Yenni Sudita*
| Masrul | Irwan Prayitno | Netti Suharti | Nursyirwan Effendi | Hardisman Dasman | Yantri Maputra | Satya Widya Yenny
© 2023 IIETA. This article is published by IIETA and is licensed under the CC BY 4.0 license (http://creativecommons.org/licenses/by/4.0/).
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This study aimed to assess the impact of the Sudita Model on the frequency and timeliness of HIV-positive status disclosure to partners in Jambi City, Indonesia. A quasi-experimental design employing a non-equivalent control group with a pre-test and post-test approach was utilized. The research was conducted in Jambi City, Jambi Province, Indonesia, beginning in June 2021. The ADDIE model approach, which includes 1) Analysis, 2) Design, 3) Development, 4) Implementation, and 5) Evaluation, was employed for model development. A sample size of 78 individuals was divided into two groups: an intervention group utilizing the Sudita Model and a control group using the Ministry of Health Module (M. Kemenkes). The research variables included the number of HIV status disclosures to partners and the time (in days) required for disclosing HIV status to partners between the intervention and control groups before, after one month, and after three months of intervention. Data analysis was performed using the General Linear Model Repeated Measures multivariate test. The results indicated a significant increase in the average number of HIV-positive status disclosures to partners after one and three months of intervention, rising from an average of 16 individuals (at month one) to 26 individuals (at month three), with a p-value of 0.000. The Sudita Model intervention results demonstrated a significant enhancement in the timeliness of HIV-positive status disclosure to partners, with an average disclosure time of 28.9 days for the Sudita Model compared to 54.4 days for the Ministry of Health Module. In conclusion, the Sudita Model is more effective in increasing the frequency and speed of HIV-positive status disclosure among couples than the Ministry of Health Model. The Sudita Model's influence on accelerating HIV-positive status disclosure to partners suggests that changes in the behavior of people living with HIV/AIDS (PLWHA) can be facilitated by providing comprehensive information about HIV/AIDS and continuous support tailored to the evolving needs of PLWHA via persuasive communication approaches.
Sudita Model, disclosure of HIV-positive status, HIV AIDS, behavior
Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) pose significant global health challenges [1]. As of June 2018, Indonesia reported a cumulative total of 301,959 HIV and AIDS cases, representing 47% of the estimated 640,443 people living with HIV/AIDS in the country in 2018 [2]. In Jambi Province, Indonesia, 2,143 HIV/AIDS cases were documented from 1999 to December 2019, including 1,179 HIV and 964 AIDS cases. Jambi City accounted for 1,570 HIV and AIDS cases by the end of 2019. The primary risk factor for HIV transmission was heterosexual intercourse (58.4%), followed by homosexual transmission (26.4%), perinatal transmission (8%), and bisexual transmission (8.3%) [3].
Effective strategies are urgently needed to expand HIV case identification, facilitate early detection, and prevent progression to AIDS. In this context, promoting HIV testing among partners is critical for early case detection. The partner notification method, which involves disclosing one's HIV-positive status to partners, has proven effective in extending the reach of HIV testing [4]. Disclosing an HIV-positive status to partners serves multiple purposes, including increasing self-acceptance, reducing isolation, promoting safe and healthy sexual practices, motivating people living with HIV/AIDS (PLWHA) to access treatment and care, preventing mother-to-child transmission, and enabling socioeconomic support from partners, families, and communities [4].
In an effort to expedite HIV case identification in Jambi City and curb transmission while reducing new cases, the Sudita Model was developed. Existing models primarily focus on the disclosure of HIV status to partners without adequately preparing PLWHA or considering potential impacts and risks post-disclosure. The Sudita Model offers a novel approach that emphasizes empowerment and persuasive communication prior to status disclosure and aims to restore meaning to the lives of PLWHA following disclosure. Key aspects of the Sudita Model include: 1) empowerment through the provision of information and support to address challenges associated with disclosing HIV-positive status to partners [5]; 2) the application of persuasive communication techniques to influence attitudes, opinions, and behaviors of partners [6]; and 3) a community-based approach in which peers and companions play active roles in intervention and support [7].
This innovative strategy aims to facilitate outreach and support for PLWHA through constructive mechanisms, minimizing negative consequences associated with disclosure and ultimately increasing HIV testing among partners to disrupt the chain of HIV/AIDS transmission. Given the rising number of HIV and AIDS cases in Jambi City, an innovative and comprehensive approach is necessary to address the challenges of HIV-positive status disclosure to partners and to enhance HIV testing rates among couples.
