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Published in final edited form as: AIDS Care. 2019 Mar 5;31(8):958–964. doi: 10.1080/09540121.2019.1587363

Positive Religious Coping Predicts Self-reported HIV Medication Adherence at Baseline and Twelve-month Follow-up Among Black Americans Living with HIV in the Southeastern United States

Tonia Poteat 1, Jonathan Mathias Lassiter 2,3
PMCID: PMC6702942  NIHMSID: NIHMS1534217  PMID: 30836764

Abstract

This paper presents the results of secondary data analyses investigating the influence of religious coping on HIV medication adherence across time among 167 Black Americans living with HIV (BALWH) in the Southeastern United States. Participants were recruited from a large urban clinic in Atlanta, GA and completed questionnaires about their religious coping at baseline assessment and about their medication adherence at baseline and 12-month follow-up assessment. Descriptive analyses and multiple linear regression were used to determine the association between religious coping and HIV medication adherence. Findings indicated that after controlling for age and depressive symptoms at baseline, positive religious coping significantly predicted medication adherence at baseline and 12-month follow-up. Negative religious coping was inversely associated with medication adherence at baseline after controlling for age and depressive symptoms but not at 12-month follow-up. The implications of these findings for future research and intervention work related to medication adherence among BALWH are discussed.

Keywords: HIV, African Americans, medication adherence, religious coping

INTRODUCTION

In 2016, 17,528 Black Americans received an HIV diagnosis and only 43% of them had a suppressed viral load (Centers for Disease Control and Prevention [CDC], 2018a). This group comprised 47% of the people who received an AIDS diagnosis in the United States ([CDC], 2018a). These inequities are likely related to several breakdowns along the HIV continuum of care. Black Americans are more likely to experience barriers to receiving health care (e.g., health insurance; Sohn, 2017) and are often subjected to discriminatory experiences with healthcare providers (e.g., HIV stigma, racial bias; Williams & Wyatt, 2015) that hinder ART receipt and retention in healthcare.

For those who do receive ART, adherence is essential. Several studies have identified barriers to ART adherence (Gaston & Alleyne-Green, 2013; Sangaramoorthy, Jamison, & Dyer, 2017; Voisin, Quinn, Kim, & Schneider, 2017) such as medical mistrust (Dale, Bogart, Wagner, Galvan, & Klein, 2014; Kalichman et al., 2017) and psychological distress (Gross, Hosek, Richards, & Fernandez, 2016). Fewer studies have examined facilitators of adherence (Geter, Sutton, & Hubbard, 2018; Pellowski, Price, Allen, Eaton, & Kalichman, 2017). Among those that have assessed facilitators, faith in the sacred (or one’s higher power) emerged as a having a significant influence on medication adherence among people living with HIV (Oji et al., 2017). Given the centrality of faith in Black American communities (Pew Research Center, 2014a), religion may be particularly important to investigate when trying to understand medication adherence among this group.

Religion is a culturally-relevant force in the lives of many Black American people. It is a multidimensional phenomenon (Zinnbauer et al., 1997) defined as “the search for significance that occurs within the context of established institutions that are designed to facilitate spirituality” (Pargament, Mahoney, Exline, Jones, & Shafrankse, 2013, p. 15). Forty-seven percent of Black Americans reported attending a religious service at least once a week compared to 39% of Latinx people and 26% of Asian Americans (Pew Research Center, 2014a). Furthermore, 83% of Black Americans have reported “absolutely” believing in the sacred, while 73% have disclosed praying at least daily (Pew Research Center, 2014b). Many Black Americans believe that the sacred influences not only their spiritual development but also their mental and physical health (Holt, Clark, & Roth, 2014; Holt, Haire-Joshu, Lukwago, Lewellyn, & Kreuter, 2005). Indeed, there have been several studies conducted with Black American samples that have found that religion positively influences health outcomes (Levin, Chatters, & Taylor, 2005; Park, Holt, Le, Christie, & Williams, 2017; Taylor, Chatters, & Levin, 2003). Religious coping is a component of religion that has recently received more attention in the scholarly literature focused on health-related treatment and prevention (Chatters, Taylor, Jackson, & Lincoln, 2008; Holt, Clark, Debnam, & Roth, 2014).

