The Science and Art of Using Health Behavior Theories Reflectã¢ââ¦

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A review of wellness behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS?

BMC Public Wellness volume 7, Commodity number:104 (2007) Cite this article

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Abstract

Background

Suboptimal treatment adherence remains a barrier to the control of many infectious diseases, including tuberculosis and HIV/AIDS, which contribute significantly to the global disease burden. However, few of the many interventions developed to accost this issue explicitly draw on theories of health behaviour. Such theories could contribute to the design of more constructive interventions to promote handling adherence and to improving assessments of the transferability of these interventions across different health problems and settings.

Methods

This newspaper reviews behaviour change theories applicable to long-term treatment adherence; assesses the evidence for their effectiveness in predicting behaviour change; and examines the implications of these findings for developing strategies to improve TB and HIV/AIDS medication adherence. We searched a number of electronic databases for theories of behaviour change. Eleven theories were examined.

Results

Footling empirical evidence was located on the effectiveness of these theories in promoting adherence. However, several models have the potential to both improve agreement of adherence behaviours and contribute to the blueprint of more effective interventions to promote adherence to TB and HIV/AIDS medication.

Conclusion

Further research and analysis is needed urgently to determine which models might best improve adherence to long-term treatment regimens.

Peer Review reports

Background

Theories may aid in the design of behaviour change interventions in various ways [1–3], by promoting an understanding of health behaviour, directing research and facilitating the transferability of an intervention from 1 health upshot, geographical expanse or healthcare setting to another.

Ensuring treatment adherence presents a considerable challenge to health initiatives. Haynes et al. ([four], p2) have defined adherence as "the extent to which patients follow the instructions they are given for prescribed treatments". Adherence is a more than neutral term than 'compliance', which can be construed equally being judgmental. While programmes promoting adherence have focused on various health behaviours, this review focuses specifically on long-term adherence to tuberculosis (TB) and HIV/AIDS treatment. Not-adherence to treatment for these diseases has severe human, economic and social costs. Interrupted treatment may reduce treatment efficacy and cause drug resistance [5], resulting in increased morbidity and bloodshed and further infections. Without intervention, adherence rates to long-term medication in high income countries are approximately fifty% [6], while adherence in depression and centre income countries may be even lower [seven].

TB and HIV present item challenges to adherence. Both are chronic and infectious diseases that touch mainly the most disadvantaged populations and involve complex treatment regimens with potentially severe side effects; both are public health priorities and non-adherence may cause drug resistance [7]. These characteristics differentiate these diseases from other chronic diseases such equally asthma and hypertension where, for instance, drug resistance is non a key upshot. Treatment adherence is likewise affected by beliefs about the origins, transmission and treatment of TB and HIV, often resulting in the stigmatisation of those affected [7]. The interaction of these factors make adherence for these diseases not only a priority but a complex wellness issue.

Diverse interventions have been designed to meliorate handling adherence, but few theories draw specifically the processes involved. Currently, there are more 30 psychological theories of behaviour change [viii], making it hard to choose the most appropriate i when designing interventions. This is a detail problem within the field of adherence to long-term medications, where the consequences of non-adherence may exist astringent. Existing theories therefore demand to be examined further to determine their relevance to the issue of long-term medication adherence.

Leventhal and Cameron [9] identified 5 principal theoretical perspectives related to adherence: ane) biomedical; 2) behavioural; three) communication; 4) cognitive; and 5) self-regulatory. Each perspective encompasses several theories. More than recently, the phase perspective has emerged, which includes the transtheoretical model. The most ordinarily used theories are those within the cognitive perspective [1, 10] and the transtheoretical model [1]. This review includes a brusque description of theories within each of the five perspectives listed above, as well as the transtheoretical model. We locate these theories specifically within the realm of adherence to long-term medication, defined as medication regimens of three months or more; depict their key characteristics and evidence base; and examine their relevance and applicability with regard to adherence to long-term medication regimens for TB and HIV/AIDS. To our cognition, the surface area of long-term adherence to medication has non all the same been addressed in reviews of health behaviour theories.

While the focus of this review is on factors affecting consumers, we acknowledge that adherence is a complex and dynamic phenomenon, which relates to consumers, providers, health systems and broader socio-economical and political contexts. Although the theories chosen for this review focus mainly on providers and consumers, this is non the only area in which adherence can be promoted. The review is intended as an information source for those wishing to develop theory-based interventions focusing on intra- or interpersonal factors to increment TB and/or HIV handling adherence.

