A quantitative analysis of food insecurity and other barriers associated with ART nonadherence among women in rural communities of Eswatini.

BACKGROUND: Eswatini has the highest global prevalence of HIV despite decades of universal access to free antiretroviral therapy (ART). We conducted a mixed methods study to investigate barriers to ART adherence among women living with HIV (WLHIV) in rural communities of Eswatini. Qualitative findings were reported in our previous publication. This subsequent paper expands on our qualitative analysis to examine the magnitude to which identified barriers impacted ART adherence among WLHIV in the same communities. METHODS: We used an exploratory sequential design to collect data from WLHIV (n = 166) in rural Eswatini. Quantitative data were collected using interviewer-administered survey questionnaires between October and November 2017. ART adherence was measured using the CASE Adherence Index, with scores less than 10 indicating nonadherence. Log-binomial regression models were used to examine the extent to which critical barriers affected ART adherence among study participants. RESULTS: A majority of the women in our study (56%) were nonadherent to ART. Of the barriers identified in our prior qualitative analysis, only eight were found to be significantly associated with ART nonadherence in our quantitative analysis. These include, with adjusted risk ratios (ARR) and 95% confidence intervals (95% CI): household food insecurity (ARR: 3.16, 95% CI: 1.33-7.52), maltreatment by clinic staff (ARR: 2.67, 95% CI: 1.94-3.66), forgetfulness (ARR: 1.80, 95% CI: 1.41-2.31), stress (ARR: 1.47, 95% CI: 1.14-1.88), gossip (ARR: 1.57, 95% CI: 1.21-2.04), mode of transport (ARR: 0.59, 95% CI: 0.44-0.79), age (ARR: 0.98, 95% CI: 0.97-0.99), and lack of community support (ARR: 0.55, 95% CI: 0.35-0.85). CONCLUSIONS: Among numerous barriers identified in our study, food insecurity was found to be a significant contributor toward ART nonadherence among women living with HIV in rural Eswatini. Future strategies aimed at improving ART adherence in Eswatini should include programs which provide food and nutrition support for people living with HIV, particularly rural women living in poverty.

Individual, household, and community level barriers to ART adherence among women in rural Eswatini.

BACKGROUND: Despite access to free antiretroviral therapy (ART) for all people living with human immunodeficiency virus (HIV), noncompliance to treatment continues to be a significant challenge in Eswatini. Yet studies investigating barriers to ART adherence in Eswatini are scarce. Most notably, there is a lack of research regarding rural women in Eswatini, who are currently the country's most vulnerable to HIV infection. Therefore, the objective of the study is to investigate individual, household, and community level barriers to ART adherence among rural women living with HIV. METHODS: We conducted a qualitative study to investigate individual, household, and community level barriers to ART adherence. We conducted focus group discussions with HIV-infected women (n = 4) from rural villages in Eswatini, and in-depth interviews with healthcare workers (n = 8) serving the area clinics. Open and axial coding techniques were used for data analysis and interpreted within a social ecological framework. RESULTS: Our findings revealed several individual level barriers including hunger, side effects of ART, personal stress, lack of disclosure of HIV status, alcohol use, and forgetting to take ART. Lack of food, unemployment and scarcity of financial resources were identified as critical barriers at the household level. Community and institutional barriers encompassed factors related to health delivery such as lack of privacy, travel time, transportation costs, excessive alcohol use by healthcare workers, maltreatment, public and self-stigma, gossip, and long waits at clinics. CONCLUSIONS: Rural women living with HIV face multilevel barriers to ART adherence. Support programs aimed at increasing ART adherence among this vulnerable population need to develop targeted polices to alleviate challenges rural women face, beginning with expanding qualifications for food assistance programs.

Division of Household and Childcare Labor and Relationship Conflict Among Low-Income New Parents.

