Non-Adherence to Prescribed Antihypertensives in Primary, Secondary and Tertiary Healthcare Settings in Islamabad, Pakistan: A Cross-Sectional Study

Sajid Mahmood, Zahraa Jalal, Muhammad Abdul Hadi, Hasan Orooj, Kifayat Ullah Shah, Sajid Mahmood, Zahraa Jalal, Muhammad Abdul Hadi, Hasan Orooj, Kifayat Ullah Shah

Abstract

Objective: This study aimed to assess the prevalence and predictors of non-adherence to antihypertensive medication among patients with hypertension attending various healthcare settings in Islamabad, Pakistan.

Methods: A questionnaire-based cross-sectional study was conducted in selected healthcare facilities between September 2017 and December 2018. The study was conducted in primary, secondary and tertiary healthcare settings in Islamabad, Pakistan. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). Sociodemographic and clinical data of recruited patients were collected through a structured questionnaire. Binary logistic regression analysis was performed to determine covariates significantly associated with medication adherence and blood pressure control.

Results: A total of 776 hypertensive patients were invited and 741 (95%) completed the questionnaire. The mean ± SD age of participants was 53.6±12.6 years; 284 patients (38.3%) had high adherence, 178 (24%) had moderate adherence and 279 (37.7%) were non-adherent to the prescribed antihypertensive therapy. Binary regression analysis revealed that old age (OR 1.783 [95% CI: 1.172-2.712]; P=0.013), being educated (OR 2.018 [95% CI: 1.240-3.284]; P=0.036), entitlement to free medical care (OR 1.369 [95% CI: 1.009-1.859]; P=0.044), treatment duration (OR 2.868 [95% CI: 1.913-4.299]; P=0.001), number of medications (OR 1.973 [95% CI: 1.560-2.495]; P=0.001), presence of any comorbidity (OR 2.658 [95% CI: 1.836-3.848]; P=0.001) and blood pressure control (OR 3.103 [95% CI: 2.268-4.247]; P=0.001) were significantly associated with good adherence. Similarly, age (OR 1.998 [95% CI: 1.313-3.040]; P=0.004), entitlement to free medical care (OR 1.498 [95% CI: 1.116-2.010]; P=0.007), treatment duration (OR 1.886 [95% CI: 1.143-3.113]; P=0.013), presence of any comorbidity (OR 1.552 [95% CI: 1.123-2.147]; P=0.008) and adherence level (OR 3.103 [95% CI: 2.268-4.247]; P=0.001) had significant association with controlled blood pressure. The following were the main reasons for non-adherence to prescribed antihypertensive medication: "don't feel need for regular use" (24.7%), "Carelessness" (13.4%) and "adverse effects" (11.2%).

Conclusion: The prevalence of non-adherence to antihypertensive medications was high in the study population and poor medication adherence could potentially explain poor blood pressure control. Evidence-based targeted interventions on both medication adherence and blood pressure control should be introduced and implemented for better treatment outcomes.

Keywords: Asia; Pakistan; adherence; antihypertensives; blood pressure control; cross-sectional study; hypertension.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

© 2020 Mahmood et al.

Figures

Figure 1
Figure 1
Flowchart showing the participants from each healthcare setting.

