A structural equation modeling approach to the concepts of adherence and readiness in antiretroviral treatment

Use of path modeling to inform a clinical decision support application to encourage osteoporosis medication use

BACKGROUND

Osteoporosis medication use is suboptimal. Simple interventions personalized to a patients' stage of readiness are needed to encourage osteoporosis medication use.

OBJECTIVES

To estimate interrelationships of sociodemographic factors, perceived fracture risk, health literacy, receipt of medication information, medication trust and readiness to use osteoporosis medication; and apply observed relationships to inform design specifications for a clinical decision support application that can be used for personalized patient counseling.

METHODS

Data from a national sample of older women (n = 1759) with self-reported history of fractures and no current use of osteoporosis medication treatment were used to estimate an acceptable path model that describes associations among key sociodemographic characteristics, health literacy, perceived fracture risk, receipt of osteoporosis medication information within the past year, trust in osteoporosis medications, and readiness to use osteoporosis medication. Path model results were used to inform an application for personalized patient counseling that can be easily integrated into clinical decision support systems.

RESULTS

Increased age (β = 0.13), trust for medications (β = 0.12), higher perceived fracture risk (β = 0.21), and having received medication information within the past year (β = 0.21) were all positively associated with readiness to use osteoporosis medication (p < 0.0001). Whereas, health literacy (β = -0.09) was inversely associated with readiness to use osteoporosis medication (p < 0.0001). Using these results, a brief 6-item question set was constructed for simple integration into clinical decision support applications. Patient responses were used to inform a provider dashboard that integrates a patient's stage of readiness for osteoporosis medication use, predictors of readiness, and personalized counseling points appropriate to their stage of readiness.

CONCLUSION

Content of counseling strategies must be aligned with a patient's stage of readiness to use treatment. Path modeling can be effectively used to identify factors for inclusion in an evidenced-based clinical decision support application designed to assist providers with personalized patient counseling and osteoporosis medication use decisions.

Understanding the factors associated with initiation and adherence of osteoporosis medication in Japan: An analysis of patient perceptions

OBJECTIVES

This study aimed to identify factors associated with initiation and adherence of osteoporosis medication from a patient perspective.

METHODS

A web-based survey was developed based on health behavior theories. Descriptive analyses were conducted for all survey items. Analyses in a structural equation modeling framework were conducted to identify factors associated with treatment initiation and adherence.

RESULTS

Five hundred forty-five women completed the questionnaire. A majority were currently receiving medications for osteoporosis (n = 376, 69.0%) and 25.0% of these patients (n = 94) were considered adherent to their treatment. Knowledge was strongly associated with osteoporosis treatment initiation (standard error [SE], 0.58). Greater knowledge of disease was associated with increased likelihood of initiating medication. Medication complexity (SE, 0.49) and perceived susceptibility to fracture and loss of independence (SE, -0.37) were also associated with initiation. Perceived barriers (SE, -0.85) such as inconvenience, lack of efficacy and financial burden were observed to be the greatest obstacle to adherence. The greater the perceived barriers, the less likely patients were to adhere to medication. Patients' perception of self-efficacy (SE, 0.37) also affected adherence. The greater the patient perception of ability to independently manage their medication, the more likely they were to adhere to the medication.

CONCLUSIONS

Different factors were found to be associated with initiation and adherence of osteoporosis medication. Patient knowledge of their disease and the perception of barriers were found to be the most influential. Empowering patients with the knowledge to better understand their disease and decreasing the perception of barriers through education initiatives may be effective in improving patient outcomes.

Factors informing HIV providers' decisions to start antiretroviral therapy for young people living with behaviorally acquired HIV

PURPOSE

Young people with behaviorally acquired HIV (BHIV) are less likely than adults to initiate antiretroviral therapy (ART) despite meeting treatment criteria. We explored critical factors involved in healthcare providers' decision making regarding ART initiation for young people with BHIV (aged 12-24 years).

METHODS

Semistructured interviews were conducted with 23 HIV providers from diverse training backgrounds caring for youth with BHIV at four adult clinics and one pediatric clinic in a high prevalence urban city. Interview domains probed clinical and nonclinical patient characteristics, the role of adherence, and provider attitudes working with youth to establish decision-making priorities for ART initiation. The constant comparative approach was used to develop grounded theory on providers' decision making on ART initiation.

RESULTS

Clinical criteria, particularly the CD4 count, and the public health implications of HIV transmission determined the urgency for ART initiation. However, patient-related concerns regarding treatment readiness and adherence hampered the decision to initiate, especially at higher CD4 counts. Providers who acknowledged developmental characteristics of youth (e.g., evolving adult identity and self-efficacy around health management) appeared more cautious in assessing future ART adherence and responded with intensive clinical support. Extensive involvement of multidisciplinary teams was identified as an important strategy to retain youth in care, whereas strengthening youth-targeted approaches may be an unmet need in adult clinics.

