Revista Latinoamericana de Medicina

Conductual / Latin American Journal of

Behavioral Medicine

ISSN: 2007-0799

rlmc.editora@gmail.com

Sociedad Mexicana de Medicina

Conductual A. C.

México

Álvarez Arenas, Erika Mariana; González Mendoza, Ronald Daniel; Miaja Ávila, Melina;

Piña López, Julio Alfonso; Fierros Dávila, Luis Enrique

Validation of a brief questionnaire for assessing psychological variables and medication-

adherence behaviors among HIV-positive persons from Venezuela

Revista Latinoamericana de Medicina Conductual / Latin American Journal of Behavioral

Medicine, vol. 5, núm. 1, enero, 2015, pp. 1-8

Sociedad Mexicana de Medicina Conductual A. C.

Distrito Federal, México

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Validation of a brief questionnaire for assessing psychological variables andmedication-adherence behaviors among HIV-positive persons from Venezuela

Validación de un cuestionario breve que mide variables psicológicas y conductasde adhesión a los medicamentos en personas VIH-positivas de Venezuela

The objective of this cross-sectional study was to validate a brief version of a questionnaire forassessing psychological variables and adherence behaviors (VPAD-24) among 124HIV-positive Venezuelan persons under different treatment regimens of antiretroviralmedication. For data analyses SPSS for Windows (v. 19.0) and AMOS package (v. 18.0) wereused. The brief version of the VPAD extracted three factors (past competencies, motives, andcurrent competencies) accounting for 52.3% of the variance, showing an adequacy fit of data tothe theoretical model: x2 [65, N = 124] = 105.30, p < 0.01; DF= 0.33 [DFMI = 2.70]; NCPP = 0.86 [NCPPMI = 3.33]; GFI = 0.89, AGFI = 0.84, CFI = 0.88; RMSEA = 0.07. The VPADVenezuelan version resulted to be adequate and provides guidance for further research on therelationship between the psychological variables of a theoretical model and adherencebehaviors in HIV-positive persons under different treatment regimens of antiretroviralmedication.

Keywords: validation, psychological variables, adherence behaviors, HIV-positive persons,Venezuela.

El objetivo de este estudio transversal fue evaluar la versión breve de un cuestionario que midevariables psicológicas y conductas de adhesión (VPAD-24) en una muestra de 124 venezolanosVIH-positivos expuestos a diferentes regímenes de tratamiento con medicamentosantirretrovirales. Para el análisis de los datos se utilizaron el paquete SPSS para Windows (v.19.0) y el paquete AMOS (v. 18.0). El cuestionario arrojó una estructura de tres factores(competencias pasadas, motivos y competencias presentes) que explican 52.3% de la varianza,mostrando un buen ajuste de los datos al modelo teórico: x2 [65, N = 124] = 105.30, p < 0.01;DF= 0.33 [DFMI = 2.70]; NCPP = 0.86 [NCPPMI = 3.33]; GFI = 0.89, AGFI = 0.84, CFI = 0.88;RMSEA = 0.07. La versión venezolana del VPAD resultó ser adecuada y provee lineamientospara futuras investigaciones sobre la relación entre las variables psicológicas de un modeloteórico y las conductas de adhesión en personas VIH-positivas expuestas a distintos regímenesde tratamiento con medicamentos antirretrovirales.

Pa la bras cla ve: validación, variables psicológicas, conductas de adhesión, personasVIH-positivas, Venezuela.

Acqui red im mu no de fi ciency syndro me (AIDS) is a glo balhealth pro blem af fec ting more than 35 mi llion peo ple aroundthe world (UNAIDS, 2014). Des pi te the evi den ce that an ti re -tro vi ral the rapy (ART) has led a sig ni fi cant de cli ne of both

Re vis ta La ti noa me ri ca na de Me di ci na Con duc tualVol. 5, Núm. 1, Agos to 2014-Enero 2015

