M. Barton Laws

Taking Antiretroviral Therapy for HIV Infection: Learning from Patients' Stories

AbstractOBJECTIVE: To describe how people with HIV understand and experience the problem of adhering to antiretroviral medication regimens. DESIGN: We performed a qualitative study based on interviews with HIV-infected patients, including 46 clients of AIDS service organizations, who were sampled according to age, ethnicity, and injection drug use history, and a convenience sample of 15 patients. Interviews were conducted in English or Spanish and were audiotaped and transcribed. PARTICIPANTS: Of 52 respondents who had prescriptions for antiretroviral therapy, 25 were randomly selected for indepth analysis. Of these, 5 reported having an AIDS diagnosis, 15 reported symptoms they attributed to HIV, and 5 reported having no symptoms of HIV disease. MEASUREMENTS AND MAIN RESULTS: Investigators prepared structured abstracts of interviews to extract adherence-related data. One investigator compared the abstracts with the original transcripts to confirm the interpretations, and used the abstracts to organize and classify the findings. Most subjects (84%) reported recent nonadherent behavior, including ceasing treatment, medication “holidays,” sleeping through doses, forgetting doses, skipping doses due to side effects, and following highly asymmetric schedules. Initially, most reported that they were not significantly nonadherent, and many did not consider their behavior nonadherent. Only a minority clearly understood the possible consequences of missing doses. Most said they had not discussed their nonadherence with their physicians. CONCLUSIONS: Many people rationalize their difficulty in adhering to HIV treatment by deciding that the standard of adherence they can readily achieve is appropriate. Physicians should inquire about adherence-related behavior in specific detail, and ensure that patients understand the consequences of not meeting an appropriate standard.

A new method for evaluating the quality of medical interpretation.

ObjectivesTo develop and implement a method to evaluate the quality of medical interpretation in a pediatric outpatient setting and explore the patterns and correlates of errors and failures in translation. Design, Setting, and PatientsObservational study of a convenience sample of 13 Spanish-speaking families attending pediatric outpatient clinics at an urban teaching hospital, their English-speaking providers, and interpreters. Visits were audiotaped and transcribed. The transcripts were divided into segments consisting of continuous sections of dialogue in a single language, plus any translation of that dialogue, and segments were coded for characteristics of the translation, word count, and the identity of the speakers. Main Outcome MeasuresTranslation quality on an ordinal scale derived from a set of nominal codes. ResultsWe found that 66.1% of segments in which translation should have occurred were translated with substantial errors or omissions or not translated at all. In 29.8% of segments, the interpreter engaged in speech unrelated to interpretation. Quality of interpretation was inversely associated with the word count per segment and, independently, whether the interpreter engaged in speech acts which did not consist of interpretation, which we call “role exchange.” We give several examples and qualitative discussion of “role exchange” and show that it not necessarily associated with mistranslation but may have egregious consequences. ConclusionsInterpreters who lack appropriate training fail to interpret accurately. Engaging in speech behaviors other than interpreting is associated with a higher rate of errors.

The Latina Breast Cancer Control Study, Year One: Factors Predicting Screening Mammography Utilization by Urban Latina Women in Massachusetts

This study identifies factors associated with screening mammography utilization for Latina women age 40 and older in two Massachusetts cities, who are predominantly of Caribbean origin. It is a crosssectional survey based on an area probability sample, using bilingual Latina interviewers. Sixty-one percent of the sample was Latina, 99% of whom were interviewed in Spanish. Ethnicity, educational attainment, and acculturation were unrelated to recent screening. While distinct healing traditions were found among some Latinas, their use was unrelated to screening. Higher fatalism scores had a bivariate association with lower probability of screening. In a logistic regression, predictors were having health insurance or access to free care; having discussed mammography with a physician in the past 2 years; the difference between 67 and respondents age (negative coefficient); and city of residence. Having a regular source of care was a predictor when substituted for insurance status. Insurance status and age principally determine whether subjects are screened, mediated by access to physician services and whether physicians recommend screening. Results suggest that universal medical insurance, and efforts to influence physician practices, are key to promoting screening mammography among this population.This study identifies factors associated with screening mammography utilization for Latina women age 40 and older in two Massachusetts cities, who are predominantly of Caribbean origin. It is a crosssectional survey based on an area probability sample, using bilingual Latina interviewers. Sixty-one percent of the sample was Latina, 99% of whom were interviewed in Spanish. Ethnicity, educational attainment, and acculturation were unrelated to recent screening. While distinct healing traditions were found among some Latinas, their use was unrelated to screening. Higher fatalism scores had a bivariate association with lower probability of screening. In a logistic regression, predictors were having health insurance or access to free care; having discussed mammography with a physician in the past 2 years; the difference between 67 and respondents age (negative coefficient); and city of residence. Having a regular source of care was a predictor when substituted for insurance status. Insurance status and age principally determine whether subjects are screened, mediated by access to physician services and whether physicians recommend screening. Results suggest that universal medical insurance, and efforts to influence physician practices, are key to promoting screening mammography among this population.

