https://doi.org/10.33698/NRF0289-Kmendalin Nongspung, Kavita Narang, J.S Thakur
ABSTRACT:
Background: Hypertension is the leading risk factor in non-communicable diseases and the number is increasing worldwide. Poor adherence has been described as the most important cause of uncontrolled blood pressure. Objective: To assess the treatment adherence of hypertensive patients. Material and methods: The study was conducted in two community sites of Chandigarh. Total of 250 participants diagnosed with hypertension were selected by systematic random sampling. Participants were interviewed as per interview schedule comprises of socio demographic prole, clinical prole, dietary habits, Hillbone High Blood Pressure Compliance Scale. Data was collected from July 2018 till November. Descriptive statistics was used to analyze the data, where mean, percentage and frequency were used to describe the data. Results: As per the hillbone highblood pressure compliance scale score only 17.6% of the subjects were adherent to the treatment. The main reasons for non adherence were forgetfulness (54.4%), stopped when felt sick (69.6%) and when felt better (59.6%). Only 24.8% had controlled blood pressure. Conclusion: There is very low adherence to treatment among hypertensive patients.
Key words: treatment adherence, hypertension.
Correspondence at
Dr. Kavita Narang Lecturer
National Institute of Nursing Education PGIMER Chandigarh
Introduction:
Non-communicable diseases (NCDs) are the most frequent causes of prolonged disability and premature death worldwide. Non-communicable diseases (NCD) are chronic diseases that are not transmitted from one person to another. They are of long duration and generally slow progresssion. NCD cause premature morbidity, dysfunction and reduced quality of life.1 Globally 71% of all deaths occur due to non communicable diseases.2
Hypertension is one of the most important preventable contributors to non communicable disease and death. Hypertension is estimated to cause 7.5 million deaths, about 12.8% of the total of all deaths. Hypertension affects people of all age group, nations and countries. Globally 9.4 million people die every year due to hypertension. WHO South East Asian report, 2017 shows that death due to hypertension accounts for about 1.5 million lives eachyear in the Region.According to the WHO 2017 estimates Prevalence of hypertension In India is 24%. 3,4 Uncontrolled hypertension has been attributed to patient’s failure to follow properly a prescribed regiment. Global of these areas are usually the migrants from other states and neighbouring country. The inclusion criteria were diagnosed Health Observatory (GHO)4 study shows hypertensive patients taking treatment. that uncontrolled blood pressure is a major risk factor for haemoragic stroke and coronary heart disease. In addition, c o m p l i c a t i o n s o f u n c o n t r o l l e d hypertension include stroke, heart failure, renal impairement, retinal haemrrhage and visual impairement. Poor treatment adherence is a roadblock to better quality of life in hypertensive patients. Problems in treatment adherence are widespread, and seriously compromise the effectiveness of antihypertensive treatment.5
Non-adherence is a multifaceted concept the focus on persistence and is related not only to individual’s behavioral factors, but also to the disease itself, complexity and duration of the treatment, possible adverse drug reactions, cost of treatment, and social factors.6 There are a number of reasons for non adherence to treatment which needs to be understood by the health professional. Thus, need was felt to assess level of adherence and factors related to adherence among hypertensive patients.
Objective:
To assess the treatment adherence of hypertensive patients.
Material and methods:
T h e s t u d y w a s c o n d u c t e d i n Chandigarh. It is a city and a union territory in the Northern part of India that serves as a capital of the states of Punjab and Haryana. The study was conducted in two peripheral communities of Chandigarh. The residents Females with Pregnancy Induced Hypertenion were excluded. Total of 250 subjects diagnosed as hypertensive patients were selected by systematic random sampling (every 4th of the subjects from the sampling frame). Participants were interviewed as per interview schedule comprises of socio demographic prole, clinical prole, dietary habits, Hillbone High Blood Pressure Compliance Scale. The scale had 14 questions answered as none(1score), sometimes (2 score), often (3 score), always (4 score) Minimum score was 14 and maximum score was 56. Score of more than 14 indicated adharence and score less than 14 indicated nonadherence. Ethical clearance was taken from Institute Ethics Committee, PGIMER, Chandigarh and written informed consent was taken from the participant. Data was collected from July to November 2019. Participants were interviewed in their home; they were r s t m a d e c o m f o r t a b l e a n d t h e n interviewed as per the interview scheduled. As per the Seventh Joint National Committee (JNC 7) guidelines Blood pressure were measured. Descriptive statistics was used to analyze the data, where mean, percentage and frequency were used to describe the data.
Results:
Age of 250 participants were between the range of 51-60 years (34.4%) with the mean age of 59.62±12.88 years. Most of the participants (74.4%) were males. Majority of them 86% were married and 87.6% of them had joint family. As per the educational status nearly half (46.8%) were matriculate passed and 36% were illiterate. Majority of the participants (88.9%) belonged to Hindu religion. Per-capita monthly income of the family ranged Rs 10,000-60,000 with the mean of Rs 15760±9682.0. Nearly half of the subjects (42.8%) belonged to lower middle socioeconomic status as per BG Prasad scale 2018.