Methods

A search was performed on MEDLINE, CINAHL, Pre-CINAHL, PsycInfo, ScienceDirect and ERIC databases using the keywords 'health and behaviour and (model or theory)'; '(model or theory); (adherence or concordance or compliance)', from the start date of each database to February 2005. Additional searches were performed in the University of Cape Town library, Google and Google Scholar. Citations were also identified from included papers. Finally, all databases consulted were searched again using the names of theories as keywords, with 'meta-analysis' or 'systematic review' in April 2005. Experts were consulted for comments and references. Published articles or volume chapters in English, describing a particular theory, and articles that presented a meta-analysis of the theory, were included. Manufactures were excluded if they did not satisfy the same criteria. Where possible, interventions related to TB or HIV adherence were identified. No authors were contacted. Several additional randomised controlled studies or other articles were also included as examples of the use of theories in intervention development. In this newspaper we apply the term 'theory', instead of 'model', and the term 'variable', instead of 'construct', when referring to a part of the theory.

Results

Table ane presents the theories included in this commodity and references to meta-analyses synthesizing the testify for each. Below, we summarise each perspective and the theories within it and provide examples of its application to adherence behaviours [come across boosted file 1]. We then examine the usefulness of these theories in developing interventions to promote long-term adherence.

Table 1 Summary of selected health behaviour theories*

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The biomedical perspective

The biomedical perspective incorporates the biomedical theory in which patients are assumed to be passive recipients of doctors' instructions [11]. Wellness or affliction is traced dorsum to biomedical causes, such as bacteria or viruses, and treatment is therefore focused on the patient's body [11]. In keeping with this mechanistic view of illness, mechanical solutions, such as prescribed pills, are preferred [12]; non-adherence is understood to be caused by patient characteristics, such as age and gender [12]. Technological innovations to promote adherence, such as Medication Effect Monitoring Systems ^®, are sometimes rooted in this perspective [7]. However, despite its implicit apply by many health professionals, this perspective is infrequently used explicitly in interventions.

A fundamental limitation of this theory is that it ignores factors other than patient characteristics that may touch on health behaviours – for example, patients' perspectives of their own illness [seven]; psycho-social influences [12]; and the impacts of the socio-economic surroundings. The socio-economic environment or demographics may, nonetheless, be markers for other factors that lend themselves to intervention even though they themselves cannot exist inverse [thirteen]. The danger of using demographics equally proxy variables for adherence is that certain groups that come to be seen equally "lost causes" may exist excluded (e.yard. [14]). This biomedical theory has recently been integrated into a larger "biopsycho-socio-environmental" theory, which incorporates the wider socio-environmental context [11]. However, this theory is non located strictly inside the biomedical arroyo. Due to the assumption that patients are passive and the focus on biomedical factors, it is unlikely that the biomedical theory tin contribute significantly to TB or HIV medication adherence. Patients are more often than not active decision makers and practise not merely receive and follow instructions passively. No meta-analyses specifically examining this perspective were identified.

Behavioural (learning) perspective

This perspective incorporates behavioural learning theory (BLT) which is focused on the environment and the teaching of skills to manage adherence [7]. It is characterised past the utilise of the principles of antecedents and consequences and their influence on behaviour. Antecedents are either internal (thoughts) or external (environmental cues) while consequences may exist punishments or rewards for a behaviour. The probability of a patient following a specific behaviour will partially depend on these variables [vii].

Figure 1

Behavioural learning theory.

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Effigy 2

Wellness belief model.

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Effigy 3

Protection motivation theory.

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Figure 4

Revised protection motivation theory.

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Figure five

Social cerebral theory.

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Figure 6

Theory of reasoned action.

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Figure 7

Theory of planned behaviour.

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Figure 8

Information motivation behavioural skills model.

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Figure 9

Self regulation theory.

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Figure ten

Transtheoretical model.

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Adherence promoting strategies informed by this perspective, such as patient reminders, have been found to improve adherence [15]. Several interventions incorporating elements of BLT have also been reported to be constructive for adherence to long-term medications [4]. However, a more recent meta-assay examining adherence to highly active antiretroviral (ARV) therapy concluded that interventions with cue dosing and external rewards – approaches derived from BLT -were as efficacious as those without [xvi]. Another randomised controlled trial on ARVs reported a negative effect when using electronic reminder systems [17]. Further evidence is therefore needed on the effectiveness of these types of strategy.

BLT has been critiqued for lacking an individualised approach and for non considering less conscious influences on behaviour not linked to immediate rewards [12]. These influences include, for example, past behaviour, habits, or lack of acceptance of a diagnosis. The theory is express, too, by its focus on external influences on behaviour. Programme planners should therefore consider carefully individuals' perceptions of appropriate rewards before using such theory to inform programme design. Interventions cartoon on behavioural theory are oftentimes used in combination with other approaches, although seldom explicitly. No meta-analyses were found that examined this perspective.

