Assessment of Adherences to Medication Therapy in Hypertensive Patients and Effect of Patient Counseling in Tertiary Care Hospital
- *Corresponding Author:
- Muhammad Khan
Department of Pharmaceutical Sciences, Abbottabad University of Science and Technology, Abbottabad, Pakistan.
E-mail: [email protected]
Citation: Khan M, Khan SM, Dar ZR. Assessment of Adherences to Medication Therapy in Hypertensive Patients and Effect of Patient Counseling in Tertiary Care Hospital. J Basic Clin Pharma 2017;8:S041-S043.
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.
The physician ability to understand non-adherence to therapy is limited and interventions by clinical pharmacist to improve compliance has effective results. However, poor compliance accounts for worsening of disease state and ultimately will increase the health care cost. The study aimed to investigate the medication adherence in hypertensive patients and the effect of counseling in a tertiary health care setting. The study was carried out in Ayub Teaching Hospital Abbottabad, KPK, Pakistan. It is a multispecialty tertiary care hospital with a modernized cardiology department. It caters to the need of both in and out patients. An assessment was made on hypertensive patients who are receiving multiple drugs were included in the study. A medication adherence questioner was prepared based on literature. Among 300 patients 205 were adherent to medication whereas 95 were non adherent and those non adherent patients were given verbal and non-verbal counseling regarding adherence to therapy. Health professionals can solve the problem of patient compliance by providing effective patient counseling. Certain technique can be adapted like motivational interviewing, teach- back method which can help to ensure patient understanding regarding the therapy.
Compliance, patient counseling, adherence to therapy
Adherence to therapy is defined as the extent to which the patients take medications as prescribed by the health care provider. A prescription is a legal written document which carries all the regulations in order to ensure the safe use and to comply with the therapy. The adherence rates are higher in those patients having acute conditions as compare to those having chronic conditions.[3,4] Ability of health care provider to identify non-adherence is deprived and interventions to improve adherence to therapy have had varied outcomes.[5-7] Hypertension is defined as a blood pressure (systolic/diastolic) ≥ 140/90 mmHg. It has been estimated that hypertension is responsible for 4% of the global burden of disease. It is one the major cause of mortality and morbidity both in developing and in developed regions. Reduction in BP are directly associated with reduction in incidence of cardiovascular heart disease, stroke and renal disease.[10,11] However, the risk of cardiovascular disease and stroke increases continuously as SBP rises above 115 mmHg. However, adherence behavior is complex including ceasing to take the prescribed medications, to taking only few, to taking them in a way that differs from instructions for example, not to take after food immediately. It is estimated that overall hypertensive patients take only 53-70% of the medications prescribed for them.[13-15]
The National Institute for Health and Clinical Excellence and WHO in their respective guidelines and review strongly recommends the adoption of individualized consultation which recognizes the importance of involving the patients in therapeutic decision as a key to enable the clinician to enhance the adherence to therapy.
Primary focus on exploring patients beliefs about illness and treatment and providing rational information about illness and treatment and specific information about disease (hypertension) and its treatment (medication and life style modification) are also strongly advocated for example, by using face to face education sessions or providing information leaflets. This guidance is based on observational research. 
Certain methods can be used to improve adherence are grouped into four categories: Patient education; improved dosing schedules; improved communication between physician and patients. Educational interventions involve patients, their family members, or both can be effective in improving adherence to therapy. However, enhancing communication between the physician and the patient is a primary and effective strategy in boosting the ability of patient to follow the medication regimen. Most methods for improving adherence involves the combination of behavioral interventions and reinforcements in addition to increasing the convenience of care, providing educational information about the patient’s condition and the treatment and other forms of supervision.[20,21] However, successful methods are complex and labor intensive, and certain innovative strategies will be needed to be developed that are practical for routine clinical use.
Materials and Methods
The study was carried out in Ayub teaching hospital Abbottabad, KPK, Pakistan. This is 1500 beded hospital with a full fledge cardiology department. It satisfies the needs of both in and out patients. An assessment was made on hypertensive patients who are receiving multiple numbers of drugs. A medication adherence questionnaire was prepared based on literature.
Development of questionnaire
The items of questionnaire were constructed on the basis of study objectives. The questionnaire consisted of total 20 questions. Questions evaluated the adherence to therapy by using likert scale from 1 to 5. Higher values show increased adherence to medication. Level of adherence was measured initially and after one month interval. From those values efficacy of the counseling was determined.
Validation of questionnaire
Information was collected by interviewing the patients using a questionnaire. It is validated that the respondent understands the question properly being asked. As a result the questions are modified accordingly. Reliability of the questionnaire was assessed and the value of cronbach alpha was found to be 0.80 reflecting internally consistent items.