References

    1. Kokubo Y, Iwashima Y. Higher blood pressure as a risk factor for diseases other than stroke and ischemic heart disease. Hypertension. 2015;66(2):254–259. doi:10.1161/HYPERTENSIONAHA.115.03480
    1. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1· 25 million people. Lancet. 2014;383(9932):1899–1911. doi:10.1016/S0140-6736(14)60685-1
    1. Mills KT, Bundy JD, Kelly TN, et al. Global burden of hypertension: analysis of population-based studies from 89 countries. J Hypertens. 2015;33:e2. doi:10.1097/
    1. W.H.O report on global prevalence of hypertension published on World Health Day; 2013. Available from: . Accessed July27, 2019.
    1. Mohan S, Campbell NR. Hypertension management. Hypertension. 2009;53(3):450–451. doi:10.1161/HYPERTENSIONAHA.108.127076
    1. Prenissl J, Manne-Goehler J, Jaacks LM, et al. Hypertension screening, awareness, treatment, and control in India: a nationally representative cross-sectional study among individuals aged 15 to 49 years. PLoS Med. 2019;16(5):e1002801. doi:10.1371/journal.pmed.1002801
    1. Lu J, Lu Y, Wang X, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1· 7 million adults in a population-based screening study (China PEACE million persons project). Lancet. 2017;390(10112):2549–2558. doi:10.1016/S0140-6736(17)32478-9
    1. Shah N, Shah Q, Shah AJ. The burden and high prevalence of hypertension in Pakistani adolescents: a meta-analysis of the published studies. Arch Public Health. 2018;76(1):20. doi:10.1186/s13690-018-0265-5
    1. Khatib R, Schwalm J-D, Yusuf S, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS One. 2014;9(1):e84238. doi:10.1371/journal.pone.0084238
    1. Jaam M, Hadi MA, Kheir N, et al. A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers. Patient Prefer Adherence. 2018;12:2205. doi:10.2147/PPA.S174652
    1. Jaam M, Ibrahim MIM, Kheir N, Hadi MA, Diab MI, Awaisu A. Assessing prevalence of and barriers to medication adherence in patients with uncontrolled diabetes attending primary healthcare clinics in Qatar. Prim Care Diabetes. 2018;12(2):116–125. doi:10.1016/j.pcd.2017.11.001
    1. Cramer J, Benedict A, Muszbek N, Keskinaslan A, Khan Z. The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. Int J Clin Pract. 2008;62(1):76–87. doi:10.1111/j.1742-1241.2007.01630.x
    1. Levy G, Zamacona MK, Jusko WJ. Developing compliance instructions for drug labeling. Clin Pharmacol Ther. 2000;68(6):586–591. doi:10.1067/mcp.2000.110976
    1. Gibaldi M. Failure to comply: a therapeutic dilemma and the bane of clinical trials. J Clin Pharmacol. 1996;36(8):674–682. doi:10.1002/jcph.1996.36.issue-8
    1. Li YT, Wang HH, Liu KQ, et al. Medication adherence and blood pressure control among hypertensive patients with coexisting long-term conditions in primary care settings: a cross-sectional analysis. Medicine. 2016;95(20). doi:10.1097/MD.0000000000004864.
    1. Jalal Z, Antoniou S, Taylor D, Paudyal V, Finlay K, Smith F. South Asians living in the UK and adherence to coronary heart disease medication: a mixed-method study. Int J Clin Pharm. 2019;41(1):122–130. doi:10.1007/s11096-018-0760-3
    1. Hashmi SK, Afridi MB, Abbas K, et al. Factors associated with adherence to anti-hypertensive treatment in Pakistan. PLoS One. 2007;2(3):e280. doi:10.1371/journal.pone.0000280
    1. Ahmed N, Abdul Khaliq M, Shah SH, Anwar W. Compliance to antihypertensive drugs, salt restriction, exercise and control of systemic hypertension in hypertensive patients at Abbottabad. J Ayub Med Coll Abbottabad. 2008;20(2):66–69.
    1. Ali M, Hameed J, Zia MH, Masood RA, Shahzad A. Patient compliance in systemic hypertension and to identify causes of non-compliance. J Islam Int Med Coll. 2013:48.
    1. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74. doi:10.1097/00005650-198601000-00007
    1. Meghani ST, Sehar S, Punjani NS. Comparison and analysis of health care delivery system: pakistan versus China. Int J Endorsing Health Sci Res. 2014;2:46–50.
    1. Islam A. Health sector reform in Pakistan: future directions. J Pak Med Assoc. 2002;52(4):174–182.
    1. Morisky DE, Ang A, Krousel‐Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens. 2008;10(5):348–354. doi:10.1111/j.1751-7176.2008.07572.x
