Moderate to severe generalized anxiety disorder symptoms are associated with physical inactivity in people with HIV/AIDS: a study from Uganda

Abstract

The aim of this cross-sectional study was to explore the prevalence of moderate to severe generalized anxiety disorder (GAD) symptoms and its association with physical activity in people living with HIV (PLHIV) in Uganda. Two hundred and ninety-five PLHIV (median [interquartile range] age = 37.0 years [16.0]; 200 women) completed the GAD-7, Physical Activity Vital Sign, Patient Health Questionnaire-9, and the Alcohol Use Disorders Identification Test. An adjusted odds ratio for physical inactivity in people with moderate to severe GAD symptoms was calculated using binary logistic regression analyses. The prevalence of moderate to severe GAD symptoms was 9.1%. Those with moderate to severe GAD symptoms had a 16.8 times higher odds (95% CI = 5.0–55.9) for not complying with the physical activity recommendations. The current study shows that moderate to severe GAD symptoms are strongly associated with physical inactivity in PLHIV living in a country such as Uganda.

Keywords

HIV anxiety depression physical inactivity

Introduction

Despite the fact that HIV testing and HIV/AIDS counselling services have been scaled up and antiretroviral therapy (ART) has become more widely available in the public health domain,¹ many people living with HIV (PLHIV) in sub-Saharan Africa (SSA) still have a high risk for mental illness co-morbidity. For example, a study from Uganda indicated that the prevalence of major depressive disorder was 11.7%, and the prevalence of alcohol use disorder was 10.5% in 256 community-based PLHIV.² The prevalence of co-morbid generalized anxiety disorder (GAD) in PLHIV in SSA is less researched, but the available prevalence ranges from 0.8% among 618 PLHIV attending two HIV clinics in semi-urban Uganda³ to 33% in 400 PLHIV attending a HIV clinic in Nigeria.⁴ GAD can be defined as an anxiety condition characterized by persistent and excessive worries or fears that cause significant distress, and impair occupational, social, and physical functioning due to fatigue, poor concentration, headaches, muscle tension, shortness of breath, upset stomach, and sleep disturbance.⁵

The common mental co-morbidity in PLHIV may suggest that integrated intervention strategies (health promotion, prevention, treatment, care, and support) for these conditions are needed. Identifying and treating, for example, co-morbid GAD symptoms is vital as it may have important consequences for health care cost saving, patient retention in care, and HIV-disease management.^6–8 This is particularly relevant in a context where mental health care delivery for PLHIV is largely absent.⁹

Understanding variables associated with GAD symptoms in PLHIV is an important first step in order to devise interventions that can effectively be implemented in these settings. Previous research indicated that GAD is associated with a poor socio-economic status, chronic mental (i.e. depression)¹⁰ co-morbid somatic health conditions,¹¹ and unhealthy lifestyle choices including smoking,¹² alcohol abuse,¹³ and physical inactivity.¹⁴ A recent study from Uganda revealed that PLHIV are at risk for not complying with the international physical activity guidelines of being physically active for at least 150 min/week at minimum moderate intensity.²

To the best of our knowledge, no study to date has examined the association of GAD symptoms with physical inactivity in PLHIV in a low-income country such as Uganda. Therefore, the aim of the current study was to assess whether moderate to severe GAD symptoms in this population were associated with physical inactivity when controlling for relevant demographic (age, gender, employment, and educational status), mental (i.e. presence of depression), physical (i.e. presence of a chronic condition), and lifestyle (i.e. alcohol use and smoking) variables. We hypothesized that the presence of moderate to severe GAD symptoms was associated with physical inactivity even after controlling for relevant demographic, mental, physical, and lifestyle variables in Ugandan PLHIV.

