|Year : 2022 | Volume
| Issue : 1 | Page : 59-66
Effectiveness of quality-of-life counselling with hatha yoga among human immunodeficiency virus-infected adolescents: Randomised control trial
Rajathi Sakthivel1, Shankar Shanmugam Rajendran2
1 Professor, Hindu Mission College of Nursing, Chennai, India
2 Associate Professor, College of Nursing, Madras Medical College, Chennai, India
|Date of Submission||09-Jun-2021|
|Date of Decision||06-May-2022|
|Date of Acceptance||10-May-2022|
|Date of Web Publication||05-Jul-2022|
Dr. Rajathi Sakthivel
Hindu Mission College of Nursing, Affiliated to the Tamil Nadu Dr. M. G. R. Medical University, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Adolescents are high risk and underserved group in the international and national response to acquired human immunodeficiency virus (HIV) epidemics. Children with HIV infection may experience more difficulties in their daily life because of parental death from acquired immunodeficiency syndrome and social stigmatisation may worsen their quality of life (QOL). The therapeutic practice of Hatha Yoga and QOL counselling promotes healthy practices, develops positive attitudes and enhances well-being of adolescents living with HIV (ALHIV). The aim of this study was to evaluate the effectiveness of QOL counselling with Hatha Yoga in HIV-infected adolescents. A randomised control trial design was adopted for the study. A total of 388 HIV-infected adolescents were randomised into experimental (195) and control groups (193) by the simple random technique. Data were collected from HIV-infected adolescents/caregivers from four main antiretroviral therapy Centres in Chennai, India, through Health Related QOL Assessment Questionnaire. QOL counselling was provided only to the experimental group and Asanas were demonstrated by the researcher. At the end of data collection, cursory instructions regarding QOL counselling and yoga were also given to the control group. Data were collected from both groups in 3-month intervals from the time of allotment ('0', 3rd and 6th months). . In both groups, mean QOL score in pre- and post-test score was 163.6 versus162.9 at '0' month and 215.6 versus166.0 at '6' month, respectively. The mean difference in QOL gain score was 51.97 in the experimental and only 3.09 in control group. There were significant changes in QOL score in the experimental group. The factors such as age and gender of ALHIV and caregiver's age, gender, relationship with adolescents and residence are significantly associated with increased QOL. The motivational QOL counselling along with yoga has effectiveness to increase QOL among HIV-infected adolescents in the experimental group.
Keywords: Acquired immunodeficiency syndrome and human immunodeficiency virus-infected adolescents, counselling, quality of life, Yoga
|How to cite this article:|
Sakthivel R, Rajendran SS. Effectiveness of quality-of-life counselling with hatha yoga among human immunodeficiency virus-infected adolescents: Randomised control trial. Indian J Cont Nsg Edn 2022;23:59-66
|How to cite this URL:|
Sakthivel R, Rajendran SS. Effectiveness of quality-of-life counselling with hatha yoga among human immunodeficiency virus-infected adolescents: Randomised control trial. Indian J Cont Nsg Edn [serial online] 2022 [cited 2022 Aug 16];23:59-66. Available from: https://www.ijcne.org/text.asp?2022/23/1/59/349819
| Introduction|| |
The recent advances in the clinical test and Highly Active Anti-Retroviral Therapy (HAART) management have transformed the fatal disease of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) into chronic and potentially manageable disease. However, constant management is required for comorbid illnesses or iatrogenic effects from HAART medications. In the absence of a cure, HIV-infected children/adolescents will require adherence to HAART on a lifelong basis, which is a pre-requisite for their survival. Unfortunately, adolescents are considered a high-risk and underserved group in the international and national response to HIV epidemics. It may be due to absconding from school, starting new jobs, commencing sexual act, and experimenting with alcohol or misusing illegal substances making their life more complicated. The HIV infection/AIDS do not only affects physical health but also affects individual overall quality of life (QOL). When compared to other illness, children with HIV infection may experience additional difficulties in their daily life due to parental death from AIDS and social stigmatisation which may worsen their QOL.,
The HIV-health-related QOL (HIV-HRQOL) may be a primary measure of management for Behaviourally Infected Adolescents (BIAs) and young adults due to the unique stress experienced during the cognitive and sexual development stage. Moreover, BIAs have increased concerns regarding stigma compared with perinatally infected adolescents (PIAs) and increased challenges in coping with physical and social aspects. Nevertheless, the increased stigma may cause depression and negatively impact social support for both groups of adolescents (BIAs and PIAs). The PIAs have been reported to experience lower QOL compared to the other age groups because of the long-term requirement for life-saving drugs of HAART with pill burden and its side effects.,
Adolescents Living with HIV (ALHIV) also experiences extreme psychosomatic and behavioural problems such as suicide, attempted suicide and suicidal ideations. Lack or delay in disclosing psychosomatic symptoms may prevent acceptance and participation in HIV care. The stressful events of anxiety, depression, stigma and lack of social support have been reported to the progression of HIV to AIDS. The prevalence of depression ranges from 22% to 38% in HIV-infected adolescents. The management of depression in HIV/AIDS may not extend the life but can reduce the risk of suicide and offer reasonable QOL. A study done in Yunnan exploring the impact of HIV/AIDS among 116 HIV affected and 109 control families, reported that children from HIV impacted families had a worse HRQOL score than those from unaffected families.
