Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE DEMOGRAPHIC AND SOCIAL-COGNITIVE (SELF-EFFICACY AND DEPRESSION) CORRELATES OF MEDICATION ADHERENCE TO ANTIRETROVIRAL THERAPY (ART)
IN PERSONS INFECTED WITH HIV DR RAZI FARAZ KHAN
Psychology Department Barkatullah University Bhopal, Madhya Pradesh India
Abstract:-Adherence plays an important role in the effectiveness of ART because individuals who demonstrate lower levels of adherence are at greater risk for increased levels of morbidity, treatment failure, and the development of drug resistant forms of HIV.
Adherence is a concept with social and emotional components. Self-efficacy for taking ART is a consistent predictor of ART adherence and Depression has also been associated with ART adherence. The purpose of this study was to explore the role of social-cognitive (Self- efficacy and Depression) and demographic variables in determining medication adherence to ART among persons with HIV-infection. Social Cognitive Theory (SCT) was used to examine the self-reported medication adherence to antiretroviral theory. By using a cross-sectional study design, present study was done with sample of 335 persons infected with HIV and receiving antiretroviral therapy (ART) at ART centre located in Bhopal District of Madhya Pradesh.
The relationship of Demographic factors such as Gender, Marital status and Family type were significantly related to medication adherence among persons infected with HIV receiving ART. Self efficacy was found significantly and positively correlated with pill identification (r = .76, p < .01) and adherence (r = .98, p < .01). This indicates that participants with high self efficacy reported higher in pill identification and adherence as compared to participants with low self efficacy. Depressive symptom was found significantly and negatively correlated with pill identification (r = -.63, p < .01) and adherence (r = -.85, p < .01).
To study the mediating role of self-efficacy and depressive symptoms in the relationship of psychosocial variables and medication adherence; relationship between study variable is necessary. Other than gender, marital status, and family type dimension of the Demographic factor were not correlated in the hypothesized directions with Self-efficacy and depressive symptoms.
So that the hypothesis that Self-efficacy and depressive symptoms will significantly mediate the relationship of demographic factors to medication adherence not possible to test in this study with existing data.
The Social-Cognitive and Demographic Correlates of Medication Adherence may be a useful tool in research and clinical practice to anticipate and address potential treatment adherence problems .Results have been discussed in the view of the existing theoretical model of health behavior.
Keywords: Medication Adherence, Antiretroviral Therapy, Self efficacy, Depression.
INTRODUCTION AND REVIEW OF LITERATURE
Medication-taking is an essential component of self-management in HIV/AIDS. Antiretroviral therapy (ART) is a key component of improving health outcomes of HIV-positive individuals.
Adherence plays an important role in the effectiveness of ART because individuals who demonstrate lower levels of adherence are at greater risk for
increased levels of morbidity, treatment failure, and the development of drug resistant forms of HIV (Palella et al., 1998; Paterson et al., 2000; Sethi et al., 2003). To achieve optimal effectiveness for reducing viral load, patients take 90- 95% of their prescribed antiretroviral medication (Paterson et al., 2000).
Adherence is a concept with social and emotional components. If adherence it to be attained in the setting of HIV
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE treatment, the “how to” of adherence is
the means to achieving relevant personal goals. Antiretroviral medication adherence is associated with multiple factors interwoven patient, medication, disease, environment, and system-related factors. Several factors are associated with adherence. Depression and psychiatric illness, active alcohol or drug use, and lack of social support have been found to be associated with lower adherence (Paterson et al., 2000;
Chesney, 2000). Psychiatric disorders also may constitute barriers to adherence. Even mild conditions such as depressed mood, as elicited on self-report rating scales, may be associated with medication non-adherence, either because of impaired concentration, which is one of the criteria for diagnosing mood disorders, or because of feelings of hopelessness and despair.
