Transcript Adherence Self

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
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)
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.
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).
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.
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.
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?
Theoretical Framework
Patient Characteristics
Depression
Health care Provider
Engagement
Stigma
Environmental/
Contextual factors
Adherence Selfefficacy
Self-compassion
Self-esteem
Sense of
coherence
Medication
adherence
Outcomes
Regulatory
factors
Moderator/Target of interest: gender
Variables of interest of Social Action Theory (Ewart, 1991)
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
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
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
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.
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)
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)
Correlations among study variables and adherence.
Variable
2
3
7
8
9
11
12
13
1
.699**
-.102
-.230**
.245**
-.239**
.421**
.174**
-.107
.053
-.001
-.023
.128*
.060
2. adher30d
.699**
1
-.102
-.254**
.254**
-.278**
.450**
.257**
-.094
.044
.063
-.095
.121*
.082
3. HCPE
-.102
-.102
1
.089
-.098
.113*
-.157**
-.180**
.110*
-.079
-.057
-.090
-.099
-.017
4. CESD
-.230**
-.254**
.089
1
-.643**
.612**
-.273**
-.639**
.386**
-.093
-.183**
.010
-.100
-.030
.245**
.254**
-.098
-.643**
1
-.693**
.365**
.603**
-.293**
.086
.132*
-.072
.164**
.048
-.239**
-.278**
.113*
.612**
-.693**
1
-.388**
-.589**
.336**
-.123*
-.153**
.028
-.152**
.045
7. ASE
.421**
.450**
-.157**
-.273**
.365**
-.388**
1
.332**
-.165**
.059
.167**
-.025
.054
.045
8. SOC
.174**
.257**
-.180**
-.639**
.603**
-.589**
.332**
1
-.346**
.097
.171**
.039
.064
-.017
9. STIGMA
-.107
-.094
.110*
.386**
-.293**
.336**
-.165**
-.346**
1
.042
-.170**
.017
-.096
-.120*
.053
.044
-.079
-.093
.086
-.123*
.059
.097
.042
1
-.139*
-.039
.133*
.061
11.INCOME
-.001
.063
-.057
-.183**
.132*
-.153**
.167**
.171**
-.170**
-.139*
1
-.004
.041
-.053
12.CHILDREN
-.023
-.095
-.090
.010
-.072
.028
-.025
.039
.017
-.039
-.004
1
.050
-.167**
13.AGE
.128*
.121*
-.099
-.100
.164**
-.152**
.054
.064
-.096
.133*
.041
.050
1
-.009
14.ETHNICITY
.060
.082
-.017
-.030
.048
.045
.045
-.017
-.120*
.061
-.053
-.167**
-.009
1
1. adher3d
5. SCS
6. SE
10. EDU
1
4
5
6
10
**. Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed)
14
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.
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
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.
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
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.
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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