The Program for the Study of Health Care Relationships funded 11 researchers in CT to study various aspects of health care relationships and adherence. The individuals listed below each received grants for one year (2001-02). They were awarded funds on the basis of a competitive review process and the scientific merit of their proposals. The wide range of disciplines they represent and their research interests demonstrated the diversity and complexity inherent in studying health care relationships.

• Development of an Instrument to Measure Patients' Trust of Health Care Providers
• Exploration of the Effect of Nausea, Self-Efficacy, and Health Care Relationships on Medication Adherence in HIV/AIDS Patients
• Advance Care Planning: A Team Approach
• Assisting Older Adults To Communicate Their Pain After Surgery
• The Effect of a Specialized RN Intervention Designed to Maximize Patient-Provider Relationships on Adherence to Anti-Depressant Medication
• Pilot Study of Rapid Electronic Adherence Reporting with Provider Feedback on Adherence to Antiretroviral Therapy (HCR 01-12)
• Development of a Measure of Family Management of Childhood Chronic Illness
• The Contribution of Health Care Professionals to Parent and Child Self-Management of Type 1 Diabetes
• Enhancing Treatment Access and Adherence among Women of Hispanic Origin: The Roles of Relationships and Cultural Responsiveness in Behavioral Health Care
• Elicitation of Patient with Adaptive Conjoint Analysis

Exploration of the Effect of Nausea, Self-Efficacy, and Health Care Relationships on Medication Adherence in HIV/AIDS Patients

Elizabeth H. Anderson, PhD, APRN, Margaret H. Spencer, MS, APRN, Seja-Joyce Fishman, MS, APRN, Kathleen Tummillo, MS, APRN

Recruitment
Eighty persons were interviewed for this study. Nine persons (11%) were lost to follow-up related to death (1), incarceration (1), or not keeping follow-up medical appointments possibly related to reusing street drugs (7). Interviews were conducted at HIV/AIDS clinics at Hartford Hospital (46), Burgdorf Clinic (23), St. Francis Hospital and Medical Center (2), and Trinity Hill Health Care inpatient unit (10).

Sample: Consisted of 46 (57.5%) men and 34 (42.5%) women with HIV/AIDS. Ethnic/racial backgrounds were Black (42.5%), Hispanic (41.3%), and Caucasian (15.0). Average age was 42.9 (SD = 8.6) with a range of 19 to 62 years. The majority had less than a high school education (57.5%), reported never having been married (55.0%), and were currently on disability (63.3%). Yearly income was less than $10,000 for 85%.

Risks for HIV were primarily unprotected sex (55%) and intravenous drug use (22.5%). Average time from diagnosis of HIV to interview was 105 months (SD = 57.5). Laboratory results showed participants had an average CD4 count of 222.8 (SD = 227.6) and Viral Load of 300,309.5 (SD = 915,331.4). Ninety-one percent had previously been on anti-retroviral (ART) drug regimes. At the time of interview, the average number of doses of oral medications within 24 hours was 16.1 (SD = 9.4).

Instruments
All instruments had acceptable validity and reliabilities for both interviews. Specific standardized alphas were as follows: Health Care Provider Relationships (alpha .64, .74); Self-efficacy in Taking HIV Medications (alpha .97, .97); Morrow Assessment of Nausea and Emesis (alpha .72, .61); Quality of Life (alpha .90, 91); Profile of Mood Subscales (alphas range .78 to .90; .77 to .92); and Self-Reported Measure of Medication Adherence (alpha .66, .67).

Research question 1
What is the relationship among variables of Health Care Relationships, self-efficacy, nausea, ART drug adherence, quality of life, and mood? This was answered with two-tailed Pearson correlations with the above variables. Results revealed that positive health care provider relationships were significantly associated with high self-efficacy in taking HIV medications (r = .27, p = .027), improved quality of life (r = .34, p = .004), and decreased mood disturbance (r = -. 30, p = .011), but not with medication adherence or nausea/vomiting. Medication adherence was significantly and positively associated with self-efficacy in taking HIV medications (r = .31, p = .009), decrease in mood disturbance (r = -. 24, p = .046), not missing medication dosages (r = -. 25, p = .035) and taking medications on time (r = -. 32, p = .008). The experience of nausea and vomiting was associated with decreased quality of life (r = .46, p = .000) and an increase in negative moods (r = -. 29, p = .014).

Research Question 2
What is the significance of Health Care Relationships on ART drug adherence over and above self-efficacy and nausea? In multiple regression analysis, variables for co-variation were selected based on: (a) a correlation of .3 or greater with ART drug adherence; (b) less than .8 correlation with other co-variates; and (c) degree of variability. Variables of Nausea and Health Care Relationships did not meet these criteria. Consequently, in this sample, Health Care Relationships would not have demonstrated a significant effect on drug adherence over and above self-efficacy and nausea. However, following the same criteria, step wise multiple regression analysis revealed that Health Care Relationships, Mood, and Nausea/Vomiting accounted for .56 % of the variance in quality of life in persons with HIV/AIDS [F (3, 66) = 27.64, p = 000]. Likewise, Health Care Provider Relationships, self-efficacy in taking medications, and nausea/vomiting accounted for 28% of the variance in Mood Disturbance in persons with HIV/AIDS [F (3, 66) = 8.33, p = 000]. Health Care Relationships accounted for 5% of the unique variance over and above nausea/vomiting and self-efficacy [F (3, 66) = 4.9, p = .031] in the outcome of Mood Disturbance. Consequently, study results suggest that Health Care Provider relationships with persons with HIV/AIDS significantly affect patients' self-efficacy in taking medications, their quality of life and mood.

Qualitative Interviews
From 1195 significant words, phrases, and sentences, ten themes emerged. The themes can be organized into three categories: Positive Relationships, Negative Relationships, and Childhood Experiences. Themes in Positive Relationships were: Caring With the Heart, Competent Provider, Sat Down With Me, and Patients' Commitment. Negative Relationship themes included: Uncaring Practices, Incompetent Provider, Poor Communication, and Patient Responses. The third category, Childhood Experiences, had two themes: Horrifying and Warm. It should be noted that participants spoke about dentists, physicians, nurse practitioners, nurses, and health aides.

In summary, participants valued providers who cared for them, listened to them, explained "everything" and "talked straight," were "there for them," and were "real smart." Some described their physician or nurse practitioner as a "friend" or "like family." Participants, who actively used street drugs and/or missed appointments or stopped their medications, saw providers' persistence in caring for them and any anger as a demonstration that the providers cared about them.

Participants angrily reported "hating" health care providers who had talked down to them, didn't care about them, were there for the money, and never provided explanations. One reported being angry when he learned that he had never been told to take his medications with food and had nausea/vomiting so he changed health care providers.

In addition, several participants reported having "scary" experiences as children when restrained for injections and being taken away from family for treatment or hospitalized. One reported standing for hours across from the clinic trying to get up the courage to see the health care provider.

Health Care Relationships seemed to strongly influence participants' choice of a health care provider, the taking of their medications, and keeping appointments. On the whole this sample was extremely satisfied with their current health care providers and reported taking their medications in order to "live longer."

Copyright 2003Yale University School of Nursing, Yale University, New Haven, CT 06536All Rights Reserved