The objective of this study is to assess the impact of the Sudita Model on the frequency and timeliness of HIV-positive status disclosure to partners in Jambi City.
2.1 Types and research designs
The design of this study at this stage is a quasi-experiment using a non-equivalent control group with a pre-test and post-test approach. This research was conducted starting in June 2021 in Jambi City, Jambi Province, Indonesia.
2.2 Research sample
The study sample size was 78 which were divided into 2 groups, namely the intervention group with the Sudita Model 39 people and the control group was the Ministry of Health Module (M. Kemenkes) 39 people.
The inclusion criteria for the sample in this stage of the study are as follows: a. People living with HIV/AIDS (PLWHA) who have not disclosed their positive HIV status to their partners. b. Able to communicate effectively. c. Aged between 21 and 60 years. d. Willing to participate as research subjects.
2.3 Intervention Sudita Model
The Sudita Model is a model that focuses on providing information and support to PLWHA through a persuasive communication approach to build self-confidence. Its aim is to empower PLWHA to disclose their HIV-positive status to their partners. The interventions conducted include: 1. Empowerment: This involves providing comprehensive support and information about HIV/AIDS through mentoring and guidance. 2. Persuasive communication: This is done rationally, aiming to influence the ideas and beliefs of PLWHA, fostering a sense of conviction. It also includes an emotional approach that touches on aspects of sympathy and empathy, inspiring PLWHA to disclose their HIV status to their sexual partners.
The role of outreach workers is to provide support and guidance to PLWHA until they gain self-confidence and are able to disclose their HIV status to their sexual partners. The intervention duration for PLWHA is 3 months.
2.4 Data collection
The variables measured are the quantity and speed of disclosing HIV-positive status to partners in the city of Jambi. The measurement instrument used in this stage of the study is a questionnaire on disclosing HIV status to partners. The measurement scale for disclosing HIV-positive status to partners consists of closed-ended questions with answer options. The measurement scale for PLWHA behavior consists of closed-ended questions with answer options ranging from "strongly agree," "agree," "undecided," "disagree," to "strongly disagree".
For the intervention group and control group in the pre-test stage (before the intervention model is implemented), a questionnaire is administered to assess the behavior of PLWHA in disclosing their HIV-positive status to their partners. The pre-test results are measured using a scoring system. A post-test is conducted one month after the intervention to assess the behavior of disclosing HIV status using the same questions as in the pre-test. A final evaluation is conducted at the 3-month follow-up after the intervention to assess the success of implementing the Sudita Model training. For the control group (comparison group), using the HIV disclosure module provided by the Ministry of Health in Indonesia. The control group is used to test the effectiveness of the module being used.
2.5 Model development
Model development is carried out using the ADDIE model approach, namely 1) Analysis, 2) Design, 3) Development, 4) Implementation, and 5) Evaluation.
Analysis and Identification of Research Problems. Analysis and identification of research problems in phase I used quantitative methods to identify factors related to the disclosure of HIV-positive status in partners.
Design of the Sudita Model. Design is the stage of building the design of the Sudita Model and preparing modules for model intervention. The Sudita Model was developed as an effort to prevent and control HIV/AIDS in Jambi City by using the method of disclosing HIV-positive status to partners, this model is in line with the National Action Plan (RAN) for HIV/AIDS Prevention and Control and PIMS in Indonesia for 2020-2024. For the development of the Sudita Model to be effective and efficient, it is necessary to prepare the design construction (Figure 1).
The Development of the Sudita Model. The development stage is the design construction process by realizing the concept that has been made into a product in the form of a module that is ready for use. The compiled module is used as material for training on disclosing HIV-positive status to partners. The module was developed so that PLWHA can disclose HIV-positive status to partners through the Sudita Model. The module used in the training consists of a module for disclosing HIV-positive status for outreach workers and assistants, serving as a sustainable model.
The Implementation of the Sudita Model. The implementation stage of the Sudita Model is a form of empowerment intervention by providing comprehensive assistance and information about HIV/AIDS using a persuasive communication approach, to overcome problems related to disclosing HIV-positive status to partners. The Sudita Model is community-based, where outreach and assistants will facilitate PLWHA by providing intervention before disclosure of HIV-positive status is carried out.
