Treatment adherence and its determinant factors amongst outpatients with Hypertension: A Case of Iran

 

Najimeh Beygi1, Mahlagha Dehghan2, Sedigheh Iranmanesh3

1MS Student of Critical Care Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

2Assistant Professor, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

3Associate Professor, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

*Corresponding Author Email: m_dehghan86@yahoo.com

 

ABSTRACT:

Background: hypertension is known as a dangerous and life threatening disease without any clinical symptom. Lots of patients have not controlled their hypertension well due to poor adherence to treatment regimen. The aim of this study was to investigate adherence to treatment regimen among hypertensive patients of Fasa city in Iran.

Method: This was a cross-sectional study. Participants: Two hundred patients with primary hypertension were selected using convenience sampling. Data were gathered by a two-part questionnaire including 1) demographic information form, and 2) Hypertensive Treatment Adherence Scale. Results: Findings showed that mean score of adherence to treatment regimen was 86.22 ± 7.68. 53.5% of patients adhered to their treatment regimens. Also, those patients with insufficiently controlled blood pressure had lower adherence to their treatment regimens than those patients who controlled their blood pressure sufficiently. Conclusion: Findings indicated that adherence to treatment regimen among patients with hypertension is acceptable in Iranian population but it is far from the ideal condition.

 

KEYWORDS: Hypertension, Adherence, treatment, high blood pressure.

 

 


INTRODUCTION:

Hypertension is one of concerns throughout the world. Such disease has brought about extensive challenges in health of society (1). Hypertension is one of the most prevalent risk factors for cardiovascular diseases leading to myocardial infarction, brain storm, cardiac failure, vision disorders, renal failure and early death (2). Hypertension is the cause of 7.5 million deaths in the world and this amount includes 12.8% of all deaths (3).

 

Approximately, 65 million people in America are affected by hypertension and the incidence of hypertension is increasing continuously (4). In Iran, incidence of hypertension in 30-55 year old population and those older than 55 years have been estimated by 23% and 50% respectively. This disease has reported by 1.3% in men compared to women (3).

 

Like most of chronic diseases, this illness has a close relationship with life style, mental health and patient’s quality life and if it is not well controlled, it will cause different diseases, considerable disability, reduction of productivity and life quality (5). Therefore, concerning its high incidence, it is very important to treat hypertension which has been paid attention by health systems (6). According to studies available in Iran, treatment of such disease is difficult for many patients and about half of hypertensive patients are under treatment among whom only 30% of patients controlled their hypertension (3).

 

Concerning long duration of treatment and lack of disturbing symptoms of hypertension, patients usually avoid taking their medications and the most common cause of uncontrolled hypertension is lack of adherence to treatment regimen. 50% of chronic patients in developed countries (compared to developing countries) have adhered to their treatment regimen (1). Results of a study done in America showed that between 30 and 60% of patients adhered to their treatment regimen (7). Also, a study done in Iran shows that about 60% of hypertensive patients do not adhere to their medicinal and non-medicinal treatment regimens (8).

 

Non-adherence to treatment regimen (defined as; lack of matching of individual behavior with treatment advices) is a complex behavioral process and many factors such as personal characteristics of patients, the mutual relationship between patient and doctor and healthcare system are effective on it (9). among the most common causes of non-adherence to treatment regimen are side effects of medications, forgetfulness, belief in ineffectiveness of medication and high price of medications and they may have detrimental consequences such as relapse of disease, hospitalization and increase of side effects like relative risk of death for patients with coronary artery disease and increase of mortality. In contrast, increasing adherence to treatment regimen will improve considerably outcomes of the treatment (10).

 

Considering that long term adherence to treatment in chronic diseases such as hypertension is an important means for increase of effects of medications (11), it is necessary to correct behavior (diet, exercise, smoking, avoiding alcohol, and taking medication) and to increase information about risks of hypertension for controlling the disease (4). Few studies have been conducted in Iran about treatment adherence in patients with hypertension and they have addressed medication adherence among such patients. Therefore, the present study aims to investigate condition of adherence to treatment regimen in patients with hypertension in Fasa city, in Iran.