Communication perspective

Communication is said to be "the cornerstone of every patient-practitioner relationship" [[11], p. 56]. This perspective suggests that improved provider-client communication will enhance adherence [7, 11] and implies that this tin be achieved through patient instruction and good health care worker communication skills – an approach based on the notion that communication needs to exist clear and comprehensible to be effective. It besides places emphasis on the timing of treatment, education and comprehension. An example of an intervention utilising this perspective is one that aims to improve client-provider interaction. Critiques of this perspective fence that information technology ignores attitudinal, motivational and interpersonal factors that may interfere with the reception of the bulletin and the translation of cognition into behaviour change [12].

A number of reviews have examined the effects of interventions including communication elements [18–21]. However, few of these have examined the effects of advice on health behaviours specifically. Two reviews focusing on interventions to improve provider-customer communication showed that these tin amend communication in consultations, patient satisfaction with care [xviii] likewise as health outcomes [21]. However, these reviews also show limited and mixed evidence on the effects of such interventions on patient health care behaviours, such as adherence.

Advice components have been used within several adherence interventions but seldom explicitly or equally the main component. Such interventions are unlikely to succeed in isolation in improving long-term adherence to medications considering of the influence of external factors, such equally the costs of accessing healthcare for handling. Advice interventions are also typically restricted to provider-customer interactions and boosted social or financial back up may thus be required.

Cognitive perspective

The cognitive perspective includes theories such as the wellness conventionalities model (HBM), social-cognitive theory (SCT), the theories of reasoned action (TRA) and planned behaviour (TPB) and the protection motivation theory (PMT). These theories focus on cognitive variables as part of behaviour modify, and share the assumption that attitudes and beliefs [22], also as expectations of hereafter events and outcomes [23], are major determinants of wellness related behaviour. In the face up of various alternatives, these theories propose, individuals will choose the activeness that volition lead most probable to positive outcomes.

These theories accept noticeable weaknesses, nonetheless: firstly, that non-voluntary factors can impact behaviour [23]; devoting time to conscious deliberation regarding a repeated selection also seems uneconomical [22]. Secondly, these theories practice not adequately address the behavioural skills needed to ensure adherence [seven]. Thirdly, these theories give little attention to the origin of beliefs and how these behavior may influence other behaviours [24]. In addition, information technology has been argued that they ignore other factors that may touch on on adherence behaviour, such as ability relationships and social reputations [25], and the possibility that risk behaviour may involve more than one person [26]. Information technology has as well been suggested that they focus on a single threat and prevention behaviour and do not include possible additional threats competing for the individual's attention [24].

Health Belief Model

The HBM views health behaviour change as based on a rational appraisal of the rest betwixt the barriers to and benefits of action [12]. According to this model, the perceived seriousness of, and susceptibility to, a disease influence individual's perceived threat of disease. Similarly, perceived benefits and perceived barriers influence perceptions of the effectiveness of health behaviour. In plow, demographic and socio-psychological variables influence both perceived susceptibility and perceived seriousness, and the perceived benefits and perceived barriers to action [1, 7]. Perceived threat is influenced by cues to action, which can be internal (e.one thousand. symptom perception) or external (eastward.thousand. health communication) (Rosenstock, 1974 in [7]).

High-perceived threat, low barriers and high perceived benefits to activeness increment the likelihood of engaging in the recommended behaviour [27]. Mostly, all of the model'southward components are seen as independent predictors of health behaviour [28]. Bandura [29] notes, nevertheless, that perceived threats – specially perceived severity – accept a weak correlation with health activeness and might even result in avoidance of protective action. Perceived severity may also non be as important equally perceived susceptibility. Recently, self-efficacy was added into the theory [30], thereby incorporating the need to feel competent before effecting long-term change [31].

In that location are two main criticisms of this theory: firstly, the relationships between these variables have not been explicitly spelt out [32] and no definitions accept been constructed for the individual components or articulate rules of combination formulated [28]. Information technology is assumed that the variables are not moderated by each other and take an condiment effect [32]. If, for example, perceived seriousness is high and susceptibility is low, it is still assumed that the likelihood of activeness will exist high -intuitively i might assume that the likelihood in this case would be lower than when both of the variables are high [22, 32]. The HBM also assumes that variables touch wellness behaviour straight and remain unmoderated by behavioural intentions [22]. The second major weakness of HBM is that important determinants of health behaviour, such equally the positive furnishings of negative behaviours and social influence, are non included [22, 32]. In addition, some behaviours such as smoking are based on habits rather than decisions [33]. While the theory may predict adherence in some situations, it has not been plant to practise and so for "risk reduction behaviours that are more linked to socially determined or unconscious motivations" [[12], p.165].

