The Role of Nutritional Status in the Quality of Life (QoL) of PLHIV
DOI:
https://doi.org/10.56338/mppki.v9i9.10729Keywords:
People Living With HIV, Nutritional Status, Quality of Life, Metacognitive, Health DeterminantsAbstract
Introduction: Despite significant advances in antiretroviral therapy (ART), multiple factors continue to be associated with the Quality of Life (QoL) among people living with HIV (PLHIV). Although nutritional status may play an important biological role in the observed relationships, limited evidence exists regarding its statistical mediating role between behavioural, environmental, personal, and metacognitive factors and QoL among PLHIV receiving long-term treatment.
Methods: This study employed an analytical cross-sectional design using Structural Equation Modelling–Partial Least Squares (SEM-PLS). Participants were selected using purposive sampling based on predefined inclusion criteria. Sample size adequacy was determined using the 10-fold rule and G*Power analysis with a medium effect size (f² = 0.15), significance level of 0.05, and statistical power of 0.80. A total of 127 PLHIV receiving ART participated in the study.
Results: Among 126 PLHIV analysed (purposive, service-based sample), the measurement model showed strong convergent validity (AVE > 0.80) and reliability (Cronbach’s alpha > 0.89). Personal, behavioural, environmental, and metacognitive factors were each significantly associated with nutritional status, with personal factors showing the strongest effect (β = 0.468; p < 0.001). Nutritional status, in turn, was significantly associated with Quality of Life (β = 0.746; p < 0.001), while none of the four determinants showed a significant direct association with QoL once nutritional status entered the model. Bootstrapped indirect effects were significant for all four determinants (β = 0.249 to 0.349; 95% CI excluding zero), a pattern consistent with a statistical mediation model rather than evidence of a causal mechanism. The structural model accounted for 66.2% of the variance in QoL (R² = 0.662).
Conclusion: In this cross-sectional sample of PLHIV aged 30 years and above, nutritional status showed a statistical pattern consistent with mediating the associations between personal, behavioural, environmental, and metacognitive factors and Quality of Life, explaining 66.2% of its variance (R² = 0.662). These findings should be read as hypothesis-generating rather than proof of a causal pathway, given the cross-sectional design.
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References
UNAIDS. The urgency of now: AIDS at a crossroads. Geneva: Joint United Nations Programme on HIV/AIDS; 2024. Report. Available from: https://doi.org/10.18356/9789211066135
The WHOQOL Group. The World Health Organization quality of life assessment (WHOQOL): Development and general psychometric properties. Soc Sci Med. 1998;46(12):1569–85. Available from: https://doi.org/10.1016/S0277-9536(98)00009-4
Dinas Kesehatan Provinsi Sulawesi Selatan. Profil Kesehatan Provinsi Sulawesi Selatan Tahun 2020. Makassar: Dinas Kesehatan Provinsi Sulawesi Selatan; 2020. Available from: https://ghdx.healthdata.org/organizations/south-sulawesi-provincial-health-office-indonesia
Dinas Kesehatan Kabupaten Sidenreng Rappang, Bidang Pencegahan dan Pengendalian Penyakit (P2P). Laporan Tahunan Program HIV/AIDS dan PIMS Tahun 2024. Sidenreng Rappang: Dinas Kesehatan Kabupaten Sidenreng Rappang; 2025.
Miners A, Phillips A, Kreif N, Rodger A, Speakman A, Fisher M. Health-related quality of life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population. Lancet HIV. 2014;1(1): e32–40. https://doi.org/10.1016/s2352-3018(14)70018-9
Degroote S, Vogelaers D, Vandijck DM. What Determines Health-Related Quality of Life Among People Living With HIV: An Updated Review of the Literature. Archives of Public Health. 2014;72(1):40. https://doi.org/10.1186/2049-3258-72-40
Lazarus J V, Safreed-Harmon K, Barton SE, Costagliola D, Dedes N, Del Amo Valero J. Beyond Viral Suppression of HIV – The New Quality of Life Frontier. BMC Med. 2016; 14:94. https://doi.org/10.1186/s12916-016-0640-4
Thapa R, Amatya A, Pahari DP, Bam K, Newman MS. Nutritional Status and Its Association with Quality of Life Among PLHIV in Nepal. AIDS Res Ther. 2015; 12:14. https://doi.org/10.1186/s12981-015-0056-9
Palermo T, Rawat R, Weiser SD, Kadiyala S. Food access and diet quality are associated with quality-of-life outcomes among HIV-infected individuals in Uganda. PLoS One. 2013;8(4): e62353. https://doi.org/10.1371/journal.pone.0062353.
