improving adherence and quality of care and prevention through mobile technology and patient...
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Improving adherence and quality of care and prevention through mobile technology and patient
education.
IAS Workshop Rome 2011
Linda-Gail Bekker
The Desmond Tutu HIV Centre
UCT
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Todays workshop…..
• The Importance of ART Adherence in HIV Treatment and Prevention
• Adherence Interventions - What the Science Tells Us
• Panel Discussion • Presentation of An Adherence Counseling
Program (Life Steps) • Key Components of Adherence Programming• Panel Discussion
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Panel
• Conall O’Cleirigh, PhD• Kenneth Mayer, MD• Francois Venter, MD• Ian Sanne, MD• Daniella Mark, PhD• Linda-Gail Bekker, MD,PhD.
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Optimal outcome
High quality care RECEIVED
High quality care delivered
Delivering high quality care is a necessary, but not sufficient, factor in achieving optimal outcomes
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Adherence
• To Prevention• To Testing• To Care• To Treatment• To Programs
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Why would poor adherence be a problem?
• Poor outcomes on the individual level– Treatment failure
• Resistance and fewer treatment options• Viral rebound• Illness• Death
• Poor outcomes in prevention effectiveness• Risk inhibition• Condom migration• Increased susceptibility
• Poor outcomes on the population level– Resistant virus emergence and fewer treatment options– Increased transmission– Higher morbidity and mortality burdens
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The Challenge of Adherence
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MEMS Adherence and Incomplete Viral Suppression
Paterson DL et al. Ann Intern Med. 2000:133:21
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Adherence to therapy is a strong predictor of viral load suppression, immune recovery, lack of disease progression, and reduction in mortality.
Poor adherence can cost lives…
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Mellors JW, Munoz A, Giorgi JV, et al. Ann Intern Med. 1997;126:946-954.
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Near perfect adherence is required to maintain low viral load…..
• Clinical trials 80-90% remain undetectable at one year• Only 50 % undetectable in clinical practice (Deeks et al
Toronto 1997).
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Adherence, Viral Load, and Resistance
Pill count percent adherence
Bangsberg D, et al. AIDS. 2000:14:357
Log
10 H
IV R
NA
cop
y nu
mbe
rs7
0
1
2
3
4
5
6
0 10 20 30 40 50 60 70 80 90 100
Resistant*
Sensitive
*Primary Drug Resistant Mutation IAS-USA
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10% Adherence difference = 21% reduction in risk of AIDSAdherence and AIDS-Free Survival
Bangsberg D, et al. AIDS. 2001:15:1181
Prop
orti
on A
IDS-
Free
Months from entry
P = .0012
0 5 10 15 20 25 30
0.00
0.25
0.50
0.75
1.00
AdherenceO 90–100%O 50–89%O 0–49%
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Summary of Mean Adherence Using Objective Measures
Bangsberg AIDS 2000 67% MEMS
73% Unannounced pill count
Paterson Annals Int Med 2000 74% MEMS
Liu Annals Int Med 2001 63% MEMS
83% Clinic pill count
McNabb CID 2001 53% MEMS (drug exposure)
Arnsten CID 200180%53%
Clinic pill countMEMS
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“[some] claim that a lack of compliance is the only reason for a treatment-naïve patient to fail therapy within the first 6 months”
[Don Smith 2000]
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Will “widespread, unregulated access to antiretroviral drugs in sub-Saharan Africa, [in the absence of directly observed therapy] lead to the rapid emergence of drug resistant viral strains, spelling doom for the individual, curtailing future treatment options, and
[leading] to transmission of resistant virus?”
Harries AD, Nyangulu DS, Hargreaves NJ, Kaluwa O, Salaniponi FM. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001; 358:410-4.
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“Ask Africans to take their drugs at a certain time of day, and they do not know what you are talking about” [Natsios, USAIDS,2001].
“One of the barriers in the expansion of ARV programmes is the widely held prejudicial view that, due to poverty and lack of education, individuals in Africa may be less likely to maintain adherence to antiretroviral therapy than their HIV-positive counterparts in the developed world.” Orrell et al, Barcelona 2002
There is an expectation that patients in Africa will be poorly adherent to antiretroviral therapy:
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The Back Story: 1990s - early 2000“Adherence seen as potential barrier to ART in RLS”
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Directly Observed vs Self Administered Therapy During Incarceration: Proportion with < 50 Copies/ml
Fischl et al 8th CROI, 2001 abstract 528
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HIV DOT in Haiti
• 60 patients with late stage clinical disease– Enteropathy with severe weight loss– CNS dysfunction or severe neuropathy– Repeated opportunistic infections unresponsive to
antimicrobials
• Excellent clinical response• Toxicity uncommon• Promoted as a model for resource poor settings
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TuberculosisWitnessed Therapy vs Self Administered Therapy
• South Africa Zwarenstein Lancet 1998; 352:1340-3.