Patient attributes
Patient characteristics have been the focus of numerous investigations of adherence. However, age, sex, education, occupation, income, marital status, race, religion, ethnic background, and urban versus rural living have not been definitely associated with adherence (Haynes, 1979; Kaplan & Simon, 1990).
In particular, factors such as perceived susceptibility to illness, perceived severity of illness, self-efficacy and perceived control over health behaviours appear to be correlates (Haynes, 1979;
Becker & Rosenstock, 1984).
Self-efficacy
Psychologist Albert Bandura has defined self-efficacy as one's belief in one's ability to succeed in specific situations. One's sense of self-efficacy can play a major role in how one approaches goals, tasks, and challenges (Bandura,1977) .The theory of self-efficacy lies at the center of Bandura’s social cognitive theory, which emphasizes the role of observational learning and social experience in
the development of
personality.Reductions in depression may also be associated with the cognitive elements present in depression (Beck,
1961).Cognitive intensity experimental condition than a “true” control condition (i.e., “comparison condition“). In addition, as self efficacy is the perceived ability to control the environment and stressors, its measurement is inexact. The concept of self efficacy may differ between cultures and cognitive behavioral skills may not be as meaningful in certain cultures. Self efficacy, or beliefs about one's capabilities and potential to meet situational demands, influences effort, perception of control, personal choices, thought patterns, depression and perceived stress (Bandura, 1995. Self efficacy refers to a personal judgment about a person's perceived ability to mobilize resources over events and has been related to both general and specific behaviors (Cruess et al., 2002).
Behavioral interventions emphasize and increase self efficacy (Bandura, 1994).Group cognitive behavioral interventions provide skills such as re- framing of stressors (looking at stressors from another perspective), coping, relaxation, assertiveness and anger management, while promoting attitude and behavioral change regarding stressors through increased self efficacy and collective (group) efficacy (Lazarus &
Folkman, 1984; Compas, Davis, Forsythe, & Wagner, 1987). Interventions targeting self efficacy also reduce feelings of helplessness, anxiety and depression, which may lead to reductions in sexual and IDU risk behaviors (Murphy, Stein, Schlenger, & Maibach, 2001). Adults living with HIV are twice as likely to be depressed as uninfected populations (Vance, Moneyham, Fordham, &
Struzick, 2008), and the lifetime prevalence of depression in HIV infected individuals is between 22% and 45%
(Penzak, Reddy, & Grimsley, 2000).self efficacy has been related to decreased distress, anxiety, anger and confusion among men (Antoni et al., 1991;Cruess et al., 2000) and women with HIV (Ironson et al., 2005). ART adherence levels are adherence self-efficacy, or confidence in one’s ability to adhere to a treatment plan (Bandura, 1989; Bandura et al., 1989). In the context of HIV treatment
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE adherence, self-efficacy has been
reported as a correlate to adherence (Ammassari et al., 2002; Catz, Kelly, Bogart, Benotsch, & McAuliffe, 2000;Fogarty et al., 2002; Gifford et al., 2000; Johnson et al., 2003;Kalichman et al., 2001; Murphy, Greenwell, &
Hoffman, 2002;Reynolds et al., 2004).
Self-efficacy and Adherence
Self-efficacy is an integral component of major theoretical frameworks addressing health behaviour change, including social cognitive theory and the health belief model. Self-efficacy for taking ART is a consistent predictor of ART adherence (Ammassari et al., 2002).
Depression and Adherence
Depression has also been associated with ART adherence, though less consistently (Ammassari, et al., 2002; Berger- Greenstein et al., 2007; Chander, Himelhoch et al., 2006). In a large study, individuals with depression had greater odds of non-adherence (Tucker et al., 2003), but in other studies, significant relationships between depression and adherence were not sustained in multivariate analysis (Catz et al. 2000).
The nature of these relationships remains imprecisely defined, particularly in light of the established interrelationships between self-efficacy and depression.
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being( Salmans, Sandra ,1997). Depressed people can feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt, or restless. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions, and may contemplate, attempt, or commit suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains, or digestive problems may also be present( "NIMH · Depression").
