Compliance~Adherence and

Care Management in HIV Disease

Michele Crespo-Fierro, MS/MPH, RN, CRNI, ACRN

With the changing perspectives of the HIV epidemic

and the introduction of protease inhibitors to treat
human immunodeficiency virus (HIV) disease, the issue
of compliance has gained considerable interest among
health care providers. The idea that clients with HIV
disease should succumb to a patriarchal system of
medical care has been challenged by AIDS activists
since the beginning of the epidemic. The concept that
there is only one explanation for "'noncompliance" is
outdated. The reasons for noncompliance are multifaceted in nature and include psychosocial factors, complex medication and treatment regimens, ethnocultural
concerns, and in many instances substance use. Therefore, the notion that there is one intervention to resolve
noncompliance is at best archaic. Interventions to enhance compliance include supervised therapy, improving the nurse-client relationship, and patient education, all o f which should be combined with
ethnocultural interventions. Plans to enhance compliance must incorporate person-specific variables and
should be tailored to individualized needs.
Key words: Compliance, culture, ethnicity, patient
education, substance abuse
S i n c e the introduction of antiretroviral therapy and
chemoprophylaxis to prevent opportunistic infections,
survival among people with human immunodeficiency
virus type 1 (HIV-1) infection has increased, resulting
in a chronic disease condition that can be stabilized
with therapy for many years (Feinberg, 1996). This
shifting paradigm of the HIV-1 illness trajectory requires that health care providers (HCPs), community
based AIDS organizations, legislators, policy makers,
and economists, as well as people living with HIV
Michele Crespo-Fierro, MS/MPH, RN, CRNI, ACRN, is a
clinical nurse specialist, HIV lnfection, VtsitingNurse Service
of New York.

(PLWHIV) disease, seriously reconstruct their understanding of this illness.

Perhaps the greatest impact of the new knowledge
about HIV has been, and will continue to be, on the
issue of medication and treatment compliance. Although the term compliance is often used by HCPs, its
interpretation often has different meanings to different
people. Haynes (1979) def'mes it as "the extent to which
a person's behavior, in terms of taking medications,
following diets or executing lifestyle changes coincides
with medical advice" (p. ii). O'Hanrahan and O'Malley
(1981) have explained compliance as "following medical advice sufficiently to achieve a therapeutic goal"
(p. 298). According to these definitions, compliance
requires the client to bend to the will of a predetermined
medical regimen.
The interpretations of compliance provided by physicians and their perspective of disease management is
often quite different from other HCPs. Nurses who have
examined physician-driven definitions of compliance
have found them to be paternalistic, to inhibit the
client's autonomy, and to be exclusively concerned
with medical practice as opposed to health care (Weust,
1993). In a review of several nursing studies, Weust
(1993) noted that the term compliance is linked to
medical practices as opposed to "autonomous nursing
practice" and postulates that the use of this term by
HCPs serves to disempower clients, which then requires activities to empower them (p. 219). Most of
these empowerment-enhancing activities axe employed
by nurses and social workers.
In the treatment of HIV disease, many HCPs have
become accustomed to, and even assess for, clients'
activities to empower themselves. Some activities have
been thoroughly supported, such as the founding of
various community-based AIDS service organizations
such as Gay Men's Health Crisis in New York City to

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 8, No. 4, July/August 1997, 43-54
Copyright 9 1997 Association of Nurses in AIDS Care

44 Crespo-Fierro/ Complianceand Care Management

disseminate information in order to make informed

treatment choices and militant activist groups such as
ACT-UP (AIDS Coalition to Unleash Power) to protest
drug approval delays at the Food and Drug Administration and to fight against pharmaceutical companies to
demand equal access to drugs for the poor and disenfranchised (Ungvarski & Ballard, 1995). Other strategies that have been less supported by some HCPs are
Harm Reduction activities (Springer, 1991), such as
needle exchange programs.
Sometimes the individual client's desire to be empowered is perceived by the HCP to be noncompliant
behavior. There are times when HCPs tolerate noncompliance such as when a terminally ill person refuses
recommended treatments. The Patient Self-Determination Act of 1991 now provides Protection for an individual to make such treatment choices (Idemoto et al.,
1993). Nurses and other HCPs often make social judgments about a client's behaviors (Johnson & Webb,
1995). The social judgments once made may either
serve to bond or alienate the client to the HCP. In some
situations, such as a client using illegal drugs for pain
control when the HCP is inadequately managing the
symptom, the clinician may admonish the client or
withdraw treatment because of a conflict with treatment choices.
The primary purpose of this article is to examine
various perspectives of those decisions and behaviors
of clients that may lead to the label of noncompliance
by the HCP. The secondary purpose is to discuss various strategies to address this phenomenon as they relate
to the care management of PLWHIV.

Variables Related to Compliance

The factors that lead to problems in an individual's
ability to comply with prescribed medication regimens
and therapies are diverse and often multifaceted in
nature. It is not only naive of the HCP but also a
disservice to relationship of the HCP and client to
believe that a single variable is contributing to a noncompliant situation. Additionally, generalizations
about populations, for example, all drug users are noncompliant with a plan of care, can be erroneous. Issues
affecting compliance for a PLWHIV include psychosocial, medications and treatment, culture, and substance abuse (see Table 1). For each individual
PLWHIV, many of these factors coexist and their level
of importance varies from person to person.

Table 1. FactorsRelatedto NoncompliantBehavior

Factor

Examples

Psychosocial Locusof control (Flaskemd, 1995b; Pepler &

factors
Lynch, 1991; Ragsdaleet al., 1995)
Ineffectivecommunication(Chung et al., 1995)
Mental health problems (Smith et al., 1996)
Trust (Sheffieldet al., 1994, Torres & Staats, 1989)
Internalconflict,social stress, stigma(Chesney&
Folkman, 1994; Haskemd, 1995a)
Paternalisticbehaviorof the HCP (Weust, 1993)
Medications Complex regimens(Baileyet al., 1995)
and
Inconvenientdosing schedules(Vogelet al., 1993)
treatments Skepticismabout treatmentefficacy(Mossaret al.,
1993; Muma et al., 1995)
Ethnocultural Lack of understandingculturalinfluences
issues
(Beechem,
1995; Flaskerud, 1995b; Grossman,
1996; Leininger,1991a; Spruhan, 1996)
Differingworldview(Flaskerud, 1995b)
Substanceuse Continuingsubstanceuse (Jimemezet al., 1996;
Smith et al., 1996; Solomon,1991)
Lack of social support (O'Brien & McLellan, 1996)
Tenuous living arrangements(Jimemezet al.,
1996; Smith et al., 1996)
Negativeviews of addiction(O'Brien &
McLeHan, 1996)

