Quantitative Research Critique
Kemal2020
Quantitive_2.pdf
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3862
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
ASSOCIATION OF ALCOHOL AND DRUG USE AND ADHERENCE TO ANTIRETROVIRAL TREATMENT
ASSOCIAÇÃO DO USO DE ÁLCOOL E DROGAS E A ADESÃO AO TRATAMENTO ANTIRRETROVIRAL
ASOCIACIÓN DEL USO DE ALCOHOL Y DROGAS Y LA ADHERENCIA AL TRATAMIENTO ANTIRRETROVIRAL
Regina Célia de Oliveira1, Danielle Chianca de Andrade Moraes2, Elizandra Cassia da Silva Oliveira3, Juliana da Rocha Cabral4, Jéssica Ferreira de Moura Pereira5, Cleytiane Stephany Silva Santos6
ABSTRACT
Objective: to analyze the use of alcohol and drugs in people living with the human immunodeficiency virus and adherence to antiretroviral treatment. Method: quantitative, analytical study with 322 people living with the Human Immunodeficiency Virus assisted at the outpatient clinic of two public reference hospitals. For the collection of data related to adherence, the CEAT-HIV instrument was used. The ASSIST was used to evaluate the consumption of alcohol and other substances. A descriptive analysis of the sociodemographic characteristics was carried out and a database was created in the Program Epi Info 7, version 7.0.9. The values obtained through the application of CEAT-VIH were compared. The Pearson correlation test and the Chi square contingency test with a 0.05 significance level were used in the analysis of the data. Results: 44.72% of the sample presented low adherence to treatment. The level of adherence associated with use of alcohol (p = 0.156), tobacco (p = 0.215), marijuana (p = 0.434) and cocaine (p = 0.155). Conclusion: although there was low adherence, there was no significant association between alcohol and drug use in people living with Human Immunodeficiency Virus and adherence to antiretroviral treatment. Descriptors: Acquired Immunodeficiency Syndrome; Medication Adherence; Anti-Retroviral Agents; Street Drugs.
RESUMO
Objetivo: analisar o uso de álcool e drogas em pessoas vivendo com o vírus da imunodeficiência humana e adesão ao tratamento antirretroviral. Método: estudo quantitativo, analítico, com 322 pessoas vivendo com o Vírus da Imunodeficiência Humana assistidas no ambulatório de dois hospitais públicos de referência. Para a coleta de dados relacionada à adesão, foi utilizado o instrumento CEAT–VIH. Para avaliação do consumo de álcool e outras substâncias, utilizou-se o ASSIST. Realizou-se a análise descritiva das características sociodemográficas e criou-se um banco de dados no Programa Epi Info 7, versão 7.0.9. Foram comparados aos valores obtidos mediante a aplicação do CEAT-VIH. Na análise dos dados, foram empregados os testes de correlação de Pearson, teste de contingência de Qui-Quadrado com nível de significância de 0,05. Resultados: 44,72% da amostra apresentaram baixa adesão ao tratamento. O nível de adesão associado ao uso do álcool (p=0,156), tabaco (p=0,215), maconha (p=0,434) e cocaína (p=0,155). Conclusão: embora haja baixa adesão, não houve associação significativa entre o uso de álcool e drogas em pessoas vivendo com o Vírus da Imunodeficiência Humana e a adesão ao tratamento antirretroviral. Descritores: Síndrome de Imunodeficiência Adquirida; Adesão à Medicação; Antirretrovirais; Drogas Ilícitas.
