FACULTY:Susan Gallego, LCSW Director of Client Services, San Francisco AIDS Foundation (San Francisco, CA)Brian Giddens, ACSW, LICSW Associate Director, Social Work, Univ. of Washington Medical Center (Seattle, WA)Susan Haikalis, ACSW, LCSW Executive Director, Community Health Resource Center (San Francisco, CA)
bio (biology)refers to thephysical andmedicalaspects ofourselves
psycho(psychology)refers to theemotionalaspects of ourlives
social refers tosocio-cultural,socio-political,and socio-economic issues
spiritual refersto the waypeople findmeaning in theirlives
BIO/PSYCHO/SOCIAL/SPIRITUAL
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n There are a variety of cultural experiences(gender, ethnicity, sexual orientation andage)
n Some aspects of culture and enduring(values and world views) while other aspectschange (idiomatic expressions, style ormode of dress)
n People identify with multiple culturalidentities
DIVERSITY IN PRACTICE
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Refers to the process by which individuals andsystems respond respectfully and effectively topeople of all cultures, languages, classes, races,ethnic backgrounds, religions, and otherdiversity factors in a manner that recognizes,affirms, and values the worth of individuals,families, and communities and protects andpreserves the dignity of each.
CULTURAL COMPETENCE
Cite: NASW Standards for Cultural Competence, 2001 6
Discuss with the client:n What are their primary cultural beliefs and values?
ß Individualism versus collectivism
ß What is their concept of time
ß How do they view or conceptualize disease?
ß What are the cultural beliefs about the cause andtreatment of disease
ß Is there a historical context of culture and healthcare(that may lead to mistrust)?
ß For example: Tuskegee syphilis study or bloodbanks’ refusal to accept blood from MSMs
WORKING WITH DIVERSE POPULATONSEXAMPLES OF CULTURALLY COMPETENT
PRACTICE
7
3%
2%
1%5%
6% 8% 8%
14%
14%
39%
Mental Health Health Child Welfare/FamilySchool Social Work Aging AdolescentsAddictions International OtherMultiple Answers
SOCIAL WORKPRIMARY PRACTICE AREAS
Cite: NASW (PRN1,3, 2000) 8
“THE ROLE OF SOCIAL WORK INHEALTHCARE PROVISION”
Social Worker
Physician
Nurse
Pharmacist
Other Providers
Assessment and
Treatment Planning
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n To be in a state of adherence; fidelity; steadyattachment
n To follow a prescribed course of action
ADHERENCE
10
n Reduces morbidity and mortality bysuppressing viral replication to as low aspossible for as long as possible. Improvesimmune system functioning and increasesCD4 levels
n Reduces the emergence of resistance andcross-resistance to medications
n Improves the quality of life for clients livingwith HIV/AIDS and other chronic illness
WHY IS ADHERENCE SO IMPORTANTFOR PERSONS LIVING WITH HIV/AIDS?
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UNDERSTANDING HIV/AIDSPROMOTES ADHERENCE
n The virus mutates rapidly and may becomeresistant to the drugs
n Successful adherence (95-99%) to beconsistent.
n Ensure use of 3 drug combination therapy ofHighly Active Antiviral Therapies (HAART)
n Work with health provider to monitor statusand change regiment if needed
Viral load is the best predictor of diseaseprogression. The goal is to maintainundetectable level of viral load (<50)
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n Continued drug/alcohol use after infection withHIV
n Substance use may significantly impact themedication schedule
n Persons actively using, as well as those inrecovery, are also faced with other challengesassociated with HIV/AIDS
SUBSTANCE USEAND ADHERENCE
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n Many providers believe substance abusetreatment must be initiated prior tobeginning HAART
n Clients in recovery may relapse
n Recovery is a life-long event
n Client capacity to remain clean and soberprovides opportunity to build on currentcoping mechanisms and daily routines
CLINICAL ISSUES
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n Many clients with HIV/AIDS experience mentalhealth concerns that affect their day-to-dayfunctioning
• Adjustment issues• Depression• Feeling anxious
n Other clients may be diagnosed with mentalhealth problems that emerge as a result ofstressors of a diagnosis of HIV/AIDS or otherlife events
• Mood and anxiety disorders• Adjustment disorders• Post traumatic stress
MENTAL HEALTH
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n A comprehensive assessment will take intoaccount presenting issues, longevity ofsymptoms, family and social history,substance use and psychiatric history
n Cultural perspectives of coping withchronic illness must be considered
Access/ResourcesAccess/Resources Social SupportSocial Support Adherence TechniquesAdherence Techniques
DETERMINANTS OFSUCCESSFUL ADHERENCE
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n Often primarily in caregiver roles rather thanonly patients/clients
n Women may share their medications, oftenwith children
n Women frequently have other priorities:
WOMEN AND ADHERENCE:WHAT DO WE NEED TO KNOW?
