Observance to antiretroviral treatment in the rural region of the Democratic Republic of Congo: a cognitive dissonance

Introduction This study aimed to understand the influence of local media, religion and cultural beliefs on the therapeutic compliance of patients living with HIV. Methods This study was conducted in two rural hospitals in the Central Kongo province of the Democratic Republic of Congo. Semi-directional interviews were conducted with patients on antiretroviral therapy using a phenomenological qualitative method. Results Our results indicated that patients living with HIV in the rural region of the Democratic Republic of Congo are in a constant state of tension between the messages for compliance to antiretroviral treatment advocated by caregivers, and those broadcasted by audiovisual media, religious leaders and local beliefs. This dissonance constitutes a real barrier to therapeutic compliance. Conclusion Collaborative strategies between healthcare providers, patients, as well as religious, media and traditional organizations are urgently needed.


Introduction
Human immunodeficiency virus (HIV) remains a major public health problem [1]. In December 2017, 36.7 million people across the world were living with HIV, among which 70% in Africa [2,3]. Access to antiretroviral therapy (HAART) among HIV-positive individuals allows to reduce AIDS-related morbidity and mortality. In this respect, patient compliance is crucial for a successful treatment [4]. A good compliance to treatment may help to achieve the goal set fundamental by the United Nations Organization for AIDST, i.e. treating with antiretroviral therapy (ART) 90% of the patients and achieving a 90% viral suppression [5]. Nevertheless, subjects on antiretroviral therapy in rural areas of Africa, face various barriers that may undermine compliance to HIV-treatment [6]. Although communication approaches have been successful on HAART compliance behaviors [7], they also generated cognitive disruption [8]. In fact, after the diagnosis of the disease, the primary knowledge of HIV individuals about HAART is generally constructed on the basis of information provided by health workers, society, media and associations [9]. This information is quickly confronted and interpreted according to dynamic relationships between individuals [10] and may also be interpreted differently depending on the cultural context [11]. Several studies also showed that the whole system of information and communication around HIV raises major questions in Africa regarding potential disharmonies observed in diffusion channels [12]. Indeed, many shortcomings have been identified in operations concerning behavior change with regard to HIV prevention and compliance to treatment [12]. Jelliman et al. even argue that media are responsible for the stigmatization of HIV patients under HAART [13].
Our study was based on the well-known Festinger's theory on cognitive dissonance. This theory suggests that each individual has an inner desire to maintain all one's attitudes and beliefs in harmony [14]. However, this balance can be called into question when two or more cognitions come into opposition, generating a cognitive dissonance. This state is psychologically very disturbing for the individual [15], causing a state of tension which in turn motivates the need to recover a coherent cognitive universe [16]. As underlined above, compliance to therapeutic regimens is the result of a dynamic process of human behavior and interactions. Therefore, characterizing the quality of the information, the beliefs and how they relate to mental representations of patients may enable to identify possible barriers to compliance [17]. Several works have underlined the need to use good and appropriate information to properly deliver educational messages and to improve the effectiveness of followup [18]. Cognitive dissonance can exist when the situation experienced by an individual conflict with one's knowledge or beliefs.
Vaidis used this theory to elucidate pre-existing attitudes and behaviors [19]. This approach was also used by Schoenfish to explain a risk that an individual can take in the when facing a well-known danger [20]. At Nsona-Nkulu Hospital in Mbanza-Ngungu and Saint Luc in Kisantu, patients are frequently confronted to regular local media speeches, traditional and religious beliefs concerning cure of the disease; however, the effects of these speeches on the observance of the patients receiving treatment are not well known. It seems therefore necessary to consider all cultural aspects in the promotion of compliance to HAART [21]. In this study, we aimed to understand the influence of the media, religious practices and traditional beliefs on compliance to HAART among patients from rural areas of the Democratic Republic of Congo. Study design and patients' recruitment: we used a qualitative approach based on a phenomenological method in order to characterize patients' experiences and their own interpretations during the antiretroviral treatment process [22]. Adult volunteers (≥ 18), being on antiretroviral therapy for at least 3 months, speaking one of the three study languages (French, Lingala or Kikongo) were locally recruited. Consent was obtained through.

