Functional health literacy, medication-taking self-efficacy and adherence to antiretroviral therapy

Correlates of HIV treatment adherence self-efficacy among adolescents and young adults living with HIV in southwestern Uganda

Adherence to antiretroviral therapy (ART) among adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa is sub-optimal compared to younger children and older adults. Adherence self-efficacy is one of the intrapersonal factors most strongly correlated with ART adherence. The role of adherence self-efficacy in ART adherence among AYLHIV is not well studied in Uganda. We enrolled 300 AYLHIV between October and December 2021 from an HIV clinic in southwestern Uganda. We collected information on adherence self-efficacy, HIV stigma, depression, self-management, and social skills. We used linear regression to estimate the association between adherence self-efficacy and the covariates of interest. At multivariable adjustment self-management (b = 0.29, 95% CI 0.23-0.35, p<0.001) and social skills (b = 0.16, 95% CI 0.08-0.24; p<0.001) were statistically significantly associated with adherence self-efficacy. The findings imply that interventions directed at enhancing self-management and social skills in AYLHIV may increase adherence self-efficacy and, potentially, HIV outcomes among AYLHIV.

Association of mental health symptoms on HIV care outcomes and retention in treatment

OBJECTIVE

The purpose was to examine associations between HIV care engagement and mental health symptoms among persons living with HIV (PLWH) receiving ART. This study builds upon previous findings indicating a significant association between mental health and retention in HIV care,¹ while also advancing the literature by examining the impact of substance use on this link, as well as potential bidirectional associations.

METHOD

Participants of the current study were 493 patients who engaged in care and received antiviral therapy (ART) from Infectious Disease physicians between 2017 and 2019 in a large academic medical center.

RESULTS

Results from hierarchical regression analyses revealed that patients who missed more days of ART medication had higher depressive symptoms, even when accounting for the effect of demographic variables and alcohol use. Further, depressive symptoms predicted significant variance in number of "no show" visits, but was not individually predictive of ""no show"" visits beyond the effect of other HIV care outcomes (e.g., number of days of medication missed).

CONCLUSION

Findings reflect linkages among HIV treatment adherence, mental health, and substance use, and highlight the need to target mental health symptoms to improve outcomes among PLWH and prevent HIV transmission.

Cognitive Function and the Relationship With Health Literacy and Secondary Prevention in Patients With Acute Coronary Syndrome at Early Discharge: A Prospective Observational Study

BACKGROUND

Cognitive impairment (CI) may contribute to difficulties in understanding and implementing secondary prevention behavior change after acute coronary syndrome (ACS), but the association is poorly understood.

OBJECTIVES

The aim of this study was to explore the prevalence of CI in patients 4 weeks post ACS and the association with health literacy and secondary prevention.

METHODS

Patients with ACS who were free from visual deficits, auditory impairment, and dementia diagnoses were recruited and assessed 4 weeks post discharge for cognitive function (Montreal Cognitive Assessment and Hopkins Verbal Learning Test), health literacy (Newest Vital Sign), depression (Patient Health Questionnaire), physical activity (Fitbit Activity Tracker and Physical Activity Scale for the Elderly), and medication knowledge and adherence.

RESULTS

Participants (n = 45) had an average age of 65 ± 11 years, 82% were male, 64% were married/partnered, and 82% had high school education or higher. Overall CI was identified in 28.9% (n = 13/45) of the patients 4 weeks after discharge, which was composed of patients detected on both the Montreal Cognitive Assessment and Hopkins Verbal Learning Test (n = 3), patients detected on Montreal Cognitive Assessment alone (n = 6), and patients detected on Hopkins Verbal Learning Test alone (n = 4). Fewer patients with CI had adequate health literacy (61.4%) than patients with normal cognition (90.3%, P = .024). Significant correlations were found between Hopkins Verbal Learning Test scores and medication knowledge (0.4, P = .008) and adherence (0.33, P = .029).

CONCLUSIONS

In this exploratory study, 30% of patients with ACS demonstrated CI at 4 weeks post discharge. Two screening instruments were required to identify all cases. Cognitive impairment was significantly associated with health literacy and worth further investigation.

Racial disparities in the association between resilience and ART adherence among people living with HIV: the mediating role of depression

Research examining the mediating role of depressive symptoms in the association between resilience and antiretroviral therapy (ART) adherence is lacking. Therefore, this study aims to examine the mediating role of depression between resilience and ART adherence, as well as to explore whether this relationship varies across racial background. A total of 327 people living with HIV and on ART in South Carolina were surveyed about their ART adherence and mental health, including resilience and depressive symptoms. Path analyses were conducted to determine the direct and indirect effects between resilience, depressive symptoms, and ART adherence. After adjusting for age, gender, income, education, employment and time since diagnosis, among Black individuals, resilience was negatively associated with depressive symptoms (β = --0.248, p < 0.001); depressive symptoms were negatively associated with ART adherence (β = -0.166, p = 0.020); however, resilience was not significantly associated with ART adherence. Among White individuals, there was no statistically significant association. The indirect effect between resilience and ART adherence through depressive symptoms was statistically significant (β = 0.041, p = 0.040) for Black individuals, while not statistically significant for White individuals (β = 0.024, p = 0.578). Interventions aimed at improving ART adherence, which attenuate depressive symptoms through accentuating resilience may be especially beneficial for Black populations living with HIV.

Self-efficacy for self-management and its influencing factors among adults living with HIV on antiretroviral therapy in northwest Ethiopia

Previous research has identified that self-efficacy is an essential factor in the process of self-management; however, the evidence is lacking concerning factors influencing self-efficacy in low-income countries. Therefore, this study examined factors influencing self-efficacy. A validated survey tool was orally administered to 415 adults living with HIV. Many of the respondents, 82.4%, do not have a regular job while one-fourth (25.5%) of the respondents were from a rural area. A mean self-efficacy score, 19.76 ± 0.12 out of a maximum of 24 was identified. This self-efficacy score was positively correlated with age, educational level, income and job status, but negatively correlated with gender, residency and drug side effects. Income, residency in rural, and experiencing drug side effects were significant predictors of self-efficacy and explained 5.4% of the variance. Better income (β = 0.514, p = 0.029) was associated with a higher self-efficacy score but living in rural areas (β = -0.520, p = 0.043) and experiencing drug side effects (β = -1.246, p = 0.001) were associated with a lower self-efficacy score. The use of Individual and Family Self-Management Theory helps clinician and patients to work together to identify factors influencing self-efficacy and to intervene.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

The role of online social networks in improving health literacy and medication adherence among people living with HIV/AIDS in Iran: Development of a conceptual model

