Author: admin

As people living with HIV (PLWH) age, some frequently encounter both medical and behavioral challenges that can impact their ability to age successfully. One significant challenge is decreased cognitive efficiency that can result in HIV-Associated Neurocognitive Disorder (HAND), affecting nearly 44% of PLWH.¹ The seriousness and prevalence of these cognitive impairments (eg, forgetfulness, difficulty with medication adherence) may escalate with the onset of age-related neurological issues (ie, transient ischemic attacks, white matter hyperintensities) and age-related comorbidities known to impact brain function (ie, diabetes, heart disease).^2–4 These cognitive impairments impact instrumental activities of daily living (IADLs) such as medication adherence and driving safety.⁵ Processes leading to such cognitive impairments remain complex, involving factors like neuroinflammation, depression, substance misuse, and inadequate mental stimulation. Over time, these mechanisms can diminish cognitive reserve and overall brain health, leading to observable cognitive impairments associated with HAND.²

Nurses and allied healthcare professionals seek treatments to protect one from cognitive impairments as PLWH age. Given the complexity of many PLWH being prone to polypharmacy issues and multiple comorbidities (ie, renal and hepatic insufficiency), non-pharmacological treatments are preferred to avoid medical complications. Also, there are no pharmacological approaches shown to produce robust and sustained neurological or cognitive benefits.² Thus, behavioral approaches are preferred.

One behavioral approach in which much evidence has emerged is cognitive training. Cognitive training refers to structured mental exercises specifically designed by neuroscientists that require patients to engage in these exercises, requiring them to use targeted thought processes (often associated with certain brain structures) to complete the exercises; these thought processes approximate certain cognitive skills/domains that can be quantified by specific cognitive performance tests.^6–8 These cognitive training approaches often target improvement in particular cognitive domains such as speed of processing, working memory, and executive functioning. For example, in a pretest/posttest study of 46 PLWH, participants were assigned to either a no-contact control group or a speed of processing training group. Those in the speed of processing training group underwent 10 hours of specially designed computer games that required swift processing of complex visual information.^7,9 Compared to the control group, those in the training group experienced improvements in a cognitive measure of speed of processing as well as a measure of everyday functioning. In a systematic review of 13 cognitive training studies in PLWH, researchers found that, in general, cognitive training improved performance in the cognitive domain in which cognitive training occurred (ie, speed of processing training improved speed of processing performance, executive functioning improved executive functioning performance);¹⁰ however, studies were not able to improve global cognition, and these studies were not powered or designed to examine cognitive changes longitudinally. Also, none of these studies incorporated the concept of cognitive intra-individual variability (IIV).

Cognitive IIV refers to the natural fluctuations observed in cognitive performance when the same cognitive test is taken multiple times (referred to as inconsistency) or across different cognitive tests (referred to as dispersion); such variability has been shown to provide predictive value beyond traditional mean-based cognitive measures.^11–13 In other words, the measure of the spread in variability of cognitive performance may possess more predictive value than the average or summed scores of such cognitive measures. For a hypothetical example, as seen in Figure 1, Jeff and Sam (fictitious names) took a reaction time test and when looking at their average score, they both performed at the same level. We would assume that they are functioning similarly; however, when looking at the spread/variability in their reaction time, we see that Sam had a lot more variability in his reaction time. From what we know about cognitive IIV, this is not a good cognitive indicator for Sam.

Elevated cognitive IIV is suggested to signify poor coordination of cognitive abilities, potentially indicating subtle cognitive decline.¹⁴ This variability in cognitive performance is linked to cognitive impairment and decline across diverse clinical populations. For example, in a prospective cohort comprising 897 community-dwelling older adults (70+ years), Holtzer et al discovered that baseline cognitive IIV (ie, dispersion) was a predictor of developing dementia three years later.¹⁵ This association held true even after adjusting for the mean-based cognitive performance at the initial baseline assessment.

Cognitive IIV also is relevant to the study of neuroHIV. In a systematic review, focusing on 13 neuroHIV studies examining cognitive IIV, researchers concluded that it holds promise as an approach to identify subtle cognitive impairments not captured by traditional mean-based cognition.¹⁴ In PLWH, increased cognitive IIV has been associated with: 1) poorer cognitive performance and decline over time, 2) cortical atrophy involving both gray and white matter volume, 3) heightened mortality risk, and 4) difficulties in everyday functioning.^14,16,17

Given the impact of cognitive IIV in neuroHIV, we proposed using executive functioning training to improve executive functioning which we hypothesized will reduce cognitive IIV. Based on the Executive Dysfunction Hypothesis, it posits that cognitive IIV emerges because there is poor coordination of the other cognitive domains which creates such vicissitudes in cognitive function, and this coordination relies heavily on executive functioning.¹⁴ This point is pertinent; a meta-analysis of 37 studies of PLWH found executive dysfunction may be more pronounced than in those without HIV.¹⁸ Thus, if executive functioning can be improved, perhaps this will reduce cognitive IIV and possibly produce better outcomes. Fortunately, cognitive training studies using executive functioning training have been able to improve this cognitive ability in older adults and those with HIV;^10,14,19 unfortunately, these studies did not include measures of cognitive IIV.

Based on the above literature, the purpose of this article was to characterize an approach to administer executive functioning training to PLWH to reduce their cognitive IIV. In this study, participants are randomized into either a 20-hour executive functioning training group or a no-contact control group; this is referred to as the Executive Functioning Training (EFT) Study. To contextualize the EFT Study, this current article used a descriptive case comparison approach to describe the treatment outcomes of two participants in the treatment group that received the executive functioning training compared to two participants in the no-contact control group. From this, implications of this study to nursing care for cognitively vulnerable PLWH are provided.