Adolescents are the most vulnerable group to get infected and transmit HIV in the community due to their risky behaviours. About 31% of HIV prevalence in India is among adolescents aged between 10 and 24 years. HAART has given new hope for long-term survival and better QOL among persons with HIV disease.,
Apart from this, developing good practices such as Complementary and Alternative Management of Yoga early in life has been shown to be beneficial in improving the immunity and QOL of ALHIV/AIDS. Nurses play a crucial role in creating an optimal environment that is: safe, non-judgmental and confidential that is vital to increase the safety and well-being of adolescents., However, limited data are available on the effectiveness of nurse-led Hatha yoga among ALHIV.
Objectives of the study
The objectives of the study were to assess the level of QOL both in the experimental and control groups, to evaluate the effectiveness of QOL counselling and Hatha yoga among HIV-infected adolescents and to find an association between the post-test QOL gain score with selected demographic variables among HIV-infected adolescents.
| Methods|| |
A randomised control trial was conducted with a total of 400 participants from four anti retroviral therapy (ART) centres, Chennai, by the simple random sampling technique. The sample size was calculated using 80% power and 5% error and with 10% attrition rates (191 + 19 = 210). The final required sample size was fixed as 200/group. The inclusion criteria for study participation were (i) Adolescents aged between 10 and 17 years and (ii) both genders and (iii) who were in Stage I to III and willing to participate in the study. Adolescents who were hospitalised during the study period were excluded from the study.
The study was approved by the Institutional Ethics Committee from Madras Medical College, Chennai, Tamil Nadu. (No. 30102013) The purpose of the study was explained and permission was obtained from National AIDS Control Organisation, Tamil Nadu State AIDS Control Society and the main four ART Centres, Chennai. Informed consent was obtained from parents and assent was obtained from ALHIV. Confidentiality of data and anonymity of the participants were ensured.
We used three instruments to collect data sociodemographic pro forma, HIV-related questionnaire and QOL. Sociodemographics of adolescents and their caregiver's information's included the age, gender, education, the religion of adolescents and caregiver's age, sex, caregiver's relationship to adolescents, education, occupation, income and residence. The HIV-related questionnaires consisted of 10 questions regarding duration since HIV diagnosis (years), probable route of transmission, HIV stage, ART history and side effects, history of antituberculosis treatment (ATT) drugs and facilities for availing social and financial support. The QOL questionnaire designed by AIDS Clinical Trial Group includes two categories of 5–11 and 12–20 years related to areas of general health ratings, physical functioning, psychological well-being, social role functioning, health care services and symptoms distress management with scores ranging from 71 to 338. Each domain was scored separately, summed and then transformed to a scale ranging from 0 to 100 with higher scores indicating better QOL. It was interpreted as 0%–50% poor, 51%–75% moderate and 76%–100% good QOL. The instrument was validated for its content by subject experts. The reliability of the structured questionnaire was assessed by Cronbach's Alpha method and was found to be 0.88.
Data collection procedure
After the formal approval obtained from all concerned departments, the researcher identified 400 adolescents based on eligibility criteria [Figure 1]. Data for the sociodemographic pro forma and HIV-related questionnaire were collected from their parents/caregivers and review of hospital records. The QOL data were collected with 3-month intervals (0, 3 and 6) from adolescents/caregivers of ALHIV.
