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HIV & AIDS Review. International Journal of HIV-Related Problems
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Original paper

Investigating social support, self-efficacy, and factors affecting adherence to medication in people living with HIV/AIDS: application of IMB model

Mohammad Saeed Jadgal
1, 2
,
Ehsan Movahed
3
,
Moradali Zareipour
4

1.
Tropical and Communicable Diseases Research Center, Iranshahr University of Medical Sciences and Health Services, Iranshahr, Iran
2.
Department of Public Health, School of Nursing and Midwifery, Iranshahr University of Medical Sciences and Health Services, Iranshahr, Iran
3.
Department of Public Health, School of Public Health, Jiroft University of Medical Sciences, Jiroft, Iran
4.
Department of Public Health, School of Health, Khoy University of Medical Sciences, Khoy, Iran
HIV AIDS Rev 2022; 21, 2: 109-114
Online publish date: 2022/04/13
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Introduction

Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) have physical, psychological, and social consequences on people living with HIV (PLHIV) [1]. Globally, 36.9 million people are living with HIV/AIDS [2]. The number of HIV patients in Iran was reported as 66,000 in 2016. Moreover, the number of new cases of HIV infections has increased by 21% since 2010, but AIDS mortality rate decreased by 14% [3]. According to the latest reported statistics, 21.7 million people have already received antiretroviral therapy (ART) up till 2017 [3]. Failure to ART adherence can cause depression and spread of infections.
The Joint United Nations Program on HIV/AIDS (UNAIDS) has set the goal of ending the AIDS epidemic by 2030 [4]. This goal includes 90% of PLHIV globally being diagnosed, on treatment, and virologically suppressed. To achieve this goal, ART adherence should be higher than 95% [5]. The goal of ART is to prevent the progress of disease, improve quality of life [6], reduce HIV symptoms, enhance immunological body, and reduce drug-related side effects [7].
A study on PLHIV in India in 2016 showed that ART adherence was at a low level [8]. But in Tehran, Brazil, and Nepal, it was 59.5% to 94.8% [9, 10]. Movahed et al. in 2019 showed that 75.4% of HIV-positive cases had good adherence, with most patients (74.6%) believing that ART had a positive effect on their health. In addition, 67.2% of partici­pants were satisfied with a support of other people. In this regard, 71.3% of patients mentioned that their family members and friends encouraged them to take ART [11]. Results of a study by Bam et al. indicated that transportation problems and lack of knowledge led to non-adherence to treatment in PLHIV [9]. Also, low social support can result in a negative impact on patients’ physical and mental well-being [12]. Low social support could result in poor adherence to medication and immune suppression, and finally lead to depression. The prevalence of depression among PLHIV in sub-Saharan Africa was 9% to 32% [13]. In Ethiopia, it ranged from 7.3% to 73.3% [12].
Therefore, in order to adherence more to drugs, skills and self-efficacy should be increased in HIV/AIDS individuals. The Information-Motivation-Behavioral Skills (IMB) model is one of the models widely considered in the area of ART adherence in health psychology [14]. In this model, information is considered as a prerequisite of personal and social motivation, while risk perception is a motivational requirement for learning skills [15]. The results of a study by Alexander et al. showed that behavioral skills were significantly affected by mediating effects of information and motivation in treatment adherence [14]. Given the prevalence of HIV/AIDS and importance of ART for PLHIV, ART adherence seems to be the best and most effective way to improve patients’ quality of life. In addition, a limited number of studies were conducted on this subject in Iran. Therefore, the present research was carried out to investigate the social support, self-efficacy, and factors affecting adherence to medication in people living with HIV/AIDS, with the application of IMB model.

Material and methods

Study and setting
This intervention study was conducted among HIV/AIDS-positive patients, who were over 18 years of age. These patients were referred to the Behavioral Diseases Counseling Center of Iran in 2018.

Sampling
Inclusion criteria for the study participants were having 18 years or more and using ART for 6 months. Exclusion criteria was lack of cooperation. Since the statistical population included 183 individuals, census sampling method was applied, with total of 117 people participating in the study.

Intervention
Intervention included eight 60-90 minute training sessions carried out over the course of 14 weeks, based on participants’ opinions about timely drug administration and practical solutions using IMB model (Table 1). Following the intervention, the researcher returned to the counseling center every Monday for three months to refresh the contents.

Data collection
AIDS Clinical Trials Group (ACTG) questionnaire, designed by Kekwaletswe for HIV-positive patients, was used in the present study. The questionnaire consists of three parts. First part of the questionnaire deals with self-efficacy of adherence and beliefs with regard to usefulness of drugs. This section contains three items, which should be answered on a 4-point Likert scale (ranging from 0 = ‘I am not sure at all’ to 3 = ‘I am completely sure’). Second part considers social support, in which participants’ satisfaction with family and friends’ support is assessed in one item (0 = ‘very dissatisfied’ to 3 = ‘very satisfied’). Patients’ satisfaction with family and friends’ support in taking ART is also evaluated in one item (0 = ‘not at all’ to 4 = ‘very much’). Third part of the questionnaire considers causes of ART non-adherence, including 18 items (0 = ‘never’, 1 =’ rarely’, 2 = ‘sometimes’, and 3 = ‘often’). Kekwaletswe et al. confirmed the validity and reliability of this questionnaire by Cronbach’s α of 0.71 [16, 17]. To conduct this study in the Iranian culture and among people of Kerman, necessary adjustments were made in ACTG questionnaire. Its’ content validity was confirmed by a panel of experts, including 10 physicians and infection specialists of the Kerman University of Medical Sciences. Reliability of the adjusted questionnaire was also calculated as 0.79 by Cronbach’s α. Ethics approval and consent to participate
After obtaining ethics code from the Ethics Committee of Yazd University of Medical Sciences (IR. SSU. SPH. REC 1396.83), the researcher received a list of eligible individuals referred to the Behavioral Diseases Counseling Center, Iran. Prior to sampling, participants were provided with explanations on the study purpose, and confidentiality of their information was reassured. Participants were also requested to sign an informed consent forms to participate in the study.

