|Year : 2015 | Volume
| Issue : 6 | Page : 241-245
|Perceived family support and factors influencing medication adherence among hypertensive patients attending a Nigerian tertiary hospital
Akintunde J Olowookere1, Samuel Anu Olowookere2, Ademola Oluwasegun Talabi3, Amarachukwu Chiduziem Etonyeaku3, Oluwatoyin E Adeleke4, Oluwatosin O Akinboboye4
1 Department of Accident and Emergency, Obafemi Awolowo University Teaching Hospital, Osun State, Nigeria
2 Department of Community Health, College of Health Sciences, Obafemi Awolowo University Teaching Hospital, Osun State, Nigeria
3 Department of Surgery, College of Health Sciences, Obafemi Awolowo University Teaching Hospital, Osun State, Nigeria
4 Department of Family Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
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|Date of Web Publication||20-Nov-2015|
| Abstract|| |
Background and Aim: Drug adherence determines a patient's quality of life and delays the development of complications. The study assessed perceived family support and other factors that determine medication adherence among hypertensive patients in a tertiary hospital. Materials and Methods: Descriptive cross-sectional study. Consenting adult patients on antihypertensive attending the Medical Outpatient Clinic of Federal Medical Centre Owo, Ondo State, Nigeria. Results: Four hundred and twenty patients were studied. The mean age of the patients was 60.6 ± 11.7 years (range 21-85 years). There were 206 (49%) males and 214 (51%) females. Most respondents were Yoruba (86.2%), married (76.7%), and had primary education (27.6%). Most (61%) were adherent to antihypertensive therapy. Common reasons for poor adherence include belief of cure (43%), high cost of treatment (33%), and the experiencing of side effects (27%). Patients with good family support had better adherence compared to those with poor family support (P < 0.05). Conclusion: Poor family support and other factors were identified as causes of poor adherence among these hypertensive patients. Strategies targeting these factors will improve drug adherence, thereby preventing poor treatment outcomes among these patients.
Keywords: Adherence to antihypertensives, family support, out-of-pocket payment
|How to cite this article:|
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;8:241-5
|How to cite this URL:|
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 [serial online] 2015 [cited 2019 Oct 16];8:241-5. Available from: http://www.atmph.org/text.asp?2015/8/6/241/162668
| Introduction|| |
Hypertension is an independent risk factor for cardiovascular diseases whereas poor medication adherence generally results in poor treatment outcomes.  Worldwide, studies have showed that when hypertension is well-controlled, there is an effective decrease in the incidences of cerebrovascular diseases and cardiovascular disease,  especially among the elderly, and the benefits are more than twice in young people. , Therefore, hypertension is not a normal aging process in the elderly and should be treated aggressively when diagnosed in all ages. 
Various reasons are responsible for the difficulty to control blood pressure while inadequate adherence to medications is usually cited as the main cause.  Although many methods are used to define "adequate adherence," one of the most commonly used definitions is that "the patient takes 80% or more of the prescribed antihypertensive medicines." , The rate of antihypertensive adherence varies with the method of assessing adherence, patient background, age group studied, and complexity of prescription. 
Studies worldwide suggest that 25% of patients discontinue their antihypertensive treatment after 6 months of commencing therapy. , This had been associated with the increased risk of hospitalization for cardiovascular problems among those who discontinued therapy. Factors associated with an increased likelihood of continuing treatment were better medical management and communication by the prescriber, early changes in treatment if adverse effects were experienced more during follow-up visits, and opting for nondiuretics as an initial choice of therapy. This study emphasizes the importance of monitoring treatment and adverse effects, and making appropriate changes promptly to improve adherence. ,
Factors affecting medication adherence include the experience of adverse drug effects, lack of clear instructions, sensory impairments in the elderly, daily dose frequency, combination of multiple drugs, cost to control blood pressure, accessibility of drugs, and patients' perceptions about hypertension and treatment. ,
There is a need to understand why patients may not adhere to prescribed treatment interventions and to develop strategies to increase adherence rates, thus improving overall clinical outcome. Reasons for nonadherence to pharmacological therapy can roughly be grouped under three main headings: patient-, physician-, and medication-related. There are a number of direct patient-related reasons for nonadherence to antihypertensives. , These include forgetfulness; negative attitude toward medication; frustration with poor therapeutic responses; preconceived beliefs regarding health and medication; cultural beliefs; lack of education or inadequate literacy skills; and poor language proficiency. In addition, a poor understanding of the cost-benefit of a prescribed drug, including a lack of understanding of the benefit of the medication and a fear of drug-related adverse events may also contribute to patient nonadherence. Inadequate follow-up by physicians may compound the problem by sending out the message to patients that adherence to medication is not important. , Medication-related reasons include high dosing frequency, polypharmacy, and adverse effects. 