Depression has been considered a risk factor for nonadherence to highly
active antiretroviral therapy (HAART)(
Ammassari A, et al .2004; Bouhnik AD, et al .2005; Tucker JS, et al .2003).
Because depression is negatively associated with HAART adherence and with clinical outcome measures for these patients( Bouhnik AD, et al .2005; Singh N, et al 1999) screening for depression is essential (Simoni JM, et al.2003; Starace F, et al.2002).
Social Cognitive Theory
This theory evolved from social learning theory and may be the most comprehensive theory of behaviour change developed thus far (Redding CA,et al. 2000). It posits a multifaceted causal structure in the regulation of human motivation, action and well-being (Bandura A,2000) and offers both predictors of adherence and guidelines for its promotion (Bandura A,1997).. The basic organizing principle of behaviour change proposed by this theory is reciprocal determinism in which there is a continuous, dynamic interaction between the individual, the environment and behaviour(Redding CA,et al., 2000).
The Present study
The purpose of this study was to explore the role of social-cognitive and demographic variables in determining medication adherence to ART among persons with HIV-infection. In addition, the potential mediating roles of self- efficacy and depression on the
process(es) between the
person/environment and the behaviour were evaluated.
The overall impact of socio- cognitive and demographic factors on adherence, full understanding of the interplay between these factors such as sociodemographic, clinical, and other adherence-related psychosocial factors such as depression, social support, self- efficacy, and personality is needed. This warrants for additional research on the topic for improved understanding of the multidimensionality of the relationship between variables and to focus on improving medication adherence among persons with HIV infection. As there is
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE limited information available from India
on adherence to ART and its determinants or predictors, the present study was explore the factors associated with medication adherence among persons infected with HIV. Thus, the overall purpose of the study was to determine the role of demographic and social-cognitive factors in adherence to antiretroviral therapy in HIV infected persons.
The Objectives
The main objectives of the present study were:
1. To examine the role of social cognitive factors such as self-efficacy and depressive symptoms in medication adherence of HIV infected persons.
2. To study the complex relationship of demographic and social psychological factors in determining medication adherence.
3. To study the mediating role of self- efficacy and depressive symptoms in the relationship of psychosocial variables and medication adherence.
The Hypotheses
The following hypotheses were proposed and tested in the present study.
1. Demographic factors will be significantly related to medication adherence among persons infected with HIV receiving ART.
2. Social psychological factors such as self- efficacy and depressive symptoms will be significant correlates of medication adherence among persons receiving ART.
3. Self-efficacy and depressive symptoms will significantly mediate the relationship of demographic factors to medication adherence.
Significance of the study
Adherence plays an important role in determining quality of life, in either positive or negative ways. The aim of the present study was to examine the role of demographic and psycho-social factors that influence ART adherence in Indian socio-cultural context.
Limitation and Strength of the Present Study:
These limits include use of self measure, the cross sectional nature of research design and characteristic of the participants who were mainly from lower class families many of the younger participant’s more than one chronic illness. Despite the above limitations, present study has several important methodological strengths such as utilizing a clinical sample to answer research questions under investigation, using a large sample size, employing psychometrically sound self report measures and testing theoretically and clinically important hypothesis.
Research Design
Using a cross-sectional study design, present study was done using a sample of 335 persons infected with HIV and receiving antiretroviral therapy (ART) at ART centre located in Bhopal District of Madhya Pradesh.
Measures
The questionnaire used in the present study was a 7-page stapled booklet.
Cronbach’s alphas were found satisfactory and scales were therefore formed, by summing components. The section that the present analyses examined asked questions about Socio- cognitive and demographic related characteristics, Medication adherence, Self-efficacy, Depression, Social support, Personality and HIV/AIDS Stigma. Here for this paper explaining only demographic related characteristics and Self-efficacy, Depression.