Psychosociai Factors
Psychosocial factors related t0 compliance are often
concerned with a group dynamic, interpersonal relationships such as within the family or health care setting, and society at large. Chesney and Folkman (1994)
have postulated that the stress of living with HIV
disease, that is, the stigma and the uncertainty of the
illness, can delay access to care and affect a patient's
ability to be compliant with the complicated medication and treatment regimens. Pepler and Lynch (1991 )
studied relational messages between nurses and terminally ill patients, some of whom were diagnosed with
AIDS, and found that control was a major theme, as
evidenced by different situations in which nurses or
patients exerted control. The least frequently observed
behavior was a patient who was willing to relinquish
control to the nurse.
Ragsdale, Kotarba, Morrow, and Yarbrough (1995)
examined perceptions of control over health in HIVpositive indigent women. The authors found that the
women had high scores for both internal and external
locus of control. They concluded that this finding reflected the paradoxical nature of living with HIV disease or possibly the conflicting forces in their everyday

JANAC Vol.8, No. 4, July/August1997 45

lives. It also was noted that the relationship between the

women and a patriarchal health care system made many
demands upon them, often conflicting with other
responsibilities.
The interactions between the HCP and client, as well
as the client's feelings about the HCP, appear to have
an effect on the potential for compliance with treatment
regimens. Chung, Hart, and McColl (1995) examined
physician-client communication at a sexually transmitted disease (STD) clinic and its impact on client return
to the clinic for follow-up to HIV antibody testing.
Those clients who did not initially return cited social
factors as well as the doctor's ability to communicate
with the client as reasons for not returning for care. In
a study of factors that were important in engaging
minority women in HIV-related clinical trials, physician trust was cited as an important client concern
(Sheffield, Kloser, Gill, & Correll, 1994). Torres and
Staats (1989) in a study of PLWHIV living in a congregate residential setting found that familiarity with the
physician enhanced compliance with the treatment plan
and clinic visits.
Internal conflicts and social stress will also affect the
ability of a PLWHIV to comply with a prescribed
regimen. Internal conflicts a patient may be dealing
with include concern over HIV transmission, protection from infection, guilt over previous lifestyle, and
concerns about personal relationships (Flaskerud,
1995a). Social stressors may include fear of disclosure
and exposure, stigma, employment and insurance, social support limitations, and family concerns (Flaskerud, 1995a).
Medications and Treatments

Prescribed medications and treatments, and the requisite instructions on their proper use, can also positively or negatively affect the ability of the PLWHIV
to be adherent to the regimen. The more complex the
regimen, the less likely the patient is to follow the
treatment plan, regardless of age and educational levd
(Bailey, Ferguson, & Voss, 1995). Vogel, Grady, and
Ropka (1993) studied factors affecting investigational
medication compliance and found the major reasons
participants cited for noncompliance were forgetting
the dose or the inconvenience of dosing schedule, that
is, waking up in the middle of the night to take the
medicine or having to self-inject a drug.

Numerous other factors that can also affect adherence with HIV-related drug regimens have also been
identified. Muma, Ross, Parcel, and Pollard (1995)
conducted a study to examine zidovudine adherence in
persons with HIV infection and found four factors
related to compliance: (a) problems taking and skepticism about zidovudine, (b) their degree of concern
about HIV disease, (c) their perceived Severity of HIV
illness, and (d) barriers to taking the medication. They
also identified that skepticism about the efficacy of the
medication prescribed and ethnicity were significant
independent predictors of variance in compliance. In a
comparative study of compliant and noncompliant
PLWHIV taking prophylactic medications, Mossar,
Lefevre, Deutsche, Wesch, and Glassroth (1993) found
that PLWHIV were more likely to be noncompliant
when they believed that the medications were of little
value, had less faith in the traditional medical system,
were less educated, and were more likely to use alternative therapies.
Ethnocultural Issues

Cultural factors play a very important role in the

decision-making process for medications and treatments for clients (Charonko, 1992). Often because of
culturally insensitive delivery of health care, no effort
is made by the health care professional to effectively
interact with the client. Language and literacy barriers
may not be addressed by the educational materials used
in a health care encounter. The motivation of some
cultural groups to please authority, or to distrust authority, may establish barriers to developing the relationships necessary to ensure medication and treatment
adherence (Leininger, 1991a). The importance of understanding and respecting the cultural background of
the client and family has been frequently cited in the
literature (Beechem, 1995; Flaskemd, 1995b; Grossman, 1996; Spmhan, 1996). The research and the anecdotes cited by these authors give clear examples of how
making an effort to understand a client's cultural beliefs
can go a long way in fostering a therapeutic relationship, which could then result in better disease management.
Locus of control is another issue that may affect care
management. Studies have shown that ethnic people of
color, persons of lower socioeconomic groups, and
older individuals are often found to have an external
locus of control (Flaskemd, 1995b; Jenkins, Lamar, &

46 Crespo-Fierro/ Complianceand Care Management

Thompson-Crumble, 1993; Marin, 1989). They feel

that illness is caused by external forces over which they
have little control. The assumption made by many
HCPs is that people with an external locus of control
do not have the capacity or interest in health promotion,
disease prevention, or illness treatment, and as a consequence are often labeled as "hard to reach" or "noncompliant" (Flaskerud, 1995b, p. 425). Despite the fact
that many HCPs attribute fatalistic attitudes to some
racial and ethnic groups, nursing research has revealed
that many people of color actively participate in healthpromoting interventions (Flaskerud, 1994; Flaskerud
& Calvillo, 1991; Flaskerud & Rush, 1989; Flaskerud
& Thompson, 1991).
Noncompliance as seen in PLWHIV can often stem
from negative treatment encounters they have experienced in the past. For example, the labeling of Haitian
nationality as a specific risk category for AIDS in the
early 1980s built barriers to engaging in care that have
been difficult to overcome. The labeling of persons
with a history of substance use as part of a manipulative
and noncompliant subculture has become for many a
self-fulfilling prophecy. There is a paucity of available
studies that have discovered and described the impact
of culture on compliance (Rubel & Garro, 1992). Studies are also needed to determine if culturally insensitive
health care has an effect on future access to care and
medical and functional outcomes.
Substance Use
Continuing substance use can also interfere with the
PLWHIV's ability to manage medication and treatment
regimens. Often, substance use is narrowly defined as
illegal drug abuse. However, the misuse of alcohol,
over-the-counter and prescription drugs, and complementary or alternative therapies can also have a comparable impact on adherence. Solomon (1991) emphasizes the need to be fully aware of the substance use
patterns of the client, particularly in home care, in order
to develop a plan of care that is realistic and achievable.
In Chicago, Jimenez, Johnson, Hershow, and Wiebel
(1996) studied factors influencing compliance with
tuberculosis (TB) treatment among injecting drug users
(IDUs) with or at risk for HIV infection. The authors
identified several factors that inhibit adherence behaviors: (a) lack of stable living arrangements, for example, shelters, abandoned buildings, family members'
homes; (b) environments that facilitate substance use,