In Nigeria, reasons for nonadherence are compounded by a high level of poverty, fake drugs, and inadequate distribution of trained staff. Since the Federal Medical Centre in Owo, Ondo State, Nigeria was established, no study had focused on the effects of family support and other factors influencing medication adherence among the hypertensive patients; hence, the need for this study.
| Materials and Methods|| |
The study was conducted at the Medical Outpatient Department of the Federal Medical Centre, Owo, Ondo State, Nigeria. It is a federal government owned specialist hospital based in Owo with catchment from other parts of Ondo State and beyond.
A descriptive cross-sectional study design aimed at documenting factors affecting the drug adherence of hypertensive patients was conducted. Systematic random sampling method was used to select consenting hypertensive patients who had received care at the Medical Outpatient Department of the hospital for at least 3 months. Exclusion criteria included nonconsenting, comorbid, and pregnant patients.
The required sample size of 288 was calculated using a formula for estimating the minimum sample size in descriptive health studies [n = Z 2 pq/d 2 ]  and finding from a previous study  where 25% were reported. The minimum sample size was increased by 10% to take care of incomplete/nonresponse and refusals.
Data were collected with a pretested interviewer-administered questionnaire that had biodata, family characteristics, and perception of family support using the Perceived Social Support Family-Scale (PSS-Fa).
The PSS-Fa is a 20-item validated measure of family support. The subject answered "yes", "no", or "do not know" to questions on his/her feelings and experiences with his/her family. Each response that led to family support was given a score of 1 while a response indicating lack of family support was given a score of 0. Summated scores were used to arrive at a family support score for each subject, with a possible score range of 0-20 points. Higher scores indicated higher level of perceived family support with scores equal to or greater than 11 taken as strong family support, scores 7-10 taken as weak family support while scores equal or less than 6 taken as no family support. The PSS-Fa has been found to have good reliability and validity. The original Perceived Social Support Scale has an alpha coefficient of 0.90 indicating that the scale has excellent internal consistency. The alpha for the PSS-Fa ranged from 0.88 to 0.91. 
Clinical checklist data were obtained from the respondent's clinic records. This included comorbidity history, and blood pressure profile at the baseline and at 3 months.
Degree of adherence by individual patients was estimated manually by means of patient self-report. The degree of adherence from patient self-report  was estimated using the following formula:
From the formula, level of adherence by individual patients was categorized into those with less than 80% adherence and those with equal to or more than 80% adherence. Adherent patients were defined in this study as individuals with at least 80% adherence level.
Data collected were entered into SPSS version 16 (SPSS Inc., Chicago, IL, USA) and analyzed using descriptive and chi-square statistics. P-value of less than 0.05 was accepted as significant.
Ethical approval was obtained from the Federal Medical Centre Ethics and Research Committee. Informed consent was obtained from each respondent before administering the questionnaire. To ensure anonymity, no names were recorded. Confidentiality of collected data was maintained throughout the study.
| Results|| |
Four hundred and twenty patients on antihypertensive drugs were studied. The mean age of the patient was 60.6 ± 11.7 years (range 21-85 years). There were 206 (49%) males and 214 (51%) females. Most respondents were Yoruba (86%), married (77%), and had primary education (28%). Most (61%) were adherent to antihypertensive therapy. Nonadherence was higher in the younger age group, respondents with lower education, and rural dwellers [Table 1].
|Table 1: Association between sociodemographic characteristics and drug adherence of respondents|
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[Table 2] reported that nonadherence was higher among newly diagnosed hypertensive patients, those with higher pill burden, and those without family support (P < 0.05).
|Table 2: Association between level of drug adherence and some health variables of respondents|
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[Table 3] showed that common reasons for nonadherence include forgetfulness (43%), belief of cure (34%), lack of fund to purchase drugs (27%), side effects (27%), and health workers strike (19%).