Study was conducted on total of 300 patients of either sex after taking the written informed consent and using the medication adherence patients were categorized into two groups like adherent and nonadherent. Patient inclusion and exclusion criteria were established [Table 1]. Among 300 patients 205 were adherent to the therapy while 95 were non adherent. The non-adherent patients were given verbal and non-verbal counseling in a private counseling room. Hence, they were grouped as follow:
|18 years and above patients of either sex
Patients who were willing to participate and give the consent form
In patients and out patients who were diagnosed for hypertension
Pregnant and lactating women
Patients in ICU
Table 1: Basic eligibility criteria
• Group 1: 185 patients who are adherent and has normal BP.
• Group 2: 20 patients who are adherent but has abnormal BP.
• Group 3: 95 patients who are non-adherent and has a high BP.
In these different groups, it was observed that there were some patients who are on multiple drugs and they were adherent and has a normal BP, 78 patients who had 5 drugs of which 64 were adherent with normal BP and 14 were non adherent with high BP. There were 54 patients on 4 drugs; of which 30 were adherent with normal BP, 10 were adherent with high BP and 14 were non adherent with high BP. From 88 patients on 6 drugs; 43 were adherent with normal BP while remaining 45 were non adherent with high BP. Among the 79 patients on 8 drugs; 11 were adherent with the therapy having normal BP, 5 were adherent with high BP, and 63 were non adherent with high BP [Table 2].
|Number of drugs||GP1||GP 2||GP 3|
Table 2: Number of drugs used in different groups
Regarding the education levels in these groups, there were 34 patients who had secondary level of education; of which 4 were adherent with normal BP, and 5 were adherent with high BP, and 25 were non adherent with high BP. There were 53 patients with secondary level of education; of which 26 were adherent with normal BP, 3 were adherent with high BP and 24 were non adherent with high BP.
From 67 patients who had pre university level of education; 33 were adherent with the normal level of BP, 5 were adherent with the high BP, and the remaining 29 were non adherent with the high level of BP.
Among 78 patients with the graduate level of education, 38 were adherent with the normal level of BP, 6 were adherent with the high BP, and 34 were non adherent with the high level of BP [Table 3].
|Level of Education||GP1||GP 2||GP 3|
|Pre university level||33||5||29|
Table 3: Educational status of population
Following the guidelines of WHO for BMI, it was observed that there were maximum number of patients who were overweight, followed by the patients of normal weight and obese [Figure 1].
Among the gender wise distribution of the population there were 60% of males and 40% females [Figure 2].
Regarding the occupation there were different categories like retired, business, employees and house wife a specific trend was observed in adherence to the therapy. Among 80 patients who were retired; there were 27 who were adherent to the therapy and have a normal BP, while 19 were adherent and have a high BP, and 34 were non adherent with a high BP.
There were 30 patients who were housewife and staying at home of which 18 were adherent with the normal BP, 4 were adherent with a high BP, and 8 of them were non adherent with the therapy with a high BP. While among the 39 patients who were employees; 21 were adherent and had a normal BP, 5 were adherent with a high BP, and 13 were non adherent and had a high BP.
From 60 patients who were involved in the business, 25 were adherent and had a normal BP, 6 were adherent with high BP, and 29 were non adherent with a high BP [Table 4].
Table 4: Occupational Level among the Population
It was observed that the number of patients with the normal level of BP decreased as the number of drugs is increased with the maximum number of 64 in 5 drug categories and minimum of 11 in 8 drug category. The number of patients with the high BP values remains the same whether they were on 6 or 8 drugs. However the number of nonadherent patients with high BP value is increased as the number of drugs is increased in the therapeutic regime.
However, the number of graduates were more in the group 1 of the study and there were less graduates in group 2 as compare to group 3 so it revealed that no matter there were more educated people but they were not adhering to the drug therapy as compare to the group 1 where there were more secondary school and pre university level is the reason for more adherence to the therapy.
It was observed during the study that the number of patients who belong to group 3 in the business category of the patients were greater in the number as compare to group 1 of that category which revealed that patients in business category were non adherent to the therapy and its due to their busy schedule.
While analyzing the data of patients in the retired patient’s category it was clearly observed that the number of patients was more in group 3 which was non adherent to the therapy and it’s due to their age and poor memory which yields to not taking of the dose in time.
Among the group 1 (adherent with the normal BP) and group 2 (adherent with high BP) there was no significant changes as these patients were already adherent to their medications. However, there was remarkable improvement in adherence to the therapeutic regime after patient counseling of group 3, and it is observed that counseling the patients at the time of dispensing the medication will highly increase the adherence rate.
