The Influence of Self-efficacy on The Relationship Between Depression and HIV-related Stigma with ART Adherence Among The Youth in Malawi

Eric Umar, Judith A Levy, Geri Donenberg, Mary Ellen Mackesy-Amiti, Hening Pujasari, Robert C Bailey
| Abstract views: 936 | PDF views: 667



Depression and HIV-related stigma, among other factors, have been inversely linked independently with adherence to antiretroviral therapy (ART) among the youth. However, the processes through which the various factors influence this relationship is not fully known. Guided by Social Action Theory, we examined the interactive mechanisms through which depression, HIV-related stigma, and self-efficacy influenced ART adherence and whether or not these relationships are moderated by gender. A total of 450 HIV-positive youth (13–24 years) in Malawi receiving ART participated in this cross-sectional study. Moderated mediation analyses were conducted using Hayes’ PROCESS macro 2.11 in SPSS. ART adherence was measured by pill count. Findings showed that self-efficacy mediated the effects of depression and stigma on ART adherence. The analyses also revealed that gender moderated both the direct and indirect influence of depression and stigma (via self-efficacy) on ART adherence. Furthermore, self-efficacy simultaneously mediated and moderated the relationship between stigma and ART adherence. The interactive mechanisms through which various factors influence ART nonadherence must be considered to design effective interventions. To reduce the impact of depression and stigma on ART adherence, medication self-efficacy should be bolstered while taking gender in consideration.


Keywords: Adolescent, Antiretroviral adherence, Malawi, Moderated mediation, Social action theory, Youth




Pengaruh Efikasi Diri Terhadap Hubungan antara Depresi dan Stigma HIV dengan Kepatuhan Terapi ART pada Remaja di Malawi. Depresi dan stigma HIV, di antara faktor-faktor lain, berhubungan terbalik secara independen dengan kepatuhan terapi antiretroviral (ART) pada remaja. Akan tetapi, dalam prosesnya faktor yang memengaruhi hubungan ini belum sepenuhnya diketahui. Berdasarkan Teori Perilaku Sosial, penelitian ini dilakukan bertujuan untuk mengkaji mekanisme interaktif depresi, stigma HIV, dan efikasi diri yang memengaruhi kepatuhan ART, dan untuk mengetahui apakah hubungan ini dimoderasi oleh gender atau tidak. Sebanyak 450 remaja dengan HIV-positif (13–24 tahun) di Malawi yang menerima ART ikut berpartisipasi dalam penelitian potong lintang ini. Analisis mediasi moderated dilakukan dengan menggunakan Hayes 'PROCESS macro 2.11 pada SPSS. Kepatuhan ART diukur menggunakan jumlah pil. Hasil penelitian menunjukkan bahwa efikasi diri memediasi efek depresi dan stigma pada kepatuhan ART. Hasil analisis juga mengungkapkan bahwa jenis kelamin memoderasi pengaruh langsung dan tidak langsung dari depresi dan stigma (melalui efikasi diri) terhadap kepatuhan ART. Lebih lanjut,efikasi diri secara bersamaan mediasi dan moderasi hubungan antara stigma dan kepatuhan ART. Mekanisme interaktif dengan berbagai faktor yang memengaruhi ketidakpatuhan ART harus dipertimbangkan untuk merancang intervensi yang efektif. Untuk mengurangi dampak depresi dan stigma terhadap kepatuhan ART, efikasi diri pengobatan harus didukung saat mempertimbangkan jenis kelamin.


Kata kunci: Kepatuhan antiretroviral, Malawi, Mediasi tingkat menengah, Teori Perilaku Sosial, Remaja


Antiretroviral adherence; Adolescent; Youth; Moderated mediation; Social Action Theory; Malawi

Full Text:



Aderomilehin, O., A. Hanciles-Amu, and O.O. Ozoya. (2016). Perspectives and Practice of HIV Disclosure to Children and Adolescents by Health-Care Providers and Caregivers in sub-Saharan Africa: A Systematic Review. Front Public Health. 4: p. 166. doi: 10.3389/fpubh.2016.00166

Avert. (2015). HIV and AIDS in Malawi. Retrieved from:

Avert. (2016). AIDS and HIV in Malawi. Retrieved from:

Bekker, L.G., et al. (2015). Building our youth for the future. J Int AIDS Soc. 18(2 Suppl 1): 20027. oi: 10.7448/IAS.18.2.20027

Cluver, L.D., et al. (2016). Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa? AIDS Care. 28 Suppl 2:73-82. doi: 10.1080/09540121.2016.1179008.

Dlamini, P.S., et al. (2009). HIV stigma and missed medications in HIV-positive people in five African countries. AIDS Patient Care STDS. 23(5): p. 377-87. doi: 10.1089/apc.2008.0164

Dow, D.E., et al. (2016). Evaluating mental health difficulties and associated outcomes among HIV-positive adolescents in Tanzania. AIDS Care. 28(7): p. 825-33. doi: 10.1080/09540121.2016.1139043

Ewart, C.K. (1991). Social action theory for a public health psychology. Am Psychol. 46(9): p. 931-46.

