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THE EFFECT OF TEXT MESSAGING ON HOSPITAL VISITS AND BLOOD PRESSURE CONTROL IN LITERATE ADULTS ATTENDING THE OUTPATIENT DEPARTMENT IN BINGHAM UNIVERSITY TEACHING HOSPITAL JOS
SUMMARY
Background: Hypertension is a global challenge and despite the availability of effective treatments, the control of high blood pressure is far from optimal, with lack of adherence to blood pressure lowering medication being a major factor. Non-attendance to hospital outpatient appointment is a major burden on healthcare systems. Text messaging offers a number of benefits over other techniques of reminder like postal card and telephone reminders. The aim of the study was to assess the effect of text messaging on improving hospital visits and blood pressure control in adult hypertensives in Bingham University Teaching Hospital Jos.
Methodology: The study was carried out between July 2013 and January 2014. Seventy- two consenting hypertensives receiving care at the Out Patient Departments of Bingham University Teaching Hospital Jos were recruited and randomly allocated into an Intervention group (those receiving text messages) and a Control group (those not receiving text messages). The sociodemographic characteristics and clinical parameters (blood pressure, height and weight) were obtained from both groups using 72 standardized questionnaires. The data was imputed and analyzed using SPSS (Statistical Package for Social Sciences) software version 20. Results were presented in tables and figures, Relationships were determined using chi-squares, student t-test and statistical means.
Results: Post intervention, at the first visit (four weeks later) there was a statistically significant difference in the mean change in systolic blood pressure (p= <0.000) and mean diastolic blood pressure (p= <0.000) between the Intervention and the Control groups. At eight weeks there was a statistically significant difference in the systolic blood pressure (p=<0.000) as well as the diastolic blood pressure (p=<0.000) between the Intervention and the Control groups. Also at the third clinic visit (after 12 weeks), the mean systolic blood pressure had a statistically significant difference between the Intervention group and the Control group (p=<0.000). There was also a statistically significant difference in the diastolic blood pressure (p=<0.000) between the Intervention and the Control groups over the follow up period.
Following intervention, there was a significant difference in the level of adherence to hospital visits between the Intervention and the Control groups. This difference was statistically significant for the first visit (p= 0.001), second visit (p=0.008) and third visit (p = 0.002) .
Adherence to hospital visits led to an improvement in blood pressure control in the Intervention and Control group.
Conclusion and Recommendations: The results of this study demonstrated that text messaging greatly improved adherence to hospital visits in the Intervention group compared to the Control group. The blood pressure was affected by the intervention as there was a significant difference in the mean change in blood pressure across the hospital visits. From the outcome of this study adherence to clinic appointment led to an improvement in blood pressure control. Text messaging can be used to improve adherence to hospital visit and in turn improve blood pressure control.
