Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study
Identifieur interne : 002835 ( Pmc/Checkpoint ); précédent : 002834; suivant : 002836Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study
Auteurs : Norma C. Ware [États-Unis] ; John Idoko [Nigeria] ; Sylvia Kaaya [Tanzanie] ; Irene Andia Biraro [Ouganda] ; Monique A. Wyatt [États-Unis] ; Oche Agbaji [Nigeria] ; Guerino Chalamilla [Tanzanie, États-Unis] ; David R. Bangsberg [États-Unis]Source :
- PLoS Medicine [ 1549-1277 ] ; 2009.
Abstract
Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.
Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.
Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.
Url:
DOI: 10.1371/journal.pmed.1000011
PubMed: 19175285
PubMed Central: 2631046
Affiliations:
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<front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background</title>
<p>Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.</p>
</sec>
<sec id="st2"><title>Methods and Findings</title>
<p>Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.</p>
</sec>
<sec id="st3"><title>Conclusion</title>
<p>Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.</p>
</sec>
</div>
</front>
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<pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Med</journal-id>
<journal-id journal-id-type="iso-abbrev">PLoS Med</journal-id>
<journal-id journal-id-type="publisher-id">pmed</journal-id>
<journal-id journal-id-type="publisher-id">plme</journal-id>
<journal-id journal-id-type="pmc">plosmed</journal-id>
<journal-title-group><journal-title>PLoS Medicine</journal-title>
</journal-title-group>
<issn pub-type="ppub">1549-1277</issn>
<issn pub-type="epub">1549-1676</issn>
<publisher><publisher-name>Public Library of Science</publisher-name>
<publisher-loc>San Francisco, USA</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">19175285</article-id>
<article-id pub-id-type="pmc">2631046</article-id>
<article-id pub-id-type="doi">10.1371/journal.pmed.1000011</article-id>
<article-id pub-id-type="publisher-id">08-PLME-RA-1572R2</article-id>
<article-id pub-id-type="sici">plme-06-01-18</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject>
</subj-group>
<subj-group subj-group-type="Discipline"><subject>Infectious Diseases</subject>
</subj-group>
</article-categories>
<title-group><article-title>Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study</article-title>
<alt-title alt-title-type="running-head">Explaining Adherence Success in Africa</alt-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Ware</surname>
<given-names>Norma C</given-names>
</name>
<xref ref-type="aff" rid="aff1">1</xref>
<xref ref-type="corresp" rid="cor1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Idoko</surname>
<given-names>John</given-names>
</name>
<xref ref-type="aff" rid="aff2">2</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kaaya</surname>
<given-names>Sylvia</given-names>
</name>
<xref ref-type="aff" rid="aff3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Biraro</surname>
<given-names>Irene Andia</given-names>
</name>
<xref ref-type="aff" rid="aff4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Wyatt</surname>
<given-names>Monique A</given-names>
</name>
<xref ref-type="aff" rid="aff1">1</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Agbaji</surname>
<given-names>Oche</given-names>
</name>
<xref ref-type="aff" rid="aff2">2</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Chalamilla</surname>
<given-names>Guerino</given-names>
</name>
<xref ref-type="aff" rid="aff5">5</xref>
<xref ref-type="aff" rid="aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Bangsberg</surname>
<given-names>David R</given-names>
</name>
<xref ref-type="aff" rid="aff1">1</xref>
<xref ref-type="aff" rid="aff7">7</xref>
<xref ref-type="aff" rid="aff8">8</xref>
</contrib>
</contrib-group>
<aff id="aff1"><label>1</label>
Harvard Medical School, Boston, Massachusetts, United States of America</aff>
<aff id="aff2"><label>2</label>
Jos University, Jos, Nigeria</aff>
<aff id="aff3"><label>3</label>
Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania</aff>
<aff id="aff4"><label>4</label>
Mbarara University of Science and Technology, Mbarara, Uganda</aff>
<aff id="aff5"><label>5</label>
Muhimbili University/Dar es Salaam City Council/Harvard School of Public Health HIV/AIDS Care and Treatment Program, Dar es Salaam, Tanzania</aff>
<aff id="aff6"><label>6</label>
Harvard School of Public Health, Boston, Massachusetts, United States of America</aff>
<aff id="aff7"><label>7</label>
Massachusetts General Hospital, Boston, Massachusetts, United States of America</aff>
<aff id="aff8"><label>8</label>
Harvard Initiative for Global Health, Cambridge, Massachusetts, United States of America</aff>
<contrib-group><contrib contrib-type="editor"><name><surname>Beyrer</surname>
<given-names>Chris</given-names>
</name>
<role>Academic Editor</role>
<xref ref-type="aff" rid="edit1"></xref>
</contrib>
</contrib-group>
<aff id="edit1">Johns Hopkins University, United States of America</aff>
<author-notes><corresp id="cor1">* To whom correspondence should be addressed. E-mail: <email>norma_ware@hms.harvard.edu</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><month>1</month>