ÿ Care givingÿ Housingÿ Parenting
n Limited social support system of their ownn Best support is other HIV positive women’s
network
ÿ Foodÿ Income
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CASE OF TERESA
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You are a social worker staffing the “drop in” clinic at a tri-county community health clinic.You have just met Teresa for the first time, and she appears anxious and extremely gaunt.During the initial tells you that she has been living in the homeless shelter for two weeks, havingleft he home to get away from her abusive partner. She then explains the shelter staff told hershe needed to see a doctor in order to continue staying at the shelter. As you ask her more questions about her health history, she starts to get agitated and tells you,“I know I’m sick and that no-good boyfriend of mine probably gave me this.” She then tells you she is so stressed at times she gets chest pains. Teresa also discloses that she has AIDS, andused to see an “AIDS doctor” in another state who, “kept telling me I had to take all sorts of pills.” You notice that Teresa has what appears to be old “track marks” on her arms. When you ask Teresa about how she has managed to support herself, she shrugs and says, “whatever ittakes.” When you ask about other supports or family, you learn that her mother threw her out whenshe learned Teresa had AIDS, forcing Teresa to leave behind her (then) 3 year old daughter. Teresasays she is 26 years old and used to have in a childcare center. When you return to the interview room (after stepping out to see if the doctor is still available), Teresastartles awake, and apologizes and says she just gets so tired sometimes and it is happening more and more. Before she walks into the exam room she stares down at the floor and starts crying. She states, “I’m so sick and so overwhelmed.”
ASSESSAssess client knowledge and readiness.n Knowledge level of HIV/AIDS and related
drug therapies.
n Is information accessible and linguisticallyappropriate
n Culturally competent assessments
n Use the stages of change to help clientunderstand his/her readiness
ADHERE MODEL
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n What are your short and long term goals fortreatment?
n Tell me what you know about HIV/AIDS. Whatare your current medicines and medicationdoses (including non-HAART medicines)?
n What do you feel or believe about the servicesof your current HIV treatment?
n Tell me about how you have made decisions inthe past? Who helps you with these decisions?
n Where and who do you draw your personalstrengths from?
Cite: Despotes, J. , et. al (2003)
SAMPLE ADHERENCEASSESSMENT CHECK-LIST
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Begin or restart amedication schedule
Plan how theywill fit
medicationsinto their daily
schedule
Talking with theclient about living
with HIV/AIDS
STAGES OF CHANGE BEHAVIOR
Main
tenan
cePlanning
andPreparation
Contemplation
Pre-Contemplation
Action
Source: Prochaska & Di Climente (1986); NASW (2002)
Begin to considermedications
Addressbarriers to
takingmedications
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Dialogn Dialog with your client(s) about their health
belief and options.