© 2015 So cie dad Mexica na deMe di ci na Conductual

1

Co rres pon den ce: Ju lio Alfon so Piña Ló pez. Gui ller mo Prie -

to No. 18. Co lo nia Cons ti tu ción. Her mo si llo, So no ra, C.P.83150, Mé xi co. Tel.: +52-662-2592151. Email: pina.lo -pez.julio@gmail.com

Luis Enrique Fierros DávilaUniversidad de Sonora, México

Erika Mariana Álvarez ArenasUniversidad Centroccidental “Lisandro Alvarado”

Barquisimeto (Lara), Venezuela

Ronald Daniel González MendozaUniversidad Centroccidental “Lisandro Alvarado”

Barquisimeto (Lara), Venezuela

Julio Alfonso Piña LópezUniversidad de Sonora, México

Melina Miaja ÁvilaInstituto de Bienestar In te gral. Hos pi tal Zambrano Hel lion.

Instituto Tecnológico de Monterrey, México

AIDS-re la ted mor bi dity and mor ta lity, me di ca tion-ad he ren cebeha viors among HIV-po si ti ve per sons li ving in re sour ce-li -mi ted set tings —e.g., La tin-Ame ri ca and the Ca rib bean coun -tries— re mains a great con cern for health aut ho ri ties (Cohn &Ba ker, 2010; Wools-Ka lous tian & Ki mai yo, 2006). In fact, insome of the se coun tries few re search re ports have do cu men tedhow many HIV-po si ti ve per sons are un der an ART re gi men,but ove rall, few have do cu men ted which are the psycho lo gi caland/or so cial va ria bles fa ci li ta ting or not the prac ti ce of tho sebeha viors (e.g., Arri vi lla ga, Ross, Use che, Alza te, & Co rrea,2009; Jo nes, Cook, Cec chi ni, Sued, Bo fill, Weiss et al., 2015;Va re la & Gal da mes, 2014).

In Ve ne zue la, for exam ple, peo ple aged 15 or more withHIV amoun ted clo se to 100,000 by the end of 2013, and lessthan a half of them have been un der an ART re gi men (WHO,2013). Ne vert he less, the lack of spe ci fic in for ma tion about thenum ber of HIV-po si ti ve per sons that con sis tently and ef fi -ciently are prac ti cing me di ca tion-ad he ren ce beha viors is verycon cer ning. In a search on the Inter net of both na tio nal and in -ter na tio nal da ta ba ses led to only two works spe ci fi cally ad -dres sing the is sue of ad he ren ce to treat ment among HIV-po si -ti ve per sons un der going one of the dif fe rent ART re gi mens.On the first one, me di ca tion-ad he ren ce beha viors were as ses -sed among 46 HIV-po si ti ve per sons, 69.7% of who took theiran ti re tro vi ral me di ca tions > 95% (Bas tar do, Cas tro, Suá rez,To rres, Co men ga, & Du mas, 2013). On the se cond one, whichin clu ded 82 HIV-po si ti ve per sons, 71.2% re por ted a good ad -he ren ce in the last four days, even though 62.2% of them in for -med they con ti nued drin king al cohol and 23.2% in an ex ces si -ve way (Bas tar do, 2014).

Ta ken into ac count the abo ve sce na rio and the im por tan ceof the is sue of me di ca tion-ad he ren ce beha viors in HIV-po si ti -

ve per sons from Ve ne zue la, this study was jus ti fied in apsycho lo gi cal mo del to as sess psycho lo gi cal va ria bles and ad -he ren ce beha viors in per sons with HIV, e.g., me di ca tion con -sump tion, la bo ra tory tes ting, diet and exer ci se (Piña & Sán -chez-Sosa, 2007). Such a mo del at tempts to ar ti cu la te the in te -rac tion bet ween psycho lo gi cal and bio lo gi cal va ria bles in fourpha ses (Fi gu re 1). The first pha se in vol ves three psycho lo gi calpro cess va ria bles: stress-re la ted si tua tions (per so na lity) dea -ling with de ci sion-ma king and to le ran ce to both am bi guity andfrus tra tion; the mo ti ves un derl ying ad he ren ce beha viors; andthe per for man ce of past and cu rrent beha vio ral com pe ten cies.Pha se two en tails HIV in fec tion and lat ter de ve lop ment of ot -her co-mor bi di ties (e.g., op por tu nis tic in fec tions). Pha se threein clu des two dif fe rent beha viors: ad he ren ce beha viors and di -sea se-re la ted beha viors (e.g., stress, de pres sion, irri ta bi lity,etc). Fi nally, pha se four com pri ses con ven tio nal bio lo gi calmar kers (e.g., CD4 cell-count and le vels of vi ral load) and ot -her health results.

