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New model of adherence teaches IMB skills
Motivation often is the biggest barrier
HIV patients who are better informed, have some social support, and who are not concerned about medication side effects have a higher self-reported adherence, a new study shows.
"Adherence is an extremely complex phenomenon, and it needs to be tailored to each individual person and to where they are in the process of thinking about medications," says Deborah Konkle-Parker, PhD, FNP, of the University of Mississippi Medical Center, division of infectious diseases in Jackson, MS.
Adherence requires a multi-factorial approach because of the complex reasons why people will choose not to take a medication that is saving their lives, experts say.
This is why investigators have been exploring the use of a long-standing model of health behavior in psychological literature, called the information-motivation-behavioral (IMB) skills model, in an intervention to improve antiretroviral medication adherence.
"The better informed and motivated a person is, the more likely it is that he/she will seek information through other functions to help develop the necessary behavioral skills," says K. Rivet Amico, PhD, an assistant research professor at the Center for Health, Intervention & Prevention, University of Connecticut in Storrs, CT.
Amico and Konkle-Parker are among the researchers who are studying using the IMB skills model among a population of HIV-infected people in the Deep South, which they define as including the Carolinas, Georgia, Mississippi, Alabama, and Louisiana.
These southern states were singled out because they carry a disproportionate share of the AIDS epidemic, Amico notes.
"One-third of the U.S. population resides in the south, but 44 percent of AIDS cases are there," she says. "When you look further into it, you see that there was a 38 percent increase in new AIDS cases in the Deep South, compared with a 13 percent increase in all other southern states and 17 percent in the rest of the United States."
So, the AIDS epidemic is a crisis in the Deep South, which makes treatment adherence of critical importance, Amico says.
The study had a convenience sample of 150 participants at a large infectious disease clinic in Jackson, MS. Konkle-Parker approached patients as they waited for an HIV care appointment in the clinic, asking them if they were prescribed antiretrovirals and if they would be willing to complete a computer-delivered survey of medication adherence.1
The IMB approach looks at the HIV patients' personal motivation, which addresses their beliefs. These beliefs include their thoughts about their medication and the side effects, Amico explains.
"It also looks at barriers that come from the difficulty of having to adhere at a time when there is no end point," Amico says.
The behavioral skills addressed include patients' actual set of skills for adhering and their confidence in doing so, she adds.
"How hard is it for you to take your meds at work? Do you have the skills for taking medication in these different contexts?" Amico says.
It's not enough to inform patients about their disease and treatment and then to obtain their buy-in to adhering to their drug regimen, Amico notes.
"If patients don't have the skills they need to be confident in the action of taking medications in different situations, then they won't be able to sustain adherence over time," she explains. "Motivation and information are important, but these have to be combined with behavioral skills."
In the IMB model, it is motivation that might present HIV patients with the biggest difficulty, Konkle-Parker says.
"This has a lot to do with the cultural context," she says. "Stigma is very huge against HIV and against homosexuality in the South."
In Konkle-Parker's Mississippi clinic, the HIV population mainly involves African Americans who have a low income and typically a high school education.
"Stigma is very big in that community," she says.
One key to combating stigma is to show patients that their medications and clinic visits are things that will help them improve their health, even if the antiretrovirals might make them feel worse initially, Konkle-Parker says.
"A lot of times if patients have antiretroviral drug side effects, they'll stop coming back to get medical care," she adds. "They think, 'Oh, I feel fine, so I didn't need to come in anymore.'"
Through an IMB intervention, they learn how to manage their symptoms on a daily basis, as well as look at the bigger picture involving the physical costs of taking the drugs versus the physical benefits.
The IMB research so far suggests that helping HIV patients become better informed and helping them foster social support are important steps to assisting patients in implementing better health behaviors on a daily basis, Amico says.
"We're helping people develop strategies for getting to clinics and how to take their medications despite issues of nondisclosure," Amico says. "To the extent you can do those things in an intervention, you will have effective responses in increasing and sustaining adherence over time."
The main point is to tailor the intervention to the individual, Konkle-Parker says.
"Any particular person may have barriers that are completely different from someone else," she says. "Giving one person pill boxes may not help, but for another person it may be the exact thing they need."
Konkle-Parker uses the IMB skills assessment to guide her to patients' particular deficits, and in any intervention, she addresses those specific barriers.
Assessing patients' obstacles or deficits is not time consuming, Amico says.
Clinicians could use a checklist or options protocol, asking questions that will lead them to what is most problematic for a particular patient, Amico says.
"The more you help patients get some ideas of what's getting in their way, the better you are able to offer suggestions on what to do about that," Amico says.
"In my intervention study, I specifically did a very low labor intensive, low tech intervention," Konkle-Parker says. "I tested an intervention that involved two face-to-face sessions with myself as the interventionist and not a clinical care provider."
This would be similar to if an adherence counselor conducted the intervention, she notes.
The intervention included telephone check-ins after the two meetings, so it was not time consuming, Konkle-Parker says.
Another strategy could be using computer software to provide an assessment that patients complete while waiting in a clinic for their appointment, Amico says.
"There is active research into how we can best utilize that clinic situation," she adds. "Many clinics have long waits."
An IMB assessment tool would not measure specific barriers, such as transportation and housing, but it addresses behavioral skills that influence adherence, Konkle-Parker says.
"The assessment tool would ask how easy it is for the patient to pick up his or her HIV medications," she explains. "When the clinician sees from the assessment that one thing is hard for the patient to deal with, then the clinician can say to the patient, 'Tell me about it.'"
This approach starts a dialogue between clinicians and patients, and from that dialogue, solutions will follow.
All of these approaches are patient-centered, meaning they address what the needs are of a particular patient, and follow-up from there.
"You find out what the patients' needs and situations are and you think about how to deal with these situations," Konkle-Parker says.
Motivational interviewing is one strategy to doing this, she says.
"If it's clear from the assessment that a patient is not highly motivated to taking medications in a public setting, for instance, then you ask the patient how he feels about that," Konkle-Parker says. "You may need to provide the patient with information, and through motivational interviewing, you could create a sense in the patient that this is a problem that he has to deal with."
Many clinics are moving toward a more patient-centered approach, Amico notes.
"When the diagnosis is A, the problem is B, and the solution is C is a more prescriptive approach," Amico says. "Seeing the patient as a valuable player in his or her own solution is a strategy that supports people in doing their own assessments of what gets in the way of their adherence."
Sometimes, just asking the right questions, such as through an assessment tool, can be an intervention.
"One of the findings in my intervention pilot study was that every person, whether in the intervention group or not, improved in all of the outcomes of self-reported adherence from the beginning to the end of the study," Konkle-Parker says. "The only thing they had in common was they all did the assessment tool throughout the study, so it does bring up the question of whether the assessment itself is bringing issues to mind."