rrl hypertension compliance.docx

7/27/2019 RRL HYPERTENSION COMPLIANCE.docx

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Factors Associated with Treatment Compliance in

Hypertension in Southwest Nigeria

Hypertension is an important condition among adults, affecting nearly one billion peopleworldwide. Treatment with appropriate medication is a key factor in the control of hypertension and reduction in associated risk of complications. However, compliance withtreatment is often sub-optimal, especially in developing countries. The present studyinvestigated the factors associated with self-reported compliance among hypertensive subjectsin a poor urban community in southwest Nigeria. This community-based cross-sectional studyemployed a survey of a convenience sample of 440 community residents with hypertension andeight focus-group discussions (FGDs) with a subset of the participants. Of the 440hypertensiverespondents, 65.2% were women, about half had no formal education, and half

were traders. Over 60% of the respondents sought care for their condition from the hospitalwhile only 5% visited a chemist or a patent medicine vendor (PMV). Only 51% of the subjectsreported high compliance. Factors associated with high self-reported compliance included:regular clinic attendance, not using non-Western prescription medication, and having socialsupport from family members or friends who were concerned about the respondent'shypertension or who were helpful in reminding the respondent about taking medication. Beliefsabout cause of hypertension were not associated with compliance. The findings of the FGDsshowed that the respondents believed hypertension is curable with the use of both orthodoxand traditional medi cines and that a patient who feels well could stop using antihypertensive

medication. It is concluded that treatment compliance with antihypertensive medicationremains sub-optimal in this Nigerian community. The factors associated with high self-reportedcompliance were identified. More research is needed to evaluate how such findings can beused for the control of hypertension at the community level.

INTRODUCTION

Hypertension is an overwhelming global challenge, which ranks third as a means of reduction indisability-adjusted life-years (1). It affects approximately one billion people worldwide (4.5% of the current global burden of disease) 340 million of these in economically-developed and 340

million in economically-developing countries. Annually, it causes 7.1 million (or one-third of)global preventable premature deaths (2,3). Due to the fact that hypertension is one of the mostimportant modifiable risk factors for cardiovascular diseases (4), treatment that commencesonce it is recognized reduces the cardiovascular risk of the individual. Therefore, access totreatment with antihypertensive medication and compliance with treatment are key factors inthe control of hypertension. Hypertension, the leading cause of mortality and the third largestcause of disability, is poorly controlled worldwide. It is estimated that almost one-half of


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patients drop out entirely from treatment within one year (5). The failure to controlhypertension takes an unacceptable toll on patients and their families. In addition to thepersonal cost, to the individual patient, uncontrolled hypertension creates huge, avoidableeconomic burdens when viewed in terms of the general population.

The total number of estimated deaths resulting from all types of cardiovascular diseases andhypertensive heart disease recorded for Nigeria in 2004 by the World Health Organization(WHO) was 201,500 and 10,700 respectively (6) and placed Nigeria in the 16th position globally.Although these numbers are low compared to 922,700 and 229,000 deaths reported for theUSA and the United Kingdom respectively, it is clear that there is a growing health problem thatrequires an intervention. Uncontrolled blood pressure has been demonstrated to be a majorrisk factor contributing to more than 500,000 cases of stroke and one million myocardial

infarction cases reported each year in the United States alone (7). An estimated 14.55 millionpeople, worldwide, aged 30-80 years, were reported to have died as a result of hypertension-related conditions in 2005, of which 7.03% were reported for sub-Saharan Africa (8).

Traditionally, the term compliance has been employed to mean the extent to which the patient,when taking a drug, complies with the clinician's advice and follows the regimen (9).Compliance with treatment is defined and characterized when medical or health advicecoincides with the individual's behaviour with regard to the use of medication, recommended

changes in lifestyle, and attendance to medical appointments (10). Poor compliance withtreatment is the most important cause of uncontrolled blood pressure (11). Results of studies inthe United States revealed that long-term compliance with treatment is always a problem inany chronic disease condition, and hypertension is no exception. More than 50% of patients inthe United States, who were prescribed antihypertensive medications actually discontinuedtherapy within 12 months (12). A common reasongiven for stopping medication relates toadverse effects, although the patient's knowledge about the disease, attitudes regardingtreatment of an often asymptomatic condition, and personal health beliefs, together with costof medications and availability of healthcare, are major contributors (12).

Multiple factors contribute to poor compliance with long-term antihypertensive therapy. Manypatients have negative attitudes towards taking medication, especially if they feel well (13).According to Jadelson et al., the major reasons for non-complianceare multi-factorial and rangefrom lack of adequate guidance to socioeconomic status (14). Although the socioeconomicstatus has not consistently been found to be an independent predictor of compliance low


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socioeconomic status may put patients in developing countries in the position of having tochoose between competing priorities (15). Such priorities include demands to direct the limitedresource available to meet the needs of other family members, such as children or parents, forwhom they care. Some factors reported to have a significant effect on compliance are: poor

socioeconomic status (poverty), low level of education, unemployment, lack of effective socialsupport networks, unstable living conditions, long distance from treatment centre, high cost of transport, cultural and lay beliefs about illness and treatment, and forgetfulness (16).

The present study describes treatment-compliance patterns among hypertensive subjects in aNigerian community and investigates the factors associated with good compliance, includingdemographic factors, beliefs about hypertension, and the availability of social support.

The study was conducted in the Idikan community, Ibadan, a city in the southwestern Nigeria,as part of a larger community-based study of the sociological aspects of hypertension. Idikan islocated in the indigenous part of the city of Ibadan. Idikan is a densely-populated urbancommunity within Ibadan city, with a population of 7,883 (17). Health facilities in thecommunity include an outreach clinic run by the Department of Community Health of theUniversity of Ibadan, a small dental clinic run by the Dental Centre of the University CollegeHospital (UCH), and private clinics. There are also registered patent medicine stores(pharmacies) and traditional healing homes in the area, all of which are accessible to members

of the community.

