ROLE OF PATIENT EDUCATION IN MEDICATION ADHERENCE AMONG HYPERTENSIVES IN TERTIARY HOSPITALS IN EKITI STATE

ROLE OF PATIENT EDUCATION IN MEDICATION ADHERENCE AMONG HYPERTENSIVES IN TERTIARY HOSPITALS IN EKITI STATE

SUMMARY

Hypertension is a global health issue among the adult population with high morbidity and mortality rates. As the case detection rates of hypertension increase in adult Nigerians, achieving target blood pressure (BP) control has become an important management challenge. Poor adherence to medication is associated with difficulty in achieving target BP control. Therefore, the aim of this study is to determine the role of patient education in medication adherence among hypertensives in tertiary hospitals in Ekiti State.

Quasi-experimental study was performed on 580 adult patients (290 in intervention group and

290 in control group) with primary hypertension who had been on treatment for at least 6 months.

Relevant data were collected using interviewer administered semi-structured questionnaire. Intervention were run based on Hypertension Fact Questionnaire (HFQ) content been used as a patient education guide only for intervention group. The educational session was at every clinic visit.

The difference in the mean knowledge score in the intervention group increased to a statistically significant level (p < 0.05), from 9.5 ± 2.8 to 10.9 ± 3.0. An increase of 8.7 ± 0.2 (p < 0.001) in mean adherence score was found in the intervention group while a marginal difference of 0.2 ± 0.5 (p = 0.059) was found in the control group after the intervention. The knowledge level, adherence status and blood pressure control were statistically significantly different between the two groups (p < 0.05). Knowledge level and adherence to medication had significant association among the intervention group (p < 0.05).

Good knowledge about hypertension is linked to better medication adherence and ultimately improved BP control. Physicians will do well to educate hypertensive patients on hypertension and its treatment with a view to improving medication adherence in them.

TABLE OF CONTENTS

Title page                                                                                                                                i

Declaration                                                                                                                             ii

Certification           iii Dedication           iv

Acknowledgements                                                                                                                v

List of abbreviations                                                                                                               vi

List of Tables and Figures                                                                                                      vii

Table of contents                                                                                                                    viii

Summary                                                                                                                                1

Chapter One: Introduction                                                                                                      2

Chapter Two: Literature Review                                                                                            9

Chapter Three: Materials and Methods                                                                                  43

Chapter Four: Results                                                                                                             52

Chapter Five: Discussion and Conclusion                                                                             77

Recommendations and Limitations                                                                                        91

References                                                                                                                              92

Appendices

• Informed consent form                                                                                                 106
• Questionnaire                                                                                                             107
• Letters of study approval from Ethical and Research Committee                                   108

 

CHAPTER ONE

1.1   INTRODUCTION.

Hypertension is one of the most prevalent chronic diseases. Hypertension presents an overwhelming global challenge and ranks third as a cause of disability-adjusted life-year.^1,2 Childhood and maternal underweight, and unsafe sex ranked first and second respectively. The burden of hypertension is currently centred in economically developed countries, it was projected that developing countries will feel a greater impact due to their larger population proportion.² Indeed study estimated that up to three-quarters of the world’s hypertensive population will be in economically developing countries by the year 2025². Nigeria, like most other developing countries is undergoing epidemiological transition and faces the double burden of communicable and non-communicable diseases.^3,4 Of the latter, hypertension is one of the most important treatable causes of morbidity and mortality.³ This means that developing countries will be under two heavy burdens of communicable diseases and noncommunicable diseases especially hypertension.⁴ This will eventually have negative impact on the already over-stretched and inadequate health facilities in low-resource countries like Nigeria. Whereas communicable diseases exact a heavy toll on younger Africans, hypertension takes its toll on adult and middle-aged African populations on whom the young depends for survival.⁴                                                                It has been well documented that uncontrolled blood pressure increases the risk of ischemic heart disease 3-to 4-fold, ^{5, 6} and the overall cardiovascular risk by 2-to 3-fold.¹ The incidence of stroke increases approximately 3-fold in patients with borderline hypertension and approximately 8-fold in

those                                                with                                                definite                                               hypertension.¹