– No difference
• Thailand Kamolratanakul Trans R Soc Trop Med Hyg 1999; 93:552-7.
– Rural areas: DOTS better than SAT– Urban areas: no difference
• Pakistan Walley Lancet 2001; 357:664-9.– Clinic DOTS, family DOTS, SAT: no difference
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AIDS 2003
• Self report mean Adherence = 90%• UDVL = 71%
Compared to Avg US Adherence~70-80%
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Somerset Hospital data, Cape Town (Orrell et al):
• Adherence assessed by counting tablet returns.– Increasing adherence significantly associated with reduction in VL.
C o rre la tio n : r = -.2 8 5 5 , p < 0 .0 0 0 1
0 .2 0 .4 0 .6 0 .8 1 .0 1 .2 1 .4
A d h e re n c e a t w e e k 4 8 (G e n e ra l c o h o rt)
-5
-4
-3
-2
-1
0
1
2
3
VL
cha
ng
e (L
og
10
cop
ies/m
L)
9 5 % c o n fid e n c e
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Somerset Hospital data, Cape Town (Orrell et al):
Discontinuations
• 16.2% discontinued therapy over 48 wks -were younger, had higher viral loads, lower CD4 counts.
• Socioeconomic status, gender, home language, WHO stage not associated with discontinuation
• only 4% dropouts were due to adverse events
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Somerset Hospital data, Cape Town (Orrell et al)
Factors predicting poor adherence: • Three times a day dosing• Younger age• Not speaking English (language of site staff)
Factors NOT predicting adherence:• Socio-economic status• Gender• Symptomatic HIV disease/baseline viral load
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Somerset Hospital data, Cape Town (Orrell et al)
Factors predicting virological failure:
• Adherence <95%• Complex dosing (food, 3 times a day)• Dual nucleoside regimens• High baseline viral load / low baseline CD4
South Africa Clinical Trials: 63% VL<400 Sanne I, Ive P, Mcintyre J 1st IAS Conference on HIV Pathogenesis and
Treatment, Buenos Aires, 2001 #321
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Good adherence in 87.9% accessing ART through a government treatment programme.
[AIDS 2002, 16: 1361]
Data from Senegal:
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The Response
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2. Resistance patterns are different with similar adherence to different regimens
• NNRTI Resistance develops quickly and
nearly linearly
• Boosted PIResistance develops more slowly
and in a bell shaped curve
Bangsberg NY PRN 2009
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Adherence and virological outcome –PIs
0
10
20
30
40
50
60
70
80
%V
L b
elo
w d
etec
tio
n
<70 70-80 80-90 90-95 95-100
%adherence
Ann Intern Med 2000;133:21
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Relationship between resistance & adherence -NNRTIs
05
1015202530354045
Rat
e pe
r 10
0 pe
rson
yea
rs
100 90-99 80-89 70-79 60-69 <60
% adherence
Clinical Infectious Diseases 2003; 37:1112–8
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Adherence declines over time
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Most recent meta-analysisReview of Adherence at 2 years
Rosen et al. PLoS 2007– 32 studies in SSA 1996-2007– ~75,000 patients in non-research ART
programs– Average follow-up time reported 9.9 mo, 77% retention– 6 mo = 80% pts retained– 12 mo = 60% pts retained
– At 2 Years*:• BEST CASE = 84% • WORST CASE = 46%• AVERAGE = 61%
61% at 24 months
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Virological failure vs. single breakthrough?Kaplan-Meier failure estimate for time to first, then second consecutive HIV RNA level > 1000 copies/ml.
