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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

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.

Jan 04, 2016



  • Lynda Tyer-ViolaPhD RN,Kathleen Sullivan PhD RN,Paula Reid PhD RN,Inge Corless PhD RN FAAN, Patrice Nicholas PhD RN FAAN, andA. J. GuarinoPhD


  • HIV Nursing Research NetworkA network of nurses actively researching international topics concerning persons living with HIV/AIDS The Networks Theoretical Foundation posits that HIV/AIDS remains a significant world wide threat to public healthThe Networks 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 StudiesStudy I: Predictors of Adherence in HIV/AIDSUS 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, BrazilStudy II: Symptom Management for Persons with HIV DiseaseUS sites: Boston, MA; New York, NY; Palo Alto, San Fancisico, CA; Patterson, NJ; International sites: Oslo, NorwayStudy 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, TaiwanStudy IV: The Efficacy of the HIV/AIDS Symptom Management ManualUS 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, SwazilandStudy 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.

  • BackgroundComprehensive 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 ones social relationships, influences PLWH medication adherence. The influence of support and satisfaction with ones 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 CoherenceAn attribute that depicts an individuals capacity to respond to stressors and a reflection of an individuals overall well-being and ability to cope with stress (Pham, Vinck, Kinkodi and Weinstein , 2010). Self Efficacy Individuals 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 ones ability to comply with a treatment plan, has been consistently linked to adherence over time.

  • Self CompassionExtending 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 QuestionsTo identify what contextual, environmental and regulatory factors affect adherence to ARV medication in women residing in North America.Research QuestionIs there a relationship between contextual, environmental and regulatory factors and the outcome of medication adherence? Of these correlates, what factors predict medication adherence?

  • Theoretical FrameworkVariables of interest of Social Action Theory (Ewart, 1991)

  • MethodsData 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 VariablesContextual / 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) Cronbachs alpha overall = 0.91

    Perceived Stigma Scale. 40-item scale. measures the stigma perceived by people with HIV, using Goffmans definition of stigma. (Berger, Ferrans, & Lashley, 2001) Cronbachs 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). Cronbachs 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). Cronbachs alpha overall = 0.72

    Rosenberg Self-Esteem Scale (SE) 10-item scale. overall feelings of self-worth or self-acceptance. Cronbachs alpha overall = 0.72HIV- 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. Cronbachs alpha overall = 0.96

  • Outcome Variables3-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 InterestGender (n = 338) women currently on ART medications.

  • Sample DemographicsOf 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 American82% had children 59% said their income was barely adequate66% screened positive for depression symptoms (CESD > 16)

  • ResultsIs 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 FactorsSelf Compassion (SCS)Self Esteem (SE)Adherence Self Efficacy (ASE) Sense of Coherence (SOC)

  • Correlations among study variables and adherence. Variable12345678910111213141. adher3d1.699**-.102-.230**.245**-.239**.421**.174**-.107.053-.001-.023.128*.0602. adher30d.699**1-.102-.254**.254**-.278**.450**.257**-.094.044.063-.095.121*.0823. HCPE-.102-.1021.089-.098.113*-.157**-.180**.110*-.079-.057-.090-.099-.0174. CESD-.230**-.254**.0891-.643**.612**-.273**-.639**.386**-.093-.183**.010-.100-.0305. SCS.245**.254**-.098-.643**1-.693**.365**.603**-.293**.086.132*-.072.164**.0486. SE-.239**-.278**.113*.612**-.693**1-.388**-.589**.336**-.123*-.153**.028-.152**.0457. ASE.421**.450**-.157**-.273**.365**-.388**1.332**-.165**.059.167**-.025.054.0458. SOC.174**.257**-.180**-.639**.603**-.589**.332**1-.346**.097.171**.039.064-.0179. STIGMA-.107-.094.110*.386**-.293**.336**-.165**-.346**1.042-.170**.017-.096-.120*10. EDU.053.044-.079-.093.086-.123*.059.097.0421-.139*-.039.133*.06111.INCOME-.001.063-.057-.183**.132*-.153**.167**.171**-.170**-.139*1-.004.041-.05312.CHILDREN-.023-.095-.090.010-.072.028-.025.039.017-.039-.0041.050-.167**13.AGE.128*.121*-.099-.100.164**-.152**.054.064-.096.133*.041.0501-.00914.ETHNICITY.060.082-.017-.*.061-.053-.167**-.0091**. Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed)

  • 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

  • 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

  • DiscussionRegulatory 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

  • LimitationsVariation in enrollment of women between sitesSelf selection of participantsOverall, non-random recruitment may introduce biasSelf 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.

  • ConclusionsRegulatory 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.

