|Year : 2015 | Volume
| Issue : 1 | Page : 18-23
Prevalence of non-adherance and its associated factors of hypertensive patients at Jimma University Specialized Hospital in Southwest Ethiopia
Asmamaw Yenesew, Fanta Gashi, Ramanjireddy Tatiparthi
Department of Pharmacy, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
|Date of Web Publication||5-Jun-2015|
Department of Pharmacy, Jimma University, P.O. Box 378, Jimma
Source of Support: None, Conflict of Interest: None
Background: Hypertension is an overwhelming disorder worldwide with high morbidity and mortality rates; this may be due to poor adherence. Poor adherence leads to a bad outcome of the disease and increases the more loss of expenditure on resources. Adherence is a methodology of coincidence between the medication advices and patient's medication management behavior; it includes dosing frequency and time of intake. This study mainly focuses on the prevalence of adherence and its factors affecting on hypertensive patients follow-up at Jimma University Specialized Hospital (JUSH).
Methods: It is a hospital-based cross-sectional survey designed with a sample size of 150 subjects. This study is conducted at chronic ambulatory care unit in JUSH from January 24 to February 7, 2014. The collected data were executed for 95% confidence interval between the various demographic levels to identify the significance of the results.
Results: The sociodemographic survey of this study showed from the total of 150 respondents, majority of the characteristics were in the categories of sex, female subjects have higher percentage of 56.7% non-adherence significantly, when compared with male subjects, the same significance was observed in age group of 50 years and illiterates of educational level in 63.3% and 50%, respectively. The significant differences were not observed in the characteristics of occupation, area of residence, income, and marital status of the participants. Various factors was analyzed to determine the different reasons behind the non-adherence of hypertensive medication, most of them (120 subjects) reported side effects of hypertensive medications and forgetfulness is one of the major factors, that misses their medication, followed by financial and religious believes.
Conclusion and Recommendations: The non-adherence to hypertensive medication was high at JUSH. Hence, the pharmacists and other health care professionals should work in collaboration for escalating the patient's quality of life. They need to stress the importance of antihypertensive adherence to the patient's life and the benefits of their medication.
Keywords: Associated factors, hypertension, Jimma University Specialized Hospital, non-adherence
|How to cite this article:|
Yenesew A, Gashi F, Tatiparthi R. Prevalence of non-adherance and its associated factors of hypertensive patients at Jimma University Specialized Hospital in Southwest Ethiopia. Indian J Health Sci Biomed Res 2015;8:18-23
|How to cite this URL:|
Yenesew A, Gashi F, Tatiparthi R. Prevalence of non-adherance and its associated factors of hypertensive patients at Jimma University Specialized Hospital in Southwest Ethiopia. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 Aug 24];8:18-23. Available from: http://www.ijournalhs.org/text.asp?2015/8/1/18/158216
| Introduction|| |
The prevalence of hypertension (HTN) is very high at worldwide and most of the studies showed that despite the availability of effective medications, half of the patients are not cover,  and more than half of them have blood pressure (BP) >140/90 mmHg.  Approximately 50 million individuals were suffering from HTN in USA and more than 1 billion at worldwide.  HTN burden is increasing at exponential speed in both developed and developing countries; it is expected to one-third of the hypertensive patients by 2025. 
Along with growth of the hypertensive patients, co-morbidity and mortality rates are also increasing significantly, this may be due to poor adherence. It is one of the biggest challenges to the health care professionals to adhere the patients. HTN can attacks to the irrespective age of people.  Based on lack of studies available on adherence of patients at Jimma University Specialized Hospital (JUSH), it is the one of the oldest public attending hospitals in Southwest Ethiopia, established in 1937 by Italian raiders. Geographically, it is located at Jimma city, 350 km Southwest away to the Ethiopian capital, Addis Ababa. It provides the service for inpatients and outpatients throughout the year. The chronic ambulatory care is one of the major services providing by the JUSH.  This study was designed to assess the magnitude and its associated factors of non-adherence on hypertensive patients.