n Clarify possible consequences of non-adherence
n Inform of costs and relative benefits
n Review the purpose of HAART and names ofeach medicine
n Review side effects and self-care strategies
ADHERE MODEL
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DIALOG WITH CLIENTS ABOUT THECHALLENGES AND BENEFITS OF
ADHERENCE
n Improved health andenergy
n Minimize episodes ofhealth problems andside effects
n Clinical results (CD4 ↑,viral load Ø)
n Possible reduced side-effects
n Achieve other personalgoals
n Increased side effectsof medications
n Pill burdenn Challenge to daily
routinen Disclosure issues
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HolisticA holistic approach includes culture
n Think environmental
nWork with clients to identify adherence“social support list”
n Share resources to help with all aspects ofadherence (e.g., mental health services, childcard, support groups, financial assistance)
ADHERE MODEL
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n My Eating Habits
n My Sleeping Patterns
n My Daily Commitments
n My Regular Exercise
n My Social Supports
n My Financial/LegalSituation
n My Housing Situation
FITTING TREATMENT INTOOUR LIFESTYLE: A WORKSHEET
(when and how many times a daydo you eat)
(when, how often and how long yousleep)
(include paid employment, childcare, volunteer work or school)
(walking, aerobics, dance or goingto the gym)
(include your friends, family partner,spiritual organization or supportgroup)
(include all related issues, such asincome, insurance, citizenship orprison)
(stable housing, safety orhomelessness)
Cite: AIDS Action Committee MA (2003) 28
Empowern Empower all clients to implement action plan
nWork with clients to identify cues, remindersand current activities (e.g. television or radioprograms or current daily self-care regiments)that will increase adherence success or helpprepare them for medications
n Strengths based focus
ADHERE MODEL
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nOutline daily schedule (meals, activities)nMatch treatment plan with habitsn Utilize timed reminders (watch, phone, friend,
TV, beepers, timers)n Use pill boxes, individualized pre-packagingnMake plan for weekends, holidays,
“exceptions”n Identify community resources that “fit” the
clients schedule; work with current resourcesto accommodate clients work schedule.n Promote client – centered contracting
Mental Health Mental Health & Substance & Substance
AbuseAbuseServicesServices
Strong Strong ProviderProvider
Capability Capability BuildingBuilding
Support Support SystemsSystems
Nutritional Nutritional CounselingCounseling
ADHEREADHERE
Client-CenteredClient-Centered
AIDS Action 2001 33
Thank you for yourparticipation.
Please remember tocomplete the evaluation
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Acuff, C. et at. (1999) Mental Health Care for People Living with or affected by HIV/AIDS: apractical guide. Research Triangle Institute: NC.
AIDS Action Committee of Massachusetts (2003) Talking with your Healthcare Provider[online] Retrieved from http://www.aac.org/site/PageServer?pagename=info_doctor
AIDS Action (2001) A Guide to CBO Adherence Programs Washington, DC: Author
Coping with Hope: HIV/AIDS Treatment Decisions/Adherence. (2001) [Multiple authors].Center for Mental Health Services (CMHS) Mental Health Care Provider Education inHIV/AIDS Programs. Rockville: MD
Corbin, J. and Strauss, A. (1988) Unending work and care: Managing Chronic Illness atHome. Jossey-Bass
Despotes, J., Noel, E., Novak, E., and Farrington, B., (2003) Adherence Counseling: A ClientCentered Approach. Midwest AIDS Training and Education Center. Chicago, IL.
HIV/AIDS, Mental Health, and Substance Use: An Integrated Response. (2002). [Multipleauthors]. HIV/AIDS Spectrum: Mental Health Training and Education of Social WorkersProject, National Association of Social Workers, Washington, DC.
Linsk, N., and Bonk, N., (2000) Adherence to Treatment of Social Work Challenges. InHIV/AIDS in the Year 2000: A Sourcebook for Social Workers. Lynch, V. (editor), Allyn andBacon. Needham Heights: MA.
NASW Standards for Cultural Competence in Social Work Practice. (2001) NationalAssociation of Social Workers. Washington, DC:author.
National Association of Social Workers (2003). Practice research network survey project 2:Final report. Washington, DC: Author.
Paterson, D. (1989) In Abstracts of the 6th conference of retroviruses and opportunisticinfections. Chicago, IL. January 31-February 4, 1989. Abstract No. 92.
Prochaska, J. O., and DiClemente, C. C. (1986). Toward a comprehensive model of change.In W.R. Miller and N. Heather (Eds.) Treating addictive behaviors: processes of change (pp.3-27). New York: Plenum Press.
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References
In reproducing this material, please contact NASW.
Credit as follows: NASW HIV/AIDS Spectrum: Mental HealthTraining and Education of Social Workers Project (2003)[Multiple Authors] National Association of Social Workers (NASW),Washington, DC.
Developed under contract with the Center for Mental HealthServices (CMHS) of the Substance Abuse and Mental HealthServices Administration. United States Department of Health andHuman Services, Rockville, MD. Contract #280-01-8055. A specialthank you to the authors of Coping with Hope: HIV TreatmentDecisions and Adherence: A Multi-Disciplinary Mental HealthServices Curriculum. (2000) developed through support of thefederal Center for Mental Health Services, Rockville, Maryland.
This publication may not be reproduced or distributed for a feewithout the specific, written authorization of the NASW HIV/AIDSSpectrum Project.