RESUMEN
Objetivo: analizar el uso de álcohol y drogas en personas viviendo con el virus de la inmunodeficiencia humana y adherencia al tratamiento antirretroviral. Método: estudio cuantitativo, analítico, con 322 personas viviendo con el Virus de la Inmunodeficiencia Humana asistidas en el ambulatorio de dos hospitales públicos de referencia. Para la recolección de datos relacionada a la adherencia, fue utilizado el instrumento CEAT–VIH. Para evaluación del consumo de alcohol y otras sustancias, se utilizó el ASSIST. Se realizó el análisis descriptivo de las características sociodemográficas y se crió un banco de datos en el Programa Epi Info 7, versión 7.0.9. Fueron comparados a los valores obtenidos mediante la aplicación del CEAT-VIH. En el análisis de los datos, fueron empleados los testes de correlación de Pearson, test de contingencia de Chi-Cuadrado con nivel de significancia de 0,05. Resultados: 44,72% de la muestra presentaron baja adherencia al tratamiento. El nivel de adherencia asociado al uso del alcohol (p=0,156), tabaco (p=0,215), marihuana (p=0,434) y cocaína (p=0,155). Conclusión: aunque haya baja adherencia, no hubo asociación significativa entre el uso de alcohol y drogas en personas viviendo con el Virus de la Inmunodeficiencia Humana y la adherencia al tratamiento antirretroviral. Descriptores: Síndrome de Inmunodeficiencia Adquirida; Cumplimiento de la Medicación; Antirretrovirales; Drogas Ilícitas. 1Nurse, PhD Professor, University of Pernambuco, State University of Paraíba/UPE/UEPB. Recife (PE), Brazil. E-mail: [email protected]; 2 Nurse, PhD student in Nursing, University of Pernambuco, State University of Paraíba/UPE/UEPB Recife (PE), Brazil. E-mail: [email protected]; 3Nurse, PhD student in Nursing, University of Pernambuco, State University of Paraíba/UPE/UEPB Recife (PE), Brazil E-mail: [email protected]; 4Nurse, Master student in Nursing, University of Pernambuco, State University of Paraíba/UPE/UEPB Recife (PE), Brazil. E-mail: [email protected]; 5Undergraduate student in Nursing, University of Pernambuco. Recife (PE), Brazil. E-mail: [email protected]; 6Undergraduate student in Nursing, University of Pernambuco. Recife (PE), Brazil. E-mail: [email protected]
ORIGINAL ARTICLE
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3863
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
Acquired Immunodeficiency Syndrome
(AIDS) is an infectious disease characterized by
changes in its evolution. It has come to be seen
over time as a pathology related to behaviors
of vulnerability to HIV infection, and can
affect all people, regardless of class, gender,
race or ethnicity, sexual orientation and age
range.1
According to the epidemiological bulletin of
the Ministry of Health, since the beginning of
the AIDS epidemic in Brazil up to June 2015,
798,366 cases of the disease were reported in
the country, 615,022 (77%) of which were
reported in the notification system (SINAN),
45,306 (5.7%) in the mortality information
system (SIM) and 138,038 (17.3%) in the
laboratory examination control system and
medication control system (SISCEL/SICLOM),
identified by the probabilistic relationship of
the data as an underreporting of SINAN. In
addition, there are differences in the
proportion of data in relation to the regions of
the country. The South and Center-West
regions have a higher proportion of SINAN
cases than the North, Northeast and Southeast
regions.2
The proportional distribution of AIDS cases
in the country, according to the region, shows
that cases are concentrated in the Southeast
and South regions, each accounting for 53.8%
and 20% of the total cases identified from 1980
to June 2015; the Northeast, Central-West and
North regions correspond to 14.6%, 5.9% and
5.7% of the total cases, respectively. From the
beginning of the epidemic in 1980 to December
2014, 290,929 deaths were identified, with
AIDS as the main cause (CID10: B20 to B24),
and most cases were in the Southeast region
(61%), followed by the South (17.4%),
Northeast (12.3%), Central West (5%) and
North (4.2%) regions.2
With the introduction of antiretroviral
therapy (ART) in Brazil, there has been a
change in the profile of the HIV/AIDS
epidemic, which has allowed, over the years,
an increase in the survival of people living with
HIV/AIDS (PLHA) so that the perception of the
society about this syndrome has has changed
from a death foretold to a chronic disease. ART
has provided a significant decrease in
mortality rate, favoring a substantial increase
in CD4 count and reduction of viral load,
slowing the progression of the disease and
increasing the survival of patients.3
Adherence to antiretroviral therapy is of
paramount importance because the failure of
the drug treatment due to nonadherence
compromises the effectiveness of
antiretrovirals and can lead to viral
resistance.4 However, for a drug adherence,
the patient should be understood as having an
active role, so that he/she participates and
assumes responsibility for his/her treatment.5
Despite the benefits, many PLWHA have
adherence difficulties related not only to the
clinical repercussions of the treatment, but
also due to the difficulty in accessing the
service and, consequently, access to
medicines.6
Adherence to treatment through the use of
ART is a complex process that encompasses
subjective factors intrinsic to the person and
to their social group that influence the
adherence process, thus allowing a real
therapeutic association between client and
caregiver.7 It is also worth noting that the
number of deaths due to this disease has been
declining in recent years due to the free entry
and distribution of this therapy in Brazil.2
● To analyze the association of alcohol and
drug use by PLWHA and adherence to
antiretroviral therapy.