The Evaluation of the Sudita Model. An indicator of the success of this model is the ability of PLWHA in disclosing HIV-positive status to partners and groups that receive interventions with the Sudita Model effectively increasing the number of disclosures and the speed of disclosing HIV-positive status to partners.
2.6 Data analysis
Bivariate analysis involved an independent t-test between the intervention and control groups at pretest, posttest at 1 month, and posttest at 3 months. Multivariate analysis involved the General Linear Model Repeated Measures, comparing data based on the measurement time points: pretest, posttest at 1 month, and posttest at 3 months.
2.7 Research ethics
Description of ethical approval number: 476/UN.16.2/KEP-FK/2021 from The Research Ethic Committee of Medical Faculty Andalas University, in order to protect human rights and welfare of medical/health research subject.
Figure 1. The design for the development of the Sudita Model
3.1 Number of disclosures of HIV-positive status in partners
The success of the intervention carried out, before and after the model intervention between the two groups and knowing the difference in mean values through repeated observations (1 month and 3 months after the intervention), can be seen in the following Table 1.
Based on Table 1, it was found that the average score for the number of disclosures of HIV-positive status in couples in the first measurement (before being given the intervention) showed a value of p = 0.775, which means that there was no difference in the mean value between the intervention group and the control group before being given the model intervention. The difference in the mean value of the number of disclosures of HIV-positive status in couples 1 month of intervention between the intervention group and the control group showed a difference in increasing the number of disclosures of positive HIV status in couples where the p-value showed p = 0.255, meaning that there was no significant effect after 1 month of model intervention.
Table 1. Value of average score number of disclosures of HIV status in pairs between the intervention group and the control group before, after 1 month, and after 3 months given the intervention model (n=78)
|
Time |
Group |
n |
Mean + |
SD |
Minimum- Maximum |
% ∆ |
p t-test |
p-Multivariate |
|
Pretest |
Intervention |
39 |
16.13 |
1.99 |
14-21 |
0.40 |
0.775 |
0.000 |
|
Control |
39 |
16.26 |
1.96 |
15-21 |
||||
|
Posttest at 1 month |
Intervention |
39 |
19.92 |
5.72 |
15-30 |
3.53 |
0.255 |
|
|
Control |
39 |
18.56 |
4.69 |
15-29 |
||||
|
Posttest at 3 month |
Intervention |
39 |
26.38 |
4.82 |
17-32 |
7.51 |
0.002 |
|
|
Control |
39 |
22.69 |
5.09 |
15-32 |
Figure 2. Number of increased disclosures of HIV-positive status in couples based on group at the start of the study, 1 month and 3 months after the intervention
The mean increase in the number of disclosures of HIV-positive status in partners 3 months after the intervention, for both the intervention group and the control group statistically obtained p = 0.002, meaning that there was a significant effect after 3 months of the model intervention. The group that received the Sudita Model intervention was more effective in increasing the number of disclosures of HIV-positive status to partners than the group that received the Ministry of Health Model intervention. Based on the results of the multivariate test through the General Linear Model Repeated Measures to find out whether there was an increase in the mean value of the number of disclosures of positive HIV status in partners after 1 month and 3 months of intervention, it showed that there was an increase in the mean value where the value of p = 0.000. The increase in the number of disclosures of HIV-positive status in couples before the intervention, 1 month after the intervention, and 3 months after the intervention (Figure 2).
Based on Figure 2, it was found that the difference in scores on the number of disclosures of positive HIV status was higher 3 months after being given the model intervention compared to measurements after 1 month of the model intervention. This shows that the effect on the score of the number of disclosures of HIV-positive status in new partners was evident 3 months after the model intervention in both the intervention group and the control group. However, if we look at the difference in the effect score on the number of disclosures of HIV-positive status between the intervention group and the control group, it is found that the intervention group with the Sudita Model changes faster than the Ministry of Health Model group. The results of the Sudita Model intervention in disclosing HIV-positive status to partners showed that there was a significant increase in the number of disclosing HIV-positive status to partners after being given the intervention. The Sudita Model was more effective in increasing the number of disclosures of HIV-positive status in couples compared to the group using the Ministry of Health Model.
