This study delves into the critical issue of antiretroviral therapy (ART) adherence among individuals living with HIV/AIDS in Ethiopia. Understanding and improving adherence is crucial for effective HIV treatment, preventing drug resistance, and improving patient outcomes. While the global fight against HIV has seen significant progress, ensuring consistent medication adherence remains a key challenge, particularly in diverse sociocultural contexts. This research investigates not only whether patients are taking their medication, but also how well they adhere to the prescribed dosing schedules, and explores the sociocultural factors that shape their experiences with ART regimens. By examining these elements within the Ethiopian context, this study provides valuable insights for healthcare providers and policymakers seeking to optimize ART adherence and improve the lives of people living with HIV.
Introduction
Antiretroviral therapy (ART) has dramatically transformed the landscape of HIV/AIDS, turning a once-fatal illness into a manageable chronic condition. Early successes in ART adherence in African nations were encouraging [1, 2, 3]. However, sustained long-term adherence to complex medication regimens presents ongoing challenges [4, 5, 6]. Suboptimal adherence has serious consequences, including treatment failure, the development of drug resistance, increased HIV transmission risk, disease progression, and higher mortality rates [7, 8, 9, 10, 11, 12]. In resource-limited settings like Ethiopia, where monitoring systems may be less robust and access to second-line treatments is constrained [2, 13], understanding and addressing adherence behaviors is paramount to prevent treatment failure [4] and implement effective support interventions.
Numerous studies have quantified ART adherence among people living with HIV/AIDS (PLWHA) in sub-Saharan Africa [1, 14, 15, 16]. Reviews indicate that approximately 77% of adults on ART in the region achieve high adherence levels (above 80%), comparable to or even exceeding adherence rates in other global settings [17, 18]. Despite these seemingly positive statistics, a significant proportion, around 35%, of individuals starting ART are no longer engaged in care after three years [19]. Similarly, a substantial percentage experience immunological failure due to various factors, including poor adherence, insufficient drug concentrations [20], and drug resistance mutations [21, 22, 23]. These figures underscore the necessity for a deeper understanding of how individuals integrate long-term medication practices into their daily routines and lives.
Adhering to ART regimens involves navigating multiple complexities, including strict adherence to dosage, medication schedules (dose timing), and sometimes dietary restrictions [24, 25, 26]. For instance, maintaining appropriate time intervals between doses is crucial [27], as deviations in dose timing can negatively impact clinical outcomes [28, 29]. However, the critical level of strictness required for dose scheduling remains debated. Varied perceptions exist among patients and clinicians regarding what constitutes a missed or delayed dose [24], and surprisingly few studies have thoroughly considered dose timing when measuring adherence [28, 30]. While the impact of missed doses on viral rebound is relatively well-documented, the specific relationship between dose timing and viral rebound requires further investigation. A recent study suggests that missing consecutive doses poses a higher risk of viral rebound and resistance compared to simply mistiming a dose [31]. Nevertheless, to fully grasp risky adherence patterns, we must investigate the effects of dose timing on overall adherence [28]. Even if dose timing is less clinically critical than previously thought, poor dose timing might still indicate broader risky adherence behaviors, especially in contexts where time is tracked more by social cues than by strict clock time. This is particularly relevant in settings like Ethiopia, where cultural perceptions of time may differ from Western, clock-centric norms. Understanding “What Time Is It In Ethiopia” in a social context, therefore, becomes important when considering medication schedules.