The study consisted of two components: a quantitative study using a community-based surveyof hypertensive subjects and a qualitative study using focus-group discussions (FGDs) on asubset of the participants. The subjects for the quantitative study were adult (aged above 25years) residents of Idikan who are known to have hypertension. Previous studies in thecommunity had conducted household screening for hypertension, which facilitated theidentification of hypertensive subjects in the community. The subjects for this study were

selected from a list of known hypertensive subjects residing in the community that wasprepared for one such previous hypertension study (18) and was updated for the present studyduring visits to the home. Four hundred and forty hypertensive subjects were enrolled using aconsecutive sampling method. The inclusion criteria were: (a) adults aged over 25 years, (b)having diagnosed hypertension by blood-pressure measurements, and (c) awareness of thehypertension status. The only exclusion criteria were refusal to participate and recent (less thanthree years) diagnosis of hypertension since the study required respondents to have experience


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living with hypertension to be able to answer the questions. After obtaining informed consent,the subjects were administered a semi-structured questionnaire that had items on severalissues, including healthcare-seeking for their hypertension, their beliefs about hypertension,compliance with treatment, and availability of social support (from family and friends).

The goal of the FGDs was to capture in-depth information that is complementary to thequantitative study (survey). This instrument guide had questions on knowledge, beliefs,perceptions, care-seeking behaviour, other experiences, and compliance with treatment forhypertension. Specific probes were included on the reasons (the why and how) for therespondent's beliefs, attitude, and actions regarding hypertension they have. Eight FGDs werecarried out. A purposive sampling technique was used for selecting participants for groupdiscussion, and discussants were homogeneous in characteristics within each group. There

were four groups of males and four groups of females. Each group comprised 6-8 discussants.The inclusion criteria were individuals who were aged 45-60 years. They would have also beendiagnosed of high blood pressure for 3-7 years. This allowed for having experiences living withhypertension while minimizing the forgetfulness of care-seeking over time. The key variablereflected in the composition of the focus groups was gender (male vs female). Gender isimportant because it reflects a major determinant of life experiences of people in thecommunity and to ensure that the discussion and interaction among the participants in theFGDs is free and open. This provided relatively-homogenous focus groups that facilitated freeand open discussion on which theamount of information that was elicited depends.

Analysis of data

Management and analysis of the survey questionnaire data were done using the SPSS software(version 14) (SPSS Inc., Chicago, USA). Frequencies of the responses to the questions werecomputed and presented as percentages. The association between categorical variables wastested using the chi-square test. Compliance was defined using the question on how frequentlypeople missed taking their medication. Compliance as a variable was defined and used in twoways. First, compliance was scaled as: high compliance (where the respondent never missesor rarely misses to take his/her medication doses); medium compliance (where therespondent sometimes misses taking medication); and low compliance (where therespondent regularly or fairly regularly misses to take his/her medication. T hese variableswere used for identifying the factors associated with compliance in general. Second, since thedesired goal of treatment for hypertension is that the patient complies with taking medicationfor controlling his/her high blood pressure, high compliance (where the respondent never


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misses or rarely misses to take his/her medication doses) was used for identifying the variablesassociated with this goal of therapy.

Qualitative data were transcribed as soon as possible after each FGD session. The first authoranalyzed the qualitative data, reading through all notes and transcripts of the FGDs andidentifying emerging themes relating to treatment compliance. Computer-assisted qualitativedata analysis (CAQDAS) was also done using the ATLAS.ti software.

Ethical approval

Ethical approval for the study protocol was obtained from the Institutional Review Committeeof the University of Ibadan/University College Hospital, and written informed consent wasobtained from all the participants.

Of the 440 survey respondents, 65.2% were women. About half (51.1%) of the respondents hadno formal education. In terms of occupation, 50% were traders, and about 26% were retired ornot working while 11% were artisans. The respondents were aged 25-90 years. Their mean agewas 60 [standard deviation (SD) 12] years. Dividing the age distribution of the respondents into10-year bands, the peak age-categories were 46-55 years and 56-65 years comprising 29.3%

and 29.1% of the respondents respectively. There was no significant relationship between thegender of the respondents and their age distribution. The large majority (71%) oftherespondents were married (Table 1). A large proportion (63.4%) of the respondents sought carefor their condition from a hospital (the University College Hospital, the community healthcentre, or a private hospital) while 5% visited a chemist or a patent medicine vendor. About9.5% of the respondents who visited the hospital also used traditional medicine while 7.3%visited the chemist and used traditional medicine. None visited a traditional healer exclusively.

Factors associated with good compliance

Educational status and religion were two factors that often influenced knowledge, beliefs,attitudes, and practices relating to health and other domains of life. The findings showed thathigh self-reported compliance was not associated with the religion professed by therespondent. Almost equal percentages of Muslims and Christians (57.8% vs 59.2%) showed high


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self- reported compliance (2=0.797, p=0.671). Concerning education, there was no clear -cuttrend with high self- reported compliance (2=6.683, p=0.24 5), although those with primaryeducation showed a higher frequency of high self-reported compliance when compared withrespondents with other categories of educational levels. Beliefs about the perceived cause of

hypertension were not significantly associated with treatment compliance.

There was no association between believing that anxiety or stress is a cause of hypertensionand high self-reported compliance. On the other hand, a higher percentage of those whoseresponse to the question on the cause of hypertension was Do not know reported highcompliance compared to those who professed to know the cause of hypertension (68.8% vs56.2%) (Table 2). Keeping regular clinic appointments and use/non-use of non-Westernmedication were significantly (p


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Belief in the necessity of antihypertensive medication was high among the respondents, andthe majority believed that it was necessary to take antihypertensive medication even if onedoes not feel sick. About 19% believed that one should only take medication when there are

symptoms and had strong concerns about the potential adverse effects of taking medicationevery day or did not see the need for taking medication when one is not feeling ill. This findingalso provides a preliminary insight into the mechanism by which beliefs relating to medicationmight influence compliance. Some of these findings were similar to those reported in previousstudies (20,21). Familoni et al., in a 2004 study in Nigeria, reported that only about one-third of patients knew that hypertension should ideally be treated for life, and 58.3% believed thatantihypertensive drugs should be used only where there are symptoms while the remaining6.3% believed that the treatment should be for a period of time and not for life (22). Although ithas been suggested that it is sometimes possible to withdraw drug therapy and continue

lifestyle-modification after several years (23), the consensus is that almost all who arehypertensive before treatment will become hypertensive again if treatment is stopped. Thispractice has sometimes resulted in disastrous consequences.