The two reviews identified that examined this theory had inconclusive results. A critical review [34] examined 19 studies which involved sick role behaviours, such as compliance to antihypertensive medication. While the 4 dimensions of the model produced pregnant effects in most of the studies included [34], the studies had considerable methodological gaps. A more contempo meta-analysis [35] indicated that while the HBM was capable of predicting ten% of variance in behaviour at all-time, the included studies were heterogeneous and were unable to support conclusions every bit to the validity of the model. Therefore further studies are needed to assess the validity of this theory. When applying this theory to long-term medication adherence, it is besides important for the influence of socio-psychological factors to exist considered. For example, cultural beliefs almost TB – such every bit its relationship with witchcraft [36] – may reduce an adherence intervention'southward effectiveness.

The protection-motivation theory

According to this theory, behaviour modify may exist achieved past appealing to an individual's fears. Three components of fright arousal are postulated: the magnitude of impairment of a depicted outcome; the probability of that effect'due south occurrence; and the efficacy of the protective response [37]. These, information technology is contended, combine multiplicatively to determine the intensity of protection motivation [22], resulting in action occurring equally a effect of a desire to protect oneself from danger [37]. This is the only theory within the broader cognitive perspective that explicitly uses the costs and benefits of existing and recommended behaviour to predict the likelihood of change [23].

An of import limitation of this theory is that not all environmental and cognitive variables that could touch on on attitude change (such as the pressure to adapt to social norms) are identified [37]. The about recent version of the theory assumes that the motivation to protect oneself from danger is a positive linear function of beliefs that: the threat is severe, one is personally vulnerable, 1 can perform the coping response (self efficacy) and the coping response is constructive (response efficacy) [22]. Beliefs that health-impairing behaviour is rewarding but that giving it up is costly are causeless to take a negative effect [22]. All the same, the subdivision of perceived efficacy into categories of response and self efficacy is mayhap inappropriate – people would not consider themselves capable of performing an action without the means to do information technology [29].

A meta-assay examining this theory constitute simply moderate effects on behaviour [39]. The revised PMT may be less cumbersome to apply than the TRA – it besides does non presume that behaviour is always rational. [39]. The PMT may be advisable for adherence interventions as it is unlikely that an individual consciously re-evaluates all of their routine behaviours such as, for example, taking long-term medication. However, the influence of social, psychological and environmental factors on motivation requires consideration by those using this arroyo.

Social-cognitive theory

This theory evolved from social learning theory and may exist the most comprehensive theory of behaviour alter developed thus far [1]. It posits a multifaceted causal construction in the regulation of human being motivation, activeness and well-being [40] and offers both predictors of adherence and guidelines for its promotion [29]. The bones organising principle of behaviour change proposed by this theory is reciprocal determinism in which there is a continuous, dynamic interaction betwixt the individual, the environment and behaviour [i].

Social-cognitive theory suggests that while knowledge of health risks and benefits are a prerequisite to change, additional self-influences are necessary for change to occur [41]. Beliefs regarding personal efficacy are amid some of these influences, and these play a fundamental office in change. Health behaviour is also affected by the expected outcomes – which may exist the positive and negative furnishings of the behaviour or the textile losses and benefits. Outcomes may also be social, including social approval or disapproval of an activeness. A person'southward positive and negative self-evaluations of their health behaviour and wellness status may as well influence the upshot. Other determinants of behaviour are perceived facilitators and barriers. Behaviour modify may be due to the reduction or elimination of barriers [41]. In sum, this theory proposes that behaviours are enacted if people perceive that they accept command over the effect, that at that place are few external barriers and when individuals have conviction in their ability to execute the behaviour [28].

A review reported that cocky efficacy could explicate between 4% and 26% of variance in behaviour [42]. However, this analysis was limited to studies of practice behaviour, and did not include reports that examined SCT as a whole. Due to its wide-ranging focus, this theory is difficult to operationalise and is often used only in office [43], thus raising questions regarding its applicability to intervention development.

Theory of planned behaviour and the theory of reasoned activeness

The first work in this area was on the TRA [44].

The TRA assumes that most socially relevant behaviours are nether volitional control, and that a person's intention to perform a particular behaviour is both the immediate determinant and the single all-time predictor of that behaviour [45]. An intention to perform a behaviour is influenced past attitudes towards the action, including the individual's positive or negative beliefs and evaluations of the event of the behaviour. It is likewise influenced by subjective norms, including the perceived expectations of important others (eastward.g. family or work colleagues) with regard to a person'due south behaviour; and the motivation for a person to comply with others' wishes. Behavioural intention, it is contended, so results in action [44]. The authors argue that other variables besides those described above tin can only influence the behaviour if such variables influence attitudes or subjective norms. A meta-assay examining this theory constitute that it could explicate approximately 25% of variance in behaviour in intention lone, and slightly less than 50% of variance in intentions [45]. This suggests that back up for this theory is limited.

