Un modelo psicológico en los comportamientos de adhesión teraéutica en personas con VIH

• Autores: Juan José Sánchez Sosa, Oscar Cázares Robles, Julio Alfonso Piña López
• Localización: Salud mental, ISSN 0185-3325, Vol. 32, Nº. 5, 2009, págs. 389-398
• Idioma: español
• Títulos paralelos:
  • A psychological model for therapeutic adherence behaviors in persons with HIV
• Enlaces
  • Texto completo (pdf)
• Dialnet Métricas: 3 Citas
• Resumen
  • español

    Introducción La infección por VIH es un padecimiento que demanda la práctica consistente y eficiente de los comportamientos de adhesión al tratamiento antirretroviral en sí y a otras actividades de apoyo al mismo. Sin embargo, en años recientes se ha identificado una diversidad de variables psicológicas y sociales (i.e., depresión, estrés, bajos niveles de motivación y carencia de apoyo social, principalmente) que dificultan la práctica de esos comportamientos, favoreciendo así el progreso clínico de la enfermedad y una reducción en la calidad y tiempo de sobrevida en las personas con VIH.

    En el subcampo de conocimiento conocido como psicología y salud existen diversos modelos teóricos con los que se ha buscado dar cuenta de cómo es que esas variables influyen sobre los comportamientos de adhesión; destacan, principalmente, el autorregulatorio, el de creencias en salud y el de información–motivación–habilidades conductuales. En general, se trata de modelos que, o bien privilegian el análisis de lo psicológico a partir de conceptos de naturaleza cognoscitiva, o bien carecen de análisis de fenómenos como los de estrés y personalidad, así como de los comportamientos asociados a la enfermedad.

    El presente estudio se realizó con base en un modelo psicológico para la investigación de los comportamientos de adhesión terapéutica; se trata de un modelo interactivo y funcional en el sentido de consignar la interacción de un conjunto de variables psicológicas y biológicas a lo largo de cuatro fases comportamentales en el proceso del desarrollo de padecimientos crónicos. En la primera se incluyen variables psicológicas de procesos y resultados; en la segunda el diagnóstico de la infección por VIH y el posterior desarrollo de otras enfermedades oportunistas; la tercera, psicológica, contempla la práctica de dos tipos de comportamientos, los de adhesión terapéutica y los asociados a la enfermedad; finalmente, en la cuarta se contemplan los indicadores biológicos convencionales y los resultados de salud.

    Materiales y método Se condujo un estudio transversal que tuvo como objetivo identificar predictores de los comportamientos de adhesión al tratamiento antirretroviral en 68 personas con VIH. Los participantes respondieron a dos instrumentos: i) factores psicológicos y comportamientos de adhesión, y ii) situaciones vinculadas con estrés. Para el análisis de los datos se utilizaron estadísticas univariadas, la x2 de Pearson, la prueba T para muestras independientes y un análisis de regresión lineal múltiple.

    Resultados Del total de participantes, 58 (85.3%) respondieron que se habían administrado sus medicamentos todos los días de la última semana y los restantes 10 (14.7%) lo habían hecho con inconsistencia, diferencia que resultó significativa (x2 [1] =33.882; p<0.001). La prueba T para muestras independientes arrojó una sola diferencia significativa entre las personas con VIH adherentes y no–adherentes en la variable motivos ( t [66] = –27.954; p<0.001); finalmente, el análisis de regresión lineal múltiple aportó como predictores de los comportamientos de adhesión a las variables motivos (β = 0.802; p<0.001) y bajos niveles de estrés vinculados con toma de decisiones ( β = –0.268; p<0.01) y con tolerancia a la frustración (β = –0.280; p<0.01), con un coeficiente de determinación [R2 ajustado] = 0.629, es decir, que las tres variables explican 62.9% de la varianza total.

    Discusión Los resultados muestran que las personas con VIH 100% adherentes son aquellas que se encuentran claramente motivadas y que en general experimentan bajos niveles de estrés relacionados con la toma de decisiones y tolerancia a la frustración. Estos hallazgos sugieren que en el diseño e instrumentación de programas de intervención orientados a mejorar la adhesión de estos pacientes es indispensable incorporar módulos o componentes basados directamente en dichos factores, poniendo especial énfasis en programas interdisciplinarios

  • English

    Introduction HIV infection is a disease that demands a consistent and efficient practice of adherence behaviors related to antiretroviral treatment. However, research findings in the last few years have shown that psychological and social variables (e.g., depression, stress, low motivation, as well as little or no social support) interfere with the practice of those behaviors. This facilitates the clinical progression of the disease, and reduces the quality of life and survival time in people living with HIV.