Methods

Participants and procedure

We conducted a cross-sectional study in two community health care centers in the Buikwe district in Central-Uganda (North-Buganda). The HIV prevalence in the district was 3.8% in 2018.¹⁵ The two centers were selected as they were located within the catchment area from a local non-governmental organization, i.e. Africa Social Development and Health Initiatives (ASHDI). All people with a registered diagnosis of HIV who are followed by ASHDI and who currently receive ART were interviewed by a trained clinical officer in psychiatry. ASHDI provides HIV prevention, care, treatment, and social support services among individuals and families in these rural communities. The key services provided include home-based health care, medication, counselling, and distribution of emergency food. Patients were interviewed in a separate room when they were waiting for their consultation. No compensation was given for participation. Patients were informed that non-participation would not affect their relationship with the health center. All participants gave their written informed consent. Participants who could not read discussed the consent form first with the clinical officer and a relative before providing consent with a finger print. The study was approved by the ethical committee of Mengo Hospital and by the Uganda National Council for Science and Technology.

Socio-demographic and clinical variables

Patients were asked whether they had a paid job (yes versus no), whether they received education (yes versus no), and whether they smoked (yes versus no). Age, gender, and the presence of chronic somatic co-morbidities (yes versus no) were obtained from the medical files. For calculating the body mass index (BMI), body weight was measured in light clothing to the nearest 0.1 kg using a SECA beam balance scale, and height to the nearest 0.1 cm using a wall-mounted stadiometer.

GAD-7

The GAD-7¹⁶ is a seven-item instrument that is used to measure or assess the severity of GAD. Each item asks the individual to rate the severity of his or her symptoms over the past two weeks. Each item is scored on a Likert scale with symptoms rated as 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). The optimal cut-off for the presence of moderate to severe GAD symptoms is ≥10.¹⁶ The questionnaire was interviewer-administered. The GAD-7 was used as it was validated before for screening GAD symptoms in PLHIV in primary care settings in SSA.¹⁷

Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9¹⁸ is a widely used and validated instrument that performs well in PLHIV both as dichotomous diagnosis of depression and a continuous severity score. In Ugandan PLHIV, the PHQ-9 has a very high sensitivity and specificity, and can be considered useful for screening PLHIV for depression.¹⁹ A cut-off of ≥10 has been shown to be the optimum cut-off for major depression,¹⁸ also in this patient group.¹⁹ The questionnaire was interviewer-administered.

Alcohol Use Disorders Identification Test (AUDIT)

To assess the presence of alcohol use disorders in this study, we used the AUDIT,²⁰ which was developed by the World Health Organization as a simple method of screening for alcohol use disorders. The AUDIT comprises three domains: hazardous alcohol use (frequency of drinking, typical quantity, and frequency of heavy drinking), dependence symptoms (impaired control over drinking, increased salience of drinking, and morning drinking), and harmful alcohol use (guilt after drinking, blackouts, alcohol-related injuries, and other concerns about drinking). The AUDIT was adapted for local use through the use of pictures and local terms for standard alcohol units. In accordance with previous research in Uganda, a score of 8 or more was considered to be a positive screening result.²¹ The questionnaire was interviewer-administered.

Physical Activity Vital Sign (PAVS)

Physical activity was assessed using the PAVS, comprising of two simple questions.²² The first question was: ‘On average how many days per week do you engage in moderate to vigorous physical activity like a brisk walk?’. It was explained by the clinical officer to patients that this meant that due to the physical activity their heart rate increased and they breathed more deeply and faster than normal, with some experiencing sweating. The second question was: ‘On those days, how many minutes do you engage on average in physical activity at this level?’. Next the research assistant multiplied the two responses together to calculate the minutes per week of self-reported moderate to vigorous physical activity and verified whether the patient was achieving the recommended target of 150 min/week of moderate to vigorous physical activity (yes = 1; no = 0).^23–25

Statistical analyses

Continuous data were assessed for normality using the Shapiro–Wilk test and found not to be normally distributed. There were no missing data. Mann–Whitney U tests were therefore used to compare continuous variables between those with versus without GAD. Fisher’s exact tests were used to compare distributions of dichotomous variables. We did control for multiple testing. The level of significance was set at P < 0.0038 (0.05/13). An adjusted odds ratio for physical inactivity in PLHIV with versus without moderate to severe GAD symptoms was calculated using a binary logistic regression. We adjusted for significant correlates with moderate to severe GAD symptoms in the univariate analyses. Statistical analyses were performed with IBM SPSS Statistics, version 26.

