Depression is the most common neuropsychiatric mental condition found among people living with HIV (PLHIV). Despite its high prevalence, depression remains under diagnosed amongst PLHIV, and determining its prevalence is very cumbersome. As a mental condition, it has been associated with increased comorbidity, non-adherence to HAART, suicidal attempts, unsafe sex practice, just to name a few. Support groups have been shown to play an important role in the improvement of the quality of life of PLHIV and could be a means of managing depressive symptoms that arise in their lifetime. The aim of this research was to assess the role of support groups in the management of depression amongst PLHIV at the Bamenda Regional Hospital (BRH). This was a hospital based, observational cross sectional and descriptive study used to gather information from, one hundred and fifty two (152) HIV positive patients sticking to appointments at the treatment centre of BRH. The patient health questionnaire 9 (PHQ-9) was the screening tool for depression. Minimal, mild, moderate, moderately severe and severe depression constituted the levels of depression in which participants with depressive symptoms felt. A score of nine and above (≥9) was considered positive for depression. Further, the role of support groups were assessed through other questions that constituted the questionnaire and the activities carried out in support groups were observed and compared to standards of practice. Analysis revealed that 29.61% (95% CI: 22.5% - 35.7%) were positive for depression, and 108 (71.06%) participants presented with depressive symptoms. The role of support groups to participants was that it helps them in adhering to medication, filling hopeful and aiding them in disclosing their seropositive status to family members. The student t-test: t (70, N = 71) = ?0.468, p = 0.641, showed no significant difference amongst support groups attendees and non-attendees, however, they are important to PLHIV and its practice at the level of Bambui District Hospital should be improved.
Depression is a common mental disorder (CMD) manifested by low mood, loss of interest or pleasure, disturbed sleep or appetite, feelings of guilt or low self-worth, low energy and trouble concentrating. Depression is common and affecting more than 300 million people worldwide (WHO, 2017). Global studies have shown a wide variation in the prevalence of depression, but overall this prevalence is approximately 10% in general populations (Andrade et al., 2003; Stein et al., 2008; Herman et al., 2009). Evidence from these studies went further to highlights that there is nearly twofold increased prevalence of depression in people living with HIV (PLHIV), compared to the general population (Ciesla & Roberts, 2001; Bing et al., 2001).The combination of these two common illnesses has profound consequences because of a significant impact on the person living with HIV and AIDS and, in to a greater extent healthcare systems. As a matter of fact, Cameroon has the largest HIV/AIDS epidemic in sub-region of Africa with an estimated HIV prevalence of 5.3%, 610,000 people living with HIV, with 48,000 adults newly infected and 37,000 AIDS related deaths reported in 2009 (UNAIDS, 2010). Recent findings have shown that persons with depressed mood are more likely to engage in high-risk sexual behaviour (Gore-Felton & Koopman, 2002), and could also lead to non-adherence to HAART, higher risk for co-morbid disorders and premature death ( Farinpour et al., 2003; Cook et al., 2004; Horberg et al., 2008). Consequently, failure to recognize and treat depression endangers not only the patient, but the community as well. It is therefore primordial to early identify depression prior to its management, unfortunately in Cameroon, the management of HIV/AIDS emphasizes on somatic aspects of the disease and neglects psychiatric manifestations, and depression is therefore under diagnosed. This is essentially due to the fact that mental health services are not effectively integrated into HIV/AIDS clinical care (L’akoa et al., 2013).
Depressive tendencies are reduced if the patient’s condition is known and accepted by the patient’s family and when he involves himself in gratifying activities which could be professional, social or otherwise. On the other hand, risks for depression among HIV/AIDS patients increase when recent affective losses occur (death or rejection of all sorts), an accelerated evolution of opportunistic infections, increasing rate of hospitalizations; its duration as well as physical deterioration. Furthermore, in patients with HIV disease, severity of depression correlates with rapidity of decline in CD4 count, suggesting that failure to treat depression may accelerate HIV disease progression and impact on survival (Ross, 2004).
With HIV being a chronic disease, people living with HIV (PLHIV) face a lot of challenges such as, adherence to medication, poor nutrition, withstanding medication side effects, lack of support from family members, just to name a few, stigma. People facing similar conditions, especially unpleasant ones often find comfort, support and strength in being together with people in the same situation like them. Hence support groups can help reduce level of depression or prevent PLHIV at risk from developing it. Ndu et al. (2011) who conducted a study on; role of support groups in managing depression in Nigeria concluded that, being part of a support group turn to reduce the level of depression among PLHIV.