Li L, Lee SJ, Thammawijaya P, Jiraphongsa C, Rotheram-Borus MJ. Stigma, social support, and depression among people living with HIV in Thailand. AIDS Care. 2009;21(8):1007–13. https://doi.org/10.1080/09540120802614358
Hall E, Davis K, Ohrnberger J, Pickles M, Gregson S, Thomas R, et al. Associations between HIV stigma and health-related quality-of-life among people living with HIV: cross-sectional analysis of data from HPTN 071 (PopART). Sci Rep. 2024; 14:12835. https://doi.org/10.1038/s41598-024-63216-3
Zhang Y, Chai C, Xiong J, Zhang L, Zheng J, Ning Z, et al. The impact of anxiety, depression, and social support on the relationship between HIV-related stigma and mental health-related quality of life among Chinese patients: a cross-sectional, moderate-mediation study. BMC Psychiatry. 2023; 23:818. https://doi.org/10.1186/s12888-023-05103-1
World Health Organization. Nutrient Requirements For People Living With HIV/AIDS. Geneva: WHO; 2003. Report. Available from: https://www.who.int/publications/i/item/9241591196.
Suttmann U, Ockenga J, Selberg O, Hoogestraat L, Deicher H, Müller MJ. Incidence And Prognostic Value of Malnutrition and Wasting in Human Immunodeficiency Virus-Infected Outpatients. J Acquir Immune Defic Syndr (1988). 1995;8(3):239–46. https://doi.org/10.1097/00042560-199503010-00004
Iheme GO. Health-Related Quality of Life and Nutritional Status of People Living With HIV/AIDS in South-East Nigeria; A Facility-Based Study. Human Nutrition & Metabolism. 2023; 32:200190. https://doi.org/10.1016/j.hnm.2023.200190
Bandura A. Social Cognitive Theory Of Self-Regulation. Organizational Behavior and Human Decision Process. 1991;50(2):248–287. https://doi.org/10.1016/0749-5978(91)90022-L
Cao Z, Yan P, Hou F, Gu X, Peng H, Ma L, et al. The mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients. Lazzeri C, editor. PLoS One. 2026 Jan 29;21(1): e0341826. https://doi.org/10.1371/journal.pone.0341826
Jara AG, Sema FD, Tekele MT, Ergena AE, Belachew EA, Tesfaye AH. Self-efficacy of PLHIV For Self-Management at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: a cross-sectional study. BMC Primary Care. 2024; 25:198. https://doi.org/10.1186/s12875-024-02502-5
Kang H. Sample Size Determination And Power Analysis Using The G*Power software. J Educ Eval Health Prof. 2021 Jul 30; 18:17. https://doi.org/10.3352/jeehp.2021.18.17
Schober P, Vetter TR. Sample Size and Power in Clinical Research. Anesth Analg. 2019 Aug;129(2):323–323. https://doi.org/10.1213/ane.0000000000004316
Hair JF, Risher JJ, Sarstedt M, Ringle CM. When to use and how to report the results of PLS-SEM. European Business Review. 2019 Jan 14;31(1):2–24. https://doi.org/10.1108/ebr-11-2018-0203
Parmenter K, Wardle J. Development of a general nutrition knowledge questionnaire for adults. European Journal of Clinical Nutrition.1999 Apr 1;53(4):298–308. https://doi.org/10.1038/sj.ejcn.1600726
Silvia PJ, Duval TS. Objective Self-Awareness Theory: Recent Progress and Enduring Problems. Personality and Social Psychology Review. 2001 Aug 1;5(3):230–41. https://doi.org/10.1207/s15327957pspr0503_4
Novrianto R, Marettih AKE, Wahyudi H. Validitas Konstruk Instrumen General Self Efficacy Scale Versi Indonesia. Jurnal Psikologi. 2019 Jul 30;15(1):1. https://doi.org/10.24014/jp.v15i1.6943
Schwarzer R, Born A, Iwawaki S, Lee YM, Saito E, Yue X. The Assessment of Optimistic Self-Beliefs: Comparison of the Chinese, Indonesian, Japanese, and Korean Versions of the General Self-Efficacy Scale. Psychologia. 1997;40(1):1–13
Cade J, Thompson R, Burley V, Warm D. Development, Validation and Utilisation of Food-Frequency Questionnaires – A Review. Public Health Nutrition. 2002 Aug 2;5(4):567–87. https://doi.org/10.1079/phn2001318
Chesney MA, Ickovics JR, Chambers DB, Gifford AL, Neidig J, Zwickl B, et al. Self-Reported Adherence to Antiretroviral Medications Among Participants in HIV Clinical Trials: The AACTG Adherence Instruments. AIDS Care. 2000 Jun 27;12(3):255–66. https://doi.org/10.1080/09540120050042891
