Mujeeba Ashraf  ( Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan. )
Rabia Nisar Virk  ( Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan. )

Objectives: To explore the constructs of the Health Belief Model in order to predict medication adherence in patients with human immunodeficiency virus.

Method: The correlational study was conducted at Jinnah Hospital, Lahore, Pakistan, from March to May 2019, and comprised patients positive for human immunodeficiency virus aged 18-55 years and taking antiretroviral therapy from at least three months. Data was collected using the Urdu version of the health belief scale (HBS), cues to action, and adherence determination questionnaire (ADQ). Data was analysed using SPSS 22.

Results: Of the 150 subjects, 109(72.7%) were males, 36(24%) were females and 5(3.3%) were transgender. The overall mean age was 33.17+/-8.22 years. The perceived susceptibility, severity and barriers to engage in human immunodeficiency virus-preventive behaviour significantly positively predicted medication adherence (p<0.05). Perceived benefits were not helpful in understanding medication adherence pattern (p>0.05).

Conclusion: There was need to introduce awareness campaign regarding the importance of taking regular medication by human immunodeficiency virus patients.

Keywords: Health belief model, HIV in Pakistan, Medication adherence, Perceived severity, Perceived barriers. (JPMA 71: 1409; 2021)

DOI: https://doi.org/10.47391/JPMA.1463

 

Introduction

 

According to Pakistan's National acquired immunodeficiency syndrome (AIDS) Control Programme (NACP), in 2019 approximately 165,000 people were living with human immunodeficiency virus (HIV) and only 17,149 patients were registered with NACP for getting antiretroviral treatment.¹ However, the Joint United Nations Programme on HIV and AIDS (UNAID) reported that in 2019 only 12% of HIV patients were on treatment. In addition, 5% of HIV-positive sex workers, 16.2% drug injectors, and 10.2% transgender were taking antiretroviral therapy in Pakistan.² This low level of treatment coverage increases the disease-related mortality rate in Pakistan.

This might be because of various countries in the Asia-Pacific region are dependent on international funding. For example, Indonesia (58%), Bangladesh (84%), Philippines (68%) and Pakistan (64 %) depend on donor-funding to provide antiretroviral therapy (ART) to HIV patients.³

ART contributes to slowing down of HIV progression and prevents opportunistic diseases, which, in turn, promotes healthier lives and increases life expectancy of HIV patients.⁴ For achieving these benefits, perfect medication adherence (MA) is considered necessary. In the context of Asia-Pacific region, factors considered important in increasing MA in HIV patients include effective communication style of the care provider, HIV treatment literacy, and early referral from health workers or the co-infected3. However, research showed that in chronic medical conditions, MA falls 20-80%.⁴ Also, studies indicate that patients with HIV are not achieving optimal MA level due to various psychosocial factors, including, age, profession, gender, literacy level, injecting drug use, and fear of diagnosis at public hospitals.^3,5,6

Besides, the challenges to address non-adherence were based on behaviour theories that are used for behaviour-change. The health belief model (HBM) focuses on various factors, including perceived severity of a disease, perceived susceptibility of an individual to that disease or susceptibility to disease progression, perceived benefits linked with health behaviour to combat the disease, perceived barriers to practising healthy behaviour, cues to action, and self-efficacy to change health behaviour, including adherence, in chronic health conditions, such as HIV and diabetes.⁷ In short, HBM is utilised for the detection of disease, finding an acceptable remedy and getting well. The essential idea of HBM is a mechanism to reduce and avoid disease conditions and to clarify or predict health behaviours in various conditions.^8,9

In Europe, studies have been done using HBM in HIV patients.⁴ In Pakistan, less research has been carried out on MA in people living with HIV. The current study was planned to explore HBM constructs to predict MA in patients with HIV.

 

Patients and Methods

 

The correlational study was conducted at Jinnah Hospital, Lahore, Pakistan, from March to May 2019, After approval from the institutional ethics review committee and AIDS control programme in Lahore, the sample was raised using purposive sampling technique from Jinnah Hospital, which is a 1250-bed public-sector teaching hospital.

Those included were HIV patients aged 18-55 years and on ART for at least three months.  Those not willing to participate were excluded.