Additionally, The TRA omits the fact that behaviour may not always be under volitional command and the impacts of by behaviour on current behaviours [22]. Recognising this, the authors extended the theory to include behavioural command and termed this the TPB. 'Behavioural control' represents the perceived ease or difficulty of performing the behaviour and is a part of control beliefs [45]. Conceptually it is very similar to self-efficacy [22] and includes noesis of relevant skills, experience, emotions, past rails record and external circumstances (Ajzen, in [46]). Behavioural control is assumed to have a straight influence on intention [45]. Meta-analyses examining the TPB have constitute varied results regarding the effectiveness of the theory'southward components [47–49]. Although not conclusive, the results of the analyses are promising.

Sutton [45] suggests that the TRA and TPB require more conceptualisation, definition and boosted explanatory factors. Attitudes and intentions can also be influenced past a diversity of factors that are not outlined in the to a higher place theories [22]. Specifically, these theories are largely dependent on rational processes [50] and do not allow explicitly for the impacts of emotions or religious beliefs on behaviour, which may be relevant to stigmatised diseases like TB and HIV/AIDS.

Information-motivation-behavioural skills (IMB) theory

This theory was developed to promote contraceptive use and prevent HIV transmission. IMB was synthetic to exist conceptually based, generalisable and simple [51]. Information technology has since been tailored specifically to designing interventions to promote adherence to Art [52]

This theory focuses on 3 components that effect in behaviour change: information, motivation and behaviour skills. Information relates to the basic cognition about a medical condition, and is an essential prerequisite for behaviour alter but not necessarily sufficient in isolation [51]. A favourable intervention would establish the baseline levels of information, and target data gaps [51]. The second component, motivation, results from personal attitudes towards adherence; perceived social back up for the behaviour; and the patients' subjective norm or perception of how others with the condition might behave [7]. Finally, behavioural skills include factors such every bit ensuring that the patient has the skills, tools and strategies to perform the behaviour equally well as a sense of cocky-efficacy – the belief that they can attain the behaviour [51].

The components mentioned above need to be direct relevant to the desired behaviour to be effective [7]. They can besides be moderated by a range of contextual factors such as living weather condition and access to wellness services [52]. Information and motivation are thought to actuate behavioural skills, which in turn result in risk reduction behavioural change and maintenance [51]. The theory is said to be moderately effective in promoting behaviour change [7], and has been shown to have predictive value for Art adherence [53]. Withal, no meta-analyses were identified that assessed the furnishings of this model. The reward of IMB is its simplicity and its contempo application to ART adherence suggests that it may be a promising model for promoting adherence to TB medication.

Self-regulation perspectives

Self-regulatory theory is the master theory in this domain. Developed to conceptualise the adherence process in a style that re-focuses on the patient [54], the theory proposes that it is necessary to examine individuals' subjective feel of health threats to understand the way in which they adapt to these threats. Co-ordinate to this theory, individuals form cognitive representations of health threats (and related emotional responses) that combine new data with past experiences [55]. These representations 'guide' their choice of particular strategies for coping with health threats, and consequently influence associated outcomes [56]. The theory is based on the assumption that people are motivated to avert and care for affliction threats and that people are active, self-regulating trouble solvers [57]. Individuals, it is implicitly assumed, will endeavor to reach a state of internal equilibrium through testing coping strategies. The process of creating health threat representations and choosing coping strategies is causeless to exist dynamic and informed by an individual's personality, and religious, social and cultural context [55]. In improver, a complex interplay exists betwixt environmental perceptions, symptoms and beliefs about disease causation [54].

The cocky-regulation theory offers little guidance related to the design of interventions [vii] and no meta-analyses examining evidence for the effectiveness of this theory were identified. While the theory seems intuitively advisable, specific suggestions are needed as to how these processes could promote adherence.

Stage perspectives

The transtheoretical model (TTM)

This theory is most prominent among the phase perspectives. Information technology hypothesizes a number of qualitatively different, discrete stages and processes of change, and reasons that people motion through these stages, typically relapsing and revisiting earlier stages before success [58, 59]. This theory is said to offering an "integrative perspective on the construction of intentional change" [[60], p. 1102] – the perceived advantages and disadvantages of behaviour are crucial to behaviour change [61].

