On-Time Appointment Keeping and Associated Factors among Human Immunodeficiency Virus-Positive Adult Patients Accessing Antiretroviral Therapy at Health Centers in East Gojjam Zone, Northwest Ethiopia, 2019

Tariku, Mengistie Kassahun; Belete, Abebe Habtamu; Worede, Daniel Tarekegn; Misikir, Sewnet Wongiel

doi:https://doi.org/10.1155/2023/1416187

AIDS Research and Treatment

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Abstract Background Methods Results Discussion Conclusion Abbreviations Data Availability Ethical Approval Consent Disclosure Conflicts of Interest Authors’ Contributions Acknowledgments Supplementary Materials References Copyright Related Articles

Research Article | Open Access

Volume 2023 | Article ID 1416187 | https://doi.org/10.1155/2023/1416187

On-Time Appointment Keeping and Associated Factors among Human Immunodeficiency Virus-Positive Adult Patients Accessing Antiretroviral Therapy at Health Centers in East Gojjam Zone, Northwest Ethiopia, 2019

Mengistie Kassahun Tariku,¹Abebe Habtamu Belete,¹Daniel Tarekegn Worede,¹and Sewnet Wongiel Misikir²

Academic Editor: Kwame Yeboah

Received19 Mar 2023

Revised13 Nov 2023

Accepted16 Nov 2023

Published30 Nov 2023

Abstract

Background. The magnitude of on-time appointment keeping among HIV-positive adult patients was not identified in Ethiopia. Hence, this study aimed to assess on-time appointment keeping and associated factors among human immunodeficiency virus-positive patients accessing antiretroviral therapy in the East Gojjam Zone, Northwest Ethiopia. Methods. A community-based cross-sectional study was performed on 830 HIV-positive patients from April 1 to May 10, 2019, in East Gojjam Zone. A systematic random sampling technique was used to include study subjects, and data were collected through face-to-face interviews. Bivariable and multivariable binary logistic regression analyses were performed. Independent variables with a value of <0.05 were considered statistically significant cut points. Results. The prevalence of on-time appointment keeping was 62.1%. Being >24 years old (adjusted odds ratio (AOR) = 2.13; 95% confidence interval (CI) = 1.54–4.25), being unmarried (AOR = 0.59; 95% CI = 0.45–0.82), taking a drug regimen of tenofovir + lamivudine (3TC) + efavirenz (EFV) (AOR = 2.11; 95% CI = 1.84–3.62), taking ART ≥12 months (AOR = 4.32; 95% CI = 2.22–8.40), having a mobile (AOR = 2.22; 95% CI = 1.44–3.64), and getting adherence support (AOR = 1.83; 95% CI = 1.16; 95% 1.16–3.50) were significant factors. Conclusion. On-time appointment keeping was low. Adherence support and appointment reminders should be strengthened.

1. Background

Adherence to antiretroviral therapy (ART) is an inclusive idea consisting of two basic components: medication adherence and on-time attendance at scheduled clinic appointments [1]. Appointments are classified as “on-time” if the patients attend the clinic within seven days of the scheduled clinic appointment [2]. On-time appointment keeping provides a high-level assessment of how well populations of patients at a clinic perform in picking up prescribed ART on or before the pill run-out date. It also estimates clinic performance in successfully engaging patients to attend scheduled appointments [2]. The World Health Organization (WHO) recommended that the acceptable clinic-level performance of on-time appointment keeping should be above 80% [2]. It is vital for 100% lifetime medication adherence [3].

In the management of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), on-time clinical attendance for pharmacy refills, laboratory investigations, and clinician assessments are crucial for successful treatment achievements and good clinical outcomes [4]. When patients miss scheduled appointments, the opportunity to early identify and manage treatment failure vanishes [4, 5].

Although medication adherence is supposed to be the most important factor in treatment outcome, the previous study has revealed that missed clinic appointments from ART clinics are significantly associated with virological failure [6], drug resistance, and an increased risk of AIDS-related illness or death [5].