Conditional Economic Incentives to Improve HIV Treatment Adherence: Literature Review and Theoretical Considerations

We present selected theoretical issues regarding conditional economic incentives (CEI) for HIV treatment adherence. High HIV treatment adherence is essential not only to improve individual health for persons living with HIV, but also to reduce transmission. The incentives literature spans several decades and various disciplines, thus we selectively point out useful concepts from economics, psychology and HIV clinical practice to elucidate the complex interaction between socio-economic issues, psychological perspectives and optimal treatment adherence. Appropriately-implemented CEI can help patients improve their adherence to HIV treatment in the short-term, while the incentives are in place. However, more research is needed to uncover mechanisms that can increase habit formation or maintenance effects in the longer-term. We suggest some potentially fruitful avenues for future research in this area, including the use of concepts from self-determination theory. This general framework may have implications for related research among disadvantaged communities with high rates of HIV/AIDS infection.ResumenSe presentan aspectos teóricos sobre incentivos económicos condicionados para la adherencia al tratamiento del VIH. Una alta adherencia al tratamiento antirretroviral es esencial para mantener la salud de las personas que viven con el VIH y también para reducir la transmisión del virus. La literatura de incentivos abarca varias décadas y disciplinas diferentes, por lo que selectivamente se señalan conceptos útiles de la economía, la psicología y el tratamiento clínico del VIH para dilucidar la compleja interacción entre el entorno socioeconómico, la perspectiva psicológica y la adherencia óptima al tratamiento. Programas de incentivos adecuadamente implementados pueden ayudar a los pacientes a mejorar su adherencia al tratamiento del VIH en el corto plazo, mientras los incentivos se mantienen. Sin embargo, se requieren más estudios para descubrir los mecanismos que promueven la formación de hábitos a largo plazo. Se sugieren áreas para investigaciones futuras como la incorporación de conceptos de la teoría de la autodeterminación. Este marco conceptual general puede ser aplicado a la investigación con las poblaciones más desfavorecidas y las tasas más altas de VIH/SIDA.

Provider-patient Adherence Dialogue in HIV Care: Results of a Multisite Study

Few studies have analyzed physician–patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician–patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African–American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients’ understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.ResumenPocos estudios han analizado en detalle el diálogo entre médicos y pacientes sobre la adherencia del paciente al tratamiento con antirretrovirales (ARVs). Se describe globalmente encuentros entre médicos y pacientes en el tratamiento del VIH, con enfoque en el diálogo sobre ARVs, usando un sistema que aplica a cada enunciado un código para el tema, y para el acto de del habla.Estudio observaciónal con uso de grabaciones de consultas externas rutinarias de personas con VIH en clínicas especializadas.Los proveedores fueron 34 médicos y 11 proveedores de otras clases. De 415 pacientes, 66% fueron hombres, 59% Africano-Americanos. 78% informaron tomar ARVs actualmente.Aproximadamente 10% de los enunciados se refirieron al tratamiento con ARVs. Entres los que usaron ARVs, 15% tuvieron algún diálogo sobre la resolución de problemas de adherencia al tratamiento. El diálogo sobre la resolución de problemas incluyó significativamente más actos directivos y enunciados en la clase de control, comparado a otros temas. Los proveedores dominaron la conversación, hicieron 5 veces más preguntas que los pacientes, y 21 veces más enunciados directivos. Los proveedores hicieron pocas preguntas abiertas, y raras veces chequearon el entendimiento del paciente.Los médicos responden al reto de atender a los pacientes con VIH adoptando un acercamiento que se centra en el médico, lo que se evidencia particularmente en la discusión sobre la adherencia al tratamiento con ARVs.