Methods

Study Design

We are examining in an on-going randomized control trial the feasibility of a 2-group pretest/posttest experimental study targeting recruitment of 120 PLWH aged 40+ years (for additional details, see Odii et al).²⁰ This current descriptive case comparison study is a smaller piece of the larger parent EFT randomized clinical trial (on-going). As a descriptive case comparison study, only descriptive analyses are provided of selected cases in the experimental condition and compared to demographically matched cases (ie, case comparison); this is done to illustrate and highlight the basic structure and design of the larger parent study. The first two participants to complete the executive functioning training arm (n = 2) were compared to demographically matched participants in the no-contact control group (n = 2); their data were analyzed by examining pretest/posttest changes (~12 weeks) in their cognitive IIV scores and other outcome variables (ie, depressive symptomatology). These cases in the experimental condition were selected because they were the first two who finished all the training protocol including receiving the full dose (ie, 20 hours) of the executive functioning training (ie, consecutively completed the study from the start of the study). Also, they were very representative of the overall sample so far (middle-aged African Americans). Thus, we chose participants in the control group who were most closely aligned to their basic demographics, to methodologically control for these demographic variables. Overall, this is a nested, exploratory, and preliminary comparison of cases selected from the parent trial, conducted for illustrative and hypothesis generating purposes rather than inferential statistical analysis. As this was a descriptive study of a treatment protocol, causal inferences are limited. The EFT Study was approved by the University of Alabama at Birmingham (UAB) Institutional Review Board (IRB-300008561). All participants provided informed consent, in accordance with the Declaration of Helsinki.

Recruitment

In the EFT study, participants were recruited from two sources: 1) recruited via flyers posted at the UAB HIV clinic and 2) the CINCS (Centers for AIDS Research Network of Integrated Clinical Systems) participation list at the same UAB HIV clinic as these participants indicated that they wanted to be recruited and contacted for future studies. With the first source, the flyer had our office number instructing participants to call us to ask for more details. With the second source, study staff called potential participants from the CINCS list. All participants from both recruitment sources were administered a telephone screen to determine whether they met study criteria. Specifically, eligibility criteria were: a) be 40+ years of age; b) be diagnosed with HIV for at least 1 year; c) have no severe neuro-medical comorbidity (eg, schizophrenia); d) be able to drive; e) reside within 60 miles of the research center; f) not be legally blind or deaf; g) able to understand/speak English; h) be stably housed; i) not undergoing radiation or chemotherapy; j) have no history of significant brain trauma; and k) not be diagnosed with COVID-19 within the past 3 months. The rationale for these eligibility criteria were to ensure participants were able to attend in person visits at the research center and to ensure that any cognitive problems present were likely due to HIV and not to other causes (ie, brain trauma). The focus on PLWH in this older age group (40+ years) was prompted by the higher prevalence of cognitive impairments.^1,2

Instruments

Administration time of the pretest/baseline and posttest assessments took approximately 2 hours each. Assessments were administered in-person by a trained technician (S.B.) at our university research center. Although not reported in this descriptive case comparison article, there were several measures administered at each assessment that measured quality of life, training satisfaction, cognitive function, and more (for more information, see EFT study protocol article).²⁰ Yet, for this descriptive case comparison study, to contextualize the study we only reported the measures below as they describe the sample demographics, health status, basic educational quality, depressive symptomatology, and reaction time and cognitive IIV measures pertinent to the overall study hypothesis (ie, executive functioning training will reduce cognitive IIV).

Demographics and Health

Basic demographic information (ie, age, gender, ethnicity, education) along with HIV-related clinical data (CD4+T lymphocyte count, HIV viral load) were gathered by self-report at pretest/baseline. We acknowledge self-reported health information is susceptible to poor health literacy/health numeracy and recall bias.²¹

Center for Epidemiologic Studies Depression Scale-Revised (CES-D)

The CES-D consists of 20 items reflective of statements about mood in which participants rate how often they felt that way in the past week ranging from 0 (rarely or none of the time) to 3 (most or all of the time). These were tallied with total scores ranging from 0–60; a score of ≥16 indicates clinically relevant depressive symptomology.²²

Connor’s Continuous Performance Test (CCPT; 3rd Edition)

The CCPT is a widely accepted test of sustained/selective attention and impulsivity; it is commonly used in the cognitive IIV literature and produces IIV inconsistency coefficients as well as several measures of reaction time, attention, inhibition, and impulsivity.²³ The CCPT instructs participants to swiftly press the space bar whenever a non-“X” letter (ie, target) appears on the screen, aiming for the fastest response. Additionally, participants are required to withhold this response when the letter “X” (ie, non-target) is presented. Targets (non-“X” letters) make up 90% of the letters presented. Each letter is displayed for 250 ms, and there is an inter-stimulus interval (ISI) of 1, 2, or 4 seconds between letters. The complete test consists of a 1-minute practice block and approximately 14 minutes of testing, divided into six blocks. Each block can be further divided into three sub-blocks of 20 trials, each with a specific ISI set to 1, 2, or 4 seconds. CCPT outcome variables are represented as t-scores, standardized by age and gender. Lower t-score values indicate better performance, reflecting quicker or more consistent responses. There are 13 values produced from the CCPT, but not all are relevant for this descriptive analysis; thus, seven are reported and for all of them, higher scores indicate worse performance. 1. Detectivity (d’) – This measure indicates how well participants discriminate targets from non-targets. 2. Omissions (%) – Considered an indicator of inattentiveness, it measures how many targets were missed. 3. Commissions (%) – Considered an indicator of impulsivity, it measures the number of incorrect responses to non-targets. 4. Perseveration (%) – Considered an indicator of impulsive, anticipatory, or repetitive responding, it measures how many responses occur within 100 ms following the presentation of a stimulus. 5. Hit Reaction Time (HRT) – This measure is the only indicator of response time (RT) central tendency. 6. HRT Standard Deviation (HRT SD) – A measure of inconsistency, this measure denotes the standard deviation of the participant’s Hit RT across all test trials. 7. Variability – This measure represents the standard deviation of Hit SD across trial sub-blocks; this is considered one of the other main inconsistency indices.