This is a quantitative, descriptive,
exploratory study. The population was
composed of PLWHA adults and young people
using ART with registration in the medication
control system (SICLOM). The sample was
calculated considering the 95% confidence
level, 10% loss percentage and 75% prevalence,
obtaining a total of 322 subjects, being 112 in
Garanhuns and 210 in Caruaru. Data collection
was performed from July 2015 to July 2016.
Patients older than 18 years, having used
ART for at least 6 months and having been
monitored in the last 12 months regarding CD4
count and viral load were included. Those with
a mental disability that compromised the
understanding of the research and the
pregnant women were excluded from the
study. The study was carried out in the
specialized care services in HIV/AIDS (SAE), in
the municipalities of Garanhuns (Espaço Pró-
Vida) and Caruaru (Amélia Pontes Health
Center), located in the rural region of
Pernambuco.
In order to collect data regarding
sociodemographic data and clinical aspects, a
form was used consisting of blocks that include
the variables of the research, which were
collected through interview and survey in the
patients' medical records, thus gathering data
on the sociodemographic characteristics of
patients.
INTRODUCTION
OBJECTIVE
METHOD
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3864
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
For data collection related to adherence, a
Spanish instrument was validated for
Portuguese language, the CEAT-VIH, prepared
by Professor Eduardo Remor of the
Autonomous University of Madrid, who
authorized its use for this research. This
instrument was applied in the moments that
preceded the patients' appointments in the
outpatient clinic and had the purpose of
evaluating the adherence to ART in PLWHA. It
presents a multidimensional character,
consisting of 20 items, covering the main
factors associated to the adherence behavior.8
In order to evaluate the consumption of
alcohol and other substances, a validated
instrument named Alcohol, Smoking and
Substance Involvement Screening Test (ASSIST)
was used. This is a structured questionnaire
containing eight questions about the use of
nine classes of psychoactive substances
(tobacco, alcohol, marijuana, cocaine,
stimulants, sedatives, inhalants, hallucinogens
and opioids). The questions address the
frequency of use in life and in the last three
months, problems related to use, concern
about the use by people close to the user, loss
of performance of expected tasks,
unsuccessful attempts to cease or reduce use,
feeling of compulsion and use by injection.
Each answer corresponds to a score ranging
from 0 to 8. The score ranging from 0 to 3 is
considered as no intervention, except for
alcohol, which ranges from 0 to 10 in this
category; from 4 to 26 is indicative of a brief
intervention; and 27 or more is indicative of
more intensive treatment.9
For data analysis, the guidelines suggested
by the author of the CEAT-HIV were followed.
Initially, a descriptive analysis of the
sociodemographic characteristics was carried
out and a database was created in the Epi Info
7 Program, version 7.0.9, which contains the
data obtained through interviews. In order to
continue the adherence evaluation and alcohol
use in the present study, the values obtained
through the application of CEAT-VIH were
compared. Pearson correlation test and the
Chi-Square contingency test with a 0.05
significance level were used in the analysis of
the data. The project was approved by the
Research Ethics Committee (CEP), under
approval certificate No.
55169316.0.0000.5192.
Table 1 shows the sociodemographic
profile of the sample, which was
characterized by age range between 40 and
60 years (51.24%), male participants
(61.18%), with low level of education
represented by incomplete primary
education (45.03%), brown color (48%) and
married individuals (39.4%).
The treatment time of PLWHA with
antiretrovirals ranged from 6 months to 20
years, with a mean of 5.66 years and a
standard deviation of 4.5 years. Regarding
the level of adherence to ART, based on the
Cuestionario para la Evaluación de La
Adhesión al Tratamiento Antirretroviral, it
was obtained low adherence (44.72%), high
adherence (29.19%) and moderate adherence
(26.09%).
Table 1. Distribution of people living with HIV/AIDS under antiretroviral treatment according to sociodemographic profile in the Caruaru and Garanhuns Specialized Care Services (PE), 2016, Brazil. (n=322)
Variable n %
Age range 18 to 28 years 31 9.63 29 to 39 years 103 31.99 40 to 60 years 165 51.24 More than 60 years 23 7.14 Gender Female 125 38.82 Male 197 61.18 Degree of education None 33 10.25 Incomplete Primary Education 145 45.03 Complete Primary Education 30 9.32 Incomplete Secondary Education 24 7.45 Complete Secondary Education 67 20.81 Incomplete Higher Education 11 3.42 Complete Higher Education 12 3.73 Color (self-declared) Yellow 6 2.00 White 106 33.00 Natives 3 1.00 Brown 155 48.00 Black 52 16.00 Marital status Married 127 39.44
RESULTS
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3865
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
Regarding the association between
adherence to ART in PLWHA and the
classification of intervention for use of
alcohol, tobacco, marijuana and cocaine, it
can be seen in Table 2 that no significant
association was found between these
observations and the use of alcohol (p = 0.156),
tobacco (p = 0.215), marijuana (p = 0.434) and
cocaine (p = 0.155).