CONCLUSION

Evaluation of providers' awareness of the developmental features of youth and characteristics of youth-targeted approaches in clinics caring for youth with BHIV may inform interventions to increase youth engagement in care and subsequent decisions to successfully initiate ART.

HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts

A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Readiness in HIV Treatment Adherence: A Matter of Confidence. An Exploratory Study

Adherence to treatment is recognized as the essence of a successful HIV combination therapy. Optimal adherence implies a readiness to begin the treatment on the part of the patient. A better understanding of the "readiness phenomenon" will become an asset for optimizing HIV treatment. However, few studies have focused on understanding the process underlying the choice to adhere. The aim of this study is to understand the readiness process that leads to adhering to the HIV treatment, from both patient and professional perspectives. Twenty-seven in-depth interviews, with a qualitative exploratory design, were the source of our data. Participants were recruited in two hospitals in Paris. Throughout the data-collection process, analysed data were supplied to all participants and the research team, thus allowing for shared constructions. Four themes, interrelated with a constitutive pattern, emerged from the data we collected. Being ready to begin and adhere to treatment is a matter of confidence in oneself, as well as in relatives, in the treatment and in the health professional team. These themes are not constant and unvarying; instead, they constitute a picture moving across time and life events. Results of this study show that adherence that goes beyond "complying with" the medical instructions, but depends on how much of an active role the patient plays in the choice to adhere.

The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya

OBJECTIVE

The objective of this study was to explore the influence of traditional medicine and religion on discontinuation of antiretroviral therapy (ART) in one of Africa's largest informal urban settlement, Kibera, in Nairobi, Kenya.

METHODS

Semi-structured face-to-face interviews were conducted with 20 patients discontinuing the African Medical and Research Foundation (AMREF) ART program in Kibera due to issues related to traditional medicine and religion.

RESULTS

Traditional medicine and religion remain important in many people's lives after ART initiation, but these issues are rarely addressed in a positive way during ART counseling. Many patients found traditional medicine and their religious beliefs to be in conflict with clinic treatment advice. Patients described a decisional process, prior to the actual drop-out from the ART program that involved a trigger event, usually a specific religious event, or a meeting with someone using traditional medicine that influenced them to take the decision to stop ART.

CONCLUSION

Discontinuation of ART could be reduced if ART providers acknowledged and addressed the importance of religious issues and traditional medicine in the lives of patients, especially in similar resource-poor settings. Telling patients not to mix ART and traditional medicine appeared counter-productive in this setting. Introducing an open discussion around religious beliefs and the pros and cons of traditional medicine as part of standard counseling, may prevent drop-out from ART when side effects or opportunistic infections occur.

Development of an easy to use tool to assess HIV treatment readiness in adolescent clinical care settings

Optimal management of HIV disease requires high levels of lifelong adherence once a patient initiates highly active antiretroviral therapy (HAART). Because suboptimal adherence to HAART is associated with adverse consequences, many providers are hesitant to prescribe HAART for patients whom they perceive as not being ready to initiate treatment. Accurately predicting HIV treatment readiness is challenging. Despite the importance of this construct, few reliable and valid instruments to assess HIV treatment readiness have been developed; none of these have been validated with adolescents and young adults, who comprise an increasing proportion of new HIV cases diagnosed. As a first step to achieve this goal, we developed the HIV Treatment-Readiness Measure (HTRM) for administration by way of audio computer-assisted self-interview (ACASI) and conducted a study to examine its internal consistency, test-retest reliability, acceptability, and preliminary factor structure. We recruited 201 adolescents and young adults living with HIV from 15 adolescent medicine clinics that were part of the Adolescent Trials Network for HIV Interventions. Youth completed the initial assessment and two weeks later the retest assessment. The refined HTRM had high internal consistency (α = 0.84). Test-retest reliability using both sum scores and mean scores were high. The HTRM was also highly acceptable and feasible to use in routine clinical practice. In exploratory factor analysis we found that a five-factor solution was the best fit; each of the subscales (Disclosure, Psychosocial Issues, Connection with Care, HIV Medication Beliefs, and Alcohol and Drugs) had good to acceptable alphas and eigenvalues greater than 2.0. Our findings support conducting a future study to examine the tool's predictive validity.

Readiness: the state of the science (or the lack thereof)

HIV treatment guidelines state that patients' readiness should be assessed before initiating highly active antiretroviral therapy (HAART) to assure adherence. None of the guidelines provide a way to measure readiness. Therefore, this article sought to review the literature on readiness to determine if there was a viable predictor of adherence. Twenty-seven articles were reviewed. Nine described studies that examined the relationship between a measure of readiness and HAART adherence. No readiness measure demonstrated clinical utility as a predictor of adherence. Study flaws included small sample sizes (only one study >100 patients), short follow-up periods (all ≤1 year and six were ≤5 months, four ≤1 month), measures of readiness that related poorly to adherence, and inconsistent adherence measures (eight different measures were used by the researchers). Neither the guidelines nor the literature will help clinicians judge who should initiate HAART and who should delay treatment.