TABLE OF CONTENTS
Acknowledgement…………………………………………………………………………i
Declaration…………………………………………………………………………………ii
Dedication………………………………………………………………………………….iii
Certification………………………………………………………………………………..iv
Table of contents……………………………………………………………………………v
List of tables……………………………………………………………………………….ix
List of figures……………………………………………………………………………….x
Abbreviations………………………………………………………………………………xii
Summary………………………………………………………………………………..…..1
CHAPTER 1: INTRODUCTION…………………………………………………..…….3
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Introduction…………………………………………………………………….……….3
- Statement of the problem…………………………………………………….………..7
- Aim and objectives……………………………………………………….……………8 1.4. Justification for the study……………………………………………….……………..8
CHAPTER 2 : LITERATURE REVIEW………………………………..……………10
2.1. Hypertension ……………………………………………………………………….10
2.1.1. Definition and classification of hypertension……………………….………………10
2.1.2. Epidemiology of hypertension……………………………………….……………..12
2.1.3. Pathophysiology of hypertension…………………………………………………..14
2.1.4. Management of hypertension……………………………………….………………22
2.2. Adherence………………………………………………………………….……………34
2.2.1. Definition of adherence………………………………………………….………….34
2.2.2. Factors affecting adherence to hospital visit…………………………….………….35
2.2.3. Methods of improving adherence to hospital visit………………………..………..39
2.2.4. Effect of hospital visit on blood pressure control………………………….……….41
2.3. Text messaging………………………………………………………………….………44
2.3.1. Definition of text messaging………………………………………………….…….44
2.3.2. Effect of text messaging on hospital visit and blood pressure control……………….45
CHAPTER THREE : MATERIALS AND METHODS…………………………………47
3.1. Study area………………………………………………………………………………..47
3.2. Study population……………………………………………………………………….47
3.3. Study design…………………………………………………………………………….48
3.4. Sample size determination………………………………………………………………48
3.5. Sampling method……………………………………………………………………….49
3.6. Selection criteria………………………………………………………………………..49
3.7. Study protocol…………………………………………………………………………..50
3.8. Method of data analysis…………………………………………………………………52
3.9. Ethical consideration…………………………………………………………………..53
CHAPTER FOUR: RESULTS…….……………………………………………………54
4.1. Socio-demographic characteristics of study participants at baseline…………………..55
4.2. Medical history of the study participants………………………………………………58
4.3. Clinical parameters of the study participants …………………………..…………….59
4.4 Adherence to hospital visits among the study participants……….……………………64
4.5. Effect of text message on adherence to hospital visit by the study participants
over three months………………………………………………………………………………………..66
4.6. The relationship between adherence to hospital visit and blood pressure control
among the study participants………………………………………………………………69
CHAPTER FIVE : DISCUSSION, CONCLUSION, RECOMMENDATIONS..……72
5.1. Baseline socio-demographic characteristics of the study participants………………….72
5.2. Baseline clinical parameters of the study participants………………………………….81
5.3. Adherence to hospital visit among the study participants……………………………..84
5.4. The effectiveness of text messaging in improving adherence to hospital visits….…….85
5.5. The effectiveness of text messaging in improving blood pressure control…………….87
5.6. Relation between adherence to hospital visit and blood pressure control……………..89
5.7. Limitations of the study………………………………………………………………..89
5.8. Conclusion………………………………………………………………………………90
5.9. Recommendations……………………………………………………………………….90 5.10. References…………………………………………………………………………….92
CHAPTER ONE
INTRODUCTION
1.1. INTRODUCTION
Hypertension is a global challenge which ranks third as a cause of disability- adjusted life years.1
Estimates indicate that up to three-quarters of the world’s hypertensive population will be in economically developing countries by the year 2025.1 With a worldwide prevalence of 26.4% in
2000, it is projected that hypertension will afflict 29.2% of the world’s population by the year 2025.1
It is the most important cardiovascular risk factor worldwide, Nigeria inclusive, where it affects at least 24.5% of the adult population in a study conducted in Sokoto among ethinc Hausa and Fulanis 2 and it accounts for substantial morbidity and mortality. In a study in South-South Nigeria it was reported that the prevalence was 23.6%, 18% in females, and 31.2% in males.3 This is similar to a study conducted in a suburban Christian community in South west Nigeria where the prevalence was 22.6%.4 In Ga district of Ghana the prevalence rate was 25.4% in a cross sectional study in 2006. 5 This was slightly lower than another study in the Ashanti Region of Ghana with a prevalence of 28.7% .6 Whereas a study conducted in France confirmed higher prevalence rates of hypertension, 44% in males and 42% in females, than those in Sub- saharan Africa.7 The magnitude of cardiovascular disease in Nigeria has become such that needs very urgent attention to avoid an imminent epidemic in the country. It is also a significant cause of burden of disease since its progression has repercussion on the heart, blood vessels, the brain, the kidneys and the eyes.8 In addition to the large health burden, there is an enormous financial burden associated with the disease.9
Recommendations for lifestyle modification to treat and prevent hypertension include the following :
- Performing 30-60 minutes of moderate aerobic exercise four to seven times a week.