After taking informed consent, demographic and clinical data was collected from the subjects using a self-generated proforma and other tools. As most of the participants were illiterate, all data-collection tools were administered orally on patients by the researchers. Permission to translate and use the AIDS Health Belief Scale (AHBS),¹⁰ Cues to Action Scale (CAS)¹¹ and Adherence Determination Questionnaire (ADQ)¹² were obtained from the relevant authors through e-mail. The translation process was carried out in two steps; forward and backward translations with assessment measures in the first step, and a pilot study to test comprehension in the second step.

The AHBS, developed by Zagumny and Brady in 1998, was used to assess HBM components perceived severity of contracting HIV, perceived benefits of prevention methods, perceived susceptibility to contracting HIV, and perceived barriers to engaging in HIV-prevention behaviours. It has 16-items scored on a 6-point scale ranging from 1 = strongly disagree to 6 = strongly agree, with no middle point. Its reliability ranges from 0.82 to 0.93.¹⁰

CAS, developed by Wilson et al. in 1991 based on HBM, was used to assess participants' exposure to cues that could influence them to engage in an HIV/AIDS preventive health behaviour. The scale has 10 items, with a score range of 0-10. Cronbach's alpha reliability was 0.40.¹¹

The ADQ, developed by DiMatteo et al. in 1993, is based on HBM and consists of 38 short statements rated on a Likert scale from 1 = strongly disagree to 5 = strongly agree. It has seven subscales: perceptions of the interpersonal aspects of medical care received, beliefs about the severity of the disease, beliefs about susceptibility to disease, beliefs about the perceived utility of the recommendations, subjective norms regarding adherence, intentions to adhere, and the presence of supports and the absence of barriers to adherence. The alpha reliability of the subscales ranged from 0.65 to 0.85.¹²

Data was analysed using SPSS 22.¹³ Spearman-Brown correlation analysis and linear regression analysis was used as required, to find out which HBM components could predict MA.

 

Results

 

Of the 170 adults approached, 150(88.2%) participated; 109(72.7%) males, 36(24%) females and 5(3.3%) transgenders. The overall mean age of the sample was 33.17±8.22 years.  Also, 142(94.7%) subjects were Muslims; 113(75.3%) belonged to urban areas; and 103(68%) were working. Further, 81(54%) participants had not used any type of addictive drugs (Table-1);

 

 

150(100%) had HIV-1 infection; and 110(73.3%) had no family members infected with HIV. The mean age of HIV onset was 30.4±7.94 years and the mean duration of infection was 2.86±2.57 years. Of the total, 101(67.3%) participants had no disease before HIV infection; 126(84%) had no psychological co-morbidity with HIV; 74(49.3%)showed complete MA behaviour; and 76(50.6%) had partial MA behaviour

overall AHB and perceived susceptibility, severity, and barriers to engaging in HIV-preventive behaviour subscales were significantly positively correlated with overall MA (p<0.05). However, CAS was non-significantly positively correlated with overall MA (p>0.05) (Table-2).

 

 

No demographic variable was controlled for regression analysis as no significant correlation was found between demographic variables and the studied variables. Analysis showed that perceived severity, susceptibility and barriers to engage in HIV-preventive behaviour significantly predicted MA, but perceived benefit was not significant in this regard (p>0.05). The studied variables explained 24% variance in MA, and the behaviour increased by 2.0 with each unit increase in perceived severity, and by 0.78 with each unit increase in perceived barriers to engaging in HIV-preventive behaviour, but MA behaviour decreased by -0.72 with each unit increase in perceived susceptibility (Table-3).

 

 

Discussion

 

Findings indicated that MA was significantly positively correlated with three components of HBM. Also, linear regression analysis revealed that perceived severity, susceptibility, and barriers to engaging in HIV-preventive behaviour significantly predicted MA, which is in line with literature.^14,15

Moreover, in patients susceptible to the disease, MA behaviour decreased and this might be because their cluster of differentiation (CD) counts were in a controlled range. This is in line with the literature.^14,16 Also, perceived barriers to engage in HIV-preventive behaviours increased MA which reflected the capacity to deal with barriers and the ability to take necessary actions.¹⁷

In the current sample, except one, all HBM components explained MA. Literature presents a variety of results regarding HBM and MA in HIV patients.^18,19 This might be because of the use of varied types of HBM scales in different researches.²⁰

Despite being the first study on the matter conducted in Lahore, the current study has its limitations as data was collected only from the one hospital. Also, the study was correlational, and, therefore, no causal relationship could be identified. The scales used were self-reported measures and may manifest socially-desirable responses. However, the scales have been widely used and the findings of the current study have significant correlation with other data-sets. Future longitudinal studies should explore the perceived cost of antiretroviral drugs in terms of finance and other factors to assess variables that may predict MA.

