Skip to main content

Advertisement

SpringerLink
Log in

Literacy, Social Stigma, and HIV Medication Adherence

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND

Prior studies have linked limited literacy to poorer HIV medication adherence, although the precise causal pathways of this relationship have only been initially investigated.

OBJECTIVE

To examine whether social stigma is a possible mediator to the relationship between literacy and self-reported HIV medication adherence.

DESIGN

Structured patient interviews with a literacy assessment, supplemented by medical chart review, were conducted among patients receiving care at infectious disease clinics in Shreveport, Louisiana and Chicago, Illinois. Literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), while stigma was measured using items taken from the Patient Medication Adherence Questionnaire (PMAQ).

PARTICIPANTS

Two hundred and four consecutive patients participated.

RESULTS

Approximately one-third of the patients (30.4%) were less than 100% adherent to their regimen, and 31.4% had marginal (7th–8th grade) or low (≤ 6th grade) literacy. In multivariate analyses, patients with low literacy were 3.3 times more likely to be non-adherent to antiretroviral regimens (95% CI 1.3–8.7; p < 0.001). Perceived social stigma was found to mediate the relationship between literacy and medication adherence (AOR 3.1, 95% CI 1.3–7.7).

CONCLUSIONS

While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, perceived social stigma mediated this relationship. Low literacy HIV intervention strategies may also need to incorporate more comprehensive psychosocial approaches to overcome stigma barriers.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low literacy. J Gen Intern Med. 1999;14(5):267–73.

    Article  PubMed  CAS  Google Scholar 

  2. Wolf MS, Davis TC, Osborn CY, Skipkauskas S, Bennett CL, Makoul G. Literacy, self-efficacy, and HIV medication adherence. Patient Educ Couns. 2007;65(2):253–60.

    Article  PubMed  Google Scholar 

  3. Miller LG, Liu H, Hays RD, et al. Knowledge of antiretroviral regimen dosing and adherence: a longitudinal study. Clin Infect Dis. 2003;36:514–18.

    Article  PubMed  Google Scholar 

  4. Paasche-Orlow MK, Cheng DM, Palepu A, Meli S, Faber V, Samet JH. Health Literacy, Antiretroviral Adherence, and HIV-RNA Suppression: A Longitudinal Perspective. J Gen Intern Med. 2006;21(8):835–40.

    Article  PubMed  Google Scholar 

  5. Pignone MP, Dewalt D. Literacy and health outcomes Is adherence the missing link? J Gen Intern Med. 2006;21(8):896–7.

    Article  PubMed  Google Scholar 

  6. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren K, Rask K. Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy. J Gen Intern Med. 2006;21(12):1215–21.

    Article  PubMed  Google Scholar 

  7. Paasche-Orlow MK, Wolf MS. the causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(Suppl 1):S19–26.

    PubMed  Google Scholar 

  8. Crandall CS, Coleman R. AIDS-related stigmatization and the disruption of social relationships. Pers Relatsh. 1992;9:163–77.

    Article  Google Scholar 

  9. Moneyham L, Seals B, Demi A, Sowell R, Cohen L, Guillory J. Perceptions of stigma in women infected with HIV. AIDS Patient Care STDS. 1996;10:162–7.

    Article  PubMed  CAS  Google Scholar 

  10. Herek GM, Capitanio JP. Aids and sexual prejudice. Am Behav Sci. 1999;42:1130–47.

    Google Scholar 

  11. Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: Prevalence and trends. Am J Public Health. 2002;92:371–7.

    PubMed  Google Scholar 

  12. Blendon RJ, Donelan K. Discrimination against people with AIDS: The public’s perspective. New Engl J Med. 1988;319:1022–6.

    PubMed  CAS  Google Scholar 

  13. Burris S. Studying the legal management of HIV-related stigma. Am Behav Sci. 1999;42:1229–43.

    Article  Google Scholar 

  14. Craft SM, Serovich JM. Family-of-origin factors and partner violence in the intimate relationships of gay men who are HIV positive. J Interpers Violence. 2005;20(7):777–91.

    Article  PubMed  Google Scholar 

  15. D’Augelli AR. AIDS fears and homophobia among rural nursing personnel. AIDS Educ Prev. 1989;1:277–84.

    PubMed  CAS  Google Scholar 

  16. Derlega VJ, Lovejoy D, Winstead BA. Personal accounts on disclosing and concealing HIV-positive test results: weighing the benefits and risks. In Derlega VJ, Barbee AP, eds. HIV and Social Interaction. Thousand Oaks, CA: Sage: 1998:147–64.