Procedure
Necessary permission for the collection of data was obtained from the Authorities.
Participants were individually contacted at the time of their visit to ART clinic.
Detailed information about socio- demographic and other characteristics of the participants was collected with the help of questionnaire. Following this, questionnaires measuring psychological and other variables were administered individually to each participant. Other
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE information such as disease
characteristics, stage and duration of infection and other biological markers were collected from clinic records. Pill identification test was conducted by the researcher.
Ethical Considerations
The study was approved by the Research Degree Committee of Barkatullah University and Permission was obtained from the MP State AIDS control Society, Department of AIDS Control, Government of India. Subsequently, each prospective respondent was approached by me (researcher) and the purpose and demands of the study were explained.
They were informed that participation was voluntary and were assured of anonymity and confidentiality of information before informed consent was obtained.
Data Screening and Analysis
All screening and analytic procedures were conducted in SPSS 18.0. Missing data analysis, outlier examination, and checking of statistical assumptions were performed prior to analysis. Descriptive statistics (i.e., measures of central tendency and variability for continuous variables; frequency distributions of categorical variables) were used to characterize the sample
Major Findings of the Study
The age of the participants range from 18 to 70 years, (Mean 35.57, SD 10.08).The
marital status of patients, 96.41% was married and 3.59% were unmarried.
Family status of patients 21.79 % were living in joint families and 78.20% were leaving in nuclear families and 40.60 % belongs to rural background remaining 59.40 % from urban area. Educational status of participants, 45.07% were have Primary 23.58% were have secondary School and 31.34% were have College pass outs. Working status of participants all 129 female were house wifes,50.15 % of male participants were work on daily wages basis and remaining 11.35 % were service class. Duration of illness range from 3 to 8 years,(Mean 3.86, SD 1.21).
Habit of addiction like Tobacco, Alcohol and intravenous drug were present in 63% of participants. In 46.86% of participants were have one or more HIV infected persons in their family. 26.86 % of participants have co infected with Tuberculosis.
To analyzed hypothesis that Social psychological factors such as self- efficacy and depressive symptoms will be significant correlates of medication adherence among HIV infected persons receiving ART Pearson’s coefficient of correlation was used.
Table 1 Coefficient of Correlation Scores on socio cognitive factors such as self- efficacy, depressive symptoms, stigma and interpersonal social support with medication adherence among HIV infected persons receiving ART.
Variables M SD Pill Identification Adherence more than 95% , less than 95%
Self efficacy 97.90 26.80 .76** .98**
Depressive
symptoms 20.00 14.56 -.63** -.85**
*p < .05. **p < .01.
Coefficient of correlations of self efficacy was found significantly and positively correlated with pill identification (r = .76, p < .01) and adherence (r = .98, p < .01).
This indicates that participants with high self efficacy reported higher in pill identification and adherence as
compared to participants with low self efficacy.
Depressive symptom was found significantly and negatively correlated with pill identification (r = -.63, p < .01) and adherence (r = -.85, p < .01). This indicates that participants with higher depressive symptoms reported less in pill
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE identification and adherence as
compared to participants with less depressive symptoms.
Table Mediation Analysis :Inter-correlations between study variables Demographic factors to Medication Adherence as mediated by Self-efficacy and Depressive symptoms
2 3 4 5 6 7 8 9
Demographic factors
Gender - .19 - .06 -.11 - .84 ** .37* .12 -.12 -.12*
Age -.20* -.17 .14 .27* -.00 .01 .01
Marital status .05 .03 -.30* -.15 .13
-.15* .15*
Education .29* -.16 * -.02 -.00 .02
Occupation -.41* -.10 .10 .09
Family type .12 -.10* .11*
Self efficacy -.92** .98**
Depressive symptom - .85**
Medication adherence
* p< .05
** p< .01
Mediation Analysis
Examining the relationships between demographic factors to medication adherence as mediated by self-efficacy and depressive symptoms. Correlational analyses were conducted to determine whether the predicted relationships existed between, Demographic factors to medication adherence and Self-efficacy and depressive symptoms. The inter correlations between each case variable are presented in Table for testing mediation effects; relationship between study variable is necessary. Other than gender, marital status, and family type dimension of the Demographic factor were not correlated in the hypothesized directions with Self-efficacy and depressive symptoms.So that the hypothesis that Self-efficacy and depressive symptoms will significantly mediate the relationship of demographic factors to medication adherence not
possible to test in this study with existing data.
