Research Article | Volume 3 - Issue 1 | Article DOI :
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Andrew Zekeri1* and Cordelia C. Nnedu2
1Department of Psychology and Sociology, Tuskegee University, USA
2Professor and Dean, School of Nursing and Allied Health, Tuskegee University, USA
Corresponding Author:
Andrew Zekeri, Professor of Sociology and Graduate Faculty - Department of Psychology and Sociology, Tuskegee University, 1200 West Montgomery Road, Room 44-325 John A Kenney Hall, Tuskegee, AL 36088, USA, Tel: 334-727-8086 .
Keywords
Perceived barriers; Medication adherence; African american patients; Antiretroviral therapy; Alabama’s
black belt.
Abstract
In Alabama’s Black Belt, African Americans are disproportionately affected by Acquired Immunodeficiency Syndrome (AIDS). New treatments that slow the progression of human immunodeficiency virus (HIV) infection offer hope for individuals living with HIVIAIDS, but lack of adherence to medications remain significant obstacles to HIV treatment in rural Alabama.
Lack of adherence limits the potential benefit of antiretroviral therapy to improve the health of those living with HIV/ AIDS. As an extension previous research on HIV/AIDS the purpose of the current research is to explore perceived reasons for lack of adherence to medication experienced by HIV-infected African Americans living in Alabama’s Black Belt region of the United States. Qualitative research results showed that Perceived Barriers to Medications Adherence are: lack of health insurance, Financial constraints and Poverty, Lack of Trust in White Medical Health Professionals, Household Food Insecurity and HIV medicine side effects, poor Mental Health, Social Stigma and Alcohol Use, Lack of transportation, Trouble swallowing pills and Substance use, Not Enough Black Medical practitioners in the Black Belt, and Poor Public Goods and Services. Endorsing HIV/AIDS Conspiracy beliefs such as “AIDS is a form of genocide against Blacks” is an important barrier to medication adherence in the sample. It is important that all members of the healthcare team address potential barriers to medication adherence in order to achieve viral suppression and optimize outcomes in patients with HIV.
Introduction
In Alabama’s Black Belt, African Americans are disproportionately affected by Acquired Immunodeficiency Syndrome (AIDS). New treatments that slow the progression of Human Immunodeficiency Virus (HIV) infection offer hope for individuals living with HIVIAIDS, but lack of adherence to medications remain significant obstacles to HIV treatment in rural Alabama. Despite a wide availability of effective treatments for HIV disease, many African Americans in the rural south infected with HIV are not adhering to medication regiments. HIV-infected African Americans, particularly those residing in Alabama’s Black Belt, have greater difficulty adhering to care [1-3]. Lack of adherence limits the potential benefit of antiretroviral therapy to improve the health of those living with HIV/ AIDS. Because HIV requires lifelong treatment, people with HIV should regularly visit their health care provider. As an extension of previous research on HIV/AIDS [2-7], the purpose of the current research is to explore perceived reasons for lack of adherence to medical care experienced by HIV-infected African Americans living in Alabama’s Black Belt region of the United States. The sociological tradition used in this research stresses the need to see a situation from the point of view of the people who are in it. Thus, it directs the investigator to seek out and listen to African Americans own statements of their experiences. The voices of patients who participated in this study have important implications for policymakers and medical practitioners interested in eliminating racial health disparities and promote equity in health.
RESEARCH METHOD The study site
Alabama’s Black Belt, the site selected for this study, is an ideal case for research examining the prevalence and severity of medication adherence in rural southern areas of the United States. The region is identifiable by the concentration of black people that inhabits it. It is a desperately poor place—among the poorest places in the United States. It is home to persistent poverty, poor employment, unemployment, limited education, poor health, single parenthood, and heavy dependence on public assistance programs [1-4]. The residents are, as the President’s National Advisory Commission on Rural Poverty put it in 1967, “people left behind.” In 2025, it is still a place left behind in many respects. The poverty—stricken character of the area contrasts sharply with the affluence of white society. Majority of the counties in the area are among those counties categorized by the USDA as counties of “persistent poverty.” The intent of the Johnson’s Administration’s Great Society program “to eliminate the paradox of poverty in the midst of plenty,” continues to remain a paradox in Alabama’s Black Belt Counties.