A wide array of factors – behavioral, structural, and sociocultural – contribute to poor adherence. Sociocultural factors, such as stigma, fear of disclosure, limited social support, reliance on traditional healers, social norms, and gender inequalities, can significantly hinder adherence across various African contexts [6, 14, 16, 32, 33, 34, 35, 36]. In response to these challenges, qualitative research is increasingly exploring patient perspectives on ART requirements [37] and the strategies they employ to manage their therapy within their unique belief systems, experiences, and social realities [34, 37]. This patient-centered approach is vital for understanding medication-taking behavior from the patient’s viewpoint [38]. However, the social processes and contextual factors influencing adherence are incredibly diverse and require more in-depth exploration [16]. Furthermore, the evidence base for the effectiveness of various adherence intervention strategies remains limited [39, 40]. To comprehensively understand the complexities of medication practices [34, 41], it’s crucial to study them across diverse settings and sociocultural contexts, motivating the current research.
This study aimed to assess ART adherence among PLWHA in Ethiopia using self-reported data [42]. The study had two primary objectives: first, to evaluate the extent to which patients take their medication (dose adherence) and adhere to the prescribed regimen, including dose scheduling; and second, to explore the sociocultural context shaping PLWHA’s understanding of and relationship with ART adherence requirements, particularly regarding regular dose timing. Recognizing that perceptions and practices of time and schedules vary significantly, individuals engage with regimen expectations based on clock time in diverse ways. We argue that to effectively address incomplete adherence, we must understand how individuals navigate regimen recommendations from their own perspectives and within their specific sociocultural environments.
Methods
Participants
This research was part of a larger mixed-methods study conducted at the HIV clinic of a teaching hospital in Addis Ababa, Ethiopia. Participants were seropositive individuals attending the clinic for routine follow-up visits or prescription refills. Clinic nurses randomly selected patients from daily lists to inform them about the study. Interested individuals were then referred to the research team for detailed explanations of the study’s nature, purpose, and potential risks.
Eligibility criteria included being 18 years or older and having received ART for at least six months prior to the study. Individuals with serious or acute illnesses that could impair their ability to reflect on their experiences were excluded. Out of 112 eligible patients invited, 105 agreed to participate. Reasons for non-participation included fear of accidental disclosure, discomfort with audio recording, or lack of time. Two individuals who initially agreed did not attend the interview. Most participants preferred interviews on or shortly after their clinic visits. To minimize bias, a general explanation about research on their care experience was provided, avoiding specific mention of adherence to prevent influencing responses. All participants provided written consent and received 20 birr (approximately US$2) for transportation, a standard practice at the clinic. The study received ethical approval from the Institutional Review Boards of Northwestern University, the National Science and Technology Commission of Ethiopia, and Addis Ababa University.
Data Collection
Data collection occurred between May and October 2008, involving semi-structured in-depth interviews with 105 ART patients and clinic observations. Adherence data were gathered using an interview schedule with standardized questions adapted from Chesney et al.’s instrument for antiretroviral medication adherence [43].
Observations
The lead author conducted clinic observations throughout the fieldwork to understand how clinic experiences might relate to patient medication practices. Observation sessions, lasting 2-4 hours, took place at various times of day. The initial month focused on understanding clinic procedures and building rapport with staff. Subsequent observations centered on the clinic’s physical and social environment, visit lengths, patient volume, privacy, waiting times, and patient-provider interactions, particularly concerning medication adherence. A checklist guided observations, with brief notes taken during sessions and detailed summaries written daily. Field notes were regularly reviewed, and observations were clarified through communication with clinic staff, aligning with the iterative nature of qualitative data collection [44].
Interviews
All in-depth interviews were conducted by the first author in Amharic, the official language of Ethiopia. Interviews averaged 75 minutes, some reaching two hours. The interview guide was pre-tested with four patients at the clinic for clarity, cultural appropriateness, and translation validity, and updated based on preliminary findings. Interviews were conducted in a private clinic room and digitally recorded with permission. The interviews explored participants’ daily experiences with ART and the challenges of managing their illness and medications. Observational notes were recorded for each participant post-interview.