Online social networks have been used to enhance human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) prevention, diagnosis, and treatment programs worldwide. This study aimed to develop a conceptual model of using online social networks in improving health literacy and medication adherence among people living with HIV/AIDS in Iran. This mixed-method sequential exploratory study was conducted in three phases. Firstly, a series of semi-structured interviews with a purposive sample of 29 HIV-positive patients were conducted to investigate the perceptions and experiences of HIV-positive patients about using online social networks to support health literacy and medication adherence. Thematic analysis was used to analyse qualitative interviews, extract potential components, and design a conceptual model. Then, a Delphi study with 27 HIV-positive patients was subsequently conducted to examine the consensus of patients on the proposed model. Finally, the trustworthiness and credibility of the proposed model were reviewed and evaluated by expert panel members from epidemiology and public health. Seven themes and 24 sub-themes emerged from the qualitative interviews. Five themes encompassed components of online social networks that supported communication and information-seeking behaviour of people living with HIV/AIDS. The two other themes encompassed social support and health-related outcomes including medication adherence. The credibility of the proposed conceptual model was confirmed methodologically using the expert panel and Delphi technique. Our findings highlighted that using online social networks has empowered Iranian people living with HIV/AIDS, making them more connected, safe, and able to access HIV/AIDS-related information and services. The role of online social networks in improving health literacy and medication adherence was also demonstrated in a conceptual model to understand the supportive components of online social networks in the HIV care continuum as well as customized interventions to improve the success of antiretroviral therapies.

Patient-Reported Experiences of Medication Adherence at a Community-Based HIV Clinic, Ghana

There is little information on patients' medication adherence experiences at community-based clinics in Ghana. This study investigated adherence to antiretroviral medication among people living with HIV (PLHIV) attending a community-based HIV clinic. PLHIV (N = 349) completed a questionnaire battery on medication adherence, doctor-patient communication, HIV stigma, patient general self-efficacy, perceived social support, and on patient spirituality. Linear Regression was used to analyze the data. Results showed that doctor-patient communication (β = .38, 95% CI [0.09, 0.18], P <.001) and social support from significant others (β = .46, 95% CI [0.18, 0.67], P <.001) were positively associated with medication adherence in this sample. In contrast, HIV stigma (β = -.16, 95% CI [-0.58, -0.09], P <.01), patient spirituality (β = -.22, 95% CI [-0.44, -0.00], P <.05), and patient general self-efficacy (β = -.14, 95% CI [-0.17, -0.02], P <.01) were negatively associated with medication adherence. There is a need for educational interventions targeted at enhancing doctor-patient communication and social support while reducing stigma among PLHIV in Ghana.

The association of self-efficacy and health literacy to chemotherapy self-management behaviors and health service utilization

BACKGROUND

Increasing demands on Canada's healthcare system require patients to take on more active roles in their health. Effective self-management has been linked to improved health outcomes; and there is evidence that effective behaviors, and subsequent healthcare utilization, are linked to self-efficacy and health literacy; however, this link has had minimal testing in the cancer context. Our aim is to examine the association between self-efficacy, health literacy, chemotherapy self-management behaviors, and health service utilization.

DESIGN AND METHODS

A cross-sectional survey that included validated measures of self-efficacy, health literacy, chemotherapy self-management, and health service utilization was completed by participants (N = 213). Multivariable modeling using hierarchical linear regression was used to examine the association between variables.

RESULTS

Self-efficacy contributed significantly to explaining variation in chemotherapy self-management score. Health literacy was not significantly associated with any of the dependent variables.

CONCLUSION

Participants with higher self-efficacy had higher chemotherapy self-management scores compared to participants with low self-efficacy. Contrary to evidence in the chronic disease self-management literature, this study demonstrated that health literacy was not associated with chemotherapy self-management behavior nor was it associated with self-efficacy. Building patient self-efficacy in the context of chemotherapy self-management could be particularly helpful both in the cancer center and in the domain of oral chemotherapy management at home where patients are required to take on significant responsibility for self-management.

The effect of self-efficacy on health literacy in the German population

Concerning the determinants of health literacy (HL) mostly socio-demographic or -economic factors have been considered, much less so psychological factors such as self-efficacy. To date, it has mostly been considered to explain the relationship of HL and health outcomes. However, self-efficacy could also be an important determinant for HL. This study therefore examines the effect of self-efficacy on comprehensive HL within the general population in Germany. Data from the German HL Survey (HLS-GER), a cross-sectional, computer-assisted personal interview study among 2000 respondents aged 15+ years in 2014 were used. Self-efficacy was measured using the German version of general self-efficacy short scale (ASKU), comprehensive HL was measured using the German version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47). Correlation and multi-variate linear regression analyses were performed to analyze independent effects of socio-demographic factors-age, gender, social status, educational level and migration background-functional HL and self-efficacy on comprehensive HL. Self-efficacy and comprehensive HL are statistically significantly correlated (Spearman's Rho = 0.405; p < 0.01), respondents with better self-efficacy had better HL scores. Both concepts are significantly associated with most socio-demographic factors and functional HL. Self-efficacy showed the strongest association with HL in the multivariate analyses (model 2: β =0.310, p < 0.001). The effect size of the other predictors decreased, when adding self-efficacy into the equation, but remained statistically significant. Self-efficacy is a rather strong predictor of comprehensive HL. Future research and measures to improve HL should therefore take self-efficacy adequately into account.

The importance of domain-specific self-efficacy assessment for substance use and HIV care continuum outcomes among adults in an urban HIV clinic network

Despite the prominence of self-efficacy as a predictor of antiretroviral therapy (ART) adherence, relatively little work has examined domain-specific associations with steps in the care continuum or the possibility that substance use may have domain-specific associations with self-efficacy. This study analyzed data from a sample of 174 people living with HIV recruited through three clinics in the New York City metro area. Consistent with hypotheses, path analysis showed that appointments kept and viral load were each predicted only by their respective domain-specific self-efficacy components (i.e., self-efficacy for keeping appointments, B = 0.01, p = .04; and self-efficacy for taking ART medications, B = -0.02, p < .01). Path models also indicated domain-specific associations with substance use. Self-efficacy for keeping appointments was negatively associated with severity of drug use (B = -1.81, p < .01); meanwhile, self-efficacy for taking ART medications was negatively associated with severity of alcohol use (B = -0.52, p < .01). Accordingly, studies assessing barriers to retention in the HIV care continuum should conduct multi-domain assessments of self-efficacy for differential associations with specific behaviors. Furthermore, HIV care providers might consider screening for domain-specific self-efficacy to identify patients at risk of drop-out and tailoring interventions to various care continuum domains.