    The intersection area between psychology and health involves widely diverse theoretical models, including self–regulation, health beliefs, and the one linking information–motivation–behavior. Such models have sought to account for the way in which the addressed variables affect adherence behavior. While analyzing psychological factors, these models usually emphasize either cognitive concepts or adopt a more traditional stance such as relating adherence behavior to personality, motivation, behavioral skills and stress management. Although this diversity seems inclusive, it fails to integrate explanations on therapeutic adherence under a more comprehensive theoretical umbrella. Thus, the present study was conducted within the scope of an interactive–functional model which attempts to articulate the interaction of sets of biological and psychological variables along four phases. The first involves psychological processes and results variables; the second comprises the diagnostic of HIV infection and later development of other opportunistic diseases; the third contains two types of behavior: therapeutic adherence and disease–related behaviors; the fourth involves conventional biological indicators and health outcomes.

    This model contrasts with others not only in the sense of proposing an inter–behavioral approach derived from Kantor's work, including articulated behavioral and personality theories, but it also proposes an interactive and functional emphasis on analyzing those variables assumed to determine therapeutic adherence behaviors. Such variables subsume personality phenomena, behavioral competencies and motives to behave. Thus, the approach includes those consistent ways in which HIV–positive persons interact with stress–related situations which contain unpredictable, ambiguous or uncertain stimulus signals and behavior consequences. The behavioral competencies category synthesizes what the patient knows on HIV, including those self–care actions that need to be taken efficiently. For instance, what is HIV–AIDS, what are the clinical stages of the infection, what medications help, how should they be used and, above all, why is so important to take medications in a consistent and efficient manner on the basis of the indications of the healthcare personnel. On the other hand, motives or motivation refer, in the traditional conception, to variables related to willing to act. It is said that a person is motivated to engage in therapeutic adherence behaviors when he/she is willing to behave accordingly, after having understood the relation between such behavior and some specific consequences. Such consequences may vary widely, ranging from interpersonal in nature, such as verbal praise or support from others, and intrinsic, such as self–perceived physical and psychological well–being.

    Materials and method A cross–sectional study was carried out in order to identify predictors of adherence behaviors related to antiretroviral treatment in a group of 68 persons living with HIV. Participants answered two self–administered questionnaires: i) psychological factors and adherence behaviors, and ii) stress–related situations in three modalities: decision–making, tolerance to ambiguity, and tolerance to frustration. Data analysis included univariate statistics, the Pearson's x2 test, the T–test for independent samples, as well as a linear multiple regression analysis.

    Results Of the total of participants, 58 (85.3%) reported that they self–administered their antiretroviral medication everyday of the last week, and 10 (14.7%) did it with some inconsistence. Differences were significant (x2 [1] =33.882; p<0.001); the T–test showed a significant difference among adherents and non–adherents in the motivation variable (t [66] = –27.954; p<0.001). Finally, the linear multiple regression analysis contributed as predictor of the adherence behaviors at variables like motivation (β =O.8O2; p<0.001), as well as low stress–related situations in the modalities of decision–making ( β = –0.268; p<0.01) and tolerance to frustration ( β = –0.280; p<0.01), with the adjusted determination coefficient [adjusted R2] = 0.629, thus explaining 62.9% of the total variance.

    Discussion The results of this study show that persons with HIV who are 100% adherent to antiretroviral medication are those who are clearly more motivated and are experiencing less stress–related to decision–making, as well as higher levels of tolerance to frustration.

    These findings suggest that interventions aimed at improving the treatment of HIV–positive patients should expressly include components related to these factors. It seems especially relevant to consider two additional aspects: first, once psychological factors are identified and explained through research, they need to be translated into viable intervention strategies subject to systematic methodological evaluation. Second, interventions must be consistent with the theoretical assumptions underlying the model used so that those techniques designed or selected to establish adequate medication use and other adherence and well–being–inducing behaviors will actually result effective.

    Given the context of the institutional treatment of this condition, it seems especially relevant to insure that such programs actually have an interdisciplinary character in order to facilitate and maintain therapeutic adherence. Such inter–professional collaboration is especially important in a public healthcare context in which resources, ranging all the way from facilities, equipment and caregiver salaries to the schooling of the patients, pose special challenges in places like Latin American countries, where real optimization can occur mainly through the quality of integrated professional performance. After all, the key healthcare ingredient in public health problems affecting ever–growing portions of the population, such as the HIV infection, remains the human being, i.e., actual persons with biological, psychological, and social functional components.