Abstract

We report the adaptation and validation of the Information-Motivation-Behavioral skills ( IMB ) model of ART adherence ( Fisher , Fisher , Amico , & Harman , 2006 ) to

Table 4 . Nested Model Comparisons ( full mediation versus

a population of treatment-experienced Romanian young adults .

Subscales

partial mediation models )

Background

Aim

Methods

Due to nosocomial infection in the late 1980 ’ s , many HIV-infected young adults in Constanta , Romania have been receiving antiretroviral treatment ( ART ) since childhood . The Baylor Black Sea Foundation offers psychosocial support services for this unique population . The transition to adulthood brings the specific challenge of moving from caregiver-managed to self-managed adherence . Adherence support in this cohort is needed , but presently there is limited guidance for intervention targets or content .

We applied the IMB model to this population to identify core factors and specific adherence-related issues that require intervention , and to develop an assessment tool for use in research and clinical practice .

We adapted an IMB-model-based self-report questionnaire on ART adherence ( LifeWindows Project Team , 2006 ) to Romanian via focus groups , back-transla-

Information ( 16 items )

Motivation ( 13 items )

Behavioral skills ( 19 items )

about drug actions and side effects about correct ART utilization and adequate self-care various misinformed heuristics and implicit theories ( e . g . non-adherence appropriate when feeling well ; non-adherence does not impact treatment effectiveness )

Attitudes / Beliefs about ART and adherence ( side effects , pill fatigue , frustration with treatment burden , efficacy concerns ) Perceptions of significant others ’ support for adherence Perceptions of doctor-patient relationship Privacy & disclosure concerns Hope for cure Altruistic motivation For self-cueing ART intake For updating ART adherence related facts For acquiring medication For incorporating regimen into daily routine For managing side-effects and ARV taste For managing treatment privacy For maintaining adherence in special situations ( changes of routine , social events , alcohol use , emotional or physical difficulties , temporary lack of practical support , increase in regimen complexity )

Figure 1 . Path analyses of the IMB model ( pill count )

. 51 **

information

motivation

. 14 *

behavioral skills

. 68 **

e1

. 58

e2

pill count

. 07

Path analysis IMB model Standardized estimates

χ ( 2 ) = 2.863 p =. 239 RMSEA = . 05 (. 00 -17)

CFI = . 996

tion and cognitive interviewing . The resulting questionnaire ( see Table 1 ) was completed by a random sample from our target population , together with measures of adherence ( Dima , Schweitzer , Diaconita , Remor , & Wanless , 2012 ; Remor , 2002 ) and socio-demographic factors . Additional clinical data were collected :

Table 2 . Bivariate associations between IMB constructs and adherence and viral load measures

Results

viral load , physician-assessed adherence , and pill count . Data was analysed using R ( R Development Core Team , 2009 ) and SPSS AMOS ( Arbuckle , 2010 ).

• Sample : 162 participants aged 18-24 , 85 females , mean treatment duration 9 years ( range 1-22 years ), 80 from urban areas , 147 unemployed ( of which only 39 currently studying ), 22 with children .

• Scores on adherence-related information , motivation and behavioural skills were significantly correlated with adherence indicators ( self-report , physician ’ s assessment and pill count ) and viral load ( Table 2 ).

• Path analyses of the relationships stipulated by the IMB-model confirmed previous research ( e . g . Amico et al , 2009 ): behavioural skills mediated the relationship between information and motivation ( as predictors ) and pill count and self-reported adherence ( as outcomes in separate analyses ; Figures 1 and 2 ; Table 4 ).

External criterion Self-reported adherence Doctorassessed adherence

Pill count 1 = < 65 % 2 = 65-95 % 3 = 95-100 %

Viral load

0 = > 400 c / ml 1 = </= 400 c / ml

0.20 ** 0.25 ** 0.28 **

0.07 0.13 0.22 **

Figure 2 . Path analyses of the IMB model ( self-reported

. 51 **

information

motivation

. 14 *

behavioral skills

. 68 **

e1

. 58

e2

. 17

Path analysis IMB model Standardized estimates

χ ( 2 ) = 1.828 p =. 401 RMSEA = . 00 (. 00 -. 15 )

CFI = 1.00

• Nonparametric IRT analyses ( Mokken ; van der Ark , 2007 ) identified several distinct issues relevant to adherence ( Table 3 ).