There are many concepts that refer to compliance, for example compliance, adherence,commitment, and concordance. According to Kontz, the most important t hing is how thecontent of the concept is defined (24). A major factor accounting for the inadequate treatmentof hypertension is poor compliance. The findings of this study revealed that almost half of therespondents reported high compliance with treatment with drug, and 86% claimed highcompliance with keeping their appointments with doctors. Reasons for compliance withtreatment include fear of the complications of hypertension and the desire to control bloodpressure. Benson, in 2002, reported that patients comply with medication regimen for variousreasons, including perceived benefits of medication, fear of complications associated withhypertension, and feeling better on medication (21). The latter reason is contrary to thegenerally-held belief among physicians that hypertension is a largely asymptomatic disease(25).

Interestingly, about one-half of the study respondents were non-compliant to their medication.The results of the FGDs suggest that the decision to stop using antihypertensive medication isinfluenced by the beliefs the respondents hold concerning these medications. The identificationof the factors determining non-compliance and a better knowledge about them could allow theimplementation of measures that could enable their correction and providing the adequate


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control of blood-pressure levels. In this study, reasons for non-compliance with medication aremultifactorial and range from low level of knowledge regarding hypertension as a disease andlack of adequate guidance to socioeconomic aspects. The identification of side-effects of treatment used represents another cause of non-compliance with treatment. This finding lays

credence to the submission of Hyman and Pavlik that a primary reason given for stoppingmedication relates to adverse effects, although the patient's knowledge about the disease,attitudes towards treatment of an often asymptomatic condition, and personal health beliefs,together with cost of medications and the availability of healthcare, are major contributors(12). One central theme that runs through the data in this study is the issue of socioeconomicstatus of the respondents. Financial hardship is a significant barrier to complying withtreatment and is a contributory factor to non-compliance. If people are hungry, nothingmatters, except food. People either take medication very late when they have had somethingto eat or forget about it while trying to deal with other problems of poverty. This findingcorroborates the observed association among poor compliance, ignorance, and lack of funds forthe purchase of drugs reported by Isezuo and Opara (26).

While stress and anxiety were the two most common perceived causes of hypertension amongthe respondents, the findings showed that those who held these beliefs did not show bettercompliance than others. However, those who did not know the cause of hypertension showedbetter compliance with medication than others. This implies that not having preconceived ideasabout the cause of hypertension made it more likely that the respondents would comply with

treatment. This observation was also common to other beliefs about hypertension (beingcurable, preventable, serious, leading to complications, and so on) where those who respondedDo not know showed a tendency to better compliance. Other studies that have investigatedthe relationship between beliefs and compliance reported that patient's belief and lack of knowledge, along with other factors, influenced their response to treatment (27,28).

Social support networks are important in the long-term management of chronic conditions,such as hypertension, which requires a radical and life-long change in the lifestyle of the

affected person. In the present study, those who had support from friends or family members(concerned about their illness, giving reminders about medication) had better compliance withtreatment than those who did not, although this difference was the greatest for those who hadthe support of friends. This is an important finding and is consistent with what has beenreported for multiple chronic diseases in several parts of the world (29). Interestingly, theevidence from the present study shows that support from friends is a stronger factorinfluencing high self-reported compliance than support from family members. This may be a


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reflection of the fact that most people in the community (and in cities in general) see, talk, andinteract more with their friends than with their family members who do not live nearby.Another explanation may be that those with hypertension are more likely to discuss theirhealth problems with their friends than with their family members, thereby inadvertently

limiting the support they could receive from the latter.

Limitation

A potential limitation of this study is that compliance was measured using self-report and,therefore, suffers from the problems of recall. Inclusion of methods, such as pill-counts or moresophisticated electronic methods, may have helped more accurately assess compliance.

However, this was not feasible within the context of a community-based study. Nonetheless,the study provides useful data in this important area of compliance to therapy for a non-communicable disease.

Conclusions

It is concluded that the control of hypertension is still sub-optimal in this community, with onlyone-half of the affected persons reporting high compliance with treatment. The factors

associated with high self-reported compliance included: regular clinic attendance, not usingnon-Western prescription medication, and having social support from family members orfriends who were concerned about the respondent's hypertension or who were helpful inreminding the respondent about taking medication. Most respondents believed thathypertension is curable with the use of both orthodox and traditional medicines and that apatient who feels well could stop using antihypertensive medication. On the other hand,specific beliefs about the cause of hypertension were not associated with compliance.

It is recommended that similar research be conducted in developing countries on factorsaffecting compliance in hypertension and similar diseases that require life-long medication forcontrol. Furthermore, studies are needed on how such findings can be used for guiding localhypertension-control efforts.


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A grounded theory of patient medication

noncompliance in men diagnosed with

hypertensionProQuest Dissertations and Theses, 2011

Dissertation

Author: Richard C Edwards

Although research regarding patient noncompliance has increased, no consensus has emergedregarding the superiority of any theory, model, or tool to understand the causes of noncompliant behavior. The purpose of this qualitative, grounded theory study was to useinductive analysis to discover a theory of noncompliance that explains medicationnoncompliance. Research questions examined respondents perceptions, beliefs, and attitudestowards their medical care; their relationship with their health care provider; and how thesefactors affected their behavior (taking medications). Twenty five men, ages 30-50 years, whowere clinically diagnosed with hypertension and were not regularly taking their medication,participated in the interviews. Semistructured interviews were completed with the men, andopen, axial, and selective coding were used to identify emergent themes and patterns in thedata. Results showed that noncompliance is not a unitary phenomenon but rather reflects avariety of cognitive and emotional influences. Financial instability, provider trust, and locus of control for medication compliance were concepts that emerged to explain noncompliance. It isrecommended that the emergent model be tested in larger samples as well as among thosewith other health conditions. Implications for social change include improved providereducation on factors related to noncompliance, improved communication between patientsand health care providers, heightened trust, and recognition that improving compliance is amutual responsibility of patients and providers. Implications for social change also includeimproved compliance which can lead to better physical health as well as decreased health carecosts for individuals suffering from health conditions.