- Maintaining a healthy body weight (body mass index of 18.5 kg/m2 _ 9kg/m2) and a waist circumference < 102cm for male and < 88cm for female.
- Limiting alcohol consumption to no more than 14 standard drinks per week for males and 9 standard drinks per week for females.
- Following a diet that emphasizes fruits, vegetables and low fat dairy product, dietary and soluble fiber, whole grains and protein from plant source and food low in saturated fat and cholesterol.10
Antihypertensive therapy should be considered in adult patients regardless of age. Considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme inhibitor (ACEI), long acting calcium blocker, angiotensin receptor blocker (ARB) or Beta blocker. A combination of two first line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic is 10 mmHg above target. 10 Despite the availability of effective treatments, the control of high blood pressure in the community is far from optimal, with lack of adherence to blood pressure lowering medication being a major factor. Poor adherence to prescribed medication regimens is a major problem, as only about half of the patients who have been diagnosed with hypertension adhere to prescribed medications.11
There are several factors that are known to affect adherence to medications which include the age of the patient, low socioeconomic status, co-morbid conditions, severity of disease, 12 side effect of medication and patient’s understanding of the importance of the disease. 13 A study was conducted in 2011 in Gondar Ethiopia among adult hypertensive on drugs and it revealed that longer distance to the health facility was a big barrier to adherence to treatment especially if it was accompanied with poor infrastructure (transportation).14 Fear among patients about the longterm use of antihypertensives and the possibility of being stuck with it for the rest of their life was another cause of non adherence to medication. 15 Other causes of non adherence include low literacy, lack of health insurance coverage, poor social support, family instability and
homelessness.16
Non attendance to hospital outpatient appointment is a major burden on healthcare systems. It is an intractable problem. In the United States of America, more than $ 1.3 million is wasted every year by patients who fail to turn up to the specialist appointments .17 Many reasons for patients not keeping hospital appointments have been reported, including the patient/caregiver forgetting the appointment and confusion over the date and time of the appointment. 18
Previously, various forms of reminders have been assessed, with varying degrees of success in reducing broken appointments. These include the use of automated and personalized phone calls,
but they are costly and time consuming.19
Many different methods to improve adherence to medication regimen have been proposed and tested. Good communication between health care providers and patients can improve adherence and outcomes. Verifying the patients’ understanding of the disease and its treatment and providing education where gaps in understanding exist has also improved adherence to medication. 16 Adequate information provided to the patient can decrease fear and anxiety, but time constraints of Family Physician consultation and resource constraints are an obstacle to addressing individual needs. 15 Correlating medication taking with other daily routine, using medication organizer or charts, decreasing pill burden are other methods that have been used to improve adherence. Mailed refill reminders and self monitoring are methods that achieve smaller improvement in compliance but cost less. 20
Text messaging offers a number of benefits over other techniques. It is a cheaper and more efficient method.21 Short messaging service has the capacity for large batches of individualized group messages to be sent at one time. SMS messages have a number of characteristics that make them appropriate for use in a healthcare setting, including direct patient communication, privacy, confidentiality, swift delivery of messages and receipt of responses, and convenience for health providers and patients.21 A study conducted in Jordan among students in 2012 revealed that though it was a good tool as an educational material, text messaging had limited storage capacity and limited number of characters could be sent at a time.22 A similar study in Ede Federal Polytechnic Osun state among graduating students in 2012 showed that some of the disadvantages of text messaging included that it could be used aid crime especially to perpetuate examination malpractice, it may negatively affect writing skill/grammar, it may be vague and ambiguous because of its abbreviation of language, the message sent could be misinterpreted especially when there were omission of important words needed to make the message complete, it may be mistakenly sent to the wrong recipient and may be responded late if the receiver had a busy or tight schedule. 23 It further revealed that it was limited to literate people. Mobile phone text message system could only be used by those could read and write the language communicated. 23
1.2. STATEMENT OF THE PROBLEM
Despite the development of many effective antihypertensive drugs, target blood pressures are reached in only a minority of patients in clinical practice. Lack of hospital visits invariably leading to poor adherence to drug therapy and the occurrence of side effects are among the main reasons commonly reported by the patient and physician to explain the poor result of actual antihypertensive therapies. 24 Only 50% of patients treated with hypertension medication have their blood pressure controlled and a key factor contributing to poor blood pressure control is suboptimal adherence to prescribed therapy. 25 This has made hypertension one of the primary risk factors for heart disease and stroke, and leading cause of death worldwide. Nearly two-thirds of hypertensives live in low and middle income countries, resulting in huge economic burden.