Religious coping is the use of religious beliefs, interpersonal relationships, and other strategies to navigate life stressors (Pargament, Smith, Koenig, & Perez, 1998). Religious coping has two components: positive and negative religious coping. Positive religious coping is a problem-solving style that relies on collaborating with the sacred to navigate stressors in one’s environment and is grounded in understanding that the sacred is affirming and benevolent (Pargament et al., 1998). Negative religious coping is a problem-solving style that interprets life stressors as resulting from abandonment by the sacred or punishment from the sacred or demonic forces (Pargament, Koenig, & Perez, 2000). Positive religious coping has been linked to positive health outcomes such as decreased psychological distress (Brewster, Velez, Foster, Esposito, & Robinson, 2016) and alcohol use (Montgomery, Stewart, Bryant, & Ounpraseuth, 2014). Negative religious coping has been found to be associated with poor health outcomes such as prolonged grief disorder (Boulware & Bui, 2016) and elevated depressive symptoms among people with HIV (Dalmida, Koenig, Holstad, & Wirani, 2013). These findings indicate that religious coping has the potential to be both a barrier and facilitator for ART medication adherence. Previous research attest to the influence of religious coping on stressor appraisal and meaning-making (Mattis, 2002; Park, 2005). For example, Mattis (2002, p. 311) found that Black American women used religion as a means of “(a) interrogating and accepting reality, (b) gaining insight and courage needed to engage in spiritual surrender, (c) confronting and transcending limitations, (d) identifying and grappling with existential questions and life lessons, (e) recognizing purpose and destiny, (f) defining character and acting within subjectively meaningful moral principles, (g) achieving growth, and (h) trusting in the viability of transcendent sources of knowledge and communication.” These ways of making meaning could represent underlying mechanisms that explain how religious coping influences medication adherence. However, before we explore underlying mechanisms, an investigation of religious coping’s relationship with medication adherence among Black Americans living with HIV (BALWH) is warranted. This study aims to address this gap in the scholarly literature.

This paper presents the findings of secondary data analysis that examined the immediate and long-term influences of both positive and negative religious coping on ART medication adherence among BALWH in the Southeastern United States. We hypothesized that 1) positive religious coping at baseline would be directly associated with ART medication adherence at baseline, and 2) negative religious coping at baseline would be inversely associated with ART medication adherence at baseline. Additionally, we hypothesized that 3) positive religious coping at baseline would have a long-term effect and predict ART medication adherence at 12-month follow-up, and 4) negative religious coping at baseline would be inversely associated with ART medication adherence at 12-month follow-up.

METHODS

Participants

This secondary analysis was performed using baseline and 12-month follow-up data from the “Get Busy Living” study, a randomized controlled study designed to test whether a motivational interviewing intervention would enhance medication adherence among people with HIV (DiIorio, Resnicow, McDonnell, Soet, McCarty, & Yeager, 2003; Shinitzky & Kub, 2001). A convenience sample of 247 adults was recruited from a large urban clinic in Atlanta, Georgia. Participants met the following inclusion criteria: 18 years of age or older living with HIV infection, on a new antiretroviral therapy regimen containing a protease inhibitor, referred by an adherence nurse educator and access to a telephone and VCR. Written informed consent was obtained from all participants. Analyses for the present paper were conducted with the 167 Black Americans in the sample who provided medication adherence data at both baseline and 12-month follow-up.

Procedures

Participants used Computer Assisted Self-Interview with audio (ACASI) at baseline and at 12-month follow-up to complete study surveys. Emory University’s and Grady Health System’s Institutional Review Boards provided ethical oversight for the parent study to ensure participants’ safety. This secondary analysis received expedited approval from the Emory University Institutional Review Board.

Measures

Participants’ sexual orientation, gender, income, and age were assessed. The constructs of interest in this study were: religious coping and medication adherence. We also assessed depressive symptoms as we expected them to co-vary with medication adherence (Catz, Kelly, Bogart, Benotsch, & McAuliffe, 2000; Gonzalez, Batchelder, Psaros, & Safren, 2011).