Results

Participants

All 295 patients (median [interquartile range] age = 37.0 years [16.0]; 67.8% [n = 200] female) who are currently receiving ART agreed to participate. In total, 27 of the 295 participants had a GAD-7 score of 10 or higher (prevalence = 9.1%). The prevalence of major depressive disorder was 10.2% (30/295), while the prevalence of alcohol use disorder was 3.4% (10/295). Sixty patients (20.3%) did not comply with the physical activity guidelines. Forty-four patients (14.9%) had received no formal education and 97 patients did currently not have a job (32.9%). Fifteen patients smoked (5.1%). The median number of cigarettes smoked was 5.5 (interquartile range = 18). Thirty-six patients (12.2%) had a chronic somatic condition. The most reported somatic chronic conditions were ulcers (n = 7), hypertension (n = 6), low back pain (n = 6), and cardiovascular disease (n = 4).

Differences in socio-demographic and clinical variables between PLHIV with versus without GAD

As can be seen in Table 1, those with GAD were less likely to have a paid job, more likely to have a chronic condition, more likely to have depression, and less likely to comply with the physical activity guidelines. After adjusting for the employment, chronic condition, and depression status, those with GAD still had a 16.8 times higher odds (95% CI = 5.0–55.9) for not complying with the physical activity recommendations than those without moderate to severe GAD symptoms.

Table 1.

Differences in demographic and clinical characteristics between people living with HIV with and without generalized anxiety disorder.

Variable	With moderate to severe generalized anxiety disorder symptoms (n = 27)	Without moderate to severe generalized anxiety disorder symptoms (n = 268)	P value
Age (years)	37.0 (9.2)	36.0 (16.0)	0.38
Gender (men/women)	6/21	89/179	0.29
Paid employment (yes/no)	10/17	188/79	0.002*
Having received any education (yes/no)	24/3	227/41	0.78
Body mass index	20.1 (5.5)	21.1 (4.1)	0.97
Smokers (smokers/non-smokers)	2/25	13/255	0.41
Having a chronic co-morbidity (yes/no)	9/18	27/241	0.002*
PHQ-9 total score	8.5 (4.7)	3.5 (6.0)	<0.001*
Presence of major depression (PHQ-9≥10) (yes/no)	12/15	18/250	<0.001*
AUDIT total score	0.0 (3.2)	0.0 (1.0)	0.70
Presence of alcohol use disorder (AUDIT≥8) (yes/no)	1/26	9/259	0.62
Physical activity levels (PAVS total score) (min/week)	47.5 (270.0)	480.0 (1290.0)	<0.001*
Complying with physical activity guidelines (PAVS) (yes/no)	7/20	228/40	<0.001*

AUDIT: Alcohol Use Disorders Identification Test; PAVS: Physical Activity Vital Sign; PHQ: Patient Health Questionnaire.

Moderate to severe generalized anxiety disorder symptoms = a GAD score of ≥10.

*Significant when P < 0.0038; Mann–Whitney U tests were used for continuous variables and Fisher’s exact tests for categorical data. Data expressed as median (interquartile range) for continuous variables and as ratios for categorical data.

Discussion

General findings

To the best of our knowledge, the current study is the first to explore the association between moderate to severe GAD symptoms and physical inactivity in PLHIV in a rural community in a low-income country.

