Levels of self-reported depression and anxiety among HIV-positive patients in Albania: a cross-sectional study

Unmet healthcare needs in Southeastern Europe: a systematic review

Objectives

This study sought to systematically review the existing literature on self-reported unmet healthcare needs in Southeastern Europe.

Methods

A systematic literature review of quantitative evidence in English and Bulgarian was performed in July 2023 using the following databases: Medline, Embase and EconLit. Publications were only included if they used self-reported unmet healthcare needs as an indicator of access to healthcare, concerned people living in Albania, Bosnia and Herzegovina, Bulgaria, Greece, Kosovo, Montenegro, Serbia, North Macedonia or Romania and if they were published after 2003. Quality assessment of the included publications was performed using the Appraisal tool for Cross-Sectional Studies (AXIS) tool.

Results

Twenty-three publications of varying quality were included in the review. Significantly more evidence was available for Greece, Bulgaria and Romania than for the rest of the region. Data collected through Pan-European surveys were commonly used, but almost half of the studies were only descriptive. Generally, the prevalence of unmet healthcare needs has decreased over the years. Unmet healthcare needs were higher among people of lower socioeconomic and educational status, ethnic minorities and migrants and high cost was consistently identified as the primary barrier to accessing healthcare.

Conclusion

Unmet healthcare needs are more prevalent among already disadvantaged societal groups. A trend of a declining prevalence of unmet needs has been observed, but it is more notable in the more socioeconomically developed countries. Improving financial protection should be a priority for the healthcare systems.

Anxiety and Associated Factors Among Clients on Highly Active Antiretroviral Therapy (HAART) in Public Hospitals of Southern Ethiopia: A Multi-Center Cross-Sectional Study

Background

Anxiety is an unpleasant feeling of fear, apprehension, and nervousness without any apparent stimulus. Anxiety is one of the co-morbidities that are often overlooked in treating patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Anxiety is worse among people with HIV/AIDS than the general population. Few studies have been conducted on prevalence of anxiety in people receiving antiretroviral treatment and limited evidence is available on its associated factors. Therefore, the objective of this study was to investigate the magnitude and associated factors of anxiety among clients on highly active antiretroviral therapy in public hospitals of Southern Ethiopia.

Methods

An institution-based cross-sectional study was conducted in public hospitals of Southern Ethiopia. Simple random sampling method was used to recruit study participants. Data collection was done by using a structured questionnaire regarding medical data related to HIV/AIDS. Seven items of the Hospital Anxiety and Depression Scale (HADS) were also used to measure the anxiety level. Oslo social support scale and perceived stigma scale were used to measure social support and stigma respectively. Bivariate and multivariate logistic regression analyses were computed with 95% CI to identify different explanatory variables. Significance was declared at p<0.05. Multi-collinearity was checked by variance inflation factors and Hosmer-Lemeshow test was used to check model fitness.

Results

Prevalence of anxiety among clients on HAART in selected public hospitals of Southern Ethiopia was found to be 25.6%. Females (AOR=3.24, 95% CI [1.32, 7.97]), being widowed (AOR=5.47, 95% CI [1.08, 29.72], monthly income 1425-2280 Ethiopian birr (AOR=7.29, 95% CI [2.55, 20.88]), comorbid conditions (AOR=5.47, 95% CI [1.92, 15.62]), perceived stigma (AOR=8.34, 95% CI [3.49, 19.91]) were factors associated with anxiety.

Conclusion

Approximately one-fourth of participants living with HIV/AIDS had anxiety. Being female, widowed, medium income, comorbid conditions, and perceived stigma were significantly associated with anxiety. This finding highlights the importance of mental health assessment, early detection and treatment of anxiety as an integral component of HIV/AIDS care.

Comorbidity of mental ill-health in tuberculosis patients under treatment in a rural province of South Africa: a cross-sectional survey

OBJECTIVES

Tuberculosis (TB) remains prevalent despite the availability of effective anti-TB medications, and accumulating evidence suggests a high rate of mental disorders in people with TB. This is because TB and psychiatric disorders share several risk factors, such as poverty, homelessness and substance use disorder. Moreover, psychiatric comorbidities in patients with TB are associated with poor treatment outcomes. This study explored the psychiatric comorbidity and clinical correlates in individuals receiving TB treatment.