 

Conclusion

 

Perceived severity, susceptibility and barriers to engage in HIV-preventive behaviour significantly predicted MA. The findings can be used to develop strategies to improve HIV MA.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

References

 

1.      Riaz F. An alarming rise in HIV. News release. The News International Media Centre. [Online] 2019 [2020 August 27]. Available from URL: https://www.thenews.com.pk/tns/detail/567746-alarming-rise-hiv

2.      Aidsdatahub. Country profiles Bangkok: The HIV and AIDS Data Hub. [Online] 2017 [Cited 2020 August 27]. Available from URL: http://www.aidsdatahub.org/Country-Profiles

3.      Koirala S, Deuba K, Nampaisan O, Marrone G, Ekström AM. Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh, Indonesia, Lao, Nepal, Pakistan, Philippines and Vietnam. PLoS One 2017;12:e0176914. doi: 10.1371/journal.pone.0176914.

4.      Simoni JM, Frick PA, Pantalone DW, Turner BJ. Antiretroviral adherence interventions: a review of current literature and ongoing studies. Top HIV Med 2003;11:185-98.

5.      Nachega JB, Uthman OA, Anderson J, Peltzer K, Wampold S, Cotton MF, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS 2012;26:2039-52. doi: 10.1097/QAD.0b013e328359590f.

6.      National Agency for the Control of AIDS (NACA). National HIV Prevention Plan 2014-2015. [Online] [Cited 2014 January 01]. Available from URL: https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_334880.pdf

7.      Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q 1984;11:1-47. doi: 10.1177/109019818401100101

8.      Hayden J. Introduction to Health Behavior Theory, 2nd ed. Burlington, MA: Jones & Bartlet Learning; 2014.

9.      DiMatteo MR, Haskard KB, Williams SL. Health beliefs, disease severity, and patient adherence: a meta-analysis. Med Care 2007;45:521-8. doi: 10.1097/MLR.0b013e318032937e.

10.    Zagumny MJ, Brady DB. Development of the AIDS Health Belief Scale (AHBS). AIDS Educ Prev 1998;10:173-9.

11.    Wilson D, Manual A, Lavelle S. Psychological predictors of condom use to prevent HIV transmission among Zimbabwean students. Int J Psychol 1991;26:705-21. doi: 10.1080/00207599108247161

12.    DiMatteo MR, Hays RD, Gritz ER, Bastani R, Crane L, Elashoff R, et al. Patient adherence to cancer control regimens: Scale development and initial validation. Psychol Assess 1993;5:102. Doi: 10.1037/1040-3590.5.1.102

13.    Field A. Discovering statistics using IBM SPSS statistics, 4th ed. London, UK: SAGE Publications Ltd; 2013.

14.    Gao X, Nau DP, Rosenbluth SA, Scott V, Woodward C. The relationship of disease severity, health beliefs and medication adherence among HIV patients. AIDS Care 2000;12:387-98. doi: 10.1080/09540120050123783.

15.    Polit DF, Beck CT. Nursing Research: Principles and Methods, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

16.    Iriyama S, Nakahara S, Jimba M, Ichikawa M, Wakai S. AIDS health beliefs and intention for sexual abstinence among male adolescent students in Kathmandu, Nepal: a test of perceived severity and susceptibility. Public Health 2007;121:64-72. doi: 10.1016/j.puhe.2006.08.016.

17.    Brown LK, DiClemente RJ, Reynolds LA. HIV prevention for adolescents: utility of the Health Belief Model. AIDS Educ Prev 1991;3:50-9.

18.    Barclay TR, Hinkin CH, Castellon SA, Mason KI, Reinhard MJ, Marion SD, et al. Age-associated predictors of medication adherence in HIV-positive adults: health beliefs, self-efficacy, and neurocognitive status. Health Psychol 2007;26:40-9. doi: 10.1037/0278-6133.26.1.40.

19.    Turner BJ, Fleishman JA, Wenger N, London AS, Burnam MA, Shapiro MF, et-al. Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. J Gen Intern Med 2001;16:625-33. Doi: 10.1046/j.1525- 1497.2001.016009625.x

20.    Blackwell B. Compliance. Psychother Psychosom. 1992;58:161-9. doi: 10.1159/000288624.