Adherence Data
Participants were questioned about their prescribed medications, dosage times, and the number of pills per dose. Regimen details and dosing instructions were verified against patient charts. Three-day and seven-day recall reports were used to assess medication intake (pills taken/pills prescribed) over the recent three and seven days [30, 45]. While self-reported adherence can overestimate actual adherence [30], these recall periods provided context for qualitative data and quantified adherence based on reasonable memory recall, especially for timing. Participants were asked: “Did you take your medication yesterday?”, “The day before yesterday?”, and “Three days ago?”, extending to seven days for the weekly measure. For twice-daily regimens, morning and evening doses were asked about separately. A ‘missed dose’ was defined as any dose not taken on the prescribed calendar day [24].
Adherence to dose-time instructions was assessed using the question: “Have you altered how you are supposed to take your HIV medications over the last 3 days/7 days?” [27]. “Yes” responses prompted reflection on dose-time adherence within windows, based on recall of instances and schedule alterations using clock time. When clock time estimation was difficult, social time indicators like church service lengths or local radio/TV show durations were used. For twice-daily regimens, morning and evening doses were assessed separately for both recall periods.
To mitigate self-report method limitations [26], several techniques were employed to encourage accurate reporting. The first author assured confidentiality, emphasizing no clinic affiliation, and that the study wouldn’t affect clinic relationships. Adherence questions were framed acknowledging the inconvenience of regular pill-taking, normalizing non-adherence [26]. Participant trust was evident, with many disclosing regimen deviations not shared with providers. Social time markers relevant to daily routines were used to reduce recall bias. Questions were simple and rephrased as needed to prevent misinterpretation.
Data Analysis
Qualitative data from interviews and observations were analyzed thematically using inductive and iterative processes. Adherence data were analyzed quantitatively.
Observation field notes and communications were reviewed, summarized, and iteratively analyzed to identify patterns and themes through reading, categorization, and comparison. Congruence and differences with interview findings were examined. Methodological and theoretical memos were written throughout data collection and analysis to inform analytic ideas and identify core categories [44, 46, 47].
Interviews were transcribed and translated into English shortly after to maintain data fidelity. Emerging insights were validated and elaborated in subsequent interviews. The first author translated half the interviews; research assistants translated the rest, with the first author reviewing transcripts against audio recordings. Interview transcripts were entered into HyperRESEARCH (version 2.8.3; Researchware Inc., www.researchware.com) for data management. The first author conducted all coding. After initial coding, audio records and full transcripts were revisited to ensure accuracy and ground developing analyses.
While theoretical sampling wasn’t used for recruitment, data analysis employed an inductive approach informed by grounded theory [44, 48]. Three-step coding was used: line-by-line analysis to identify provisional concepts relevant to each interview question; condensation of codes into categories and subcategories based on content similarities; and examination of patterns within and between categories using the constant comparative method [44] to generate thematic explanations of diverse regimen experiences [48].
Adherence data and socio-demographic information were analyzed using SPSS (Version 19.0) [49]. Adherence measures (3- and 7-day) were calculated using two metrics. First, adherence to dose was the proportion of doses taken in 3/7 days divided by the total prescribed dose (continuous variable, 0-100%). Second, adherence to schedule was the proportion of doses taken within a 30-minute window of the prescribed time divided by the total possible doses. Both measures were dichotomized at a 95% threshold (adherent/non-adherent) [7].
While consensus on ‘on-time dosing’ is lacking, prior studies used a ±1-hour window [28]. This study used a stricter 30-minute window to be sensitive to participants’ time perception. Social time is prevalent in Ethiopia, and punctuality based on clock time is less emphasized. Observations noted participants arriving at the clinic significantly late but perceiving themselves as only “a little” late. Similarly, a 1-hour interview was perceived as “a very long time” initially, but “not at all” after 90-115 minutes. A ±30-minute window was deemed the closest estimate to the ±1-hour window, acknowledging these time perception differences. Doses taken outside this window were considered non-adherent to schedule.