for example, "shooting galleries" or "rock houses"; (c)

the stigma of TB, often superseding the stigma of HIV,
making it difficult to procure drugs and find a place to
sleep; and (d) drug needs that take precedence over
other health care needs. In Oregon, Smith, Whetstine, Butsch, and McAlister (1996) studied newly
diagnosed HIV-infected persons enrolled in a wellness
program and found that personal disorganization associated with a history of injection drug use, alcoholism/problem drinking, criminal record, family dysfunction, mental health problems, unemployment, and
housing problems were associated with a high attrition
rate.
O'Brien and McLellan (1996) suggest that both the
public's and HCP's perception that addiction is more
of a character disorder rather than a chronic medical
condition obstructs the ability to appropriately manage
this pervasive problem. The authors compared data on
treatment success rates for addictive disorders and
three selected medical disorders including diabetes,
hypertension, and asthma. The success for nicotine,
cocaine, opiod, and alcohol dependence ranged from
30% to 60%, compared to medication compliance rates
for diabetes, hypertension, and asthma, which ranged
from 30% to 50%. When patient characteristics associ=
ated with noncompliance in addictive diseases, diabetes, hypertension, and asthma, are studied, they are
identical and include socioeconomic status, comorbid
psychiatric conditions, and lack of family support
(O'Brien & McLellan, 1996).
Interventions
With a greater understanding of the importance of
medication compliance to maintain health in the face
of chronic illness, there is now an increased emphasis
on the types of interventions that can increase compliance. Interventions to manage compliance are provided
in Table 2.
In a systematic review of the literature concerning
interventions to assist with medication compliance in
non-HIV populations, Haynes, McKibbon, and Kanani
(1996) discovered too much variance in the clinical
problems, adherence interventions, measures and reporting of adherence, and the clinical outcomes to
properly perform meta-analysis. Consequently, only 13
studies were examined for statistically significant findings on the effect of interventions and treatment outcomes. The interventions included dosing variations

JANAC Vol. 8, No. 4, July/August 1997 47

Table 2. Interventionsto manage noncompliance

Intervention
Supervisedtherapy
Nurse-clientrelationship

Patient education

Ethnoculturalinterventions

Examples
Directlyobservedtherapy (DOT) (El-Sadret al., 1995; El-Sadret al., 1996)
Surrogatefamily model (EI-Sadret al., 1995; EI-Sadret al., 1996)
Integratedcare (all care providedon site) (Goviaet al., 1994; O'Connor et al., 1992; Wall et al., 1995)
Case management(Pincus-Strom, 1989)
Nurses with HIV experience(Baylor& McDaniel, 1996)
Trust building (Wendt, 1996)
Acceptance,respect,individualizedtreatment,nonjudgmentalattitudes (Meeks-Festaet al., 1994;
Mullins, 1996)
Flexible, short-term,realistic goals (Redland& Stuifbergen,1993)
Use of theory-basedpractice (Leininger,1991b; Pender, 1987; Prochaskaet al., 1992; Springer, 1991)
Patient reminders(Besch, 1995; Korenet al., 1994)
Outreach (Petersonet al., 1993; Pilote et al., 1993)
Videotapes (Healton& Messed, 1993; Solomon& DeJong, 1988)
Multiculturalteams (MacLachlan& Carr, 1994)
Incorporatingethnoculturalpractices(Haskerud, 1995b)
Cultural competence(Campinha-Bacote,1993; Flaskerud, 1995b)

(once vs. twice daily), patient educational materials

(reading materials, workbooks), phone call follow-up,
self-monitoring of symptoms, counseling, and therapy.
The small number of studies and the variety of disease
processes (asthma, hypertension, infectious process,
schizophrenia, and epilepsy) and the various interventions made it difficult to adequately compare their
effects on compliance or on outcomes. The authors
concluded that although certain, often complex interventions can assist to some degree in helping with the
problem of medication compliance, further studies are
needed to identify strategies that will increase the level
of adherence.

Supervised Therapy/Integrated Programs

One method of assuring medication compliance that
has regained popularity in recent years is supervised or
directly observed therapy (DOT). Primarily used in the
treatment of tuberculosis (TB) and psychiatric disorders in communal living situations, its purpose is to
assure completion of therapy to avoid relapse. A novel
approach to the use of DOT for tuberculosis patients in
New York City incorporated a surrogate family model
and included group activities such as field trips and hot
meals, transportation tokens, coupons for meals, support groups, and clinic and home visits (EI-Sadr,
Medard, & Dickerson, 1995; E1-Sadr, Medard, &
Barthaud, 1996). In the final evaluation, high rates
of treatment completion and visit adherence were
achieved.

Some HCPs have called for the use of DOT to

manage noncompliance in HIV disease management as
in the treatment of TB. Advocates of DOT should be
aware of the differences in the two diseases, including
(a) HIV disease is not as easily transmitted as TB, (b)
treatment for HIV disease is more complicated in that
it is actually a cluster of illnesses, (c) medication dosing
schedules span a 24-hour period as opposed to once a
day therapy, (d) treatment for HIV disease is presently
a lifetime endeavor, whereas most protocols for TB
average 1 year, and (e) HIV disease involves a far
greater number of behavior changes to maintain health
and slow disease progression. Considering the costs
associated with such a program, combined with the
expense of medications, in the current climate of cost
containment, it does not appear that DOT is a viable
option.
One cohort of PLWHIV disease who are accustomed
to supervised therapy are those enrolled in a methadone
maintenance treatment program (MMTP). The integration of primary care along with antiretroviral therapy
into MMTP services is another example of providing
medications with consistent supervision. The convenience of receiving care in one location was attractive
to the clients in these studies and yielded positive
results (Govia et al., 1994; O'Connor, Molde, Honrey,
Shocker, & Schoottenfeld, 1992; Wall, Sorenson, Batki,
& Delucchi, 1995). Because all MMTP services do not
provide comprehensive primary care, this option may
be limited in certain areas. Another issue of concern is
that receiving HIV-related services at the program may
disclose the client's serostatus to others.