So, ba sed on the afo re men tio ned theo re ti cal mo del, thiswork is ai med to va li da te the sim pli fied ver sion of a ques tion -nai re to as sess psycho lo gi cal va ria bles and ad he ren ce beha -vior, which was ori gi nally de sig ned and va li da ted in Me xi co(Piña, Co rra les, Mun ga ray, & Va len cia, 2006).

METHOD

Par ti ci pants

This cross-sec tio nal study was ba sed on a pur po si ve sam -pling. From Ja nuary-Fe bruary 2015, HIV-po si ti ve men andwo men were seen in rou ti ne cli nic ap point ments, as part of theac ti vi ties of the Na tio nal Pro gram on AIDS (PRONASIDA) in

2 ÁLVAREZ, GONZÁLEZ, MIAJA, PIÑA Y FIERROS

Fi gu re 1. Psycho lo gi cal mo del for the re search of ad he ren ce beha viors (PMAB).

the Sta te of Lara, Ve ne zue la. The HIV/AIDS Cen ter at tendsmen and wo men un der cu rrent ART re gi men with an ti re tro vi -ral me di ca tion, and also pro vi des psycho lo gi cal and so cial sup -port. Par ti ci pants bet ween 18 and 64 years of age un der ARTre gi men were eli gi ble for in clu sion. A to tal of 124 HIV-po si ti -ve per sons com ple ted the sim pli fied ver sion of the VPAD,aged 18-64 (M = 40; SD = 11.2). Ni nety-one (73.4%) par ti ci -pants were male, ni nety-se ven (78.2%) were sin gle, sixty-four(51.6%) had ear ned some/com ple te uni ver sity de gree, andeighty-six (69.4%) were cu rrently em plo yed. Length of in fec -tion (months sin ce HIV diag no sis) was 72.2 (SD = 71.7). Addi -tio nally, ha ving no psycho lo gi cal pro blems and/or cog ni ti vede fi cit li mi ting the un ders tan ding of di rec tions or items wascon si de red as well. The par ti ci pant’s cha rac te ris tics are sum -ma ri zed in Table 1.

Pro ce du re

Accor ding with re cent re com men da tions (Sti rratt, Dun -bar-Ja cob, Cra ne, Si mo ni, Cza jows ki, Hi lliard et al., 2015),self-re port mea su res of me di ca tion-ad he ren ce beha viors, ori -gi nally de sig ned and va li da ted in ot her coun tries, needs to ac -com plish ment with se ve ral steps. In or der to avoid the sour cesof error, one of them in clu ded the ad mi nis tra tion of the sim pli -fied ver sion of the VPAD by the two first aut hors (both fromVe ne zue la), with the main pur po se to re view the cla rity and

com prehen si bi lity of the items. Be fo re this step, eli gi ble par ti -ci pants vo lun ta rily sig ned the in for med con sents prior to par ti -ci pa tion in this study, and over a two months pe riod were seenusing face-to-face in ter views. Each par ti ci pant re cei ved thesame ins truc tions about the con tent of the VPAD and the wayto res pond to the items; af ter com ple ting the ques tion nai re,each one was put ted in an in di vi dual en ve lo pe. Par ti ci pantswere not reim bur sed for com ple ting the sur vey. The study wasap pro ved by the Re search De part ment of the Psycho logy Pro -gram in the Uni ver si dad Cen troc ci den tal “Li san dro Alva ra -do” and by the Re search Area of the Na tio nal Pro gram onAIDS (PRONASIDA), both in the Sta te of Lara, Ve ne zue la.