The reported prevalence of hypertension varied around the world, with the lowest prevalence in rural India (3.4% in men and 6.8% in women) and the highest prevalence in Poland (68.9% in men and 72.5% in women).⁷ According to the national health survey of Pakistan, the prevalence rate of hypertension is 18% in Pakistan population of greater than 15years of age, with a prevalence rate of hypertension of

16.2% and 21.6% in rural and urban population, respectively. In Kuwait, the most recent data on

hypertension showed prevalence rate of 26.3%, while in Cameroun, the reported prevalence varies from 12-22% in those above 25yrs^{7, 8} The prevalence of hypertension in Nigeria, which was 15.3% (urban) and 10.6% (rural) in the general population⁹ was later estimated in the hospital setting to be 15-20%⁴.

Although hypertension is asymptomatic, it usually leads to severe health problems such as stroke, heart diseases, kidney diseases and even death. Hypertension is a major risk factor and a powerful predictor of cardiovascular morbidity and mortality with proven benefit after treatment¹⁰. Therefore, control of hypertension will protect against stroke, congestive cardiac failure and all other causes of mortality. The goal of therapy is to reduce cardiovascular and renal morbidity and mortality. The target blood pressure was defined by the JNC VII and the World Health Organization/International

Society of Hypertension (WHO/ISH) as <140mmHg systolic and <90mmHg diastolic for the general and <130mmHg systolic and <85mmHg diastolic for special high risk populations¹⁰. Treatment may be nonpharmacological (lifestyle modifications), or pharmacological.

Studies worldwide, including many Nigeria studies indicate that despite the availability of safe and effective medical therapy, over half of all hypertensive patients do not take any treatment^11,12 and more than half of those on treatment have blood pressure over the 140/90mmHg threshold.^11,12 The target blood pressure control is important in the management of hypertension and prevention of complications. Good control however depends on good dietary modification, life style modification and adherence to medication. The World Health Organization (WHO) describes poor adherence as the most important cause of uncontrolled blood pressure and estimates that 50–70% of people do not take their antihypertensive medication as prescribed.¹³ Moreover, level of awareness of consequences of nonadherence to antihypertensive therapy was reported to be very low in Nigeria; as high as about 50% of hypertensive patients are ignorant of the disease and its complications.¹⁴ This could be as a result of inadequate information, education and poor communication skills.¹⁵

A lot of factors have been attributed to poor adherence depending on the region and the demographic characteristic of the study, which includes poor knowledge of disease and ignorance of need for longterm treatment, high cost of medications, adverse drug reactions, religious practices and cultural beliefs, lack of access to medical care and facilities and use of complimentary medications and practices¹⁵. Especially common are poor knowledge, understanding and perception of hypertension or when a complex antihypertensive drug regimen is prescribed.

Moreover, poor adherence to therapy has been shown to be associated with an increased risk of complications of hypertension,¹⁶ hence the need for increased awareness and an improved approach to

the management with particular attention to adherence. 

1.2. STATEMENT OF THE RESEARCH PROBLEM. 

Nigeria is a low-resource country with 65% of her 140 million population living below the poverty level¹⁷ and hypertension affects 15-20% of this population.¹⁸ Several studies have shown that

morbidity and mortality due to severe hypertension and its complications is high among Nigerians.^1-4,19 This has been attributed to a combination of factors, most commonly poor knowledge and awareness, poor attitude towards medication use and lack of fund to procure drugs.^3,14,20,21 These and other factors have contributed much to poor adherence to antihypertensive therapy, hence inadequate blood pressure control in majority of patients on treatment.^{3, 14} The reported high incidence of complications

among those on treatment is attributable to poor adherence¹⁴.