Intervention

We maintained a stratified randomization method with permuted block and treatment allocation between African Americans/Caucasians, men/women, and low/high cognitive IIV scores (cutoff = 55 on the HRT SD (Hit Rate Standard Deviation) on the Connor’s Continuous Performance Test (Version 3 (CCPT-3)). This intervention was described in the consent form and then once assigned to the intervention, participants were described the cognitive training more. During the training sessions, participants were personally shown how to engage in the cognitive training by the trained technician (S.B.) who answered questions; this staff person also checked in on the participant frequently during the training sessions to answer any questions that arose. Otherwise, the training software was designed to be self-administered and it provided instructions and prompts to facilitate the training exercises.

Those assigned to the EFT group were assigned to 20 hours of complex mental exercises requiring one to set shift, that is to maintain at least two sets of rules and decide which is appropriate to determine the correct response. For example, in “Mind Bender” the participant is presented two rules. The first rule might be when presented the spelling of two different numbers, select the word that spells the highest number (“seven” vs “four”). But the second rule might be when presented two digits, select the lowest number (“4” vs “7”). Participants will be presented pairs of either words or digits of number where they have to make this selection as quickly as possible, based on either the first or second rule. The effect size for EFT from a prior HIV cognitive training study using these exercises was large (d = −0.89).⁸ The exercises were created by BrainHQ (POSIT Science Inc). The training consisted of four modules. One, “Mind Binder” is a “set shifting” exercise where one is presented with two rules, but one must choose the correct answer based upon the rules provided in this exercise (explained above). Second, “Mixed Signals” requires one to listen to a number, letter, or other information while looking at a similar set of information. For example, in one version of this, one might hear the word “four” but is visually presented “444”, since there are not four digits, one does not respond and waits for the next presentation; but in the next presentation one might hear the word “three” but is presented “444” and since there are three digits, one presses the “YES” button as soon as possible. Variations and rules of this change while one must ignore competing information; this exercise is similar to the Stroop test. Third, “Card Shark” is an extension of a visual n-back paradigm using an aspect of executive functioning (ie, working memory). More specifically, participants are presented standard playing cards which are added sequentially, one at a time. The card is presented one at a time, and the participant must decide if the current card that is flipped over matched the one just presented. After this mastery, this exercise becomes more difficult and one must decide if the current card that is flipped over matched the one presented two back (or more for later levels) in the sequence. And fourth, “Freeze Frame” is an extension of the go/no go paradigm using an aspect of executive functioning (ie, working memory). Participants are shown a target imagine and then a series of other images that may or may not match the target. If the presented image does not match the target, they are instructed to click “NO” but if it does match the target, they are instructed to “freeze”, that is, do nothing and wait for the next image to be presented. For these four exercises, participants could train up to two hours at a time at our research center. Participants spread out their training over several weeks to fit their schedule. A picture of the software and gaming features is available in Figure 2.

Figure 2 Executive Functioning Training Exercises.

Data Analysis

We chose the first participants who completed the executive functioning training and then selected two other participants in the no-contact control group who were the closest demographic match to the first two participants. A descriptive pretest/posttest comparison of these cases was constructed (Table 1) to examine changes in CCPT scores, with particular focus on the cognitive IIV scores of HRT SD and Variability. Our statistician developed and generated the comparisons by: 1) calculating the change within each participant, 2) then averaging those changes for each group, and 3) then calculating the point difference in change (EFT – Control). Positive point difference scores reflect therapeutic benefit attributed to the control condition, and negative point difference scores reflect therapeutic benefit attributed to the training condition. Absolute value higher point different scores indicate more therapeutic benefit.

Table 1 Case Comparisons Between the Executive Functioning Training Group and the No-Contact Control Group

Results

As seen in Table 1, all four cases were African Americans 45 to 58 years of age. Participants by and large did not know their CD4+ T lymphocyte count > 200 cells/mm,³ but all reported being undetectable Both participants in the executive functioning training group received the full training (ie, 20 hours of training). Compared to the no-contact control group, those in the executive functioning training group had higher levels of depressive symptomatology at baseline and posttest; the training did not appear to reduce these symptoms. Using the absolute value point difference scores of 5 or greater for the CCPT as a cut-off, compared to the no-contact control group, it appears that those in the executive functioning training group experienced benefits on Detectability (d’) (by −5.5 pt difference) and Hit RT (by −24.5 pt difference). Furthermore, for the two indicators of cognitive IIV, Hit SD and Variability showed marked improvements compared to the no-contact control group by a −16 point difference and a −9 point difference, respectively. Negligible changes were observed for Omission, Commissions, and Perseveration. These results were novel because this is the first time (to our knowledge) that any study has been designed to specifically address and reduce cognitive IIV in any population. The fact that this descriptive case comparison study found reductions in Hit RT and other variability metrics was encouraging.

Discussion

Our interim descriptive case comparison study suggests an emerging pattern of improvement on cognitive variables of discrimination (Detectivity) and reaction time (Hit RT) as well as cognitive IIV (HRT SD, Variability) resulting from the executive functioning training. Based on the Executive Dysfunction Hypothesis, cognitive IIV may result from executive dysfunction; more specifically, as executive function is considered a foundational cognitive ability that directs and orchestrates the use of other cognitive functions, if executive functioning is compromised, this will exert downstream effects whereby one has poor coordination of other cognitive abilities resulting in cognitive IIV; this in turn would compromise everyday functioning. Thus, by improving executive functioning through computerized executive functioning training, this could strengthen such cognitive abilities that may harmonize cognitive functioning across and within cognitive domains.

Although these preliminary findings are promising, clearly more research is required such as how much training (ie, dosage) is needed to achieve this goal of reducing cognitive IIV, whether it be 10 hours, 20 hours, or 50 hours. In a meta-analysis of 52 cognitive training studies in older adults (combined N = 4,885), Lampit et al suggested that 20 hours seems to be the optimal training amount in general as more than that introduces training fatigue.²⁴ That is an important consideration as such training can be very intense and requires much focus on the part of the participant. But that may not apply to all types of cognitive training; for example, improving executive functioning could require more time to accomplish than trying to improve another cognitive domain such as psychomotor ability. In fact, that might explain why the literature reports different training effect sizes of different cognitive domains because some may require more training time (dosage) to change than others. Although the parent EFT study will not be able to resolve these issues that are pernicious in the cognitive training literature, it will add to the literature by providing information about the efficacy of using 20 hours of executive functioning training in a population of PLWH.