Even though there has been increased public and patient awareness of the ways of immunodeficiency virus (HIV) infection prevention and the benefits of antiretroviral therapy (ART) globally [7], the interruption of scheduled clinical appointments has been high in Africa [8]. Healthcare delivery systems, patient-related, sociodemographic, psychosocial, and clinical-related factors are associated with clinic appointment attendance [9, 10]. Sometimes HIV-positive patients are appointed orally. This leads to missing the appointment [5].

Antiretroviral therapy (ART) distribution and HIV/AIDS preventive programs are both localized in Ethiopia. As a result of prior research’s primary focus on medication adherence, Ethiopia’s current HIV treatment strategy is faith based [5], but there is limited evidence for the magnitude of on-time appointment keeping and associated factors [11]. Therefore, this study aimed to assess on-time appointment keeping and associated factors among human immunodeficiency virus-positive adult patients accessing antiretroviral therapy at health centers in East Gojjam Zone, Northwest Ethiopia.

2. Methods and Procedure

2.1. Study Design Setting

A community-based cross-sectional study design was performed from April 1 to May 10, 2019, at government health centers in East Gojjam Zone. This zone is found in the Amhara region, of Northwest Ethiopia. It is the second most populated zone in the region, with 2,719,119 total estimated population. There were eight government hospitals and 102 government health centers in this zone. Out of the total government health facilities, all hospitals and 23 health centers provided ART services and care for patients. About 11302 HIV-positive patients received ART at these health facilities [12]. All adult HIV-positive patients receiving ART and having scheduled appointments from May 03/2018 to May 03/2019, at selected government health centers in East Gojjam Zone were included in the study. In contrast, HIV-positive women who were pregnant, labouring, lactating women, or seriously ill patients were excluded. Those HIV-positive patients whose appointments had no registered appointment dates were also excluded.

2.2. Sample Size Determination and Sampling Technique

The sample size was determined using a single population formula. It was calculated via the formula (n = ((Z/2)²P (1 − P))/S²) with consideration of a 95% confidence interval and 5% margin error (S). The assumption of on-time appointment keeping of 43% was taken from the study conducted in three countries of Africa [5]. The calculated sample size was 377. This calculated sample size was also multiplied by the design effect of 2, and by adding 10% nonresponse, the total sample size was 830. A multistage sampling technique was employed to select study participants. The lottery method, a simple random sampling technique, was used to select 8 governmental health centers from 23 governmental health centers. The total sample size was proportionally distributed to eight governmental health centers. A total of 6139 eligible HIV-positive patients attended ART at selected health centers. During the time of the health center visit, study participants were selected by systematic random sampling at intervals of seven from each health center.

2.3. Data Collection Procedure

Based on a review of pertinent literature [13, 14], a structured questionnaire (Appendix 3) and checklist (Appendix 2) were designed. As identifiers, patient record numbers were used to connect patients with their medical histories. Primary data were gathered by HIV-positive community health workers who had completed grade ten or higher in education (HIV-positive voluntary community health workers are also employed as ART defaulter tracers in Ethiopia.) and conducted face-to-face interviews with patients. Patients’ addresses were obtained from health centers. Home visits served as the method for gathering data. Secondary data were also taken from the medical records of chosen ART patients.

The dependent variable was on-time appointment keeping. Appointment keeping can be easily accessed from attendance records. If a patient has been visiting within seven days of all scheduled clinic appointments for 12 months, or within 24–48 hours before the “original” scheduled appointment [15], it is scored as 1 (yes); if a person has missed one or more scheduled clinic appointments for any reason(s), it is scored as 0 (no) [16]. This study did not consider unscheduled visits to an emergency room, an inpatient ward, or any ward [15].