We examine the relationships among the division of housework and childcare labor, perceptions of its fairness for two types of family labor (housework and childcare), and parents' relationship conflict across the transition to parenthood. Perceived fairness is examined as a mediator of the relationships between change in the division of housework and childcare and relationship conflict. Working-class, dual-earner couples (n = 108) in the U.S Northeast were interviewed at five time points from the third trimester of pregnancy and across the first year of parenthood. Research questions addressed whether change in the division of housework and childcare across the transition to parenthood predicted mothers' and fathers' relationship conflict, with attention to the mediating role of perceived fairness of these chores. Findings for housework indicated that perceived fairness was related to relationship conflict for mothers and fathers, such that when spouses perceived the change in the division of household tasks to be unfair to either partner, they reported more conflict, However, fairness did not significantly mediate relations between changes in division of household tasks and later relationship conflict. For childcare, fairness mediated relations between mothers' violated expectations concerning the division of childcare and later conflict such that mothers reported less conflict when they perceived the division of childcare as less unfair to themselves; there was no relationship for fathers. Findings highlight the importance of considering both childcare and household tasks independently in our models and suggest that the division of housework and childcare holds different implications for mothers' and fathers' assessments of relationship conflict.

Convergence in patient-therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment.

OBJECTIVE: This study tested whether discrepancy between patients' and therapists' ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment. METHOD: Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N = 357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD). RESULTS: Patients' and therapists' alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up. CONCLUSIONS: The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.

Longitudinal changes in spouses' HPA responses: Convergence in cortisol patterns during the early years of marriage.

OBJECTIVE: Drawing on theories of bidirectional influence between relationship partners (Butler, 2011; Diamond & Aspinwall, 2003), the authors applied dyadic analytic methods to test convergence in cortisol patterns over time in newlywed couples. METHOD: Previous studies of bidirectional influence in couples' cortisol levels (Liu, Rovine, Klein, & Almeida, 2013; Papp, Pendry, Simon, & Adam, 2013; Saxbe & Repetti, 2010) found significant covariation in couples' daily cortisol levels over several days, but no studies have tested whether cortisol response similarity increases over time using a longitudinal design. In the present study, 183 opposite sex couples (366 participants) engaged in a conflict discussion in a laboratory visit about 6 months after their marriage, and again about 2 years into the marriage. At each visit, spouses provided saliva samples that indexed cortisol levels before, during, and after the discussion. This multimeasure procedure enabled modeling of spouses' cortisol trajectories around the conflict discussion. RESULTS: Findings showed significant convergence in couples' cortisol trajectories across the early years of marriage; couples showed significantly greater similarity in cortisol trajectories around the conflict discussion as their relationship matured. Cohabitation length predicted stronger convergence in cortisol slopes prior to the conflict discussion. Couples' relationship dissatisfaction was associated with a greater degree of convergence in spouses' acute cortisol levels during the conflict discussion. CONCLUSIONS: Findings suggest that spouses increasingly shape each other's cortisol responses as their relationship matures. Findings also indicated that increased similarity in acute cortisol levels during conflict may be associated with poorer relationship functioning.

Links between Adolescents' Closeness to Adoptive Parents and Attachment Style in Young Adulthood.

This study examined whether adolescents' closeness to adoptive parents (APs) predicted attachment styles in close relationships outside their family during young adulthood. In a longitudinal study of domestic infant adoptions, closeness to adoptive mother and adoptive father was assessed in 156 adolescents (M = 15.7 years). Approximately nine years later (M = 25.0 years), closeness to parents was assessed again as well as attachment style in their close relationships. Multilevel modeling was used to predict attachment style in young adulthood from the average and discrepancy of closeness to adolescents' adoptive mothers and fathers and the change over time in closeness to APs. Less avoidant attachment style was predicted by stronger closeness to both APs during adolescence. Increased closeness to APs over time was related to less anxiety in close relationships. Higher closeness over time to either AP was related to less avoidance and anxiety in close relationships.

The role of patient pain and physical function on depressive symptoms in couples with lung cancer: a longitudinal dyadic analysis.