Another consideration is how robust will the training effect be over time (eg, weeks, months, or years) as such training effects may fade without being boosted with additional training sessions. In a large study of community-dwelling older adults (without HIV), Edwards et al found that 10 hours of speed of processing training was quite robust overtime, resulting in a remarkable reduction in the prevalence of dementia (by 29%) over a span of 10 years when compared to a control group.²⁵ This highlights the impressive long-term advantages of cognitive training. Unfortunately, our EFT Study was not designed to ascertain the sustained duration of cognitive benefits from such training.

Strengths and limitations of this descriptive case comparison study are as follows. First, given the pilot nature of our study, a small sample was used to describe the protocol so inferences cannot be concluded; albeit, the preliminary findings are meant to provide insights and generate discussion. Second, participants in the experimental group had higher levels of depressive symptomatology at baseline and posttest compared to the cases in the control group. It is not clear why those two participants randomized to the experimental condition would have such higher levels of depressive symptomatology; we assume this is just random. Participants were randomized after the baseline assessment, so being randomized to the experimental condition would not have exerted an influence on depressive mood. Interestingly, although depressive symptomatology has been shown to negatively affect cognition,²⁶ those in the experimental condition still improved on some of the measures of cognition and cognitive IIV. Third, clinical and statistical significance cannot be determined at this time given the pilot nature of this study. As there are only 4 cases, we cannot make inferential (ie, statistically significant) conclusions as such inferential statistics would require larger samples sizes. Nor can we, at this time, provide definitive statements of whether the improvements are clinically significant as we do not have enough sample size to calculate whether the reductions in cognitive IIV are correlated to medication adherence or other clinically relevant measures. But once the study is over and the data analyses are available in the next year or two, we will be able to answer this question more definitively. Fourth, the follow-up assessment was only ~12 weeks at immediate posttest; the effects may fade over time but the study was not designed nor funded to look at a longer follow-up assessment. A longer follow-up assessment would be important to detect if the training effects are robust over time. Finally, this is a unique descriptive case comparison study that highlights and portrays an innovative cognitive training approach using cognitive IIV as an impetus for training; this is a unique contribution to the neurocognitive field.

As the parent EFT Study continues, a larger sample from this feasibility RCT will be available to determine whether executive functioning training is effective in improving executive functioning and likewise reducing cognitive IIV, measured by inconsistency and by dispersion. To our knowledge, this is the first study to attempt to reduce cognitive IIV and measure such change with both measures of cognitive IIV. Furthermore, given the relationship between cognition and everyday functioning and quality of life, the EFT study will explore whether changes in cognitive IIV translate into these non-cognitive therapeutic benefits for PLWH.

Nursing implications for practice and research are noted. First, if the EFT approach can truly change cognitive IIV, this may improve overall cognition as well. As nurses and allied health professional seek ways to improve successful cognitive aging in PLWH,² this is an approach they can educate their patients. Second, if the EFT approach can also improve everyday functioning such a medication adherence or driving an automobile, this could have real world applications in which nurses can provide clinical recommendations for use. In fact, studies do show that cognitive IIV is related to IADLs.²⁷ And third, for nurse researchers who study neurological complications from HIV and other conditions, the use of this EFT approach may produce positive clinical outcomes (ie, improved medication adherence).

Conclusion

In conclusion, nurses and allied health professionals need therapeutic strategies for their patients to reduce the risk of cognitive impairment as PLWH age. Fortunately, prior research has already shown that EFT can improve this cognitive ability, but it is unknown whether it can change cognitive IIV also. Given that cognitive IIV is lauded as a more salient predictor of cognitive decline and poorer outcomes in PLWH than mean-based cognitive measures, it is hoped that by reducing cognitive IIV as well as the underlying neurological sequelae surrounding it, we will be able to alter the trajectory of such detrimental cognitive outcomes. This approach is, as it should be, being tested in a much larger RCT study; the parent EFT study will allow us to determine whether this cognitive training improves executive functioning, reduces cognitive IIV, and improves everyday functioning such as medication adherence and self-reported IADLs. It will also be important to conduct long-term follow-up assessments to determine how robust the treatment effect is over time; if it is not, perhaps booster cognitive trainings would be needed. This EFT approach may be tested in other clinical populations in which cognitive IIV is shown to be elevated, such as breast cancer survivors.²⁸ At the intersection between nursing care and neuroscience, this cognitive IIV approach represents an innovative step in addressing these complex neurological issues in HIV care. In fact, despite the pilot nature of our study, this approach may be suitable and adaptable to other clinical populations.

Data Sharing Statement

These data pertaining to this case comparison study are available upon request to the corresponding author. These data will be deidentified. Data collection forms are also electronically available upon request. These data will be available for the next 5 years after the publication data of this article.

Acknowledgments

This work was supported by a National Institutes of Health/National Institute on Aging R21-award (1R21AG077957-02); Vance, Principal Investigator) titled “Executive Function Training to Reduce Cognitive Intra-Individual Variabilty in Adults with HIV”. The ClinicalTrials.gov number is NCT05598047.

Author Contributions

All authors meet the following IMCJE criteria: 1) Made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; 2) Have drafted or written, or substantially revised or critically reviewed the article; 3) Have agreed on the journal to which the article will be submitted; 4) Reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage; and 5) Agree to take responsibility and be accountable for the contents of the article.