The effect of the Sudita Model in increasing the number of disclosures of HIV-positive status to partners shows how a communication process can change a person's behavior. Changes in behavior and attitudes must be understood as a response to persuasive communication, which assumes that people will change their attitudes if they are provided with several reinforcing reasons for the change in attitude [8]. The effect of persuasive communication as a result of receiving messages through the communication process, so that changes in attitudes, opinions, and behavior of PLWHA are formed to disclose HIV-positive status to partners. Meanwhile, the Ministry of Health model emphasizes only alternative ways of disclosing HIV status.
This study is almost the same as research conducted by Little et al. [9] in Central Asia where there was an increase in the disclosure of HIV status after using the assisted partner notification (APN) method. In line with research conducted by Contesse et al. [10] in the United States, it was shown that most PLWHAs feel comfortable informing their partners by conveying through the geosocial network (GSN) application disclosure of HIV status. According to Chaudoir and Fisher [11] in the theory of Disclosure Process Management (DPM) that disclosure must be conceptualized as a process that involves decision-making and can form a stage of the disclosure process with long-term results, namely the avoidance of negative outcomes (such as social rejection, stigma, and relationship conflict). According to Egan [12] when PLWHA choose to disclose their status, they will reflect and think carefully because this decision will have major consequences for them and everyone around them.
3.2 Speed of disclosure of HIV-positive status in partners
Based on Table 2, it was found that during the first measurement (before the intervention model was given) there was no score, for both the intervention group and the control group. The average score of the speed of disclosing HIV-positive status to partners during 1 month of intervention between the intervention group and the control group found a difference in increasing the speed of disclosing HIV-positive status to couples where the p-value showed p = 0.399, meaning that there was no significant effect after 1 month of intervention model. The average increase in the speed of disclosing HIV-positive status in partners 3 months after the intervention, for both the intervention group and the control group statistically obtained p = 0.001, meaning that there was a significant effect after 3 months of the model intervention. The group that received the Sudita Model intervention was more effective at increasing the speed of disclosure of HIV-positive status to partners than the group that received the Ministry of Health Model intervention.
There was an increase in the mean rate of disclosure of HIV-positive status in partners after 1 month and 3 months of intervention, it showed that there was an increase in the mean value where the value of p = 0.000. Increased speed of disclosure of HIV-positive status in couples before the intervention, 1 month after the intervention, and 3 months after the intervention (Figure 3).
Table 2. Average day rate of disclosure of positive HIV status on pairing between intervention group and control group before, after 1 month and after 3 months given intervention model (n=78)
|
Time |
Group |
n |
Mean ± |
SD |
Minimum-Maximum |
% ∆ |
p t-test |
p-Multivariate |
|
Pretest |
Intervention |
39 |
0 |
0 |
0 |
0 |
0 |
0.000 |
|
Control |
39 |
0 |
0 |
0 |
||||
|
Posttest at 1 month |
Intervention |
39 |
15.67 |
7.38 |
7-30 |
10.59 |
0.399 |
|
|
Control |
39 |
19.50 |
9.67 |
7-30 |
||||
|
Posttest at 3 month |
Intervention |
39 |
28.92 |
12.66 |
7-62 |
30.39 |
0.001 |
Figure 3. Speed of disclosure of HIV status positive in couples by group at baseline research, 1 month and 3 months after the intervention
Based on Figure 3, it was found that the difference in the speed of disclosing HIV-positive status was longer at 3 months after being given the model intervention compared to measurements after 1 month of the model intervention. This shows that the effect on the speed of disclosure of HIV-positive status scores in new partners was evident 3 months after the model intervention in both the intervention group and the control group. However, if we look at the difference in the effect of disclosing HIV-positive status between the intervention group and the control group, it was found that the intervention group with the Sudita Model (M. Sudita) disclosed HIV-positive status faster than the Ministry of Health Model group (M. Kemenkes).
The results of the Sudita Model intervention show that the speed of disclosing HIV-positive status to partners increases significantly, with the Sudita Module the average speed of disclosing HIV-positive status is 28.9 days while the Ministry of Health Module is 54.4 days. The Sudita Module is more effective in increasing the speed of disclosure of HIV-positive status in couples than the group using the Ministry of Health Model. This research is by the systematic review and meta-analysis conducted by Gabbidon et al. [13] individuals who can express their status quickly, are proven to be adaptive, more confident, more competent, reliable, more able to have a positive attitude, trust others and be more objective and open. Conversely, individuals who are less capable of self-disclosure (self-disclosure) are proven unable to adapt, lack self-confidence, arise feelings of fear, and anxiety, and feel inferior and closed.