Religious coping.

The Brief Religious Coping Scale (Pargament, Feuille, & Burdzy, 2011; Brief RCOPE) was used to measure religious coping. Religious coping was assessed with two subscales – positive religious coping and negative religious coping. Both scales were composed of seven items each. Participants were asked to rate items, assessing their use of religious coping, on a Likert scale ranging from 1 (not at all) to 4 (a great deal). Example scale items include: “looked for a stronger connection with God,” and “sought help from God in letting go of my anger.” Religious coping was calculated by summing the seven items on each subscale. Higher scores indicate more frequent use of a particular type of religious coping – positive or negative. The Cronbach alphas for the positive and negative religious coping subscales were .88 and 85, respectively. This measure was administered at baseline only.

Medication adherence.

The Antiretroviral General Adherence Scale (AGAS) is a 5-item instrument designed to assess general adherence to prescribed antiretroviral regimen (Holstad, Foster, Diiorio, McCarty, & Teplinskiy, 2010). It was adapted from the Tuberculosis General Adherence Scale (TBGAS) originally designed to measure adherence to tuberculosis therapy (McDonnell, Turner, & Weaver, 2001). The AGAS measures the ease and ability of respondents to take HIV medications over the previous 30 days as recommended by their health care provider. Sample items include: “I found it easy to take my antiretroviral medications as my health care provider advised,” and “I took my medications exactly as my healthcare provider advised. Each item is rated on according to six categories ranging from 1 (none of the time) to 6 (all of the time). After recoding two negatively worded items, the items are summed for a total score with a range from 5 to 30. Higher scores indicate better adherence. The coefficient alpha for this sample was 0.85. This measure was administered at baseline and 12-month follow-up.

Depressive symptoms.

Participants’ depressive symptoms were measured using the 20-item Center for Epidemiologic Studies Depression Scale (Radloff, 1977; CES-D). They rated sample items such as “I felt that I was just as good as other people,” and “I felt that everything I did was an effort” on a Likert scale with options ranging from 0 (rarely/none of the time) to 3 (most of the time). The scale score was calculated by summing all item scores. Possible range of scores is 0 to 60, with higher scores indicating the experience of more depressive symptoms. Cronbach’s alpha for this measure in this sample was .91.

Data Analysis

All data preparation and analyses were conducted with SPSS 25. Descriptive statistics (including means, standard deviations, and percentages) were generated for the following sociodemographic characteristics: gender, sexual orientation, income, and age. In addition, descriptive statistics were obtained for psychometric scales of interest: religious coping styles (i.e., positive religious coping, negative religious coping), depressive symptoms, and medication adherence. Next, we used Pearson correlations to explore the bivariate relationships between the positive and negative religious coping at baseline, depressive symptoms at baseline, and medication adherence at baseline and 12-month follow-up. Then, regression analyses were conducted to examine the associations between religious coping and medication adherence. Specifically, we simultaneously entered positive religious coping and negative religious coping (both scores collected at baseline) to predict medication adherence at baseline and 12-month follow-up. We statistically controlled for age and depressive symptoms for analyses predicting medication adherence at baseline and 12-month follow-up. We also controlled for baseline medication adherence when predicting 12-month follow-up medication adherence. The assumptions for the statistical tests were evaluated and determined to be met.

RESULTS

Sample Characteristics

Participants had an average age of 41.4. More men (64.8%) than women (33.3%) comprised this sample and there were comparable percentages of heterosexual (53.2%) and sexual minority participants (46.8%). Most participants (72%) reported having low monthly incomes with them making $750 or less per month. Participants reported high levels of positive religious coping (M = 22.7) and moderate levels of negative religious coping (M = 10.7). They also endorsed experiencing depressive symptoms that were close to the clinical levels (M = 14.1, range 0 – 60, clinical cutoff = 16). Medication adherence scores were relatively high at baseline (M = 26.0) and at 12-month follow-up (M = 25.9).