Funding

This work was supported by a National Institutes of Health/National Institute on Aging R21-award (1R21AG077957-02); Vance, Principal Investigator) titled “Executive Function Training to Reduce Cognitive Intra-Individual Variabilty in Adults with HIV”. The ClinicalTrials.gov number is NCT05598047.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Wei J, Hou J, Su B, et al. The prevalence of Frascati-criteria-based HIV-Associated Neurocognitive Disorder (HAND) in HIV-infected adults: a systematic review and meta-analysis. Front Neurol. 2020;11:581346. doi:10.3389/fneur.2020.581346

2. Waldrop D, Irwin C, Nicholson WC, et al. The intersection of cognitive ability and HIV: a review of the state of the nursing science. J Assoc Nurses AIDS Care. 2021;32(3):306–321. doi:10.1097/jnc.0000000000000232

3. Vance DE, Brew BJ. Plasma neurofilament light chain protein predicts greater brain-age gap, cognition, and cardiovascular risk in people with HIV. AIDS. 2024;38(7):1081–1083. doi:10.1097/QAD.0000000000003880

4. Aung HL, Gates TM, Mao L, Brew BJ, Rourke SB, Cysique LA. Abnormal cognitive aging in people with HIV: evidence from data integration between two countries’ cohort studies. AIDS. 2022;36(8):1171–1179. doi:10.1097/QAD.0000000000003230

5. Vance DE, Fazeli PL, Gakumo CA. The impact of neuropsychological performance on everyday functioning between older and younger adults with and without HIV. J Assoc Nurses AIDS Care. 2013;24(2):112–125. doi:10.1016/j.jana.2012.05.002

6. Chang L, Lohaugen GC, Andres T, et al. Adaptive working memory training improved brain function in human immunodeficiency virus-seropositive patients. Ann Neurol. 2017;81(1):17–34. doi:10.1002/ana.24805

7. Vance DE, Fazeli PL, Azuero A, et al. A 2-year, randomized, clinical trial examining the effects of speed of processing cognitive training on quality-of-life indicators in adults with HIV-associated neurocognitive disorder in Birmingham, Alabama: results of the Think Fast Study. J Assoc Nurses AIDS Care. 2024;35(2):104–121. doi:10.1097/JNC.0000000000000449

8. Vance DE, Fazeli PL, Azuero A, Wadley VG, Raper JL, Ball KK. Can individualized-targeted computerized cognitive training benefit adults with HIV-associated neurocognitive disorder? The Training on Purpose Study (TOPS). AIDS Behav. 2021;25(12):3898–3908. doi:10.1007/s10461-021-03230-y

9. Vance DE, Fazeli PL, Ross LA, Wadley VG, Ball KK. Speed of processing training with middle-age and older adults with HIV: a pilot study. J Assoc Nurses AIDS Care. 2012;23(6):500–510. doi:10.1016/j.jana.2012.01.005

10. Vance DE, Fazeli PL, Cheatwood J, Nicholson WC, Morrison SA, Moneyham LD. Computerized cognitive training for the neurocognitive complications of HIV infection: a systematic review. J Assoc Nurses AIDS Care. 2019;30(1):51–72. doi:10.1097/JNC.0000000000000030

11. Bangen KJ, Weigand AJ, Thomas KR, et al. Cognitive dispersion is a sensitive marker for early neurodegenerative changes and functional decline in nondemented older adults. Neuropsychology. 2019;33(5):599–608. doi:10.1037/neu0000532

12. Batterham PJ, Bunce D, Mackinnon AJ, Christensen H. Intra-individual reaction time variability and all-cause mortality over 17 years: a community-based cohort study. Age Ageing. 2014;43(1):84–90. doi:10.1093/ageing/aft116

13. Bellgrove MA, Hester R, Garavan H. The functional neuroanatomical correlates of response variability: evidence from a response inhibition task. Neuropsychologia. 2004;42(14):1910–1916. doi:10.1016/j.neuropsychologia.2004.05.007

14. Vance DE, Del Bene VA, Frank JS, et al. Cognitive intra-individual variability in HIV: an integrative review. Neuropsychol Rev. 2022;32(4):855–876. doi:10.1007/s11065-021-09528-x

15. Holtzer R, Verghese J, Wang C, Hall CB, Lipton RB. Within-person across-neuropsychological test variability and incident dementia. JAMA. 2008;300(7):823–830. doi:10.1001/jama.300.7.823

16. Morgan EE, Woods SP, Delano-Wood L, Bondi MW, Grant I; Group HIVNRP. Intraindividual variability in HIV infection: evidence for greater neurocognitive dispersion in older HIV seropositive adults. Neuropsychology. 2011;25(5):645–654. doi:10.1037/a0023792

17. Morgan EE, Woods SP, Grant I; Group HIVNRP. Intra-individual neurocognitive variability confers risk of dependence in activities of daily living among HIV-seropositive individuals without HIV-associated neurocognitive disorders. Arch Clin Neuropsychol. 2012;27(3):293–303. doi:10.1093/arclin/acs003

18. Walker KA, Brown GG. HIV-associated executive dysfunction in the era of modern antiretroviral therapy: a systematic review and meta-analysis. J Clin Exp Neuropsychol. 2018;40(4):357–376. doi:10.1080/13803395.2017.1349879

19. Chiu HL, Chan PT, Kao CC, et al. Effectiveness of executive function training on mental set shifting, working memory and inhibition in healthy older adults: a double-blind randomized controlled trials. J Adv Nurs. 2018;74(5):1099–1113. doi:10.1111/jan.13519

20. Odii IO, Hathaichanok P, Hopkins C, et al. Executive functioning training for reducing cognitive intra-individual variability in people living with HIV: a pilot randomized, controlled trial protocol. Nurs Res Rev. 2025;15:17–20.