Self-ad mi nis te red ques tion nai re

HIV-po si ti ve per sons res pon ded to the VPAD ques tion nai -re, de sig ned and va li da ted in Me xi co (Piña et al., 2006). Theori gi nal ver sion of the VPAD-24 yiel ded a four-fac tor struc tu -re with the fac to rial analy sis in va ri max ro ta tion: 1) Cu rrent ad -he ren ce beha vior and treat ment; 2) Mo ti ves un derl ying me di -ca tion-ad he ren ce beha viors; 3) Cu rrent beha vio ral com pe ten -cies; 4) Past beha vio ral com pe ten cies, with va lues abo ve 1 ex -plai ning 65.5% of the to tal va rian ce. An ove rall Cron bach’salp ha coef fi cient of 0.85 was ob tai ned with the test of re lia bi -lity. The sim pli fied ver sion used here con sists of 18 items inSpa nish lan gua ge. Item num ber six mea su res me di ca tion-ad -

3VALIDATION OF A BRIEF QUESTIONNAIRE AMONG HIV-POSITIVE PERSONS FROM VENEZUELA

Ta ble 1. De mo grap hic and cli ni cal va ria bles among 124 HIV-po si ti ve per sons.

he ren ce beha viors (e.g., in the last month, did you take all theme di ca tion as pres cri bed by your physi cian?), whi le the ot her17 items were ori gi nally fo cu sed on three fac tors re gar ding ad -he ren ce to treat ment: past beha vio ral com pe ten cies (fiveitems), mo ti ves (four items) and cu rrent beha vio ral com pe ten -cies (eight items).

Data co llec tion and analy ses

The in ter nal con sis tency was es ti ma ted by means of Cron -

bach’s alp ha coef fi cient (a). Three va lues were ta ken into ac -count: high > 0.70, ade qua te > 0.60 and low < 0.60 (Cron bah & Sha vel son, 2004). The ad just ment of the dis tri bu tion to a nor -mal cur ve was con tras ted with a Kol mo go rov-Smir nov (ZK-S) test. The di men sio nal struc tu re was first drawn by means of anex plo ra tory fac tor analy sis (EFA), with the met hod of ex trac -tion of the main com po nents and va ri max ro ta tion; the num berof fac tors was set by the ex pec ta tion. Tho se items with fac to rial loads be low 0.40 were eli mi na ted. Se condly, the struc tu re wascon tras ted with a con fir ma tory fac tor analy sis (CFA). The mo -dels were cal cu la ted by high ve ri si mi li tu de, and es ti ma ted pa -ra me ters were stan dar di zed. Se ven in de xes for in ter pre tingdata ad just ment were con si de red ac cor ding to re com men da -tions:

1. Two ba sic: the dis cre pancy func tion (DF) and thechi-squa red test (x2).

2. Two no cen tra lity: the no cen tra lity-ba sed po pu la tionpa ra me ter (NCPP) and the Root Mean Squa re Error ofAppro xi ma tion (RMSEA) of Stei ger-Lind.

3. Three com pa ra ti ve: good ness-of-fit in dex (GFI) ofJöres kog and Sörbom, the GFI ad jus ted for de grees of

free dom (AGFI), and the com pa ra ti ve fit in dex (CFI)(Jöres kog & Sörbom, 1986; Klem, 2010).

Good fit va lues for the in de xes were as fo llows: p of x2 >0.05; DF and NCPP < 1/4 of the res pec ti ve va lue to the in de -pen dent mo del; GFI > 0.95; AGFI and CFI > 0.90; RMSEA <0.05. The ade qua te va lues in de xes were as fo llows: p of x2 >0.01; DF and NCPP < 1/3 of the res pec ti ve va lue to the in de -pen dent mo del; GFI > 0.85, AGFI and CFI > 0.80; RMSEA <0.08 (Ruiz, Par do & San Mar tín, 2010). Cal cu la tion was donewith SPSS pac ka ge for Win dows 19.0 and the AMOS pac ka gever sion 18.0.