Table 2. Evaluation of the level of adherence and classification of intervention for use of alcohol, tobacco, marijuana and cocaine in the Caruaru and Garanhuns Specialized Care Services, Pernambuco, Brazil, 2016. (n=322).
Alcohol use intervention(2)
Level of adherence
(1)
No Intervention
Brief Intervention
Intensive Intervention
Total p-value(3)
Low 110 30 4 144
p= 0.156 Moderate 70 13 0 83 High 82 12 1 95 Total Group 262 55 5 322
Tobacco Use Intervention (2) Level of
adherence (1)
No Intervention
Brief Intervention
Intensive Intervention
Total p-value (3)
Low 85 44 15 144
p=0.215 Moderate 53 27 3 83 High 64 22 9 95 Total Group 202 93 27 322
Marijuana Use Intervention(2) Level of
adherence (1)
No Intervention
Brief Intervention
Intensive Intervention
Total p-value (3)
Low 135 9 0 144
p=0.434 Moderate 81 2 0 83 High 89 6 0 95 Total Group 305 17 0 322
Cocaine Marijuana Use Intervention(2) Level of
adherence (1)
No Intervention
Brief Intervention
Intensive Intervention
Total p-value (3)
Low 141 3 0 144
p=0.155 Moderate 83 0 0 83 High 95 0 0 95
Total Group 319 3 0 322
(1): Levels defined according to the adherence classification to the antiretroviral treatment of the validated
version for the Portuguese language (Brazil) of the “Cuestionario para la Evaluación de la Adhesión al
Tratamiento Antiretroviral”.
(2): Classification carried out by the ASSIST instrument.
(3): From the Pearson Chi-square test.
The analysis revealed that the
sociodemographic characterization of the
individuals converges with the profile of the
HIV epidemic in Brazil, that is, men, aged more
than thirty years, with low education, low
income and having sexual transmission as the
main route of contagion.6
Simirlarly, the municipality of Itapira (SP)
showed that 69.50% of PLWHA were men and
30.50% were women, characterizing a
masculinity ratio of 2 men for 1 woman.10 A
survey carried out in a reference hospital in
Single 121 37.58 Widowed 26 8.07 Divorced 48 14.91 Time of treatment Less than 1 years (from 6 months) 8 2.48 1 to 5 years 159 49.38 5 to 10 years 110 34.16 More than 10 years 45 13.98 Level of adherence (1) High 94 29.19 Moderate 84 26.09 Low 144 44.72
Total 322 100
(1): Levels defined according to the adherence classification to the antiretroviral treatment of the
validated version for the Portuguese language (Brazil) of the “Cuestionario para la Evaluación de la
Adhesión al Tratamiento Antiretroviral”
DISCUSSION
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3866
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
Pernambuco on infectious diseases indicated
that more than 50% of the individuals were also
male, which agrees with data of the present
study.11
According to the Epidemiological Bulletin of
STD/AIDS, in Brazil from 1980 to June 2015,
798,143 cases of AIDS were registered, and 65%
of this total was among men and 35% among
women. In the period from 2004 to 2008, the
sex ratio had been 15 cases in men for every
10 cases in women. However, as of 2009, there
has been a reduction in cases of AIDS in women
and an increase in cases in men, reflecting in
the sex ratio, which was 19 cases of AIDS in
men for every 10 cases in women in 2014.2
With regard to low schooling, this may
represent difficulties for access to health
services. Low schooling has also been found
and described in the literature, and a study
stated that AIDS has reached more broadly
people with low educational level and with
socioeconomic vulnerabilities.12 Several
studies in different regions of Brazil also
pointed to low schooling as the most prevalent
level of education. Given this fact, it can be
concluded that a low education or low
knowledge about ART can lead to low drug
adherence.1-2,12-3
Regarding color, in this research, the brown
one was predominant, which converges with
the data published on the epidemiological
bulletin of HIV/AIDS of the year 2015, which
showed that, comparing the proportional
distribution of AIDS cases according to
race/color by sex from 2005 to 2014, it was
observed that there is no difference in the
proportions of whites, yellows, browns and
natives according to sex, except among blacks,
for whom the proportion of men is lower than
that of women. In addition, according to the
bulletin, there has been an increase in the
proportion of cases among self-declared
browns and a decrease in the proportion of
cases among whites.2
Concerning the marital situation, this study
found that the majority was married, followed
by the single ones. Corroborating this
research, it was observed that 55.4% of the
patients were single and 36.3% were
married/in a stable union.14
Regarding treatment time and ART, similar
studies also evaluated drug adherence through
CEAT-VIH and obtained a treatment time of 1
to 5 years.14-5
It has been observed that low adherence to
ART is a concerning issue. The professionals in
this context are extremely important as they
are responsible for encouraging, clarifying and
raising patients’ awareness about of the care
with their own health, seeking, above all, a
better quality of life. Insufficient drug
adherence can lead to complications,
increased number of hospitalizations,
opportunistic diseases, higher expenditures for
the Unified Health System, overcrowding,
increased mortality and, especially, poor
quality of life.3-4
Nevertheless, non-adherence to treatment,
especially for PLWHA, is a broader problem.