CHAPTER 2: LITERATURE REVIEW Introduction The purpose of this study was to determine whypatients do not comply with a health care providers orders or instructions. In this chapter, Ireview the literature on patient noncompliance. Reasons for noncompliance and the relevanceof grounded theory for a study of this type are reviewed. In grounded theory research, aliterature review can serve as part of data collection and as a source of emergent theory. This


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review covers patient surveys, adverse drug events, demographics, socioeconomics, provider-patient relationships, communication, and trust. Appendix A includes a summary of peer-reviewed research. An initial literature search was conducted using Ovid and PubMeddatabases. PubMed is accessible from any personal computer with Internet access, but Ovid is

only accessible through Area Health Education Center (AHEC) digital libraries located at AHECfacilities. The Ovid search was performed by library staff at the Southern Regional AHEC, andthe search results were forwarded to me. Search results that were not available from PubMedor Ovid were furnished through the U.S. Army Medical Command Library at Womack ArmyMedical Center. The initial search used the following terms: medication, federal patientstandards, primary care, adherence, quality patient standards, compliance, noncompliance,physician,and relationship. That search yielded 184 sources. After the initial search results, Iconducted a second search using terms more specific to the study: noncompliance, medication,prescriptions, prescription medications, patient noncompliance,and surveys. That searchyielded 52 sources. An additional PubMed

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search using the term medication noncompliance surveys yielded 347 sources, many of whichwere either disease-specific or confined to a specific component such as cost- benefit ratio orautomated drug dispensing monitoring. Patient Surveys and Noncompliance Loghman-Adham(2003) wrote, The study of human behavior in relation to taking medications or followingmedical advice has not kept pace with scientific breakthroughs. As medicines become moreeffective, access to health care and patient noncompliance will become the leading causes of

treatment failure. (p. 155) The most significant detrimental effect of noncompliance iseconomic. According to Renal Data Systems, noncompliance has a direct impact onhospitalization, Medicare and Medicaid, and insurance expenditures in excess of $1300 perpatient per day (as cited in Loghman-Adham, 2003, p. 155), amounting to $100 billion a year(Wertheimer & Santella, 2003b, p. 207). Chapman (2004) noted that many researchers haveattempted to determine risk factors for noncompliance, which range from persistent failure totake the prescribed medication at one extreme or single episodes of noncompliance at theother extreme (p. 782). According to Wertheimer and Santella (2003a), a multiplicity of studies focusing on adherence [compliance] has resulted in conflicting data and contradictoryresults over the last 25 years (p. 257). No specific n oncompliance surveys are discussed in theliterature; instead, patient responses regarding noncompliance are included in studies withbroader noncompliance themes. Some researchers have speculated that patients who aresurveyed may not want to admit they are noncompliant in their medication regimens (Egede,2003; Taylor,

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Galbraith, & Mills, 2002). When surveyed patients admit they are noncompliant, they mightfear that a health care provider will view their behavior as demonstrating a lack of confidence in the way they comply with the medical recommendations (Waeber, Burnier, & Brunner,2000, p. S25). Haynes et al. (2007) found several valid reasons for noncompliance, including

poor instructions, poor provider -patient relationship, and patients disagr eement with theneed for treatment (p. 2). One tool for determining noncompliance is the medicationpossession ratio (MPR), a measurement of the first prescription to the last prescription. TheMPR provides some degree of certainty that a patient is taking medications as prescribed(Cooke & Fatodu, 2006). Providers have found, however, that some patients stop and thenrestart taking a medication, sometimes call the toothbrush effect (Denzii, 2001, p. 44), whichsuggests there may well be a vacuum of noncompliance that has not been accounted for (p.44). Most postdischarge patient surveys attempt to assess provider quality and do not includemedication noncompliance as a measure of that quality. Provider quality surveys list servicesrendered, including how patients are greeted when they approach the front desk and how theyare treated by staff and nurses (White, 1999). Patient satisfaction surveys show your staff andthe community that youre interested in quality (White, para. 2), which becomes a mark etingtool. According to Fromer, If we physicians dont get on board and try to make the data as goodas possible and get our scores as high as possible, were going to be hurt in the marketplace.Well be noncompetitive. Thats the biggest reason of all t o be doing this. (as cited in White,1999, para. 3)

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One popular postdischarge patient survey is the Hospital Consumer Assessment of Health careProviders and Systems (HCAHPS). It has a core set of questions that can be combined withcustomized, hospital-specific items (Centers for Medicare and Medicaid Services, 2007, para. 2).The HCAHPS does not include any medication noncompliance items. Adverse Drug Events andNoncompliance Cohen (2001) found that patients typically quit their prescribed medicationregimens after 1 year. Zyczynski and Coyne (2000) found that after the first 6 months of use,persistence decreased to 84% and after 4.5 years of observation, only 47% of patients persistedwith their initially prescribed agent (p. 513). Cohen reviewed da ta from a Saskatchewan studythat revealed a dropout rate of 22% the first year and 54% after 4.5 years. Those researchersdetermined that patients were receiving adequate medication counseling but that providersrelied too heavily on information provided by the Physicians Desk Reference. Patients fear of adverse drug events (ADE) is a factor in noncompliance, but surveys do not specifically addressthat issue. Dsing (2001) suggested that side effects may directly or indirectly underlie variablecomplia nce and nonpersistence (p. 488) and should be addressed; but, Shenolikar et al. (2004)found that 84% of the patients surveyed did not think their prescribed medication regimen


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would have negative side effects. Haynes et al. (2007) cited six studies showi ng that tellingpatients about adverse effects of treatment did not affect their adherence (p. 1).