Given that the participants receive a health talk each morning before receiving their ARVs, during this period, informed consent was obtained before randomly distributing the questionnaires. This was also done with the help of the ward charge who assisted in obtaining informed consent. This was of great help to the researcher since the participants easily listen to him and readily obeys his instructions.
A simple random sampling technique was used to select participants wherein questionnaires were shared without following a specific rule in the hall. Out of nearly 100 participants on daily basis, ten to fifteen participants were selected at random. The researcher then proceeded by administering questionnaire when respondents were not reluctant nor rejected the opportunity to take part in the investigation. This was performed when they were waiting to collect drugs at the level of the pharmacy or when their files were being updated. The participants were addressed in English and “Pigin”. Those who could self-administer answer the questionnaires on their own were allowed to answer, while those who were willing to participate but could not read were interviewed and responses documented against their coded questionnaire. Support group meetings were attended all Saturdays and data collected through by answering questions stipulated in the observational guide.
Data from questionnaires were coded on Microsoft Excel and then, coded data was forwarded to IBM SPSS Version 21 for analysis. Data were presented in charts and tables following the order of the research objectives. Means and standard deviation were the main measures of central tendencies. Depression scores were compared using the student t-test to test for a significant difference. The chi-square test (x2) was used were appropriate to test for association or independence between categorical variables. P-values below 0.05 (p < 0.05) were considered statistically significant at 95% confidence interval.
Pfizer and associates have suggested the use of a simpler proxy system of scoring to estimate diagnostic categories. This site includes also information concerning making a tentative diagnosis, a guide for severity scoring, a provisional diagnosis table, and a treatment response table for primary care clinicians. The maximum score is 27 (9 questions x maximum 3 points per question). A patient’s score is given out of 27. Depression severity is graded based on the PHQ-9 score as in
The PHQ-9 has been tested for validity and reliability in a range of languages. It has been validated also for use in a variety of populations, e.g. systematic sclerosis, depression in HIV/AIDs patients, and depression in diabetes patients. A PHQ-9 score of greater than 9 has a sensitivity of 83% and a specificity of 92% for major depressive disorder diagnosis (Kroenke et al., 2001). In this study, a positive depression screen was defined as PHQ-9 score greater than or equal to nine (≥9).
The consent of all participants was obtained before administering any questionnaires. The responses of all participants were kept confidential and their identity anonymous.
Moreover, a research clearance was obtained from the school administration and the regional delegation of health for the research to begging. At the level of the research area, authorization to start data collection is given by the director of the BRH and the General Supervisor. Furthermore, at the level of the research population, consent to start data collection was obtained by presentation of all ethical forms to the ward charge.
| Total Score | Depression Severity |
|---|---|
| 1 - 4 | Minimal depression |
| 5 - 9 | Mild depression |
| 10 - 14 | Moderate depression |
| 15 - 19 | Moderately severe depression |
| 20 - 27 | Severe depression |
Kroenke K, Linzer M, deGruy FV, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994; 272: 1749-1756.
| Characteristic | Attendance to Support Groups | Total n (n%) | Statistic | ||
|---|---|---|---|---|---|
| Number of Attendees | Number of Non-Attendees | ||||
| Aware about existence of support groups | n | 70 | 73 | 143 | p = 0.007 χ2 = 7.300 |
| % | 46.4% | 48.3% | 94.7% | ||
| Not aware of the existence of support groups | n | 0 | 9 | 8 | |
| % | 0.0% | 5.3% | 5.3% | ||
| Total | n | 70 | 82 | 152 | |
| % | 46.4% | 53.6% | 100.0% | ||
n% = percentage of cases, n = number of cases, χ2 = chi-square statistic p = probability value.
those who were non attendees of support groups were nearly half of the whole distribution 70 (46.4%). On the other hand, 9 (5.3%) of those who were not aware of the existence of support groups were all non-attendees. Nevertheless, the majority of participants 143 (94.7%) were aware of the existence of support groups while only 8 (5.3%) stated that they are not aware of any support group.
A chi-square test of association reveals that a significant relationship exists between being aware of the existence of support groups and being part of a support group. χ2 (1, N = 152) = 7.300, p = 0.007, and participants who are aware of support groups are more likely to get involved in support group sessions, (OR = 0.51, CI: 0.435 - 0.599).