Health literacy of people living with HIV in a rural area in Indonesia: A cross-sectional study

Indonesia, the fourth most populated country in the world, has experienced a fivefold increase in Human Immunodeficiency Virus (HIV)-infected individuals since 2001. Little is known about health literacy in people living with HIV (PLHIV) in Indonesia. This study aimed to determine the level of health literacy among PLHIV in Indonesia and assess associations between sociodemographic variables, beliefs about medicines, stigma and health literacy. We conducted a cross-sectional study using questionnaires in PLHIV in Papua, Indonesia. The short version of the Test of Functional Health Literacy in Adults (S-TOFHLA), Beliefs about Medicines Questionnaire (BMQ) and HIV stigma scale as well as questions on demographic information were completed by the participants from two hospitals in Papua, Indonesia. In a multivariate logistic regression analysis, we assessed the association between sociodemographic variables, stigma, beliefs about medicine and low health literacy. Overall, 331 participants were included, 62.0% female, 67.0% Papuans. A total of 38.5% of participants had low health literacy. PLHIV with multi-dose regimen were less likely to have low health literacy than those taking a fixed-dose combination (OR = 0.51; 95%CI = 0.32-0.82). PLHIV who had social support in medicine-taking were more likely to have low health literacy (OR = 1.78; 95%CI = 1.07-2.97). More awareness about medication overuse (OR = 1.17; 95%CI = 1.06-1.29) and medication harm (OR = 1.10; 95%CI = 1.01-1.20) were also associated with having low health literacy. Overall, interventions targeting health literacy may be a promising strategy to improve self-management.

Neurocognitive Functioning is Associated with Self-Reported and Performance-Based Treatment Management Abilities in People Living with HIV with Low Health Literacy

OBJECTIVE

People living with HIV (PLWH) are at higher risk for poorer neurocognitive functioning and health literacy than uninfected persons, which are associated with worse medical outcomes. Aging research suggests that the effect of neurocognitive functioning on health outcomes may be more pronounced in those with low health literacy. We aimed to determine whether low health literacy might amplify the adverse effects of neurocognitive functioning on treatment management outcomes in 171 PLWH aged 40+.

METHOD

In this cross-sectional, observational study, participants completed a well-validated battery of neurocognitive, health literacy, and treatment management measures. A binary health literacy variable (low vs. adequate) was determined via established cut points on the well-validated health literacy tests. Treatment management outcomes included biomarkers of HIV (i.e., CD4 counts and viral load), self-management of HIV disease (i.e., self-reported medication adherence and self-efficacy for HIV disease management), and performance-based health-related decision-making.

RESULTS

Forty-seven percent of the sample met the criteria for low health literacy. Multivariable regressions adjusting for clinicodemographic (e.g., race, socioeconomic status) covariates revealed significant interactions for self-efficacy for HIV disease management and health-related decision-making, such that neurocognitive functioning was associated with these outcomes among those with low, but not adequate health literacy.

CONCLUSIONS

Findings suggest that low health literacy may increase the vulnerability of PLWH to the adverse effects of neurocognitive impairment on health outcomes, or conversely that adequate health literacy may provide a buffer against the health risks associated neurocognitive impairment. Interventions targeting health literacy in PLWH may mitigate the effects of neurocognitive impairment on health outcomes.

An instrument to assess HIV-related knowledge and adjustment to HIV+ status, and their association with anti-retroviral adherence

Background

Findings on the association between health literacy and anti-retroviral (ARV) adherence are inconsistent. Health literacy is usually operationalized with simple tests of basic literacy, but more complex conceptions of health literacy include content knowledge. People living with chronic illness also conceptualize and experience illness in ways other than biomedical or mechanistic models of disease.

Objective

There are no instruments that comprehensively assess knowledge of people living with HIV concerning HIV disease and treatment; or psychological adjustment to being HIV+. Little is known about the relationship between factual knowledge, or positive identification as HIV+, and anti-retroviral (ARV) adherence.

Methods

Formative work with in-depth semi-structured interviews, and cognitive testing, to develop a structured instrument assessing HIV-related knowledge, and personal meanings of living with HIV. Pilot administration of the instrument to a convenience sample of 101 respondents.

Key results

Respondents varied considerably in their expressed need for in-depth knowledge, the accuracy of their understanding of relevant scientific concepts and facts about ARV treatment, and psychological adjustment and acceptance of HIV+ status. Most knowledge domains were not significantly related to self-reported ARV adherence, but accurate knowledge specifically about ARV treatment was (r = 0.25, p = .02), as was an adapted version of the Need for Cognition scale (r = .256, p = .012). Negative feelings about living with HIV (r = .33, p = .0012), and medication taking (r = .276, p = .008) were significantly associated with non-adherence.

Conclusion

The instrument may be useful in diagnosing addressable reasons for non-adherence, as a component of psychoeducational interventions, and for evaluation of such interventions.

HIV Disclosure to Family Members and Medication Adherence: Role of Social Support and Self-efficacy

Although antiretroviral therapy (ART) is vital to people living with HIV (PLWH) by suppressing the virus and in turn preventing onward HIV transmission and reducing AIDS-related morbidity and mortality, the rates of optimal ART adherence continuously remain low. Disclosure of HIV status is considered to be a critical predictor of ART adherence. However, few studies have explored the mechanisms underlying the association between disclosure and medication adherence. The current study aims to examine the mediating role of social support and self-efficacy underlying the relationship between HIV disclosure to family members and ART adherence. PLWH in China provided data on HIV disclosure, ART adherence, perceived social support on medication adherence, adherence self-efficacy, and social-demographic information. The path analyses revealed that disclosure to family members had significant indirect effects on adherence via social support and self-efficacy. Our findings suggested that HIV disclosure might positively affect ART adherence through two psychosocial pathways: social support and self-efficacy. Future intervention to improve medication adherence among PLWH should consider targeting these two factors.

Cross-sectional evaluation of perceived health care provider engagement, self-efficacy, and ART adherence in people living with HIV/AIDS

Despite advancements in the treatment and prevention of HIV/AIDS, adherence to antiretroviral therapy (ART) remains suboptimal. Research indicates that health care provider (HCP) engagement is related to adherence, yet little is known about the specific pathways that underlie this relation. This cross-sectional study examined the relation between perceived HCP engagement and ART adherence in people living with HIV/AIDS (PLWHA), as well as the role of adherence self-efficacy in this relation. Participants (N = 207) completed self-report measures assessing monthly ART adherence, perceived ability to take ART as prescribed, and perceptions of HCP engagement. Results of a path analysis revealed a direct positive relation between perceived HCP engagement and ART adherence, and a significant indirect relation of perceived HCP engagement to ART adherence through adherence self-efficacy. Higher perceived HCP engagement was related to greater adherence self-efficacy, which, in turn was related to higher ART adherence. Findings are consistent with research demonstrating that HCP support leads to increased motivation to engage in treatment and extends past work on the importance of positive patient-provider relationships. Notably, results suggest that increasing patient perceptions of HCP engagement may be one way to boost adherence self-efficacy and improve ART adherence in PLWHA.

Health Beliefs and Medication Adherence in Omanis With Hypertension

BACKGROUND

Patients' health beliefs are essential to improve medication adherence among patients with hypertension.

