Development and validation of the HIV Medication Readiness Scale

Excellent medication adherence (>95%) is required for optimal HIV treatment success. This study aimed to develop and validate a brief scale to assess psychological readiness for successfully starting and adhering to HIV medications. HIV-positive men and women (N = 142) from an HIV outpatient clinic completed the proposed HIV Medication Readiness Scale (HMRS) prior to starting HIV medications. The 10-item HMRS demonstrated high internal consistency (alpha = .90), test-retest reliability (r = .83), and sensitivity to change following a standardized 4-session psychoeducational intervention designed to increase readiness for successful adherence. Predictive validity was supported by higher readiness scores on the day starting HIV medications, predicting higher treatment adherence at 1-month follow-up. The HMRS is a brief, easy-to-use, clinically relevant tool that can assist in identifying people living with HIV at high risk of nonadherence, who might benefit from tailored readiness counseling prior to initiating HIV medications.     

Electronic monitoring and counseling to improve medication adherence

Electronic caps, pill caps that record the date and time of pill bottle opening provide an objective measure of adherence to prescribed medication. A promising intervention to improve adherence, cue-dose training, involves reviewing patients' pill cap-generated reports concerning their medication-taking and offering individualized recommendations for remembering to take medications at specific times of day. In this preliminary study, 79 patients prescribed the antihyperglycemic medication metformin had adherence assessed during a 4-week baseline period. Adherence, defined as proportion of prescribed doses taken within a predetermined 4-h window, was measured using electronic MEMS caps. Those who had less than 80% baseline adherence (n = 33) were randomly assigned to either receive 4 months of cue-dose training (n = 16) or to a control group (n = 17). Cue-dose training was associated with significantly better adherence to metformin (mean improvement of 15%). The effects of cue-dose training on adherence to other antihyperglycemic medication did not reach statistical significance. Glycosylated hemoglobin (a measure of blood sugar control) did not differ between groups. Data from nine patients who reviewed pill cap-generated data with their primary care providers suggested that both patients and providers found the discussion moderately helpful and not at all uncomfortable.     

Examining Implementation Intentions in an Exercise Intervention: The Effects on Adherence and Self‐Efficacy in a Naturalistic Setting1

Some studies have found positive associations between implementation intentions and exercise, independent of motivational factors. However, most research has not been conducted in actual exercise contexts. In a naturalistic setting, implementation intentions may be associated with self‐efficacy (SE) beliefs. This study examined the effect of implementation intentions on adherence and SE over an 11‐week exercise program. Women (N = 72) were randomly assigned to an experimental (i.e., implementation intention) or a control group, with 52 participants completing the study. Results showed that while adherence decreased over time in both groups, the experimental group had better adherence than did the control group. Scheduling SE was also higher in the experimental group. Implementation intentions may help to maintain adherence and scheduling SE.     

Utility of the Millon Behavioral Medicine Diagnostic (MBMD) to predict adherence to highly active antiretroviral therapy (HAART) medication regimens among HIV-positive men and women

Psychosocial and behavioral factors may be strong predictors of adherence to medications in a wide variety of diseases. Newly emerging antiretroviral medications for HIV have been shown to be effective but require near perfect adherence to offer clinically significant benefits. There is currently great interest in deriving patient factors that may predict optimal medication adherence in HIV-positive persons. In this study, we examined the association of psychosocial and behavioral characteristics using the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Meagher, & Grossman, 2001) and adherence to highly active antiretroviral therapy (HAART) among 117 HIV-positive individuals on HAART regimens. Specific indexes of the MBMD were associated with HAART adherence as assessed through patient interview, at baseline assessment, and at 3-month follow-up at a point after which participants had received medication adherence training. As hypothesized, the Medication Abuse scale of the MBMD was uniquely associated with overall adherence at baseline assessment and also predictive of adherence at 3-month follow-up. Additional MBMD scales were also related to overall adherence as well as specific adherence behaviors such as missed doses, following specific instructions, and overmedicating, although the Medication Abuse scale emerged as the most consistent predictor of adherence in the study. These results suggest that the MBMD can be used to predict adherence to HAART medication in a sample of HIV-positive men and women and may subsequently be used to identify those in need of adherence counseling at the point when medications are initiated.     

Randomized controlled trial of an intervention to prevent adherence failure among HIV-infected patients initiating antiretroviral therapy.