Findings are presented in two sections: respondent characteristics and adherence rates (dose and dose schedule) using both recall periods, followed by qualitative data to contextualize quantitative results. The second section presents qualitative data on how PLWHA manage medications, particularly dose scheduling, and their diverse relationships with ART schedule requirements. Qualitative data from interviews and observations are presented concurrently and indicated as such.
Results
Participant Characteristics
The average participant age was 38 years (range: 21-58 years), and 59% were women (Table 1). The majority were Orthodox Christian (63%) and never married (37%). Approximately 42% had elementary-level education or no formal education, and 31% were unemployed. Over two-thirds had no regular income or earned less than US$50 per month.
Table 1. Socio-demographic and treatment characteristics of participants (N = 105)
| Characteristic | N (%) |
|---|---|
| Female | 62 (59) |
| Age (Mean = 37.7) | |
| 18–29 | 21 (20) |
| 30–49 | 53 (50.5) |
| 50 and above | 31 (29.5) |
| Religion | |
| Orthodox Christian | 66 (62.9) |
| Other Christians | 24 (22.9) |
| Muslim | 13 (12.4) |
| No religion | 2 (1.9) |
| Marital status | |
| Never married | 39 (37.2) |
| Married | 31 (29.5) |
| Separated/divorced/widowed | 35 (33.3) |
| Education | |
| Elementary or no education | 44 (41.9) |
| High school/vocational training | 46 (43.8) |
| College | 15 (14.3) |
| Employment | |
| Employed in formal sectors | 30 (28.6) |
| Self-employed | 43 (41) |
| Unemployed | 32 (30.5) |
| Income | |
| Under 50 dollars a month | 74 (70.5) |
| Months on ART | |
| 6–24 | 40 (38.1) |
| 25–48 | 58 (55.2) |
| 49 and above | 7 (6.7) |
| ART regimen | |
| First line regimen | 80 (76.2) |
| Second-line regimen | 25 (23.8) |
Participants had been on ART for 6 to 76 months (mean = 37.6 months). Most were ART-naïve at treatment initiation at the study clinic when medications became freely available through the national ART program in January 2005. The majority (76.2%) were on first-line, fixed-dose combination ART, primarily twice-daily regimens of a non-nucleoside reverse transcriptase inhibitor (nevirapine or efavirenz) and two nucleoside reverse transcriptase inhibitors (lamivudine and stavudine or zidovudine). A significant portion (23.8%) were on second-line drugs due to first-line regimen failure, monitored by CD4 counts or clinical inference.
Self-Reported Adherence to ART
The estimated mean adherence-to-dose rate was 95.8% (95% CI, 93–99%) using both 3- and 7-day recall data, with almost all participants reporting 100% adherence (N = 102 for 7-day recall). A large majority, 97 participants (92.4%), reported optimal dose adherence (≥95% of prescribed medication) in the 3 days prior to interviews. However, optimal adherence to dose schedule in the same period dropped to 70 participants (66.7%). Using 7-day recall data, optimal dose adherence was reported by 90 participants (85.7%), while schedule adherence was only 60 (57.1%). Failure to report dose time lapses using clock time was more common with the 7-day recall. Nine participants (8.6%) couldn’t report “on time” medication using 7-day recall, compared to three (2.9%) using 3-day recall, due to inability to quantify delays in clock time or not knowing when medication was taken.