The purpose of this research is to review the background of the persistent poor adherence to medication, identify the causes of this persistent, agonizing problem of lack of medication adherence, and suggest an approach that could be taken to turn the lack of adherence to medication crisis into a new era of hope.
The research methods
I used qualitative and quantitative methods for the study. The objective of the focus group discussions conducted at two HIV clinics in Alabama was to study the underlying reasons for lack of adherence to medications among patients living with HIV. Patients living with HIV were recruited from two AIDS clinics in Alabama. Eligible patients were to be 18 years of age or older. Over the years, more than 9 focus groups and personal interviews were conducted with 110 patients focusing on general perceptions of health and medical care; general perceptions of health care provider and adherence to medications; general perceptions of medical research and access to care. Focus groups as used in this study are not intended to statistically represent the study population, but are appropriate techniques in situation where highly efficient collection of exploratory data is necessary. Treatment adherence as used in this research includes starting HIV treatment, keeping all medical appointments, and taking HIV medicines exactly as prescribed.
The focus groups discussions in the paper provide the voice, the presence, and the perspective of African Americans who live with HIV and are generally invisible to the rest of us. Issues surrounding medication adherence are complex, difficult, and controversial.
Data analysis
Content analysis approach1 was used in the study to analyze the data. Content analysis produces a relatively systematic and comprehensive summary or overview of the data as a whole, incorporating a quantitative element.
FINDINGS
Perceived Barriers to Medications Adherence
Overall, patients had experienced some barriers for adhering to medication Therapy.
Health insurance
One of the many reasons given as barriers to HIV/AIDS care is lack of health insurance. Most of the focus group participants believed that lack of health insurance by African Americans explains a significant part of the lack of medication adherence. They believed that a high percentage of African Americans in the Black Belt are uninsured. African Americans are the least able to afford regular prescription medicines, and even over the counter medications.
Financial constraints and poverty
Interestingly, another common context, other than health insurance that was routinely heard in focus groups, was poverty and financial constraints. Most participants said that in the United States, health and access to medications are unequally distributed on the basis of socioeconomic status. Money, or the lack of it, explains much of the disparity in access to medication adherence. Cost-related medication nonadherence is associated with worsening health and greater use of health care services. Poverty restricts opportunities for individuals to find employment with good pay and provide for themselves.
Lack of trust in white medical health professionals
Another issue that came out of the interviews and discussions is distrust in white health professionals by African Americans. African Americans are more reluctant than whites to seek treatment for HIV and AIDS because they distrust the government 2-6. This is because of the infamous Tuskegee experiments conducted by the U.S. government for 40 years (from 1932 to 1972). For the experiments, 399 poor black men were recruited and led to believe that they would receive free medical treatment for what they called “bad blood,” while, in fact, they were left untreated for syphilis so that the government health researchers could study the impact of the disease on them.
Household food insecurity and HIV medicine side effects
Food insecurity also makes it difficult for individuals to manage existing health problems and it can lead to worsening conditions. Foodinsecure individuals may struggle to adhere to therapeutic diets and forgo necessary medications because of the expense and lack of food. Nearly half of adults living in severely food-insecure households reported delaying, reducing, or skipping prescription medications because of food insecurity and HIV medicine side effects [2,3]. Food insecurity was associated with poorer medication adherence in this study. These findings are consistent with two systematic review studies that evaluated the influence of food insecurity on adherence [7].
Mental health
Among the patient, forgetting to take medication and depression were mentioned as reasons for nonadherence to medication. The risk of experiencing depression, anxiety disorders, mood disorders, or suicidal thoughts increases with the severity of food insecurity for adults and lack of adherence to medications [5-7].