<year>2009</year>
</pub-date>
<pub-date pub-type="epub"><day>27</day>
<month>1</month>
<year>2009</year>
</pub-date>
<volume>6</volume>
<issue>1</issue>
<elocation-id>e1000011</elocation-id>
<history><date date-type="received"><day>3</day>
<month>6</month>
<year>2008</year>
</date>
<date date-type="accepted"><day>19</day>
<month>11</month>
<year>2008</year>
</date>
</history>
<permissions><copyright-statement>: © 2009 Ware et al.</copyright-statement>
<copyright-year>2009</copyright-year>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.</license-p>
</license>
</permissions>
<related-article id="d35e206" related-article-type="companion" ext-link-type="doi" xlink:href="10.1371/journal.pmed.1000018" xlink:title="Perspective" vol="100" page="e18"><article-title>The Role of Social Capital in Successful Adherence to Antiretroviral Therapy in Africa</article-title>
</related-article>
<abstract><sec id="st1"><title>Background</title>
<p>Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.</p>
</sec>
<sec id="st2"><title>Methods and Findings</title>
<p>Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.</p>
</sec>
<sec id="st3"><title>Conclusion</title>
<p>Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.</p>
</sec>
</abstract>
<abstract abstract-type="toc"><p>Using ethnographic data from Nigeria, Tanzania, and Uganda, Norma Ware and colleagues examine why levels of adherence to HIV/AIDS drugs are so much higher in sub-Saharan Africa than in North America.</p>
</abstract>
<abstract abstract-type="editor"><title>Editors' Summary</title>
<sec id="sb1a"><title>Background.</title>
<p>The acquired immunodeficiency syndrome (AIDS) epidemic has killed more than 25 million people since 1981, and about 30 million people (22 million in sub-Saharan Africa alone) are currently infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within ten years but in 1996, combination antiretroviral therapy (ART)—a mixture of powerful drugs—was developed. For HIV-infected people living in affluent, developed countries, HIV/AIDS became a chronic disease, but for the millions of infected people living in low- and middle-income countries, HIV/AIDS remained a death sentence—ART was simply too expensive. In 2003, this situation was declared a global health emergency. Today, through the concerted efforts of governments, international organizations, and funding bodies, nearly one-third of the people in developing and transitional countries who are in immediate need of life-saving ART receive free, reliable supplies of the drugs they need.</p>
</sec>
<sec id="sb1b"><title>Why Was This Study Done?</title>
<p>For ART to work, it must be taken regularly. If drug doses are missed, the virus can rebound and resistance to ART is more likely to develop. In poor countries, even though free antiretroviral drugs are increasingly available, many obstacles to good adherence to ART remain. These include economic obstacles (for example, the cost of traveling to clinics and the loss of earning associated with clinic attendance), and social, cultural, and behavioral barriers. Some patients fear disclosure, for example. Others receive conflicting messages about the benefits of ART. However, despite worries that the scale-up of ART provision in developing countries would be dogged by inadequate adherence, people living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of their prescribed doses of ART, a better level of adherence than in North America. In this study, the researchers investigate why ART adherence is so high in sub-Saharan Africa by analyzing qualitative data from an ethnographic study done in Nigeria, Tanzania, and Uganda. Qualitative data are often used to address “how” and “why” research questions: ethnography is a comprehensive qualitative approach to describing and explaining human behavior and culture.</p>
</sec>
<sec id="sb1c"><title>What Did the Researchers Do and Find?</title>
<p>For their study, the researchers interviewed 158 patients, 45 treatment partners (lay-people who help HIV-positive people keep to their treatment), and 49 health care workers. Patients were asked about their experiences of ART and about the help they received from their treatment partners; partners were asked about the type of help they gave and about their feelings about this help; health care workers were asked to describe a typical clinic visit and to indicate how adherence was discussed. From these interviews and observations of clinic sessions, the researchers identified several strategies used by patients and their treatment partners to overcome economic obstacles to ART adherence. These included borrowing and “begging” funds to pay for travel to clinics and making “impossible choices” to prioritize adherence, and “doing without.” The researchers' analysis also indicates that the prioritization of adherence to ART reflects the importance of relationships as a resource for managing economic hardship. So, for example, they found that treatment partners and health care workers expected patients to adhere to ART (which, by improving patients' health, improves their ability to support themselves and their families) and made their expectations known, thereby creating a responsibility among patients to adhere. Patients, in turn, adhered to their treatment to promote good will from their helpers and thus ensure their continuing help.</p>