Managing Dose Timing
Almost all participants reported receiving medication information and specific instructions. The importance of strict on-time dosing was frequently emphasized. Clinic observations confirmed consistent emphasis on regular dose timing for both new ART initiates and follow-up patients. This focus on clock time was perceived as a unique and demanding requirement compared to other chronic medications. One participant stated, “ART has to be taken for a lifetime just like other medications for chronic conditions…. The only unique requirement with ART is the fact that we have to take it ‘on-time’ all the time. No compromise!” (Male, 31 years). Meeting these expectations often required prioritizing medication timing above other activities. Some individuals meticulously adhered to clock time, treating it as a primary daily task. One participant stressed:
Just like your main job, you have to take it seriously. My goal of the day is taking the medicine. It’s the first thing on my to-do list…. Watching time is my main job. The rest of my daily activity is secondary. (Male, 38 years)
Several participants reporting schedule adherence used devices or social support, such as alarms or family reminders:
My pills time is 10 in the morning and 10 in the evening. Initially, I found it so hard to keep track of my dose time. Fortunately, I was given an alarm clock… which made my life a lot easier…. Also, if I am home, my children always tell me the time. They say, “It is your medication time, Mom,” even though they do not know what the medication is for. (Female, 38 years)
I have an alarm clock next to my bed, which is helping me to get used to taking the medicine on time. These days I even have some gut feelings when time for the medication is approaching. (Male, 57 years)
However, others struggled to consistently adhere to dose timing due to regimen integration challenges within daily routines. Even those accepting the instructions often modified them. No clear patterns emerged regarding specific events causing early or late medication intake. Three themes explained deviations from schedules: poor orientation to clock time, regimen strictness, and beliefs about dose-timing adherence.
Poor Orientation to Clock Time
Regardless of socioeconomic status, age, or gender, many participants reported instances of missed dose times. Individuals lacking clock time access or orientation, often due to illiteracy, found it particularly difficult to incorporate dose timing, even with good intentions. One participant explained:
I am told to take my pills at 8 in the morning and 8 in the evening. But I take my pills just by guessing…. I’m illiterate. I’m ashamed to ask [what the time is]… as I worry that people might know why. I do not have any control on time. (Female, 40 years)
Experiences of time were often described as “now and then” or “a while” by those not associating social time with clock time. Clinic observations confirmed limited timepiece accessibility; most interviewees lacked wristwatches or clock-indicating accessories like cell phones [field note]. For such individuals, strict schedule adherence is unrealistic.
Many participants struggled to describe their pill-taking experiences in terms of dose timing, evident during interviews when reporting time lapses. Even participants familiar with clock time (wristwatch wearers, those in time-sensitive activities, or better-educated individuals) struggled, suggesting a disconnect between subjective time perception and standardized clock time.
I often forget to take my medication on time…. If I am on the road, I do not keep track of the time and I do not even know how long the lapse was. (Male, 30 years)
I do not remember exactly how late I take my meds, but I usually miss my schedule during the daytime. (Female, 28 years)
Even when attempting to align dose time with clock time, subjective duration perception could differ from standardized clock time. One participant described: “I was late by 10 min because I started watching live soccer right before my pill time, and I did not want to get up and take my pills until they [the players] went for a break” (Male, 40 years). Given soccer half-time duration (45 minutes), the lapse was likely longer than reported. Medication practices are significantly influenced by sociocultural factors like time perception and punctuality norms.