Advanced the age, higher is the risk of developing hypertension. In the present study about 27.6% got hypertension when their age were more than 60 years. Nearly half of the subjects (46.8%) were prescribed with angiotensin receptor blocker. About 43.3% had diabetes mellitus along with hypertension. One third of the subjects (33.2%) had duration of hypertension between 6-10 years. [Table 1]
Controlled hypertension is one of the important factor to decrease complication, in the present study majority (75.2%) of the participants had uncontrolled blood pressure (>140/90mmhg) and very few (24.8%) had controlled blood pressure (<140/90mmhg).
The treatment adherence as per Hillbone high blood pressure scale showed that very few of the participants (17.6 %) were adhered (score<14) to the treatment prescribed to them and majority of them 82.4% were non adherent (score>14). [Table 2] The proportion of the participants who always forget to take high blood pressure medications was about 39 . 2 % of the participants and 31.2% always decide not to take their high blood pressure medication. Nearly half of the participants (47.2%) sometimes miss the appointment given to them, and 47.6% always miss the medication when they feel better. More than half (54%) of participans most of the times miss taking HBP pills when they feel sick [Table 3]
Table 1: Clinical profile of the hypertensive patients
N=250
| Variables | n(%) |
| Age when hypertension started |
20(8.0) 26(10.4) 27(10.8) 37(14.8) 35(14.0) 36(14.4) 69(27.6) |
| · 30-35years | |
| · 35-40years | |
| · 40-45years | |
| · 45-50years | |
| · 50-55years | |
| · 55-60years | |
| · >60 years | |
| Medications prescribed |
50(20.0) 6(2.4) 75(30.0) 2(0.8) 117(46.8) |
| Beta Blocker | |
| Ace Inhibitor | |
| Calcium Channel Blocker | |
| Diuretics | |
| Angiotensin Receptor Blocker | |
| Comorbidities
Diabetes mellitus |
104(43.2) |
| Renal disease | 13(41.6) |
| Coronary artery disease | 17(6.8) |
| Congestive cardiac failure | 1(0.4) |
| Hyperthyroidism & hypothyroidism | 7(2.8) |
| Duration of hypertension
<1year |
26(10.4) |
| 2-5 years | 85(34.0) |
| 6-10years | 83(33.2) |
| 11-20years | 41(16.4) |
| 21-30 years | 10(4.0) |
| >31 | 5(2.0) |
Table 2: Treatment adherence (as per Hillbone HBP compliance scale) among hypertensive patients N=250
| Treatment adherence (as per Hillbone Compliance Scale) | n (%) | |
| Adherence (<14) | 44(17.6) | |
| Non adherence (>14) | ||
| 206(82.4) |
Table 3: Assessment of treatment adherence to medication, diet and clinical follow up (as per Hillbone high blood compliance scale) of hypertensive patients
N=250
| Variables | None | Sometimes | Most of the time | All the time |
| 1.How often do you forget to take your HBP medicine? | 62(24.8) | 52(20.8) | 38(15.2) | 98(39.2) |
| 2. How often do you decide NOT to take your HBP medicine | 61(24.4) | 57(22.8) | 78(31.2) | 54(21.6) |
| 3. How often do you eat salty food | 52(20.8) | 131(52.4) | 59(23.6) | 8(3.2) |
| 4. How often do you take salt on your food before you eat it? | 63(13.6) | 98(39.2) | 68(27.2) | 21(8.4) |
| 5.How often do you eat fast food? | 34(13.6) | 134(53.6) | 60(24.0) | 22(8.9) |
| 6. How often do you make the next appointment before you leave the doctor’s ofce?* | 56(22.4) | 100(40.0) | 88(35.2) | 6(2.4) |
| 7.How often do you miss scheduled appointment? | 61(24.4) | 118(47.2) | 55(22.0) | 16(6.4) |
| 8. How often do you forget to get prescriptions lled? | 106(42.4) | 101(40.4) | 38(15.2) | 5(2.0) |
| 9. How often do you run out of HBP pills? | 94(37.6) | 82(32.8) | 56(22.4) | 18(7.2) |
| 10. How often do you skip your HBP medicine before you go to the doctor? |
166(66.4) |
45(18.0) | 35(14.0) | 4(1.6) |
| 11. How often do you miss taking your HBP pills when you feel better? | 54(21.6) | 47(18.8) | 119(47.6) | 30(12.0) |
| 12. How often do you miss taking your HBP pills when you feel sick? | 47(18.8) | 29(11.6) | 136(54.4) | 38(15.2) |
| 13. How often do you take someone else’s HBP pill? |
219(87.6) |
24(9.6) | 6(2.4) | 19(0.4) |
| 14. How often do you miss taking your HBP pills when you are careless? | 29(11.6) | 190(76.0) | 13(5.2.) | 18(7.2) |
Maintenance of a healthy diet have long been recommended and has proven to improve the blood pressure. The proportion of consumption of fruits was very low with 2.4% of the participants consume fruits 4-5 times in a day week and 56% consume vegetables more than 5 times in a week, 34.8% consumes oil per capita per month between 300- 500 ml and 33.2% of the subjects reuse the cooked oil. only few participants (15.6%) consume salt between 5-7gm in a day. [table 4]
Table 4: Assessment of dietary behaviour of hypertensive patients
N=250