OBJECTIVE: Compare the efficacy of a multicomponent social support intervention to standard-of-care counseling on medication adherence among HIV-infected patients initiating antiretroviral therapy. DESIGN: Randomized controlled trial. Generalized estimating equations tested for differences in the percentage of participants achieving 90% adherence. MAIN OUTCOME MEASURES: Pill-taking, electronically monitored over 6 consecutive months; plasma viral load (VL), assessed at 3 and 6 months following initiation of therapy. RESULTS: Of 226 participants who were randomized and began the trial, 87 (38%) were lost to the study by 6 months. The proportion of adherent participants declined steadily over time, with no time by group interaction. Sustained adherence was associated with increased odds of achieving an undetectable VL (OR=1.78; 95% CI=1.01, 3.13). In intention-to-treat analyses, a larger proportion of the intervention group than the control group was adherent (40.15% vs. 27.59%, p=.02) and achieved an undetectable VL p=.04). However, the majority of participants who remained on study experienced some reduction in VL (>or=1-log drop or undetectable), regardless of experimental condition. CONCLUSION: The multicomponent social support intervention significantly improved medication adherence over standard-of-care counseling; evidence for improved virologic outcomes was inconsistent. Early discontinuation of care and treatment may be a greater threat to the health of HIV patients than imperfect medication-taking.     

Medication adherence and diabetes control in urban African Americans with type 2 diabetes.

In 181 urban African Americans with Type 2 diabetes, medication adherence was assessed using a measure designed specifically for an urban, impoverished sociodemographic population. Hemoglobin A-sub(1c), blood pressure and cholesterol levels, medication-related beliefs, and depression were assessed. Seventy-four percent of the sample reported adherence to diabetes medication. Adherence, adjusted for age, was associated with lower hemoglobin A-sub(1c). The specific behaviors associated with poorer diabetes control were forgetting to take medications and running out of medications. Knowledge of blood glucose goals differed for adherers and nonadherers. Blood pressure and cholesterol medication adherence rates were not associated with actual levels of blood pressure or lipids, respectively. These data suggest that specific medication-taking behaviors are important to diabetes control and constitute logical targets for interventions. ((c) 2005 APA, all rights reserved).     

Psychosocial mediators of antiretroviral nonadherence in HIV-positive adults with substance use and mental health problems.

This study used data from 1,889 HIV-positive patients on antiretroviral (ARV) medications who participated in the HIV Cost and Services Utilization Study to investigate whether nonadherence to ARV medications among patients with mental health and substance use problems could be explained by difficulty getting and negative attitudes toward ARV medications, poor fit of the regimen with lifestyle, lack of instruction and cues for remembering the regimen from a health care provider, and poor support from others for taking ARV medications. Difficulty getting ARV medications and poor fit with lifestyle were significant mediators of nonadherence for patients with a probable psychiatric disorder. Difficulty getting medication was a mediator for heavy drinkers, and poor fit with lifestyle was a mediator for drug users who drank heavily. Further research is needed to identify and address the barriers to adherence in these populations.     

The efficacy of symbolic modeling and vicarious reinforcement in increasing coping-method adherence

The aim of this study was to test a method of increasing adherence to a coping method assignment in individuals interested in reducing stress. Eighty university students and 48 adult nonstudents were asked to write about their emotions for 15 minutes per day over 3 days. Participants were randomly assigned to experimental or control conditions, with the experimental manipulation being an adherence intervention involving symbolic modeling and vicarious reinforcement. A word count and self-report measures showed significantly higher adherence in the adherence intervention group. Additionally, the adherence intervention group showed significantly more reduction in distress than the writing instructions only group. Finally, the amount of adherence was significantly associated with amount of reduction in self-reported distress. The results provide the first evidence of the efficacy of symbolic modeling and vicarious reinforcement in increasing the use and clinical benefits of a recommended coping method.     

Adherence to antiretroviral therapy for pediatric HIV infection: review of the literature and recommendations for research

This review described and compared empirical investigations of adherence to pediatric antiretroviral therapy (ART) and predictors/correlates of adherence with regard to methodology and outcome. Thirteen empirical studies of children's adherence to ART, conducted between the years 1981 and 2002 were identified. Investigations varied by age of participant, drug therapy regimen, method of adherence assessment, and by the reporting of predictors/correlates of adherence. Conclusions from the literature are limited by the lack of common sample characteristics and adherence assessment methodologies. Nevertheless, consistent with much of the pediatric adherence literature, adherence to antiretroviral medications among children and adolescents appears to be frequently suboptimal. Few investigations identified predictors/correlates of adherence, but these appear generally similar to those found in adult samples. Recommendations for future investigations are proposed.     