OBJECTIVE

Our objective was to examine the relationship between (1) patients' beliefs about hypertension, medication, and self-efficacy and medication adherence and (2) medication adherence and blood pressure control in Oman.

METHODS

This cross-sectional study included 215 participants with hypertension. Participants completed 4 questionnaires (Arabic version) to measure medication adherence, beliefs about hypertension severity, beliefs about medication, and self-efficacy. Bivariate and multivariate logistic regression was used to conduct the analyses.

RESULTS

Higher self-efficacy (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.54-4.37), stronger beliefs about medication necessity (OR, 1.98; 95% CI, 1.21-3.23), increased age (OR, 1.06; 95% CI, 1.03-1.10), and fewer medication concerns (OR, 0.34; 95% CI, 0.20-0.57) were related to high medication adherence. Moreover, uncontrolled blood pressure was less likely in participants with high medication adherence (OR, 0.47; 95% CI, 0.24-0.93).

CONCLUSIONS

Patients' beliefs are important consideration to improve medication adherence. Clinically, patients' beliefs should be assessed, and strategies to improve medication adherence should incorporate beliefs as a key component to improve antihypertensive medication adherence. Patient education and counseling regarding hypertension and necessity and side effects of medications are important to maximize positive beliefs and improve medication adherence.

Predictors of Antiretroviral Adherence Self-efficacy Among People Living With HIV/AIDS in a Canadian Setting

BACKGROUND

Suboptimal adherence to antiretroviral therapy (ART) among people living with HIV/AIDS (PLWHA) who use illicit drugs remains an ongoing health concern. Although health outcomes associated with adherence self-efficacy have been well-documented, there is dearth research exploring the predictors of this construct. This study sought to identify possible determinants of adherence self-efficacy among a cohort of PLWHA who use illicit drugs.

METHODS

From December 2004 to May 2014, we collected data from the AIDS Care Cohort to evaluate Exposure to Survival Services, a prospective cohort of adult PLWHA who use illicit drugs in Vancouver, Canada. We used multivariate generalized estimating equation analyses to identify longitudinal factors independently associated with higher adherence self-efficacy.

RESULTS

Among 742 participants, 493 (66.4%) identified as male and 406 (54.7%) reported white ancestry. In multivariate generalized estimating equation analysis, older age at ART initiation (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 1.00 to 1.03) and recent year of baseline interview (AOR = 1.08, 95% CI: 1.05 to 1.11) were independently associated with higher adherence self-efficacy, whereas homelessness (AOR = 0.78, 95% CI: 0.65 to 0.94), ≥daily crack smoking (AOR = 0.81, 95% CI: 0.68 to 0.96), experienced violence (AOR = 0.82, 95% CI: 0.69 to 0.98), and childhood abuse (AOR = 0.75, 95% CI: 0.60 to 0.92) were negatively associated.

CONCLUSIONS

These findings highlight the potential role that personal and contextual factors can play in predicting levels of ART adherence self-efficacy. Future research should seek to identify and validate strategies to optimize adherence self-efficacy.

Health Literacy and Health Outcomes in Persons Living with HIV Disease: A Systematic Review

Low health literacy is associated with challenges for those living with HIV including medication non-adherence and poorer health outcomes. The aim of this study was to systematically review the literature on health literacy and health outcomes in persons living with HIV. The extended guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, as well as A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist were utilized to guide the approach to the review. A variety of electronic databases including PubMed, CINAHL, PsychInfo, and Cochrane Library were searched. Additional literature available on U.S. government websites was also included in the search. Search terms were used in a variety of combinations and included HIV, health literacy, adherence, and health outcomes. Forty-eight studies were identified that addressed health literacy and health outcomes in HIV. Although several studies in this review did not provide robust results of statistical significance linking health literacy with health outcomes, all of the studies addressed the key significance of health literacy within the scope of living with HIV disease. The relationship between health literacy and the identified health outcomes requires further research and explication.

Chinese health literacy scale for tuberculosis patients: a study on development and psychometric testing

BACKGROUND

The role of health literacy on tuberculosis patients has not been evaluated in China, in part because few special health literacy measurements exist.

METHODS

A three-step design process was used: (1) Scale construction: Based on the model of revised Bloom's taxonomy, the item-pool was drafted from a literature review, focus group discussion, and in-depth interviews. In addition, a Delphi survey was used in order to select items for inclusion in the scales; (2) Pilot study: Acceptability and clarity were tested with 60 tuberculosis patients; and (3) Psychometric testing: Validity analysis includes content validity, construct validity, and discriminative validity. The Cronbach's alpha coefficient, split-half reliability, and test-retest method were used to assess reliability. Finally, a receiver operating characteristic analysis was conducted to generate a cut-off point.

RESULTS

The final scale had 29 items with four domains. The item level Content Validity Index ranged from 0.70 to 1.0, and the scale level Content Validity Index was 0.95. The mean score among the lowest 27% group was significantly lower than that those of the highest 27% group (p < 0.01), which supports adequate discriminant validity. Explanatory factor analysis produced a clear four-factor construct, explaining 47.254% of the total variance. Factor 1 and Factor 2 were consistent with read and memorize TB-related words; Factor 3 was associated with understand the meaning of the health education leaflets and examine if TB patients can apply the correct approach to correct context; Factor 4 was related to the ability of TB patient to calculate and identify what unspecified assumptions are included in known conditions. The confirmatory factory analysis results confirmed that a four-factor model was an acceptable fit to the data, with a goodness-of-fit index = 0.930, adjusted goodness of fit index = 0.970, root mean square error of approximation = 0.069, and χ2/df = 2.153. The scale had good internal consistency and test-retest reliability. Additionally, the receiver operating characteristic analysis indicated that the cut-off point for the instrument was set at 45 and 35.

CONCLUSIONS

The Chinese Health Literacy scale for Tuberculosis has good reliability and validity, and it could be used for measuring the health literacy of Chinese patients with tuberculosis.

An Electronic Pre-Exposure Prophylaxis Initiation and Maintenance Home Care System for Nonurban Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly efficacious for preventing HIV but has not yet been brought to scale among at-risk persons. In several clinical trials in urban areas, technology-based interventions have shown a positive impact on PrEP adherence. In rural and small-town areas in the United States, which often do not have geographically proximal access to PrEP providers, additional support may be needed. This may be particularly true for younger persons who are more likely to face multiple barriers to accessing PrEP services. Home-based care, accomplished through a tailored mobile phone app, specimen self-collection (SSC), and interactive video consultations, could increase both PrEP initiation and persistence in care.

OBJECTIVE

The goal of this study is to assess the initiation and persistence in PrEP care for those randomized to a home-care intervention (electronic PrEP, ePrEP) relative to those assigned to the standard of care (control) condition. We will conduct additional assessments, including quantitative and qualitative analyses, to contextualize trial results and facilitate scale-up.