DESIGN

A cross-sectional survey over 10 months.

SETTING

Two primary care clinics at King Sabata Dalindyebo district, Mthatha, Eastern Cape, South Africa.

PARTICIPANT

Patients receiving TB treatment in the two clinics.

INTERVENTION

The Mini-International Neuropsychiatric Interview was used to screen for psychiatric disorders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of mental disorders in patients with TB over a 10-month period. Variation in rates by sex, employment status and HIV comorbidity.

RESULTS

In a sample of 197 participants, most patients were men (62%) and screened positive for a mental disorder (82%) with anxiety (48%), depression (38%) and substance use disorders (43%) being the most common psychiatric conditions. On average, individuals had 4 (SD 2) mental disorders. Females had higher rates of depression (p=0.005) and non-adherence to TB treatment (p=0.003), and alcohol use disorder was more common in males (p<0.001) and in those non-adherent to TB treatment. Additionally, low education levels and unemployment were associated with depressive and anxiety disorders (p<0.05).

CONCLUSIONS

Mental disorders are common in patients with TB, and mental health services need to be integrated into the management of patients with TB. Factors linked to mental disorders in this cohort, such as low education, gender and unemployment, may be useful for compiling a risk profile to help identify those with TB who may require more intensive support for their mental health.

The worldwide prevalence of anxiety in acquired immune deficiency syndrome patients: A systematic review and meta-analysis

Background: Anxiety affects social, economic, and physical aspects of daily life in patients with AIDS. Therefore, it is necessary to take preventive measures and design plans to maintain their general health. The present study was the first comprehensive systematic literature review research that examined the worldwide prevalence rate of anxiety in patients with AIDS.

Methods: We searched for papers published in the English language in the major databases including Embase, PubMed, Web of Science, Scopus, Cochrane, and Google Scholar from 2000 to October 2018. There were 40 studies which found to be eligible. These studies were independently evaluated and the collected data were entered in a data extraction form, which was then analyzed by two authors and a third author if necessary. Der Simonian-Laird model was used to estimate the prevalence rate on a Forest plot at the interval confidence of 95%.

Results: The total sample size was 24111, and the total number of people with anxiety was 5546. The results based on the random-effects model showed that the rate of anxiety prevalence in the patients was 25% (CI: 95%, 21% -30%) with heterogeneity of 97.9% and a significance level of p<0.001. The South America continent with a prevalence of 38% (95% CI, 34%-42%) had the highest anxiety prevalence rates and Africa with 19% (95% CI, 12% -29%) had the lowest anxiety prevalence rates.

Conclusion: Based on findings, the prevalence of anxiety in developed countries was partially higher than in underdeveloped countries and the obtained mean in the present study. It can be a significant point for policymakers. Therefore, WHO and the world community should have special plans for these countries.

Assessing the measurement invariance of the 10-item Centre for Epidemiological Studies Depression Scale and Beck Anxiety Inventory questionnaires across people living with HIV/AIDS and healthy people

Background

Recently, extensive research has been reported the higher rate of depression and anxiety among people living with HIV/AIDS (PLWHAs) as compared to the general population. However, no single study has been carried out to investigate whether this disparity is a real difference or it happens due to lack of measurement invariance. This study aims to assess the measurement invariance of the Beck Anxiety Inventory (BAI) and 10-item Centre for Epidemiological Studies Depression Scale (CESD-10) questionnaires across PLWHAs and healthy individuals.

Methods

One hundred and fifty PLWHAs and 500 healthy individuals filled out the Persian version of the BAI and CESD-10 questionnaires. Multi-group multiple-indicators multiple-causes model (MG-MIMIC) was used to assess measurement invariance across PLWHAs and healthy people.

Results

Our findings revealed that PLWHAs and healthy individuals perceived the meaning of all the items in the BAI and CESD-10 questionnaires similarly. In addition, although depression scores were significantly higher in PLWHAs as opposed to the healthy individuals, no significant difference was observed in anxiety scores of these two groups.

Conclusions

The current study suggests that the BAI and CESD-10 are invariant measures across PLWHAs and healthy people which can be used for meaningful cross-group comparison. Therefore, in comparison to healthy individuals, higher depression score of PLWHAs is a real difference. It is highly recommended that health professionals develop therapeutic interventions and psychological supports to promote the mental health of PLWHAs which alleviate their depressive symptoms.