Conclusions

Authors :

Alexandra Dima 1 , Ana-Maria Schweitzer 2 , K . Rivet

Amico 3

– Amsterdam School for Communication Research , University of

- Baylor Black Sea Foundation , Constanta , Romania

- Center for Health , Intervention and Prevention , University of

Contact :

a . dima @ uva . nl aschweitzer @ baylor-romania . ro

• The IMB model provided a useful theoretical framework for the identification of potential intervention targets , which may guide future adherence-support

work with this group .

• The adherence-related themes identified via Mokken analysis may provide an additional complementary approach for clinical intervention .

• This study represents an important advancement towards assessing ART adherence determinants and developing tailored adherence interventions in this

• Further validation research is recommended in this population and other Romanian populations .

References :

Amico , K . R ., Barta , W ., Konkle-Parker , D . J ., Fisher , J . D ., Cornman , D . H ., Shuper , P ., & Fisher , W . A . ( 2009 ). The information-motivation-behavioral Skills model of ART adherence in a Deep South HIV positive clinic sample . AIDS and Behavior , 13 , 66 – 75 . Arbuckle , J . L . ( 2010 ). Amos ( Version 19.0 ) [ Computer Program ]. Chicago : IBM SPSS . van der Ark , L . A . ( 2007 ). Mokken scale analysis in R . Journal of Statistical Software , 20 ( 11 ), 1-19 . Dima , A ., Schweitzer , A . -M ., Diaconita , R ., Remor , E . & Wanless , R . ( 2012 ). Adherence to ARV medication in Romanian young adults : self-reported behaviour and psychological barriers . Psychology , Health & Medicine . doi : 10.1080 / 13548506.2012.722648 Fisher , J . D ., Fisher , W . A ., Amico , K . R ., & Harman , J . J . ( 2006 ). An information-motivation-behavioral skills model of adherence to antiretroviral therapy . Health Psychology , 25 ( 4 ), 462 – 473 . LifeWindows Project Team ( 2006 ). The LifeWindows Information Motivation Behavioral Skills ART Adherence Questionnaire ( LW-IMB-AAQ ). Unpublished instrument . Retrieved September 14 , 2008 , from http :// www . chip . uconn . edu / int / F _ LWIMBARTQuestionnaire . pdf R Development Core Team ( 2009 ). R : A language and environment for statistical computing . [ Computer software ] Vienna , R Foundation for Statistical Computing . Retrieved from http :// www . R-project . org . Remor , E . ( 2002 ). Manual del cuestionario para la evaluación de la adhesión al tratamiento antirretroviral : CEAT-VIH . [ Manual of the questionnaire to assess adherence to antirretroviral treatment ]. ( PDF document ). Madrid : Department of Psychobiology and Health , Faculty of Psychology , UAM .

General themes ( H =. 30 )

Knowledge ( 4 items )

Misinformation ( 5 items )

Sub-themes ( H =. 50 )

Social support ( 2 items ) Planning ( 2 )

Motivational - behavioural skills ( 17 items )

Prioritization ( 2 )

Emotion regulation ( 7 )

Side effects ( 3 )

Long-term harm ( 3 )

Content examples

Information about drug actions , correct ART utilization , interactions with alcohol Skills for updating ART adherence-related facts “ I can interrupt pill-taking if my blood tests are fine ” “ if I cannot take one of the pills , it ’ s ok to take only the others ” “ it is important to take the strongest pill of those prescribed by the doctor ;

I can skip the other ones ” “ the doctor could prescribe better pills for me than those I ’ m taking now ” “ it is important to take pills every day , irrespective of the hour ” Perceived social support and skills for obtaining support Skills for managing a busy schedule and changing routines Skills for managing adherence when feeling well and dealing with competing goals Skills for dealing with lack of privacy and fear of disclosure Skills for maintaining adherence in situations of emotional conflict and social pressure Pill fatigue , frustration with chronic condition and treatment burden Concerns about and skills for dealing with side effects “ it is better to wait until the disease evolves before taking pills more often ” Concerns with long-term effects on physical appearance and worsening health status Difficulties in acquiring medication