Independent variables were sociodemographic (such as sex, age, residence, educational status, occupation, marital status, and monthly income), healthcare delivery systems (such as paper-based appointments, follow-up counseling, ever-faced unavailability of health workers, appointment time convenience, and satisfaction), patient-related, psychosocial (Appendix 3), and clinical-related factors (Appendix 2). The perceived social stigma was assessed using ten questions with “yes” or “no” response choices [17]. Perceived stigma was defined by having at least 1 yes answer out of the 10 questions. Satisfaction was measured by using sixteen questions [18]. Satisfaction was defined as having equal to median or above median of 16 satisfaction-related questions.

2.4. Data Quality Control

Before data collection, a questionnaire was translated into the local language (Amharic) and converted back into English to check its consistency. Two days of training were given to eight data collectors and four supervisors about the data collection process. To check the consistency of the questionnaire, a pretest was performed. The collected data were checked for completeness and consistency daily by supervisors. Before data entry, the completeness and consistency of the data were also checked.

2.5. Data Entry and Analysis

After checking data completeness, it was coded and entered into EpiData version 3.1, and then it was exported to SPSS version 23 for analysis. Before binary logistic regression analysis, descriptive analysis was performed. A bivariable analysis was conducted. Independent variables with a value of <0.2 in bivariable binary logistic regression analysis were selected for multivariable binary logistic regression analysis. A multivariable binary logistic regression analysis was performed. Each independent variable with a value of less than 0.05 was considered a statistically significant cut point in multivariable binary logistic regression analysis.

3. Results

3.1. Sociodemographic and Economic Characteristics

The study included 825 participants with a 99.4% response rate. Out of the total study participants, 416 (50.4%) were female. The median age was 37 years, with an interquartile range (IQR) of 33–43 years. Four hundred and sixty-nine (56.8%) were urban dwellers. Regarding educational level, 361 (43.2%) had no formal education. Nearly three-tenths (28.8%) of the participants were merchants. Four hundred and eighty-four (58.7%) were married. The median monthly income was 1720 (IQR = 1234 to 2562) birr (Table 1).

3.2. Clinical Characteristics

Among the total study participants, 369 (44.7%) had stage I HIV. The median CD4 count was 430 (IQR = 254–650) cells/mm³. The majority, 694 (84.1%) of participants, had a working functional status. Seven hundred and thirteen (86.4%) had normal nutritional status. More than half (475, or 57.6%) of the study participants have taken the TDF + 3TC + EFV drug regimen. Five hundred thirty-three (64.6%) people encountered an opportunistic infection. More than three-fourths, or 649 (78.7%), of participants, did not experience side effects (Table 2).

3.3. Psychosocial, Behavioral, and Healthcare Delivery System Characteristics

More than three-fifths of study participants had not faced stigma. Four hundred ninety-five (60.0%) were members of the PLWHA association. Three-fourths (74.2%) of the study participants had not received social support. Nearly, three-fifths, or 518 (62.8%) of study participants, have gotten paper-based appointments. Four hundred and seventy-eight (57.9%) had not gotten follow-up counseling. Nearly, three-fifths of study participants’ appointment times were not convenient. Nearly half, that is, 389 (48.2%), were substance abusers (Table 3).

3.4. Outcome Data

Of the total study participants, 512 (62.1%; 95% CI: 58.9%–65.3%) participants attended on-time appointments. Among the study participants who missed scheduled appointments, 159 (50.8%) and 87 (27.8%) missed the appointments due to forgetfulness and hopelessness, respectively (Figure 1).