48 Crespo-Fierro/ Complianceand CareManagement

Nurse-Cfient Relationship
The nurse-patient relationship can be a very powerful tool that can greatly affect compliance. The nature
of this relationship can go far in enhancing a client's
willingness to make an effort to make changes in his or
her behavior; however, it could also be the reason a
client is completely lost to follow-up when the client is
offended by the nurse's behavior or attitude. Judgmental attitudes appear to arise more often with HCPs
in HIV disease than with other diagnostic categories.
In a review of the literature, Flaskemd (1995c) noted
that although nurses' knowledge of the pathophysiology of the disease has increased over t.heyears, negative
attitudes toward groups of persons at high risk for HIV
disease, as well as uneasiness with death and dying,
continue to prevail. Nurses with experience in caring
for PLWHIV appear to have a more positive outlook on
working with this cohort compared to nurses with no
such experience (Baylor & McDaniel, 1996).
The key element of the nurse-client relationship is
the establishment of trust. Wendt (1996) writes of the
importance of building trust in the nurse-client relationship. Strategies to build a trusting relationship include
(a) establishing credibility; (b) using an empathetic,
nonjudgmental approach; (c) respecting the client's
privacy; (d) expecting testing behaviors from the client;
and (e) learning to trust the client (Wen&, 1996). When
PLWHIV were asked what were the most important
nurse caring behaviors they wanted to see, the highest
ranking themes were acceptance, respect, treatment of
the person as an individual, and nonjudgmental attitudes of the nurse toward the patient (Mullins, 1996).
In a similar study, Meeks-Festa, Uhle, Munjas,
Gerszten, and Creger (1994) studied PLWHIV satisfaction with nursing care. Although positive ratings were
identified for helpfulness, availability, patience, and
respect, the results identified two major areas that
needed improvement: the need for more information on
medications and treatment procedures.
Walsh (1991) categorizes behaviors and attitudes of
HCP's approaches to client care as either an "I can" or
"I can't" position. In the "I can" position, the HCP is
more likely to be able to deal with clients creatively and
effectively in order to achieve the desired outcomes. In
the "I can't" position, the ability to work successfully
with a client is defeated from the start. Table 3 illustrates the differences in both positions. It is important
to note that no HCP is locked into a position and has

the ability to change. Equally important is the fact that

many HCPs may, from time to time, have some attributes from both positions; however, recognizing them
is the first step toward change.
The increasing use of case managers in managed
care offers another venue for assisting clients in matters
of adherence. Because the majority of staff employed
as case managers are professional nurses, the opportunity exists to develop creative strategies for improving
patient outcomes. Pincus-Strom (1989) proposes the
use of case management strategies in order to more
effectively support a substance-using client with HIV
infection in order to meet the concrete needs of the
client, noting the ability of the case manager to develop
contacts and resources within the community. If the
role of the case manager is allowed to go beyond
gatekeeping functions to strictly limit costs, the comprehensiveness of the case manager's approach could
provide the client the individualized care that is necessary to achieve compliance with medical regimens.

Patient Education
The primary purpose of patient education is to assist
the client with decision making regarding health promotion and treatment decisions (Ungvarski & Schmidt,
1995). It is important to note that after information is
provided to a client, some may select to follow all the
advice, some will select portions, and yet others will
reject all the information. The ultimate decision belongs to the client and in no way implies failure on the
part of the HCP. The education process should include
goals that are flexible, short term, and realistic for the
client's life situation (Redland & Stuifbergen, 1993).
All education should take into account that failures and
relapse may occur and the client should be prepared by
the HCP to handle these situations.
Perhaps the most used method of attempting to
enhance compliance, employed by HCPs, is patient
education employing face-to-face teaching and the use
of printed materials. Printed materials such as pamphlets and self-care guides are a means of extending the
patient teaching process outside the hospital, clinic, and
office setting. Major advantages of printed materials
include (a) they can be reviewed at the client's convenience; Co) care partners and family members, who
may not be with the client at the time the initial teaching
is performed, can read the material and participate more
knowledgeably in the plan of care; and (c) they can be

JANAC Vol. 8, No. 4, July/August 1997 49

Table 3. A Comparison of "I Can" and "I Can't" Attitudes of

Health Care Providers
The "I Can" Position

The "I Can't" Position

Has a neutral attitude

Hopeful even if patient is
dysfunctional
Knows there's a problem
and wants to solve it
Thinks about what can be
done differently to get a
different outcome
Exhibits equanimity and
composure
Has realistic expectations
of self and patients

Has a blaming attitude

Hopelessno matter what changes
patient makes
Thinks patients shouldn't be allowed
to get away with their behavior

Maintains a sense of
competence
Recognizes that patients
can be difficult and it
often has nothing to do
with the care giver
Perceives the difficult
patient as an opportunity
Sets appropriate limits
with careful thought and
not out of anger, and is
consistent in applying
limits
Asks for and accepts help
easily
Accepts, modifies, and
builds on suggestions

Thinks patients have to change their

ways
Exhibits high emotional pitch, intense
frustration, anger, or extreme apathy
Expects to be able to give care
according to plan and gain
cooperation of all patients
Feels like a failure
Takes difficultbehavior personally

Perceives the difficult patient as a

burden
Sets limits in anger or out of impulse;
limits are either too rigid or too
vague; is inconsistent in applying
limits
Has difficultyeither asking for or
accepting help
Rejects suggestions as not doable
or too much trouble

Adapted with permission from Walsh (1991, p. 32).

re-reviewed when the need or a question arises. However, the limitations of printed materials include the
literacy level of the client and care partners, the primary
spoken and read language of the individuals, and visual
limitations associated with the sequelae of HIV/AIDS,
for example, cliorioretinitis or blindness.
Glazer, Kirk, and Bolser (1996) evaluated printed
materials to teach breast self-examination and found
that although the reading level of the materials being
provided was at a ninth grade level, the average reading
level of the target population was a sixth grade level.
These findings underscore the need to prepare materials
that can be used by the maximum number of clients.
Additionally, considering the time, effort, and costs
associated with the development of printed materials,
they should be kept simple and pr/tctical.

At the Visiting Nurse Service of New York, with an

average daily census of 1,700 PLWHIV, an HIV/AIDS
self-care guide was developed by the clinical nurse
specialists (Ungvarski, Schmidt, & Crespo-Fierro,
1996). In order to control for the reading level of the
material being written, a word processing program with
the capability of evaluating the grade level of the material being prepared was used. Although the goal was
to keep the information at a sixth grade level, the
authors found this difficult. The final product was
evaluated to be between a sixth and eighth grade level.
The same method was used to prepare the Spanish
version of the guide. However, problems were encountered with language and literacy among the Haitian
community because many of the clients speak but do
not read Creole. Plans are under way to seek funding
for audio taping of the teaching guide in Creole, Spanish, and English. Patient satisfaction surveys of the
guide have yielded an overall rating of 4.57 on a scale
of 0 to 5, with 5 being the highest rating. Interestingly,
the only major complaint from a few clients and care
partners is that the language is too simplistic.
Although expensive, another means of overcoming
reading problems is with the use of videotapes. In an
attempt to provide information on symptom management in HIV disease, Ross Products Division of Abbott
Laboratories collaborated with the Association of
Nurses in AIDS Care, the Physicians Association for
AIDS Care, and the Nutritionists in AIDS Care, and
prepared a videotape on managing weight loss, pain,
and fatigue (Ross Products Division, 1994). The videotape was made available for free for PLWHIV. It has
proved to be most useful for clients who were illiterate
and clients with diminished visual acuity. Studies have
shown that the use of videotapes in patient education
have the most success in increasing knowledge levels
(Healton & Messeri, 1993; Solomon & DeJong, 1988).
Combining patient education with another incentive
has also been successful in improving compliance.
Chaisson, Keruly, McAvinue, Gallant, and More
(1996) conducted a controlled study to increase the rate
of return to clinic for purified protein derivative (PPD)
test reading. Significantly higher rates of return to
clinic were found among the groups who received a
food voucher and education.
Patient reminders have been used to improve compliance with medical visits and medications. Besch
(1995) describes the use of timers and recorders on

