Exploring predictors of ARV adherence among HIV positive women in North America

1. Exploring predictors of ARV adherence among HIV positive women in North America Lynda Tyer-Viola PhD RN, Kathleen Sullivan PhD RN,  Paula Reid PhD RN , Inge Corless PhD RN FAAN , Patrice Nicholas PhD RN FAAN, and A. J. Guarino PhD HIV INTERNATIONAL HIV/AIDS NURSING RESEARCH NETWORK

2. HIV Nursing Research Network • A network of nurses actively researching international topics concerning persons living with HIV/AIDS • The Network’s Theoretical Foundation posits that HIV/AIDS remains a significant world wide threat to public health • The Network’s Research Agenda will positively influence quality of care and patient outcomes across the spectrum of HIV disease. • Funding is external and internal (and mostly personal) (see Holzemer, 2007)

3. International collaborative Network Studies • Study I: Predictors of Adherence in HIV/AIDS US sites: Birmingham, AB; Boston, MA Highland, NY; Honolulu, HI; Oakland, Sacramento, San Francisco, California; Seattle, WA; Tampa, FL International sites: London, England; Oslo, Norway; Sao Paulo, Brazil • Study II: Symptom Management for Persons with HIV Disease US sites: Boston, MA; New York, NY; Palo Alto, San Fancisico, CA; Patterson, NJ; International sites: Oslo, Norway • Study III: Self-care Symptom Management in HIV/AIDS. US sites: Boston, Fall River, MA; Columbus, OH; Fresno, San Francisco, CA; Harlingen, Temple, TX; New York, NY; Patterson, NJ Richmond, VA; San Juan, PR; Wilmington, NC. International sites: Bogota, Colombia; Oslo, Norway; Taipei, Taiwan • Study IV: The Efficacy of the HIV/AIDS Symptom Management Manual US sites: Boston, MA; Chicago, IL; Corpus Christi, Harlingen, Houston, TX; Philadelphia, PA; Salt Lake City, UT; San Diego, San Francisco, CA; San Juan, Vega Baja, PR International sites: Nairobi, Kenya; Gauteng, South Africa; Mbabane, Swaziland • Study V: Study V: Exploring the Role of Self-compassion, Self-efficacy and Self esteem for HIV-positive Individuals Managing Their Disease. US sites: Boston, MA; Chicago, ILs; Corpus Christi, Harlingen, Austin, TX; San Francisco, CA; Cleveland, OH, Durham, NC, Honolulu, HI, Newark, NJ, New York, NY & San Juan, PR, International sites: Namibia, China & Bangkok.

4. Background • Comprehensive review of the adherence literature to HAART concluded women to be less adherent than men (Puskas et al, 2011). • Social support and perceived satisfaction with one’s social relationships, influences PLWH medication adherence. The influence of support and satisfaction with one’s healthcare provider in relation to self, is currently unknown. (Johnson et al, 2006). • Although the relationship between self-efficacy and HIV medication adherence is well documented, the connection between self and adherence has not been investigated (Johnson et al, 2007). • In a meta-analysis of predictors of adherence in women, depression was common however, the concepts of self-esteem, self-compassion and sense of coherence and the role they may play on HIV management has not been so well studied (Voils et al, 2007).

5. Focus on Self Sense of Coherence • An attribute that depicts an individual’s capacity to respond to stressors and “a reflection of an individual’s overall well-being and ability to cope with stress” (Pham, Vinck, Kinkodi and Weinstein , 2010). Self Efficacy • Individual’s actions are based on social behaviors and cognitive processes. Self efficacy is based on external influences and self perceptions. • Adherence self-efficacy is confidence in one’s ability to comply with a treatment plan, has been consistently linked to adherence over time. 

6. Self Compassion • Extending feelings of kindness to oneself (Neff & Vonk, 2009). People are often harder on themselves than on others for fear of becoming self indulgent. • Self criticism can result in negative feelings and can be a poor motivational force Self Esteem • Evaluation of oneself in relation to others. • Can be viewed in comparison to self compassion as having the same benefit of positivity towards oneself.

7. Study Aim & Research Questions • To identify what contextual, environmental and regulatory factors affect adherence to ARV medication in women residing in North America. • Research Question • Is there a relationship between contextual, environmental and regulatory factors and the outcome of medication adherence? • Of these correlates, what factors predict medication adherence?

8. Theoretical Framework Patient Characteristics Depression Health care Provider Engagement Stigma Adherence Self-efficacy Self-compassion Self-esteem Sense of coherence Medication adherence Outcomes Environmental/ Contextual factors Regulatory factors Moderator/Target of interest: gender Variables of interest of Social Action Theory (Ewart, 1991)

9. Methods • Data for this cross-sectional study was obtained from the International Nursing Network for HIV/AIDS Research, Study V: Exploring the Role of Self-compassion, Self-efficacy and Self esteem for HIV-positive Individuals Managing Their Disease • A subset of 338 women currently on ART were studied from the full data file of 2182 patients comprising 16 sites from five countries and Puerto Rico. • After consent, participants self-completed a study packet • Remuneration varied from site to site depending on funding. • US gift cards ranging from $15 to $25 for each participant

10. Study Variables Contextual / Environmental • Demographics: age, education, race, children, income • Center for Epidemiology Studies Depression Scale (CES-D) The CES-D 20-item scale. non-diagnostic screening tool that measures the current level of depressive symptoms in community populations (Radloff, 1977) Cronbach’s alpha overall = 0.91 • Perceived Stigma Scale. 40-item scale. measures the stigma perceived by people with HIV, using Goffman’s definition of stigma. (Berger, Ferrans, & Lashley, 2001) Cronbach’s alpha overall = 0.94