Methods
Data collection: semi-directional individual interviews were conducted in three languages, two local (Kikongo and Lingala) and one official (French). Open-ended questions were asked to patients using the language of their choice, allowing them to freely and easily talk about their disease and HIV-related issues [23]. All interviews were conducted in quiet locations, i.e. in HIV office of each health facility. In addition, interviews were carried out privately to ensure Page number not for citation purposes 3 total confidentiality. Codes were used instead of names in order to obtain patients' consent to respect the anonymity of patients.
Information was collected by a nursing researcher, specializing in public health and speaking the three before-mentioned languages.
When patients refused to record their voice, information was written on paper, extending the time of the interview. The principal investigator was the only one involved in the process and also the only one to keep all the contents. Data analysis: based on the transcriptions of each interview, a content analysis was performed using the Hsieh method [26]. This approach has been extensively used in nursing research studies [27].
This method enables to objectify the phenomenon in question. Codes with verbatim meaning were identified and then grouped into subthemes. Then, a thematic and comparative analysis was carried out manually with the "sphinx Lexica" software. Codings expressing the aspects sought in the study were established. Finally, the verbatims producing dissonant effects (favorable and unfavorable) to the observance were removed. Thus, before beginning the interview, the interviewer read carefully the informed consent form in the language of choice of the patient. A copy of the consent form, was provided to interviewees, in case they have questions later. Providing an informed consent was a selection criterion for the enrolment in the study. Each interview was recorded using dictaphones and notes were also taken. Any patient for whom informed consent was originally sought was free to interrupt the interview and withdraw the consent at any time of the study. The confidentiality of data registration and notes was strictly respected.
Written patient data were systematically stored in a locked cabinet.
Computer files were protected using passwords. The recordings used during the analyses were destroyed afterwards.

Results
A total of 50 interviews were conducted among patients aged This design prevents people living with HIV from initiating antiretroviral therapy as soon as possible. Moreover, for patients on antiretroviral therapy, this cultural belief arouses the appearance of a cognitive dissonance Figure 1.
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Discussion
Our study enabled us to better understand the influence of media, religions and cultural beliefs on compliance to antiretroviral therapy in 50 patients from rural regions of RDC. The phenomenological based approach also permitted us to thoroughly investigate patients' personal experiences [24]. We adapted this approach in the context of patients receiving antiretroviral therapy in order to understand their reactions when facing different speeches from medias [25].
Participants in our study revealed the different sources of dissonance they faced.  [27]. In addition, mass media, especially newspapers and magazines, very often stigmatize population by only focusing on dramatic effects of the disease and by considering the epidemic as a major event [28]. Thus, "the myths on AIDS reflect a diversity of representations in Africa. This reinforces the urgent need to adapt messages according to the context of their dissemination" [29].

Dissonance in broadcast messages
Inconsistencies and contradictory messages from communication channels prevents from a correct understanding of messages. They also, create cognitive conflicts responsible for behavioral changes [12]. An effective control of message broadcast concerning health issues seems therefore of high importance to enable a better compliance to treatment. Such beliefs on antiretroviral therapy (ARV) are crucial for the compliance with treatment but are still too poorly documented in sub-Saharan African countries [35]. Kemppainen et al. [36] demonstrated that the majority of participants did believe that HIV was a serious and chronic disease that can be controlled through appropriate antiretroviral therapy, although traditional treatments still remains, the main medication against diseases. In addition, it has also been showed that individuals who believed that the cause of HIV/AIDS was due to misfortune or God's will were also those who were more likely to believe that the progression of their illness was linked to destiny [30]. We also found that compliance to treatment was also related to patients' ties with their family and how they communicate with their relatives [36].  The mobilization and involvement of cultural leaders (some spiritual leaders, opinion leaders, etc.) as a strategy to improve adherence to antiretroviral treatment would be a good therapeutic education strategy in this context.