As WHO describes poor adherence is one of the most important cause of uncontrolled BP and it increases the risk of ischemic heart disease 3-4 fold  and the overall cardiovascular risk by 2-3 fold.  The incidence of stroke increases approximately 3-fold in the patients, those who are on borderline HTN. The term, adherence is preferred over compliance because it is a collaborative relationship between the patients and the healthcare-workers.  Compliance is a person's medication-taking behavior coincides with the medical advices given to him.  Adherence includes both dosing regularity and timing of intake, and for some specific patient populations (e.g. for HIV/AIDS patients).
Adherence can see in different forms, patients may fail in right dose, right time, and frequency of dose. Non-adherence also involves in time of food intake, leads to changes in the bioavailability and metabolism. If a health care professional does not identify the cause of non-adherence, it becomes more difficult to solve non-adherence. This can be achieve by self-reporting, pill counting, and in some cases measuring serum or urine drug levels. Most of these, self-reporting are the most practicable and can recommended.
Although the efficacy of antihypertensive (AHT) agents has been confirmed, the maintenance of BP levels within the desirable range remains unsatisfactory. This may be due to non-adherence; it becomes an issue of treatment effectiveness.
According to the WHO,  adherence is a multidimensional phenomenon determined by sets of factors, termed "dimensions," which involve socioeconomic factors, medication therapy, patient condition, the health care provider and health care system.
An early study by Haynes et al.  showed that adequate control of HTN was associated with taking at 80% of a prescribed regimen. Non-adherence rates for patients with HTN are reported to be 50% after 1-year and 85% after 5 years. , There is a lack of studies conducted about the adherence on AHT therapy in Ethiopia, this study is designed and it can help to increase the awareness among the medical officers, prescribers, pharmacists, other health care professionals, and managers of healthcare to develop different strategies to minimize non-adherence to the therapy.
Poor adherence to AHT is usually associated with a bad outcome of the disorder and wastage of limited health care resources. In Ethiopia, particularly in this study area, very little is known about the adherence status and associated factors. Therefore, A cross-sectional study organized to assess prevalence of adherence and its associated factors for AHT therapy among the patients, who follow-up at JUSH from January 24 to February 7, 2014.
| Methods|| |
Non-adherence was defined as the patients who taken few or no doses of regimen prescribed by the health care professionals.
Moderately adherence was defined as the patients, those who taken many doses, but not regularly enough to control their disorder.
Adherence was defined as the patients, those who taken adequate the amounts of medications in accordance with prescribed regimen.
Study design and subjects
A cross-sectional based study was designed on outpatients attending at JUSH. Minimum 6 months of patients under medication were selected and ensured that all the patients were in the age between 18 and 80 years followed up the visit from January 24 to February 7, 2014. The study population was determined to be count of 150 subjects.
Hypertensive patients, those who are admitted to the inpatient wards, pregnancy related HTN, and the patients diagnosed hypertensive but <6 months of medication were excluded from the study.
The following factors selected to study the results, sociodemographic characteristics; medication related factors, side effects of the therapy, reasons for the non-adherence were determined.
Data collection and data processing
Properly defined and structured questionnaires were used to collect the data from every participant in this survey. Seamless training was given to the data collectors and continuous advices kept them to maintain the quality of the data. Close supervision has made by the principal investigator and counter checked the collected data.
Data analysis was performed to check the accuracy, consistency, and ensure to avoid the missing of instructions during the collection of data. The 95% confidence interval was used to determine the presence and strength of association. P < 0.05 is considered as significant for analysis. Each study participant was adequately informed about the purpose of the study by data collectors and was assured to maintain the confidential.
| Results|| |
A total of 150 patients were interviewed and data collected by using questionnaires. From total of the patients 85 (56.7%), 65 (43.3%) were female and male, respectively. The majority 73.3% of the study participants were married and 63.3% of the patients are in the age group of >50 years. The half of the study population were illiterates and 49.3% were have income between 501 and 2000 Birr/month and most of them (63%) are living in rural areas. Significant differences were observed between the sex, age, and educational level of the participants can be seen in [Table 1].
|Table 1: Sociodemographic characteristics of study participants at JUSH |
Click here to view
The majority 70 (46.7%) of the patients were on AHT for 2-4 years and 30% were had a family history. Most of the respondents 56.7%, 38% were on BID and TID, respectively. The 48.7% of the patients on more than three drugs daily. The cost of therapy bears themselves (64%). The last follow-up visit of 90 (60%) of the patient was before 1-month or less, followed by 50 (33.3%) patients with last 2 months ago. A greater portion of subjects 80 (53.3%) had systolic BP (SBP) of 140/90-159/99. Among the total, 24% of patients has developed complications and 41.7% of them developed cardiovascular disease. Majority (58%) of the patients had frequent mood of depression. Only 75 (50%) of the study subjects were initially diagnosed through symptoms. These all results can be seen in [Table 2].