Discussion
Self-efficacy expectation was the variable most strongly associated with adherence.
This association was also reported in other studies (. Gifford AL, et al.,2000;
Eldred LJ, et al.,1998; Chesney MA, et al.,2000; Tuldrà A, et al.,2000; Catz SL, et al.,2000). In agreement with Bandura's Socio-cognitive theory, individuals who do not believe in their ability to adhere to treatment would tend to make less effort towards adopting measures to facilitate adherence or to modify behaviors which increase the risk of non adherence. Self- efficacy expectation may influence adherence by acting on motivational, cognitive, and emotional processes, thus changing the meaning and value of external influences, the evaluation of the
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE consequences of following treatment, and
treatment-related choices.
Depressive symptom was found significantly and negatively correlated with pill identification and adherence.
This indicates that participants with high depressive symptoms reported less in pill identification and adherence as compared to participants with less or no depressive symptoms.Other studies showing that depression, stress and psychiatric conditions are risk factors for non-adherence (Paterson DL, et al.,2000;
Chesney MA, et al.,2000; Gordillo V, et al.,1999; Catz SL, et al.,2000).
Furthermore, the evidence for association between negative affects and self-efficacy expectation supports the view that physical and emotional conditions at the time of performing a behavior are one of the sources of self-efficacy (Bandura A,1997).
Tests for mediation effects
Correlational analyses were conducted to test whether the hypothesize relationships existed between Self- efficacy and depressive symptoms, and demographic factors to medication adherence. Bivariate correlations were conducted to assess whether the predicted relationships existed between Self-efficacy and depressive symptoms and demographic factors to medication adherence. These correlations supported initial predictions, therefore MacKinnon’s (2008)and Baron and Kenny’s (1986) method for establishing mediation was used to ascertain whether Self-efficacy and depressive symptoms mediated the relationship between demographic factors to medication adherence. Baron and Kenny’s (1986) test for mediating effects allows for one mediator, and as such, was adapted by MacKinnon (2008) to accommodate two mediators.
Figure 1. Path diagram for the two-mediator model with study variables (MacKinnon 2008)
A causal step method is recommended by MacKinnon (2008) to assess multiple mediating effects. MacKinnon has adapted the Baron and Kenny (1986) steps to establish mediation are as follows. Step 1: the independent variable (X) must affect the dependent variable (Y); Step 2: the independent variable (X) must affect the first mediator (M1), and the independent
variable (X) must affect the second mediator (M2); Step 3: the mediator must affect the
dependent variable (Y) when the independent variable (X) is controlled, Step 4: the direct effect must be nonsignificant. combined mediating effects were analyzed using the steps recommended by MacKinnon (2008).
Study variables Demographic; gender, marital status, and family were all correlated in the hypothesized directions.
Results of the correlational analysis are displayed in Table For testing mediation effects; relationship between study variables is necessary. Other than gender, marital status, and family type Mediator 2
Depressive symptoms
Mediator 1 Self efficacy
DV Medication Adherence IV
Demograp hic factor
Vol.03, Issue 04, April 2018, Available Online: www.ajeee.co.in/index.php/AJEEE dimension of the Demographic factor
were not correlated in the hypothesized directions with Self-efficacy and depressive symptoms.
So that the hypothesis that Self-efficacy and depressive symptoms will significantly mediate the relationship of demographic factors to medication adherence is not possible to test in this study with existing data.
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