 

METHODS:

Study design and setting:

This was a cross-sectional study. The research setting was cardiac clinic of Valiasr hospital in Fasa city, in Iran.

 

Sampling and sample size:

The research population was hypertensive patients who referred to the Valiasr hospital. The research sample was all hypertensive patients who had criteria for entering the study or wanted to participate in the study. Inclusion criteria were: 1) hypertensive patients who were taking at least one anti-hypertensive drug, 2) having hypertension for at least 6 months, 3) being able to read and write and to understand Persian language. Also, exclusion criteria were: 1) having severe physical problems such as brain storm, cancer, hepatic failure, end stage cardiac failure, 2) having secondary hypertension (hypertension resulted from a specific reason such as renal diseases or diseases of endocrine glands or pregnancy induced hypertension). Connivance sampling was used. The following formula has been used to estimate the amount of the sample size.

            Z2 * SD2

n = ---------------

            d2

Confidence coefficient was considered 95%. The amount of d has been considered as 0.15 (SD). Therefore, the sample size was 171 and concerning the missing probability, 200 subjects were considered.

 

Measurements:

Data was gathered by a two part questionnaire. The first part includes demographic and clinical characteristics such as age, gender, married status, education, occupation, income, duration of having hypertension, duration of taking anti-hypertensive drug, number of anti-hypertensive medications, having other diseases, amount of systolic and diastolic blood pressure and body mass index (BMI).

 

The second part was Hypertensive Treatment Adherence Scale (HTAS). This scale was designed and validated by Dehghan et al. in 2015 (12, 13). HTAS includes 23 items with 4 subscales such as medication adherence and monitoring (8 items), adherence to diet (10 items), exercise (2 items), and smoking (3 items). The scoring was based on five point Likert’s scale (no= 1, yes frequently=2, yes sometimes= 3, most of the times=4, yes always=5). On this basis, the scores resulted from this scale will range from 23 to 115. Psychometric results of this scale showed that this scale was acceptable regarding face validity, construct and criterion validity. Also, internal consistency of the scale was 0.76 and test-retest coefficient was 0.74. According to HTAS, scores above 86 indicate adherence to treatment regimen and scores £ 86 indicated non-adherence to treatment regimen (12).

 

Data collection:

The questionnaire was given to eligible patients. A nurse answered the questions of patients when completing the questionnaire. The same nurse measured patients BMI and blood pressure. A skillful nurse was introduced to cardiac clinic of Valiasr hospital in order to measure blood pressure. Blood pressure was measured by calibrated sphygmomanometer (NOVA, made in Germany). Patients had to avoid drinking Caffeine (Coffee and tea), alcohol, and tobacco 30 minutes before measuring their blood pressure.  They had to eat breakfast, their bladders should be empty and they should not take adrenergic drugs. They have to rest 5 minutes before measuring their blood pressure and they should not speak with anybody during measuring their blood pressure. The blood pressure was measured twice in seating position from the right hand and with 10 minute interval between each measurement. If the blood pressure was ≥ 140/90 mmHg (in patients with diabetes ≥ 130/80 mmHg), indicated insufficiently controlled, and if it was < 140/90 mmHg (in patients with diabetes < 130/80 mmHg), considered as sufficiently controlled hypertension (14). The weight and height of the patients were measured by the same nurse. The weight was measured with light cloths by a digital scale (Sanayeh Pand Co, made in Iran) and the height was measured in upright position by a meter. Body Mass Index (BMI) was calculated by following formula:

           Weight (Kg)

BMI= -------------------------

           Height (m2)

 

BMI less than 18.5 was considered as the low weight, between 18.5 and 24.9 as normal, between 25 and 29.9 as overweight and higher than 30 as obese.

 

Statistical analysis:

All data were analyzed by SPSS version 18. Descriptive statistics (frequency, percentage, mean, and standard deviation) was used in order to describe demographic and clinical characteristics and treatment adherence of subjects. Also, univariate and multi-variate linear regressions were applied to determine the relation between demographic variables and treatment adherence score in patients with hypertension. The 0.05 significance level was used in this study. 