METHODS

This 2-arm, randomized controlled trial will enroll young men who have sex with men (YMSM) aged between 18 and 24 years from rural areas of Georgia, Mississippi, and North Carolina. The trial will seek to recruit a diverse sample, targeting 50% participation among highly impacted groups of black or Latino men who have sex with men. Intervention participants will receive a study app that incorporates a messaging platform, a scheduling and milestone-based tracking system for PrEP care progress, electronic behavioral surveys, and interactive video consultations with a clinician. Complemented by SSC kits mailed to laboratories for standard PrEP-related monitoring, the ePrEP system will allow participants to access PrEP care without leaving their homes. YMSM randomized to the control condition will receive a listing of nearest local PrEP providers to receive standard PrEP care. Both groups will complete quarterly electronic surveys. The primary outcome, assessed at 6 and 12 months after randomization, will be the difference in the proportion of intervention versus control participants that achieve protective levels of the active metabolite of oral PrEP (tenofovir diphosphate in dried blood spots).

RESULTS

Enrollment will begin in May 2019, with study completion in 2022.

CONCLUSIONS

This trial will determine whether home PrEP care provided through an app-based platform is an efficacious means of expanding access to PrEP care for a diverse group of YMSM in rural and small-town areas of the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03729570; https://clinicaltrials.gov/ct2/show/NCT03729570 (Archived by WebCite at http://www.webcitation.org/78RE2Qizf).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13982.

Health beliefs and medication adherence in patients with hypertension: A systematic review of quantitative studies

OBJECTIVE

This review synthesizes findings of quantitative studies examining the relationship between health beliefs and medication adherence in hypertension.

METHODS

This review included published studies in PubMed, CINHAL, EMBASE, and PsycINFO databases. Studies were included if they examined beliefs of patients with hypertension. Quality of the studies was evaluated using the Quality Assessment Tool for Systematic Review of Observational Studies.

RESULTS

Of the 1558 articles searched, 30 articles were included in the analysis. Most beliefs examined by studies of this review in relation to medication adherence were beliefs related to hypertension severity and susceptibility to its consequences, medication effectiveness or necessity, and barriers to medication adherence. Higher medication adherence was significantly related to fewer perceived barriers to adherence (e.g, side-effects) was fairly consistent across studies. Higher self-efficacy was related to higher medication adherence. Patients' beliefs and their relationship to medication adherence appear to vary unpredictably across and within countries.

CONCLUSION

Clinicians should assess beliefs for individual patients. When individual beliefs appear likely to undermine adherence, it may be useful to undertake educational interventions to try to modify them.

PRACTICAL IMPLICATIONS

Clinicians should explore individual patients' beliefs about hypertension and blood pressure medications, discuss their implications for medication adherence, and try to modify counterproductive beliefs.

Resilience and HIV: a review of the definition and study of resilience

We use a socioecological model of health to define resilience, review the definition and study of resilience among persons living with human immunodeficiency virus (PLWH) in the existing peer-reviewed literature, and discuss the strengths and limitations of how resilience is defined and studied in HIV research. We conducted a review of resilience research for HIV-related behaviors/outcomes of antiretroviral therapy (ART) adherence, clinic attendance, CD4 cell count, viral load, viral suppression, and/or immune functioning among PLWH. We performed searches using PubMed, PsycINFO and Google Scholar databases. The initial search generated 14,296 articles across the three databases, but based on our screening of these articles and inclusion criteria, n = 54 articles were included for review. The majority of HIV resilience research defines resilience only at the individual (i.e., psychological) level or studies individual and limited interpersonal resilience (e.g., social support). Furthermore, the preponderance of HIV resilience research uses general measures of resilience; these measures have not been developed with or tailored to the needs of PLWH. Our review suggests that a socioecological model of health approach can more fully represent the construct of resilience. Furthermore, measures specific to PLWH that capture individual, interpersonal, and neighborhood resilience are needed.

Development and initial validation of the appropriate antibiotic use self-efficacy scale

OBJECTIVE

While there are various medication self-efficacy scales that exist, none assess self-efficacy for appropriate antibiotic use. The Appropriate Antibiotic Use Self-Efficacy Scale (AAUSES) was developed, pilot tested, and its psychometric properties were examined.

METHODS

Following pilot testing of the scale, a 28-item questionnaire was examined using a sample (n = 289) recruited through the Amazon Mechanical Turk platform. Participants also completed other scales and items, which were used in assessing discriminant, convergent, and criterion-related validity. Test-retest reliability was also examined.

RESULTS

After examining the scale and removing items that did not assess appropriate antibiotic use, an exploratory factor analysis was conducted on 13 items from the original scale. Three factors were retained that explained 65.51% of the variance. The scale and its subscales had adequate internal consistency. The scale had excellent test-retest reliability, as well as demonstrated convergent, discriminant, and criterion-related validity.

CONCLUSIONS

The AAUSES is a valid and reliable scale that assesses three domains of appropriate antibiotic use self-efficacy.

PRACTICE IMPLICATIONS

The AAUSES may have utility in clinical and research settings in understanding individuals' beliefs about appropriate antibiotic use and related behavioral correlates. Future research is needed to examine the scale's utility in these settings.

Viral suppression among HIV-infected methadone-maintained patients: The role of ongoing injection drug use and adherence to antiretroviral therapy (ART)

INTRODUCTION

Methadone maintenance therapy (MMT) is associated with improved virologic outcomes, yet no studies have explored factors associated with viral suppression in HIV-infected patients on MMT. Given the critical role of sustained viral suppression in maximizing benefits of antiretroviral therapy (ART), we sought to assess factors associated with viral suppression in patients stabilized on MMT.

METHODS

A sample of 133 HIV-infected, methadone-maintained patients who reported HIV-risk behaviors were assessed using an audio-computer assisted self-interview (ACASI). Multivariable logistic regression was used to identify significant correlates of viral suppression.

RESULTS

Among all participants, self-reported HIV risk behaviors were highly prevalent and over 80% had achieved viral suppression. Independent correlates of viral suppression were: having optimal adherence to ART (aOR = 4.883, p = .009), high CD4 count (aOR = 2.483, p = .045), and ongoing injection drug use (aOR = 0.081, p = .036). Furthermore, results revealed a significant interaction effect that involved optimal ART adherence and injection of drug use on viral suppression (aOR = 2.953, p = .029).

CONCLUSION

Overall, our findings highlight unaddressed HIV-related treatment challenges faced by certain group of methadone-maintained patients. These findings have significant implications for the HIV treatment as prevention efforts and, thus, indicate the need for comprehensive efforts to promote viral suppression in this risk population.

Health Literacy and Demographic Disparities in HIV Care Continuum Outcomes

Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.