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Time The length of time a patient spends with a provider and remains with the same providerover multiple visits is directly related to patient satisfaction and health (see Table 5). Table 5Patient Satisfaction and Provider Relationship Patient- Provider Relationship Remained withProvider Saw Same Provider Trust Level Communication Score Provider Knowledge of PatientQuality of Health > 3 years Most a,c Most a Increased d Increased d Increased d Increased d

< 3 years 66% b 95% b ,c Decreased d Decreased d Decreased d Decreased d

a Donahue, Ashkin, and Pathman (2005).

b Helme and Harrington (2004). c Fan, Burman, McDonell, and Fihn (2005). d Parchman andBurge (2003).

Wilson et al. (2007) suggested that developing familiarity with the patient in a long -termrelationship could be associated with less vigilance by the physician or less counseling in areasin which the patient may have initially shown resist ance (p. 7). Based on the satisfaction andtrust achieved in long-term patient-provider relationships, however, it is not unreasonable toexpect that fostering long -term relationships between patients and their physicians may helppromote the outcome of greater patient satisfaction (Wilson et al., 2007, p. 7). Loghman -Adham (2003) found that a strong relationship between the patient and health provider is

associated with improved compliance (p. 161). Duration of a patient -provider over time is notthe only temporal variable to be considered. The length of consultation time is also important.McGrath (1999) found that

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some providers voiced concerns that they had insufficient time to counsel patients about theirmedication regimens and any associated ADEs. Feldman, Murtaugh, Pezzin, McDonald, andPeng (2005) noted that various studies have attempted to trace the impact of changes inpractitioner behavior to actual improvements in patients self - management of chronic

conditions or to patient outcomes (pp. 865-866); but, most patient surveys do not link aproviders behavior to a patients noncompliance. Demographic and Socioeconomic DataRegarding the effect of demographic variables on noncompliance, Schillinger et al. (2000) foundno statistically si gnificant differences with regard to gender, race/ethnicity, languagecapabilities, prior outpatient and inpatient utilization, proportion with attending-level primarycare physicians, distance from the hospital (by zip code), or prevalence of chronic medical


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conditions (p. 332). On the other hand, Wilson et al. (2007) found that noncompliant patientswere more likely to be nonwhite, without health insurance, less educated, *to+ report incomeof less than $25,000 and . . . [to have] fair to poor health st atus (p. 5). It should be noted thatthese patients were responding to Medicare prescription drug benefit law changes in 2006.

Piette, Heisler, Krein, and Kerr (2005) concluded that although socioeconomic status could be acausal factor in noncompliance, other findings suggest that factors other than cost may eitheronly buffer or accentuate the impact of financial pressures on patients adherence behavior (p.1749). They only included diabetic patients who used Veterans Health Administration hospitals.

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Provider-Patient Relationships, Communication, and Trust Schneider et al. (2004) used cross-sectional analysis to determine if better provider-patient relationships and verbalcommunication would reduce noncompliance in patient medication regimens. Participants

were from the metropolitan Boston area. They found no relationship between adherence andspecific measures of the provider-patient relationship (p. 1096). On the other hand, Chapman(2004) found that patients would like their physicians to teach them [how to take theirmedications], tell them about new/alternate medications and procedures as they becomeavailable, and offer new ways to make their regimen easier (p. 401). Murphy et al. (2001), in astudy of insured patients, found that the quality of interpersonal treatment affected patientswillingness to comply with medical advice or treatment'' (p. 124). Specifically, the quality of the provider- patient relationship has been associated with outcomes that include patientscompliance with medi cal advice (Murphy et al., 2001, p. 126). Murphy et al. concluded that

effective provider-patient communication can do things like build trust and reduce theemotional stress of a patient (p. 126). This in turn can help the provider diagnose and has aneffect on both management decisions and ultimately results in a positive health outcome (p.126). Trust is an important part of the patient-provider relationship. Kerse et al. (2004) foundthat trust, or concordance, was related to continuity and patient satisfaction (p. 456) and thatprimary care consultations with higher levels of patient -reported provider-patientconcordance were associated with one- third greater medication compliance (p. 455). Krupatet al. (2002) found that trust in the provider-patient relationship reduced noncompliance toprescribed medical regimen recommendations.

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Wilson et al. (2007) studied provider-patient communication with patients on Medicare andMedicaid. They found a correlation between noncompliance and dialogue between patientsand providers. Among patients surveyed with three or more chronic conditions, 24% reportedthey had not discussed their medication regimens with their provider for over 12 months sincetheir last visit. Also, 38% admitted noncompliance when changing their original prescription


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medication to a generic medication and not initially discussing this with their provider. Cline,Bjrck-Linn, Israelsson, Willenheimer, and Erhardt (1999) found that the information given topatients appears uncomplicated and is reinforced by medication charts, thus allowing patientsthe possibility to refer to it if they were unsure of the verbal instructions (p. 148). When

patients were surveyed regarding their prescriptions, only 55% of the patients could correctlyname what medication had been prescribed, 50% were unable to state the prescribed doses,and 64% could not account for when the medication was to be taken (Willenheimer & Erhardt,1999, p. 147). Although providers verbally described appropriate medication regimeninstructions, apparently they did not determine patients ability to understand and adhere tothe regimen. McGrath (1999) concluded that the nature of provider -patient communication isunclear in particular as there have been no studies that have inve stigated physiciansperspectives and how they might shed light on the problem of noncompliance (p. 732).McGrath added that compliance would improve if patient-provider communication improved(p.732). Larson & Yao (2005) argued that a healing patient-provider relationship andcommunication were essential to quality healthcare and had a direct impact on compliance


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Why hypertensive patients do not comply

with the treatmentResults from a qualitative study

Juan J Gascna, Montserrat Snchez-Ortuob, Bartolom Llorc, David Skidmored, Pedro JSaturnoa,c and for the Treatment Compliance in Hypertension Study Group

Background. Medical non-compliance has been identified as a major public health problem inthe treatment of hypertension. There is a large research record focusing on the understandingof this phenomenon. However, to date, the majority of studies in this field have been focusedfrom the medical care perspective, but few studies have focused on the patients' point of view.

