Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania

PLoS ONE, Volume 14, No. 10, Year 2019

Interpretation

Introduction Mental health disorders in pregnant women living with HIV are associated with poor maternal and child outcomes, and undermine the global goals of prevention of mother-to-child transmission of HIV (PMTCT). This study aimed to determine prevalence of depression and anxiety and identify factors associated with these common mental health disorders among HIV-infeced pregnant women in Tanzania. Methods We enrolled 200 pregnant women living with HIV from antenatal care clinics in the Kilimanjaro region. Women were eligible if they were in the second or third trimester of pregnancy and had been in PMTCT care for a minimum of one month. Data were collected via interviewer administered surveys. Participants self reported depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and anxiety symptoms (Brief Symptom Index, BSI). Multivariate logistic regression models examined factors associated with depression, anxiety, and comorbid depression and anxiety. Results 25.0% of women met screening criteria for depression (EPDS ≥10). Depression was significantly associated with being single (aOR = 4.2, 95% CI = 1.1–15.5), food insecurity (aOR = 2.4, 95% CI = 1.0–6.4), and HIV shame (aOR = 1.2, 95% CI = 1.1–1.3). 23.5% of participants met screening criteria for anxiety (BSI ≥1.01). Anxiety was associated with being single (aOR = 3.6, 95%CI = 1.1–11.1), HIV shame (aOR = 1.1, 95% CI = 1.1–1.2) and lifetime experience of violence (aOR = 2.3, 95% CI = 1.0–5.1). 17.8% of the sample met screening criteria for both depression and anxiety. Comorbid depression and anxiety was associated with being single (aOR = 4.5, 95%CI = 1.0–19.1), HIV shame (aOR = 1.2, 95%CI = 1.1–1.3) and lifetime experience of violence (aOR = 3.4, 95% CI = 1.2–9.6). Conclusion Depression and anxiety symptomatology was common in this sample of pregnant women living with HIV, with a sizable number screening positive for comorbid depression and anxiety. In order to successfully engage women in PMTCT care and support their well-being, strategies to screen for mental health disorders and support women with mental illnesses are needed. This was a cross-sectional study among HIV-positive pregnant women in the Kilimanjaro Region. Participants were recruited at nine antenatal clinics, including six from the Moshi municipality and three from the Moshi district. As per Tanzanian national PMTCT guidelines, all pregnant women who test positive for HIV initiate antiretroviral therapy (ART) for lifetime use [22]. Women were eligible to enroll in the study if they were in the second or third trimester of pregnancy and had enrolled in PMTCT care at one of the study antenatal clinics at least one month prior. Additionally, age 18 years and above and provided a written informed consent. The structured survey was based on the baseline survey of a 12 month longitudinal survey of HIV-positve pregnant women in the Kilimanjaro Region [23]. Pregnant women living with HIV presenting for their routine antenatal care were consecutively approached by the clinic nurses informed of the study and asked if they were interested in obtaining more information. Between Juy 2016 and August 2017 436 pregant women living with HIV who attended ANC were approached, 221 experessed interest in the study and were referred to the research office for screening and enrollment (Fig 1). After obtaining informed consent, a structured survey was verbally administered in Swahili by a trained data collector. Study activities were conducted in private offices located within the study clinics. The assessment took approximately 60 minutes to complete. Participants were reimbursed for transportation costs (5,000 Tanzania shillings; approximately $2.30 U.S.) and were provided with light snacks during the interview. Participants with distress and thought of self-harm were counselled by the study nurse and also helped to create an individualized safety plan. Additionally, they were referred back to the clinic counsellor for further support. The data collection tools were translated into Swahili and then back-translated into English by two independent translators. If there was a difference between the two after back translation, a team of Swahili and English-speaking study staff reached consensus on the final wording. In addition to socio-demographic variables (age, level of education, employment status, prior pregnancy, and relationship status), the following measures were included in the survey. Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) [24]. The EPDS contains ten questions asking about depressive symptoms over the past seven days. Each question has four possible responses, with a score of 0 to 3. Items were summed, with a possible range of 0 to 30 and higher scores indicating more depression symptoms (α = 0.88). A score of 10 was used as a cut-off to indicate possible depression [25]. Anxiety was measured using the six-item anxiety subscale of the Brief Symptom Index (BSI-18) [26]. Items asked about anxiety symptoms over the past seven days, with response options on a 5-point scale, ranging from 0 (not at all) to 4 (extremely). Items were averaged, with a possible range of 0 to 5 (α = 0.92). Based on instrument norms for a non-clinical, female population, a score of 1.01 or higher was used as a cut-off to indicate probable anxiety [27]. An 8-item measure was adapted from Speizer and colleagues to assess attitudes about pregnancy [28]. Items were summed, with a possible range from 0 to 24 and higher scores indicating more positive attitudes about the pregnancy (α = 0.91). The modified WHO intimate partner violence tool was used to assess for history of intimate partner violence, including questions about emotional, physical, and sexual abuse. The violence scores were dichotomised, with a yes to any of the aforementioned questions being indicative of a lifetime history of violence [29]. A stigma measure was adapted from the Holzemer HIV/AIDS Stigma Instrument (HASI) [30]. The 11 items asked about stigmatizing experiences as a result of HIV (e.g., someone stopped being a friend). Items were summed, with a possible range from 0 to 33 and higher scores indicating greater experience with stigma (α = 0.88). The HIV and Abuse Related Shame Inventory (HARSI) was used to measure HIV shame [31]. The current study adapted 13 statements from the 14-item HIV-related shame subscale of the measure. The 13 items asked about internalized feelings related to living with HIV (e.g., I put myself down for becoming HIV positive, I am ashamed that I’m HIV positive). Items were summed, with a possible range from 0 to 52 and higher scores indicating greater shame (α = 0.86). Four items from the Household Food Insecurity Access Scale (HFIAS) were used to assess household food availability over the past 30 days [32]. We adapted four questions from the nine-item household food insecurity scale (e.g. In the past month, how often could you not feed your family?). The measure was dichotomized into whether or not someone reported any food insecurity. The Perceived Availability of Support Scale (PASS) was used to measure social support [33]. The participants were asked to respond to 8 questions (e.g., Would someone be available to talk to you if you were upset, nervous, or depressed?). Scores ranged from 8 to 40 with higher scores indicating greater perceived support from others (α = 0.82). Of the tools used to measure outcomes and the explanotory variables, only food security and enacted stigma assessment tools have been validated in Tanzania [32]. Though not in Tanzania, some have been validated in other East African countries, for example, anxiety measure (BSI) has been validated in Kenya [34] Women enrolled were asked if they had disclosed their HIV status to anyone or a sexual partner (Have you told anyone about your HIV status?). Also, their partner HIV status. Ethical approval for the study was provided by the University of Cape Town Human Research Ethics Committee. The ethical review boards of the Tanzanian National Institute for Medical Research and Kilimanjaro Christian Medical University. Eligible participants were asked to sign a form providing informed consent before their participation. Participants who could not read or write were asked to provide a thumbprint and their consent was verified by the signature of an impartial witness of the participant’s choice. Stata Version 14.0 was used to analyse the data. Frequency distributions and descriptive statistics were calculated for categorical and continuous variables. Three multivariate logistic regression models were developed to assess the factors associated with depression, anxiety, and comorbid depression and anxiety. To control for confounders and reduce residual confounding effects, factors with a p-value of 0.15 or less in bivariate analysis were considered eligible for inclusion in the multivariate analysis, along with demographic variables (age, level of education and marital status) that were selected a priori. Factors with a p-value of less than 0.05 in the final model were considered statistically significant.