929 641 421 328 229 162 127 86 51
0.00
0.05
0.10
0.15
0.20
0.25
Patients at Risk of starting Second Line therapy
0.00
0.05
0.10
0.15
0.20
0.25
0 4 8 12 16 20 24 28 32 360 4 8 12 16 20 24 28 32 36
Duration on Treatment (months)
Prop
ortio
n of
pati
ents
on
prog
ram
First HIV RNA > 1000 copies/ml
First and second consecutive HIV RNA > 1000 copies/ml
75%
Antiviral Therapy 2007; 12: 83-88
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Nonadherence Predicts Early Treatment Discontinuation
Initial 30 Day Adherence Discontinue w/in 6 Months
<50% (40/52) 77%
50-80% (4/43) 9%
81-90% (0/24) 0%
>90% (0/33) 0%
Total (44/152) 29%
REACH unpublished data
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Retention in care• Adherence is more than just beginning therapy,
it is sticking to it. LTFU rates are high…
Proportion remaining in care (Kaplan-Meier)
Complete Censored
no breakthrough re-suppressed failed
0 1 2 3 4 5 6 7 8 9
Time (years)
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cu
mu
lative
pro
po
rtio
n r
em
ain
ing
in
ca
re
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Resistance at fist-line failureSusceptible Possible
low level resistance
Low level resistance
Intermediate resistance
High resistance
Lamivudine / emtricitabine
22 (20%) - - 4 (4.0%) 86 (78%)
Abacavir 20 (18%) 55 (50%) 15 (14%) 20 (18%) -
Zidovudine 98 (89%) 1 (1.0%) 6 (5.5%) 3 (2.7%) 2 (1.8%)
Stavudine 87 (79%) 6 (5.5%) 12 (11%) 5 (4.5%) -
Didanosine 76 (69%) 9 (8.1%) 9 (8.1%) 14 (13%) 2 (1.8%)
Tenofovir 97 (88%) 1 (1.0%) 4 (3.6%) 8 (7.3%) -
Efavirenz 10 (9.0%) 2 (1.8%) - 13 (12%) 85 (77%)
Nevirapine 10 (9.0%) 2 (1.8%) 1 (1.0%) 4 (4.0%) 93 (85%)
Etravirine 10 (9.0%) 15 (14%) 49 (45%) 32 (29%) 4 (4.0%)
Protease Inhibitors
93 (84%) 16 (15%) 1 (1.0%) -
Orrell, Antiviral Therapy , 2009
Of 110 people, most had dual class resistance. Only 7% wild-type.
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Results from Gugulethu
Susceptible Possible low level resistance
Low level resistance
Intermediate resistance
High resistance
Lamivudine / emtricitabine
43 (98%) - - - 1 (2%)
Abacavir 41 (93%) 2 (5%) - - 1 (2%)
Zidovudine 42 (95%) - 2 (5%) - -
Stavudine 42 (95%) 1 (2%) 1 (2%) - -
Didanosine 41 (93%) 1 (2%) 1 (2%) - 1 (2%)
Tenofovir 44 (100%) - - - -
Efavirenz 29 (66%) - - 3 (7%) 12 (27%)
Nevirapine 29 (66%) - 1 (2%) - 14 (32%)
Protease Inhibitors
38 (86%) 6 (14%)* - - -
* T74S
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Probability of virologic failure stratified by the interval of time between 1st-lineART failure and 2nd-line ART initiation.
Levison, AIDS 2011, in press
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So we know adherence is key…..
• How do we then ensure it ?– At initiation– In a sustainable way
• How do we measure it– In the treatment setting– In the prevention setting
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Objective vs. Subjective Adherence Measurement Tools
Subjective Measures• Patient interview
– Pill recognition– 3, 4, 7, 30 day patient report– Visual-analog scale– Rating scale– Computer assisted self
interview (CASI)
Objective Measures• Electronic monitoring• Announced pill count
-- Clinic/Private Practice• Unannounced pill count– Home or usual place of residence– Telephone a la Kalichman• Pharmacy refill• Drug/biomarker levels– Plasma– Hair– Breath
In the absence of viral loads – use adherence measures as a marker.
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Monitoring adherence
• Physician assessment - poor (no better than random!)
• Questionnaires - specific, insensitive (only last 3 days)
• Pill counts - good (overestimate in general; pill dumpers)
• Pharmacy records – fair (monthly medicine collection)
• Drug levels - single time points only
• Electronic monitoring – better but expensive!
… use a combination
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Physicians Predict Adherence Not Much Better Than Random
Bangsberg 2001 JAIDS HAARTPaterson 2000 Annals Int Med HAARTHaubrich 1999 AIDS HAARTSteiner 1995 Arch Int Med AZTBosely 1995 Eur Resp J Inhaled terbutalineCharney 1967 Pediatrics PenicillinCaron 1978 Clin Pharmacol AnatacidsGilbert 1980 Can Med Assoc J DigoxinBlowey 1997 Ped Nephrology CyclosporinMushlin 1977 Arch Int Med Hypertensive
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Wisebag, Wisecase
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REACH Adherence Measures
• 3-day patient report
• MEMS electronic cap
• Unannounced pill count – home or usual place of
residence
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Other ways to monitor Drug levels
• Plasma• Other body fluids• PBMC• breath• Hair
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Approaches to managing adherence
• Treatment readiness vs. adherence – data show that “readiness” is a distinct factor that influences adherence - Study in 828 people from Sweden (SÖdergard, Patient Educ Couns 2007)
focus on individuals readiness for change, examine factors than CAN change and be changed by the individuals.
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• Psycho-social interventions: establishing provider-patient relationships. Adherence a process of negotiating a tailored plan – “flexible rigidity” (Reir, Soc Work Health Care 2006)
• Treating depression improves adherence (Yun, JAIDS 2005)
Approaches to managing adherence
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Approaches to managing adherence
• Different population in developed world – more marginalised, homeless, drug users.