Nursalam N, Sukartini T, Misutarno M, Priyantini D. Adherence to Antiretroviral Therapy, CD4 Count, Viral Load And Opportunistic Infections in People With HIV/AIDS: A Cross-Sectional Study. Jurnal Ners. 2024 Feb 29;19(1):88–94. https://doi.org/10.20473/jn.v19i1.49958
Walker SN, Sechrist KR, Pender NJ. The Health-Promoting Lifestyle Profile. Nurs Res. 1987 Mar;36(2):76–81. https://doi.org/10.1097/00006199-198703000-00002
Kuan G, Kueh YC, Abdullah N, Tai ELM. Psychometric Properties of the Health-Promoting Lifestyle Profile II: Cross-Cultural Validation oftThe Malay Language Version. BMC Public Health. 2019 Dec 13;19(1):751. https://doi.org/10.1186/s12889-019-7109-2
Sarason IG, Levine HM, Basham RB, Sarason BR. Assessing social support: The Social Support Questionnaire. Journal of Personality and Social Psychology. 1983 Jan;44(1):127–39. https://doi.org/10.1037/0022-3514.44.1.127
Sherbourne CD, Stewart AL. The MOS Social Support Survey. Social Science Medicine. 1991 Jan;32(6):705–14. https://doi.org/10.1016/0277-9536(91)90150-b
Berger BE, Ferrans CE, Lashley FR. Measuring Stigma in People With HIV: Psychometric Assessment of the HIV Stigma Scale. Research in Nursing & Health. 2001 Dec 26;24(6):518–29. https://doi.org/10.1002/nur.10011
Alfieri A, Rusetiyanti N, Susetiati DA, Radiono S, Marchira CR, Pudjiati SR. Role of Sociodemographic Characteristics on Self-Stigma Among Young MSM Living with HIV in Yogyakarta, Indonesia: A cross-sectional study. International Journal of STD & AIDS. 2025 Jan 7;36(1):72–9. https://doi.org/10.1177/09564624241288286
Fauk NK, Hawke K, Mwanri L, Ward PR. Stigma and Discrimination Towards People Living with HIV in the Context of Families, Communities, And Healthcare Settings: A Qualitative Study In Indonesia. International Journal of Environmental Research and Public Health. 2021 May 19;18(10):5424. https://doi.org/10.3390/ijerph18105424
Leininger M. Culture Care Theory: A Major Contribution to Advance Transcultural Nursing Knowledge and Practices. Journal of Transcultural Nursing. 2002 Jul 1;13(3):189–92. https://doi.org/10.1177/10459602013003005
Rosenstock IM. Historical Origins of the Health Belief Model. Health Educ Monogr. 1974 Dec 1;2(4):328–35. https://doi.org/10.1177/109019817400200403
Krieger N, Williams DR, Moss NE. Measuring Social Class in US Public Health Research: Concepts, Methodologies, and Guidelines. Annu Rev Public Health. 1997 May;18(1):341–78. https://doi.org/10.1146/annurev.publhealth.18.1.341
Schraw G, Dennison RS. Assessing Metacognitive Awareness. Contemp Educ Psychol. 1994;19(4):460–75. https://doi.org/10.1006/ceps.1994.1033
Abdullah R, Soemantri D. Validation of Metacognitive Awareness Inventory in Academic Stage of Undergraduate Medical Education. eJournal Kedokteran Indonesia. 2018;6(1):15–23. 2018;6(1):15-23 https://doi.org/10.23886/ejki.6.8621
FANTA (Food and Nutrition Technical Assistance III Project). Nutrition Assessment, Counseling, and Support (NACS): A User's Guide — Module 2: Nutrition Assessment and Classification. Washington, DC: FHI 360/FANTA; 2016. https://www.fantaproject.org/sites/default/files/download/Cutoffs-2.10-NACS-Users-Guide-Apr2016.pdf
World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva: World Health Organization; 2000. Available from: https://iris.who.int/handle/10665/42330
Muhammad NN, Shatri H, Djoerban Z, Abdullah M. Validity and Reliability Test of Indonesian Version of World Health Organization Quality of Life-HIV BREF Questionnaire to Measure the Quality of Life Patients with HIV/AIDS. Jurnal Penyakit Dalam Indonesia. 2017 Sep 30;4(3):112. https://doi.org/10.7454/jpdi.v4i3.137
Ringle CM, Wende S, Becker JM. SmartPLS 3. Bönningstedt: SmartPLS GmbH. 2015. Available from: http://www.smartpls.com
Fornell C, Larcker DF. Evaluating Structural Equation Models with Unobservable Variables and Measurement Error. Journal of Marketing Research. 1981 Feb 1;18(1):39–50. https://doi.org/10.1177/002224378101800104
Henseler J, Ringle CM, Sarstedt M. A new criterion for assessing discriminant validity in variance-based structural equation modeling. Journal of the Academy of Marketing Science. 2015;43(1):115–135. https://doi.org/10.1007/s11747-014-0403-8
