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© 2010 Baylor College of Medicine
Determinants of Adherence to HIV Medication in Adolescents Living in
Constanta, Romania A Qualitative Application of the
Information-Motivation-Behavioral (IMB) skills model
Ana-Maria Schweitzer, Baylor Black Sea Foundation, Constanta, Romania
Alexandra Dima, School of Health in Social Science, University of Edinburgh, UK
K. Rivet Amico, Center for Health, Intervention and Prevention, University of Connecticut, USA
Background Information Nosocomial infection in the late
1980’s (> 1200 patients in the initial group,
> 700 still alive) HIV-infected adolescents receiving
antiretroviral (ARV) medication since childhood (>450 on ARV for >1 year)
Baylor Black Sea Foundation – multidisciplinary care within the HIV centre of excellence
© 2010 Baylor College of Medicine
Adolescence – The Problem of Adherence
Up to 60% - at least once in their life time have or will have issues with adherence to ARV
>90% of all detectable viral load cases are known to have issues with adherence
Adolescents change from having adherence largely managed by a care-giver to self-management
© 2010 Baylor College of Medicine
© 2010 Baylor College of Medicine
The IMBS Model
(Fisher et al, 2006)
Adherence information
Adherence motivation
Adherence behavioral skills
Adherence behaviour
Health outcomes
Moderators: mental health, living conditions, healthcare, etc.
© 2010 Baylor College of Medicine
IMB Cross-Culturally
Qualitative work necessary to apply the model in this new socio-cultural context
4 key questions: Are the model’s concepts relevant in the new setting? Comprehensiveness – are the concepts important in the
new setting? Accurateness – are the meanings of the concepts
accurate in the new setting? Does the model capture the complexity of adherence in
the new setting?
(Ware et al, 2006)
The Focus Groups2 groups - 20 adolescents, 1
group - 9 health professionals
Convenience sampling – from HIV patients and service providers
Written invitation – purpose (discussion group on adherence to medication), location, time, confidentiality
© 2010 Baylor College of Medicine
© 2010 Baylor College of Medicine
The Focus Groups
Semi-structured format (support group) Intro – meeting purpose and warm-up exercises Information
What questions did you have about the treatment and how did you look for answers?
What do you know well/ less well about treatment? Motivation
What motivates you/makes you feel less motivated to take your pills?
Contexts / Behavioural skills Situations when it is easy/difficult for you to take the pills –
solutions End – feed-back regarding services What advice would you give to a newly diagnosed
person?(similar format adapted for health professionals reporting on patient
behavior)
© 2010 Baylor College of Medicine
Results – Emerging Themes
Information / Misinformation How the medications are supposed to be taken Side effects If I feel ok, it’s ok to skip medications Skipping medications does not affect health
If I cannot take one of the pills, it is ok to take only the others
If I take the strongest pill, I can skip the others I can interrupt pill-taking if my blood tests are fine It is important to take pills every day, irrespective
of the hour
© 2010 Baylor College of Medicine
Results – Emerging Themes
Motivation (barriers / facilitators) Fear of being seen by other people Frustration about “having a limited freedom” Good relationship with healthcare provider Social support
Future plans for family, profession Hope that a cure will be found sooner or later Fear of being sick and hospitalized Discouraged by death of friends under treatment
© 2010 Baylor College of Medicine
Results – Emerging Themes Behavioural skills to …
Search for information Obtain support from others Manage adherence with busy schedule Manage adherence in context of emotional problems
Take pills in privacy Adhere when the support from care-giver is
temporarily missing/ no longer available Maintain adherence while dealing with interpersonal
conflict Manage adherence to multiple treatments
© 2010 Baylor College of Medicine
Conclusions How did the model do given Ware et al.'s
(2006) key questions? Relevance – the model’s 3 core concepts were not
directly tested, but used as a basis for the focus group guideResults suggest that Information, Motivation, and Behavioural Skills are relevant for our population
Comprehensiveness – no new concepts emerged (e.g. compared to African settings)
Accurateness – new themes within the 3 core concepts emerged (e.g. specific to long term treatment experience, adolescence, relationships)
Complexity – the variety of outputs extracted from raw data allow us to approach adherence flexibly in clinical practice
Limitations: convenience sampling, social desirability
Cognitive-behavioral Determinants Of Adherence Among Hiv-positive Adolescents In Romania
This study is supported by a grant from BIPAI and the Abbott Fund and developed by the Baylor Black Sea Foundation at the Centrul Clinic de Excelenta - Spitalul Clinic de Boli Infectioase Contanta - Baylor College of Medicine - Texas Children’s Hospital – Abbott Fund
Team of investigators : R.B.Wanless1, A.L.Dima2, A.-M. Schweitzer3, L.Vlahopol3 , E.A. Caraveteanu3 ,
I. Stochita3 , R.Diaconita3, R.K Amico4 , E.Remor5 , S.Ruta6 , S.Rugina 7
1 Baylor International Pediatric AIDS Initiative, Houston, 2University of Edinburgh, Clinical and Health Psychology, Edinburgh, UK 3Baylor Black Sea Foundation Romania, Constanta, Romania, 4University of Connecticut, Connecticut, United States, 5 Facultad de Psicología, Universidad Autónoma de Madrid, 6 Institutul de Virusologie Stefan Nicolau, Romania, 7 Spitalul Clinic de Boli Infectioase, Romania
© 2010 Baylor College of Medicine
© 2010 Baylor College of Medicine
Thank You! Questions? Contact details: office@baylor-romania.ro
References:
Fisher, J.D., Fisher, W.A., Amico, R., & Harman, J.J. (2006). An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health Psychology, 25(4), 462-473
Ware, N. C., Wyatt, M.A. & Bangsberg, D. (2006). Examining Theoretical Models of Adherence for Validity in Resource-limited Settings: A Heuristic Approach.” Journal of Acquired Immune Deficiency Syndromes. 43(S1):S18-S22