50 Crespo-Fierro/ Complianceand Care Management

medication bottles that will remind patients of the

scheduled dose by beeping and then register when the
bottle is opened. For patients with HIV disease on
multiple medications with multiple doses per day, however, the cacophony of beeps could be quite distressing.
Koren, Barrel, and Corliss (1994) performed a smallscale study to replicate the f'mdings of other studies on
usual care and the use of postcard reminders and telephone calls to clients to improve compliance with clinic
visits. Their findings showed no significant difference
between usual care and telephone call intervention or
postcard reminders. However, it was felt that the telephonic intervention was preferred because it allowed
those clients who wished to reschedule an appointment
the opportunity to do so at that time, and it added a
personal touch.
Another tool often used in the nurse-patient process
to increase patient compliance is the patient contract. It
is negotiated between the nurse and the client and,
ideally, contains the goals to which they have mutually
agreed. Burchman and Pagel (1995) described their
success with the use of a patient contract in the treatment of chronic nonmalignant pain and a resulting
retention and compliance rate of 79% over a 3-year
period. This program is an example of the success that
can be achieved with a detailed protocol and the staff
commitment to support it.
Outreach has been a very successful tool in improving the participation of clients in their health care. The
use of peer health advisers (PHA) to improve compliance with homeless populations to improve outcomes
of TB treatment has been reported (Peterson, Pilote,
Zolopa, & Moss, 1993; Pilote, Peterson, Zolopa, &
Moss, 1993). Pilote and colleagues compared clients
receiving usual care with a client being assigned to a
PHAor given a money incentive in the form ofpayment
to go to clinic. When compared to usual care, both of
the intervention groups significantly improved compliance. In this same program, Peterson and associates
(1993) concluded that community-based projects work
best if they involve the target population, in this case,
using PHAs who are homeless themselves.
Interactive high-tech patient teaching materials are
the newest approach to managing various disease processes. Using behavioral psychology models such as
the Transtheoretical Model of Readiness for Change
(Prochaska, DiClemente, & Norcross, 1992), these programs are specifically designed to continue to engage

the client in care. The recent advances in information

technology such as the Internet and World Wide Web
have been used as conduits of information among
HCPs, and this benefit is now being extended to clients.
Some programs use the home pages and chat rooms
sponsored by major companies in the health care field
to interact and share information with clients in an
informal and bulletin-like manner. One program uses
an interactive phone module that records the client's
responses to questions about his or her disease management. A report is then generated based upon the client's
responses and sent both to the client and the provider
of care (physician, nurse practitioner, home care
agency, etc.). Each set of questions and the report are
individualized for each client based on those responses
and emphasize areas of knowledge (medication or disease) where more work is needed. With this report, the
provider of care can address those knowledge gaps or
therapeutic management issues at the next contact
(Ruth Habicht, personal communication, December 4,
1996). The major limiting factors in the use of interactive computers for care management are the accessibility to equipment for the poor and the computer literacy
of the client.
Ethnoculturai Interventions
The treatment of HIV disease, prescribed within the
context of the existing ethnocultural beliefs and pracrices, as opposed to the traditional context of biomedical and nursing beliefs, is more likely to succeed in that
it will represent the worldview of the community
served (Flaskerud, 1995b). MacLachlan and Carr
(1994) propose the importance of using traditional
healers to promote health protection and promotion
behaviors. They studied the flow of information about
HIV disease in African countries and the perceived
credibility of modem medical practitioners and traditional healers. There was not a significant difference
between perceived credibility of the two groups. Consequently, they suggest that both traditional healers and
modern medical practitioners be used to engage clients
into care. The local healers can also be an excellent
source of information about their treatments for illness.
Knowledge of the ingredients of those therapies can be
used to recognize any interactions with prescribed
medications.
Studies of low-income Latina, African American,
and White women in Los Angeles found culturally

JANAC Vol.8, No. 4, July/August1997 51

driven prevention and treatment practices that were

being applied by PLWHIV, including (a) the use of
food, vitamins, and herbs to keep the body healthy and
to treat illness; (b) preventing chills, keeping the body
warm, and avoiding extremes in temperature; (c) keeping the body and environment clean; (d) balancing life
with rest and exercise; and (e) emphasizing the importance of spirituality, family, and friends in combating
illness (Flaskerud, 1994; Flaskerud & CalviUo, 1991;
Flaskerud & Rush, 1989; Flaskerud & Thompson,
1991).

Theoretical Perspectives
There are various theories that have attempted to
explain the variables associated with compliance.
Some focus on the relationship between the HCP and
the patient, and others are more patient oriented. All
suggest strategies to enhance patient compliance with
medical treatment regimens.
Pender (1987) has proposed the Health Promotion
Model of Nursing. The tenet of this model is the proposition that health promotion is an entirely different
concept than illness prevention. The model is described
in four categories: (a) health promotion, to improve
overall health; (b) primary prevention, to prevent illness; (c) secondary prevention, to prevent complications of illness; and (d) tertiary prevention, to prevent
further deterioration from disease. As a nursing theofist, the interventions she lists do not focus exclusively
on taking medications to achieve health, but rather
behavioral changes and symptom management. Her
model includes a health assessment as well as a values
clarification in which the nurse learns what is important
to the patient. Many times the client's focus may not be
on keeping clinic appointments or taking medications
but, rather, feeding the family (Anastasio, 1995). According to Pender (1987), the nature and quality of the
nurse-client relationship is essential to the implementation of these activities.
The Health Belief Model (Rosenstock, 1974) is a
health education model. It proposes that clients will
make changes in behaviors when they believe they are
at risk for harm. The focus for intervention is then on
the HCP to present information in a manner that convinces the client that the risk of the illness/problem is
real. It is then necessary for the educator to assist the
client to choose those activities that will eliminate that
risk. This model has been questioned in that it does not