Non-adherence with long-term medication for conditions such as hypertension, dyslipidaemia and diabetes is a common problem that leads to compromised health benefits and serious economic consequences in terms of wasted time, money and uncured disease.^{22, 23} In addition, a recent editorial referred to the overwhelming evidence for a decrease in morbidity and mortality with the use of antihypertensive therapy, and it was concluded that the greatest potential for improving control of hypertension lies in improving patient adherence.²³ To achieve this, there is the need for improved awareness and immediate adjustment in the management pattern with emphasis on adherence.³ Adherence to medication is a critical factor in the continued health and well-being of patients with

hypertension.

Most literatures focused on other factors affecting adherence to antihypertensive therapy, but not much has been published on the importance of information, education and counselling of patient by the attending physician on adherence to antihypertensive medication. However, few studies have suggested patient education as a useful tool to be taken seriously in managing people with

hypertension^{15, 24, 25}.  This study therefore set to address this knowledge gap by determining the relationship between patient education and adherence to medication among hypertensive accessing care in tertiary hospitals in Ekiti State, South West Nigeria.

 

 

1.3 DEFINITIONS OF THE RESEARCH SUBJECT.

Hypertension: The author defined hypertension as a systolic BP ≥ 140mmHg and diastolic BP ≥ 90mmHg or documented use of antihypertensive medications in a person previously diagnosed with hypertension.¹⁰  A patient was defined as having good BP control if his or her BP at the end of study visit was ˂ 140mmHg and ˂90mmHg by systolic and diastolic respectively.²⁶  Antihypertensive therapy: There are different classes of anti-hypertensive mediations viz: diuretics, beta –blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blocker, calcium channel blockers, alpha adrenergic antagonist, centrally acting antihypertensive drugs and direct vasodilators.^10,27

Adherence: Adherence is defined by WHO as “the extent to which a person’s behaviour–taking medication, following a diet, and/or executing lifestyle changes-corresponds with agreed recommendations from a health care provider”.⁶ An adherent patient was defined as one who had a value of ≥ 80% of Morisky medication adherence score at the time of study visit.

Patient education: This is the process by which healthcare professionals impart information to patients that will alter their health behaviours or improve their health status.²⁸

 

1.4    JUSTIFICATION FOR THE STUDY 

It has been noted that those who are the custodian of knowledge of hypertension and its resultant complication, the Physician, often times don’t adequately inform and educate patients about the disease and the need to meticulously take drugs regularly. Patients were not adequately informed that hypertension is not curable and that it is only controlled with diet, exercise, lifestyle modification and drugs. The importance of treatment in preventing complications related to the disease is not stressed, likewise the importance of regular monitoring of the BP and regular medical follow up are not stressed and reinforced at every clinic visit. Often times physicians just write prescriptions without considering the socio-economic state of the patient, which can result in poor adherence, because, patient cannot afford the prescribed drugs. This results from poor doctor-patient relationship. Patient centred care, in which patient is carried along in management plans helps in arriving at prescribing drugs that is most effective, available and affordable. Such patient centred care usually enhance adherence to medication.

This study, therefore, intends to identify the role patient education can play in medication adherence, hoping for an improved adherence to medication by patients. Family Physicians as frontline Physician can play a major role in managing hypertensive patients effectively, particularly as regard improving their medication adherence from improved doctor-patient relationship, on which patient education can thrive.

Evaluating the effect of patient education on antihypertensive drug adherence will hopefully provide useful data in the reduction of morbidity and mortality from hypertension and improve survival of affected patients.

                 

1.5. AIM AND OBJECTIVES

AIM:

To determine the role of patient education in medication adherence among hypertensives accessing care at Federal Medical Centre, Ido-Ekiti and Ekiti State University Teaching Hospital, Ado-Ekiti with a view to achieving optimal blood pressure control, thereby reducing the morbidity and mortality associated with poorly controlled blood pressure.

OBJECTIVES:                                                           

1. To assess the knowledge of respondents about hypertension
2. To estimate the extent of medication adherence among respondents
3. To determine the influence of patient education in medication adherence and blood pressure control in the respondents

 

ROLE OF PATIENT EDUCATION IN MEDICATION ADHERENCE AMONG HYPERTENSIVES IN TERTIARY HOSPITALS IN EKITI STATE

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