A study conducted in England revealed that reducing the number of daily dosing appears to be effective in increasing adherence to blood pressure lowering medication and should be tried as a first strategy. There was however no evidence on its effect on blood pressure control.26 Other interventions aimed at patient adherence to medication included patient education aimed at addressing patient’s poor knowledge of hypertension and its consequences. But this did not address misconceptions of patients especially in African Americans who believed it was a curable and not a chronic disease. Home blood pressure monitoring was another intervention; however this did not assess the long term impact on health nor was it cost effective. Behavioral counseling to address misconceptions about hypertension was attempted in the United States of America. It was effective in the first few months of implementation with benefits decreasing over time. 27 A few Nigerian studies have assessed correlates of adherence to antihypertensives medication, especially the use of daily medication reminder (taking drugs at meal time) and additional measure of monitoring blood pressure in the neighbourhood or pharmacy have improved adherence. 28 It was recommended that forming a habit of taking medication could be facilitated through monitoring by the health professional. However this requires that patients have frequent contact with health providers. 28
One of the ways this could be assessed would be through text messaging, which could increase the contact between the patient and health provider. Presently in Nigeria no study has evaluated the effect of SMS on the improvement of blood pressure control and hospital visits.
1.3. AIM AND OBJECTIVES OF THE STUDY
AIM: To assess the effect of text messaging on improving hospital visits and blood pressure control in literate adult hypertensives in Bingham University Teaching Hospital for possible adoption as an adjunct in the management of hypertension.
OBJECTIVES:
- To determine adherence to hospital visits among the study participants.
- To determine level of blood pressure control among the study participants.
- To determine the effectiveness of text messaging on improving adherence to hospital visits among the study participants.
- To determine the relationship between adherence to hospital visits and blood pressure control among the study participants.
1.4. JUSTIFICATION FOR THE STUDY
Worldwide high blood pressure causes an estimated 7.1 millions deaths a year or approximately
13% of total mortality.29 Hypertension and other communicable diseases are currently responsible for at least 20% of all deaths in Nigeria and constitute up to 60% of the patients admitted into the medical wards of most tertiary hospitals in Nigeria. 30
Lack of adherence to blood pressure lowering medication is a major reason for poor control of hypertension worldwide. Several methods have been adopted to improve adherence with little or no improvement in blood pressure control such as lifestyle modification, Patient education, behavior counseling, rewards, once daily/or once weekly dosing schedule. The most effective of the interventions were personalized patient focused programs that involved frequent contact with health professionals or a combination of interventions. In a few studies conducted, text messaging had an effect of improving hospital visits and medication adherence.
The researcher therefore intended to use text messaging as a tool to improve both hospital visits and adherence to antihypertensive medications with the view to improve blood pressure control. It was also intended that this would foster doctor and patient relationship and good communication. The aim was also to apply this in the hospital in the management of hypertensives and possibly patients with other chronic conditions like Human immunodeficiency virus and diabetes.
THE EFFECT OF TEXT MESSAGING ON HOSPITAL VISITS AND BLOOD PRESSURE CONTROL IN LITERATE ADULTS ATTENDING THE OUTPATIENT DEPARTMENT IN BINGHAM UNIVERSITY TEACHING HOSPITAL JOS
