Análisis de los logros obtenidos en la prueba ENLACE 2012

Adherence to treatment can be conceptualized within the context of health belief and explained by health behaviour theories. Theories about health behaviour provide the necessary framework for understanding patient adherence to recommendations regarding health and also provide the guiding principles for developing effective interventions to influence target behaviour of interest. In a study conducted by Schuz, et al. (2011)about changes in functional health and how this is related to medication beliefs and adherence, found out that changes in beliefs about illness appear to affect individual adherence. They suggested targeting such beliefs for intervention design in order to provide appropriate interpretation of changes in health subjects are passing through for improved medication adherence in specific illness.

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Similarly, in another study to establish the role of beliefs in medication adherence, Van Steenis, Driesenaar, Bensing, Van Hulten, Souverein, Van Dijk, et al. (2014) investigated the relationship between beliefs related to necessities of medication in asthma and concerns about the medication, showed that it would be more important to focus on necessities than on concerns in an attempt to improve adherence.This position was confirmed in the study of Rajpura and Nayak (2014) who suggested based on their findings, that a more benign perception of illness translates to lower medication adherence whereas, positive beliefs about medication and threatening beliefs about illness are crucial in shaping adherence behaviour in elderly hypertensive individuals.

Emerging from these studies, they recommended that intervention programmes aimed at strengthening medication adherence in the elderly hypertension patients should incorporate designs that address perception and beliefs about illness and the value offered bymedication in the treatment of hypertension. Furthermore, patients‟ beliefs about hypertension and its treatment, low health literacy, poor medication adherence among other factors have also been confirmed as important patient-related barriers to the control of blood pressure (Ogedegbe, 2008).

A number of health behaviour theories have accommodatedmany factors that influence decision-making into their constructs to explain how these behavioural antecedents are linked to decision-making and behavioural outcomes. Examples of such theories include the health belief model (Rosenstock, 1974), theory of reasoned action/planned behaviour (Fishbein and Ajzen, 1975), social cognitive theory (Bandura, 1977; Bandura, 2004)and the Predisposing, Reinforcing, Enabling Constructs in Educational/Environmental Diagnosis and Evaluation (PRECEDE) meta-model of Green and Kreuter, (2005) which provide an ecological perspective that contextualize all behaviour theories within its construct in a programme planning framework for intervention. The strongest evidence for the validity of these theories lies in hundreds of studies that have applied these theories to produce results consistent with their tenets.

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Health Belief Model (HBM) has been widely applied in studies to explain preventive health behaviour by examining the extent to which an individual perceives a problem as having serious consequences and a high probability of occurrence. The behaviour exhibited is determined by whether the individual (a) believes that he/she is susceptible to a particular health problem, (b) regards this problem as serious, (c) is convinced that treatment or prevention activities are effective and (d) at the same time inexpensive, and (e) receives a cue to take health promoting action. In other words, health behaviour decisions are made through computational analysis of susceptibility to disease, disease severity, cost/benefit of treatment as defined by HBM construct.

It should be borne in mind that acceptance of personal susceptibility to a condition varies from person to person, so also is the individual‟s perception of the seriousness vary. This perception must be viewed in the context of the knowledge of the condition that the individual has and how significantly his educational attainment, culturally set values and beliefs impinge on this knowledge. These modifying factors also awaken or subdue threat of the likelihood of serious consequences as a result of inactivity. Furthermore, the modifying factors enable the individual to evaluate the outcome expected in the perspective of any constraint; where the benefit clearly outweighs the constraint, the individual is motivated to take the action recommended. Finally, the individual must also be able to recognize certain important cues as reminders that prompt him or her to take necessary action to reduce the threat that is present. However, if the individual did not believe himself or herself particularly susceptible, a very strong cue to action would be required to motivate behaviour.

Conversely, a high level of perceived personal susceptibility and seriousness would require only minor stimuli to trigger the recommended behaviour.

HBM research has been used to explore a variety of health behaviours in diverse populations.

Researchers have applied the model to studies that attempt to explain and predict a variety of health behaviour response (Janz and Becker, 1984). With the advent of HIV and AIDS, the model has been used to gain a better understanding of sexual risk behaviours (Rosenstock, Strecher, & Becker, 1994; Montgomery, Joseph, and Becker, 1989) and condom-use behaviour (Hingson, Strunin, Berlin, and Herren, 1990; Ford and Norris, 1995). Its application in AIDS risk reduction research among intravenous Drug Users (IDUs) has shown

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that HBM variables are conceptually linked to how people who exhibit high-risk behaviours perceived HIV/AIDS disease (Hingson,Strunin, Berlin, and Herren, 1990; McCusker, Stoddard, Zapka, et al., 1992).

Furthermore, several studies have suggested the predictive validity of the model in predicting compliance to condom use (Ford & Norris, 1995) and HIV needle risk-practices among IDU.Therefore, any intervention guided by HBM construct, have to address health literacy and beliefs through cognitive process. HBM may be applied in conceptualizing health literacy and health belief in hypertension treatment within its constructs. Perceived threat in HBM is influenced by a variety of modifying factors and is determined by knowledge of the nature of the disease and prevention protocol, beliefs and attitudinal dispositions of the individual toward the disease and prevention. Further, the levels of the individual‟s perception of susceptibility and its seriousness and their inter-relationship with the modifying factors is influenced by recognition of appropriate cues such as symptoms or reminders.

Social cognitive theory (SCT) elaborated by Bandura, (2004) explains the triad relationship between the environment, the individual who is engaging in a particular behaviour, and the behaviour displayed. The outcome of such behaviour change is mediated through cognitive processes which involve thinking, reasoning, perceiving and believing, and that cognition about behaviour is altered most easily through actual performance or observed performance of the behaviour of interest. In other words, people change and maintain their behaviour depending on their expectations about the outcomes that will result from engaging in the behaviour change and expectations about the individual‟s ability to engage in or execute the behaviour. The SCT defines modifying factors of self-efficacy which expresses beliefs regarding one‟s ability to successfully carry out a course of action or perform a behaviour which is linked with actually having the skills necessary for performance of the desired behaviour; and outcome expectancy which reflects the beliefs that performance of such behaviour will have desired effects or consequences. This is an important factor shaping behaviour.

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Bandura argues that perceived self-efficacy influences all aspects of behaviour including acquisition of new behaviour and inhibition of existing behaviour. This was further confirmed by Strecher, Devellis, Becker, and Rosenstock (1986) in an attempt to evaluate the role of self-efficacy in achieving health behaviour change, observed that when certain skills have been acquired through personal experiences, observational learning and verbal persuasions (cognitive processes), and are successfully performed, this further enhances self-efficacy.

They concluded by ascribing a consistently positive relationship between self-efficacy and health behaviour change and maintenance (Strecher, et al., 1986). It is important to recognize the role of psycho-behavioural cognitive processes in health behaviour change.

2.5.3 The role of human behaviour in the ecology of health and disease and global disease