3.5. Factors Associated with On-Time Appointment Keeping

Females have an increased odds of 1.49 (AOR = 1.49; 95% CI: 1.19–2.73) of keeping an appointment on-time compared to males. Age >24 years old had an increased odds of 2.13 (AOR = 2.13; 95% CI: 1.14–4.25) of keeping an appointment on-time compared to patients whose ages were between 18 and 24 years. Patients whose marital status was unmarried had almost 41% (AOR = 0.59; 95% CI: 0.45–0.82) decreased odds of keeping on-time appointments compared to those who were married. Those patients who have been taking the drug regimen of TDF + 3TC + EFV had an increased odds of 2.11 (AOR = 2.11; 95% CI: 1.84–3.62) of keeping on-time appointments as compared to patients who have been taking the drug regimen of others (AZT + 3TC + EFV, AZT + 3TC + NVP, or TDF + 3TC + NVP). HIV-positive patients who have been taking ART drugs for ≥12 years had an increased odds of 4.32 (AOR = 4.32; 95% CI: 2.22–8.40) of keeping on-time appointments as compared to patients who have been taking ART drugs for less than 12 months. Those patients who had mobiles had an increased odds of 2.29 (AOR = 2.29; 95% CI: 1.44–3.64) of keeping on-time appointments as compared to those who did not have mobiles. Patients who have gotten adherence support from peer support groups had an increased odds of 1.83 (AOR = 1.83; 95% CI: 1.21–3.34) of keeping on-time appointments compared to those patients who have not gotten adherence support from peer support groups. Those patients who have disclosed their HIV-positive status to their family members had an increased odds of 1.79 (AOR = 1.79; 95% CI: 1.14–3.23) of keeping an on-time appointment as compared to patients who have not disclosed their HIV-positive status to their family members. Patients who had paper-based appointments had an increased odds of 2.16 (AOR = 2.16; 95% CI: 1.16–3.50) of keeping on-time appointments as compared to those who did not have paper-based appointments (Table 4).

4. Discussion

The main objective of this study was to assess on-time appointment keeping and associated factors. Based on this objective, the prevalence of on-time appointment keeping was 62.1% (95% CI: 58.9%–65.3%). It is similar to the findings of the WHO Global Report from 50 countries (58%) [5].

This finding is lower than those of the studies conducted in East Africa, at 75.8% [19], Cambodia at 79.6% [20], Florida at 72.1% [21], and Malaysia at 81.3% [15]. Adult HIV patients often struggle with attendance at medical appointments due to various factors including work and childcare demands, lack of medical comorbidities, transportation issues, substance abuse, and untreated mental health conditions [22]. The discrepancy can be because of how HIV services are delivered differently. Currently, 95% of HIV services in Ethiopia are provided at facilities [23]. Contrarily, HIV services are delivered differently and in communities in other nations, which may have an impact on how often people keep their appointments.

The study found that factors such as sex, age, marital status, ART regimen, adherence support, family member disclosure, mobile access, and paper-based appointments significantly contribute to on-time appointment keeping in HIV treatment.

Females had increased odds of 1.49 of keeping an appointment on time compared to males. This is consistent with the findings of a study conducted in Uganda [24]. This might be due to the fact that men are more likely to use psychoactive substances such as alcohol, leading to depression and forgetting appointment times than women [25].

Another independent factor for on-time appointment keeping was age. Patients who were older than 24 years had almost fourfold higher odds of on-time appointment keeping than those who were aged between 18 and 24 years. This finding is congruent with that of the study conducted in Uganda [24]. The possible justification is that older age groups have a greater perception of health, or patients who are younger have different lifestyles (i.e., work or school status) that prevent them from maintaining consistent medical appointment attendance [21].

Patients who were unmarried had decreased odds of 41% of keeping on-time appointments compared to patients who were married. This could be because widowed patients were unable to receive partner support (emotional support) from their partners [24, 26, 27] or because they felt hopeless [28], both of which could have caused them to miss visits.

Patients who were taking the drug regimen of TDF + 3TC + EFV had an almost threefold increase in odds of on-time appointment keeping compared to those who were taking the regimen of another drug (AZT + 3TC + EFV, AZT + 3TC + NVP, or TDF + 3TC + NVP). A possible justification might be the presence of side effects. Patients may experience side effects such as nausea, dizziness, or fatigue, which can make it difficult for them to attend their health facility appointments regularly. In addition, the high pill burden associated with these regimens may lead to nonadherence and missed appointments [14, 29]. HIV-positive patients who were taking ART drugs for ≥12 months had fourfold higher odds of keeping on-time appointments than those patients who were taking ART drugs for less than 12 months. Patients who have taken ART drugs for <12 months may have adverse drug events, existing coinfections and/or comorbidities, severely low hemoglobin, a low body mass index (severe malnutrition), and/or very low CD4 counts [14, 29], which may cause them to miss the scheduled appointment.