Our data show that the odds for physical inactivity after adjusting for employment, chronic condition, and depression status was 16.8 in PLHIV with moderate to severe GAD symptoms compared to those without moderate to severe GAD symptoms. A potential hypothesis of the link between physical inactivity and GAD symptoms in PLHIV may be explained by social withdrawal, which is common in people with GAD.²⁶ Not engaging in physical activities may lead to social solitude and withdrawal from interpersonal relationships, both of which have been linked to increased feelings of anxiety.²⁷ On the other hand, it may be that PLHIV who also have moderate to severe GAD symptoms are less inclined to engage in physical activity as a means of coping with their anxiety symptoms, as has been suggested in previous research among people with mental illness.²⁸ However, more research on the role of anxiety on physical activity participation in PLHIV is needed to make any firm conclusions. Large-scale representative data should explore the prospective relationship between physical activity and GAD in this vulnerable population. Although we adjusted for the presence of chronic conditions, it is known that, in particular, inactive people with anxiety are more likely to have a chronic somatic condition,²⁹ while vice versa the presence of chronic somatic conditions increases the likelihood of having anxiety.¹¹ For example, chronic somatic diseases can lead to negative coping strategies, which might in turn lead to higher anxiety levels.³⁰ Next to this, shared pathophysiological mechanisms such as hypothalamic–pituitary–adrenal-axis abnormalities have been postulated for physical inactivity, chronic somatic diseases, and anxiety.³¹

Although it was not a primary aim of the current study, our data did show other interesting associations with moderate to severe GAD symptoms in PLHIV that are currently underreported in the literature. For example, the observed association between lack of employment and GAD symptoms in PLHIV supports the findings of others on the relationship between GAD and social determinants of health such as poverty and housing instability.^32,33 In contrast to what we expected, we did not observe a relation between GAD symptoms and alcohol use disorder in PLHIV. The reason why no association was found between the prevalence of GAD symptoms and the prevalence of alcohol use disorder might however be due to the low prevalence rate of alcohol use disorder in the current study, i.e. 3.4% (10/295), and consequently a lack of statistical power. As in a previous community-based study in Uganda exploring the prevalence rate of alcohol use disorder using the AUDIT, it might be that also in our study there was an unwillingness to disclose alcohol use due to the internalized stigma related to it.²¹

Limitations

The current findings, although promising, should be interpreted in light of some limitations. First, the presence of GAD symptoms, major depressive disorder, and alcohol use disorder were based on questionnaires and not confirmed via structured interviews. Previous research in PLHIV already demonstrated that rates of anxiety disorder diagnoses are significantly higher when questionnaire-based assessments as compared to diagnostic interviews are employed.³⁴ Second, the construct validity and test–retest reliability of the PAVS are still unknown in this vulnerable population. A self-report physical activity questionnaire is less accurate than objective assessments,^35,36 as it may overestimate physical activity levels.³⁷ The PAVS-method also does not capture light intensity physical activity and sedentary behavior. Third, the finding from only two health care centers in rural Uganda may have limited generalizability. Fourth, due to the cross-sectional nature of this study, causal relationships cannot be established. Fifth, we did not account for other relevant clinical variables including the presence of opportunistic infections, the presence of frailty, the clinical status (e.g. HIV versus AIDS), and the level of immunosuppression (e.g. CD4 cell/µl count).

Practical implications and future research

Despite the abovementioned limitations and despite the cross-sectional nature of our study, some indications for clinical practice can be suggested. Considering the negative impact of GAD symptoms on adherence to ART, progression of the HIV illness, and quality of life of the patients,^6–8 it is important to improve the detection and provision of evidence-based treatment of GAD in PLHIV in rural African communities. The current health service delivery in Uganda is still based on the biomedical model, versus the biopsychosocial model, with a reliance on expensive pharmacotherapy which is seldom available and which patients mostly cannot afford, especially in more rural areas.³⁸ Our data demonstrate that it might be of interest to explore also the efficacy of interventions focusing on physical inactivity.

In conclusion, our data indicate that moderate to severe GAD symptoms are highly prevalent in PLHIV in rural African communities. Therefore, it is important to improve the detection of and provision of evidence-based treatment for generalized anxiety in PLHIV. Future research should explore the effect of integrating physical activity as a psychosocial intervention within the existing primary and mental health care systems in order to reduce co-morbid generalized anxiety.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Vlaamse Interuniversitaire Raad, Belgium (Global Minds). The funding body had no role in the design of the study and collection, analysis, and interpretation of data, nor in writing the manuscript.

ORCID iD

Davy Vancampfort

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