Social stigma and alcohol use
Alcohol use and social stigma were seen as barriers to antiretroviral therapy adherence in this sample. In the Black Belt, stigma is founded on fear and misinformation. Stigma is associated with behaviors that are considered deviant; a belief that HIV has been contracted due to unacceptable lifestyle choices. Some of the participants believed it is the result of a moral fault which deserves punishment.
Lack of transportation
Interestingly, another common context, other than health insurance that was routinely heard in infocus groups, was Lack of transportation to pharmacy stores that are not locally owned. Most participants said that in the United States, access to pharmacy stores are unequally distributed on the basis of socioeconomic status. Money, or the lack of it, explains much of the adherence to medications among Blacks and whites.
Trouble swallowing pills and substance use
African Americans face many barriers in taking their medications. Some of the biggest obstacles they must overcome is trouble swallowing the pills and substance abuse.
Not enough black medical practitioners in the black belt
Not enough black doctors and nurses in black communities – many participants alluded to these when asked to explain medication adherence. Many of the participants indicated that lack of African Americans health care providers as the source of much of the problem. Participants stated inadequate Afr
Poor public goods and services
Many rural communities in Alabama’s Black Belt lack some if not all of the services (health, education, recreation, transportation, safety, justice, water, wastewater treatment, solid waste disposal, energy, telecommunications, fire safety, and others) patients have come to rely upon for meeting their daily needs. In Alabama’s Black Belt, this has two severe effects. First, it means that rural community well-being is depressed by problems of access to vital resources like medications; and, second, it means that the local area is not a complete community. Both of these play a role in medication adherence.
Endorsing HIV/AIDS Conspiracy beliefs such as “AIDS is a form of genocide against Blacks” and “AIDS was created by the government to control the Black Population” are seen as important barriers to medication adherence in the sample.
CONCLUSION
In summary, in the focus group meetings patients reported that financial constraints, forgetting to take medication, lack of transportation, depression, alcohol use, social stigma, Trouble swallowing pills and Substance use and side effects to ART and food insecurity were associated with low adherence in our study. There are multiple reasons why food insecurity negatively impacts medication nonadherence. Lack of food increases hunger and results in patients prioritizing basic survival needs over other competing issues such as medication adherence. Food insecurity is also associated with decreased self-efficacy which can adversely affect mental health and adherence. Finally, patients can experience more side effects when their medications are not taken with food and their nutritional status is compromised [7]. It is important that all members of the healthcare team address potential barriers to adherence in order to achieve viral suppression and optimize outcomes in patients with HIV.
What is needed to make medication adherence better among patients in the Black Belt, from my viewpoint, is to focus on rural deficits in the fundamental requirements for social well-being, namely jobs and income, services, equality, and community. Jobs, income, and services are needed to meet needs in Alabama’s Black Belt but also to remove barriers to community development. In promoting these at whatever levels, emphasis should be put first on the needs of people and those processes by which people gain the skill and knowledge but also the power and opportunity to build their own future. With opportunities and support, the patients in Alabama’s Black Belt can be the most effective advocates for and agents of their own well-being. The main idea is to mount a real national effort to attack poverty in Alabama’s Black Belt where the rural poor are disproportionately concentrated and to do so by getting the community into the act. Building the capacity of Alabama’s Black Belt residents to work together to solve local problems is the key to solving the poverty problems. Figuring out how to build local capacity is the central challenge of the decade and will be the central challenge of the 21st century for rural sociology. The medication problems facing Alabama’s Black Belt are real ones, not theoretical ones. They call for real solutions, and sociologists have an important role to play in identifying and applying those solutions.
Citation
Zekeri A, Nnedu CC (2025) Perceived Barriers to Medication Adherence among African American Patients on Antiretroviral Therapy in Alabama’s Black Belt. SM J Fam Med 3:3-3.
