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      Association between water insecurity and antiretroviral therapy adherence among pregnant and postpartum women in Greater Accra region of Ghana

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          Abstract

          Background

          Adherence to antiretroviral therapy (ART) can substantially reduce morbidity and mortality among women living with HIV (WLWH) and prevent vertical transmission of HIV. However, in sub-Saharan Africa (SSA), more than 50% of new mothers discontinue ART and HIV care after childbirth. The role of water insecurity (WI) in ART adherence is not well-explored. We examined the relationship between WI and ART adherence among pregnant and postpartum WLWH in Greater Accra region of Ghana.

          Methods

          Using a cross-sectional survey, we recruited 176 pregnant and postpartum WLWH on ART across 11 health facilities. We examined the association between WI (measured using the Household Water Insecurity Experience Scale, and categorized as moderate and severe WI compard to low WI) and poor ART adherence (defined as scoring a below average observed CASE index score). Bivariate analysis was performed using chi-square test followed by multivariate logistic regression models. We included all variables with p-values less than 0.20 in the multivariate analysis.

          Results

          Most (79.5%) of the pregnant and postpartum WLWH enrolled on ART, were urban residents. Over 2/3 were aged 30 years and older. Overall, 33.5% of respondents had poor ART adherence. Proportion of poor ART adherence was 19.4% among those with low WI, 44.4% in those with moderate WI, and 40.0% among those with high WI. Respondents with moderate household water insecurity had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (adjusted Odds ratio (aOR) = 2.76, 95%CI: 1.14–6.66, p = 0.024), even after adjusting for food insecurity. Similarly, respondents with high WI had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (aOR = 1.49, 95%CI: 0.50–4.48, p = 0.479), even after adjusting for food insecurity.

          Conclusion

          Water insecurity is prevalent among pregnant and postpartum WLWH and is a significant risk factor for poor ART adherence. Governments and other stakeholders working in HIV care provision should prioritize water security programming for WLWH along the HIV care continuum.

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          Most cited references52

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          The REDCap consortium: Building an international community of software platform partners

          The Research Electronic Data Capture (REDCap) data management platform was developed in 2004 to address an institutional need at Vanderbilt University, then shared with a limited number of adopting sites beginning in 2006. Given bi-directional benefit in early sharing experiments, we created a broader consortium sharing and support model for any academic, non-profit, or government partner wishing to adopt the software. Our sharing framework and consortium-based support model have evolved over time along with the size of the consortium (currently more than 3200 REDCap partners across 128 countries). While the "REDCap Consortium" model represents only one example of how to build and disseminate a software platform, lessons learned from our approach may assist other research institutions seeking to build and disseminate innovative technologies.
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            A Systematic Review of Individual and Contextual Factors Affecting ART Initiation, Adherence, and Retention for HIV-Infected Pregnant and Postpartum Women

            Background Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women. Methods Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories. Results Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes. Conclusions To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.
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              The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries

              Objective Progress towards equitable and sufficient water has primarily been measured by population-level data on water availability. However, higher-resolution measures of water accessibility, adequacy, reliability and safety (ie, water insecurity) are needed to understand how problems with water impact health and well-being. Therefore, we developed the Household Water InSecurity Experiences (HWISE) Scale to measure household water insecurity in an equivalent way across disparate cultural and ecological settings. Methods Cross-sectional surveys were implemented in 8127 households across 28 sites in 23 low-income and middle-income countries. Data collected included 34 items on water insecurity in the prior month; socio-demographics; water acquisition, use and storage; household food insecurity and perceived stress. We retained water insecurity items that were salient and applicable across all sites. We used classical test and item response theories to assess dimensionality, reliability and equivalence. Construct validity was assessed for both individual and pooled sites using random coefficient models. Findings Twelve items about experiences of household water insecurity were retained. Items showed unidimensionality in factor analyses and were reliable (Cronbach’s alpha 0.84 to 0.93). The average non-invariance rate was 0.03% (threshold <25%), indicating equivalence of measurement and meaning across sites. Predictive, convergent and discriminant validity were also established. Conclusions The HWISE Scale measures universal experiences of household water insecurity across low-income and middle-income countries. Its development ushers in the ability to quantify the prevalence, causes and consequences of household water insecurity, and can contribute an evidence base for clinical, public health and policy recommendations regarding water.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: SoftwareRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: MethodologyRole: Project administrationRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Project administrationRole: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: ValidationRole: VisualizationRole: Writing – review & editing
                Role: MethodologyRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Project administrationRole: ResourcesRole: Writing – review & editing
                Role: Project administrationRole: ResourcesRole: Writing – review & editing
                Role: MethodologyRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLOS Glob Public Health
                PLOS Glob Public Health
                plos
                PLOS Global Public Health
                Public Library of Science (San Francisco, CA USA )
                2767-3375
                8 January 2024
                2024
                : 4
                : 1
                : e0002747
                Affiliations
                [1 ] Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, California, United States of America
                [2 ] Infectious Diseases Research Collaboration, Kampala, Uganda
                [3 ] Institute of Work Employment and Society, University of Professional Studies, Accra, Ghana
                [4 ] Language Center, College of Humanities, University of Ghana, Accra, Ghana
                [5 ] Africa Interdisciplinary Research Institute, Accra, Ghana
                [6 ] Department of Sociology and Social Science Policy, Lingnan University, Hong Kong, China
                [7 ] Institute of Policy Studies and School of Graduate Studies, Lingnan University, Hong Kong, China
                [8 ] Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
                [9 ] Push Aid Africa, Accra, Ghana
                [10 ] Department of Epidemiology and Biostatistics, and Office of Research, School of Nursing, University of California, San Francisco, San Francisco, California, United States of America
                [11 ] Division of HIV, Infectious Diseases and Global Medicine, School of Medicine, University of California, San Francisco, San Francisco California, United States of America
                North Carolina State University, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0002-7562-6281
                https://orcid.org/0000-0002-6617-237X
                Article
                PGPH-D-23-00961
                10.1371/journal.pgph.0002747
                10773961
                38190403
                fd79877d-0f6c-4d7e-bbe5-edd42e009ebf
                © 2024 Nutor et al

                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 credited.

                History
                : 24 May 2023
                : 30 November 2023
                Page count
                Figures: 0, Tables: 3, Pages: 14
                Funding
                Funded by: University of California, San Francisco School of Nursing Gaines Research Fund
                Award ID: GRF-2021-02
                Award Recipient :
                This work was supported by University of California, San Francisco School of Nursing Gaines Research Fund to JJN under Grant number GRF-2021-02. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                Biology and Life Sciences
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