21. Waldrop-Valverde D, Jones DL, Jayaweera D, Gonzalez P, Romero J, Ownby RL. Gender differences in medication management capacity in HIV infection: the role of health literacy and numeracy. AIDS Behav. 2009;13(1):46–52. doi:10.1007/s10461-008-9425-x

22. Radloff LS. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc. 1991;20(2):149–166. doi:10.1007/BF01537606

23. Connors Continuous Performance Test. 3rd ed. Multi-Health Systems, Inc.; 2014.

24. Lampit A, Hallock H, Valenzuela M. Computerized cognitive training in cognitively healthy older adults: a systematic review and meta-analysis of effect modifiers. PLoS Med. 2014;11(11):e1001756. doi:10.1371/journal.pmed.1001756

25. Edwards JD, Xu H, Clark DO, Guey LT, Ross LA, Unverzagt FW. Speed of processing training results in lower risk of dementia. Alzheimers Dement. 2017;3(4):603–611. doi:10.1016/j.trci.2017.09.002

26. Vance D, Larsen KI, Eagerton G, Wright MA. Comorbidities and cognitive functioning: implications for nursing research and practice. J Neurosci Nurs. 2011;43(4):215–224. doi:10.1097/JNN.0b013e3182212a04

27. Vance DE, Xu Y, Dastgheyb R, et al. Does cognitive intra-individual variability predict change in everyday functioning performance in women with and without HIV in the Women’s Interagency HIV Study? Appl Neuropsychol Adult. 2024:1–11. doi:10.1080/23279095.2024.2444573

28. Vance DE, Collette C, Frank JS, et al. Cognitive intra-individual variability in breast cancer survivors: a systematic review. Appl Neuropsychol Adult. 2023:1–15. doi:10.1080/23279095.2023.2270097

The study’s first objective was to present the characteristics of the clients of the alternative healthcare providers as captured in the study. Table 1 shows information about each participant and their identifiers, while Table 2 shows participants’ characteristics presented in both frequency and percentage format. The majority of clients (60%) were aged between 25 and 34, while 7.5% were aged between 20 and 24, 20% were aged between 35 and 44, and 10% were aged 45 and over. Only one client refused to give her age. The majority of clients (57.5%) had secondary level education, 2.5% had junior secondary level education, 37.5% had tertiary level education, and 2.5% had postgraduate level education. The majority of clients (85%) were Christians, while 15% were Muslims. The majority of clients were Yorubas (90%), 2.5% were Urhobo and Bini respectively, and 5% were Ibibio. The majority of clients were married (95%), while only 2 reported being single. Three-fifths of clients had 1 or 2 children, 27.5% had three or more children, whole 12.5% were currently pregnant with their first child. The clients were equally distributed between Lagos and Ekiti States.

From these findings, it can be observed the alternative healthcare providers’ clients, in addition to being urban dwellers, are also educated to a reasonable extent, largely Christian, and also predominantly Yoruba, though this may be accounted for by the South-West location of the study. Majority of the clients were also above 25 and married, and the majority had given birth to children previously. These findings show that the clients who choose to use alternative healthcare providers are women who are familiar with the pregnancy process, educated, exposed, and make an informed choice to make use of these health providers.

The second objective of the study addressed the motivations for women making use of traditional and faith-based birth attendants. Under this theme, ten subthemes were identified as listed below.

Subthemes

• Permission to come with companions

• Client’s perception of facility

• Complaint about hospitals

• Cost of services in facility

• Facility waiting time

• How client heard about service provider

• Factors that influenced client’s decision to use the facility

• Place of delivery and previous use of TBA or FBBA

• If client has used the same facility previously

• If client would refer provider to someone else

Permission for clients to come with companions

From the responses below, participants said they are permitted to come with their companions of choice for their antenatal visits. However, while some facilities allowed companions to come in during consultation and labour, other facilities only allowed companions in the reception area and not into the private consultation with the client.

“Yes, you can bring your friends for prayers but not into the consultation room” (E2, 28, Christian, secondary, Ekiti).

“We come with our friends so we can be chatting. Most times, the Doctor asks if you want your friend to come in with you or you want it to be private. That is, if you want to convince your friend to come, the Doctor will allow your friend to enter” (OM6, 46, Christian, secondary, Lagos).

“Yes. My husband was with me during my first and second delivery” (T5, 27, Christian, secondary, Ekiti).

“My husband can come with me. He comes for prayers” (TM6, 32, Christian, secondary, Lagos).

“No, they don’t allow visitors during consultation and even during the time of delivery” (T8, 36, Christian, tertiary, Ekiti).

The importance of being permitted to come with companions of choice is that the additional emotional support they provide can put expectant mothers at ease, and provide support and help with errands and related activities during antenatal visits, as well as during delivery. A good example of this is the participant who reported that she was able to bring a friend who she could talk to during her visit to the facility to while away time.

Client’s perception of facility

Participants generally reported satisfaction with the attitudes of the providers and their assistants, with several comparing their attitudes with the healthcare workers in hospitals. They highlighted factors like timely attention, and the friendliness and warmth of staff at the facilities as reasons for this satisfaction.

“I am incredibly satisfied with the quality of services they offer. The owner of this health facility goes above and beyond to care for us, treating us with the same level of dedication and attention as she would take care of her own children” (T3, 32, Christian, secondary, Ekiti).

“The place is okay and they attend to people quickly. They will not waste your time” (OM1, 24, Muslim, tertiary, Lagos).

“The benefit is that she is a life-saver, and patient compared to the hospital. She will patiently wait for you while in labour compared to the hospitals” (OM4, 33, Christian, tertiary, Lagos).

“They play with us and are very jovial. They don’t segregate anyone. They don’t segregate; they brought everyone together. Everyone is the same to them; they play with us” (TM4, 29, Christian, secondary, Lagos).

“I am satisfied with the approach at this facility. In comparison to hospitals, where nurses sometimes display a negative attitude towards expecting mothers, the staff here consistently treat us with kindness and compassion. Their approach is always filled with love and understanding” (T1, 26, Christian, tertiary, Ekiti).

Here, participants report the relaxed atmosphere at these facilities, in comparison to their experiences at modern health facilities, showing they appreciate the human touch to providing maternal healthcare that these alternative healthcare providers display. Participants had reports of care, compassion, patience and dedication from the service providers.

Complaints about hospitals

Study participants had some complaints about modern hospitals, with top of the list of complaints being the attitudes of health workers. A participant also expressed her dislike for medicines and injections as part of her reasons for disliking the hospitals.