The Role of Emotional Avoidance, the Patient-Provider Relationship, and Other Social Support in ART Adherence for HIV+ Individuals

Adherence to antiretroviral therapy (ART) is associated with positive health outcomes among HIV+ patients. However, non-adherence remains high. Though factors that account for non-adherence remain unclear, social support has been consistently associated with ART adherence. As such, identifying malleable factors that hinder patients' ability to form supportive relationships may have consequence for improving ART adherence. Emotional avoidance (EA) may be one such factor given that it has been linked to difficulties in social situations. The present study examined relations among EA, the patient-provider relationship, other sources of social support, and ART adherence within a sample of HIV+ ART-prescribed patients. High EA was related to poor adherence and patient-provider relationships. EA was indirectly related to poor adherence through poorer patient-provider interactions. The indirect relation of EA to ART adherence through other sources of social support was not significant. Implications for developing targeted behavioral interventions focused on improving ART adherence are discussed.

Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence

Background

Current health policies emphasize the need for an equitable doctor-patient relationship, and this requires a certain level of patient empowerment. However, a systematic review of the empirical evidence on how empowerment affects medication adherence—the extent to which patients follow the physician’s prescription of medication intake—is still missing. The goal of this systematic review is to sum up current state-of-the-art knowledge concerning the relationship between patient empowerment and medication adherence across medical conditions. As our conceptualization defines health locus of control and self-efficacy as being crucial components of empowerment, we explored the relationship between these two constructs and medication adherence.

Methods

Relevant studies were retrieved through a comprehensive search of Medline and PsychINFO databases (1967 to 2017). In total, 4903 publications were identified. After applying inclusion and exclusion criteria and quality assessment, 154 articles were deemed relevant. Peer-reviewed articles, written in English, addressing the relationship between empowerment (predictor) and medication adherence (outcome) were included.

Findings

High levels of self-efficacy and Internal Health Locus of Control are consistently found to promote medication adherence. External control dimensions were found to have mainly negative (Chance and God attributed control beliefs) or ambiguous (Powerful others attributed control beliefs) links to adherence, except for Doctor Health Locus of Control which had a positive association with medication adherence. To fully capture how health locus of control dimensions influence medication adherence, the interaction between the sub-dimensions and the attitudinal symmetry between the doctor and patient, regarding the patient’s control over the disease management, can provide promising new alternatives.

Discussion

The beneficial effect of patients’ high internal and concurrent physician-attributed control beliefs suggests that a so-called “joint empowerment” approach can be suitable in order to foster medication adherence, enabling us to address the question of control as a versatile component in the doctor-patient relationship.

Mediation effects of medication information processing and adherence on association between health literacy and quality of life

BACKGROUND

To examine whether medication related information processing defined as reading of over-the-counter drug labels, understanding prescription instructions, and information seeking-and medication adherence account for the association between health literacy and quality of life, and whether these associations may be moderated by age and gender.

METHODS

A sample of 305 adults in South Korea was recruited through a proportional quota sampling to take part in a cross-sectional survey on health literacy, medication-related information processing, medication adherence, and quality of life. Descriptive statistics and structural equation modeling (SEM) were performed.

RESULTS

Two mediation pathways linking health literacy with quality of life were found. First, health literacy was positively associated with reading drug labels, which was subsequently linked to medication adherence and quality of life. Second, health literacy was positively associated with accurate understanding of prescription instructions, which was associated with quality of life. Age moderation was found, as the mediation by reading drug labels was significant only among young adults whereas the mediation by understanding of medication instruction was only among older adults.

CONCLUSION

Reading drug labels and understanding prescription instructions explained the pathways by which health literacy affects medication adherence and quality of life. The results suggest that training skills for processing medication information can be effective to enhance the health of those with limited health literacy.

Factors Associated with Health Information Seeking, Processing, and Use Among HIV Positive Adults in the Dominican Republic

Effective treatment and management of human immunodeficiency virus (HIV) depend on patients' ability to locate, comprehend, and apply health information. This study's purpose was to identify characteristics associated with these skills among HIV positive adults in the Dominican Republic. An information behavior survey was administered to 107 participants then three logistic regressions were conducted to identify characteristics associated with information seeking, processing, and use. Never having cared for someone who was sick was significantly associated with less information seeking, processing, and use. Males were more likely to be active information seekers and those who had attended the clinic for six or fewer years were less likely to actively seek information. Younger individuals had increased odds of higher information processing and those without comorbidities had increased odds of more information use. Results may inform researchers, organizations, and providers about how patients interact with health information in limited resource settings.

Measuring Health Literacy Among Adults with HIV Infection in Mozambique: Development and Validation of the HIV Literacy Test

The role of health literacy on HIV outcomes has not been evaluated widely in Africa, in part because few appropriate literacy measures exist. We developed a 16-item scale, the HIV Literacy Test (HIV-LT) to assess literacy-related tasks needed to participate in HIV care. Items were scored as correct or incorrect; higher scores indicated higher literacy skill (range 0-100 %). We tested internal reliability (Kuder-Richardson coefficient) of the HIV-LT in a convenience sample of 319 Portuguese-speaking, HIV infected adults on antiretroviral treatment in Maputo, Mozambique. Construct validity was assessed by a hypothetical model developed a priori. The HIV-LT was reliable and valid to measure participants' literacy skills. The mean HIV-LT score was 42 %; literacy skills applicable to HIV care were challenging for many participants. The HIV-LT could be used to assess the relationship of literacy and HIV-related outcomes in diverse settings, and evaluate interventions to improve health communication for those in HIV care.

Ethnicity, Stigma and Adherence to Antiretroviral Therapy (ART) among People Living with HIV/AIDS in Guangxi, China

This study examines the impact of ethnicity and multiple types of HIV-related stigma on adherence to antiretroviral therapy (ART) among 2,146 people living with HIV/AIDS (PLWHA) in Guangxi, China who had initiated ART. The results of multiple binary logistic regressions indicate that those who had experienced enacted stigma tended to report lower adherence, while better adherence was associated with older age, being women and having a job. Ethnicity had a moderator effect on the association between internalized stigma and adherence since better adherence was associated with lower internalized stigma among participants in ethnic minority groups other than Zhuang. Our findings indicate that PLWHA of other ethnic minority groups could benefit from internalized stigma reduction interventions; PLWHA, overall, could benefit most from increased employment opportunities and acquisition of coping skills to mitigate the negative effects of enacted stigma.