The Sudita Model affects increasing the speed of disclosing HIV-positive status to partners, showing that changes in the behavior of PLWHA can be carried out by providing comprehensive information about HIV AIDS and assistance that is carried out continuously and continuously following the development of PLWHA. as well as interventions by outreach and assistants to facilitating PLWHA so that they immediately disclose their HIV positive status to their partners. Research conducted by Nurhayati [14] in Tangerang, Banten found that PLWHA who underwent assistance had a fairly good level of disclosure and were more open to others. In line with research conducted by Candra et al. [15] in Bali, it shows that self-disclosures are carried out by PLWHA because they have certain people who encourage disclosure. After disclosing to partners and families, PLWHA feels calm, and the burden of thinking about their illness is reduced.
The results of the questionnaire analysis found that the couple could not accept the positive HIV status of PLWHA because the partner felt that HIV/AIDS was a deadly, dirty disease, a disease caused by actions that violated morality and were irresponsible. The rejection of the HIV-positive status of PLWHA is because the partner thinks that HIV/AIDS is different from other infectious diseases, HIV/AIDS is a deadly disease that cannot be cured and people with HIV/AIDS must be shunned. Research conducted by Zainul [16] in Surabaya that rejection of OHDA is caused by wrong conclusions and understanding of HIV/AIDS, such as HIV/AIDS can be transmitted through social contact with PLWHA. Research conducted by Vitriawan et al. [17] in Jakarta after being diagnosed with HIV/AIDS most PLWHA shared this news with those closest to them and received positive and beneficial reactions, but some were disappointed or rejected by their partners. and those closest to him. The partner's response after knowing their positive HIV status can have both positive and negative impacts. The first thing might be that they cannot believe that their partner has HIV/AIDS. Disclosure of positive HIV status often brings consequences that sometimes make a life for HIV sufferers even more difficult after their positive HIV status is known [18].
An indicator of the success of this model is the ability of PLWHA in disclosing HIV-positive status to partners and the group receiving intervention with the Sudita Model effectively increases the number of disclosures and the speed of disclosure of HIV-positive status to partners. The new findings from the Sudita Model suggest an approach that involves empowerment and persuasive communication before disclosing one's status.
3.3 Limitations
Firstly, this study only constructs the Sudita Model, which is a development of the PRECEED-PROCEED Theory by Green et al., the Hovland/Yale Model of Persuasion by Hovland et al., and the Disclosure Processes Management Theory by Chaudoir and Fisher [11] based on existing literature. Secondly, Variables were constructed by adding variables that are relevant to the research objectives, involving outreach workers and companions as facilitators in the disclosure of HIV-positive status to partners. The generalizability of this model will be specifically applicable to areas that have similar social characteristics to the research site. However, this study did not measure the long-term success of the model in changing the behavior of disclosing HIV-positive status to partners. Third, during the data collection process, the researchers were not allowed to record or document the research implementation due to concerns from informants/respondents about the potential disclosure of their identities. It was challenging to obtain data from PLWHA due to the sensitive nature of the issue being studied, as well as difficulties in scheduling meetings.
The study found that the Sudita Model was more successful in facilitating faster disclosure of HIV-positive status to partners compared to the Ministry of Health Model. This suggests that the comprehensive information and continuous assistance provided by the Sudita Model have a positive impact on the behavior of PLWHA, enabling them to disclose their status more quickly.
The findings of this study have implications for theory, research, and practice in the field of HIV/AIDS prevention and control. The Sudita Model, with a focus on providing comprehensive information and ongoing support through a persuasive communication approach, can serve as a valuable framework for interventions aimed at promoting the disclosure of HIV-positive status.
Based on the study findings, it can be asserted that the Sudita Model is an effective approach for increasing the speed of disclosing HIV-positive status to partners. The model's emphasis on empowering PLWHA through comprehensive information and continuous assistance has demonstrated positive outcomes in terms of behavior change. Implementing the Sudita Model in HIV prevention and control programs can contribute to reducing the transmission of HIV and promoting the well-being of PLWHA.
Future research is the Sudita Model can be further developed and refined by future researchers to explore other contributing factors in the disclosure of HIV-positive status to partners.
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