Objective. Our aim was to identify factors related to non-compliance with the treatment of

patients with hypertension.

Methods. We use a qualitative study in which data were gathered from seven focus groupdiscussions conducted in March May 2001. Patients were identified as non-compliant, usingthe Morisky Green test, at two primary health care centres of the Spanish National HealthService.

Results. A complex web of factors was identified that influenced non-compliance. Patients hadfears and negative images of antihypertensive drugs. The data also revealed a lack of basicbackground knowledge about hypertension. The clinical encounter was viewed asunsatisfactory because of its length, few explanations given by the physician and low physician patient interaction.


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Conclusions. Most of the factors related to poor compliance have implications for patientmanagement. Knowing patients' priorities regarding the most important aspects of care thathave high potential for low compliance may be helpful in improvement of the quality of

hypertensive patient care.

Key words

Hypertension patient compliance physician patient relations

Gascn JJ, Snchez-Ortuo M, Llor B, Skidmore D and Saturno PJ for the Treatment Compliancein Hypertension Study Group. Why hypertensive patients do not comply with the treatment.Results from a qualitative study. Family Practice 2004; 21: 125 130.

Hypertension is the single most common and most important risk factor for cardiovasculardisease.1 Despite improvements in the detection and treatment of hypertension since the1970s, recent survey results illustrate that the condition continues to contribute, significantly,to mortality and morbidity in adults and that it is often poorly controlled in clinical practice.2Similarly, other studies suggest that the treatment's efficacy, in patients under care, isattenuated mainly by patient non-compliance with medication and lifestyle advice.3 In fact, ithas been estimated that only 60% of patients take medication as prescribed.4

Given the broad scope of the problem, ever-increasing attention has been devoted toidentifying factors which contribute to non-compliance.5 To date, the majority of studies in thisfield have been carried out in Anglo-Saxon contexts and have been focused on establishing,from the medical care perspective, the factors related to non-compliance; however, fewerstudies have focused on the patients' points of view. The last suggest that patients' non-compliance could be associated with reservations about drugs and lack of necessary knowledgeon which to build an understanding of the condition and treatment.6 8

We, therefore, decided to explore patients' opinions and expectations concerning hypertensionand its treatment in another socio-cultural settings. To address this issue, we designed aqualitative study, based on the focus groups technique, intended to provide an in-depthperspective about poor compliance in hypertension.9


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Participants

The target population comprised non-compliant hypertensive patients who were diagnosedwith and receiving treatment for hypertension. Inclusion criteria were: anyone between theages of 18 and 80 years, being treated with antihypertensives for >3 months, being non-

compliant and having sufficiently good physical and mental health to participate. Detailedinformation about the type of antihypertensive or duration of treatment could not be collected.

Procedure

In order to determine whether or not the patient was compliant, a telephone survey was firstconducted among 267 hypertensive patients, identified from clinic and computer records fromtwo primary health care centres in Murcia (Spain). The Morisky Green test10 was used in this

survey. Those patients who scored 1 point in the test were considered to be non -compliantand hence potential participants (n = 146).

Letters were sent to patients, identified as non-compliant, asking them if they would beprepared to help with some research on patients' experiences of hypertension. Approximately1 week later, they were contacted by telephone in order to ascertain their commitment toattend and to remind them of the session. An average of 20 patients at a time was contacted bytelephone to participate in each focus group until no new themes or ideas were emerging (n =

141). A total of 44 patients, 24 men and 20 women, participated in the seven focus groupssessions where conventional consent and confidentiality procedures were followed. Group sizevaried from three to 11, and sessions lasted 40 80 min. We felt that our participants might bediffident in discussing issues related to their health in the presence of the opposite sex andtherefore decided to have separate male and female groups. The venues selected for the focusgroups were neutral, being located neither in university nor hospital premises.

The focus group interview

In order to elicit information on the patient's perspective of their condition, their treatment andthe relationship with the provider, pre-determined, open-ended questions were arranged byway of a guided interview. Topics for the guided interview were determined by a review of therelevant literature and in consultation with colleagues (psychologists and GPs). The interviewform covered four domains: the diagnosing of hypertension; the patient's understanding of the


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condition; perception of the relationship between patient and health care provider; and anydifficulties in following the treatment (Box 1).

Box 1 Focus group interviewing guide

How did you find out that you had high blood pressure?

How do you feel about having high blood pressure?

What have you been told about high blood pressure and its treatment?

Have you found it easy to follow the instructions?

Is there anything you would like to say about the care you have received whilst attending thesurgery?

What do you and the doctor usually talk about in the surgery?

When you have taken medication, how has it been for you?

What kind of problems do you encounter when taking the medication?

All focus groups were facilitated by two of the authors (MSO and PPF) who represent differentbackgrounds (psychology and medicine).

Each session began with introductions and a brief explanation of the reasons for the study andof its confidentiality. The same set of questions was posed for each group, although not strictly


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in the same order. Participants were encouraged to talk freely and, if they brought up relevantpoints spontaneously, the order of the questions was varied to maintain the flow of the session.