Drawing on the Developmental-Contextual Model (Berg & Upchurch, 2007), we examined the association between changes in patient physical health (pain severity and physical function) and changes in depressive symptoms in couples with lung cancer over a 12-month period. Patients and their spouses or partners (n = 77) were recruited using rapid case ascertainment and completed five waves of data collection (baseline, 3, 6, 9, and 12 months). Multilevel modeling was used to examine aggregate and time-varying effects of patient physical health on depressive symptoms. Results indicated that for patients and spouses, patient-rated mean pain severity was significantly positively associated with patient and spouse depressive symptoms and patient-rated mean physical function was significantly negatively associated with patient and spouse depressive symptoms. More importantly, increases in patient pain severity and declines in patient physical function were significantly associated with increases in patient depressive symptoms. However, only declines in patient physical function were significantly associated with increases in spouse depressive symptoms. These time-varying effects remained even when controlling for patient gender, patient age, patient stage of disease, spouse physical health, and relationship quality. Findings suggest the importance of examining the changing illness context on the couple as a unit and the complexity of interpersonal processes in the presence of a life-threatening illness.

Symptom incongruence trajectories in lung cancer dyads.

CONTEXT: There is little known about the pattern of change in patient-family member symptom incongruence across the lung cancer trajectory. OBJECTIVES: This study examined trajectories of patient-family member incongruence in perceptions of patient physical function, pain severity, fatigue, and dyspnea in lung cancer dyads and explored the association with family member grief after patient death. METHODS: Lung cancer patients and their family members providing care (n = 109 dyads) rated patient symptoms and physical function five times over 12 months. Symptom incongruence trajectories were analyzed using multilevel modeling. RESULTS: Patient-family member incongruence did not significantly change over time, on average, except in the case of patient physical function where incongruence significantly declined. There was significant variability around trajectories of incongruence for all symptoms except fatigue. Exploratory analysis on a subsample of 22 bereaved family members found that incongruence regarding patient fatigue was associated with family member grief two months after patient death. CONCLUSION: Findings suggest the importance of modeling symptom incongruence over time and taking a dyadic approach to the illness context to identify interventions that promote adjustment and quality of life for both patient and family member.

Predictors of discrepancies between informants' ratings of preschool-aged children's behavior: An examination of ethnicity, child characteristics, and family functioning.

The present study examined predictors of discrepancies between mothers', fathers', and teachers' ratings of 3-year-old children's hyperactivity, attention problems, and aggression. Participants were families of 196 3-year-old children who took part in child and family assessments. Ethnicity was one of the most consistent predictors of discrepancies. African American mothers and fathers were more likely to rate their children's hyperactivity, attention problems, and aggression lower than teachers. In contrast, Latina mothers were more likely to rate their children as more hyperactive and inattentive than teachers. ADHD/ODD diagnoses, parental depression, number of children, and children's pre-academic skills were also predictive of discrepancies for some measures for some informants. These findings provide insight into factors that may contribute to informant discrepancies in ratings of preschool children.

Couple perceptions of fibromyalgia symptoms: the role of communication.

The objectives of the current study were to describe fibromyalgia patient-spouse incongruence regarding patient pain, fatigue, and physical function; and to examine the associations of individual and interpersonal factors with patient-spouse incongruence. Two hundred four fibromyalgia patients and their coresiding partners rated the patient's symptoms and function. Multilevel modeling revealed that spouses, on average, rated patient fatigue significantly lower than patients. Couple incongruence was not significantly different from zero, on average, for pain severity, interference, or physical function. However, there was significant variability across couples in how they rated the severity of symptoms and function, and how much incongruence existed within couples. Controlling for individual factors, patient and spouse reports of communication problems were significantly associated with levels of couple incongruence regarding patient fatigue and physical function, albeit in opposing directions. Across couples, incongruence was high when patients rated communication problems as high; incongruence was low when spouses rated communication problems as high. An important within-couple interaction was found for pain interference, suggesting that couples who are similar on level of communication problems experience low incongruence; those with disparate ratings of communication problems experience high incongruence. Findings suggest the important roles of spouse response and the patient's perception of how well the couple is communicating. Couple-level interventions targeting communication or other interpersonal factors may help to decrease incongruence and lead to better patient outcomes.