Bivariate Associations Between Religious Coping, Depressive Symptoms, and Self-Reported Medication Adherence

Positive religious coping was significantly correlated with medication adherence at baseline (r = .17, p < .05) and 12-month follow-up (r = .28, p < .01). Negative religious coping was significantly inversely correlated with medication adherence at baseline (r = −.22, p <.05) but not at follow-up (r = −.03, p = NS). Depressive symptoms were significantly inversely correlated with medication adherence at baseline (r = −.27, p < .01) and 12-month follow-up (r = −.18, p < .05).

Predictors of Medication Adherence at Baseline and 12-month Follow-up

After controlling for age and depressive symptoms at baseline, positive religious coping (B = .14, CI = .01 – .27, p < .05) significantly predicted medication adherence at baseline. Positive religious coping (B = .26, CI = .12 – .41, p < .01) was also significantly associated with medication adherence at 12-month follow-up after accounting for age, depressive symptoms, and medication adherence at baseline. Negative religious coping (B = −.15, CI = −.29 – −.01, p < .05) was inversely associated with medication adherence at baseline after controlling for age and depressive symptoms. Negative religious coping did not significantly predict medication adherence at 12-month follow-up (B = −.04, CI = −.12 – .19, p = NS).

DISCUSSION

This paper presents findings from a quantitative investigation of the influence of religious coping on ART medication adherence among BALWH. Negative religious coping was inversely related to medication adherence (i.e., as negative religious coping increased, medication adherence decreased) in the short-term but did not have a lasting impact in that we did not find a statistically significant relationship between the constructs 12 months after initial assessment. Thus, it seems that the detrimental impact of negative religious coping on medication adherence may dissipate over time. More research is needed to clarify and support these findings.

Positive religious coping was significantly related to high levels of ART medication adherence in the short- and long-term. These findings indicate that as positive religious coping increased, so did medication adherence. Although, we did not find a significant increase from baseline to follow-up in the mean scores on the ART medication adherence measure, we did observe a consistent level of adherence that was associated with positive religious coping. Previous studies that attest to the salubrious health effects of positive religious coping across time support this finding of the present study (Gall, Guirguis-Younger, Charbonneau, & Florack, 2009; Trevino et al., 2010). These findings are promising and have several implications for future research and health interventions with BAWLH.

Positive and negative religious coping among BAWLH should be assessed systematically and integrated into research and health interventions for this population. Findings from this study support other researchers’ call to add questions about religion (Lassiter & Parsons, 2016; Trevino et al., 2010) – including its multiple dimensions such as religious coping – and spirituality into survey-based and other research with people living with HIV. Such empirical inquiry will provide helpful information about prevalence and different types of religious and spiritual experiences that are related to health outcomes for people living with HIV. More research that tests mediation and moderation pathways is needed to provide insights about the different mechanisms that may explain how religious coping and influences ART medication adherence. One such mechanism may be that positive religious coping influences ART medication adherence through increasing acceptance of having to take medication daily and recognizing the purpose of the medication as life sustaining (Mattis, 2002). Such recognition and acceptance may also help foster feelings of social support from the sacred and self-efficacy related to taking one’s medication consistently (Badanta-Romero, Diego-Cordero, & Rivilla-Garcia, 2018). Understanding these mechanisms will contribute to researchers and health providers being able to be more precise in their work with BALWH.

Interventions targeting BALWH may find it beneficial to incorporate assessment and discussion of positive and negative religious coping into their activities. Evaluating intervention participants’ levels of positive and negative religious coping may help determine which members are more likely to have higher levels of medication adherence. Those with moderate to high levels of positive religious coping and low levels of negative religious coping may need to be encouraged to continuing using such strategies to maintain their medication adherence and other healthy behaviors. Those with low positive religious coping and moderate to high negative religious coping may find it helpful to explore how their coping strategies are detrimental and practice engaging in therapeutic exercises that increase their positive religious coping and decrease their negative religious coping. These sorts of interventions will require that health interventionists understand the unique ways in which religion and spirituality manifest in Black communities, as well as how they may differentially impact the health of BALWH along the intersections of sexual orientation, gender, and other social identities and structural realities.