Data analysis

With patients' permission, sessions were videotaped and later transcribed verbatim. Theanalysis was inductive and followed established conventions for ensuring that the process wasgrounded in the data rather than reflecting a pre-determined analytic framework.11 Theanalysis followed several stages. (i) In order to obtain an overall impression, the transcriptswere read repeatedly by seven researchers (JJG, MSO, BL, DS, PJS, PPF and JJA), who representthree disciplines (medicine, psychology and sociology). (ii) The seven researchers identified,independently, emergent themes. This process was iterative, with new data used to assess theintegrity of the developing analysis. (iii) The researchers met to compare analysis and an on-going dialogue between the researchers contributed to the shaping of the definite categories.(iv) To validate the categories, they were compared with established concepts in publishedresearch in this field from the initial literature review. (v) JJG and MSO examined each interviewline by line to identify relevant text units to be categorized according to the establishedunderlying categories. To ensure compatibility of text categorizing, the two researchersanalysed three transcripts jointly and the others separately. Disagreements between the tworesearchers were resolved by discussion. The analysis was finalized when all relevant text couldbe categorized.

The researchers checked the plausibility of the data interpretation and ensured that thequalitative data analysis was systematic and verifiable, as recommended by experts.9 As weaimed to find aspects related to non-compliance, our analysis focused on negative rather thanpositive outcomes.

Factors identified as influencing treatment compliance fell into three categories: beliefs andattitudes about antihypertensive drugs; beliefs and attitudes about hypertension; and clinicalencounters.

Beliefs and attitudes towards antihypertensive drugs


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Fears were expressed about the long-term use of antihypertensive medication and thepossibility of being stuck with it for the rest of one's life. Negative feelings were elicited in manycases, as antihypertensives were perceived as being damaging and not good for the body. Theadverse effects of drugs were issues of concern to most subjects. In addition, we identified

remarks indicating that the information on medicines provided in leaflets was frightening anddifficult to understand.

I was afraid of the medication, because I was told that once I started to take it I would have totake it all my life. (Participant 2; foc us group 2)

I think that has to be damaging to some part of my body. (Participant 6; focus group 7)

I don't like them (medicines), they have lots of side effects, they can make you sick I thinkthat I might get worse instead of better. (Participant 1; focus group 2)

I read the whole leaflet but I don't understand anything, and even the doctor doesn't explainit. (Participant 1; focus group 4)

I don't even want to read the leaflet, if I did I would never take any medication. (Participant 4;focus group 2)

When analysing the accounts participants gave of the medication that they were currentlytaking, we found that some patients thought that it was perfectly safe not to take it from time

to time and some admitted that they did not always take medication as prescribed. Sometimesthis was simply because they forgot it, especially if the drug had to be taken at regular intervalsthroughout the day. We also found that many patients regarded drug taking as conditional tothe symptoms they were experiencing and, basically, because they felt well, some claimed thatthey had tried to gain personal experiences of the medicines by experimenting to see how theyfelt without them. Associated with this idea was the desire to find out about alternatives suchas reducing the prescribed dose or stopping treatment for a while, once the blood pressureseemed to be controlled. In some cases, the length and routine nature of the treatment causedboredom and, consequently, the desire to drop out. Furthermore, it was also suggested thatthere was more confidence in herbal or natural remedies taken due to common knowledgethan in medicines to alleviate hypertension.

My problem is that I forget to take my medication during the day when I don't have it rightbeside me. (Partic ipant 3; focus group 7)

I've stopped taking the tablets when I've felt like it, sometimes for a fortnight or three weeks just to see. (Participant 6; focus group 6)


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always being busy, and this was mentioned in several cases. In many cases, it was stated thatphysicians did not give any spontaneous information and asked few questions. In addition, itwas emphasized that the physician seldom made eye contact during the consultation and spentthe time just taking notes. Other statements were made to the effect that it was difficult to

understand the physician's language or writing.You only get to see the doctor for five minutes. (Participan t 3; focus group 1)

There's not really any conversation, you're there explaining what's wrong with you and hedoesn't even look at you, he's just taking notes He sends you away with a few words here isyour prescription and that's it. (Participant 7; focus group 6)

The doctors could pay a bit more attention at least or explain things, because sometimes theyexplain it and you just don't understand they should explain it in a different way so that youcan understand. (Participant 1; focus group 2)

In the chemist they write on the box how I have to take the medication because I can'tunderstand what the doctor wrote. (Participant 4; focus group 5)

Some reported that the encounter with the physician created nervousness and that they didnot ask what they wanted to know. It is felt that the physician did not encourage patientinteraction and did not help to create the context that elicits the patients' underlying concernsabout hypertension and its treatment.

Whenever I go to the doctor I would want to ask if I can go running or if it's OK to ride a bicycleor not, but when I go into the surgery I don't feel comfortable and I forget everything I wantedto ask. (Participant 1; focus group 4)

He doesn't even give you the chance to tell him anything or to ask questions. (Participant 2;focus group 2)

In the consultation, the most common lifestyle changes recommended were reductions of saltintake and some exercise, but there were no rational explanations provided by the physician onwhy these changes were beneficial. This information was considered by the patients to be toogeneral and not tailored to the individual.

They give you advice: stop smoking and take some physical exercise, but they don't tell you,say, how to go walking or if you can ride a bicycle or not. (Participant 1; focus group 4)


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They've told me hundreds of times that I have to lose weight and I just don't know howbecause they never explain how to do it. (Participant 7; focus group 6)

This study reveals a complex web of factors that can influence compliance behaviour within agroup of patients diagnosed with hypertension (Figure 1). Although all the findings are not newwith respect to previous literature, these serve to confirm what has been found previously, inthe Spanish context. At first glance, the results indicated negative feelings towards medicines,low awareness about the condition and dissatisfaction with clinical encounters as barriers withregard to following treatment advice. Some of these factors were similar to those found inother studies on compliance in hypertension.7,8,12,,13 In the main, these factors can besummarized in two categories: patient and physician context related. Most of them do haveclear implications for patient management, as the predominant view that emerges is that there

is plenty of room for improvement in the patient physician communication. First, it is,arguably, surprising to discover that patients with a chronic condition, such as hypertension,lack basic background knowledge about it, such as its potential risks and why it is important tofollow the prescribed treatment even in the absence of symptoms. So it does not seem oddthat they also have lay knowledge and beliefs on medication that can, consequently, reducecompliance. These must be addressed by the physician and, if this is the case, adequateinformation should be provided to reduce the fear and anxiety derived from the use of medicines, and hence this will improve compliance. Even so, this study shows that, in theordinary clinical situation, patients often fail to understand what they are told and, what is

more, without this primary basis the patient cannot build up a rationale for the therapy.14 Thisaspect of the doctor patient relationship has been visited previously, where it was argued thatdoctors offer simple instructions on several occasions and yet the patient, due largely toanxiety, does not receive such information.15 This puts the physician in a unique position of responsibility and opportunity to act not only as diagnostician but also as a qualified patienteducator. In this respect, participants in the focus groups put the highest emphasis onphysician's empathetic qualities, in being interested, listening and devoting time to patients.