Discussion of Sexual Risk Behavior in HIV Care is Infrequent and Appears Ineffectual: A Mixed Methods Study

Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction; two others included substantial discussion which was not evidently directed at the patient’s changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.

Challenges to physician–patient communication about medication use: a window into the skeptical patient’s world

Patients frequently do not take medicines as prescribed and often do not communicate with their physicians about their medication-taking behavior. The movement for “patient-centered” care has led to relabeling of this problem from “noncompliance” to “nonadherence” and later to a rhetoric of “concordance” and “shared decision making” in which physicians and patients are viewed as partners who ideally come to agreement about appropriate treatment. We conducted a qualitative content analysis of online comments to a New York Times article on low rates of medication adherence. The online discussion provides data about how a highly selected, educated sample of patients thinks about medication use and the doctor–patient relationship. Our analysis revealed patient empowerment and self-reliance, considerable mistrust of medications and medical practice, and frequent noncommunication about medication adherence issues. We discuss how these observations can potentially be understood with reference to Habermas’s theory of communicative action, and conclude that physicians can benefit from better understanding the negative ways in which some patients perceive physicians’ prescribing practices.

A community participatory study of cardiovascular health and exposure to near-highway air pollution: study design and methods

Abstract Current literature is insufficient to make causal inferences or establish dose-response relationships for traffic-related ultrafine particles (UFPs) and cardiovascular (CV) health. The Community Assessment of Freeway Exposure and Health (CAFEH) is a cross-sectional study of the relationship between UFP and biomarkers of CV risk. CAFEH uses a community-based participatory research framework that partners university researchers with community groups and residents. Our central hypothesis is that chronic exposure to UFP is associated with changes in biomarkers. The study enrolled more than 700 residents from three near-highway neighborhoods in the Boston metropolitan area in Massachusetts, USA. All participants completed an in-home questionnaire and a subset (440+) completed an additional supplemental questionnaire and provided biomarkers. Air pollution monitoring was conducted by a mobile laboratory equipped with fast-response instruments, at fixed sites, and inside the homes of selected study participants. We seek to develop improved estimates of UFP exposure by combining spatiotemporal models of ambient UFP with data on participant time-activity and housing characteristics. Exposure estimates will then be compared with biomarker levels to ascertain associations. This article describes our study design and methods and presents preliminary findings from east Somerville, one of the three study communities.

Role Exchange in Medical Interpretation

Prior research has documented that medical interpreters engage in non-conduit roles during medical visits. However, agreement on the appropriateness of these roles and their impact on the medical encounter have not yet been achieved. The purpose of this study was to identify non-conduit behavior (role exchange), elucidate the various forms it takes among different types of interpreters, and assess its potential to affect clinical encounters. Using audiotapes from 13 pediatric outpatient visits, we found that “chance” and uncertified hospital interpreters engaged in role exchange by assuming the provider’s role; the patient’s role; and taking other non-interpretive roles such as socializing with mothers or acting in one’s alternate professional role. These behaviors occurred frequently among both types of interpreters while the provider was actively engaged in conducting the medical visit. In most instances, the interpreter did not make his or her behavior transparent to either the provider or the mother. Implications for interpreter and provider training are discussed.

Counseling to Reduce High-Risk Sexual Behavior in HIV Care: A Multi-Center, Direct Observation Study

A key opportunity to reduce HIV transmission lies with healthcare providers counseling HIV-infected patients about safer sex. We audio-recorded and transcribed clinical encounters between 45 healthcare providers and 417 of their HIV-infected patients at four outpatient sites in the United States. We used logistic regressions to evaluate associations between patient and provider characteristics, and the occurrence of discussion (any talk about sex) and counseling (advice about safer sex). Of the 417 encounters, discussion of sex occurred in 187 (45% of encounters, 95% CI: 40-50%). Counseling occurred for 49% (95% CI: 35-63%) of patients reporting unsafe sex. Discussion of sex was more likely with younger or less-educated patients and with less cultural difference between patient and provider, while counseling was associated with greater provider mindfulness and lower provider empathy. These findings suggest targets to improve communication regarding sexual risk reduction in HIV care.