“The prayers and experience at this center differ greatly from that at the hospital. While at the hospital, we often find ourselves neglected by the nurses, who may only attend to us after numerous complaints. However, at this center, our needs are addressed immediately. I usually receive prompt attention here” (E5, 31, Christian, tertiary, Ekiti).

“One of the things I don’t like about these hospitals is their injections, shouting, all their tablets, naturally, I am not a tablet person. If you give me, I will just keep it in my house, the day you will come, I will just give it back to you” (OM7, 43, Christian, postgraduate, Lagos).

“In comparison to hospitals, where nurses sometimes display a negative attitude towards expecting mothers, the staff here consistently treat us with kindness and compassion” (T1, 26, Christian, tertiary, Ekiti).

“Hmm, though in my first pregnancy I registered in hospital, I went there twice and I didn’t like their services. I didn’t register there I just said I should just go and check what they are doing so I didn’t like that place there. Coming here with the way they attended to me, I felt at home” (TM10, 41, Christian, secondary, Lagos).

Similar to the previous section, some participants expressed their grievances with the overly clinical approach taken to service delivery in hospitals. For the faith-based birth attendants, there was appreciation for the spiritual side to their service delivery, with participants reporting that the prayer sessions provided a sort of assurance to them.

Cost of services in facility

Participants generally reported that the services of the alternative healthcare providers were affordable. Though they were required to pay out of pocket for these services as these providers are usually not registered on either public or private health insurance schemes, they were able to afford the services. From the costs quoted by participants, these charges are reasonable and can be afforded by even low-income earners.

“The registration card is three thousand naira (about £2), delivery payment depends on the situation surrounding the delivery” (E4, 29, Christian, secondary, Ekiti).

“We don’t pay for everything but whenever they want to give us drugs, we pay 700 naira (about 40p), 5000 naira (about £3) for registration and 30,000 naira (about £20) for delivery” (OM1, 24, Muslim, tertiary, Lagos).

“On Mondays, we pay 500 naira (about 25p) with the concoction (aseje). Then there are some treatments that they give, herbs in powder form, they charge it together and will be deducting little by little as they give you the medication….for delivery it depends but it is not too much. You know things change year by year and different amount for each year. Like now, they are charging 20,000 naira” (about £15) (OM6, 46, Christian, secondary, Lagos).

“We pay 500 naira (about 25p) every week” (TM2, 29, Christian, tertiary, Lagos).

“They collected 4000 naira (about £2.50) for herbs, and 5000 naira (about £3) for delivery deposit” (T10, 25, Christian, secondary, Ekiti).

“I paid, but their charges are so affordable. When I gave birth to my first child, I paid 15,000 naira (about £9)” (T3, 32, Christian, secondary, Ekiti).

The general reports of affordability of services may likely serve as an attraction for clients of these facilities, given the prevailing economic conditions of the country. However, public healthcare is subsidized by the governments in both Lagos and Ekiti States, so women’s choice of the alternative healthcare providers despite similar costs in the health facilities may show that affordability is most likely not the major attraction for use of TBAs and FBBAs.

Facility waiting time

Participants reported that the waiting times at the facilities is short, and that providers don’t waste their time. One of the providers also concurred with the participants, saying that her facility tries to ensure that the clients are promptly attended to so they can go back home and rest.

“No, I do not have to wait long. They attend to us as early as possible” (E3, 29, Christian, tertiary, Ekiti).

“I don’t stay long except I want to gist and play with them and also disturb them. They don’t delay us. When there are lots of people, they already have a way of dealing with the situation; they will be attending to us as we come…. no wasting of time. It is only if the person they are attending to is lodging complaints. And if you have an emergency, they will leave that person to quickly attend to you” (OM10, 42, Christian, tertiary, Lagos).

“They attend to us on time” (TM8, 45, Christian, secondary, Lagos).

“We don’t stay long at all. The maximum time we spend here is two hours” (T7, 38, Christian, tertiary, Ekiti).

A short waiting time is more desirable for pregnant women, and may contribute to the clients’ overall perception that the service delivery is better than what obtains in modern health facilities.

How client heard about service provider

Most participants reported being referred to the provider by someone close to them, such as a family member, neighbour or church member, and a good number reported being referred by a former client of the facility. This highlights the importance of word-of-mouth advertising, and the role of satisfied former clients in bringing clients to the providers.

“My elder sister who gave birth to all of her five children recommended this place to me” (E8, 36, Christian, tertiary, Ekiti).

“My friend introduced this place to me. I explained my predicament to my friend (how I had been losing my babies) and she directed me to this place” (OM10, 42, Christian, tertiary, Lagos).

“My husband located this place for me. I lost the baby from my 1 st pregnancy so someone called my husband that there is one Yoruba woman that takes care of pregnancy very well caring for both the lives of the mother and the baby…..I delivered my 3 babies here” (OM5, 38, Christian, tertiary, Lagos).

“My relative was once here and she told me about the place” (TM7, 44, Christian, junior secondary, Lagos).

“I was referred to this place by my neighbor, who had previously given birth to her child here” (T3, 32, Christian, secondary, Ekiti).

“I heard about this place through my Mum” (T5, 27, Christian, secondary, Ekiti).

Participants reported being referred to the alternative healthcare providers by people who had either previously used the facility or otherwise had knowledge about the facility. Interestingly, two participants reported that they were referred after losing their babies from previous pregnancies, and had become repeat clients of these facilities.

Factors that influenced client to use the facility

Participants gave various reasons for their preference for alternative healthcare providers. Some women gave their motivation for use as the prayers they undertake at the faith-based maternity facilities. Others mentioned the type of care received and the fact that the providers are usually gentle and not harsh with them. Some stated their preference for herbal medicine over orthodox, and one participant said she prefers the alternative providers because they don’t present Caesarean sections as an option. Another participant said she prefers the alternative providers as she does not want to be attended to or delivered of her baby by a male doctor.

“The prayers and experience at this center differ greatly from that at the hospital. While at the hospital, we often find ourselves neglected by the nurses, who may only attend to us after numerous complaints. However, at this center, our needs are promptly addressed immediately. Moreover, I consistently receive timely attention here as well” (E5, 31, Christian, tertiary, Ekiti).