  • ReferencesBerger, B., Ferrans, C., & Lashley, F. R. (2001). Measuring Stigma in people with HIV. Psychometric assessment of the HIV stigma scale. Research in Nursing & Health, 24(6), 518-529. Corless, I. B., Guarino, A. J., Nicholas, P. K., Tyer-Viola, L., Kirksey, K., Brion, J., et al. (2012). Mediators of antiretroviral adherence: A multisite international study. AIDS Care, 9, 9.Ewart, C. K. (1991). Social action theory for a public health psychology. American Psychology, 46(9), 931-946.Holzemer , W. L. (2007). University of California, San Francisco International Nursing Network for HIV/AIDS. international Nursing Review, 54, 234-242Johnson, M. O., Chesney, M. A., Goldstein, R. B., Remien, R. H., Catz, S., Gore-Felton, C., et al. (2006). Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV-infected adults: A mediation model. AIDS Patient Care STDS, 20(4), 258-268. Johnson, M., Neilands, T., Dilworth, S., Morin, S., Remien, R., & Chesney, M. (2007). The Role of Self-Efficacy in HIV Treatment Adherence: Validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES). Journal of Behavioral Medicine, 30(5), 359-370. doi: 10.1007/s10865-007-9118-3Konttinen, H., Haukkala, A., & Uutela, A. (2008). Comparing sense of coherence, depressive symptoms and anxiety, and their relationships with health in a population-based study. Soc Sci Med, 66(12), 2401-2412.

  • Neff, K. D., Rude, S. S., & Kirkpatrick, K. L. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 41(4), 908-916. doi: 10.1016/j.jrp.2006.08.002Neff, K. D., & Vonk, R. (2009). Self-Compassion Versus Global Self-Esteem: Two Different Ways of Relating to Oneself. Journal of Personality, 77(1), 23-50. doi: 10.1111/j.1467-6494.2008.00537.xPham, P., Einck, P., Kinkodi, D., & Weinstein, H. (2010). Sense of coherence and association with exposure to traumatic events, post traumatic stress disorder and depression in eastern Democratic Republic of Congo. Journal of Traumatic Stress, 23, 313-321. Puskas, C. M., Forrest, J. I., Parashar, S., Salters, K. A., Cescon, A. M., Kaida, A., et al. (2011). Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011. [Review]. Current HIV/AIDS Reports, 8(4), 277-287. Radloff, L. (1977). The CES-D scale: A self report depression scale for research with the general population. Applied Psychological Measurement, 1, 385-401. Voils, C. I., Barroso, J., Hasselblad, V., & Sandelowski, M. (2007). In or out? Methodological considerations for including and excluding findings from a meta-analysis of predictors of antiretroviral adherence in HIV-positive women. Journal of Advanced Nursing. 2163-2077.

    Individuals with a high SOC seem able to respond more effectively to stressful life events whereas individuals whose SOC is lower have diminished capacity to handle such events.

    *ABSTRACTThis research examined self-compassion and self-esteem as they relate to various aspects of psychological functioning. Self-compassion entails treating oneself with kindness, recognizing one's shared humanity, and being mindful when considering negative aspects of oneself.Study 1(N=2,187) compared self-compassion and global self-esteem as they relate to ego-focused reactivity. It was found that self-compassion predicted more stable feelings of self-worth than self-esteem and was less contingent on particular outcomes. Self-compassion also had a stronger negative association with social comparison, public self-consciousness, self-rumination, anger, and need for cognitive closure. Self-esteem (but not self-compassion) was positively associated with narcissism.Study 2(N=165) compared global self-esteem and self-compassion with regard to positive mood states. It was found that the two constructs were statistically equivalent predictors of happiness, optimism, and positive affect. Results from these two studies suggest that self-compassion may be a useful alternative to global self-esteem when considering what constitutes a healthy self-stance.*Data were collected between August, 2009 and December, 2010. Each site recruited approximately 100 participants. Participants included adults (>18 years of age), living with HIV/AIDS, and recruited from Infectious Disease clinics and AIDS Service Organizations. of the 2182, 450 were women residing in NA*The CES-D is a 20-item scale. It is a non-diagnostic screening tool that measures the current level of depressive symptoms in community populations (Radloff, 1977). Items are rated 0=rarely or none of the time to 3=most or all of the time. A total score can range from 0 to 60. The alpha reliability estimate was 0.90 in a sample of 727 AIDS patients (Holzemer, et al., 1999).) The HCP is a 13-item scale in which clients rate the nature of their interactions with their main health care provider on a four-point scale with 1=always true and 4=never. A low score indicates greater provider engagement. The scale was submitted to a principal components factor analysis with Varimax rotation. A one-factor solution emerged with an Eigenvalue of 8.6 and explaining 66.5% of the variance. Cronbach's alpha reliability estimate was 0.96 (Bakken, et al., 2000).The PSS is a 40-item scale developed by Berger, Ferrans and Lahsley (Berger, Ferrans, & Lashley, 2001) to measure the stigma perceived by people with HIV, using Goffmans definition of stigma.

    *Chi square test was performed to determine if there were any significantly associated differences related to sociodemograhic variables and the outcome variables. *ASE was significant but low correlation with HCPengagment: this may be different for women and that they get their strength to adhere elsewhere. *

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