account for cultural, ethnic, and socioeconomic differences (Cochran & Mays, 1993).
The Harm Reduction Model was developed by social workers working with intravenous drug users specifically to reduce the risk of contracting HIV infection
through the use of injecting equipment (Springer,
1991). The model poses the idea that immediate abstinence is not a feasible goal. Rather, it is possibly a final
goal in a series of behavior changes that progressively
reduces the harm of current behaviors. An important
attribute of the HCP using this model is being able to
employ a nonjudgmental attitude with the client. The
appeal and usefulness of this model can be noted in its
application to other populations affected by HIV disease such as women at risk through heterosexual transmission (Denenberg, 1993). Persons with diabetes and
heart disease can also use the Harm Reduction Model
to modify their diets, and smokers can reduce the
number of cigarettes smoked per day.
Transcultural nursing theories (Leininger, 1991b)
and models of cultural competence (Campinha-Bacote,
1993) suggest that it is the respectful individualized
care that is offered to clients that actually engages them
and engenders trust. By continuing to render care that
is culturally competent, the nurse does not ask the client
to be compliant or to adhere to a medication regimen.
Rather, the health care team evaluates that client's
lifestyle and, in conjunction with the client, discusses
options for therapy, then offers the therapies that meet
identified needs.
The North American Nursing Diagnosis Association
(NANDA) has distinguished "management of therapeutic regimen," the process, from "noncompliance,"
the result (Lunney, in press). It is defined as "a pattern
of regulating and integrating into dally living, a program for treatment of illness and the sequelae of illness
that are (un)satisfactory for meeting specific health
goals" (North American Nursing Diagnosis Association, 1994, p. 56). Table 4 contains a listing of related
factors for this nursing diagnosis.

Conclusion
In the past two years, some important recommendations for treating HIV disease and AIDS have been
made. Guidelines on the use of antiretrovirals have
been published. An overriding concern has surfaced
that any level of noncompliance with the therapeutic
regimen will ultimately lead to the development of drug

52 Crespo-Fierro / Compliance and Care Management

Table 4. Related Factors for Management of Therapeutic Regimen

9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9

Complexity of health care system

Complexity of therapeutic regimen
Decisional conflicts
Economic difficulties
Excessive demands on individual or family
Family conflict
Family patterns of health care
Inadequate number or cues to action
Knowledge deficits
Mistrust of regimen and/or health care personnel
Perceived seriousness
Perceived susceptibility
Perceived barriers
Perceived benefits
Powerlessness
Social support deficits

Source: North American Nursing Diagnosis Association (1994,

p. 56).

resistance (Carpenter et al., 1996; Deeks, Smith,

Holodniy, & Kahn 1997; DeJong & Lange, 1995). It is
known that unless therapeutic levels of the protease
inhibitors are maintained, drug resistance can develop
quickly and cross to the other drugs in this class (Churchill, 1996). The implications for the development of
drug resistance extend well beyond a matter of loss of
efficacy in a patient and include transmission of HIV-1
that is already resistant to therapy (Erice et al., 1993).
Detailed recommendations have also been made for the
prophylaxis and treatment of opportunistic infections
(Centers for Disease Control and Prevention, 1995).
The populations most affected by HIV often have multiple comorbid conditions that also require treatment.
Consequently, the number of daily medications and
treatments that are part of a self-care regimen are
extremely complex (Ungvarski, 1994).
The challenge for HCPs is to identify strategies to
enhance compliance and develop a new philosophy
toward management of therapeutic regimens. The solution is not as easy as picking one intervention to
improve compliance. Combinations of interventions
must be considered to individualize care and improve
therapeutic management of the treatment regimen resulting in effective outcomes. As the epidemiologic
patterns change to more extensively affecting communities of color, it is imperative that treatment programs
and individual HCPs develop interventions that incorporate and emphasize cultural values, customs, and
traditions, as well as community social networks.

A good HCP-client relationship and the management of therapeutic regimens are processes and not
results. They both require a commitment on the part of
the HCP as well as the client. It is now time for nurses
and other HCPs to critically rethink their relation- ships
with their clients and their approaches to care
management.

References
Anastasio, C. J. (1995). HIV and tuberculosis: Noncompliance
revisited. Journal of the Association of Nurses in AIDS Care,
6(2), 11-23.
Bailey, A., Ferguson, E., & Voss, S. (1995). Factors affecting an
individual's ability to administer medication. Home Healthcare
Nurse, 13(5), 57-63.
Baylor, R. A., & McDaniel, A. M. (1996). Nurses' attitude toward
caring for patients with acquired immunedeficiency syndrome.
Journal of Professional Nursing, 12(2), 99-105.
Beechem, M. H. (1995). Mafia: Developing a culturally-sensitive
treatment plan in pre-hospice South Texas. Hospice Journal,
10(2), 19-34.
Besch, C. L. (1995). Compliance in clinical trials. AIDS, 9(1 ), 1-10.
Burchman, S. L., & Pagel, P. S. (1995). Implementation of a formal
treatment agreement for outpatient management of chronic nonmalignant pain with opiod analgesics. Journal of Pain and
Symptom Management, 10(7), 556-563.
Campinha-Baeote, J. (1993). The process of cultural competence:
A culturally competent model of care. Wyoming, OH: Transcultural CARE Associates.
Carpenter, C. C., Hschl, M. A., Hammer, S. M., Hirsch, M. S.,
Jacobsen, D. M., Katzenstein, S. A., Montaner, J. S., Saag, M.
S., Richman, D. D., Sehooley, R. T., Thompson, M. A., Vella,
S., Yeni, P. G., & Volberding, P. A. (1996). Antiretroviral therapy
for HIV infection in 1996. Journal of the American Medical
Association, 276(2), 146-154.
Centers for Disease Control and Prevention. (1995). USPHS/IDSA
guidelines for the prevention of opportunistic infections in
persons infected with human immunodeflciency virus: A summary. Morbidity and Mortality WeeklyReport, 42(RR-8), 1-34.
Chaisson, R. E., Keruly, J. C., McAvinue, S., Gallant, J. E., & More,
R. D. (1996). Effects on an incentive and education program on
return rates for PPD test reading in patients with HIV infection.

Journal of Acquired Immune Deficiency Syndrome and Human

Retrovirology, 11(5), 455-459.
Charonko, C. V. (1992). Cultural influences in "noncompliant"
behavior and decision making. Holistic Nursing Practice,
6(2), 73-78.
Chesney, M. A., & Folkman, S. (1994). Psychological impact of
HIV disease and implications for intervention. Psychiatric Clinics of North America, 17(1), 163-182.
Chung, D., Hart, G., & McColl, M. (1995, November 16-19).
Doctor/client communication at the Adelaide Sexually Trammitted Diseases (STD) Clinic. [abstract]. Annual Conference of
Australia Social and HIV Medicine, 7(76), 83.