 

Ethical consideration:

This project was approved by Kerman University of Medical Sciences (KUMS). The Ethics Committee of KUMS confirmed all processes and procedures used in the study (IR.KMU.REC.1394.474). After approval of KUMS and Valiasr hospital, we provided information about: 1) the goal and objectives of the study, 2) the confidentiality of the data, and 3) that the participants would be anonymous and were free to withdraw from the study at any time to all subjects. An informed consent was taken from participants who chose to participate in the study.

 

RESULTS:

Socio-demographic characteristics:

In total, 200 hypertensive patients were assessed. The mean age of participants was 58.23 ± 13.45 years. 71% (n = 142) of the participants were women and 77.9 % (n= 155) were married. 60% (n= 120) of the participants were housewife, 25% (n= 50) were employed, 10% (n= 20) were retired and 5% (n = 10) were unemployed. 44.5% (n = 89) of the patients were illiterate, 34 % (n = 68) had under diploma degree, 14% (n = 28) had diploma and 7.5% (n = 15) had above diploma degree. 65% (n= 130) of the participants had another chronic disease except HTN.  Duration of having hypertension was 6.98 ± 6.0 years and initiation of hypertension drug therapy was 6.74 ± 5.97 years. 72.1% (n = 142) of the patients have been prescribed one antihypertensive drug. The mean score of systolic and diastolic blood pressures were 129.82 ± 20.11 and 77.49 ± 10.08 mmHg respectively. 73% (n = 146) of the participants had sufficiently controlled blood pressure. The mean score of BMI was 22.54 ± 4.18 and 64.5% (n = 129) of the participants were normal, 14% (n= 28) were thin, 15.5% (n = 31) were overweight, and 6% (n = 12) were obese.

 

Treatment adherence:

According to the HTAS, treatment adherence was 86.22 ± 7.68 in patients with hypertension. According to the cut-point value of 86, 53.5% (n = 107) of the participants had treatment adherence and the rest (n = 93) did not adhere to their treatment recommendations. Among treatment adherence items the highest and lowest mean score belonged to “Do you smoke hookah (shisha)?”  (4.88 ± 0.58) and “Do you eat boiled-made foods?” (2.27 ± 1.29) respectively. The mean score of 12 items were above 4 and the mean score of 5 items were less than 3 (Table 1).

 

Associations:

The result of univariate linear regression showed there was significant correlation between treatment adherence and systolic blood pressure, diastolic blood pressure, and sufficiently controlled blood pressure (Table 2). We further conducted multi-variate linear regression with variables that had P value < 0.2 (i.e. systolic blood pressure, diastolic blood pressure, sufficiently controlled blood pressure, and compound therapy). The result showed that only sufficiently controlled blood pressure variables predicted treatment adherence score significantly (Table 3). The adjusted R2 was 0.08 and the

model goodness of fit was acceptable (F = 5.17, P = 0.001) (Table 3).


Table 1. Distribution of the Responses to the Hypertensive Treatment Adherence scale (n = 200)

No

Items

Mean (SD)

Response, n (valid percent)

No

Yes but rarely

Yes, occasionally

Yes, frequently

Yes, always

1

Do you take your antihypertensive medication based on its prescription?

4.27 (0.84)

3 (1.5)

5 (2.5)

18 (9)

82 (41.3)

91 (45.7)

2

Do you ever supply and continue your previous antihypertensive medication without referring to physician?

3.62 (1.41)

87 (43.5)

22(11)

35 (17.5)

40 (20)

16 (8)

3

Do you sometimes stop taking your medication due to any reason?

4.03 (1.05)

87 (43.8)

51 (25.6)

43(21.6)

15 (7.5)

3 (1.5)

4

Do you increase or decrease taking your medication without consulting with your physician?

4.06 (1.17)

109 (54.5)

23 (11.5)

43 (21.5)

21 (10.5)

4 (2)

5

Do you measure blood tests based on your physician order regularly?

3.92 (0.63)

4 (2)

6 (3)

5 (2.5)

171(85.5)

14 (7)

6

Do you control your blood pressure weekly?

3.26 (1.64)

53 (26.5)

20 (10.1)

15 (7.6)

43(21.7)

67 (33.8)

7

Do you refer to your doctor for controlling your blood pressure status each 3-6 months?