Depression and Associated Factors Among Adult HIV/AIDS Patients Attending Antiretroviral Therapy at Wolaita Sodo University Teaching and Referral Hospital, Southern Ethiopia

Background

Nearly, 350 million people in the world are currently living with depression. Depression happening in PLHIV leads to alteration of economic productivity, decrease of working abilities, social isolation, physical decline and difficulties in solving problems. This study investigates the burden of depression and associated factors on HIV/AIDS patients attending an ART clinic.

Methods

An institution-based cross-sectional study was implemented from April 1 to May 30, 2019 on a total of 417 HIV-positive patients. Systematic random sampling technique was used to access the study participants. Interviewer-administered structured questionnaire was used for data collection. Data were entered in to EpiData 3.1 and then were exported into Statistical Package for the Social Sciences (SPSS window version 20) for analysis.

Results

Four hundred ten (410) respondents participated in the study with a response rate of 98.3%. The burden of depression was 50.5% in this study. Male (AOR=1.53; 95%CI: 1.016–2.311), people living in urban (AOR=2.20; 95%CI: 1.29–3.75), patients who had opportunistic infection (AOR=1.98; 95%CI: 1.27–3.11), poor medication adherence (AOR=1.79; 95%CI: 1.13–2.85) and high HIV-related perceived stigma (AOR=1.66; 95%CI: 1.04– 2.67) were more likely depressed compared to their counterparts.

Conclusion

In this study, male sex, those patients living in urban areas, having opportunistic infections, poor medication adherence, and high HIV-related perceived stigma were significantly associated with depression. Hence, organizations working on HIV programs should address these factors to prevent and manage depression among HIV-positive patients.

The Role of Depression, Anxiety and Illness Characteristics on Risky Sexual Behaviour among People Living with HIV in A Malaysian Tertiary Reference Hospital

Background:

People living with HIV (PLHIV) have a longer lifespan with treatment and continue to be sexually active. To date, the extent of risky sexual behaviour among local PLHIV and its associated factors were undetermined.

Objective:

To examine the role of depression, anxiety and illness characteristics on risky sexual behaviour among PLHIV attending care in a Malaysian tertiary reference hospital (N= 406).

Method:

It was a cross-sectional study. Subjects were recruited by systematic random sampling. Risky sexual behaviour was determined by using the modified National Youth Risk Behaviour Survey. PHQ-9 and GAD-7 were used to measure the depressive and anxiety symptoms, respectively. Chi-square test was used to examine the association between the variables. Multiple logistic regression was used to examine the predictors of the study. A p value of less than 0.05 was considered significant and odds ratio was used as the measure of risk association.

Results:

Our study showed that 29.3% had risky sexual behaviour. Meanwhile, 21.9% and 26.4% had depressive and anxiety symptoms, respectively. Risky sexual behaviour was significantly associated with age, religion, education level, duration of HIV diagnosis, depressive and anxiety symptoms. From multivariate logistic regression, duration of HIV diagnosis and anxiety symptoms significantly predicted risky sexual behaviour.

Conclusion:

This study highlights that a substantial number of PLHIV had risky sexual behaviour and psychological symptoms. It is important for psychological interventions that reduce risky sexual behaviour among PLHIV who attend treatment, especially during the early phase.

Burden of HIV-Related Stigma and Post-Partum Depression: A Cross-Sectional Study of Patients Attending Prevention of Mother-to-Child Transmission Clinic at Kenyatta National Hospital in Nairobi