RESULTS

Fac tor struc tu re of the PVAB and in ter nal con sis tency

Three fac tors were drawn by means of the ex plo ra tory fac -tor analy sis (EFA) as ex pec ted. Out of the 17 ques tions, fourwere eli mi na ted af ter re sul ting in loads be low 0.40 (items 1, 8,9, and 10). As to the ot her 13 items, a three-fac tor struc tu re was crea ted, ex plai ning 52.3% of the to tal va rian ce (see Ta ble 2):the first fac tor in clu ded four out of the five in di ca tors re la ted topast beha vio ral com pe ten cies fac tor (items 2-5), which ex -plains 20.2% of the va rian ce; the se cond fac tor in clu ded fiveout of eight in di ca tors re la ted to cu rrent beha vio ral com pe ten -cies fac tor (items 11-15), which ex plains 17.7% of va rian ce;the third fac tor con sis ted of the four in di ca tors re la ted to themo ti ves fac tor (items 7.1, 7.2, 7.3 and 7.4), which ex plains the14.3% of va rian ce. The in ter nal con sis tency va lue for pastcom pe ten cies, cu rrent com pe ten cies, and mo ti ves were 0.80,0.70, and 0.53, res pec ti vely.

4 ÁLVAREZ, GONZÁLEZ, MIAJA, PIÑA Y FIERROS

Ta ble 2. Fac tor loa dings of the VPAD items on their fac tors.

The three-fac tor mo del re pro du ced with the EFA was im -me dia tely con tras ted with the CFA. Data ad just ment mostly re -sul ted ade qua te wit hin its 13 items. From the data ob ser ved, the null hypot he ses for a good ness of fit was not sus tai ned by thechi-squa re sta tis tic (x2 [65, N = 124] = 105.30, p < 0.01). Goodfit was found in DF= 0.33 [DFMI = 2.70]), meanw hi le five sho -wed an ade qua te fit (NCPP = 0.86 [NCPPMI = 3.33]; GFI =0.89, AGFI = 0.84, CFI = 0.88, and RMSEA = 0.07). As cansee in Fi gu re 2, all pa ra me ters were sig ni fi cant.

Dis tri bu tion of the VPAD-13 sca le

Dis tri bu tion of the past beha vio ral com pe ten cies, mo ti vesand cu rrent beha vio ral com pe ten cies fac tors was not ad jus tedto a nor mal cur ve. The mean of the ques tion re gar ding me di ca -tion-ad he ren ce beha viors sho wed high fre quency. The ave ra ge of the past and cu rrent beha vio ral com pe ten cies and mo ti veswas di vi ded into the num ber of items, the re fo re ob tai ning a va -lue clo se to 4. For the past and cu rrent beha vio ral com pe ten cies

fac tors, the ran ge of res pon se mo ved from 1-5; the re fo re, theave ra ge of the two beha vio ral com pe ten cies was the ans wer“Most of the time”. As for the mo ti ves fac tor, the ran ge of res -pon se va ried from 1-4, and the ave ra ge res pon se re sul ted in“The mo ti ve was qui te de ter mi ning” (see Ta ble 3).

DISCUSSION

The re sults ob tai ned in this study con firm re lia bi lity and va -li dity of the sim pli fied ver sion of VPAD in a sam ple ofHIV-po si ti ve per sons in the Sta te of Lara, Ve ne zue la. Thethree fac tors that were for med ba sed on the CFA, par ti cu larlytho se re la ti ve to mo ti ves and past beha vio ral com pe ten cies,sig ni fi cantly match the re sults drawn from the study of ori gi nal va li da tion (Piña et al., 2006). Accor ding to the lo gic of thepsycho lo gi cal mo del for the re search on ad he ren ce beha viors,the is sue it is not only about mea su ring whet her per sons withHIV are prac ti cing me di ca tion-ad he ren ce beha viors, in bothcon sis tently and ef fi ciently ways (Piña & Sán chez-Sosa, 2007;

5VALIDATION OF A BRIEF QUESTIONNAIRE AMONG HIV-POSITIVE PERSONS FROM VENEZUELA

Fi gu re 2. Stan dar di zed pa ra me ter es ti ma tes of the fi nal mo del. Mo del fit sta tis tics were as fo llow: x2 [65, N = 124] = 105.30, p <0.01; DF= 0.33 [DFMI = 2.70]; NCPP = 0.86 [NCPPMI = 3.33]; GFI = 0.89, AGFI = 0.84, CFI = 0.88; RMSEA = 0.07.