At least one side-effect of AHT therapy had been reported by the 80% of participants. Majority of the side-effects are fatigue (100%), headache (95%). peripheral neuropathy (70%), gastrointestinal (GI) side-effects (65%), cough (50%), and 53% of respondents misses their medication by different reasons can see in [Figure 1].
|Figure 1: Side effects reported by hypertensive patients at Jimma University Specialized Hospital|
Click here to view
Majority of the missing dosage due to forgetfulness (28.3%), finance burden (50%), followed by religious believes (19.6%) can see in [Figure 2].
|Figure 2: Reasons for non-adherence at Jimma University Specialized Hospital|
Click here to view
Total of the study subjects, 79 (52.9%) were adherent, 31 (20.7%) were moderately adherent, while 40 (26.4%) were non-adherent to their AHT therapy.
| Discussion|| |
In the present study, non-adherence is assessed by using the interview method. This method is simple and practical. However, in this study, the output might be overestimated. To prevent this, questions in the Morisky medication adherence scale are phrased to avoid "yes saying" bias by reversing the wording of the questions about the way patients might experience failure in following their medication regimen.
The majority of participants in this study (56.7%) were females, their mean age is 54.7 years and 50% of them were illiterates, non-adherence is significant association with both sex and age of the participants. This result is in the same line of a study done in Malaysia, where 62.8% females were participated; and their mean age was 57.8 years.  This result is less than a study conducted in Nigeria,  where 71.9% of the study patients were females and 82.4% of the subjects were illiterates also. A similar study conducted in the city of Gondar,  where 78.4% were married and 64% of the subjects were lack of family support on adherence and 33.9% were paying expenditure by themselves.
In a study done in Pakistan  availability of support is greater (54%) and 37% of medical expenses bears by the family.
The 53.3% of the subjects has SBP between 140/90 and 150/99, this is in line with a study in Gondar was 53.4%, higher than 30.4% and 43% of the patients in Brazil  and USA. 
The dose of the regime has contained at least 43.3% of patients, but a study done in Brazil reveals that 56.9% of the subjects had only one drug. In the duration  of study range between 1 and 3 years has 46.7%, but it is <53% in Ghana. 
In the present study, 50%, the study subjects were initially diagnosed as hypertensive through checkup for HTN related symptoms and only 16.7% of them were diagnosed with regular checkup indicates the patients attended at the end stage of HTN leads to tough control of BP. These results when compared to a study conducted in Pakistan, where 70.8% of the patients attended their medical checkup at end stage. This is similar to the study conducted in Malaysia,  where 53.4% were adherents in Gondar,  64.6% were adherent in Nigeria. 
Co-morbidities result from serious complications and complex regimens are favorable conditions leads to non-adherence. Co-morbidities have a significant association with non-adherence. The right education of hypertensive therapy creates a clears the perplexity about the treatment and conditions of the patients. Patient's need more awareness is more likely to adhere to their treatment.
A National Health Survey of Pakistan showed that HTN affects 18% of adolescents above 15 years of age and 33% of adults above 45 years of age and they estimated that 50-70% of people do not take their medication as prescribed. 
| Conclusion and Recommendations|| |
Subjects between the age of 50 and above were mostly affected by the HTN, and women were more vulnerable to the disorder. The clinical signs and symptoms mostly reported by the patients include fatigue, severe headache, numbness of extremities, and GI effects. Early diagnosis and management of co morbidities, adherence counseling, and patient education about the disease and its treatment is important to improve the adherence status of patients.
