|Year : 2017 | Volume
| Issue : 1 | Page : 20-25
Factors for nonadherence to antihypertensive drugs among Federal Civil Servants attending health facilities − Abuja, FCT
Amina Z Kazaure1, Aisha A Abubakar2, Mohammed S Ibrahim2, Saeed Gidado1, Kabir Sabitu2, Patrick Nguku1
1 n Field Epidemiology and Laboratory Training Programme, Ahmadu Bello University Zaria, Nigeria
2 Department of Community Medicine, Ahmadu Bello University Zaria, Nigeria
|Date of Web Publication||6-Mar-2018|
Aisha A Abubakar
Department of Community Medicine, Ahmadu Bello University Zaria
Introduction: Hypertension affects approximately one billion people worldwide. Three hundred and forty million of these in economically developed and 340 million in economically-developing countries. The World Heart Federation reports that in the developed world, about 330 million people have hypertension, and about 640 million in the developing world. Estimates indicate that up to three quarters of the world’s hypertensive population will be in economically developing countries by the year 2025. Non-adherence to antihypertensive drugs is one of the most important causes of uncontrolled blood pressure.
Materials and Methods: Between August 2013 and June 2014, we enrolled 424 hypertensive patients in a cross-sectional study using systematic sampling technique. The Morisky Green test for non-adherence was used to assess non-adherence to drugs. Information was collected regarding socio-demographic, drug related and healthcare service delivery factors to patient non-adherence using an interviewer administered questionnaire. Univariate, bivariate and multivariate analysis was conducted using Epi info software.
Results: The level of non-adherence was 69.1%. Factors that were independently associated with non-adherence were; being a Junior Civil Servant (OR 2.9: 95%CI 1.1–7.7), exhaustion of drugs before the next clinic appointment (OR 5.9: 95%CI 2.8–12.5), buying drugs in private pharmacies and open market (OR 1.9: 95%CI 1.03–3.3) and total time spent counselling of less than five minutes (OR 1.8: 95%CI 1.02–3.2).
Conclusion: The level of non-adherence in this study was found to be high. Creating special support groups for Junior Civil Servants, ensuring patients come back to the hospital to refill their drugs, improving counselling techniques and making prescribed antihypertensive drugs constantly available in the hospital, could improve the level of non-adherence to antihypertensive drugs among patients attending Federal Staff Hospitals and Clinics.
Keywords: Antihypertensive drugs, federal civil servants, nigeria, nonadherence
|How to cite this article:|
Kazaure AZ, Abubakar AA, Ibrahim MS, Gidado S, Sabitu K, Nguku P. Factors for nonadherence to antihypertensive drugs among Federal Civil Servants attending health facilities − Abuja, FCT. Sub-Saharan Afr J Med 2017;4:20-5
|How to cite this URL:|
Kazaure AZ, Abubakar AA, Ibrahim MS, Gidado S, Sabitu K, Nguku P. Factors for nonadherence to antihypertensive drugs among Federal Civil Servants attending health facilities − Abuja, FCT. Sub-Saharan Afr J Med [serial online] 2017 [cited 2018 Mar 19];4:20-5. Available from: http://www.ssajm.org/text.asp?2017/4/1/20/226661
| Introduction|| |
Hypertension affects approximately one billion people worldwide. Three hundred and forty million of these in economically developed and 340 million in economically developing countries. Hypertension is defined as a sustained diastolic pressure >90 mmHg accompanied by an elevated systolic pressure >140 mmHg. Medication nonadherence is defined as a patient’s passive failure to follow a prescribed drug regimen. Adherence on the other hand can be defined as the active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result. Adherences to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. In a World Health Organization report, adherence to antihypertensive drugs ranged from 52 to 74%. It is usual to consider patients to be sufficiently adherent with their treatment when they take at least 80% of their prescribed antihypertensive drugs. In spite of many advances made in adherence research, nonadherence rates have remained nearly unchanged in the last decades. Poor adherence with treatment is one of the most important causes of uncontrolled blood pressure. Uncontrolled blood pressure is associated with significant increase in the incidence of complications of hypertension. Nonadherence may worsen disease severity, leading to the increased utilization of medical care services and therefore increases in overall health care costs.
Data from Federal Staff Hospital Jabi registration records show that patients with hypertension have increased on a yearly basis. The proportion of patients with hypertension attending the hospital has increased from 1% in 2011 to 3% in 2013. Civil Servants can be considered to be the engine room of service delivery of the Federal Government. They are the implementers of Government policies and programs. It is assumed that this makes them very busy, stressed, and prone to hypertensive disease. The impact of their poor health leads to poor service delivery.