Hawkins, A., et al. (2016). Episodic medication adherence in adolescents and young adults with perinatally acquired HIV: a within-participants approach. AIDS Care. 28 Suppl 1: 68-75. doi: 10.1080/09540121.2016.1146210

Holzemer, W.L., et al. (2007). Validation of the HIV/AIDS Stigma Instrument - PLWA (HASI-P). AIDS Care. 19(8): p. 1002-12. DOI: 10.1080/09540120701245999

Holzemer, W.L., et al. (2009). Measuring HIV stigma for PLHAs and nurses over time in five African countries. SAHARA J. 6(2): p. 76-82.

Hudelson, C. and L. Cluver. (2015). Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review. AIDS Care. 27(7): 805-16. doi: 10.1080/09540121.2015.1011073

Ioannides, K.L., et al. (2017). Patterns of HIV Treatment Adherence do not Differ Between Male and Female Adolescents in Botswana. AIDS Behav. 21(2): p. 410-414. doi: 10.1007/s10461-016-1530-7.

Johnson, M.O., et al. (2003). Theory-guided, empirically supported avenues for intervention on HIV medication nonadherence: findings from the Healthy Living Project. AIDS Patient Care STDS. 17(12): p. 645-56. DOI: 10.1089/108729103771928708

Johnson, M.O., et al. (2007). The Role of Self-Efficacy in HIV Treatment Adherence: Validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES). J Behav Med. 2007 Oct; 30(5): 359–370. doi: 10.1007/s10865-007-9118-3

Kamen, C., et al. (2015). HIV-related stigma: implications for symptoms of anxiety and depression among Malawian women. Afr J AIDS Res. 14(1): p. 67-73. doi: 10.2989/16085906.2015.1016987.

Kekwaletswe, C.T., et al. (2016). Social Support and the Mediating Roles of Alcohol Use and Adherence Self-Efficacy on Antiretroviral Therapy (ART) Adherence Among ART Recipients in Gauteng, South Africa. AIDS Behav. DOI: 10.1007/s10461-016-1595-3

Kim, M.H., et al. (2014). Prevalence of depression and validation of the Beck Depression Inventory-II and the Children's Depression Inventory-Short amongst HIV-positive adolescents in Malawi. J Int AIDS Soc. 17:18965. doi: 10.7448/IAS.17.1.18965

Kim, M.H., et al. (2015). Factors associated with depression among adolescents living with HIV in Malawi. BMC Psychiatry. 15: p. 264. doi: 10.1186/s12888-015-0649-9

Kim, S.H., et al. (2014). Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis. AIDS. 28(13): 1945-56. doi: 10.1097/QAD.0000000000000316.

MacPherson, P., et al. (2011). Stigmatising attitudes among people offered home-based HIV testing and counselling in Blantyre, Malawi: construction and analysis of a stigma scale. PLoS One. 6(10): p. e26814. doi: 10.1371/journal.pone.0026814

Seghatol-Eslami, V.C., et al. (2017). Brief Report: Interpersonal and Intrapersonal Factors as Parallel Independent Mediators in the Association Between Internalized HIV Stigma and ART Adherence. J Acquir Immune Defic Syndr. 74(1): p. e18-e22. DOI: 10.1097/QAI.0000000000001177

Sorsdahl, K.R., et al. (2011). The prevalence and predictors of stigma amongst people living with HIV/AIDS in the Western Province. AIDS Care. 23(6): p. 680-5. doi: 10.1080/09540121.2010.525621.

Stewart, R.C., et al. (2013). Validation of screening tools for antenatal depression in Malawi--a comparison of the Edinburgh Postnatal Depression Scale and Self Reporting Questionnaire. J Affect Disord. 150(3): p. 1041-7.

Taddeo, D., M. Egedy, and J.Y. Frappier. (2008). Adherence to treatment in adolescents. Paediatr Child Health. 13(1): 19-24. oi: 10.1016/j.jad.2013.05.036

UNICEF. (2016). The AIDS epidemic continues to take a staggering toll, especially in sub-Saharan Africa. Retrieved from:

Uys, L., et al. (2009). Evaluation of a health setting-based stigma intervention in five African countries. AIDS Patient Care STDS. 23(12): p. 1059-66. doi: 10.1089/apc.2009.0085.

Wagner, G.J., et al. (2016). Effects of Depression Alleviation on ART Adherence and HIV Clinic Attendance in Uganda, and the Mediating Roles of Self-Efficacy and Motivation. AIDS Behav. doi: 10.1007/s10461-016-1500-0

Wu, P., et al. (2014). The combination of pill count and self-reported adherence is a strong predictor of first-line ART failure for adults in South Africa. Curr HIV Res. 12(5): p. 366-75.

Zhang, C., et al. (2016). Stigma against People Living with HIV/AIDS in China: Does the Route of Infection Matter? PLoS One. 11(3): p. e0151078. doi: 10.1371/journal.pone.0151078


  • There are currently no refbacks.