Challenges to nutrition management among patients using antiretroviral therapy in primary health ‘centres’ in Addis Ababa, Ethiopia: A phenomenological study

Introduction Nutritional management is a fundamental practice of concern to all patients infected with the human immunodeficiency virus (HIV). The nature of HIV/AIDS and malnutrition impacts are interlocked and intensify one another. Objective This study aimed to explore nutrition management challenges among people living with HIV on antiretroviral therapy (ART) in primary health centres in Addis Ababa, Ethiopia. Methods and materials We used a hermeneutic (interpretive) phenomenological study design. The study used in-depth interviews to describe lived experiences among adult patients aged 18 and above. We selected the participants purposively until the saturation of the idea reached. We maintained the scientific rigor and trustworthiness by applying credibility, transferability, dependability, and conformability, followed by translation and re-reading of the data has been achieved. The data have been analyzed through inductive thematic analysis assisted by NVIVO version 12 pro software. Result Nutrition management challenges for HIV patients have been described using six significant themes. The major themes were: acceptance of the disease and the health status; facilitators and barriers to treatment adherence; behavioural changes in eating patterns; experience of food insecurity issues; nutrition knowledge; and support. The themes have explained how patients using ART have been challenged to manage their nutrition ever since their diagnosis. Of all challenges, food insecurity is found to be the core reason for poor nutrition management. Conclusion and recommendation We found that many factors in managing their nutrition challenged patients with HIV. There should be an increasing interest in managing food insecurity issues as food insecurity has been strongly related to other factors.


Introduction
Nutritional management is a fundamental practice to the concern of all patients infected with human immunodeficiency infection (HIV). The nature of HIV/AIDS and malnutrition impacts are interlocked, intensify one another in a limitless manner. Objective: This study aimed to explore challenges in nutrition management among people living with HIV on antiretroviral therapy (ART) in primary health centers in Addis Ababa, Ethiopia. Methods and Materials: -A hermeneutic (interpretive) phenomenological study design was used. The study used in-depth semi-structured interviews to describe lived experiences among adult patients aged 18 and above and participants were selected purposively until saturation of idea reached. Scientific rigor and trustworthiness like credibility, transferability, dependability, and conformability were secured in each respective step. Verbatim transcription followed by translation and re-reading of the data has been secured to immerse in the data. The data has been analyzed through inductive thematic analysis assisted by NVIVO version 12 pro software. Result : -Nutrition management challenges for HIV patients have been described using six major themes. The major themes were acceptance of the disease and the health status, facilitators and barriers of treatment adherence, behavioral changes in eating patterns, and experience of food security issues, nutrition knowledge, and support. The themes have explained how patients on ART have been challenged to manage their nutrition ever since their diagnosis. Among these, food security issue among ART patients has been found to be the leading major theme for other themes in which other themes can be controlled with Conclusion and recommendation: -Taken together this research found that there was a huge challenge beyond taking medications among patients on ART. There should be a need to increase food security issues and various approaches in a different hierarchy of implementation.  Formal permission was obtained from Addis Ababa Health Office to the respective health centers where the study was conducted.
The participants were reassured that none of the real identities would be revealed. All questions and concerns were addressed before signing the informed consent.
Participants were informed that there was no direct benefit from this study except an opportunity to talk freely about their condition, which could be either a distressing or helpful experience. Also, they were informed the expected duration of interview(Maximum of 50 minutes).
The location ensured the participant's privacy and was mutually agreed upon. The participants were asked if they had any questions after completing the interview question guides. Informed written consent was a sign. The interview participants have the right to withdraw from the study at any time. If they did withdraw, no penalty, as well as the service they were getting, was not affected. They may have refused to answer any question or have the recording device stopped. If they did, the information would still be used unless they withdrew altogether. Nutritional management is a fundamental practice to the concern of all patients infected with       Meaning, a longer period a patient is with the disease the essence might be different.  Thus it has helped to have a great detail of the phenomenon by following probes to follow a 132 route of an investigation initiated by the participant. An interview meeting was scheduled at a 133 time and place that is suitable for the participant as it was a separated room next to the 134 examination and follow up the room. Interview was conducted by the primary auther.

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Participants were selected purposively until saturation of idea reached.

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Audio reecordind and note taking were made. There were two audio-tape recorders in case of 137 equipment failure. After all the questions were addressed, the researcher asked the participants 138 if there was anything additional they wanted to discuss or mention. Participants in the study 139 have also been welcomed if they thought of anything else after the interview. The body 140 language, verbal, nonverbal cues were recorded using notes immediately after the interview.

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The researcher's reflection of the interview and labeled the audiotape with the record file name.

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The reflection allowed the researcher to bracket personal assumptions and reduce bias, however 143 in IPA study the researcher interpreting based on his own experience of the phenomenon. The 144 interview was transcribed, which meant there would be a written version of the interview.  The recorded interviews were transcribed in Amharic, translated into English, and then 153 managed using NVIVO version 12 pro software. The current study has summarized massive 154 amounts of data with important features of the interview. As per Cress well description of six 155 major steps in analyzing data in phenomenology, the current study has followed six major steps 156 of analysis. First, the researcher managed the data by creating and organizing files so that they 157 can be accessed easily for analysis. Second, the principal author reads and rereads the 158 transcriptions, making notes in the margins identifying any sub-themes and wrote emerging 159 ideas form baseline codes. Third, the researcher describes the personal experiences throughout 160 the period, attempting to identify the core meaning or essence of the phenomena, the concepts, 161 or themes were derived from the data. Fourth the data has been classified by developing 162 relevant statements. The statements were grouped according to significance and meaning in the 163 coding process.
Step five was interpreting phase, which is a written description to answer 164 "what happened?" and "how the phenomenon was experienced. Thus, the essence of the 165 experience of the participants' has been revealed. The final step was summarizing findings of 166 the study, and this has been also supported with additional paragraphs which intend to interpret 167 the meaning of the experience.  This section is mainly the reliability of the study in which this study has shown in the data 175 collection and data analysis process. The accurate documentation including all documents in the final report, avoiding spelling and grammatical errors that will reduce the quality of work, 177 and a detail description of producers is included.