| Variables | n(%) | |
| Number of times fruits consumed in a day
1-2times/day 3-4times/day 4-5times/day |
34(13.6)
210(84.0) 6(2.4) |
|
| Number of times vegetables consumed prior to the week | ||
| 10(4.0) | ||
| 1-2times/week | ||
| 3-5times/week | 35(14.0) | |
| 4-5times/week | 65(26.0) | |
| >5times/week | 140(56.0) | |
| Amount of oil consumed in a month | ||
| 120-150ml | 20(8.0) | |
| 150-300 | 32(12.8) | |
| 300-500ml | 87(34.8) | |
| >500ml | 111(44.4) | |
| Number of times cooked oil was reused
1time |
83(33.2)
55(22.0) |
|
| 2times | 60(24.0) | |
| 3times | 52(20.8) | |
| Number of times nuts(almonds, walnut) is consumed in a week
1times 2times >3times |
147(58.8) |
|
| 16(6.4) | ||
| 25(10.0) | ||
| Amount of salt consumption | ||
| in a day | ||
| 16(6.4) | ||
| 1. 3.1-5gm | ||
| 2. 5.1-7gm | 39(15.6) | |
| 3. 7.1-9gm | 88(35.2) | |
| 4. >9gm | 107(43.2) |
Discussion
Hypertension is a silent killer disease. It is one of the major causes that is contributing to increase in the morbidity and mortality of noncommunicable disease. Despite the existence of effective therapies and the development of evidence-based guidelines, unconcontrolled hypertension still remains one of the biggest challenges. Uncontrolled hypertension attributes to complications affecting the heart, brain, kidneys, eyes etc. Adherence to the treatment is an important key for successful therapeutic outcome but still remains a challange. Nonadherence to the treatment is a stumbling block to a better quality of life in hypertensive patients. Thus, need was felt to assess level of adherence among hypertensive patients and factors related to it.4,6,7
The study was conducted in two community sites of Chandigarh, because the areas had similar educational status, feasible, easily accessible, and is one of the practice areas for PGIMER Chandigarh.
Hillbone High Blood Pressure Compliance Scale to assess treatment adherence. This tool was selected because it is a standardized scale, specic, reliable and valid, and is specic to hypertension. This tool has also been applied in various studies. 7,8 Tobacco and alcohol consumption are powerful cardiovascular risk factors. It is one of the of the common factor that acutely exerts a hypertensive effect, mainly through the stimulation of the sympathetic nervous system.9,10 A study by venkataraman R et al11 revealed that 16 % and 20.4% of the hypertensive patients have the habit of smoking and alcohol respectively. In the present study about 7.6% of the participants consumes alcohol and 8.2% smokes tobacco.
An improvement in the dietary habits has been proven to have good results among hypertensive patients, but however, not many patients intended to follow the strategy and measure prescribed to them.11,12 The DASH (Dietary Approaches to Stop Hypertension), have recommended to consume fuits and vegetables 4-5 servings in a day. A study by Carol R e13 showed few participants (20%) consume hypertensive diet and 70% have no knowledge or is poor to afford fruits vegetables and to make separate diet. In the present study very few participants (2.4%) consume fruits and 56% consume vegetables more than 5 times in a week only few participants (15.6%) consume salt between 5-7gm in a day.
N o n a d h e r e n c e h a v e b e c o m e increasingly alarmed as this non-adherence has been shown to reduce the effect of the treatment which can result in prolonged illness, further complications and even death. Treatment adherence on hypertension is one of the main crucial health concerns of the public. A study by Sadulla7 et al shows that the adherence was 16.2%, almost similar ndings were seen in the present study where 17.6% of the subjects were adhered to the treatment. Anup Bhusal et al8 in their study also have assessed the reason for non adherence where forgetfulness (33.6%), carelessness (34.9%), where as in the present study the reasons for non adherence were forgetfulness (54.4%), stopped when felt sick (69.6%) and when felt better (59.6%). This study concluded that there is very low adherence to t reatment among hypertensive patients. The common reasons for non adherence were forgetfulness and stops medication when feeling sick or better. Therefore, there is a need of an education program that utilizes these ndings to improve treatment adherence thereby prevent further complications. This study can also be relicated in different settings and in a bigger sample to support the ndings
Acknowledgement
The authors thank the research authorities of PGIMER Chandigarh and the participants in the study.
Conflict of interest
The authors declare noconict of interest.
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