AI Digest

Study Justification:

This study aimed to investigate the prevalence of depression and anxiety among pregnant women living with HIV in the Kilimanjaro region of Tanzania. The study is important because mental health disorders in this population can have negative effects on both maternal and child outcomes. By understanding the factors associated with depression and anxiety, interventions can be developed to support the well-being of pregnant women living with HIV and improve the success of prevention of mother-to-child transmission of HIV (PMTCT) programs.

Study Highlights:

– The study enrolled 200 pregnant women living with HIV from antenatal care clinics in the Kilimanjaro region.
– The prevalence of depression among the participants was 25.0%, and the prevalence of anxiety was 23.5%.
– Factors associated with depression included being single, food insecurity, and HIV shame.
– Factors associated with anxiety included being single, HIV shame, and lifetime experience of violence.
– 17.8% of the participants met screening criteria for both depression and anxiety.
– Strategies to screen for mental health disorders and support women with mental illnesses are needed to improve engagement in PMTCT care.

Recommendations for Lay Readers and Policy Makers:

1. Implement routine screening for depression and anxiety among pregnant women living with HIV in antenatal care clinics.
2. Develop interventions to address the identified factors associated with depression and anxiety, such as providing support for single women, addressing food insecurity, and reducing HIV-related stigma.
3. Enhance access to mental health services for pregnant women living with HIV, including counseling and support for those experiencing distress or thoughts of self-harm.
4. Strengthen social support networks for pregnant women living with HIV to improve their overall well-being.
5. Collaborate with relevant stakeholders, including healthcare providers, community organizations, and policymakers, to ensure the implementation of these recommendations.