Participants in the experimental group were requested to perform Hatha Yoga. Hatha Yoga intervention comprised of selected asanas Padmasana, Vajrasana, Trikonsana, Ardhamatsyendrasana, Ushtrasana, Bhujangasana, Shavasana and Pranayama (Alternative Nostril breathing). These Asanas were demonstrated by a researcher and study participants were instructed to provide a return demonstration. Participants were also given brochures for practicing the selected asana every day for a minimum 15–20 min on their own at home. They were also given a diary as part of the intervention and instructed to document information about Yoga intervention daily. Every month when the participants came for the pharmacy refill, the researcher reviewed the diary and provided the motivational counselling and reinforcement of asanas and repeat asana redemonstration if needed. Participants in the control group did not receive any instructions or demonstrations about Hatha Yoga and HIV care were provided using the conventional approach. The end of data collection (6th month) the cursory instructions regarding counselling and Yoga were also given to the control group.
| Results|| |
A total of 388 ALHIV participated in the study (Experimental − 195 and control − 193). The mean age of adolescents in the experimental group was 13.6 ± 2.2 years and the control group was 13.8 ± 2.4 years and nearly half of participants, i.e., 50% in experimental 57% in control were males and majority 85% and 77% belongs to Hindu Religion, respectively, in both groups. The mean age of caregivers was 44.3 ± 13.5 years and 45.5 ± 12.2 years in the experimental and control groups, respectively, and the majority 70% in experimental and 66% in control were females. Regarding relationships, the adolescents more than 60% were caregivers (Orphanage guardian) in both groups [Table 1] and [Table 2].
|Table 1: Distribution of sociodemographic variables of human immunodeficiency virus infected adolescents and caregivers in both groups|
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|Table 2: Distribution of clinical information of human immunodeficiency virus-infected adolescents in both groups|
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In the present study, 55% and 58% were diagnosed with HIV before 5–10 years in the experimental and control group and all were acquired the infection through vertical transmission. In both groups, most of the participants (71% and 66%) were in Stage I and majority of 67% and 72% were on ART between 1 and 5 years, respectively. With regard to history of tuberculosis, nearly half of the participants (55%) had tuberculosis and completed their ATT successfully. Regarding disclosure status in the experimental and control groups, 68% and 64% of participants, respectively did not know their disclosure status, especially below 12 years of age. Nearly half of the participants in both groups were not received financial sources from government, non-governmental organisations (NGOs) and social support from relatives and neighbours.
Overall quality of life
In the experimental group, at baseline assessment ('0' month), majority (81%) of the participants (among 195 participants) have poor QOL and 20% reported having moderate QOL. At 6th month evaluation, only 23% reported poor QOL, 63% reported moderate QOL and 14% of adolescents reported good QOL, whereas in the control group, majority (83%) ALHIV had poor QOL and 17% had moderate QOL. There were no participants reported good QOL throughout the study period and 78% continued to report poor QOL [Figure 2]. There is a significant improvement in QOL of ALHIV in the experimental group as compared to control group (P < 0.001).
|Figure 2: Percentage distribution of overall QOL score in experimental and control group of ALHIV. QOL: Quality of life, ALHIV: Adolescents living with human immunodeficiency virus|
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Quality of life in each time-point
At time 0 (Baseline), the mean QOL score was 163.7 for the experimental group and 162.9 for the control group with no significant difference between the two groups [Table 3]. In the 3rd month assessment, the mean QOL score increased from 163.6 to 187.8 in the experimental group, whereas in the control group, it is increased only from 162.9 to 164.3. The difference in the change in mean QOL scores from baseline scores to 3rd month between the two group was significantly different (23.43) at P ≤ 0.001 [Table 4]. In the 6th month assessment, the mean QOL score increased from 163.6 to 215.6 in the experimental group, whereas in the control group, it is increased only from 162.9 to 166.02 [Figure 3]. The total mean difference score was 49.61 and it is significant in all QOL domains at P ≤ 0.001 [Table 5].
|Table 3: Comparison of baseline level of the mean scores of quality of life in both groups of the human immunodeficiency virus-infected adolescents|
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|Table 4: Comparison of 3rd month level of the mean scores of quality of life in both groups of the human immunodeficiency virus-infected adolescents|
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|Table 5: Comparison of 6th month level of the mean scores of quality of life in both groups of the human immunodeficiency virus-infected adolescents|
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|Figure 3: Box plot diagram showings the pre and post-test overall mean QOL scores of HIV infected adolescents in both groups. QOL: Quality of life, HIV: Human-immuno deficiency virus|
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Effectiveness of quality of life with Hatha yoga
In the experimental group, the mean difference in QOL score between baseline and at 6th month was 51.97 and percentage of QOL gain score 15.1%. However, in the control group, the mean difference in QOL score was 3.09 and percentage of QOL gain score only 0.9% [Table 6].