Taking into consideration the diagnostic criteria of depression according to the PHQ-9, analysis portrayed in
| Characteristics | Categories of Responses Given by Participants | n | % |
|---|---|---|---|
| Reasons for participants for not registering or attending a support groups | Living far/lack of transportation means | 13 | 16.7 |
| Recently transferred to BRH or knew about SGs | 10 | 12.8 | |
| Personal occupations/being busy or having no time | 25 | 32.1 | |
| Other reasons | 5 | 6.4 | |
| Reluctant/ not interested to register and participate | 18 | 23.1 | |
| Not well sensitized about support groups | 6 | 7.7 | |
| Do not understand English during sensitization on support groups or education of PLHIV | 1 | 1.3 | |
| Total | 78 | 100.0 |
n = number of cases % = percentage of cases.
| Depressive Symptoms | Responses | Percent of Cases | ||
|---|---|---|---|---|
| N | Percent | |||
| Prevalence of depressive symptoms | Feeling tired | 62 | 15.90% | 57.40% |
| Lack of sleep | 57 | 14.60% | 52.80% | |
| Forgetful and restless | 55 | 14.10% | 50.90% | |
| Anhedonia | 47 | 12.10% | 43.50% | |
| Lack of appetite | 46 | 11.80% | 42.60% | |
| Self-worthlessness | 41 | 10.50% | 38.00% | |
| Sadness and feeling down | 39 | 10.00% | 36.10% | |
| Lack of concentration | 33 | 8.50% | 30.60% | |
| Suicide idea and thought of death | 10 | 2.60% | 9.30% | |
| Total | 390 | 100.0% | 361.1% | |
N = number of respondents.
feeling of being tired as the main symptom of depression that recognised 62 (15.90%) followed by insomnia 57 (16.4%) and forgetfulness/restlessness 55 (14.10). Moreover, 10 (2.6%) cases of the participants had suicide ideas or thought of death.
Missing cases 38 (25%) corresponding to participants who are not part of support groups or were part of support groups but had never attended one session.
| Categories (N = 71) | Mean ± SD | Statistics |
|---|---|---|
| In support group | 5.21 ± 5.634 | p = 0.641 t = −0.468 df = 70 |
| Not in support group | 5.62 ± 5.533 |
SD = standard deviation, N = total number of sample pairs.
| Responses of the participants with regard to how important support groups are to them | Responses | |
|---|---|---|
| N | % | |
| It helps me take my drugs regularly without missing | 22 | 22.40% |
| I have registered but never has attended a support group session | 19 | 19.40% |
| Give hope and the desire to live | 14 | 14.30% |
| It helps me talk about my status either with friends or family members | 13 | 13.30% |
| Help in learning of new behaviours, or coping skills | 11 | 11.20% |
| It is not really helpful in any way to me | 6 | 6.10% |
| It helps me not to feel stigmatise when I see people like me who are doing well | 4 | 4.10% |
| Other roles of support groups | 3 | 3.10% |
| Give education so as to know how to take care of oneself at home (nutrition and hygiene education) | 2 | 2.02% |
| Listen to good stories related to defaulters and personal care | 2 | 2.02% |
| It helps me know that I have to practice protected sex | 1 | 1.02% |
| Helps me develop my skills and provide me with financial support (bingo support group) | 1 | 1.02% |
| Total | 98 | 100.0% |
See
In relation to participants’ awareness to support group existence,
| No | Components that Guided Observations | Support Groups under Observation | |
|---|---|---|---|
| Bamenda Regional Hospital Support Group | Tubah District Hospital (BAMBUI) | ||
| 1 | Does the support group facilitate mutual support among group members and reduce isolation? | YES, At the end of each session, participants coming from the same locality are made to know themselves, share phone contact and they are paired so as to serve as relay agents among themselves. Moreover, group members show willingness to share their personal problems which sometimes even proves to be complex or very intimate. | YES, evidence by the fact that group members feel happy on observation when they meet together after one month of separation and surprisingly they are able to call each other by names despite their large numbers. |
| 2 | Does the support group improve social and family support/decrease feelings of loneliness and guilt? | YES. Participants who even intend to get married are encouraged to come with their partners so that they can be help to disclose their status. Moreover, they are continuously enlightened on the importance of disclosing their status to close relative. This helps in relieving anxiety associated with reprisals of disclosing their status. | NO, even though the group decreases feeling of loneliness to an extent, activities here were mainly limited to sharing of ARVs. |
| 3 | Does it promote greater openness and emotional expressiveness both within and outside the group? | NO. It should be noted that support group sessions that are done during the outreach at Tubah district hospital (Banbui) are done by archivist who are concerned with the management of patients’ file at the regional hospital. They have no training related to health but handle the support group of Tubah based on routine practices and observations made at the level of BRH. Their main activity focus on encouraging patients to adhere to their ARVs, do their CD4 count and to identify those who are at potential risks. Less or no time is was dedicated to discussion, but to activities that are normally performed during each clinic day when clients come for their normal visits such as registering patients and giving ARVs. No education on safer sexual practices was observed. No; no time was allocated so as to share with participants how they can valuably exploit their talents or abilities so as to improve on their quality of life. | |