The procedure of change includes independent variables that assess how people modify their behaviour [62] and the covert and overt activities that help individuals towards healthier behaviour [63]. Different processes are emphasised at different stages.

Criticisms of TTM include the stages postulated and their coverage and definitions, and descriptors of alter. Co-ordinate to Bandura [40], this theory violates all three of the basic assumptions of phase theories: qualitative transformations across discrete stages, invariant sequence of change, and not-reversibility. In addition, the proposed stages may only be different points on a larger continuum [29, 58, 63]. Bandura [29] suggests that human functioning is too multifaceted to fit into carve up, discrete stages and argues that stage thinking could constrain the scope of modify-promoting interventions. Furthermore, TTM provides little information on how people alter and why but some individuals succeed [28].

Sutton [56] argues that the stage definitions included in the TTM are logically flawed, and that the time periods assigned to each stage are arbitrary. Similarly, there is also a need for more attention to measurement, testing issues and definition of variables and causal relationships [58]. The coverage and blazon of processes included may besides exist inadequate [63].

The TTM has received much practitioner back up over the years, but less direct inquiry support for its efficacy [3, 10]. The meta-analyses identified for this review did non offering direct support for the theory; while ane found that individuals use all 10 processes of change [64], another found that interventions that used the stage perspective were not more than efficient than those not using the theory [65]. Further evidence of its efficacy is therefore needed. A strength of this theory is that it allows interventions to be tailored to individual needs. Even so, large-calibration implementation of these interventions may exist time consuming, complicated and costly. Its use may exist more than appropriate in areas where rapid behaviour alter is non necessary.

Discussion

This review has discussed a number of health behaviour theories that contribute to understanding adherence to long-term medications, such equally those for TB and HIV/AIDS.

Although the use of theory to develop interventions to promote adherence offers several advantages, it also has some limitations. Firstly, there is little evidence that allows for the straight comparison of these theories [66]. Combining studies based on even one theory, in gild to perform a meta-analysis to assess its effectiveness in predicting behaviours, is difficult due to various methodological issues in the original studies [sixty]. Furthermore, the number of theories in this field has proliferated over time, as theorists accept examined dissimilar areas of behaviour and engaged in re-examining existing explanatory theories. Researchers, wellness planners and practitioners may therefore be overwhelmed past the multitude of theories available to them and the fragmented, and often contradictory, evidence. Questions also remain regarding the applicability of these theories to contexts other than those in which they were developed. Ashing-Giwa [67], for instance, suggests that the higher up theories practice not accost socio-cultural aspects sufficiently. Issues such as the stigma fastened to TB due to its perceived relation to HIV (peculiarly in developing countries) may bear upon on the acceptability and the uptake of interventions. Farther attention should therefore be given to the question of whether theories adult in the Usa and the UK are applicable to individuals in other contexts where the disease burden from HIV/AIDS and TB is greatest.

Secondly, health behaviour change theories have tended to encompass a wide diversity of health behaviours, each qualitatively unlike. The systematic reviews identified for this paper included studies ranging from smoking cessation to mothers limiting babies' sugar intake. Item theories may be more than applicable than others to improving adherence to specific wellness behaviours. For example, adherence to long-term medication will necessarily be dissimilar to a behaviour modify required to accept upward exercise. In add-on, achieving adherence to TB medication may be seen as an urgent event for public health because of its infectiousness, and the recent emergence of extremely drug resistant strains [68]. It is hard therefore to compare the effects of the theories across wellness categories or even inside individual categories.

Thirdly, few studies were identified that had examined the selected health behaviour theories in relation to long-term medication adherence, or that had developed interventions to promote long-term adherence explicitly based on these theories, particularly for TB. Sumartojo's [xiii] assessment that a theory-based approach has largely been absent within the field of TB behavioural research appears to remain valid today.

The awarding of theories to the design of interventions remains a challenge for researchers and programme planners [69] and at that place is considerable fence concerning the effectiveness and usefulness of theory in informing intervention development (run into [two, seventy, 71]). Despite a variety of studies in a diverseness of fields, or peradventure because of this variation, we would argue that in that location is no clear bear witness nevertheless for the support of any of these theories within the field of adherence behaviours. This is not to say that these theories cannot exist useful – rather, nosotros accept insufficient evidence to conclusively decide this.

While these discussions proceed, research should aim to shed calorie-free on the key questions related to the theory-intervention debate: Do sound theories upshot in effective interventions? Does an constructive intervention constitute proof of a theory'southward value? How might theory exist used to inform the design of an effective intervention? And how tin can a theory be reliably tested? Some research work has already been undertaken in these areas: in a systematic review of antiretroviral handling adherence interventions, Amico et al. [72] found that the use of theory in amalgam an intervention did not account for variability in the intervention's efficacy. Yet, it is unclear how many of the 24 included studies in this review articulated a health behaviour change theory or the extent to which this was done.