Background: We look at how various HIV-related stigma subtypes, especially internalizing types, interact with postpartum depression (PPD) among women living with HIV. Additionally, we identify key psychosocial risk factors that influence stigma and PPD among women attending Prevention of Mother-to-Child Transmission (PMTCT) clinics. Methods: In this cross-sectional design, 123 women living with HIV were recruited. Participants ages between 18 and 50, who were at least 8 weeks postpartum seeking PMTCT services at Kenyatta National Hospital (KNH), between June and September 2014 participated in the study. HIV/AIDS Stigma Instrument-PLWHA (HASI-P) was used to assesses stigma and Postpartum depression was assessed by Edinburgh Postnatal Depression Scale (EPDS). Bivariate and multivariate regression models were used to determine the individual characteristics associated with the HIV-related stigma Scale. Post survey a few in-depth-interviews were conducted to explore individuals' stigma and depression experiences. Results: The mean age was 31.2 years (SD = 5.2). Fifty-nine (48%) women screened positive for significant depressive symptoms. Post-partum depression was a significant predictor of internalized stigma, enacted, and total stigma (P < 0.05). Older age was associated with less internalized stigma. Living with a partner was associated with more internalized stigma. Having an income above 100 USD per month was protective against stigma. Having good family social support was protective against internalized stigma. A higher educational level was protective against enacted stigma. Being treated for STIs was a risk factor for both enacted and overall stigma. Conclusions: HIV-related stigma needs to be addressed through integrated mental health care programs in PMTCT. Postpartum depression requires comprehensive management to improve short- and long-term outcomes of women living with HIV.

The impacts of depression and anxiety on quality of life among patients with HIV/AIDS and their spouses: testing dyadic dynamics using the actor-partner interdependence model

HIV/AIDS not only affects the patients, but also their entire family. This study aimed to assess the impacts of the patients' and their spouses' anxiety and depression on their quality of life (QoL) at the dyadic level. A total of 120 serodiscordant husband-wife dyads from the voluntary counselling and testing center in Shiraz, Iran, were involved in this study from February to June 2015. The WHOQOL-BREEF, CESD-10, and Beck Anxiety Inventory instruments were used, respectively, to assess the QoL, depression, and anxiety scores of the participants. The actor-partner interdependence model (APIM) was used to estimate the effects of depression and anxiety of both the people living with HIV/AIDS (PLWHA) and their spouses on their own QoL (actor effect) as well as their partners' (partner effect). The APIM analysis revealed that both PLWHAs' and their spouses' depression and anxiety showed actor effects on their own QoL. Furthermore, spouses' depression showed a significant partner effect on PLWHAs' QoL and PLWHAs' anxiety had significant partner effects on spouses' QoL. Accordingly, this data can be used to develop targeted interventions aimed at guidance and assistance of PLWHAs and their spouses to find coping strategies that improve their own QoL as well as their partners'.

Prevalence and correlates of depression and anxiety among patients with HIV on-follow up at Alert Hospital, Addis Ababa, Ethiopia

BACKGROUND

Depression and anxiety disorders are common among people living with Human Immunodeficiency Virus than the non-infected individuals. The co-existence of these disorders are associated with barriers to treatment and worsening medical outcomes, including treatment resistance, increased risk for suicide, greater chance for recurrence and utilization of medical resources and/or increase morbidity and mortality. Therefore, assessing depression and anxiety among HIV patients has a pivotal role for further interventions.

METHODS

Institution based cross-sectional study was conducted at ALERT hospital May, 2015. Data were collected using a pretested, structured and standardized questionnaire. Systematic sampling technique was used to select the study participants. Binary logistic regression analysis was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of associations.

RESULTS

The prevalence of co-morbid depression and anxiety among HIV patients was 24.5 % and prevalence of depression and anxiety among HIV patients was 41.2 % (172) and 32.4 % (135) respectively. Multivariate analysis showed that individual who had perceived HIV stigma (AOR = 3.60, 95 % CI (2.23, 5.80), poor social support (AOR = 2.02, 95 % CI (1.25, 3.27), HIV stage III (AOR = 2.80, 95 % CI (1.50, 5.21) and poor medication adherence (AOR = 1.61, 95 % CI (1.02, 2.55) were significantly associated with depression. Being female (AOR = 3.13, 95 % CI (1.80, 5.44), being divorced (AOR = 2.51, 95 % CI (1.26, 5.00), having co morbid TB (AOR = 2.74, 95 % CI (1.37, 5.47) and perceived HIV stigma (AOR = 4.00, 95 % CI (2.40, 6.69) were also significantly associated with anxiety.

CONCLUSION

Prevalence of depression and anxiety was high. Having perceived HIV stigma, HIV Stage III, poor social support and poor medication adherence were associated with depression. Whereas being female, being divorced and having co morbid TB and perceived HIV stigma were associated with anxiety. Ministry of health should give training on how to screen anxiety and depression among HIV patients and should develop guidelines to screen and treat depression and anxiety among HIV patients.