• Predictors of discontinuing therapy = injection drug use and early poor adherence. (Moss, CID 2004)
WATCH adherence at week 4 and 8. Viral loads highest at the beginning, so adherence then is especially key.
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• Non-nucleoside regimens are more forgiving: may suppress viral load with adherence >55%! NNRTI have much improved outcomes compared to PIs at 55-75% adherence range.
• PI: only likely to have suppressed VL with adherence >95%(Bangsberg , CID 2006)
Remember reduced disease progression and mortality improves with every increase in adherence level … do not drop standards!!!
Approaches to managing adherence
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Technologies use in managing adherence
• Pillboxes: simple and effective intervention and should be widely used – improves adherence by ~4.5% (drop VL 0.35 log)Best for intermittent non-adherence (80-90%). Not enough of a reinforcement for those with very poor adherence. Pill box of more benefit than changing to once a day therapy. (Petersen, CID 2007)
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Technologies use in managing adherence
Examples of MEMscaps output
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Treatment Regimen
A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people
• Bangsberg, David Ra; Ragland, Kathleenb; Monk, Alexb; Deeks, Steven Gb
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Treatment Readiness Program empowers patient to be adherent….
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Pre-treatmentCounsellor assigned to each patient. Education-group & individual treatment readiness. Home visit. Disclosure support
On-treatmentIndividual supportGroup sessionsCrisis managementAdherence monitoringRed Alert
Sizophila Treatment Support
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Surprise pill counts
• The counsellor visits his client at home and checks pill counts, entering data into his cell phone and transferring info directly to clinic database.
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Prevention: where to adherence??
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"We are really groping in the dark" Salim S. Abdool KarimQuoted in the Washington Post, November 1, 2007
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64
• BAT 24 coitally-related gel use– Insert 1 gel up to 12 hours Before sex, – insert 1 gel as soon as possible within 12
hours After sex, – no more than Two doses in 24 hours
HIVNET 012 nevirapine regimen CAPRISA 004 tenofovir gel regimenasap
asap72 hrs12 hrs
Onset of labour
Delivery
CAPRISA 004 assessed the safety and effectiveness of 1% tenofovir gel
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HIV infection rates in the tenofovir and placebo gel groups: Kaplan-Meier survival probability
Pro
ba
bil
ity
of
HIV
in
fec
tio
n
0.0 0.5 1.0 1.5 2.0 2.5
Years
Months of follow-up 6 12 18 24 30
Cumulative HIV endpoints 37 65 88 97 98
Cumulative women-years 432 833 1143 1305 1341
HIV incidence rates(Tenofovir vs Placebo)
6.0 vs 11.2 5.2 vs 10.5 5.3 vs 10.2 5.6 vs 9.4 5.6 vs 9.1
Effectiveness (p-value)
47%
(0.069)
50%
(0.007)
47%
(0.004)40%
(0.013)39%
(0.019)
p=0.019
Tenofovir
Placebo
0.20
0.18
0.16
0.14
0.12
0.10
0.08
0.06
0.04
0.02
0.00
p=0.017
(0.017)
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• High Risk MSM• Randomized 1:1 Daily Oral PREP• FTC/TDF vs Placebo• Followed on Drug for:
- HIV seroconversion- Adverse Events (especially renal &
liver)- Metabolic Effects (Bone, Fat, Lipids)- HBV Flares among HBsAg+- Risk Behavior & STIs- Adherence- If infected
‣Drug Resistance‣Viral load‣Immune responses & CD4 Count
The iPrEx Study
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FTCTDFHIV-
HIV+
Placebo
34 Samples26 PBMC0 Plasma0 Both
35Samples
1 unavailable specimen
33Samples
2 unavailable specimens1 control used for 2 cases
26Samples
Stopped testingafter 26
34 Samples34 PBMC33 Plasma33 Both
1 case > 7 days afterseroconvertion
31 Samples30 PBMC24 Plasma23 Both
2 cases off drug
Sampling for Case Control Study
FTC/TDFCases/ControlsN=36
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Drug Levels
17/35 Detectable
TFV-
DF
(fm
ol/1
06 cel
ls)
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Caprisa 004 and Iprex
• Motivational client centered counselling• Next step counselling
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ConclusionsCaution is warranted against placing too
much confidence in indicators suggesting high adherence
More confidence can be placed in estimated lower level of adherence.
Validation work with measures matched on time frame and over time for patterns of adherence are needed
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Self-report is criticalIt provides information that cannot be assessed with
alternative direct measures- challenges, facilitators, intermittent patterns of use
It is essential in open communication between prescribers of PrEP and those using it
How can we improve self-report?Address social desirability bias and minimize
memory/recall demandsCreate normative expectations for frank discussions
over high compliance
Conclusions