JANAC Vol. 8, No. 4, July/August t997

Churchill, S. A. (1996). Protease inhibitors: Implications for HIV

research and treatment. Journal of the International Association
of Physicians in AIDS Care, 2(1), 13-18.
Cochran, S. D., & Mays, V. M. (1993). Applying social psychological models to predicting HIV-related sexual risk behaviors
among African Americans. Journal of Black Psychology, 19(2),
142-154.
Decks, S. G., Smith, M., Holodniy, M., & Kahn, J. O. (1997). HIV- 1
protease inhibitors: A review for clinicians. Journal of the
American Medical Association, 277(2), 145-153.
DeJong, M., & Lange, J.M.A. (1995). Highlights of the Fourth
International Workshop on HIV Drug Resistance. Journal of the
International Association of Physicians in AIDS Care, 1(8),
25 -27.
Denenberg, R. (1993, October/November). Applying harm reduction to sexual and reproductive counseling: A health provider's
guide to supporting the goals of people with HI'V/AIDS.
SEICUS Report, pp. 8-12.
E1-Sadr, W., Medard, E, & Barthaud, V. (1996). Directly observed
therapy for tuberculosis: The Harlem Hospital experience, 1993.
American Journal of Public Health, 86(8), 1146-1149.
E1-Sadr, W., Medard, E, & Dickerson, M. (1995). The Harlem
Family Model: A unique approach to the treatment of tuberculosis. Journal of Public Health Management Practice, 1(4),
48-51.
Erice, A., Mayers, D. L., Strike, D. G., Sannerud, K. J., McCutehen,
E E., Henry, K., & Balfour, H. H., Jr. (1993). Brief report:
Primary infection with zidovudine-resistant human immunodeficiency virus type-1. New England Journal of Medicine,
328(16), 1192-1193.
Feinberg, M. B. (1996). Changing the natural history of HIV
disease. Lancet, 348, 239-246.
Flaskerud, J. H. (1994). AIDS and traditional food therapies. In
R. Watson (Ed.), Nutrition andAiDS (pp. 235-247). Ann Arbor,
MI: C.R.C. Press.
Flaskerud, J. H. (1995a). Psychosocial and psychiatric aspects.
In J. H. Flaskerud & P. J. Ungvarski (Eds.), HIV/AIDS: A guide
to nursing care (3rd. ed., pp. 308-338). Philadelphia: W. B.
Saunders.
Haskemd, J. H. (1995b). Ctdture and ethnicity. In J. H. Flaskerud &
P. J. Ungvarski (E,ds.), H1V/AIDS: A guide to nursing care (3rd.
ed., pp. 405-432). Philadelphia" W. B. Saunders.
Flaskerud, J. H. (1995c). Overview of HIV disease and nursing. In
J. H. Flaskerud & P. J. Ungvarski (Eds.), HIV/AIDS: A guide to
nursing care (3rd. ed., pp. 1-29). Philadelphia: W. B. Saanders.
Flaskerud, J. H., & Calvillo, E. R. (1991). Beliefs about AIDS,
health, and illness among low-income Latina women. Research
in Nursing and Health, 14(6), 431-438.
Flaskerud, J. H., & Rush, C. E. (1989). AIDS and traditional health
beliefs and practices of Black women. Nursing Research, 38(4),
210-215.
Flaskerud, J. H., & Thompson, J. (1991). Beliefs about AIDS,
health, and illness in low-income White women. Nursing Research, 40(5), 266-271.
Glazer, H. R., Kirk, L. M., & Bolser, F. E. (1996). Patient education
pamphlets about prevention, detection and treatment of breast

53

cancer in low literacy women. Patient Education and Counsel/rig, 27(2), 185-189.
Govia, L., Scimeca, M., el-Sadr, W., Patel, G., Nkanga, M., &
Ampy, L. (1994, August 7-12). Integration of HIV primary care
in methadone maintenance treatment programs (MMTP) in
Harlem. International Conference on AIDS (abstract no. 562C),
10(2), 71.
Grossman, D. (1996). Cultural dimensions in home health nursing.
American Journal of Nursing, 96(7), 33-36.
Haynes, R. B. (1979). Introduction. In. R. B. Haynes, D. W. Taylor,
& D. L. Sackett (Eds.), Compliance in health care (pp. i-xv).
Baltimore, MD: Johns Hopkins University Press.
Haynes, R. B., McKibbon, K. A., & Kanani, R. (1996). Systematic
review of randomized trials of interventions to assist patients to
follow prescriptions for medications. Lancet, 348, 383-386.
Healton, C. G., & Messed, E (1993). The effect of video interventions on improving knowledge and treatment compliance in the
sexually transmitted disease clinic setting. Lesson for HIV
health education. Sexually Transmitted Disease, 20(2), 70-76.
Idemoto, B. K., Daly, B. J., Eger, D. L., Lomhardo, B. A., Matthews,
T., Morris, M., & Younger, S. J. (1993). Implementing the
Patient Self-Determination Act. American Journal of Nursing,
93(1), 20-25.
Jenkins, B., Lamar, V. L., & Thompson-Crumble, J. (1993). AIDS
among African Americans: A social epidemic. Journal of Black
Psychology, 19(2), 108-122.
Jimenez, A., Johnson, W., Hershow, R., & Wiebel, W. (1996, July
7-12). Factors related to variations in TB treatment compliance
among IDUs impacted by HIV---preliminaryfindings. International
Conference on AIDS (abstract no. Mo. C. 1651), 11(1), 166.
Johnson, M., & Webb, C. (1995). The power of social judgement.
Nurse Education Today, 15(2), 83-89.
Koren, M. E., Bartel, J. C., & Corliss, J. (1994). Interventions to
improve patient appointments in an ambulatory care facility.
Journal of Ambulatory Care Management, 17(3), 76-80.
Leininger, M. M. (1991a). Selected culture care fmdings of diverse
cultures using culture care theory and ethnomethods. In M. M.
Leininger (Ed.), Culture care diversity and universality: A theory of nursing (pp. 345-372). New York: National League for
Nursing Press.
Leininger, M. M. (1991b). Culture care diversity and universality:
A theory of nursing. New York: National League for Nursing Press.
Lunney, M. (in press). Ineffective management of therapeutic regimen: Individuals. In G. K. McFarland & E. McFarlane (Eds.),
Nursing diagnosis and intervention: Planning for patient care
(3rd ed.). St. Louis, MO: Mosby.
MacLachlan, M., & Carr, S. C. (1994). Managing the AIDS crisis
in Africa: In support of pluralism. Journal of Management in
Medicine, 8(4), 45-53.
Matin, G. (1989). AIDS prevention among Hispanics: Needs, risk
behaviors and cultural values. Public Health Reports, 104(5),
411-415.
Meeks-Festz, L., Uhle, S. M., Munjas, B., Gerszten, E., & Creger,
A. (1994). HIV/AIDS clients' satisfaction with selected aspects
of clinic nursing services. Journal of the Association of Nurses
in AIDS Care, 5(4), 37-44.