While our results have been interpreted with care, it should be noted that there are some relevant limitations. First, it should be noted that the sample was limited to BALWH in the Southeastern region of the United States where religion is a particularly important part of the culture compared to some other parts of the country (Taylor, Chatters, & Brown, 2014). Thus, it may be inappropriate to generalize the findings in this study to BALWH outside of the Southeast US where religion may not be a central component of everyday life. Secondly, participants from this study were recruited from a medical center where they already had access to quality health care and ART medication. Positive and negative religious coping may not have the same influence on medication adherence among people who have severe barriers to ART medication access. Finally, our assessment of medication adherence was conducted via self-report. More objective measures of medication adherence may reveal different patterns of adherence that could complicate the relationship between religious coping and ART medication adherence. However, since we used the same measure of adherence at baseline and follow-up, any bias would be the same for each, therefore the relationship would not be affected.

CONCLUSION

The findings of this study are still promising despite the limitations discussed above. This study suggests that positive and negative religious coping significantly impact ART medication adherence even when BALWH are experiencing near clinical levels of depression. In addition, it suggests that positive religious coping is related to short- and long-term ART medication among BALWH. Positive religious coping seems to help BALWH maintain their current levels of adherence to their HIV medications. Our findings also indicate that negative religious coping may have detrimental effects on ART medication adherence (i.e., as negative religious coping increases, medication adherence decreases) in the short-term but this negative impact seems to decrease over time. Researchers and HIV interventionists are encouraged to assess and discuss both positive and negative religious coping with their patients who are BALWH. Understanding how religious coping manifests and is enacted in the lives of BAWLH will help researchers and interventionist harness a culturally-relevant resource to improve the health of Black Americans and mitigate HIV health inequities.

Table 1.

Descriptive Statistics for Sociodemographic, Religious Coping, Mental Health, and Medication Adherence Variables (N = 167)

Sociodemographic Variables N (%)/M (SD)
Sexual Orientation
 Heterosexual 90 (53.9)
 Sexual Minority 77 (46.1)
Gender
 Female 61 (36.5)
 Male 106 (63.5)
Monthly Income
 $0 – $500 41 (27.3)
 $501 – $750 67 (44.7)
 $751 – $950 11 (7.3)
 $951 – $1150 12 (8.0)
 $1151 – $6000 19 (12.7)
Age 41.4 (7.3)
Religious Coping, Mental Health, and Medication Adherence Variables M (SD)
Positive Religious Coping
(Scale range = 4 – 28)		 22.7 (4.9)
Negative Religious Coping
(Scale range = 4 – 28)		 10.7 (4.6)
Depressive Symptoms at Baseline
(Scale range = 0 – 60)		 14.1 (9.6)
Medication Adherence at Baseline
(Scale range = 5 – 30)		 26.0 (4.3)
Medication Adherence at Follow-up
(Scale range = 5 – 30)		 25.9 (5.4)
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Table 2.

Bivariate Correlations among Religious Coping, Depressive Symptoms, and Medication Adherence (N = 167)

Positive RCOPE (T1) Negative RCOPE (T1) CES-D (T1) Medication Adherence (T1/T2)
Positive RCOPE (T1)
Negative RCOPE (T1)
 .08
CES-D (T1)
 −.03 .25**
Medication Adherence (T1/T2) .17*/.28** −.22*/−.03 −.27**/−.18*
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Note. RCOPE = Religious coping. CES-D = Depressive symptoms. T1 = Baseline. T2 = 12-month follow-up.

*

p < .05

**

p < .01.

Table 3.

Association Between Religious Copings and Medication Adherence (N = 167)

Medication Adherence at Baselinea Medication Adherence at 12-month FUb
B (SE) 95% CI B (SE) 95% CI
Predictor
 Positive RCOPE .14* (.07) .01 – .27 .26** (.07) .12 – .41
 Negative RCOPE −.15* (.07) −.29 – −.01 −.04 (.08) −.12 – .19
R2 .11 .19
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Note.

a

= Controlled for age and depressive symptoms.

b

= Controlled for age, depressive symptoms, and medication adherence at baseline.

*

p < .05

**

p < .01.

Acknowledgements

This work was supported by the National Institute of Child Health and Human Development under Grant R25HD045810 and the National Center for Advancing Translational Sciences under Grant 5KL2TR001077-05.

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