An exploration of these issues may help the physician discuss with the patient theappropriateness of the proposed treatment and to find alternatives.

This implies that a new perspective on health care, one which goes beyond the biomedical sideof medicine, is needed and that physicians must become more active in their interactions with


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Patient compliance in hypertension: role of illness perceptions and treatment beliefs.

Ross S, Walker A, MacLeod MJ.

Source

Department of Medicine and Therapeutics, Medical School, University of Aberdeen,

Despite many years of study, questions remain about why patients do or do not take medicinesand what can be done to change their behaviour. Hypertension is poorly controlled in the UKand poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs aboutmedicines. This study was designed to describe hypertensive patients' beliefs about their illness

and medication using the self-regulatory model and investigate whether these beliefs influencecompliance with antihypertensive medication. We recruited 514 patients from our secondarycare population. These patients were asked to complete a questionnaire that included theBeliefs about Medicines and Illness Perception Questionnaires. A case note review was alsoundertaken. Analysis shows that patients who believe in the necessity of medication are morelikely to be compliant (odds ratio (OR)) 3.06 (95% CI 1.74-5.38), P


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Hypertension - Medical and Nursing

ManagementHypertension is also called as High blood pressure. Hyper meaning High and Tension meaningPressure. Pressure is the force generated when the heart contracts and pump blood throughthe blood vessels that conduct the blood to various parts of the blood. Hypertension, or highblood pressure, is a persistent blood pressure above 90 mm Hg between the heart beats(diastolic) or over 140 mm Hg at the beats (systolic).

Hypertension does not in itself give dramatic symptoms, but it is dangerous because it causes ahighly increased risk for heart infarction, stroke and renal failure.

There are two major types of hypertension: Essential or primary hypertension and secondaryhypertension. Primary hypertension is the most common condition, found in 95 per cent of thecases. It has no definite cause. There are several factors that may act in combination, causingthe blood pressure to increase. Secondary hypertension is found in five to ten per cent the

cases. Here, the increase in blood pressure is caused by a specific defect in one of the organs inthe body. Treating the affected organ can control or cure the hypertension.

The direct mechanisms causing hypertension is one or more of these factors:

An increased tension in the blood vessel walls.


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An increased blood volume caused by elevated levels of salt and lipids in the blood holding backwater.

Hardened and inelastic blood vessels caused by arteriosclerosis.

The primary causes behind these mechanisms are not fully understood, but these factorscontribute to causing hypertension:

A high consume of salt

A high fat consume.

Stress at work and in the daily life.

Smoking.Over-weight

Lack of exercise.

Kidney failure.

Hypertension Symptoms:

Some of the common symptoms of hypertension are:

Giddiness, Dizziness and a Feeling of Instability.

Palpitations.

Insomnia (inability to sleep well).

Digestive problems and Constipation.

Hypertension is only determined through a blood pressure measurement equipment and readsthe systolic and diastolic of the blood. There is actually no identified sign of hypertension;rather, it varies from one person to another. Some people report to have experiencedheadaches, fatigue, dizziness, blurring of vision and facial flushing.


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Symptoms only surface when signs of end-organ damage are determined or are possible;otherwise, the condition is still considered accelerated hypertension. Malignant hypertension,on the other hand, is caused by increased intracranial pressure. These could be diagnosedthrough retinal examination.

Medical Management for Hypertension

When lifestyle measures and supplements are not enough to cure the condition, medicaltreatment must be applied.

Diuretics, or medicines to increase the urine production, are used to decrease the watercontent in the blood vessels, and thereby reduce the pressure in the vessels. When the watercontent is lowered, the heart does not need to pump so hard any more, and this will alsoreduce the pressure.

Beta-adrenergic blockers are another group of medicines to treat hypertension. This group of medicines block the signals that hormones and neurotransmitters give to the vessel walls, andthe vessel walls then relax. They also slow down the heart rate to give a lower pressure exertedby the heart upon the blood.

Nursing Management for Hypertension

Diet

Diet for Hypertension

The diet is recommended for patients with hypertension:

Moderate salt restriction of 10 g / day to 5 g / day

Diets low in cholesterol and low in saturated fatty acids

Weight loss

Decrease your intake of ethanol


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Stopping smoking

Physical Exercise

Physical Exercise for Hypertension

Physical exercise or regular exercise and directed that recommended for patients withhypertension is a sport that has four principles:

Various forms of exercise that is isotonic and dynamic such as running, jogging, cycling,swimming, etc.

The intensity of exercise is good between 60-80% of aerobic capacity or 72-87% of themaximum pulse-called training zone.

The duration of exercise ranged from 20-25 minutes on the exercise zone

Frequency should exercise 3 times per week and at least a good 5 x per week

Education Psychological

Provision of psychological education for hypertensive patients include:

Biofeedback techniques - Biofeedback is a technique that is used to indicate the subject of thesigns of the state of the body that is consciously by the subject is not considered normal.Application of biofeedback is mainly used to treat somatic disorders such as headaches andmigraines, as well as for psychological disorders such as anxiety and tension.

Relaxation techniques - Relaxation is a procedure or technique that aims to reduce tension oranxiety, a way to train people to be able to learn to make the muscles in the body to relax

Health Education (Extension)

The purpose of health education is to increase patient knowledge about hypertension and itsmanagement so that patients can maintain life and prevent further complications.

rrl hypertension compliance.docx

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