4.1 (1.07)

8 (4)

15 (7.5)

13 (6.5)

78 (39)

86 (43)

8

Do you refer to your doctor in pre-determined appointment?

4.44 (0.73)

2 (1)

3 (1.5)

7 (3.5)

82 (41)

106 (53)

9

Do you eat boiled-made foods?

2.27 (1.29)

76 (38)

47 (23.5)

43 (21.5)

16 (8)

18 (9)

10

Do you eat votive foods if available?

2.85 (1.61)

65 (32.6)

29 (14.6)

24 (12.1)

32 (16.1)

49 (24.6)

11

Do you comply with low salt diet?

3.72 (1.29)

22 (11)

13 (6.5)

29 (14.5)

70 (35)

66 (33)

12

Do you eat high fiber foods and vegetables daily?

3.35 (1.0)

8 (4)

28 (14)

75 (37.5)

64 (32)

25 (12.5)

13

Do you eat fruits daily?

3.39 (1.0)

7 (3.5)

28 (14)

71 (35.5)

68 (34)

26 (13)

14

Do you eat whole grain product such as barley bread daily?

2.68 (1.18)

38 (19.1)

51 (25.6)

63 (31.7)

31 (15.6)

16 (8)

15

Do you eat fast-foods such as sandwiches and pizza?

4.59 (0.79)

145 (72.5)

37 (18.5)

11 (5.5)

5 (2.5)

2 (1)

16

Do you eat sugar, cube-sugar or sweets?

4.04 (0.94)

70 (35)

85 (42.5)

30 (15)

12 (6)

3 (1.5)

17

Do you eat junk foods such as chips and cheese puff?

4.57 (0.77)

140 (70.4)

38 (19.1)

16 (8)

4 (2)

1 (0.5)

18

Do you drink coffee?

4.75 (0.71)

171 (85.5)

16 (8)

8 (4)

2 (1)

3 (1.5)

19

Do you do exercises such as walking, swimming or cycling, 4-7 days per week?

2.38 (1.51)

87 (43.7)

37 (18.6)

16 (8)

31 (15.6)

28 (14.1)

20

Do you do exercises or walking for about 30-60 minutes, each time?

2.3 (1.52)

99 (49.5)

28 (14)

12 (6)

36 (18)

25 (12.5)

21

Do you smoke cigarette?

4.68 (0.98)

177 (88.5)

4 (2)

5 (2.5)

5 (2.5)

9 (4.5)

22

Do you smoke hookah (shisha)?

4.88 (0.58)

189 (94.5)

3 (1.5)

4 (2)

2 (1)

2 (1)

23

Are you exposed to cigarette and opium constantly?

4.24 (1.4)

149 (74.5)

5 (2.5)

10 (5)

16 (8)

20 (10)


 

Table 2. Summary of univariate linear regression analysis predicting Treatment adherence

Predictors

B

Standard Error

Confidence Interval

t

P value

Age (yr)

0.04

0.04

-0.036-0.12

1.09

0.28

Body Mass Index

-0.1

0.13

-0.36-0.16

-0.77

0.44

Systolic blood pressure (mmHg)

-0.07

0.03

-0.12- -0.14

-2.5

0.013

Diastolic blood pressure (mmHg)

-0.16

0.05

-0.26- -0.06

-3.22

0.002

Duration of having hypertension (yr)

0.03

0.09

-0.15-0.21

0.31

0.76

Initiation of hypertension drug therapy (yr)

0.07

0.09

-0.11- 0.25

0.76

0.49

Sex

0.35

1.2

-2.02-2.71

0.29

0.77

Marital status

-0.20

1.3

-2.77-2.37

-0.015

0.88

Employed

0.16

1.26

-2.32-2.64

0.13

0.90

Illiterate

-0.01

1.09

-2.17-2.15

-0.008

0.99

Other chronic illness

-0.63

1.14

-2.88-1.62

-0.55

0.58

Compound therapy*

1.91

1.22

-0.49-4.31

1.57

0.19

Sufficiently controlled blood pressure**

-4.36

1.19

-6.7- -2.02

-3.68

<0.001

* No = 1,Yes = 2 ,       **Yes = 1, No = 2;