Factors of interpersonal communication and behavioral health on medication self-efficacy and medication adherence

Despite devastating effects on health outcomes and disease progression, many people living with HIV (PLWH) are non-adherent to their medications. Medication self-efficacy is a pivotal factor in medication adherence, yet its formation and relationship with other factors are understudied. This study examines a model that considers the role of three communicative factors (patient-provider communication, social support, and social undermining) and two behavioral health factors (depression and alcohol abuse) and medication self-efficacy impacting medication adherence. Methods included a cross-sectional design using a survey questionnaire of 344 PLWH. Findings indicated that 25% of variance in medication adherence can be explained by a mediation model where depression (B = -.18) and provider-patient communication (B = .21) affect medication self-efficacy, which in turn impacts medication adherence (B = .64). Other variables, including demographics, did not add any explanatory power. These findings demonstrate the complex nature of medication adherence and the formation of medication self-efficacy.

Language and Culture in Health Literacy for People Living with HIV: Perspectives of Health Care Providers and Professional Care Team Members

Low health literacy has been linked to inadequate engagement in care and may serve as a contributor to poor health outcomes among people living with HIV and AIDS. The purpose of this paper was to examine the perspectives of health care providers and professional care team members regarding health literacy in HIV disease. A secondary data analysis was conducted from a qualitative study aimed at understanding factors that help an HIV positive person to manage their HIV disease. Data were collected from sites in Botswana, the US, and Puerto Rico. In the parent study, data were collected through focus group discussions with 135 people living with HIV, 32 HIV health care providers (HCPs), and 39 HIV professional care team members (PCTMs). SPSS was used to analyze quantitative data while ATLAS.ti was used to analyze qualitative data. The findings from analyses of the perspectives of HCPs/PCTMs suggested that linguistic and cultural factors were important themes in the exchange of HIV information between health care providers and PLHIV. These themes included ineffective communication, health seeking behavior, cultural facilitators, and complementary and alternative/traditional healing methods. Thus, this study suggests that language and culture have a major role in health literacy for PLHIV.

Aging and Functional Health Literacy: A Systematic Review and Meta-Analysis

OBJECTIVES

To review the evidence on the association between age and limited health literacy, overall and by health literacy test, and to investigate the mediating role of cognitive function.

METHOD

The Embase, MEDLINE, and PsycINFO databases were searched. Eligible studies were conducted in any country or language, included participants aged ≥50 years, presented a measure of association between age and health literacy, and were published through September 2013.

RESULTS

Seventy analyses in 60 studies were included in the systematic review; 29 of these were included in the meta-analysis. Older age was strongly associated with limited health literacy in analyses that measured health literacy as reading comprehension, reasoning, and numeracy skills (random-effects odds ratio [OR] = 4.20; 95% confidence interval [CI]: 3.13-5.64). By contrast, older age was weakly associated with limited health literacy in studies that measured health literacy as medical vocabulary (random-effects OR = 1.19; 95% CI: 1.03-1.37). Evidence on the mediating role of cognitive function was limited.

DISCUSSION

Health literacy tests that utilize a range of fluid cognitive abilities and mirror everyday health tasks frequently observe skill limitations among older adults. Vocabulary-based health literacy skills appear more stable with age. Researchers should select measurement tests wisely when assessing health literacy of older adults.

Psychosocial factors in adherence to antiretroviral therapy among HIV-positive people who use drugs

OBJECTIVE

Suboptimal adherence to antiretroviral therapy (ART) among HIV-infected people who use illicit drugs (PWUD) remains a significant concern, and there is a lack of effective adherence interventions for this population. Therefore, we sought to identify psychosocial determinants of optimal adherence, including adherence self-efficacy and outcome expectancies, with the aim of informing interventions designed to improve adherence among PWUD.

METHOD

From December 2005 to November 2013, we collected data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort of PWUD in Vancouver, Canada. We used multivariable generalized estimating equations (GEE) analysis to identify longitudinal factors independently associated with 95% or greater adherence to ART.

RESULTS

Among 667 participants, including 220 (33%) women, 391 (59%) had 95% or greater ART adherence at baseline. In multivariable GEE analysis, adherence self-efficacy, adjusted odds ratio (AOR) = 1.16, 95% confidence interval (CI) [1.11, 1.21] per 10-point increase, was independently and positively associated with adherence, while negative outcome expectancy, AOR = 0.95, 95% CI [0.93, 0.98], was negatively associated.

CONCLUSION

In light of the ongoing challenges associated with ART adherence among HIV-positive PWUD, and our findings of associations between adherence, self-efficacy, and outcomes expectancies, tailored intervention strategies based on constructs of social learning theory should be implemented and evaluated to improve adherence among HIV-infected PWUD.

Discussing the Effects of Poor Health Literacy on Patients Facing HIV: A Narrative Literature Review

BACKGROUND

Scholars describe poor health literacy as a "silent epidemic," which is challenging the functioning of healthcare systems all over the world. Health literacy is mainly meant as an individual trait which concerns the ability to obtain, process, and understand basic health information in order to effectively navigate the health system. Low health literate patients perceive poor self-efficacy dealing with their health conditions, are not willing to be involved in the provision of care, show larger risks of hospitalization and mortality, and are not aware about the determinants of well-being. Hence, limited health literacy has been associated with inadequate management of long-term conditions; nonetheless, several authors argue that health literacy has been an overlooked factor dealing with HIV.

METHODS

This study is aimed at discussing the effects of poor health literacy on people living with HIV, drawing from the findings of a narrative literature review which involved 41 papers retrieved from the databases "Scopus-Elsevier" and "PubMed."

RESULTS

The scientific literature is not consistent dealing with the relationship between health literacy and HIV treatment. For example, health literate patients seem to better understand their health conditions; on the other hand, people living with poor health literacy are likely to report higher compliance with providers' prescriptions, blindly trusting healthcare professionals.

CONCLUSION

Poor health literacy is a social barrier to access healthcare services and to appropriate health treatment among patients living with HIV. Tailored interventions should be aimed at enhancing the health skills of patients affected by HIV infection to improve their ability to navigate the health system.

Impact of health literacy level on aspects of medication nonadherence reported by underserved patients with type 2 diabetes

BACKGROUND

Medication adherence can be affected by many factors, including health literacy. The purpose of this study is to determine (1) if a relationship exists between health literacy and self-reported or objectively measured medication adherence and (2) which aspect or aspects of medication nonadherence are most associated with health literacy.

SUBJECTS AND METHODS

This is a multicenter, cross-sectional survey study of adult patients with type 2 diabetes mellitus (T2DM), taking one or more antidiabetes medication for ≥6 months with a hemoglobin A1c (HbA1c) measure on record. Data collected included patient demographics (age, gender, race, language, highest level of education, injectable diabetes medication use, last HbA1c, and diabetes medication refill history) and two survey instruments (the Morisky eight-item Medication Adherence Scale [MMAS-8] and the short-form Test of Functional Health Literacy in Adults [s-TOFHLA]). Descriptive statistics and bivariate correlations were assessed, along with linear and logistic regression.