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These results and interpretations were based supported by the collected data and also reflects 180 the objectivity of the data.   The participants were reassured that none of the real identities would be revealed. All 199 questions and concerns were addressed before signing the informed consent. Participants 200 were informed that there was no direct benefit from this study except an opportunity to talk 201 freely about their condition, which could be either a distressing or helpful experience. Also, 202 they were informed the expected duration of interview(Maximum of 50 minutes).

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The location ensured the participant's privacy and was mutually agreed upon. The participants 204 were asked if they had any questions after completing the interview question guides. Informed 205 written consent was a sign. The interview participants have the right to withdraw from the 206 study at any time. If they did withdraw, no penalty, as well as the service they were getting, was not affected. They may have refused to answer any question or have the recording device 208 stopped. If they did, the information would still be used unless they withdrew altogether.   The interviewees have asserted the drug as a food that helps to maintain their regular foods.     326 Participates in this regard have raised two major aspects of their food security experience 327 which are their purchasing power related to what is available in a nearby market and the need 328 to travel to buy cheaper foods and groceries outside their compound. They have stated as they 329 are suffered the issue to secure their food. It is also reported as a barrier to adhere to their 330 drugs. Participants reported that the limited availability of food affects their lifestyle change.

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On the contrary, some participants have also discussed there is plenty of availability of food 332 but their major problem is they cannot afford the food.   Participants explained the difficult situation to comprehend what they needed for meals.

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Their weight loss was attributed to their previous nutritional knowledge and understanding 362 and they revealed that they had poor nutrition education experience at the health center. All  Participants conveyed their lack of support from parents and the community. They identified 388 that support in the home would facilitate their lifestyle change, including assistance with meal 389 preparation. Meanwhile, they have also stated that they had adequate appliances in the home 390 to support meal preparation. While some felt it would be a challenge to be isolated and a meal 391 prepared separately for them, others described ways in which following special food 392 preparation would be helpful for them. Participants have reported experience sharing between 393 patients as it will help for patients who are newly diagnosed. They also reported this 394 experience sharing has never happened throughout their experience.   Specifically, participants who perceived themselves at low risk were less likely to seek 451 testing, regardless of risky reported sexual behavior [15].

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The present study shows that people tested due to forceful reasons which they made them get 454 tested and that lead them to experience challenges in accepting their Health Status. The  This also supported and coherent with a study conducted in Gonder that revealed that patient 520 had a chance of facing three adverse effects from their ART regimen which is in contrast with 521 a study done in Uganda, which reported an average of five side effects could be possible, 522 either way, the two findings from a relative study setting revealed that ART drugs have side 523 effects depending on its regimen [25]. In the current study, patients have reported repeatedly 524 vomiting and gastrointestinal discomfort in contrast to these studies. This could probably be 525 due to differences in patient's reports of adverse effects and the settings of the study which is 526 at the tertiary level in which patients come with the severe stage of the disease. in line with other studies that stated distance as a cause for non-adherence. Those who 534 accessed the health institution far away (>20 km) from their home were found to more likely 535 use no adherence as a coping strategy than those who were nearby (≤20 km) this variation is 536 might be due to the participants to the current study are using the nearby health centers 537 because the setting is in Addis Ababa and also the study method [27].  The study provided insight into the participant's lived experience with managing nutrition.

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Different factors influenced the nutrition management of patients which has been found by 580 triangulating data with supporting methods. Thus, data and method triangulation can be the 581 strength of this study as it is evidenced by using IDI with other supporting techniques. In that 582 case, the current study credibility has been tried to secure and thus the study has several 583 important strengths. The other major strength is qualitative studies are well suited to 584 identifying challenges from the perspective of the patients. The use of an in-depth interview 585 (IDI) approach permitted to discover a diversity of ideas and practices which most likely 586 would not have been detected using a quantitative approach.

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The limitation of the current study is quite shared with qualitative research which is 588 particularly for IPA study. The researcher in this study has by default privilege to construe 589 and report what interviewees predestined within the researcher's theoretical schemes. Using 590 this method in the current study provides room for the concept that the people's experiences 591 integrate the researcher's views. IPA also requires theme development by the researcher by 592 repeated reading of the actual data. In addition, all the required steps have been secured 593 throughout to confirm the trustworthiness of the findings.

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Taken together this research found that there was a huge challenge of nutrition-management 597 among ART patients beyond taking medications.Our study identified six themes. Acceptance 598 of disease and the health status, facilitators and barriers of treatment adherence, eating 599 behavioral change, experience of food security issues, nutrition knowledge,and support.

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Among these, food security issue among ART patients has been found to be the leading 601 major theme for other themes.The controlling mechanism for nutrition management should