    1. Berlowitz DR, Foy CG, Kazis LE, et al. Effect of intensive blood-pressure treatment on patient-reported outcomes. N Engl J Med. 2017;377(8):733–744. doi:10.1056/NEJMoa1611179
    1. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol. 2011;64(3):255–257. doi:10.1016/j.jclinepi.2010.09.002
    1. Saleem F, Hassali MA, Akmal S, et al. Translation and validation study of Morisky Medication Adherence Scale (MMAS): the Urdu version for facilitating person-centered healthcare in Pakistan. Int J Pers Cent Med. 2012;2(3):384–390.
    1. National Institute for Health and Care Excellence (NICE) [Internet]. Manchester, UK: Hypertension in adults: diagnosis and management NICE guidelines [CG127]; August 2011. [reviewed October 2013]. Available from: . Accessed December31, 2019.
    1. Nielsen JØ, Shrestha AD, Neupane D, Kallestrup P. Non-adherence to anti-hypertensive medication in low-and middle-income countries: a systematic review and meta-analysis of 92443 subjects. J Hum Hypertens. 2017;31(1):14. doi:10.1038/jhh.2016.31
    1. Khayyat SM, Khayyat SMS, Alhazmi RSH, Mohamed MM, Hadi MA. Predictors of medication adherence and blood pressure control among Saudi hypertensive patients attending primary care clinics: a cross-sectional study. PLoS One. 2017;12(1):e0171255. doi:10.1371/journal.pone.0171255
    1. Lee GK, Wang HH, Liu KQ, Cheung Y, Morisky DE, Wong MC. Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky medication adherence scale. PLoS One. 2013;8(4):e62775. doi:10.1371/journal.pone.0062775
    1. Kang CD, Tsang PP, Li WT, et al. Determinants of medication adherence and blood pressure control among hypertensive patients in Hong Kong: a cross-sectional study. Int J Cardiol. 2015;182:250–257. doi:10.1016/j.ijcard.2014.12.064
    1. Han WP, Hong SA, Tiraphat S. Factors related to medication adherence among essential hypertensive patients in tertiary hospitals in Yangon, Myanmar. J Public Health Dev. 2015;13(2):43–56.
    1. Shaik SA, Alsuwailem A, Alhargan A, et al. Medications adherence level and its associated factors among hypertensive patients at a major referral hospital, in Riyadh, KSA. Asian J Med Sci. 2016;7(4):24–30. doi:10.3126/ajms.v7i4.14085
    1. Fahey M, Abdulmajeed A, Sabra K. Measurement of adherence to anti-hypertensive medication as perceived by doctors and patients. Qatar Med J. 2006;2006(1):16. doi:10.5339/qmj.2006.1.16
    1. Saadat Z, Nikdoust F, Aerab-Sheibani H, et al. Adherence to antihypertensives in patients with comorbid condition. Nephrourol Mon. 2015;7(4). doi:10.5812/numonthly.
    1. Organization WH. Adherence to long-term therapies: evidence for action. 2003. . Accessed July 27, 2019.
    1. Yue Z, Li C, Weilin Q, Bin W. Application of the health belief model to improve the understanding of antihypertensive medication adherence among Chinese patients. Patient Educ Couns. 2015;98(5):669–673. doi:10.1016/j.pec.2015.02.007
    1. Al-Ramahi R. Adherence to medications and associated factors: a cross-sectional study among Palestinian hypertensive patients. J Epidemiol Glob Health. 2015;5(2):125–132. doi:10.1016/j.jegh.2014.05.005
    1. Hassan N, Hasanah C, Foong K, et al. Identification of psychosocial factors of noncompliance in hypertensive patients. J Hum Hypertens. 2006;20(1):23. doi:10.1038/sj.jhh.1001930
    1. Caro JJ, Salas M, Speckman JL, Raggio G, Jackson JD. Persistence with treatment for hypertension in actual practice. CMAJ. 1999;160(1):31–37.
    1. Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Public Health. 1996;86(12):1805–1808. doi:10.2105/AJPH.86.12.1805
    1. Krousel-Wood M, Thomas S, Muntner P, Morisky D. Medication adherence: a key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients. Curr Opin Cardiol. 2004;19(4):357–362. doi:10.1097/01.hco.0000126978.03828.9e
    1. Inkster ME, Donnan P, MacDonald T, Sullivan F, Fahey T. Adherence to antihypertensive medication and association with patient and practice factors. J Hum Hypertens. 2006;20(4):295. doi:10.1038/sj.jhh.1001981
    1. Youssef R, Moubarak I. Patterns and determinants of treatment compliance among hypertensive patients. 2002.
    1. Gryglewska B. How can we improve the effectiveness of treatment in elderly hypertensives? Blood Press. 2005;14(sup2):46–49. doi:10.1080/08038020500428740