Henseler J, Ringle CM, Sinkovics RR. The Use Of Partial Least Squares Path Modeling In International Marketing. In: Advances in International Marketing. Emerald Group Publishing Ltd.; 2009. p. 277–319. https://doi.org/10.1108/s1474-7979(2009)0000020014
Cohen J. Statistical Power Analysis for the Behavioral Sciences. Routledge; 2013. https://doi.org/10.4324/9780203771587
Hair JF, Ringle CM, Sarstedt M. PLS-SEM: Indeed a silver bullet. Journal of Marketing Theory and Practice. 2011;19(2):139–152. https://doi.org/10.2753/MTP1069-6679190202
Stone M. Cross-Validatory Choice and Assessment of Statistical Predictions. J R Stat Soc Series B Stat Methodol. 1974 Jan 1;36(2):111–33. https://doi.org/10.1111/j.2517-6161.1974.tb00994.x
Geisser S. The Predictive Sample Reuse Method with Applications. Journal of the American Statistical Association. 1975 Jun;70(350):320–8. https://doi.org/10.1080/01621459.1975.10479865
Tenenhaus M, Vinzi VE, Chatelin YM, Lauro C. PLS path modeling. Comput Stat Data Anal. 2005 Jan 1;48(1):159–205. https://doi.org/10.1016/j.csda.2004.03.005
Wetzels M, Odekerken-Schröder G, van Oppen C. Using PLS Path Modeling for Assessing Hierarchical Construct Models: Guidelines and Empirical Illustration1. MIS Quarterly. 2009 Mar 1;33(1):177–95. https://doi.org/10.2307/20650284
Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008 Aug;40(3):879–91. https://doi.org/10.3758/brm.40.3.879
Zimmerman BJ. Attaining Self-Regulation: A Social Cognitive Perspective. In: Boekaerts M, Pintrich PR, Zeidner M, editors. Handbook of Self-Regulation. San Diego: Academic Press; 2000. p. 13–39. https://doi.org/10.1016/B978-012109890-2/50031-7
Mengie GM, Worku T, Nana A. Nutritional knowledge, dietary practice and associated factors among adults on antiretroviral therapy in Felege Hiwot referral hospital, Northwest Ethiopia. BMC Nutr. 2018 Dec 21;4(1):46. https://doi.org/10.1186/s40795-018-0256-5
Bello TK, Gericke GJ, MacIntyre UE, Becker P. Nutrition education improves quality of life among adults living with HIV. Public Health Nutr. 2019;22(12):2290–302. https://doi.org/10.1017/s1368980019000636
Mengistu N, Hareru HE, Shumye S, Yimer S, Sisay D, Kaso AW, et al. Health related quality of life and its association with social support among people living with HIV/AIDS receiving antiretroviral therapy in Ethiopia: a systematic review and meta-analysis. Health Qual Life Outcomes. 2022 Dec 8;20(1):77. https://doi.org/10.1186/s12955-022-01985-z
Duko B, Belayhun Y, Bedaso A. Prevalence of common mental disorder and its association with perceived stigma and social support among people living with HIV/AIDS in Ethiopia: a systematic review and meta-analysis. Int J Ment Health Syst. 2024 Jul 8;18(1):25. https://doi.org/10.1186/s13033-024-00641-x
Idoko J, Folayan MO, Dadem NY, Kolawole GO, Anenih J, Alhassan E. “Why should I take drugs for your infection?”: outcomes of formative research on the use of HIV pre-exposure prophylaxis in Nigeria. BMC Public Health. 2015 Dec 10;15(1):349. https://doi.org/10.1186/s12889-015-1690-9
Mills EJ, Nachega JB, Buchan I, Orbinski J, Attaran A, Singh S, et al. Adherence to Antiretroviral Therapy in Sub-Saharan Africa and North America. JAMA. 2006 Aug 9;296(6):679. https://doi.org/10.1001/jama.296.6.679
Huang H, Tu L, Zhang X, Zhang L, Zhang J, Liu Q, et al. Social support, self-efficacy, self-esteem, and self-management behaviors among people living with HIV/AIDS in China: a structural equation modeling analysis. BMC Public Health. 2024 Nov 6;24(1):3070. https://doi.org/10.1186/s12889-024-20541-6
Crowley T, van der Merwe A, Kidd M, Skinner D. Adolescent human immunodeficiency virus self-management: Associations with treatment adherence, viral suppression, sexual risk behaviours and health-related quality of life. South Afr J HIV Med. 2020 Apr 29;21(1). https://doi.org/10.4102/sajhivmed.v21i1.1054
Dupont E, Yombi JC. Antiretroviral therapy and weight gain in naive HIV-1 infected patient: a narrative review. AIDS Rev. 2022;24(3):122–132. https://doi.org/10.24875/AIDSRev.21000092