Key Role Players:

1. Healthcare providers: Responsible for implementing routine screening and providing appropriate support and referrals.
2. Community organizations: Can play a role in providing additional support services and raising awareness about mental health among pregnant women living with HIV.
3. Policymakers: Responsible for creating policies that support the integration of mental health services into antenatal care and ensuring adequate resources are allocated for implementation.
4. Researchers: Can continue to conduct studies to further understand the mental health needs of pregnant women living with HIV and evaluate the effectiveness of interventions.

Cost Items for Planning Recommendations:

1. Training and capacity building for healthcare providers on mental health screening and support: Includes costs for workshops, materials, and ongoing supervision.
2. Development and implementation of mental health interventions: Includes costs for program development, training of intervention providers, and monitoring and evaluation.
3. Integration of mental health services into antenatal care clinics: Includes costs for infrastructure modifications, equipment, and staffing.
4. Awareness campaigns and community engagement: Includes costs for materials, events, and outreach activities to raise awareness about mental health and reduce stigma.
5. Research and evaluation: Includes costs for data collection, analysis, and dissemination of findings to inform future interventions and policies.
Please note that the cost items provided are for planning purposes and do not reflect actual costs. The specific budget for implementing these recommendations would depend on the local context and available resources.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causality. However, the study includes a relatively large sample size of 200 pregnant women living with HIV in the Kilimanjaro region. The researchers used validated measures to assess depression and anxiety symptoms, and conducted multivariate logistic regression models to identify factors associated with these mental health disorders. The study findings provide important insights into the prevalence and factors associated with depression and anxiety among pregnant women living with HIV in Tanzania. To improve the strength of the evidence, future research could consider using a longitudinal design to establish temporal relationships between variables and conduct more in-depth assessments of mental health disorders.

