© 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