Patients with mobiles had twofold higher odds of keeping on-time appointments than those without mobiles. This might be because patients who have mobile devices could receive a phone call or a reminder message from the healthcare providers. Mobile phone calling or messaging as a reminder improves adherence and clinic attendance [30].

Concerning adherence support from peer support groups, patients who have gotten adherence support from peer support groups had a more than 3-fold increase in the odds of on-time appointment keeping as compared to those patients who have not received adherence support from peer support groups. This is congruent with the findings of studies conducted in Uganda [31] and Malaysia [30]. This might be because patients with adherence support from peer support groups could get emotional support [24], which may impose on-time appointment keeping.

Furthermore, patients who disclosed their HIV-positive status to family members had a threefold increase in the odds of an on-time appointment keeping as compared with those who did not disclose their HIV-positive status. This might be because those patients who disclosed their HIV-positive status to their family members have gotten ART adherence and emotional support [24], which may enforce on-time appointment keeping.

Moreover, patients appointed with paper-based appointments experienced a sixfold increase in the odds of on-time appointment keeping as compared to those not appointed with paper-based appointments. This is in line with the finding of a study conducted in Africa [19]. A possible justification could be that patients who have appointments on paper will be less likely to forget [32].

4.1. Limitation of the Study

To avoid disclosure issues, data collectors were selected from the same health centers where the study participants were living. This could create an information bias.

5. Conclusion

The on-time appointment keeping was found to be lower than the WHO recommendations. Being female, being greater than 24 years old, being widowed, taking the regimen of TDF + 3TC + EFV, taking ART drugs for ≥12 months, having gotten adhesion support from peer support groups, disclosing HIV-positive status to a family member, having a mobile, and having paper-based appointments were factors that were significantly associated with on-time appointment keeping. Adherence support from family members, partners, and peer support groups, side effect management, and appointment reminders should be strengthened to increase on-time appointment keeping.

Abbreviations

3TC:	Lamivudine
ABC:	Abacavir
AIDS:	Acquired immune deficiency syndrome
AOR:	Adjusted odds ratio
ART:	Antiretroviral therapy
AZT:	Zidovudine
CD4:	Cluster of differentiation 4
COR:	Crude odds ratio
EFV:	Efavirenz
HIV:	Human immunodeficiency virus
IQR:	Interquartile range
NVP:	Nevirapine
TDF:	Tenofovir
SPSS:	Statistical Package for the Social Sciences
WHO:	World Health Organization.

Data Availability

The corresponding author can provide the data that were used to support the findings of the study upon request.

Ethical Approval

Ethical clearance was obtained from the Institutional Review Board (IRB) of Bahir Dar University. A permission letter was sought from the East Gojjam Zone health department. Respondents were interviewed in a separate room whenever asked the questionnaires to keep their privacy. Anyone who was not willing to take part in the study had the full right to do so.

Informed written consent was obtained from patients (Appendix 1).

Disclosure

Patients who missed scheduled appointments were linked to those who provided adherence counseling. The funders had no role in the study design, data analysis, the decision to publish, and the preparation of the manuscript.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

MK wrote the main text. Both DT and AH prepared Tables 1–4. SW wrote the abstract. All authors read and approved the final manuscript.

Acknowledgments

Our sincere and deepest gratitude goes to Bahir Dar University for funding contribution to data collection. The authors would like to acknowledge the East Gojjam Zone Department of Health, particularly those staff working at health centers. The authors would also like to acknowledge data collectors, supervisors, and study participants for the success of this study. MK received a grant from Bahir Dar University for data collection.

Supplementary Materials

Appendices: data collection tools. Appendix 1: information and consent form. Appendix 2: checklist. Appendix 3: questionnaires. (Supplementary Materials)

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Copyright © 2023 Mengistie Kassahun Tariku et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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