Statistical analysis
Descriptive statistics were applied to describe characteristics of the study population and pair t-test was applied to investigate factors of adherence to drugs for before and after the intervention in two investigated groups. To analyze the data, SPSS version 24 was used.

Results

A total of 117 HIV/AIDS-positive patients with a mean age of 42.29 ± 9.40 years participated in the study. Of all participants, 51.3% were males, 46.2% were married, 36.8% presented diploma or higher education levels, 54.7% were unemployed, 32.5% had no children, and the rest had at least one child. Furthermore, 41.5% of the individuals had an income of more than 48 $. According to Table 2, the disease was transmitted by sex in 38.4% of the persons, BMI was normal in 53.8% of patients, and CD4+ count was higher than 350 in 61.5% of participants. According to the findings, 96.6% of the respondents had HIV, viral load was less than 100 in 68% of patients, and 39.31% of them did not mention risk factors, such as substance use (Table 2).
In 17.9% of the cases, forgetfulness was the cause of ART non-adherence. Moreover, away from home and felt depressed in 9.4%, and transportation problems in 8.5% were the main reasons for ART non-adherence (Table 3).
Significant relationship was observed after the intervention based on IMB model, with self-efficacy (0.000) and social support (0.010) (Table 4).

Discussion

The main reasons for ART non-adherence included forgetfulness in taking ART (17.9%), away from home, depression (9.4%), and transportation problems (8.5%). Significant relationship was observed after the intervention based on IMB model with self-efficacy and social support. Similar to our study, Movahed et al. [11] and Fonsah et al. [18] showed that main reason for ART non-adherence was patients’ forgetfulness. However, Bam et al. mentioned side effects of ART as another major cause of ART non-adherence in these patients [9]. In a study, Hosseinalipour et al. described fatigue (28.8%), problems with medication (19.0%), and forgetfulness of taking medication (11.0%) as reason for ART non-adherence [19]. Also, in a systematic review by Shubber et al., most frequently reported individual barriers were forgetting (41.4%), being away from home (30.4%), change to daily routine (28.0%), depression (more than 15.0%), alcohol/substance misuse (12.0%), secrecy/ stigma (more than 10.0%), feeling sick (5.9%), and distance to clinic (17.5%) [20]. The number of samples, tools, and different locations produced differences in the results. But in most studies, forgetfulness and being away from home were cited as the main reasons. Differences in study tools may lead to such discrepancies between results of the present study and those reported by Bam et al. [9]. In the present study, self-efficacy and social support were increased after the intervention based on the model IMB. In Morowatisharifabad et al., risk perception and self-efficacy had the highest mean scores after intervention based on IMB model among PLHIV [21]. But in a study of Ameri et al., results were inconsistent with our data [22]. In studies by Barclay and Alexander et al., self-efficacy was shown low among HIV-positive adults [15, 23]. Numerous studies have demonstrated an appropriate effect of social support and self-efficacy on increasing drug adherence [17, 24, 25]. In a study of Wesevich et al. after couple of HIV testing and counseling (cHTC), self-efficacy increased, and there was a significant median difference (p = 0.02) for participants before and after cHTC [26]. This discrepancy in findings can be attributed to a variety in participants’ age (elderlies did not have enough trust in ART adherence), different tools, and geographic region. In our study, significant relationship between the cause of forgetfulness after intervention was not observed. But, in a study by Eftekhar Ardebili et al., according to planned behavior theory constructs, perceived behavior control had a significant relationship with medication adherence [27]. Additionally, Lyndsay et al. shown younger age and lower health literacy were associated with higher barrier scores for all IMB model constructs [28]. In a study by Costellia et al., in order to increase breast cancer screening behavior, functional breast cancer literacy and motivation interventions were important factors after intervention based on IMB model [29]. Comparison of these results showed that information model is not useful in all behaviors, as it has been more effective in promoting breast cancer screening behavior in middle-aged, older, and literate people. Therefore, in the forgetting of drugs taking behavior, the information model did not have a suitable application.

Conclusions

The IMB model can be effective in promoting self-efficacy and social support in HIV-positive individuals. Since these patients face a high level of stigma, increasing self-efficacy and social support can help them to become more self-sufficient in adhering to the medication regimen and increase their participation. However, the information model was ineffective for major problems, which had reduced adherence to the medication regimen, such as forgetting to take medications, depression, and transportation issues. It is suggested that behavioral skills of policy-makers and planners prioritize the use of daily and weekly medicine boxes, support of experienced psychologists, and reduced cost of transportation in order to avoid forgetting to take medications.

Acknowledgements

The authors would like to thank the nurses and staffs of the Behavioral Diseases Counseling Center in Kerman.

Conflicts of interest

The authors declare no conflict of interest.

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