|Table 6: Effectiveness of quality of life counselling with Hatha yoga in both groups of the human immunodeficiency virus-infected adolescents|
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Adolescents living with human immunodeficiency virus and caregiver's characteristics associated with quality of life
The factors such as age and sex of ALHIV and caregiver's age, gender, relationship with adolescents and residence variables were significantly associated with QOL in the experimental group. The younger age of 10–12 years and male sex among ALHIV had higher QOL scores of 54.96 and 54.35 compared to their counterparts in the experimental group (P value of 0.04 and 0.02, respectively). Further with regard to caregiver's age and gender, the younger age of 20–35 years was reported with higher QOL scores 57.80 (P = 0.03*) compared to other age groups and women caregivers reported higher QOL than men 53.98 (P = 0.05*). In the experimental group; moreover, women caregivers living in the rural residential areas reported higher QOL (56.19) compared to women caregivers in urban settings (P = 0.05*). The remaining characteristics of the ALHIV and their caregivers were not associated with any improvements in QOL in the experimental group [Table 7]. None of the demographic variables had an association with the difference in QOL score in the control group.
|Table 7: Association between the quality of life gain score with demographic variables of human immunodeficiency virus-infected adolescents in experimental group|
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| Discussion|| |
The intent of the study was to determine the effectiveness of QOL counselling with Hatha yoga among ALHIV. The findings from the study revealed that, QOL counselling with Hatha yoga was effective in increasing the HRQOL in ALHIV.
In our study, only half of participants in both groups, i.e., 52%–55% were received financial sources from government, NGOs and social support from relatives and neighbours. A similar study suggested that, need of counselling regarding available social support from government and non-government organisation to improve their QOL. The other study also found that, the perceived social support was highly correlated with (r = 0.527) structural measures (family/relatives, teachers and friends) and psychosocial well-being of HIV infected orphans.
Our study showed that, the QOL of ALHIV in experimental group increased dramatically after Hatha Yoga compared to ALHIV in the control group. A study done in Uganda found that, 10 weeks of peer group support intervention decreased psychological distress especially depression, anxiety in the experimental group compared with control group. In another study of HIV-infected children/adolescents found that, 4-month of yoga intervention improved the general health of the participants and there CD4 cells counts (P = 0.039) and decreased in viral load (P = 0.041) resulting in improved QOL. Additional studies also support that, the positive impact of low-cost approach of yoga on the psychosomatic state of ALHIV and regular practice of Mind fullness-Based Stress Reduction is essential to enhance the QOL of ALHIV.,
With regard to factors associated with improved QOL, in our study were the age of 10–12 years of ALHIV, especially male children were under the supervision of caregivers. According to certain cultures in India, more attention is given to male children; subsequently, this age not involving with peer group activities makes to gain more benefits when compared to the other age groups and female adolescents. With regard to caregivers' age and sex, the younger age of 20–35 years and females gained high score of mean ± SD, since the female caregivers in young age played a major role to caring the ALHIV which led to attain the high gain scores when compared to other age categories and males. Regarding the relationship with adolescents and residential area, the high gain score was seen with mothers and adolescents residing in rural areas. Because the primary caregivers of mothers showed a great attention towards the adolescent's health and mothers residing in the rural areas followed the interventions in disciplined manner, adopted the diet modifications makes easy to gained more score than the other type of caregivers even residing in urban areas.
Similar findings were reported in HIV infected children in Thailand, factors associated with poor QOL include caretakers other than parents with Odd Ratio (OR) of 4.19 and age of above 45 years OR 9.52. Another study revealed that, absence of primary caregiver as mothers in adolescent clinic was significantly associated with virologic failure (OR 4.195% confidence interval [CI] 1.5–4.3). on the contrary, another study reported that if the primary caregivers was a mother, then ALHIV were predicted to have of poor adherence to HIV treatment (OR 3.32 (95% CI 1.33–8.67) and hypothesis is that, it may be due to illness of mothers because majority of pediatric HIV infection acquired through vertical transmission.
Our study findings are generalizable to all ALHIV between the ages of 10 and 17 years but within Chennai, Tamil Nadu area. Most of the information regarding adolescents and their QOL was obtained mainly from the caregivers, since ALHIV were often not forthcoming with their personal information. The information regarding their Yoga practices also mainly relied on the ALHIV and caregivers' subjective reports indicating that the results of the study represent of caregivers' perception of QOL of ALHIV.
| Conclusion|| |
The study findings suggest that, adolescent focused interventions including behavior modifications such as Yoga may increase and improve QOL of ALHIV. However, this study has shown that, QOL Counselling with Hatha Yoga has useful intervention in enhancing QOL in HIV infected adolescents and showing a ray of hope for caregivers/parents of ALHIV in helping them to lead successful healthy life in future.
I sincerely acknowledge my gratitude to Dr.N.Usman, Director Institute of Venerology- MMC, Co- guide Dr. R.Somasekar, Professor, ICH and Advisory committee member Mrs.Thahirabegum Principal, College of Nursing, MMC, Chennai for their continuous guidance, motivation and support to complete this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]