Student Number : 9803027N - MA research report - School of Psychology - Faculty of Humanities / The recent introduction of antiretroviral treatment (ART) to the public health sector has meant that for millions of Human Immunodeficiency Virus (HIV)-positive patients this deadly disease has been transformed into a chronic condition. There has been much research done internationally on adherence to ART but in South Africa there has been little investigation in this area. This study aimed to bridge this gap by exploring expert and patient opinions and recommendatio ns regarding adherence to antiretroviral medication. To attain this, four experts and seven patients were interviewed using a semistructured interview schedule. The experts had worked within the HIV field for at least two years while the patients had been chosen from public antiretroviral roll-out programmes and had been on ART for at least six months. These interviews were audio recorded and transcribed. The transcriptions were then explored for themes using thematic content analysis. These themes were categorised and discussed under four broad categories: patients’ perceptions of barriers to adherence, patients’ recommendations for improving adherence, experts’ perceptions of barriers to adherence and experts’ recommendations for improving adherence.

Thesis advisor: Anne E. Norris / Little is known about adherence among African American women with HIV. This crossectional study investigated the direct and indirect effects of subjective wellbeing (SWB), physical activity, depression, and spiritual beliefs on adherence to antiretroviral therapy, condom use, and appointment keeping in 86 participants. These variables formed a theoretical model proposed in response to findings in the literature and clinical observations. Participants completed demographic and clinical questionnaires, the Center for Adherence Support Evaluation (CASE) Adherence Index (antiretroviral therapy adherence), Satisfaction with Life scale (SWB), Paffenbarger Physical Activity Questionnaire, CES-D (Depression), the Faith subscale of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale (spiritual beliefs), and questions regarding condom use and appointment keeping. Descriptive statistics, ANOVA, t-tests, and Chi square analyses were used to analyze clinical and demographic variables, scale means, and effects on adherence variables. Linear and logistic regression analyses were used to test study hypotheses, and path analysis was used to confirm the relationships in the linear regression model. The final model for medication adherence explained 31% of the variance. SWB had a direct effect (β = .30, p < .01). Spiritual beliefs had direct (.21), and indirect effects (.07) through SWB. Having a history of hospitalization for mental illness had direct (-.25), and indirect effects (-.06) through SWB. Physical activity had only a direct effect (β = - .19, p = .05), and no effect on SWB (p = .26). Findings failed to support relationships hypothesized in the model for condom and appointment adherence, though age was shown to have a positive effect (B = 0.06, p < .05) on appointment adherence in the final model. Further research is needed to replicate these findings in a larger cohort of African American women with HIV, and to identify factors that impact condom use and appointment keeping. Study findings argue for the need to assess spiritual beliefs, connect individuals with programs designed to enhance spiritual beliefs, and other resources that may positively influence well-being and medication adherence in this population. / Thesis (PhD) — Boston College, 2008. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

ABSTRACT The formulation and approval of the Operational Plan for Comprehensive Care, Management and Treatment for HIV/AIDS in 2003 was a major victory for the roll-out of anti-retroviral therapy (ART) in the public sector in South Africa. Since its initiation in 2004, the ART Programme has expanded rapidly and realised considerable gains in prolonging life. However, it has also faced major constraints and implementation has been uneven across provinces. This study investigates the impact of organisational capacity upon levels of adherence to ART in two public sector sites in Gauteng. The study uses the Chronic Care Model (CCM) proposed by Edward Wagner (2004). The CCM identifies four major components as crucial to effective clinical outcomes for the management of chronic care. These factors are (1) prepared proactive practice teams; (2) delivery systems design; (3) decision support; and (4) clinical information systems. Both sites demonstrated different strengths and constraints. Strengths included the presence of motivated champions leading the ART service, positive patient-provider relationships, shifting of tasks to lower level health workers to deal with the shortage of skilled staff, good relationships with non-governmental organisations and the innovation to deal with challenges in a way that does not compromise the quality of care provided to patients using the CCMT service. Overall constraints that were identified in the two facilities include the shortage of skilled staff, burn-out among staff, a shortage of space, inconsistent data collection and interpretation, as well as poor integration and collaboration between local and provincial government in relation to the shared responsibility for the provision of Tuberculosis (TB) treatment and other related CCMT services. Despite these barriers, levels of adherence exceeded 85% in both sites.