    Google Scholar 

  17. Goldin CS. Stigmatization and AIDS: critical issues in public health. Soc Sci Med. 1994;39:1359–66.

    Article  PubMed  CAS  Google Scholar 

  18. Heckman TG, Somlai AM, Kalichman SC, Franzoi SL, Kelly JA. Psychosocial differences between urban and rural people living with HIV/AIDS. J Rural Health. 1998;14:138–45.

    Article  PubMed  CAS  Google Scholar 

  19. Liebschutz JM, Geier JL, Horton NJ, Chuang CH, Samet JH. Physical and sexual violence and health care utilization in HIV-infected persons with alcohol problems. AIDS Care. 2005;17:566–78.

    PubMed  CAS  Google Scholar 

  20. Marzuk PM, Tierney H, Tardiff K, et al. Increased risk of suicide in persons with AIDS. JAMA. 1988;259:1333–7.

    Article  PubMed  CAS  Google Scholar 

  21. Chesney MA, Smith AW. Critical delays in HIV testing and care: The potential role of stigma. Am Behav Sci. 1999;42:1162–74.

    Article  Google Scholar 

  22. Golin C, Isasi F, Bontempi JB, Eng E. Secret pills: HIV-positive patients’ experiences taking antiretroviral therapy in North Carolina. AIDS Educ Prev. 2002;14(4):318–29.

    Article  PubMed  Google Scholar 

  23. Rintamaki LS, Davis TC, Skipkauskas S, Bennett CL, Wolf MS. Social stigma and HIV medication adherence. AIDS Patient Care STDS. 2006;20(5):359–68.

    Article  PubMed  Google Scholar 

  24. Fogarty L, Roter D, Larson S, Burke J, Gillespie J, Levy R. Patient adherence to HIV medication regimens: a review of published and abstract reports. Patient Educ Couns. 2002;46(2):93–108.

    Article  PubMed  Google Scholar 

  25. Singh N, Berman SM, Swindells S, et al. Adherence of immunodeficiency virus infected patients to antiretroviral therapy. Clin Infect Dis. 1999;29(4):824–30.

    Article  PubMed  CAS  Google Scholar 

  26. Parikh NS, Parker R, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33–9.

    Article  PubMed  CAS  Google Scholar 

  27. Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW. Patients’ shame and attitudes toward discussing the results of literacy screening. J Health Comm. 2007;12:1–12.

    Article  Google Scholar 

  28. Stirratt MJ, Remien RH, Smith A, et al. The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS Behav. 2006;10(5):483–93.

    Article  PubMed  Google Scholar 

  29. Peretti-Watel P, Pierret J, Lert F, Obadia Y. The Vespa Group Management of HIV-related stigma and adherence to HAART: Evidence from a large representative sample of outpatients attending French hospitals. AIDS Care. 2006;18(3):254–61.

    Article  PubMed  CAS  Google Scholar 

  30. Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr Hum Retrovirol. 2000;25(4):337–44.

    CAS  Google Scholar 

  31. Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health literacy: An overlooked factor in understanding HIV health disparities. Am J Prev Med. 2007;33(5):374–8.

    Article  PubMed  Google Scholar 

  32. Wolf MS, Davis TC, Arozullah A, et al. Relation between literacy and HIV treatment knowledge among patients on HAART regimens. AIDS Care. 2005;17(7):863–73.

    PubMed  CAS  Google Scholar 

  33. Demasi RA, Graham NM, Tolson JM, et al. Correlation between self-reported adherence to highly active antiretroviral therapy (HAART) and virologic outcome. Adv Ther. 2001;18(4):163–73.

    Article  PubMed  CAS  Google Scholar 

  34. Demasi RA, et al., Self-reported adherence to HAART and correlation with HIV RNA: initial results with the patient medication adherence questionnaire. Paper presented at the sixth conference on retroviruses and opportunistic infections (1999).

  35. Frable DE, Blackstone T, Scherbaum C. Marginal and mindful: Deviants in social interactions. J Pers Soc Psychol. 1990;59:140–9.

    Article  PubMed  CAS  Google Scholar 

  36. Limandri BJ. Disclosure of stigmatizing condition: The discloser’s perspective. Arch of Psychiatr Nurs. 1989;3:69–78.

    CAS  Google Scholar 

  37. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall; 1963.