Spouses' attachment pairings predict neuroendocrine, behavioral, and psychological responses to marital conflict.

This research investigated how spouses' attachment styles jointly contributed to their stress responses. Newlywed couples discussed relationship conflicts. Salivary cortisol indexed physiological stress; observer-rated behaviors indexed behavioral stress; self-reported distress indexed psychological stress. Multilevel modeling tested predictions that couples including 1 anxious and 1 avoidant partner or 2 anxious partners would show distinctive stress responses. As predicted, couples with anxious wives and avoidant husbands showed physiological reactivity in anticipation of conflict: Both spouses showed sharp increases in cortisol, followed by rapid declines. These couples also showed distinctive behaviors during conflict: Anxious wives had difficulty recognizing avoidant husbands' distress, and avoidant husbands had difficulty approaching anxious wives for support. Contrary to predictions, couples including 2 anxious partners did not show distinctive stress responses. Findings suggest that the fit between partners' attachment styles can improve understanding of relationships by specifying conditions under which partners' attachment characteristics jointly influence individual and relationship outcomes.

Sense of control predicts depressive and anxious symptoms across the transition to parenthood.

In this study, the authors examined the relationship between sense of control and depressive and anxious symptoms for mothers and fathers during the 1st year of parenthood. Participants were 153 dual-earner, working-class couples who were recruited during the 3rd trimester of pregnancy at prenatal education courses. Data were collected 1 month antenatally and 1, 4, 6, and 12 months postnatally. Sense of control was decomposed into 2 distinct parts: an enduring component and a malleable component that changes with context. Consistent with a cognitive theory of emotional problems, results demonstrated that a sense of control served a protective function for mental health outcomes. A higher sense of enduring control predicted lower levels of psychological distress for new parents, and increases in control over time predicted decreases in depression and anxiety. Findings hold implications for interventions with expectant parents, such as expanding prenatal education courses to include strategies for enhancing and maintaining a sense of personal control.

The enduring and contextual effects of physical health and depression on care-dyad mutuality.

Mutuality is a protective factor in family care situations, but little is known about changes in care-dyad mutuality. In this study, we examined mutuality in 103 care dyads over 20 months, and the enduring and contextual impact of older adult and family caregiver health on changes in mutuality. Care dyads consisted of frail older adults and their family caregiver. Older adults reported higher levels of mutuality than family caregivers, but their mutuality declined significantly faster over time. Although changes in physical health were more important than mean health for both older adults and family caregivers, mean depression was more important than changes in depression for older adults. This study shows the importance of examining time-varying covariates in the care dyad.

Shift Work, Role Overload, and the Transition to Parenthood.

This article examines how the work hours, work schedules, and role overload of working-class couples are related to depressive symptoms and relationship conflict across the transition to parenthood. Data are from 132 dual-earner couples interviewed 5 times across the transition. Multilevel modeling analyses revealed that working evening or night shifts, as opposed to day shifts, was related to higher levels of depressive symptoms. For mothers only, working rotating shifts predicted relationship conflict. Increases in role overload were positively related to both depression and conflict; working a nonday shift explained variance in depression and conflict above and beyond role overload. Results suggest that for new parents, working nonday shifts may be a risk factor for depressive symptoms and relationship conflict.

Caregiving as a dyadic process: perspectives from caregiver and receiver.

Most family caregiving research has relied on the perspective of the caregiver but has not systematically examined the views and opinions of the elder who is receiving care. The present study examined 63 caregiving dyads to determine how the responses of each member had an impact on the well-being of the other member of the dyad. Caregiver relationship strain predicted his or her own depression and negative health, but no significant association was found between caregiver and care recipient outcomes. Multilevel modeling was used to assess the level of dyadic discrepancy over the care recipient's needs and appraisal of caregiving difficulties. Results indicate that there is little disagreement over the care recipient's needs, but a significant amount of variation in how much the care recipient and caregiver agree on their appraisals of caregiving difficulties. Relationship strain perceived by the caregiver, but not the care recipient, was significantly associated with this disagreement.