Ii possible approaches have been suggested to addressing the difficulties raised by the multitude of existing theories on wellness behaviour change. One approach is to attempt to identify variables common to these theories. This has been undertaken for 33 health behaviour change theories [7] in order to make psychological theories more accessible and easier to select. The results of this report provide some guidance on the most important variables in psychological theories, and may assistance in the farther development of wellness behaviour change theories. A second approach is to attempt to integrate the theories. While there is a need for such theoretical integration [73], we argue that researchers and theorists alike should be cautious when picking and choosing parts of other theories to develop farther theories – and so-chosen "cafeteria-manner theorizing" – equally the resulting theories may include redundant variables [[29], p. 285].

Because some theories share overlapping variables describing using different names [8, 41], and most differences are due to an emphasis of one variable over some other [1], it would serve the evolution of this field to conduct studies to identify particular variables that perform all-time in predicting behaviour alter. For example, in a meta-analysis of randomised controlled trials testing antiretroviral treatment adherence interventions, Simoni [sixteen] establish that giving basic information to patients, and engaging them in word about helping them to overcome cerebral factors, lack of motivation and unrealistic expectations well-nigh adherence, were effective in improving adherence. Similarly, comparative studies betwixt theories could exist used to identify constructive components [74]. The field of health behaviour theory remains dynamic, and it is important to go along developing existing theories and approaches as new bear witness emerges.

Applying wellness behaviour theories to medication adherence for TB and HIV/AIDS

How optimal adherence for TB and HIV/AIDS can exist ensured remains an important question. While large numbers of studies have explored patients' and health care providers' views regarding adherence to TB treatment [75] or have described programmes to meliorate adherence to these medications, there are yet relatively few rigorous evaluations of interventions to promote adherence to TB and HIV/AIDS treatments [76, 77]; even fewer take explicitly utilised behaviour modify theories. For example, a systematic review of interventions to promote adherence to TB treatment [77] included 10 trials, none of which used an explicit theoretical framework. A similar review identified vii different randomised controlled trials of interventions to promote adherence to antiretroviral therapy [76], of which only one employed an explicit theoretical framework. Similar figures have been reported in other domains: a review of guideline implementation studies showed that less than x% of these provided an explicit theoretical rationale for their intervention [78]. Given the paucity of evidence to support any item wellness behaviour theory, we cannot therefore suggest that these theories be used routinely to pattern adherence promoting interventions. Notwithstanding, since these theories may well have practical behaviour change potential, and since the problem of medication adherence remains pregnant for both clinical medicine and public wellness, further exploratory and explanatory inquiry is needed.

A number of recommendations emerge from this review (Table 2): firstly, future research should focus not on the development of new theories but rather on the further test of those already elaborated. Several key attributes that should be encompassed past theories explaining behaviour modify have been suggested, including demonstrated effectiveness in predicting and explaining changes in behaviour across a range of domains; an ability to explain behaviour using modifiable factors; and an ability to generate clear, testable hypotheses. The theories should include non-volitional components (i.e. issues over which individuals practise not have consummate control) and take into account the influence of external factors, as perceived past individuals [2, seventy].

Table ii Recommendations for using health behaviour theories to develop long-term adherence promoting interventions in TB and HIV

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Secondly, further piece of work is required to place theories of health behaviour that are most applicative to improving adherence to long-term medication. Existing health behaviour theories should be tested systematically to establish which all-time predict effects on different kinds of behaviour for different groups of people in dissimilar contexts. For example, does a item theory predict changes in adherence behaviour for both men and women with TB in both England and Due south Africa? Some researchers have argued that experimental enquiry and increased clarity in theories and methods could assist in the identification of constructive behaviour alter techniques, thereby contributing to the development of testify-based practice in health psychology and implementation research [2, 3]. Similar efforts need to be made regarding the use of theories as applied to adherence behaviour.

Thirdly, the abundance of theories and their poor evidence base highlights the need to develop and trial interventions that use these theories appropriately (i.e. in concordance with the theory), with well defined and operationalised variables. This will assist to accelerate the study of human adherence behaviour and allow for better informed decisions related to how to these theories could be more than widely applied in practice. (Run into references [2] and [75] for guidance on developing theoretically informed interventions). Nosotros have compiled a number of examples [meet additional file 1] of the application of such theories in practice.