54

Crespo-Fierro / Compliance and Care Management

Mossar, M., Lefevre, E, Deutsche, J., Wesch, J., & Glassroth, J. (1993,
June 6-11). Factors predicting compliance with prophylactic
treaanents among HIV positive patients [abstract ]. International
Conference on AIDS (absUact no. PO-D01-3418), 9(2), 787.
Mullins, I. L. (1996). Nurse caring behaviors for persons with
acquired immunodeficiency syndrome. Applications of Nursing
Research, 9(1), 18-23.
Muma, R. D., Ross, M. W., Parcel, G. S., & Pollard, R. B. (1995).
Zidovudine adherence among individuals with HIV infection.
AIDS Care, 7(4), 439-447.
North American Nursing Diagnosis Association. (1994). Nursing
diagnoses: Definitions & classification 1995-1996. Philadelphia, PA: Author.
O'Brian, C. E, & McLellan, A. T. (1996). Myths about the treatment
of addiction. Lancet, 237, 237-240.
O'Connor, E G., Molde, S., Honrey, S., Sheckor, W. T., & Schoottenfeld, R. S. (1992). Human immunodeficiency virus infection
in intravenous drug users: A model for primary care. American
Journal of Medicine, 93(4), 382-386.
O'Hanrahan, M., & O'Malley, K. (1981). Compliance with drug
therapy. British Medical Journal, 283, 298-300.
Pender, N. J. (1987). Health promotion in nursing practice (2nd
ed.). Norwalk, CT: Appleton & Lange.
Pepler, C. l., & Lynch, A. (1991). Relational messages of control
in nurse-patient relationships. Journal of Palliative Care, 7(1),
18-29.
Peterson, J., Pilote, L., Zolopa, A., & Moss, A. (1993, June 6-11).
Insights from the street: Peex health advisors and medical care
in the homeless [abstract no. P O D 16-3909]. International Conference on AIDS, 9(2), 869.
Pilote, L., Peterson, J., Zolopa, A., & Moss, A. (1993, June 6-11).
Improving adherence to TB and HIV screening in the homeless
[abstract no. PO-B32-2247]. International Conference onAIDS,
9(1), 510.
Pincus-Strom, D. (1989, June 4-9). Developing comprehensive
services for HIV infected intravenous drug users: A guide for
case mangers [abstract no. M. E. P. 62]. International Conference on AIDS, 5, 844.
Prochaska, J., DiClemente, C., & Norcross, J. 0992). In search of
how people change: Applications to addictive behaviors. Amer/can Psychology, 47, 1102-1104.
Ragsdale, D., Kotarba, J. A., Morrow, J. R., & Yarbrough, S. (1995).
Health locus of control among HIV-positive indigent women.
Journal of the Association of Nurses in AIDS Care, 6(5), 29-36.
Redland, A. R., & Stuifbergen, A. K. (1993). Strategies for maintenance of health-promoting behaviors. Nursing Clinics of North
America, 28(2), 427-442.
Rosenstock, I. (1974). The Health Belief Model and preventive
health behavior. Health Education Monograms, 2, 354-387.
Ross Products Division. (1994). Taking charge! Managing the
symptoms of HIV [Videotape]. (Available from Ross Products
Division of Abbot Laboratories, Columbus, OH 43215-1724).
Rubel, A., & Garro, L. (1992). Social and cultural factors in the
successful control of tuberculosis. Public Health Reports, 107,
626-636.

Sheffield, D., Kloscr, P. Gill, C., & Con'ell, P. (1994, August 7-12).
Enrollment of HIV-infected minority women into clinical trials
[abstract no. PB0861]. International Conference on AIDS,
10(2), 212.
Smith, R., Whetstine, R., Butsch, E, & McAlister, R. O. (1996, July
7-12). Oregon's seropositive wellness program: Factors associated with high attrition rates among newly diagnosed HIVinfected persons [abstract no. Mo. C.1607]. International Conference onAIDS, 11(1), 159.
Solomon, M. Z., & DeJong, W. (1988). The impact of a clinic-based
educational videotape on knowledge and treatment behavior of
men with gonorrhea. Sexually Transmitted Disease, 15(3), 127132.
Solomon, R. (1991). Some concerns in providing home care. Car/ng, 10(8), 42-43.
Springer, E. (1991). Effective AIDS prevention with active drug
use. The harm reduction model. In M. Shemoff (Ed.), Counseling chemically dependent people with HIV illness (pp. 141-157).
New York: Haworth Press.
Spruhan, J. B. (1996). Beyond traditional nursing care: Cultural
awareness and successful home healthcare nursing. Home
Healthcare Nurse, 14(6), 444-449.
Tones, R. A., & Staats, J. (1989, June 4-9). Primary care at a
residence for persons with AIDS (PWAs): Bailey House, New
York City, New York [abstract no. T.E.E 57]. International
Conference on AIDS, 5, 856.
Ungvarski, E J. (1994). Co-morbidities of HIV-1/AIDS in adults.
Journal of the Association of Nurses in AIDS Care, 5(6), 20-29.
Ungvarski, P. J., & Ballard, K. A. (1995). Nurses, consumers,
activists and the politics of AIDS. In D. J. Mason, S. Talbot,
& J. Leavitt (Eds.), Policy and politics for nurses (2nd ed.,
pp. 677-697). Philadelphia: W. B. Saunders.
Ungvarski, P. J., & Schmidt, J. (1995). Nursing management of the
adult. In J. H. Flaskerud & P. J. Ungvarskl (Eds.), HIV/AIDS: A
guide to nursing care (3rd ed., pp. 143-184). Philadelphia" W.
B. Saunders.
Ungvarski, P. L, Schmidt, L, & Crespo-Fierro, M. (1996).
HIV/AIDS Self-care guide. New York: The Visiting Nurse Service of New York.
Vogel, S., Grady, C., & Ropka, M. (1993, June 6-11). Factors
affecting investigational medication compliance in healthy HIVinfected participants of randomized control trial (RCT) comparing AZT and interferon-alpha (IFN-alpha) [abstract no. POB44-2544]. International Conference on AIDS, 9(1), 559.
Wall, T. L., Sorenson, J. L., Batki, S. L., & Delucchi, K. L. (1995).
Adherence to zidovudine among HIV-infected methadone patients. Drug and Alcohol Dependence, 37(3), 361-369.
Walsh, M. (1991). Resolving the dilemmas of the difficult-to-serve.
Washington, DC: Foundation for Hospice and Home Care.
Wendt, D. (1996). Building trust during the initial home visit. Home
HeaIthcare Nurse, 14(2), 92-98.
Weust, J. (1993). Removing the shackles: A feminist critique of
noncompliance. Nursing Outlook, 41(5), 217-224.