| 4 | Does the support group facilitate integration of a changed self and body image into the patient’s current view of self? | NO. Instead, participants are enlightened on adjustment patterns that can help them improve on their body image without making them to see the effects of HIV on their physical appearance. | |
| 5 | Does it improve coping skills and normalization of experiences? | YES. New coping skills are learned and enrich the spectrum of their existing coping skills. Their sources of inspiration lies on sharing of experiences observed from other members. | |
| 6 | Improve the doctor-patient Relationship? | YES. Participants are reminded to always present the least complain related to their disease, side effects of ARVs or even opportunistic infection because any of them could proceed to a fatal complication. | |
| 7 | Is there detoxification of feelings around death and dying in the support group? | YES. Even though the participants see other PLHIV dying, they are made to understand that death results mainly from defaulting, non-adherence, social isolation and depression. | |
| 8 | Does it help patients develop a life project? | More or less. Even though they are told that HIV is not the end and that it should not prevent them from proceeding with their normal activities, no participant was observed to be given the opportunity share his or her experience or on how he/she is succeeding in business. Or other activity. | |
| 9 | Does the support group promote safer sexual practices? | YES. They are encourage on the importance of abstinence, fidelity and use of condom, and are cautioned on how resistance to HAART develops when unsafe sexual practice is carried out. | |
| 10 | Does it enhance quality of life and greater authenticity? | YES. PLHIV are encouraged to use the time with which they are left with to do valuable activities that can promote psychological, socioeconomic wellbeing. | |
Looking in the same direction, we see that out of those who were aware of support group existence 143 (94.7%), only 70 (46.4%) were support group attendees. This result is inconsistent to that found by Kekana (2011) in an almost similar descriptive research on perceived barrier to participate to support groups by PLHIV in South Africa where, majority of participant (58.06%) were instead non attendees. This difference may be accounted by the fact that, having most participants as literate, they face a lot of concern with their privacy, while in our context they instead have an unexplainable reluctance to participate. Going in the same line, a strong evidence of association between awareness and participation into support groups existed χ2 = 7.300, p = 0.007, where participants who were aware of support groups were 0.5 times more likely to take part into support groups (OR = 0.51, CI: 0.435 - 0.599). Madiba & Canti-Sigaqa (2012) reported in a qualitative study with men receiving ART in a HIV Clinic in Mthatha, South Africa that participants who were aware of support groups perceived support groups as valuable to PLHIV.
Using the PHQ-9 as diagnostic tool for depression, the results of the study reveals an overall mean depression score of 5.41 (SD = 5.55). Following this, it was found that 45 (29.61%) (95% CI: 22.5% - 35.7%) were positive for depression. Nevertheless,
In addition, feeling tired or lack of energy 62 (15.9%) was the most depressive symptom followed by insomnia 57 (14.6%) with the least being suicide ideation or preferring death 10 (2.6%) as shown in
As earlier seen in
In relation to the role of support groups,
Moreover, in comparing the mean depression scores between participants in support groups and those that are not,
This research did not do a logistic regression analysis to determine whether depressive symptoms were due to the fact that participants were not part of support groups or due to adverse effects of antiretroviral therapy, hence a problem from confounding.
Support groups in Cameroon are still emerging and in their genesis, so their efficiency in helping depressed individuals should not be over expected and therefore needs further assessment so as to accept their credibility.
Reasons why support group attendees stated that it is of no help to them were not assessed in this research; hence further assessment will mitigate this limitation.
Language barrier and illiteracy was a capital challenge in gathering information from participants since the components of the PHQ-9 needed some cognitive efforts for those who self-administered the questionnaire and understanding for those who were interviewed. In using down to earth language with illiterate participants, reliability of the responses is altered compared to when participants provide answers to questions themselves.
The authors declare no conflicts of interest regarding the publication of this paper.
Wamia, A. L., & Victorine, N. (2019). The Role of Support Groups in the Management of Depression amongst People Living with HIV at Regional Hospital of Bamenda. Open Journal of Depression, 8, 71-84. https://doi.org/10.4236/ojd.2019.84008