Ta ble 3. Des crip ti ve sta tis tics and fac tors dis tri bu tion.

Ri bes, 1990), but it is also about to un ders tand, from a theo re ti -cal pers pec ti ve, which psycho lo gi cal va ria bles of pro cess, sta te or re sult will allow its pre dic tion syste ma ti cally. Three keypsycho lo gi cal va ria bles for such pur po se are per so na lity (de ci -sion-ma king, to le ran ce to am bi guity and to le ran ce to frus tra -tion), mo ti ves, and beha vio ral com pe ten cies. The last two arecri ti cal in our theo re ti cal mo del. As va ria bles that to get herhave sho wed high per cen ta ges of pre dic tion of me di ca tion-ad -he ren ce beha viors in HIV-po si ti ve per sons; they in clu de there sults of cross-sec tion and lon gi tu di nal stu dies, ta king intocon si de ra tion the com pa ri son bet ween 100% ad he rents vs.non-ad he rents pa tients (Piña, Gar cía-Ca de na, Yba rra, & Fie -rros, 2012; Sán chez-Sosa, Fie rros, Cázares, & Piña, 2011).

Dif fe rent aut hors have poin ted out the pros and cons ofself-ad mi nis te red ins tru ments, such as self-re ports in mea su -ring me di ca tion-ad he ren ce beha viors (Berg & Arnsten, 2006;Wil son, Car ter, & Berg, 2009; Va re la, Sa la zar, & Co rrea,2008). Although some ot hers have no ted their po ten tial use ful -ness —es pe cially in coun tries whe re health ins ti tu tions rely onli mi ted re sour ces— to both the avai la bi lity of an ti re tro vi raldrugs and the in ter dis ci pli nary pro grams orien ted to pro vi dehealth care to per sons with HIV (Si mo ni, Huh, Wang, Wil son,Rey nolds, Re mien et al., 2014; Si mo ni, Kurth, Pear son, Pan ta -lo ne, Me rrill, & Frick, 2006). Ha ving re cog ni zed the po ten tialuse ful ness of self-ad mi nis te red ins tru ments such as self-re -ports, va li da tion of the sim pli fied ver sion of the VPAD in asam ple of HIV-po si ti ve per sons from Ve ne zue la was pro posed in this study.

Two re sults are worth no ting. First, in both analy sis (EFAand CFA), a three-fac tor struc tu re was crea ted. It co rres pondsto the theo re ti cal lo gic of the psycho lo gi cal mo del for re searchon ad he ren ce beha viors, who se in di ca tors of good ness of fitwere op ti mal in ge ne ral. Se cond, the asy mme tric dis tri bu tionof the item of me di ca tion-ad he ren ce beha viors and the threefac tors sho wed that most pa tients re por ted high ad he ren ce,more past and cu rrent beha vio ral com pe ten cies, and high mo ti -va tion to prac ti ce tho se beha viors, all of which may be a sig nalof so cial de si ra bi lity (Bang sberg, 2006). Hen ce, we may as sertthat the sim pli fied ver sion of the VPAD in this sam ple re pre -sents a va lid in di ca tor to sin gle out psycho lo gi cal va ria bles that are per ti nent in pre dic ting treat ment ad he ren ce beha viors inHIV-po si ti ve per sons. Cer tainly, the fact that the to tal num berof par ti ci pants in this sam ple ans we red (X = 4.97 in a ran ge of1-5) that they took their me di ca tions du ring the last monthprior to the study may sug gest an ove res ti ma tion of the ans wer, which ob viously de mands syste ma tic as sess ment in dif fe rentoc ca sions.