Ask and ye shall receive: behavioural specificity in the accuracy of subjective memory complaints

A cross‐sectional sample of adults completed an extensive set of cognitive tasks and a set of questionnaires measuring depressive affect, memory complaint, and other variables. During an interview about their prescribed medications, the participants also reported whether they were having problems remembering to take the medication as prescribed (an everyday prospective memory problem). Their medication adherence at home was then monitored for one month using pill bottles which microelectronic caps. Cognitive tasks correlated with memory complaints, as measured by the Memory Functioning Questionnaire, but not with problems in remembering to take medications. The highest correlations were with a free recall task. Conversely, reported problems with medication adherence during the interview had good predictive validity for subsequent adherence problems, but not for cognitive tasks, including a measure of prospective memory. Depressive affect was related to both the questionnaire and the interview complaints about medication adherence, but a structural equation model showed that the relationships of cognition and medication adherence to the different memory complaints were independent of depressive affect. The results are interpreted in terms of a behavioural specificity hypothesis, which states that adults' self‐reports of memory problems are valid when they focus directly on specific memory‐related behaviours in everyday contexts. Copyright © 2000 John Wiley & Sons, Ltd.     

Relationship with health care provider and adherence to HIV medications

Suboptimal adherence to antiretroviral medications was reported in a sample of 97 inner-city residents with HIV/AIDS. Most respondents had been seeing the same physician for several years. Those who perceived themselves to be more engaged with their health care provider also reported better treatment adherence. This finding, though, should be viewed with caution since self-reported measures were used. Interventions that target adherence could include patients' perceptions of providers.     

Long-term effects of lifestyle changes on well-being and cardiac variables among coronary heart disease patients

OBJECTIVE: To focus on psychological well-being in the Lifestyle Heart Trial (LHT), an intensive lifestyle intervention including diet, exercise, stress management, and group support that previously demonstrated maintenance of comprehensive lifestyle changes and reversal of coronary artery stenosis at 1 and 5 years. DESIGN AND MAIN OUTCOME MEASURES: The LHT was a randomized controlled trial using an invitational design. The authors compared psychological distress, anger, hostility, and perceived social support by group (intervention group, n = 28; control group, n = 20) and time (baseline, 1 year, 5 years) and examined the relationships of lifestyle changes to cardiac variables. RESULTS: Reductions in psychological distress and hostility in the experimental group (compared with controls) were observed after 1 year (p < .05). By 5 years, improvements in hostility tended to be maintained relative to the control group, but reductions in psychological distress were reported only by experimental patients with very high 5-year program adherence. Improvements in diet were related to weight reduction and decreases in percent diameter stenosis, and improvements in stress management were related to decreases in percent diameter stenosis at both follow-ups (all p < .05). CONCLUSION: These findings illustrate the importance of targeting multiple health behaviors in secondary prevention of coronary heart disease.     

Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample

Violence towards others by a minority of psychotic individuals is a significant public health concern. The severity of this other-directed violence (ODV) in the community may be influenced by insight into illness and adherence to psychotropic medications; however, few studies have tested these associations. Sixty male psychotic inpatients, legally detained at a forensic unit in New York City, were assessed with semi-structured interviews, supplemented with information from hospital and official records, family members and the treating clinician. Results indicated that in this unique sample of detained persons with psychotic disorders; (1) increase in the severity of community violence is associated with medication non-adherence, all dimensions of poor insight into illness, and several previously reported covariates such as substance use comorbidity; (2) no relationship was found between insight and adherence in this particular sample; (3) multivariate analyses showed that select covariates, along with medication adherence, and select insight domains predicted a total of 73% of the magnitude of ODV behavior in this sample. Overall, medication non-adherence explained a large amount of how violently participants behaved toward others. Since non-adherence was independent of poor insight, it may be more worthwhile for clinicians to develop treatment strategies to target medication adherence without directly addressing an elusive target such as insight into illness. Treatment addressing medication adherence needs to concomitantly target substance use behaviors since the latter was responsible for a substantial increase in ODV.     

Improving adherence to physical activity

Two studies tested the efficacy of Marlatt and Gordon's relapse-prevention approach in increasing attendance during an exercise program (short-term adherence) and continuation of exercise activities for 12 weeks following termination of the formal program (longer term adherence). Participants in both studies were registrants in 10-week exercise groups (jogging, aerobic dance, and pre-ski training) sponsored by the Université de Montréal Sports Centre. The intervention, designed to increase awareness of obstacles to exercise and to develop appropriate techniques for coping with them, was delivered by group leaders within the context of the regular program. Results of both studies indicate a small but consistent superiority of adherence in the experimental condition compared to the control condition. The low cost of this intervention, however, makes even small gains cost effective. Possible methods for strengthening the treatment effect are discussed.     

Goal-setting protocol in adherence to exercise by Italian adults

A goal-setting protocol, based on research in goal setting and performance and personal construct theory, was tested for its effect on adherence to a new exercise program. The Goal-setting group (n = 50) had significantly less dropout (30%) than the control group (n = 50) (74%). The Goal-setting group also had significantly better attendance (p<.0001). Suggestions for increasing confidence in findings through further research and practical implications of using the protocol to improve exercise maintenance across settings were discussed.