The consequences of this situation bring harm
to the very individual that does not adhere and
can affect the population in general. In a
study, a large part of the users were also
considered at a "low/moderate" level of
adherence. It is worth highlighting that
insufficient adherence can lead to low disease
delay and decreased quality of life, among
others, for patients under treatment.16
Regarding the association of drugs with
ART, there was no significant association
between the level of adherence and the need
of intervention due to the use of alcohol and
other drugs (tobacco, marijuana and cocaine).
This fact may also be related to the stigma still
existing in society regarding the use of alcohol
and other drugs, especially because there are
few reports surveying users about this.
However, there is a need for continuous
screening of the use of substances such as
alcohol and other drugs as a vital part of
improving adherence to HIV medication and
maintaining the overall health of PLWHA in
order to implement health promotion
actions.17
However, studies have found a significant
number of users of tobacco, alcohol, and illicit
drugs with risk for low adherence, a strong
association between alcohol use and failure in
therapy measured by self-report of the patient
and also that non-adherence was higher among
individuals using licit and illicit drugs,
however, this data had no statistical
significance.18-20
However, several factors affect adherence
to drug therapy, among them, in a harmful
way, the use of drugs. Authors have stated
that, despite the influences, it is necessary to
analyze the patients’ behavior in the face of
the disease and their social and clinical
conditions to conclude whether the use of
alcohol, tobacco and other drugs interferes in
the effectiveness of ART.12
In this sense, it was verified that most
patients followed the guidelines to have
healthy life habits, since only a small
proportion used licit and illicit drugs.6 The
ART, when associated with alcohol, increases
the risk of hepatotoxicity, and tobacco causes
Oliveira RC de, Moraes DCA, Oliveira ECS et al. Associação do uso de álcool e drogas e a adesão...
English/Portuguese
J Nurs UFPE on line, Recife, 11(10):3862-8, Oct, 2017 3867
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.12834-30982-1-SM.1110201721
pulmonary and cardiovascular complications;
illicit drugs bring the risk of toxicity.21 This
said, we can infer the need for the
professionals that accompany the PLWHA in
the SAEs to promote health education in order
to provide guidance on the non-use of these
substances, showing the real risks of this
combination. This action may contribute so
that the service has an improvement in the
level of adherence to ART.
The low adherence of PLWHA to ART in rural
areas in Pernambuco is evidenced, leading to
the assumption that there is fragility in the
promotion of user safety, although there was
no association between low adherence to ART
and use of alcohol and other drugs (tobacco,
marijuana and cocaine).
However, it is worth mentioning that
adherence to ART is influenced by several
factors, making it urgent for all those involved
in the care for PLWHA to rethink about their
care practices and to reflect on how to raise
users’ awareness about their responsibilities,
not only in the treatment, but also in the their
own health status.
It is known that the use of alcohol and other
drugs influence self-care not only for the
PLWHA. When using these substances, subjects
may be vulnerable to changing the proposed
treatment regimen. Thus, guidance on harm
and the conscious use of such drugs may
positively affect levels of adherence.
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CONCLUSION
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Submission: 2016/10/19 Accepted: 2017/09/12 Publishing: 2017/10/01
Corresponding Address
Regina Celia de Oliveira Rua Guedes Pereira, 180, Ap. 1903 Bairro Casa Amarela
CEP 52060-150 Recife (PE), Brazil
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