Finally, reports of interventions to promote adherence to long-term medications for other health issues, such as diabetes, asthma and hypertension, should be reviewed to determine how many have drawn on theory in the design and testing of these interventions; the range of theories utilised and the means in which this was washed; and the ways in which the employ of theory contributed to understanding the furnishings of these interventions. Many reviews of such interventions exist (for example, see [83, 84]) and these could act as a starting point for such work.

It is also of import to list some of the limitations of this review. Firstly, we take been unable to capture all the bachelor data on tests of health behaviour theories. Secondly, this paper examines only theories constructed by researchers and does not explore the health theories held by those receiving treatment. These lay theories of adherence with regard to antiretroviral [81] and TB treatment [75] are discussed elsewhere.

It should also be noted that any understanding of individual health behaviour, and interventions to change this, must be located inside the relevant social, psychological, economic and physical environments [28]. Much research on adherence to TB medication has indicated that poor adherence is commonly the result of factors outside the individual's control, including clinic and wellness care organisation factors (such equally interruptions to drug supply and long distances to health facilities) and structural factors (such as poverty and migration) [thirteen, 82, 83]. Similar issues take been reported for adherence to Fine art [84]. Any focus on irresolute the behaviours of individuals with TB or HIV should non issue in the neglect of these other dimensions or the further disadvantaging of the poor and vulnerable, thereby widening health disparities. Interventions that focus on providers, the provider-patient relationship, health system and contextual factors therefore also need to be developed and evaluated [76].

Conclusion

There is no uncomplicated solution to the problem of adherence, or to the area of behaviour change. Health behaviour theories may shed calorie-free on the processes underlying behaviour change. However, an explicit theoretical basis is not e'er necessary for a successful intervention and further examination is needed to determine whether theory-based interventions in health care are more effective than those without an explicit theoretical foundation [two, lxx]. This review contributes to advancing this field by describing the commonly cited health behaviour theories, presenting the testify and critique for each; discussing the applicability of these theories to adherence behaviour; and highlighting several recommendations for enquiry and theory development. To sympathise and overcome the barriers to treatment adherence, considerable research is needed. Withal, given the importance of long-term medication adherence to global public wellness, particularly in relation to the HIV and TB epidemics, such enquiry should receive much college priority.

Abbreviations

HIV/AIDS:

Human immunodeficiency virus/Acquired immunodeficiency syndrome

TB:

Tuberculosis

ARV:

Antiretroviral

SCT:

Social-cognitive theory

TRA:

Theory of reasoned action

PMT:

Protection motivation theory

HBM:

Health belief model

TPB:

Theory of planned behaviour

IMB:

Information-motivation-behavioural skills model

Fine art:

Antiretroviral therapy

TTM:

Transtheoretical model

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Acknowledgements

The authors would like to admit the Norwegian Wellness Services Enquiry Centre, the GLOBINF Network, the London School of Hygiene and Tropical Medicine and the Constructive Health Care Research Programme Consortium of the Liverpool School of Tropical Medicine for supporting Salla Munro during the grooming of this article. We would also similar to thank Judy Dick and Sheldon Allen for their comments on drafts of this review; Sylvia Louw, Anna Gaze, and Joy Oliver for their administrative support; and Simon Goudie for his editing of the paper.

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Affiliations

1. South African Cochrane Center, Medical Research Council of South Africa, P.O. Box 19070, Tygerberg 7505, Cape Town, South Africa

   Salla Munro

2. Medical Enquiry Quango of South Africa and Department of Public Health and Policy London School of Hygiene and Tropical Medicine, Wellness Systems Research Unit, Keppel Street, London, WC1E7 HT, United kingdom of great britain and northern ireland

   Simon Lewin

3. Department of Psychology Schoolhouse of Man & Community Evolution, University of the Witwatersrand, Individual Handbag X3, Wits, 2050, S Africa

   Tanya Swart

4. South African Cochrane Centre, Medical Research Council of S Africa and Deputy Dean: Enquiry Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg, Cape Town, 7505, Due south Africa

   Jimmy Volmink

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Correspondence to Salla Munro.

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Authors' contributions

JV and SL adult the idea for this paper, SM performed all searches and compiled the text, SL contributed to the writing and SL, TM and JV provided conceptual and editorial input. All authors read and approved the final manuscript.

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Munro, Southward., Lewin, Southward., Swart, T. et al. A review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS?. BMC Public Health vii, 104 (2007). https://doi.org/10.1186/1471-2458-7-104

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• Received: 14 August 2006

• Accustomed: 11 June 2007

• Published: 11 June 2007

• DOI : https://doi.org/10.1186/1471-2458-7-104

Keywords

• Health Behaviour
• Behaviour Change
• Health Belief Model
• Adherence Behaviour
• Transtheoretical Model

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