“At this midwifery center, unlike the government hospital where cesarean sections are routinely performed, they do not always suggest that option since women here typically give birth naturally and conveniently. Additionally, this midwifery center also offers prayer services as part of their services” (E10, 28, Christian, secondary).

“A lot of things motivated me ma. When I got here, I thought things will be the same as usual but as I started using this place, I saw great changes, they listen to my complaints and attend to me very well. They answer me whenever I call them” (OM10, 42, Christian, tertiary, Lagos).

“I prefer traditional, number 1, you will not have any complications in terms of breech baby, CS, or shortage of blood. Then, normally, there is always treatment for malaria. That is the main issue in pregnancy. That is why I prefer using TBA. With what I got there, most especially General hospital, before you can be attended to there, you can even collapse. Before you can collect the card, you will walk from one reception to pavement but here it is immediately. Even if you don’t have cash, they are always there to treat you immediately” (OM6, 46, Christian, secondary, Lagos).

“I have always liked herbal medicine from the beginning and they are combining it with modern medicine. I like it” (TM4, 29, Christian, secondary, Lagos).

“They attend to us well, they are not hostile. And even after delivery, they don’t charge much. Some hospital nurses will be asking for tips…but not here. But if you like, you can give them something based on the way they attend to you. I am very comfortable. All their activities are embedded in prayer. Before they start any work, they will pray and God is really working through them” (TM9, 27, Christian, secondary, Lagos).

“What I love here is the prayers but also most importantly the fact that it’s a woman that will perform the delivery for me, unlike in the hospital. I don’t like been delivered by a male doctor”(T5, 27, Christian, secondary, Ekiti).

“I have the opportunity to engage in personal consultations with mummy, the owner of this center, while in a hospital, such access is unavailable. In the hospital setting, patients are typically attended to collectively, whereas in this facility, we are seen on an individual basis, one after another” (E6 32, Christian, tertiary, Ekiti).

“One of the most significant advantages is the prayer support offered at this place. Unfortunately, I do not have access to that benefit at the hospital” (E9, 45, Christian, secondary, Ekiti).

“The benefit is that the alagbo (herbal medicine practitioner) will make some concoctions for you to eat and you will also have some herbal bath so that when you give birth, nothing will be wrong with the child such as jaundice, problem with the fontanelle. And they will take perfect care of the child” (TM5, 35, Muslim, secondary, Lagos).

The varied reasons for preferring alternative healthcare providers show that their services offer something that modern healthcare facilities do not, and that is mainly the human angle and the fact that the clients feel that the providers listen to their concerns and have their best interests at heart.

Place of delivery and previous use of TBA or FBBA

Some of the participants reported where they delivered their previous pregnancies. Most of the clients reported that they gave birth to their babies in previous pregnancies at either TBA or FBBA’s facilities, rather than in the hospital. This may likely mean that these facilities are their preferred places of delivery, rather than hospitals, if they have no complications during the delivery process.

“I was delivered of my baby here at the TBA” (OM6, 46, Christian, secondary, Lagos).

“I delivered my baby here not in the hospital where I was going… both my 1 st and 2nd child were given birth to here” (TM1, 45, Muslim, tertiary, Lagos).

“Yes, I deliver my babies here” (TM7, 43, Christian, postgraduate, Lagos).

“I gave birth to one of my babies in a place like this at Ifaki” (E1, 29, Christian, secondary, Ekiti).

“Yes, I delivered my first baby here too. And I am planning on having my second child here too” (E4, 29, Christian, secondary, Ekiti).

“I was making use of a place like this when I was in Ilorin…I used the Church (mission house) for my 1 st and 2nd babies” (OM7, 43, Christian, postgraduate, Lagos).

“I delivered all my children at the herbal medicine place. I have never been to the hospital before” (TM5, 35, Muslim, secondary, Lagos).

These responses show that the participants chose to use alternative healthcare providers for the entire pregnancy and delivery process, often only going to deliver their babies in a modern facility only when there were emergencies. This may show a high level of trust in the skill of the alternative healthcare providers by their clients.

If client has used the same facility previously

Some participants revealed that they were repeat clients at the facilities, with some having multiple previous deliveries at the same facility.

“I delivered my first baby here and plan to deliver my second baby here too” (E7, 25, Christian, secondary, Ekiti).

“I have been using this place for a very long time…..yes,you are surprised. I had issue with my 1 st pregnancy when I met her. I met her very late and since then I have been using here and she has being encouraging me not to give up” (OM3, 27, Christian, secondary, Lagos).

“I have been using here during the pregnancies and I delivered here twice too” (TM10, 41, Christian, secondary, Lagos).

“Yes, I gave birth to my first and second children here” (T6, 27, Christian, secondary, Ekiti).

Similar to their preference for TBAs and FBBAs over modern maternal healthcare facilities, these responses may show that participants possess a high level of confidence in these service providers, and believe that they will have the best pregnancy outcomes if they patronise them.

If client would refer provider to someone else

Participants generally reported satisfaction with the services and care they were given at the alternative healthcare providers, with a good number of clients reporting that they were willing to, or had already referred other women in their social network as clients to these providers.

“Very well. I have referred many people” (E1, 29, Christian, secondary, Ekiti).

“I have recommended it already for those that are yet to get pregnant, already pregnant and also to those that have given birth” (OM10, 42, Christian, tertiary, Lagos).

“I referred my younger brother’s wife to this place and she has given birth” (TM4, 29, Christian, secondary, Lagos).

“I tell people that I make hair for to come here and they told me that they are really trying here. I have brought countless of people here” (TM8, 45, Christian, secondary, Lagos).

“Yes, I have even brought like four persons and they delivered successfully” (T4, 30, Muslim, secondary, Ekiti).

These responses show that satisfied clients are willing to advertise the services of these providers, and recruit future clients, which has contributed in no small measure to the continued patronage of these providers by both returning and new clients.