 

Table 3. Summary of multivariate linear regression analysis predicting Treatment adherence

Predictors

B

Standard Error

Confidence Interval

t

P value

Systolic blood pressure (mmHg)

0.05

0.04

-0.04- 0.13

1.12

0.26

Diastolic blood pressure (mmHg)

-0.09

0.07

-0.23-0.05

-1.32

0.19

Compound therapy*

1.37

1.17

-0.94-3.68

1.17

0.24

Sufficiently controlled blood pressure**

-4.88

1.92

-8.66- -1.10

-2.55

0.012

* No = 1,Yes = 2.      **Yes = 1, No = 2


DISCUSSION:

The present study shows that about half of the patients (53%) have adhered to their treatment regimen. Concerning previous studies, the amount of adherence to medication regimen in different populations was 50-80% (15-17). Particularly in the study done by Leung et al. (18) who investigated adherence to medication regimen in a Chinese population, 64% of people adhered to their medication regimen. These results are different from those of the present study. The study conducted by Krousel-wood et al. (19) investigated 2194 hypertensive patients in the USA and found that only 14.1% of them adhered to their treatment regimen which is disagreed with results of the present study. Based on the study done by Roudsari et al. (10) in Iran, the amount of adherence to medicinal regimen was 50% and it was agreed with results of the present study. It seems that different socio-demographic indices in different communities have caused different results in the studies.

According to analyses done on the present study, adherence to treatment regimen is better in those who have sufficiently controlled hypertension than those who do not have. Other factors were not significant in our study. Based on the study conducted by Leung et al. (18), the amount of adherence to the treatment is influenced by personal factors, disease condition, factors related to health system and socio-economical factors but the number and type of prescribed medications are not effective on patients’ adherence. Based on Baggarly et al. (20), patients whose hypertension has been diagnosed recently have better adherence to treatment regimen. According to Ebadi et al., non-adherence to treatment regimen associates with demographic factors such as physical condition, socio-psychological dimensions of patients (21). Rajpura et al. stated that having good belief and attitude towards effectiveness of anti-hypertensive drugs can increase adherence to treatment in hypertensive patients (22). Rabbia et al. believed that medication monitoring in patients with hypertension is an alternative method for controlling hypertension among hypertensive patients (23). It seems that different between our results and the mentioned articles are due to different socio-demographic indices in populations under study and different scales that were used to measure adherence to treatment regimen. However we used multi-varariate linear regression to adjust confounding effect of socio-demographic factors on each other which increase the power of interpretation. 

The present study has some limitations: at first, we used the information reported by the patient in order to study adherence to treatment. This method is not enough reliable because we are not certain about correctness of information obtained by patients. However we had to use this method for data gathering because other methods do not provide us a general view about adherence to treatment in hypertensive patients. Second, we used cross-sectional survey to study hypertensive treatment adherence therefore, our study was not able to study longitudinal effect of adherence to treatment on late factors of the disease such as progress of the disease and secondary disorders related to hypertension.

 

CONCLUSIONS:

It can be understand from the results that condition of adherence to treatment regimen among hypertensive patients in Fasa city is far from the ideal condition. We believe that reaching the ideal condition for adherence to treatment regimen need more focus on factors influencing adherence to treatment regimen. Training patients and making them familiar towards hypertension induces side effects and diseases may increase adherence to treatment regimens among these patients. Further studies are suggested to evaluate different interventions such as continuous care model for improving treatment adherence among hypertensive patients.

 

ACKNOWLEDGEMENTS:

This paper has been extracted from M.S thesis of special care approved by Kerman University of Medical Science. The authors appreciate all hypertensive patients who referred to Valiasr hospital of Fasa.

 

CONFLICT OF INTEREST:

The authors declare that they have no competing interests.

 

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Received on 25.01.2017          Modified on 23.02.2017

Accepted on 29.03.2017         © A&V Publications all right reserved

Int. J. Nur. Edu. and Research. 2017; 5(3): 287-292.

DOI: 10.5958/2454-2660.2017.00059.X