    Google Scholar 

  38. Hiller DV. Overweight as master status: A replication. J Psychol. 1982;110:107–13.

    PubMed  CAS  Google Scholar 

  39. Davis TC, Michielutte R, Askov EN, Williams MV, Weiss BD. Practical assessment of adult literacy in healthcare. Health Educ Behav. 1998;25:613–24.

    Article  PubMed  CAS  Google Scholar 

  40. Davis TC, et al. Literacy testing in health care research in understanding health literacy: implications for medicine, public health. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. AMA Press: Chicago, IL; 2004:157–79.

  41. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.

    Article  PubMed  CAS  Google Scholar 

  42. Baron RM, Kenny DA. The moderator-mediator distinction in social psychology research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173–82.

    Article  PubMed  CAS  Google Scholar 

  43. Vanable OA, Carey MP, Blair DC, Littlewood RA. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav. 2006;10(5):473–82.

    Article  PubMed  Google Scholar 

  44. Berger BE, Ferran CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518–29.

    Article  PubMed  CAS  Google Scholar 

  45. Glass TR, De Geest S, Weber R, et al. Correlates of self-reported nonadherence to antiretroviral therapy in HIV infected patients: the Swiss HIV Cohort Study. J Acquir Immune Defic Syndr. 2006;41:385–92.

    Article  PubMed  Google Scholar 

  46. Gallant JE, DeJesus E, Arribas JR, et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirens for HIV. N Engl J Med. 2006;354:251–60.

    Article  PubMed  CAS  Google Scholar 

  47. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: Lippincott; 1996.

    Google Scholar 

  48. Gerber BS, Brodsky IG, Lawless KA, et al. Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Diabetes Care. 2005;28:1574–80.

    Article  PubMed  Google Scholar 

  49. Davis TC, Fredrickson DD, Arnold C, Murphy PW, Herbst M, Bocchini JA. A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level. Patient Educ Couns. 1998;35:25–3.

    Article  Google Scholar 

  50. Davis TC, Williams MV, Marin E, Parker RM, Glass J. Health literacy and cancer communication. CA Cancer J Clin. 2002;52:134–49.

    Article  PubMed  Google Scholar 

  51. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26:1–7.

    Article  PubMed  Google Scholar 

  52. Gifford AL, Laurent DD, Gonzales VM, Chesney MA, Lorig KR. Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:136–44.

    PubMed  CAS  Google Scholar 

  53. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. J Amer Med Assoc. 2002;288:2469–75.

    Article  Google Scholar 

  54. Heckman TG, Barcikowski R, Ogles B, et al. A telephone-delivered coping improvement group intervention for middle-aged and older adults living with HIV/AIDS. Ann Behav Med. 2006;32(1):27–38.

    Article  PubMed  Google Scholar 

  55. Jones DL, McPherson-Baker S, Lydston D, et al. Efficacy of a group medication adherence intervention among HIV positive women: the SMART/EST Women’s Project. AIDS Behav. 2007;11(1):79–86.

    Article  PubMed  Google Scholar 

  56. Makoul G. The Segue framework for teaching and assessing communication skills. Pat Ed Counsel. 2001;45:23–34.

    Article  CAS  Google Scholar 

  57. Murray MD, Young J, Hoke S, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trail. Ann Intern Med. 2007;146(10):714–25, May.

    PubMed  Google Scholar 

Download references

Acknowledgments

Grant support

None

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Health Literacy and Learning Program, Institute for Healthcare Studies, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Katherine R. Waite BA & Michael S. Wolf PhD MPH

  2. Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA

    Michael Paasche-Orlow MD MA MPH

  3. Department of Communication, State University of New York, Buffalo, NY, USA

    Lance S. Rintamaki PhD

  4. Department of Health Behavior, State University of New York, Buffalo, NY, USA

    Lance S. Rintamaki PhD

  5. Louisiana State University Health Sciences Center, Shreveport, LA, USA

    Terry C. Davis PhD

Authors
  1. Katherine R. Waite BA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Paasche-Orlow MD MA MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lance S. Rintamaki PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Terry C. Davis PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael S. Wolf PhD MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Katherine R. Waite BA.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Waite, K.R., Paasche-Orlow, M., Rintamaki, L.S. et al. Literacy, Social Stigma, and HIV Medication Adherence. J GEN INTERN MED 23, 1367–1372 (2008). https://doi.org/10.1007/s11606-008-0662-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-008-0662-5

KEY WORDS

Search

Navigation