    1. Olowookere AJ, Olowookere SA, Talabi AO, Etonyeaku AC, Adeleke OE, Akinboboye OO. Perceived family support and factors influencing medication adherence among hypertensive patients attending a Nigerian tertiary hospital. Ann Trop Med Public Health. 2015;8(6):241. doi:10.4103/1755-6783.162668
    1. Marín-Reyes F, Rodríguez-Morán M. Family support of treatment compliance in essential arterial hypertension. Salud Publica Mex. 2001;43(4):336–339. doi:10.1590/S0036-36342001000400010
    1. Setiati S, Sutrisna B. Prevalence of hypertension without anti-hypertensive medications and its association with social demographic characteristics among 40 years and above adult population in Indonesia. Acta Med Indones. 2005;37(1):20–25.
    1. Taibanguay N, Chaiamnuay S, Asavatanabodee P, Narongroeknawin P. Effect of patient education on medication adherence of patients with rheumatoid arthritis: a randomized controlled trial. Patient Prefer Adherence. 2019;13:119. doi:10.2147/PPA.S192008
    1. Jahangiry L, Ghanbari J, Farhangi MA, Sarbakhsh P, Ponnet K. Predictors of poor blood pressure control among Iranian hypertensive patients. BMC Res Notes. 2017;10(1):668. doi:10.1186/s13104-017-2971-4
    1. Mallya SD, Kumar A, Kamath A, Shetty A, Mishra S. Assessment of treatment adherence among hypertensive patients in a coastal area of Karnataka, India. Int J Community Med Public Health. 2017;3(8):1998–2003.
    1. Hussanin S, Boonshuyar C, Ekram A. Non-adherence to antihypertensive treatment in essential hypertensive patients in Rajshahi, Bangladesh. Anwer Khan Mod Med Coll J. 2011;2(1):9–14. doi:10.3329/akmmcj.v2i1.7465
    1. Ekram AS, Hussain SM, Boonshuyar C. Preliminary report on non-adherence to antihypertensive treatment in essential hypertensive patients: a community based survey. J Teachers Assoc. 2008;21(2):112–117.
    1. Fenerty SD, West C, Davis SA, Kaplan SG, Feldman SR. The effect of reminder systems on patients’ adherence to treatment. Patient Prefer Adherence. 2012;6:127.
    1. Jin J, Sklar GE, Oh VMS, Li SC. Factors affecting therapeutic compliance: a review from the patient’s perspective. Ther Clin Risk Manag. 2008;4(1):269. doi:10.2147/TCRM.S1458
    1. Gwadry-Sridhar FH, Manias E, Lal L, et al. Impact of interventions on medication adherence and blood pressure control in patients with essential hypertension: a systematic review by the ISPOR medication adherence and persistence special interest group. Value Health. 2013;16(5):863–871. doi:10.1016/j.jval.2013.03.1631
    1. Conn VS, Ruppar TM, Chase J-AD, Enriquez M, Cooper PS. Interventions to improve medication adherence in hypertensive patients: systematic review and meta-analysis. Curr Hypertens Rep. 2015;17(12):94. doi:10.1007/s11906-015-0606-5
    1. Palacio AM, Uribe C, Hazel-Fernandez L, et al. Can phone-based motivational interviewing improve medication adherence to antiplatelet medications after a coronary stent among racial minorities? A randomized trial. J Gen Intern Med. 2015;30(4):469–475. doi:10.1007/s11606-014-3139-8
    1. Kamal AK, Muqeet A, Farhat K, et al. Using a tailored health information technology-driven intervention to improve health literacy and medication adherence in a Pakistani population with vascular disease (Talking Rx)–study protocol for a randomized controlled trial. Trials. 2016;17(1):121. doi:10.1186/s13063-016-1244-1
    1. Zomahoun HTV, Guenette L, Gregoire J-P, et al. Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis. Int J Epidemiol. 2016;46(2):589–602.
    1. Vollmer WM, Feldstein A, Smith D, et al. Use of health information technology to improve medication adherence. Am J Manag Care. 2011;17(12):SP79.
    1. Jalal ZS, Smith F, Taylor D, Patel H, Finlay K, Antoniou S. Pharmacy care and adherence to primary and secondary prevention cardiovascular medication: a systematic review of studies. Eur J Hosp Pharm. 2014;21(4):238–244. doi:10.1136/ejhpharm-2014-000455
    1. Jalal ZS, Smith F, Taylor D, Finlay K, Patel H, Antoniou S. Impact of pharmacy care upon adherence to cardiovascular medicines: a feasibility pilot controlled trial. Eur J Hosp Pharm. 2016;23(5):250–256. doi:10.1136/ejhpharm-2015-000790

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する