|Table 3: Reasons for poor adherence to antihypertensives among respondents|
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[Table 4] reported that simplifying regimen (35.7%); informing; educating; and counseling these patients (16.7%), and addressing drug-related issues such as cost, availability, accessibility, and side effects (15.7%) will improve drug adherence.
|Table 4: Suggestions of hypertensive patients on ways to improve drug adherence|
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| Discussion|| |
This study found that nonadherence to antihypertensive drug therapy is a problem among these patients. Various studies had showed nonadherence to antihypertensives as a global problem that requires multiple solutions. ,, This study reported a nonadherence rate of 39% among the respondents. This is much less than Kabir et al. who reported 59% nonadherence rate among hypertensive patients in Kano  while Bello in 2012 reported a nonadherence rate of 32%.  This partially resulted from the different methods of measuring adherence by these authors. However, these varying results implied that nonadherence remains a problem that requires solution if there is to be improved health outcome among hypertensive patients.
This study showed that nonadherence was higher in young respondents, those with lower education, and those living in rural areas. Several studies had showed that adherence to antihypertensive drugs varies across age groups, levels of education, and the living statuses of the study population. ,, This study finding that poor adherence was higher in newly diagnosed hypertensive patients could have resulted from poor patient education on drug adherence at the commencement of antihypertensives on need to adhere to therapy to reduce the likelihood of life-threatening complications such as stroke and cardiac failure.  This study found that patients with high pill burden and those without family support had equally poor drug adherence. These findings implied that supposed drug resistance could be due to unidentified low adherence among the study population.  Various studies had reported that treatment partners and family support improve patients with chronic conditions adherence to therapy. ,, This finding emphasizes the necessity of ensuring family and social support at the commencement and continuation of antihypertensive therapy.
Forgetfulness and belief of cure were reportedly the commonest reasons for nonadherence among these hypertensive patients. This is in tandem with other adherence studies worldwide showing the importance of patient education before commencement and while on antihypertensive therapy. Also, treatment partners such as family caregivers and mobile phones had been shown to help in reminding these patients. Other reasons such as lack of funds to purchase drugs and side effects had also been reported, especially among patients under care in third world countries. This nonadherence was due to the inability to pay for prescribed drugs results from low availability and uptake of health insurance among the study population as most patients pay for drugs using the out-of-pocket method. Also, side effects could result in nonadherence as patients were unable to afford other drugs with less reported side effects.
However, some patients reported health workers' strike as a reason for their poor adherence. Health workers' strike, though not a new phenomenon in the third world countries, is gradually becoming a major reason for poor adherence, especially among patients with chronic diseases. Strike prevents patients from accessing necessary care and support from these health workers who belong to the sensitive and essential sector who were hence, not expected to go on industrial action. Life is sacred and any loss of industrial output cannot be compensated; hence, health care workers, though legally having the right to demand their rights, should be reluctant to begin any industrial agitation. Therefore, it is expected that the employer will make every effort to meet any legitimate demand by these workers so that any disagreement is sorted out through dialogue to prevent any lapse in work. 
Patients' suggestions on improving adherence such as simplifying the regimen, patient education, and addressing drug-related issues such as cost, availability, accessibility, and side effects require attention. , Studies had showed the importance of simple regimens such as single dose therapy, using cheaper generics instead of expensive branded drugs, and reducing side effects through early detection and reviewing medication. ,, Hence, these strategies will improve drug adherence and prevent poor treatment outcomes if implemented.
The study is limited in being a cross-sectional study determining adherence to antihypertensives and factors affecting adherence; no cause-effect relationship could be established. Although every effort was made to reassure the participants, some possibly did not disclose their adherence status.
| Conclusion|| |
In conclusion, nonadherence to antihypertensive was a problem among the study population. Forgetfulness, belief of cure, and drug affordability were major reasons for nonadherence. Those with good family support had good drug adherence. Suggestions to improve adherence include simplifying the regimen, educating the patient, and addressing drug-related issues. Also, every effort should be targeted to avoid health workers' strikes while reducing out-of-pocket payment through establishing and strengthening the community health insurance scheme.
Financial support and sponsorship
Conflicts of interest
The authors disclose no potential conflict of interest and received no funding for this study.
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Samuel Anu Olowookere
Department of Community Health, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
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