RESULTS

One hundred ninety-two patients with an average HbA1c level of 8.1% were included. Of these subjects, 32.8% had limited health literacy as measured by the s-TOFHLA, 58.9% had low adherence as measured by MMAS-8, and 65.1% were nonadherent based on cumulative medication gap (CMG) analysis. Age was associated with s-TOFHLA (-0.411; P<0.01) and MMAS-8 (0.157; P<0.05) scores. HbA1c was associated with MMAS-8 (-0.209; P<0.01) and CMG (0.152; P<0.05) scores. There was no significant association between s-TOFHLA and MMAS-8 or CMG. However, s-TOFHLA was positively related to MMAS-8 question 8, assessing difficulty remembering to take medications (P=0.017).

CONCLUSIONS

Health literacy level is not associated with self-reported or objectively measured medication adherence in underserved patients with T2DM. Lower health literacy scores are associated with a patient experiencing difficulty remembering to take medications.

Neurocognitive impairment is associated with lower health literacy among persons living with HIV infection

This study sought to determine the effects of HIV-associated neurocognitive disorders (HAND) on health literacy, which encompasses the ability to access, understand, appraise, and apply health-related information. Participants included 56 HIV seropositive individuals, 24 of whom met Frascati criteria for HAND, and 24 seronegative subjects who were comparable on age, education, ethnicity, and oral word reading. Each participant was administered a brief battery of well-validated measures of health literacy, including the Expanded Numeracy Scale (ENS), Newest Vital Sign (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM), and Brief Health Literacy Screen (BHLS). Results revealed significant omnibus differences on the ENS and NVS, which were driven by poorer performance in the HAND group. There were no significant differences on the REALM or the BHLS by HAND status. Among individuals with HAND, lower scores on the NVS were associated with greater severity of neurocognitive dysfunction (e.g., working memory and verbal fluency) and self-reported dependence in activities of daily living. These preliminary findings suggest that HAND hinders both fundamental (i.e., basic knowledge, such as numeracy) and critical (i.e., comprehension and application of healthcare information) health literacy capacities, and therefore may be an important factor in the prevalence of health illiteracy. Health literacy-focused intervention may play an important role in the treatment and health trajectories among persons living with HIV infection.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

BACKGROUND

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

METHODS

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

RESULTS

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

CONCLUSIONS

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

Background

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

Methods

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

Results

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

Conclusions

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Electronic supplementary material

The online version of this article (doi:10.1186/s12916-014-0142-1) contains supplementary material, which is available to authorized users.

Health literacy: impact on the health of HIV-infected individuals

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

Impact of health literacy on medication adherence: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature and estimate the effect size of the relationship between health literacy and medication adherence through meta-analysis.

DATA SOURCES

Databases searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982-2013), International Pharmaceutical Abstracts (IPA; 1970-2013), MEDLINE OVID (1966-2013), PubMed (1966-2013), PsycInfo (1966-2013), and Web of Science (1966-2013).

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria were as follows: English language; published through May 1, 2013; medication adherence as the outcome variable; use of validated measures of health literacy and medication adherence; availability of a direct (not mediating) relationship between health literacy and medication adherence; and identifiable effect size and statistical significance of the relationship. Exclusion criteria were as follows: duplicated results, irrelevant results, conference abstracts, proceeding papers, books, dissertations, reviews, editorial letters, continuing education units, or book reviews. Data included author, publication year, disease area, sample size, sampling method, location, study design, effect size of the relationship between health literacy and medication adherence, and measures of health literacy and medication adherence.

DATA SYNTHESIS

There is a small statistically significant and positive association between health literacy and medication adherence. In the conservative results, the unweighted and weighted correlation coefficients were 0.081 and 0.056 with P values <0.001. In the less conservative results, the unweighted and weighted correlation coefficients were 0.088 and 0.072.

CONCLUSIONS

The relationship between health literacy and medication adherence is statistically significant but weak. It is plausible that health literacy has a mediator relationship with other adherence determinants. Future research should explore such relationships.

The association of health literacy with physical activity and nutritional behavior in older adults, and its social cognitive mediators

Inadequate health literacy is a common problem among older adults and is associated with poor health outcomes. Insight into the association between health literacy and health behaviors may support interventions to mitigate the effects of inadequate health literacy. The authors assessed the association of health literacy with physical activity and nutritional behavior in community-dwelling older adults. The authors also assessed whether the associations between health literacy and health behaviors are mediated by social cognitive factors. Data from a study among community-dwelling older adults (55 years and older) in a relatively deprived area in The Netherlands were used (baseline n=643, response: 43%). The authors obtained data on health literacy, physical activity, fruit and vegetable consumption, and potential social cognitive mediators (attitude, self-efficacy, and risk perception). After adjustment for confounders, inadequate health literacy was marginally significantly associated with poor compliance with guidelines for physical activity (OR=1.52, p=.053) but not with poor compliance with guidelines for fruit and vegetable consumption (OR=1.20, p=.46). Self-efficacy explained 32% of the association between health literacy and compliance with physical activity guidelines. Further research may focus on self-efficacy as a target for interventions to mitigate the negative effects of inadequate health literacy.

Three types of self-efficacy associated with medication adherence in patients with co-occurring HIV and substance use disorders, but only when mood disorders are present

Background

Adherence with medication regimens for human immunodeficiency virus (HIV) is a life-saving behavior for people with HIV infection, yet adherence is challenging for many individuals with co-occurring substance use and/or mood disorders. Medication-taking self-efficacy, which is the confidence that one can take one’s medication as prescribed, is associated with better adherence with HIV medication. However, little is known about the influence that other kinds of self-efficacy have on adherence with HIV medication, especially among HIV-infected individuals with co-occurring substance use and/or mood disorders. We sought to examine the relationship between adherence with HIV medication among substance users and three specific kinds of self-efficacy, ie, one’s confidence that one can communicate with medical providers, get support, and manage one’s mood. We further sought to examine whether symptoms of depression and anxiety moderate these relationships.

Methods

Patients were recruited from three HIV clinics in the southeastern United States as part of an integrated study of treatment for HIV and substance use.

Results

We interviewed 154 patients with HIV and substance use who reported taking HIV medications. Based on symptoms of depression and anxiety using the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale-Anxiety, 63% had probable depression and/or anxiety. Higher levels of self-efficacy in provider communication (β = 3.86, P < 0.01), getting needed support (β = 2.82, P < 0.01), and mood management (β = 2.29, P < 0.05) were related to better self-reported adherence with HIV medication among study participants with probable depression and/or anxiety. The three kinds of self-efficacy were not associated with medication adherence among participants with HIV and substance use only.

Conclusion

In the search for mutable factors to improve medication adherence among individuals triply diagnosed with HIV, substance use, and mood disorders, these findings support previous research indicating the benefit of enhancing self-efficacy, and further point to three specific kinds of self-efficacy that may benefit medication adherence, ie, provider communication, getting support, and mood management.