Developing, testing and refining of a model for implementation of HIV/AIDS self-management education in a semi-rural area in KwaZulu-Natal, South Africa.

Abstract

The purpose of this study was to develop, test and refine a model for implementation of self-management

education for people living with HIV/AIDS (PLWHA) in semi-rural KwaZulu-Natal,

South Africa. The study consists of a purposive sample of 88 men and women over 18 years of age

living with HIV/AIDS. A Quasi-experimental design, incorporating pre-test and post-test

interventions and comparison groups, was used. These groups, equal in number and matched in other

respects at baseline in terms of the recruitment criteria used, were designated Group A and Group B.

Group A received seven weeks of intensive self-management education; Group B received only

traditional health education. Group B, however, received (and its members were informed that they

would do so) self-management education immediately after my intervention had concluded.

Arrangements were made to prevent the two groups from interacting, or even meeting.

A conceptual model derived from the relevant literature on self management, and in particular on

the teaching of self management to PLWHA, was tested using data from participants’ health-related

quality of life, CD4 counts, and viral loads before and after the self-management education

intervention. Testing comprised an investigation into whether or not the outcomes included in the

model adequately reflected those reported in the literature on effective self-management education,

and also whether or not the predicted relationships between intervention and those outcomes existed

in practice.

A priori assessment produced data for preparation and development of the new intervention devised

by the researcher. The assessment process involved the collection of data on participants’

perceptions of health, their difficulties of living with HIV/AIDS, self-management education needs;

preferred methods of learning and perceived barriers to participation in this self-management

education programme. Participants’ health-related quality of life was measured at baseline and at the

twenty-fourth week, using an SF-36 questionnaire. Data on participants’ CD4 cell counts and viral

loads were obtained from the clinic records at baseline and in the twenty-fourth week; comparisons

were made for sample means using the data available on all participants in both groups. In-depth

group interviews were conducted for systematic sampling of the intervention group after intervention

to substantiate the effectiveness of the intervention.

Results indicated a significant trend toward improvement in health-related quality of life. The indepth

group interview results demonstrated that participants showed improvement in their health

status through the acquisition of self-management skills, health practices, and communication with

healthcare providers. Post-intervention results showed that the two groups were statistically

significantly different in terms of their mean scores on physical functioning (t=3.900; df=79;

p<0.0001 < 0.05), vitality (t=3.285; df=79; p=0.002< 0.05) and general health (t=2.107; df=79;

p=0.039 < 0.05), physical health (p=0.001< 0.05) and role limitation due to emotional problems

(p=0.007 < 0.05). No statistically significant difference appeared in terms of their mean scores on

mental health (t=1.422; df=79; p=.158 > 0.05), bodily pain (t=-.138; df=79; p=0.891> 0.05) and

social functioning (p=0.249 > 0.05). Post-intervention, the two groups are statistically different in

terms of their CD4 count mean scores (t=3.741; df=80; p<.0001 <0.05). The mean CD4 cell counts

increased over the period of investigation; paired t-tests for difference between intervention and

comparison groups were statistically significant (p < 0.05) for these variables. However, the

differences between the two groups in terms of their viral load were not statistically significant. This

may be the result of the fact that as researcher, I had no influence over the process by which viral

load data were obtained: both at baseline and after the intervention, they were retrieved from

patients’ records, in which viral load was expressed, for example, as ‘below 25 copies per mil’. This

was of course an approximation; after the intervention, they were expressed similarly as ‘below

detectable limits’, or ‘below 80 copies per mil.’

My conceptual model provides a consistent, reproducible approach to assessment, monitoring, and

evaluation of the key components of self-management education and allows for measurement over

time and the tracking of changes; it has in addition a predictive ability. Overall, the programme

seemed to have a positive impact on the health-related quality of life of PLWHA. The study

confirms the effectiveness of self-management education in improving the health and well-being of

PLWHA, even in a resource-limited semi-rural setting.