Prevalence and correlates of depression and anxiety among patients with tuberculosis at WolaitaSodo University Hospital and Sodo Health Center, WolaitaSodo, South Ethiopia, Cross sectional study

BACKGROUND

Anxiety and depression are frequently and highly occurring mental disorders in patients with tuberculosis. When depression and anxiety co-morbid with tuberculosis, it leads to poor adherence to anti TB medication, which is important barrier to global control of tuberculosis & increases the risk of morbidity and mortality due to TB. Cross sectional study was conducted to assess prevalence and correlates of depression and anxiety among patients with TB at WolaitaSodo University Hospital and Sodo Health Center, WolaitaSodo, Ethiopia.

METHODS

Institution based cross-sectional study was conducted in 2014.A total of 417 TB patients, who had regular follow up at WolaitaSodo University Hospital and Sodo Health Center, WolaitaSodo, South Ethiopia, were recruited to assess depression and anxiety and its associated correlates. Depression and anxiety were assessed through face to face interviews by trained psychiatry nurses using the hospital anxiety and depression scale (HADS). Correlates for depression and anxiety were assessed using a structured questionnaire, Oslo social support scale and TB stigma Scale.

RESULTS

The prevalence of depression and anxiety among patients with TB were 43.4% (181) and 41.5% (173) respectively. When we adjusted for the effect of potential confounding variables, patients who had co-morbid HIV infection [AOR = 5.90,(95% CI: 2.34,15.93)], poor social support [AOR = 18.06, (95% CI:11.21,25.45)] & perceived TB stigma [AOR = 10.86, (95% CI:10.26,23.47)] were more likely to have depression as compared to individuals who had no co-morbid HIV infection, good social support and no perceived TB stigma respectively. Patients who had co-morbid HIV infection [AOR = 9.61,(95% CI:3.56,25.96)], poor social support [AOR = 8.93,(95% CI: 5.01,15.94)], perceived TB stigma [AOR = 3.11,(95% CI:1.78,5.42)], being female [AOR = 1.72 (95% CI: 1.06, 2.95)], current substance use[AOR = 4.88, (95% CI: 1.79, 13.28)] and being on intensive phase of TB treatment [AOR = 1.91, (95% CI: 1.08, 3.39)] were more likely to have anxiety as compared to individuals who had no co-morbid HIV infection, good social support, no perceived TB stigma, being male and being on continuous phase of TB treatment respectively.

CONCLUSION

Developing guidelines and training of health workers in TB clinics is useful to screen and treat depression and anxiety among TB patients.

Stigma in Ethiopia: association with depressive symptoms in people with HIV

Rates of depression among people living with HIV can be as high as 50%. In many settings, HIV-related stigma has been associated with depressive symptoms which may lead to poor engagement in care and ultimately, poorer health outcomes. Stigma is a major issue in Ethiopia but data examining the relationship between stigma and depression in Ethiopia are lacking. We performed a mixed-methods cross-sectional study to examine the relationship between stigma of HIV/AIDS and depressive symptoms in Gondar, Ethiopia. We interviewed patients who presented for routine HIV care at Gondar University Hospital during the study period, examining depressive symptoms and HIV/AIDS-related stigma using standardized measures. Multiple-regression was used to assess the relationship between depressive symptoms, stigma, and gender. Of 55 patients included in this analysis, 63.6% were female and most participants had limited formal education (69%, less than 12th grade education). The majority reported experiencing both stigma (78%) and depressive symptoms (60%) ranging in severity from mild to moderately severe. Higher levels of HIV-related stigma were significantly associated with higher levels of depressive symptoms (β = 0.464, p ≤ 0.001). Although gender was associated with stigma, it was not associated with depressive symptoms (β = -0.027, p > 0.05). Results suggest the importance of psychosocial issues in the lives of people with HIV in Ethiopia.

