La teoría de expertos y novatos en la resolución de problemas

A number of research questions were raised in this study among which was to find out the extent to which the two interventions will affect predisposing, reinforcing and enabling factors involved in hypertension treatment among the participants. At immediate-post intervention, the impact of the intervention was measured for personal-level predisposing factors and environmental-level reinforcing and enabling factors involved in medication adherence and appointment-keeping. Interestingly, all variables were influenced.Comparing measures derived for control and the two intervention groups respectively for these variables, showed significant differences between the groups for all the variables. (See Table 4.7) The impact of the intervention for the two experimental groups as measured by the effect size (ES) as defined by Cohen‟s d, for all the variables in predisposing factors showed large effect size that was significant at 95% confidence.(See Tables 4.10 and 4.11) However, changes for control group compared with baseline values recorded only a small effect size for each variable that was not significant.(See Table 4.9)

Educational approaches appear to be most effective in influencing predisposing factors improving the patients‟ understanding of the nature of the disease, consequences of poor medication regularity, and the over all attitudinal dispositions for engaging hypertension treatment.The results in this study are consistent with findings of other investigators who have demonstrated the relevance of personal-level factors such as health literacy, knowledge, perceptions, beliefs about illnesses and their treatment on medication adherence (Olubodun, et al., 1990; Nutbeam, 2000; Erhun, et al., 2005; Schuz, et al., 2011; Omeje and Nebo, 2011;

Adeyemo, et al., 2013; Van Steenis, et al., 2014; Rajpura and Nayak, 2014).

Reflecting on the programme during the KIIs 12 months after follow-up, some of the participants stated that all they needed was someone to explain clearly the far-reaching implications of their conditions and show them how taking the prescribed drugs will help

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control their blood pressure. The responses from these participants are a demonstration of the value of a structured health education and counseling on outcome of hypertension treatment;

“…able to understand how the medicines can control blood pressure and what can happen to a person who is not taking the medicines regularly. I think the programme was useful”. (Patient-Female, I2HF)

“…now I clearly understand why I should not joke with my medications”. “I understand better the nature of my condition and how it may become better or worse.

I do not have to die of heart problem or stroke”. “Everything about the treatment I am taking is reasonable”. I now understand that appointment with the clinic is important to monitor the progress of treatment”. (Patient-Female, I2HF)

The study also explored how reinforcing and enabling factors involved in hypertension treatment may be influenced by the intervention. Immediate post intervention evaluation of level of reinforcing factors showed that experimental one and experimental two groups were significantly impacted by the intervention unlike control that reported very small change from baseline. (See Table 4.12) Similarly, enabling factors reported by participants in the control, experimental one group and experimental two groups, measured at post immediate intervention and compared with baseline to derive the impact of the intervention showed that the effect size for control was small and was not significant, compared with the effect size computed for intervention one group and intervention two groups respectively.

Furthermore, comparing the impact of the intervention on both experimental groups showed that experimental two group results was better for reinforcing factors with larger effect size of 4.76(CI95%: 4.04 to 5.48) than experimental group one with 1.88(CI95%: 1.44 to 2.33).

(See Table 4.12) This is expected because intervention two incorporated social support as offered by a family member. Combining educational strategy with social support provided the reinforcements offered by the behavioural techniques as predicted by the conceptual framework. As can be seen from the results at immediate-post intervention for experimental two group, which incorporated reinforcements as reminders offered by a family member,

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encouragements and other support needed to drive adherence, the findings showed that reinforcement was more prominent in this group than in experimental one group or control.

Reflecting on the overall impact of the programme on Key Informants‟ perspective reported that the programme enabled them to understand the value of regular medication in the treatment of hypertension and helped them to resolve to adhere to their treatment regimens:

“…able to understand how the medicines can control blood pressure and what can happen to a person who is not taking the medicines regularly. I think the programme was useful”. (Patient-Female, I2HF)

“…now I clearly understand why I should not joke with my medications”. “I understand better the nature of my condition and how it may become better or worse.

I do not have to die of heart problem or stroke”. “Everything about the treatment I am taking is reasonable”. I now understand that appointment with the clinic is important to monitor the progress of treatment”. (Patient-Female, I2HF)

Some of the patients interviewed experienced some difficulties in purchasing their medications as these were out of stock and also expensive but since they had been counselled not to stop their medication it became a challenge they had to overcome:

“…my biggest challenge sometimes medications are not available in the pharmacy and I have to go to chemist shops to buy them…” (Patient-Male, I₁HF)

“...the drugs are expensive and sometimes not available in the chemist shops, but I have been able to locate pharmacy shop where they have my medicines…”(Patient-Female, I₂HF)

Some complained of adverse drug reactions during the follow-up period, but had their medications adjusted to enable them maintain adherence.

“…except coughing with a particular drug RAMIPRIL which has been changed or in some the dosage reduced…” (Clinic Nurse,I1HF)

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