Thus, the re are li mi ta tions that need to be ta ken into ac -count for fu tu re stu dies. First, we can not ig no re that con si de -ring that this is a study con duc ted in one Ve ne zue lan sta te, cau -tion is nee ded when pre ten ding to ge ne ra li ze the re sults to allpeo ple with HIV in the country who are also ex po sed to one ofthe va rious treat ment re gi mens with an ti re tro vi ral me di ca tion.Se cond, it is im por tant to men tion that, in the case of the mo ti -ves fac tor, the Cron bach’s alp ha was mo de ra te (0.53), com pa -red with the ori gi nal ver sion of the VPAD (Piña et al., 2006), as

well as their adap ta tion and va li da tion among wo men withbreast can cer from Peru (Me jía, Mén dez, Piña, & La bo rín,2013). A pos si ble ex pla na tion re gar ding the se data could bethat the ma jo rity of the par ti ci pants in this study re por ted a high fre quency of me di ca tion-ad he ren ce beha viors, as a con se quen -ce of highly le vels of past and cu rrent beha vio ral com pe ten -cies; in this sen se, it is rea so na ble to think that the par ti ci pantsdo not con si de red im por tant the mo ti ves un derl ying me di ca -tion ad he ren ce beha viors, but this one in self and what has been done re gar ding ot her di sea se and the HIV as well. Fi nally, it iscri ti cal to un der li ne that due to fi nan cial is sues, it was not pos -si ble to rely on the re sults of the lab tests to de ter mi ne the CD4cell counts and the le vels of vi ral load, which could have per -fectly help to con firm the ef fects of the com pe ten tial prac ti ceof me di ca tion-ad he ren ce beha viors on the con di tion of thepar ti ci pants (Iron son, O’Clei righ, Flet cher, Lau ren ceau, Bal -bin, Li mas, Schnei der man et al., 2005; Lan ge beek, Gi solf,Reiss, Ver voot, Hafsteinsdóttir, Ritcher et al., 2014).

In or der to off set such li mi ta tions, it would be ne ces sary towork in the draf ting of a more am bi tious re search pro ject whe -re: a) To in clu de a re pre sen ta ti ve sam ple of HIV-po si ti ve per -sons from ot her re gions of the country; b) To con si der the to ta -lity of va ria bles of the theo re ti cal mo del, es pe cially both theva ria ble per so na lity and the di sea se-re la ted beha viors —e.g.,stress, de pres sion, irri ta bi lity, etc., and c) The usa ge, alongwith the mea su re of auto-re por ting of the ad he ren ce beha viors,of ot her di rect and in di rect mea su res that will allow us to com -pa re the re lia bi lity and va li dity of the first, in re gards of thecoun ting of pills, phar ma ceu ti cal re cords and con ven tio nalbio lo gi cal mar kers, e.g. vi ral load le vels and lymphocy te count CD4+ (Fried man, Stall, Sil ves tre, Wei, Shop taw, He rrick et al., 2015; Thomp son, Bid good, Pe tróc zi, Den hol-Pri ce, & Fiel der,2009).

It is ne ces sary, ba sed on the re sults ob tai ned, to co lla bo ra te with the health aut ho ri ties of the dif fe rent ins ti tu tions in de sig -ning, im ple men ting, and as ses sing in ter dis ci pli nary in ter ven -tion pro grams to im pro ve the prac ti ce of ad he ren ce beha viors,as well as tho se beha viors re la ted to psycho lo gi cal and so cialad just ments to both di sea se and treat ments (Gar cía-Ce di llo &Ro drí guez, 2014; Gue va ra & Ga lán, 2010; Na va rro, Pé rez, Cu -rran, Bur gos, Fei joo, To re lla et al., 2014; Sán chez-Sosa, Yba -rra, & Piña, 2012) . In con clu sion, the sim pli fied ver sion of theVPAD ques tion nai re should be down si zed to 14 items, in clu -ding the 13 items ma king up the three di men sions in fluen cingad he ren ce beha viors. The struc tu re con sis ted of three fac torsand data was ade qua tely fit. The three-fac tor struc tu re mat chesthe re sults ob tai ned in the ori gi nal va li da tion study (Piña et al.,2006).

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