</sec>
<sec id="sb1d"><title>What Do These Findings Mean?</title>
<p>The findings offer a possible explanation of adherence success in sub-Saharan Africa. The high level of adherence to ART can be explained as a means of fulfilling social responsibilities. Adherence, the researchers suggest, not only improves personal health (the main driver for ART adherence in resource-rich environments) but also preserves “social capital” in essential relationships. In other words, in sub-Saharan Africa, adherence to treatment may protect the relationships that individuals living in extreme poverty rely on to help them survive.</p>
</sec>
<sec id="sb1e"><title>Additional Information.</title>
<p>Please access these Web sites via the online version of this summary at <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pmed.1000011">http://dx.doi.org/10.1371/journal.pmed.1000011</ext-link>
.</p>
<list list-type="bullet"><list-item><p>This study is further discussed in a <italic>PLoS Medicine</italic>
<ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pmed.1000018">Perspective by Agnes Binagwaho and Niloo Ratnayake</ext-link>
</p>
</list-item>
<list-item><p>Information is available from the US National Institute of Allergy and Infectious Diseases on <ext-link ext-link-type="uri" xlink:href="http://www.niaid.nih.gov/factsheets/hivinf.htm">HIV infection and AIDS</ext-link>
</p>
</list-item>
<list-item><p><ext-link ext-link-type="uri" xlink:href="http://hivinsite.ucsf.edu/InSite">HIV InSite</ext-link>
has comprehensive information on all aspects of HIV/AIDS, including an article about <ext-link ext-link-type="uri" xlink:href="http://hivinsite.ucsf.edu/InSite?page=kb-03-02-09#S7X">to antiretroviral therapy</ext-link>
</p>
</list-item>
<list-item><p>Information is available from Avert, an international AIDS charity, on <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/aafrica.htm">HIV and AIDS in Africa</ext-link>
(including detailed information on HIV/AIDS in Nigeria and Uganda) and on <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/drugtreatment.htm">providing AIDS drug treatment for millions</ext-link>
</p>
</list-item>
<list-item><p>The World Health Organization provides information about <ext-link ext-link-type="uri" xlink:href="http://who.int/mediacentre/news/releases/2007/pr16">universal access to HIV treatment</ext-link>
(in several languages)</p>
</list-item>
<list-item><p>The US Centers for Disease Control and Prevention also provides information on <ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/globalaids/default.html">global efforts to deal with the HIV/AIDS pandemic</ext-link>
</p>
</list-item>
</list>
</sec>
</abstract>
<counts><page-count count="7"></page-count>
</counts>
<custom-meta-group><custom-meta><meta-name>citation</meta-name>
<meta-value>Ware NC, Idoko J, Kaaya S, Biraro IA, Wyatt MA, et al. (2009) Explaining adherence success in sub-Saharan Africa: An ethnographic study. PLoS Med 6(1): e1000011. doi:<ext-link ext-link-type="doi" xlink:href="10.1371/journal.pmed.1000011">10.1371/journal.pmed.1000011</ext-link>
</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
</front>
</pmc>
<affiliations><list><country><li>Nigeria</li>
<li>Ouganda</li>
<li>Tanzanie</li>
<li>États-Unis</li>
</country>
<region><li>Massachusetts</li>
</region>
</list>
<tree><country name="États-Unis"><region name="Massachusetts"><name sortKey="Ware, Norma C" sort="Ware, Norma C" uniqKey="Ware N" first="Norma C" last="Ware">Norma C. Ware</name>
</region>
<name sortKey="Bangsberg, David R" sort="Bangsberg, David R" uniqKey="Bangsberg D" first="David R" last="Bangsberg">David R. Bangsberg</name>
<name sortKey="Bangsberg, David R" sort="Bangsberg, David R" uniqKey="Bangsberg D" first="David R" last="Bangsberg">David R. Bangsberg</name>
<name sortKey="Bangsberg, David R" sort="Bangsberg, David R" uniqKey="Bangsberg D" first="David R" last="Bangsberg">David R. Bangsberg</name>
<name sortKey="Chalamilla, Guerino" sort="Chalamilla, Guerino" uniqKey="Chalamilla G" first="Guerino" last="Chalamilla">Guerino Chalamilla</name>
<name sortKey="Wyatt, Monique A" sort="Wyatt, Monique A" uniqKey="Wyatt M" first="Monique A" last="Wyatt">Monique A. Wyatt</name>
</country>
<country name="Nigeria"><noRegion><name sortKey="Idoko, John" sort="Idoko, John" uniqKey="Idoko J" first="John" last="Idoko">John Idoko</name>
</noRegion>
<name sortKey="Agbaji, Oche" sort="Agbaji, Oche" uniqKey="Agbaji O" first="Oche" last="Agbaji">Oche Agbaji</name>
</country>
<country name="Tanzanie"><noRegion><name sortKey="Kaaya, Sylvia" sort="Kaaya, Sylvia" uniqKey="Kaaya S" first="Sylvia" last="Kaaya">Sylvia Kaaya</name>
</noRegion>
<name sortKey="Chalamilla, Guerino" sort="Chalamilla, Guerino" uniqKey="Chalamilla G" first="Guerino" last="Chalamilla">Guerino Chalamilla</name>
</country>
<country name="Ouganda"><noRegion><name sortKey="Biraro, Irene Andia" sort="Biraro, Irene Andia" uniqKey="Biraro I" first="Irene Andia" last="Biraro">Irene Andia Biraro</name>
</noRegion>
</country>
</tree>
</affiliations>
</record>
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