Regimen Strictness and Social Life
Some participants found “on-time” dosing instructions overly demanding, intimidating, and stressful, leading to regimen modifications. One participant described it as: “It [the regimen recommendation] is so suffocating. It is very stressful to know that you have to be punctual all the time. Even minutes… the instructions they gave us when we start the medication are so strict that we have to be conscious about minutes and seconds. I think being punctual all the time is not humanly possible, and I came to a conclusion that my anxiety about time is not going to make any difference” (Female, 29 years). Some perceived the punctuality norm as unattainable or hindering social participation:
I am very much forgetful, and my work situation does not allow me to take my pills on time. It is really impossible. (Female, 28 years)
Adhering to the dose schedule is never easy for me. If I am at home I try to keep the time. But if I am traveling, it is just impossible to be punctual. I am planning to visit my sister this evening, and I am not sure if I will be able to take my pills on time. (Male, 40 years)
Difficulty meeting regimen demands often stemmed from a lack of guidance on safe regimen integration. Observed counseling sessions and follow-up visits were brief and prescriptive, not addressing patient concerns adequately. Providers primarily instructed, and patients rarely questioned or explored practicalities [field note]. Consequently, patients adapted regimen recommendations as needed, creating practical adherence strategies. Many intentionally modified dose times for social events, religious practices like fasting, or to manage HIV disclosure and stigma:
I take them [pills] when it is convenient. But I skip my dose to not let people know about my pills and be suspicious [of my HIV status]. I skip my dose time quite often. (Male, 39 years)
But during fasting, the way the medication is taken is not convenient…. I eat at 6:00 and I take my pills at 9:00. Then I take the morning dose at 4 o’clock in the morning [last time when one can eat or drink]. (Female, 27 years)
Younger participants were more comfortable adjusting pill spacing. Strict schedule adherence often decreased over time as initial strictness normalized:
I know that I have to take my meds on time… twice a day, at 8 a.m. and 8 p.m. I was pretty much strict on time when I started the medication. I used to be too conscientious. But as time goes by, I mean… when you take the medication for a while you tend to normalize the activity…. Nowadays, I just know that I have to take it twice a day. (Female, 30 years)
Beliefs About Dose-Timing Adherence
Beliefs about dose-timing relevance also influenced adherence, often shaped by healthcare provider information. While instructed on regular medication intake, guidance on missed doses or schedule deviations was lacking. Participants frequently questioned the interviewer about appropriate flexibility in schedules, asking: “How much of a delay is too detrimental?”, “What if doses are too close?”, “How long a delay is better skipped?”, “How to best manage medication with my life?”, and “Does timing really matter?” [field note].
Lack of clear instructions on safe dose time ranges or agreed-upon acceptable timing existed. Provider perceptions of adherence varied. A resident physician stated, “It is a matter of disciplining patients… time lapse may not have any real impact for some drugs. Some… have a half-life as long as 4 days.” Another doctor suggested “±2 hours is the best bet” [field note].
Uncertainty about dose-time adherence led some PLWHA to question its necessity and deviate from schedules, believing regular timing was unimportant, prioritizing dose intake over precise timing. One participant said:
I follow my medication regimen appropriately. There are times when I take my pills later or earlier than 8 o’clock. I don’t think this is a problem at all. I take my dose even if it is late. (Male, 42 years)
Conversely, when schedule deviations were believed to cause immediate harm, adherence was stricter. Those experiencing negative consequences of non-adherence actively reoriented to clock time and adopted punctuality. One participant stated:
Adhering to dose schedule is an obligation that I have to fulfill in order to stay alive. I learned that the hard way. I became sick and bedridden for messing up with my dose time. If I die who would support the three children that I am raising?… I would not mess up my dose time now. (Female, 49 years)
Discussion
This study revealed two key findings: high self-reported dose adherence among PLWHA in Ethiopia, but lower adherence to dose schedules; and that time perception, regimen strictness, and beliefs about dose timing significantly influenced adherence to schedules, explaining the discrepancy between dose and schedule adherence rates.
Over 90% of participants reported optimal dose adherence (≥95%) in the preceding 3 days, consistent with other Ethiopian studies [50, 51, 52, 53]. However, schedule adherence in the same period was lower at 67%. This difference, despite potential self-report overestimation, highlights the distinction between dose and schedule adherence. Given emerging evidence suggesting dose adherence is more critical than precise timing [31], these data indicate strong ART adherence in this setting. Even those less oriented to Western clock time were highly dose-adherent.
Qualitative data underscored the challenges and burdens patients faced integrating “time” into medication routines. Some experienced significant delays, while others struggled to accurately measure delays due to limited clock time experience. Clock time adherence was particularly challenging for those outside clock-driven social activities, requiring extra effort as it wasn’t natural [54]. Such practices could indicate risky adherence patterns if leading to clinically insufficient adherence. Adherence conversations are crucial to understanding individual time perceptions and addressing risky patterns early.