Background: Eating disorder (ED) researchers continue to explore the effectiveness of e-therapy in improving symptoms and its treatment acceptability, however issues relating to poor uptake, adherence and dropout pose a challenge. Within this portfolio, the systematic review aimed to explore adherence to e-therapy for the treatment of ED, specifically exploring rates and predictors of uptake, completion, and dropout from randomised controlled trials (RCT) of ED e-therapy. The empirical project aimed to explore in-depth symptom change for ED cases engaged in blended internet-based cognitive behavioural therapy (ICBT) and face-to-face ED input. Acceptability of blended input was also explored. Methods: For the systematic review, literature searches were undertaken in March and September 2017 across EMBASE, PsycINFO, MEDLINE, Ovid and Cochrane Central Register of Controlled Trials (CENTRAL) and ProQuest databases. Key papers were assessed against five quality criteria (random assignment to groups, blinding to treatment allocation, quality of content, level of contact, sample size with sufficient power). Using a retrospective case series design, the empirical project explored changes over time of ED, anxiety, depression, quality of life (QoL), motivation for change, overall psychological functioning and clinician-rated/patient-rated improvement. Standardised health assessment measures captured symptoms over multiple time-points, and data was analysed using t-tests, multi-level modelling (MLM) and visual analysis. Acceptability of treatment was tentatively explored using an open feedback questionnaire. Results: Systematic review results identified intervention (content, acceptability, delivery method/location), participant (nature of symptoms, BMI, education, prior therapy, personality, views on e-therapy) and therapist-related factors (therapeutic support) were indicated in predicting uptake, completion and dropout across ED e-therapy. In the empirical project, study findings were inconclusive regarding symptom change attributable to blended input. Model fit improved when severity of ED symptoms predicted overall psychological functioning and patient-rated improvement over time, however findings were non-significant - potentially due to the study being underpowered. Conclusions: Promising evidence exists for ED e-therapy as an acceptable treatment option, however understanding which content nurtures engagement best is needed. Further research is needed into the factors predicting ED blended treatment outcome.

<p>Abstract</p><p>The aim of the study was to examine the relation between estimated fluidintake and real fluidintake among dialysis patients. The data were collected through study specific questionnaire and data from the medical record. Patients attached to eleven Swedish dialysis units were asked to participate. The number of patients that fulfilled the inclusion criteria were 222 persons of whom145 (65%) chose to participate in the study. The dialysis patients estimated their fluid intake for a day in average 9,06 deciliter. The dialysis patients real fluid intake for a day were in average 10,34 deciliter. The results showed that 58% of the dialysis patients that participated in the study had an estimated fluid intake less than what they actually consumed. The relation between estimated fluid intake and real fluid intake was r=0,288, which showed a fairly poor relation.</p>

Abstract The aim of the study was to examine the relation between estimated fluidintake and real fluidintake among dialysis patients. The data were collected through study specific questionnaire and data from the medical record. Patients attached to eleven Swedish dialysis units were asked to participate. The number of patients that fulfilled the inclusion criteria were 222 persons of whom145 (65%) chose to participate in the study. The dialysis patients estimated their fluid intake for a day in average 9,06 deciliter. The dialysis patients real fluid intake for a day were in average 10,34 deciliter. The results showed that 58% of the dialysis patients that participated in the study had an estimated fluid intake less than what they actually consumed. The relation between estimated fluid intake and real fluid intake was r=0,288, which showed a fairly poor relation.

The objective of this study was to explore the link between school climate and bullying behaviour through a case study of two high schools. Grade 10 students received the two day Cross-Cultural Conflict Resolution (XCCR) Module initiated by YOUCAN. Phase I of this study involved the development of an XCCR Logic Model, which aimed to clarify the objectives and key elements of the XCCR Module. Phase II involved the in depth analysis of the XCCR Module through an 84-item survey and qualitative semi-structured interviews with school and program staff. Data from this study did not indicate any changes in bullying behaviour or school climate between pre-and post-implementation. This study highlights a need to incorporate measures for program adherence and program fidelity in future studies. The results of this study provided two practical contributions, an XCCR Logic Model and information about bullying and school climate for the participating schools.