11. Regulatory • Sense of Coherence Scale (SOC) 13-item instrument consisting of four meaningfulness, five comprehensibility, and four manageability items to measure sense of coherence (Antonovsky, 1993; Konttinen, Haukkala, & Uutela, 2008). Cronbach’s alpha overall = 0.60 • Self-Compassion Scale (SCS) 12-item scale participants rate how they deal with difficult situations on a 5 point Likert scale (Neff, 2003). Cronbach’s alpha overall = 0.72 • Rosenberg Self-Esteem Scale (SE) 10-item scale. overall feelings of self-worth or self-acceptance. Cronbach’s alpha overall = 0.72 • HIV- Adherence Self-Efficacy (ASE) 12- item scale . patient confidence to carry out health-related behaviors (asking physician questions, keeping appointments, adhering to medication) (Johnson et al, 2006). • Engagement with Health Care Provider (HCPE) 13-item scale. Participants rate the nature of their interactions with their main health care provider on a four-point scale with 1=always true and 4=never. Cronbach’s alpha overall = 0.96

12. Outcome Variables • 3-Day and 30-Day Visual Analog Scale. Participants are asked to mark how often they took their medications in the past 3 days (30 days), on a scale of 0% of the time to 100% of the time. Target of Interest • Gender (n = 338) women currently on ART medications.

13. Sample Demographics • Of the 450 women who participated in the study from North America, 338 stated they were taking medications now. • Most participants had a High School education (39%) or less (37%). • Mean age 45 (sd=9.1) • 50% were African American • 82% had children • 59% said their income was barely adequate • 66% screened positive for depression symptoms (CESD > 16)

14. Results Is there a relationship between contextual, environmental and regulatory factors and the outcome of medication adherence? • The following variables were significantly related to 3 and 30 day adherence (p = .01) • Contextual/Environment Factors • Age • Fewer symptoms of depression(CESD) • Regulatory Factors • Self Compassion (SCS) • Self Esteem (SE) • Adherence Self Efficacy (ASE) • Sense of Coherence (SOC)

16. Results What Contextual, Environmental and/or Regulatory factors predict medication adherence? • The Contextual factors were represented by age, having children, income, and ETHNICITY. Only age was significantly correlated with 3 (r = .14) and 30 day (r = .13) adherence yet it was not significant in simultaneous regression analyses (p< .05). • The Environmental factors were represented by stigma and depression (CESD), and health care provider engagement (HCPE). The variables were all correlated (p < .05). The dependent variables of 3 day and 30 day adherence were regressed on all four independent variables. The models accounted for 5 and 7% of the variance respectively in adherence and the F values were significant (F = 5.300, p < .000, F= 6.155, p <.000). Examination of the standardized coefficients revealed that CESD was the only significant predictor (p = .000) with squared partial correlation of 3.2% for both results. A lower screening score for depression predicts self reported adherence. • The Regulatory factors were represented by sense of coherence, self compassion, self esteem and adherence self efficacy and chronic disease self efficacy. The variables were all correlated (p <.05). The dependent variables of 3 day and 30 day adherence were regressed on all five variables. The models accounted for 19 and 22% of the variance respectively for adherence and the F values were significant (F = 14.685, p < .000, F = 17.89, p < .000). Examination of the squared partial coefficients revealed that adherence self efficacy was the only significant predictor (p = .000) with squared partial correlations of 9.6 and 9.9% respectively. A higher score of adherence self efficacy predicts self reported adherence.

17. Results cont. • Taking into account the results of the three separate regressions only adherence self efficacy and screening for depression were predictive of adherence. • The model for 3 day adherence accounted for 19% of the variance, F(6, 332) = 37.08, p < .001). Examination of squared part-coefficient revealed that 14% of 3 day adherence is uniquely explained by Adherence Self Efficacy and 1% by fewer symptoms of depression • The model for 30 day adherence accounted for 22% of the variance, F(6, 332) = 45.16, p < .001). Examination of squared part-coefficient revealed that 15% of 30 day adherence is uniquely explained by adherence self efficacy and 2% by fewer symptoms of depression

18. Discussion • Regulatory factors have a medium to strong correlation with medication adherence (p < .01). • Health care provider engagement and stigma were not related to adherence. • In the overall sample, HCPE was significant (Corless et al, 2012). • Self esteem and self compassion are often highly correlated (r = -.693) and are related to life satisfaction, a meaningful life, happiness, optimism, and positive affect (Neff et al, 2007a, 2007b). • The difference is that self compassion is relevant when self esteem tends to falter- when one fails or feels inadequate (Neff, 2009, p. 567). This variable needs to be evaluated further.

19. Discussion cont. • Although regulatory factors were highly correlated, Adherence self efficacy and fewer symptoms of depression were the only predictors of adherence at 3 and 30 days. • Research continues to show that depression affects adherence and should be addressed in relation to self efficacy throughout treatment. • Adherence self efficacy addresses behaviors that affect care and could be a target of interventions beyond the provider relationship

20. Limitations • Variation in enrollment of women between sites • Self selection of participants • Overall, non-random recruitment may introduce bias • Self report of adherence was measured with an estimate of what percentage of time medications were taken and was heavily weighted to the positive. • There was no validated measure biological marker of adherence.

21. Conclusions • Regulatory factors are highly correlated. Although described as separate, self esteem and self compassion are intrinsically linked with this population. • Depression in women continues to play a role in medication adherence and screening should be on going. • Adherence self efficacy and its constructs should be a focal point of adherence interventions such as what helps with treatment integration into every day life and ‘sticking to’ a treatment plan with deviations. • Future research is warranted related to concepts of self as regulatory factors.

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