Time perception is only one factor. PLWHA manage multiple challenges: status concealment, stigma, financial insecurity, and spiritual life. Many intentionally disregard dose timing to develop medication self-efficacy. Some integrate medication into social environments [55], while others, especially younger and longer-term patients, adjust schedules to reduce psychological stress and negative social consequences (e.g., stigma, disclosure) during social events.
Beliefs about ART also shape dose-time relationships [27, 56]. In this study, doubts about regular dose timing stemmed from uncertainties about optimal compliance windows. While evidence suggests less strict timing is needed for newer HIV medications [12, 57], and missed doses are more critical than timing [31], no clear consensus exists on safe dose lapse ranges [24]. This ambiguity may cause confusion and support alternative strategies [55] or reduced adherence [58].
Strict dose-timing instructions were stressful and potentially counterproductive. This overemphasis adds to regimen complexity. Ethiopian HIV guidelines raised ART initiation CD4 thresholds [59, 60]. With more healthier individuals eligible for ART, unrealistic timing demands may discourage early initiation. Schedule adherence requires distinguishing acceptable flexibility [54] without undue stress. Providers and patients need a shared understanding of optimal adherence considering individual contexts.
Patients demonstrate agency in regimen deviations. A patient-centered approach is essential to understand treatment integration [38, 61]. This study showed patient reluctance to ask treatment questions during brief clinic visits, partly due to visit brevity, but also due to perceived lack of entitlement to question procedures and provider-centered instruction [field note]. Providers should appreciate individual differences, listen, and negotiate, fostering shared decision-making [61, 62], allowing patients to discuss concerns and enabling tailored adherence support. This reinforces communication’s role in patient-provider agreement [63, 64] and quality relationships [38]. The paternalistic doctor-patient dynamic in the study area hinders patient perspectives and beliefs, crucial for adherence [38, 58, 65]. While patient empowerment is needed, providers must initiate shared decision-making in contexts of power imbalance.
Regardless of reasons for timing deviations, assessing them is challenging due to prevalent time notions. Socially based time management in Ethiopia may explain difficulties in translating gross time to clock time and estimating duration. Time estimations in social-time-oriented societies are likely misleading due to limited reconciliation of social and clock time. Self-report, the most feasible adherence assessment [26], could be improved by considering sociocultural contexts and commensuration skills (comparing social and clock time). Researchers in non-Western cultures should account for design aspects based on precise dose timing. Assessing HIV treatment adherence could be more accurate and less burdensome by asking patients to rate regimens generally [30, 66, 67], especially regarding timing.
Study limitations include reliance on self-report, lacking objective adherence measures. The clinic setting lacked routine viral load data, preventing correlation with immunological success. The study focused on patients engaged in care for at least 6 months, potentially missing experiences of those who dropped out. While time perception was considered, and social activities were used to validate timing data, precision in dose timing estimates couldn’t be guaranteed, limiting validity. Finally, the sample, though socio-demographically diverse within Ethiopia, represented a specific social and clinical context, limiting generalizability. However, insights into medication practices remain valuable and potentially transferable.
A major strength is the use of multiple data sources [68]. Rich qualitative accounts from interviews and observations [41] explained quantitative adherence rate variations when considering dose timing. Interviewers probed adherence in multiple ways, minimizing misinterpretation and enabling response cross-checking. Time perception, commensuration skills, and cultural contexts affecting medication practices and measurement were explored. The first author conducting all interviews in the local language minimized social desirability bias by avoiding interpreters or clinic staff involvement.
In conclusion, this study contributes to understanding medication practices in non-Western settings, focusing on ART adherence in Ethiopia through observation and interview data. We found high dose adherence but variable dose timing. Providers in similar settings should engage in adherence conversations to help patients safely integrate regimens into their complex social lives.
Acknowledgments
This study was supported by the department of Sociology and The Graduate School of Northwestern University, and by Grant Number T32HS000011 from the Agency for Healthcare Research and Quality.
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