Majority 65 (28.3%) of patients misses their medication due to forgetfulness, followed by financial problem 50 (21.7%), religious 45 (19.6%).
This study has the following limitations: Self-reporting was used as the only method of measuring adherence. In addition, it did not consider the hypertensive patients who did not visit the hospital during the time of the study. Hence, the extent of generalizability is limited only to those similar patients who are on chronic illness follow-up care.
Patient adherence to anti-hypertensive medication was estimated as 52.9% in the study and non-adherence was 26.4%. This has several implications to the health delivery system and pharmacy practice in the country. The following recommendations are intended to assist health institutions to offer better medication counseling and to design better strategies for optimal adherence rates.
- The pharmacists, dispensing technicians should be adequately trained in proper counseling to hypertensive patients on their medication
- Effective communication and counseling techniques for pharmacists and pharmacy staff should be developed through regular in-service training
- Physicians must educate their patients about their conditions and the importance of adherence
- The hospital should have free service for special case like for very poor patients and for very old patients who had no sufficient income for themselves.
| References|| |
Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002;288:455-61.
Brody DS. An analysis of patient recall of their therapeutic regimens. J Chronic Dis 1980;33:57-63.
Angaran DM. Telemedicine and telepharmacy: Current status and future implications. Am J Health Syst Pharm 1999;56:1405-26.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.
Habtamu A, Mesfin A. Assessments of adherence to hypertension medications and associated factors among patients attending Tikur Anbessa Specialized Hospital Renal Unit, Addis Ababa, Ethiopia. Int J Nur Sci 2013;3:1-6.
Edo TA. Factors affecting compliance with anti-hypertensive drug treatment and required lifestyle modifications among hypertensive patients on Praslin Island. Afr J Nurs Midwifery 2012;14:3-17.
Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P, et al.
Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension 1995;26:60-9.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al
. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289:2560-72.
Balkrishnan R. The importance of medication adherence in improving chronic disease related outcomes: What we know and what we need to further know. Med Care 2013;9:1-44.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.
Whitworth JA, World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens 2003;21:1983-92.
Haynes RB, Taylor DW, Sacket DL, editors. Compliance in Healthcare. Baltmore, Md: The John Hopkins University Press; 1979. p. 49-62.
Garfield FB, Caro JJ. Achieving patient buy-in and long term compliance with antihypertensive treatment. Dis Manag Health Outcomes 2000;7:13-20.
Caprara A, Rodrigues J. Asymmetric doctor-patient relationship: Rethinking the therapeutic bond. Ciên Saúde Colet 2004;9:139-46.
Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med 1990;150:1881-4.
Eselin JA, Carter BL. Hypertension and left ventricular hypertrophy: Is drug therapy beneficial? Pharmacotherapy 1994;14:60-88.
Conrad P. The meaning of medications: Another look at compliance. Soc Sci Med 1985;20:29-37.
Hawkins DW, Bussey HI, Prisant LM. Hypertension in Dipiro′s Pharmacotherapy. A Pathophysiologic Approach. New York: Elsevier; 1992. p. 139-43.
Horne R, Weinman J. Patients′ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 1999;47:555-67.
Baum D, Creer TL. Medication compliance in children with asthma. J Asthma 1986;23:49-59.
Plange-Rhule J, Phillips R, Acheampong JW. Hypertension in renal failure in Ghana1. J Hum Hypertens 1997;3:37-40.
Ahmad NS, Ramli A, Islahudin F, Paraidathathu T. Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia. Patient Prefer Adherence 2013;7:525-30.
Chelkeba L, Dessie S. Antihypertension medication adherence and associated factors at Dessie Hospital, North East Ethiopia, Ethiopia. Int J Res Med Sci 2013;1:191-7.
Adeyemo A, Tayo BO, Luke A, Ogedegbe O, Durazo-Arvizu R, Cooper RS. The Nigerian antihypertensive adherence trial: A community-based randomized trial. J Hypertens 2013;31:201-7.
Ohene Buabeng K, Matowe L, Plange-Rhule J Unaffordable drug prices: The major cause of non-compliance with hypertension medication in Ghana. J Pharm Pharm Sci 2004;7:350-2.
[Figure 1], [Figure 2]
[Table 1], [Table 2]