This study has clearly shown the positive impacts of patient counseling.
However, there are certain things which health care professionals can do in order to tackle the problem of adherence to therapy. However, this study confirms that counseling intervention by the pharmacist improves the patient knowledge towards disease management and also increases the compliance rate. This study also concluded that patient counseling role of pharmacist is very important in other chronic disease management such as diabetes, cardiovascular diseases. It has been revealed that patient adherence can be enhanced by improving the patient level of understanding regarding the disease state and also emphasizing the importance of therapeutic plan. However, techniques like teach back method and motivational interviewing can help to understand the importance of counseling provided. This study also concluded that pharmacist plays a critical role in the disease management and adherence to the therapeutic plan.
- Steiner JF, Earnest MA. The language of medication-taking. Ann InternMed 2000;132:926-30.
- Aronson JK. A prescription for better prescribing. Br J ClinPharmacol2006;61:487-91.
- Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J. VA NaltrexoneStudy Group 425. Medication compliance feedback and monitoring ina clinical trial: Predictors and outcomes. Value Health 2003;6:566-73.
- Haynes RB, McDonald HP, Garg AX. Helping patients followprescribed treatment: Clinical applications. JAMA 2002;288:2880-3.
- Burnier M. Long‑term compliance with antihypertensive therapy:Another facet of chronotherapeutics in hypertension. Blood PressMonit 2000;5:S31-4.
- Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC,Kanani R. Interventions for helping patients to follow prescriptions formedications. Cochrane Database Syst Rev 2000;CD000011.
- Miller LG, Liu H, Hays RD, Golin CE, Beck CK, Asch SM, et al.How well do clinicians estimate patients’ adherence to combinationantiretroviral therapy? J Gen Intern Med 2002;17:1-11.
- EzzatiM, LopezA, RodgersA, Vander HoornS, MurrayC. Selected major risk factors and global and regionalburden of disease. Lancet 2002;360:1347-60.
- LewingtonS, ClarkeR, QizilbashN, PetoR, Collins R.Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual datafor one million adults in 61 prospective studies. TheLancet 2002;360:1903-13.
- MacMahonS, PetoR, Collins R, Godwin J, Cutler J,Sorlie P,et al. Blood pressure, stroke, and coronaryheart disease: Part 1, prolonged differences in bloodpressure: prospective observational studies correctedfor the regression dilution bias. The Lancet 1990;335:765-74.
- Kokubo Y, KamideK, OkamuraT, WatanabeM,HigashiyamaA, Kawanishi K,et al. Impact ofhigh and normalblood pressure on the risk of cardiovasculardisease in a Japanese urban cohort: The Suita Study.Hypertension 2008;52:652-9.
- ElzubierAG, HusainAA, SuleimanIA, HamidZA.Drug compliance among hypertensive patients inKassala, Eastern Sudan. East Mediterr Health J 2000;6:100-5.
- Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M.Adherence to prescribed antihypertensive drug treatments, longitudinal study of electronically compileddosing histories. Br Med J 2008;336:1114-7.
- MoriskyDE, AngA, KrouselWM, WardHJ.Predictive validity of a medication adherence measurein an outpatient setting. J ClinHypertens2008;10:348-54.
- Nunes V, Neilson J, O’FlynnN, CalvertN, KuntzeS,Smithson H,et al. Clinical Guidelines and EvidenceReview for Medicines Adherence: Involving Patients inDecisions about Prescribed Medicines and SupportingAdherence. National Collaborating Centre for PrimaryCare and Royal College of General Practitioners:London, 2009.
- HaynesR, AcklooE, Sahota N, McDonaldH, Yao X.Interventions for enhancing medication adherence.Cochrane Database of Systematic Reviews 2008;CD000011.
- BouvyML, HeerdinkER, UrquhartJ, GrobbeeDE, HoesAW,LeufkensHG. Effect of a pharmacist-led intervention on diureticcompliance in heart failure patients: A randomized controlled study.J Card Fail 2003;9:404-11.
- Maro EE, Lwakatare J. Medication compliance among Tanzanianhypertensives. East Afr Med J 1997;74:539-42.
- FeldmanR, BacherM, CampbellN, DroverA, ChockalingamA.Adherence to pharmacologic management of hypertension. Can JPublic Health 1998;89:116-8.
- HaynesRB, MontagueP, Oliver T, McKibbonKA, BrouwersMC,KananiR. Interventions for helping patients to follow prescriptions formedications. Cochrane Database Syst Rev 2000;CD000011.
- Deepika V. Hypertensioncounseling requires a Multifactorial approach. Pharmacy Times 2005.