Background - Communicable respiratory illness is a serious occupational threat to healthcare workers. A key reason for occupational transmission is failure to implement appropriate barrier precautions. Facial protective equipment, including surgical masks, respirators and eye/face protection, is the least adhered to type of personal protective equipment used by healthcare workers, yet it is an important barrier precaution against communicable respiratory illness. Objectives - To describe nurses’ adherence to recommended use of facial protective equipment and to identify the factors that influence adherence. Methods - A two-phased study was conducted. Phase 1 was a cross-sectional survey of nurses in selected units of six acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses. Results – Of the 1074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of facial protective equipment. Multivariable analysis revealed four organizational predictors of adherence: ready availability of equipment, regular training and fit testing, organizational support for health and safety, and good communication. Following the survey, 112 observations in 14 intensive care units were conducted that showed a 44% competence rate with proper use of N95 respirators. Common gaps included failure to verify the seal and touching the face piece. Multivariable analysis revealed knowledge of recommended use of facial protective equipment as a significant predictor of competence. Discussion – Despite the SARS experience and the resulting investment in our public health system, nurses’ adherence to recommended use of facial protective equipment and competence in effective use of N95 respirators remains suboptimal. To improve adherence, organizational leaders should focus on equipment availability, training and fit testing, organizational support for health and safety, and positive communication. To improve competence in effective use of N95 respirators, strategies to increase knowledge should be implemented. These efforts should assist to reduce occupational transmission of communicable respiratory illness and foster a healthier and safer working environment for nurses.

Heart failure is a chronic condition that increases the risk for death and disability. Beta blockers and ACE inhibitors have become standard treatments in heart failure because clinical trials have demonstrated their beneficial effect on mortality and morbidity in these patients. As not much is known about adherence to these medications, the main objectives of this project were to determine long term adherence to ACE inhibitors and beta blockers and determine how various degrees of adherence to a beta blocker can affect major health outcomes in patients with heart failure.<p> Data was obtained from Saskatchewan health from January 1, 1994 to December 31, 2003 for all heart failure patients from their first hospitalization for heart failure. Adherence was calculated using the fill frequency measure of adherence, and all survival analyses were completed using the Cox proportional hazards model.<p>Although 14, 000 patients were admitted to hospital for a first admission for heart failure, only 1143 subjects started a beta blocker and 5084 subjects started an ACE inhibitor within 3 months of the index hospitalization. Within the first year, adherence was excellent for both beta blockers (80.8 percent) and ACE inhibitors (82.5 percent). The proportion of patients remaining adherent slowly decreased to reach approximately 60 percent, for both medication classes, after 4 years. There was no significant difference in all-cause mortality between patients with high adherence and low adherence, but there appeared to be a trend towards decreased survival time in those remaining adherent throughout the study period [HR = 1.18 (95% CI: 0.98 to 1.43; p=0.07)].<p>Since the overall rate of adherence to beta blockers was excellent in most patients during the first year, it is possible that non-adherence is not responsible for a significant burden of mortality in Saskatchewan heart failure patients, and perhaps and the focus of quality improvement should be optimal prescribing of evidence-based therapies, and continued adherence over time.

<p>Cardiovascular disease is a leading cause of death and hospitalizations in Canada. Most risk factors for cardiovascular disease are known, and many are modifiable. One such risk factor that often goes unrecognized is non-adherence. Pharmacists are ideally positioned to have an influence on cardiovascular risk reduction, including supporting medication adherence; however it is still unknown whether typical (non-specialist) pharmacists can provide strategies that are effective and sustainable in todays health care system. Thus, the overall objective of this research project was to determine what interventions typical pharmacists can adopt to effectively facilitate cardiovascular risk reduction within the constraints of the current practice environment. This objective was accomplished through 4 related studies: 1) a randomized controlled trial involving a pharmacist-directed cardiovascular risk reduction collaboration within a family physician practice; 2) a systematic review identifying and evaluating published interventions by community pharmacists for cardiovascular disease or diabetes; 3) the design of a pilot study evaluating a novel community pharmacy intervention aimed at cardiovascular risk reduction and; 4) the examination of adherence patterns among antihypertensive medication users to identify associated factors and high-risk periods for non-adherence.</p> <p>Although the randomized controlled trial did not show a statistically significant benefit of the pharmacist intervention on cardiovascular risk, it did demonstrate the feasibility of incorporating a pharmacist into a collaborative role, without the need for an advanced or specialized degree. Results from the systematic review yielded several studies involving community pharmacists and cardiovascular disease or diabetes. However, the majority of these studies were of poor quality, evaluated complex and intensive interventions, and provided questionable clinical benefits. The design of the pilot study demonstrated the feasibility of developing high quality, robust research involving community pharmacists. Finally, the observational study examining adherence patterns to antihypertensive agents revealed two important findings that can guide the development of future strategies to support adherence: the first year of therapy, and particularly the first dispensation, is a critical time for the development of non-adherence and, contrary to previously published studies, adherence is similar between all classes of antihypertensive medications.</p> <p>This program of research did not identify one particular pharmacist intervention as being superior for cardiovascular risk reduction in todays practice environment. However, it did highlight the need for improved study quality and the development of interventions that are practical and can be realistically implemented by pharmacists in todays practice environment.</p>