART adherence .................................................... 23
How food insecurity contributes to treatment nonadherence .............................. 27
Interaction of Food and ART Medications ........................................................... 32
Effects of Adherence to ART ................................................................................. 34
Summary ............................................................................................................... 36
Interventions for Food Security for PLHIV: Integrated with HIV Treatment .................. 37
Food assistance programs .................................................................................... 38
Integrated HIV and livelihood programs .............................................................. 41
Combination food assistance and livelihood programs ....................................... 44
viii
Analysis of interventions for food security and ART adherence ...........................45
Summary and implications for research................................................................45
Background Information on Zambia ................................................................................. 47
CHAPTER 2: THEORIES AND CONCEPTUAL FRAMEWORK,
PROGRAM MODEL AND, RESEARCH QUESTIONS ...................................................... 57
Theories and Conceptual Framework ................................................................................ 57
Health belief model .............................................................................................. 58
Social cognitive theory ......................................................................................... .61
Conservation of resources theory ........................................................................ 63
Memberships theory of poverty ........................................................................... 66
Information-motivation-strategy model ............................................................. 68
Integrated conceptual framework for food insecurity and
ART adherence ..................................................................................................... 69
Summary ............................................................................................................... 71
Program Model: Integrated HIV and Livelihood Program ............................................... 71
Empirical support for the program model ............................................................. 73
Definition of Concepts and Research Questions ............................................................... 75
Definition of key concepts in the program model ................................................. 75
Research Questions .............................................................................................. 78
CHAPTER 3: RESEARCH DESIGN AND METHODS ................................................................. 82
Project Setting .................................................................................................................. 82
Project Description .......................................................................................................... 85
Sample .............................................................................................................................. 90
Research Design ................................................................................................................ 91
Data Collection ................................................................................................................. 93
Measures .......................................................................................................................... 93
Analysis Plan ..................................................................................................................... 97
ix
CHAPTER 4: RESULTS ............................................................................................................... 120
Descriptive Results .......................................................................................................... 121
Prevalence of Food Insecurity ......................................................................................... 124
Risk Factors for Food Insecurity among ART Patients ................................................... 127
Relationship between Food Insecurity and ART Adherence ........................................... 132
Impacts of Health & Wealth ............................................................................................ 139
Chapter 5: DISCUSSION, IMPLICATIONS, LIMITATIONS, AND CONCLUSIONS ................. 146
Discussion ........................................................................................................................ 146
Prevalence of food insecurity ............................................................................... 146
Economically poor households and food insecurity ............................................ 148
Food insecurity and optimal adherence to antiretroviral therapy ...................... 153
Impacts of Health & Wealth ................................................................................ 161
Implications and Limitations .......................................................................................... 168
Policy implications .............................................................................................. 168
Practice implications.............................................................................................171
Research implications .......................................................................................... 174
Strengths and limitations .................................................................................... 176
Conclusions ..................................................................................................................... 183
APPENDIX A: ANTIRETROVIRAL MEDICATIONS AND RECOMMENDED
FOOD INTAKES AND SIDE EFFECTS ......................................................................... 217
APPENDIX B: ANALYSIS OF INTERVENTIONS FOR FOOD SECURITY
AND ART ADHERENCE ................................................................................................. 219
APPENDIX C: ARV DRUGS and WHO TREATMENT GUIDELINES ...................................... 228
APPENDIX D: SELECTION OF LUNDAZI DISTRICT AND
LUMEZI MISSION HOSPITALS .................................................................................... 230
APPENDIX E: COVARIATE SELECTION (RESEARCH QUESTION 3) ................................... 234
REFERENCES ............................................................................................................................ 242
x