Prevalence of Depressive Symptoms Amongst Highly Active Antiretroviral Therapy (HAART) Patients in AIDSRelief Uganda

There is limited data on the prevalence of depression in HIV and AIDS patients in Sub-Saharan Africa and little resources have been allocated to address this issue. Depression affects patient adherence to treatment and predisposes patients to resistance which poses a public health threat. It also affects quality of life and productivity of patients. From August 2008 to March 2009, 731 patient adherence surveys were administered to assess disease, treatment knowledge and services received. The primary variable of interest was patients' level of depressive symptoms score, constructed using factor analysis from five survey questions relating to: sadness, need to be alone, hopelessness and confusion and was categorized as no depressive symptoms (score 0), low depressive symptoms (score 1-2), moderate depressive symptoms (score 3-4) and high depressive symptoms (score 5-10). Majority of the patients on highly active antiretroviral therapy (HAART) (59%) were found to have depressive symptoms and this was more among women than men (66% vs 43%). There was some association of depressive symptoms with non-disclosure (70% of those who had not disclosed had depressive symptoms compared to 53% among those who had disclosed). There is a high prevalence of depressive symptoms among adult patients on HAART. There is need for in-depth evaluation to find out the root causes of depressive symptoms among HAART patients in AIDSRelief clinics. There is need to integrate mental health management in HIV care and treatment as well as training the existing health workers on mental health management.

Functional social support, psychological capital, and depressive and anxiety symptoms among people living with HIV/AIDS employed full-time

BACKGROUND

Psychological distress (e.g., depression and anxiety) has been regarded as the main cause of leaving work for people living with HIV/AIDS (PLWHA) in workplaces. This study aims to explore the associations of functional social support (FSS) and psychological capital (PC) with depressive and anxiety symptoms among PLWHA employed full-time.

METHODS

This cross-sectional study was performed in Liaoning, China, during the period of December 2010-April 2011. The Center for Epidemiologic Studies Depression Scale, the Zung Self-Rating Anxiety Scale, the Duke-UNC Functional Social Support Questionnaire, and the Psychological Capital Questionnaire were completed by PLWHA employed full-time. Structural equation modeling was used to test the proposed relationships between variables. Asymptotic and resampling strategies were performed to explore the mediating roles of PC and its components (self-efficacy, hope, optimism, resilience).

RESULTS

Of 320 participants surveyed, 66.3% had depressive symptoms, and 45.6% had anxiety symptoms. Significant negative associations of FSS and PC with depressive and anxiety symptoms were revealed. PC (a*b = -0.209, BCa 95% CI: -0.293, -0.137, p < 0.05), hope (a*b = -0.103, BCa 95% CI: -0.192, -0.034, p < 0.05), and optimism (a*b = -0.047, BCa 95% CI: -0.106, -0.008, p < 0.05) significantly mediated the association between FSS and depressive symptoms. PC (a*b = -0.151, BCa 95% CI: -0.224, -0.095, p < 0.05) and self-efficacy (a*b = -0.080, BCa 95% CI: -0.158, -0.012, p < 0.05) significantly mediated the FSS-anxiety symptoms association.

CONCLUSIONS

FSS and PC could help reduce depressive and anxiety symptoms among PLWHA employed full-time. PC fully mediates the associations of FSS with depressive and anxiety symptoms. In addition to enhancing FSS, PC development could be included in the prevention and treatment strategies for depressive and anxiety symptoms targeted at PLWHA employed full-time.

How to Understand the Experience of Persons Living with HIV: Implications for Clinical Practice and Research

Objetivo: las personas que viven con una enfermedad crónica experimentan procesos complejos de transformación personal para adaptarse a su nueva condición de salud. El objetivo del artículo es develar el significado de vivir con VIH en personas que fueron diag- nosticadas en etapa de sida. Materiales y métodos: estudio cualitativo descriptivo en el que se realizaron entrevistas en profundidad a 15 personas que viven con VIH (PVVIH) en etapa de sida, que se atienden en el sistema público de salud chileno. Resultados: del análisis de contenido emergieron seis dimensiones del significado de vivir con la enfermedad: cambios personales posteriores al diagnóstico; apoyo social y acompañamiento, resignación a la adquisición del VIH; percepción de discriminación / rechazo; revelación del diagnóstico; cuidar a otros de la adquisición del VIH. Conclusiones: los hallazgos orientan a los profesionales de la salud sobre las estrategias que se deben utilizar en la atención directa de las personas que viven con VIH con el fin de otorgar un cuidado integral considerando el apoyo para el desarrollo de estrategias de autocuidado y la revelación del diagnóstico a su núcleo cercano, para reducir los costos psicosociales asociados a la enfermedad.