Abstract

This was a cross-sectional study among HIV-positive pregnant women in the Kilimanjaro Region. Participants were recruited at nine antenatal clinics, including six from the Moshi municipality and three from the Moshi district. As per Tanzanian national PMTCT guidelines, all pregnant women who test positive for HIV initiate antiretroviral therapy (ART) for lifetime use [22]. Women were eligible to enroll in the study if they were in the second or third trimester of pregnancy and had enrolled in PMTCT care at one of the study antenatal clinics at least one month prior. Additionally, age 18 years and above and provided a written informed consent. The structured survey was based on the baseline survey of a 12 month longitudinal survey of HIV-positve pregnant women in the Kilimanjaro Region [23]. Pregnant women living with HIV presenting for their routine antenatal care were consecutively approached by the clinic nurses informed of the study and asked if they were interested in obtaining more information. Between Juy 2016 and August 2017 436 pregant women living with HIV who attended ANC were approached, 221 experessed interest in the study and were referred to the research office for screening and enrollment (Fig 1). After obtaining informed consent, a structured survey was verbally administered in Swahili by a trained data collector. Study activities were conducted in private offices located within the study clinics. The assessment took approximately 60 minutes to complete. Participants were reimbursed for transportation costs (5,000 Tanzania shillings; approximately $2.30 U.S.) and were provided with light snacks during the interview. Participants with distress and thought of self-harm were counselled by the study nurse and also helped to create an individualized safety plan. Additionally, they were referred back to the clinic counsellor for further support. The data collection tools were translated into Swahili and then back-translated into English by two independent translators. If there was a difference between the two after back translation, a team of Swahili and English-speaking study staff reached consensus on the final wording. In addition to socio-demographic variables (age, level of education, employment status, prior pregnancy, and relationship status), the following measures were included in the survey. Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) [24]. The EPDS contains ten questions asking about depressive symptoms over the past seven days. Each question has four possible responses, with a score of 0 to 3. Items were summed, with a possible range of 0 to 30 and higher scores indicating more depression symptoms (α = 0.88). A score of 10 was used as a cut-off to indicate possible depression [25]. Anxiety was measured using the six-item anxiety subscale of the Brief Symptom Index (BSI-18) [26]. Items asked about anxiety symptoms over the past seven days, with response options on a 5-point scale, ranging from 0 (not at all) to 4 (extremely). Items were averaged, with a possible range of 0 to 5 (α = 0.92). Based on instrument norms for a non-clinical, female population, a score of 1.01 or higher was used as a cut-off to indicate probable anxiety [27]. An 8-item measure was adapted from Speizer and colleagues to assess attitudes about pregnancy [28]. Items were summed, with a possible range from 0 to 24 and higher scores indicating more positive attitudes about the pregnancy (α = 0.91). The modified WHO intimate partner violence tool was used to assess for history of intimate partner violence, including questions about emotional, physical, and sexual abuse. The violence scores were dichotomised, with a yes to any of the aforementioned questions being indicative of a lifetime history of violence [29]. A stigma measure was adapted from the Holzemer HIV/AIDS Stigma Instrument (HASI) [30]. The 11 items asked about stigmatizing experiences as a result of HIV (e.g., someone stopped being a friend). Items were summed, with a possible range from 0 to 33 and higher scores indicating greater experience with stigma (α = 0.88). The HIV and Abuse Related Shame Inventory (HARSI) was used to measure HIV shame [31]. The current study adapted 13 statements from the 14-item HIV-related shame subscale of the measure. The 13 items asked about internalized feelings related to living with HIV (e.g., I put myself down for becoming HIV positive, I am ashamed that I’m HIV positive). Items were summed, with a possible range from 0 to 52 and higher scores indicating greater shame (α = 0.86). Four items from the Household Food Insecurity Access Scale (HFIAS) were used to assess household food availability over the past 30 days [32]. We adapted four questions from the nine-item household food insecurity scale (e.g. In the past month, how often could you not feed your family?). The measure was dichotomized into whether or not someone reported any food insecurity. The Perceived Availability of Support Scale (PASS) was used to measure social support [33]. The participants were asked to respond to 8 questions (e.g., Would someone be available to talk to you if you were upset, nervous, or depressed?). Scores ranged from 8 to 40 with higher scores indicating greater perceived support from others (α = 0.82). Of the tools used to measure outcomes and the explanotory variables, only food security and enacted stigma assessment tools have been validated in Tanzania [32]. Though not in Tanzania, some have been validated in other East African countries, for example, anxiety measure (BSI) has been validated in Kenya [34] Women enrolled were asked if they had disclosed their HIV status to anyone or a sexual partner (Have you told anyone about your HIV status?). Also, their partner HIV status. Ethical approval for the study was provided by the University of Cape Town Human Research Ethics Committee. The ethical review boards of the Tanzanian National Institute for Medical Research and Kilimanjaro Christian Medical University. Eligible participants were asked to sign a form providing informed consent before their participation. Participants who could not read or write were asked to provide a thumbprint and their consent was verified by the signature of an impartial witness of the participant’s choice. Stata Version 14.0 was used to analyse the data. Frequency distributions and descriptive statistics were calculated for categorical and continuous variables. Three multivariate logistic regression models were developed to assess the factors associated with depression, anxiety, and comorbid depression and anxiety. To control for confounders and reduce residual confounding effects, factors with a p-value of 0.15 or less in bivariate analysis were considered eligible for inclusion in the multivariate analysis, along with demographic variables (age, level of education and marital status) that were selected a priori. Factors with a p-value of less than 0.05 in the final model were considered statistically significant.

Materials

https://efashare.b-cdn.net/materials/192f1ed82cf8800d516cc417ae880b93c35aec2cf71718402de7e280095d187b/pone.0224515.s001.xls

Innovations

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health for pregnant women living with HIV:

1. Integrated Mental Health Services: Implementing integrated mental health services within antenatal care clinics can help identify and address depression and anxiety among pregnant women living with HIV. This can involve training healthcare providers to screen for mental health disorders and provide appropriate support and referrals.

2. Mobile Health (mHealth) Interventions: Developing mobile health interventions, such as smartphone applications or text message-based programs, that provide information, support, and reminders for pregnant women living with HIV can improve access to maternal health services. These interventions can include mental health resources and tools for self-assessment and self-management of depression and anxiety symptoms.

3. Peer Support Programs: Establishing peer support programs specifically tailored for pregnant women living with HIV can provide a supportive and non-judgmental environment for sharing experiences, coping strategies, and emotional support. Peer support can help reduce stigma, increase engagement in PMTCT care, and improve mental well-being.

4. Community-Based Outreach: Implementing community-based outreach programs to reach pregnant women living with HIV who may face barriers to accessing antenatal care. These programs can involve community health workers or volunteers who provide education, counseling, and support services directly in the community, addressing the unique needs and challenges faced by this population.

5. Task Shifting: Training and empowering non-specialist healthcare providers, such as nurses or midwives, to deliver mental health services and support to pregnant women living with HIV. This can help alleviate the shortage of mental health specialists and increase access to care in resource-limited settings.

6. Collaborative Care Models: Implementing collaborative care models that involve a multidisciplinary team of healthcare providers, including mental health specialists, obstetricians, and HIV specialists, working together to provide comprehensive care for pregnant women living with HIV. This model can ensure that mental health needs are integrated into routine antenatal care and that appropriate referrals and follow-up are provided.

It’s important to note that the feasibility and effectiveness of these innovations may vary depending on the local context and available resources. Further research and evaluation are needed to determine the most appropriate and sustainable approaches to improve access to maternal health for pregnant women living with HIV.

AI Innovations Description

Based on the provided information, the recommendation to improve access to maternal health for pregnant women living with HIV in the Kilimanjaro region, Tanzania is to implement strategies to screen for and support women with mental health disorders, specifically depression and anxiety.

The study found that depression and anxiety symptomatology was common among pregnant women living with HIV in the region, with a significant number screening positive for comorbid depression and anxiety. The factors associated with these mental health disorders included being single, food insecurity, HIV shame, and lifetime experience of violence.

To address this issue and improve access to maternal health, the following actions can be taken:

1. Implement routine screening: Integrate mental health screening, specifically for depression and anxiety, into the antenatal care services provided to pregnant women living with HIV. This can be done using validated screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) and the Brief Symptom Index (BSI-18).

2. Provide mental health support: Establish a system to provide appropriate mental health support to pregnant women who screen positive for depression and anxiety. This can include referral to mental health professionals, counseling services, and support groups.

3. Address social determinants: Address the social determinants of mental health, such as food insecurity and experiences of violence, by implementing interventions that aim to improve access to nutritious food and provide support for survivors of violence.

4. Reduce stigma: Develop and implement stigma reduction programs that aim to reduce HIV-related stigma and shame. This can include community education, awareness campaigns, and support groups for women living with HIV.

5. Strengthen social support networks: Enhance social support networks for pregnant women living with HIV by providing opportunities for peer support, connecting women with support groups, and ensuring access to supportive services.

By implementing these recommendations, access to maternal health for pregnant women living with HIV can be improved, leading to better maternal and child outcomes and supporting the global goals of prevention of mother-to-child transmission of HIV.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health for pregnant women living with HIV:

1. Integrated care: Implement integrated care models that combine maternal health services with HIV care and support. This can involve co-locating antenatal care clinics with HIV treatment centers to provide comprehensive services in one location.

2. Mental health screening: Integrate routine mental health screening into antenatal care for pregnant women living with HIV. This can help identify and address depression and anxiety early on, improving overall maternal well-being and outcomes.

3. Peer support programs: Establish peer support programs for pregnant women living with HIV. Peer support can provide emotional support, reduce stigma, and improve adherence to HIV treatment and antenatal care.

4. Community outreach: Conduct community outreach programs to raise awareness about maternal health and HIV prevention, targeting pregnant women and their families. This can help reduce stigma, increase knowledge about available services, and encourage early engagement in care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women living with HIV accessing integrated care, the percentage screened for mental health disorders, the percentage participating in peer support programs, and the percentage reached through community outreach.

2. Data collection: Collect baseline data on the current status of access to maternal health for pregnant women living with HIV in the target area. This can involve surveys, interviews, and data from health facilities and community organizations.

3. Model development: Develop a simulation model that incorporates the identified indicators and their relationships. This can be done using statistical software or specialized simulation tools.

4. Parameter estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This can involve statistical analysis and expert input.

5. Scenario testing: Simulate different scenarios by adjusting the input parameters to reflect the potential impact of the recommendations. For example, simulate the impact of increasing the percentage of pregnant women accessing integrated care or the percentage participating in peer support programs.

6. Analysis and interpretation: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This can involve comparing different scenarios, identifying key drivers of change, and assessing the feasibility and cost-effectiveness of the recommendations.

7. Recommendations and implementation: Based on the simulation results, make recommendations for implementing the identified innovations to improve access to maternal health for pregnant women living with HIV. Consider the potential challenges, resource requirements, and sustainability of the recommendations.

8. Monitoring and evaluation: Implement the recommended innovations and establish a monitoring and evaluation system to track progress and measure the actual impact on access to maternal health. This can involve regular data collection, analysis, and adjustment of strategies based on the findings.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of innovations on improving access to maternal health for pregnant women living with HIV and make informed decisions for implementation.

Authors & Co-Authors

Statistics:

Citations: 30

Authors: 7

Identifiers:

DOI: 10.1371/journal.pone.0224515

Research Areas:

Community Interventions, Disparities, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury

Study Countries:

Kenya, Multi-Countries, Tanzania

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female