Studies have been conducted in the past on factors associated with nonadherence to antihypertensive drugs in the different parts of Nigeria.,,, Factors identified in previous studies include the level of education, medication taking, appointment keeping, food and salt consumption, alcohol consumption, associated complications, cost of medication, counseling, absence of symptoms, side effect of drugs, nonavailability of drugs, exhaustion of prescribed drugs, normal blood pressure during previous clinic visit, forgetfulness, and busy schedule. There is limited information concerning patient nonadherence to antihypertensive drugs among Federal Civil Servants in Abuja. Therefore, this study would contribute toward providing improved management plans suited for them.
The study was conducted to assess the level of nonadherence to antihypertensive drugs among Federal Civil Servants attending Federal Staff Hospitals and Clinics in Abuja and to identify the factors that are associated with nonadherence to antihypertensive drugs.
| Materials and methods|| |
This was a cross-sectional descriptive study conducted between August 2013 and June 2014. Study participants were Federal Civil Servants with hypertension registered at Federal Staff Hospitals and Clinics in Abuja. Federal Staff Hospitals and Clinics Abuja are Federal Health Facilities serving Federal Civil Servants and the general public. There is one hospital and four clinics. Both outpatient and inpatient services are offered in the hospital and clinics. Hypertensive clinics are conducted twice a week in the hospital whereas patients with hypertension are seen throughout the week in the clinics. The average patient attendance per month in the outpatient department for the year 2013 was 10,526 patients in Federal Staff Hospital Jabi.
The inclusion criteria were patients of age 18 years of age and above. Those who were on prescribed antihypertensive medications for at least the previous 1 month and patients must be Federal Civil Servants. The exclusion criteria were patients who were too ill to answer the questionnaire. Patients who agreed to participate in the study were given a written consent form to fill. The sample size was estimated using the proportion of nonadherence to antihypertensive drugs from a previous study in Kano, Nigeria and by applying the formula for cross-sectional studies for estimating sample size. The sampling technique was systematic sampling. Patients were selected by systematic sampling from a listing on the clinic days., The selected patients were interviewed using an interviewer-administered structured questionnaire.
Nonadherence was assessed using the Morisky scale. Morisky–Green test was used for evaluating patient’s nonadherence to medications. The test consisted of four questions: Have you ever forgotten to take your medicine? Are you sometimes neglectful in regard to your medicine hours? Do you skip your medicine hours when you are feeling well? When you feel badly due to the medicine, do you skip it? One point was given to a correct response and zero points given to wrong responses. A patient could get a maximum of four points and a minimum of zero points. According to the protocol of the Morisky–Green test, patients were considered adherent to the treatment when they obtained the maximum score of four points, and patients were considered nonadherent when they obtain three points or less.
Data were collected using a structured pretested questionnaire administered by trained interviewers. Part A consisted of sociodemographic factors and knowledge about hypertension and its management. Part B covered drug-related factors. Part C covered healthcare service delivery factors. Four interviewers were trained before the administration of the questionnaire. The interviewers were trained for 2 days. In addition, a pretest of the questionnaire was performed before the administration of the final questionnaire. Data handling and coding were performed after the data collection. After the participants were interviewed, two sitting blood pressure measurements were taken in the right arm with pretested mercury sphygmomanometers and stethoscopes approximately 2 min apart and the average of the two readings were used to determine the blood pressure level. The cuff size was 23 cm × 12.5 cm. For all readings, Korotkoff phases I and V were used to establish the levels of systolic and diastolic blood pressure, respectively., Patients with hypertension were defined as those with raised blood pressure of more than or equal to 140/90 mmHg at the time of data collection. Controlled hypertension was defined as an average blood pressure reading <140/90 mmHg at the time of data collection.,
Frequencies, proportions, and summary statistics were used to describe the study population in relation to relevant variables. A P value of <0.05 was considered to be statistically significant for all analyses. Odds ratio (OR) for nonadherence was reported at 95% confidence interval (CI). All statistical analyses univariate, bivariate, and multivariate analysis were performed using Epi info version 3.4.3 statistical software (CDC Atlanta, Georgia, USA) and Microsoft Excel spreadsheet.
Ethical clearance was obtained from the National Health Research Ethics Committee of Nigeria, Federal Ministry of Health Abuja. Written consent was obtained from participants before the commencement of the study. Each study participant was adequately informed about the purpose, method, anticipated benefits, and the risk of the study by the data collectors. Written informed consent was obtained from the study participants, and anonymity was maintained to ensure confidentiality.
| Results|| |
A total of 424 patents took part in the study at Federal Staff Hospitals and Clinics Abuja between August 2013 and June 2014. The respondents had a mean age of 50.1 years and standard deviation of 6.98 and age range of 31–65 years. The age group (50–59) years had the highest frequency at 205/424 (48.3%). There were more males than females (240/424; 56.6%). Majority of the patients were married (354/424; 83.5%). 305/424 (71.9%) had up to tertiary level of education. Majority (349/424; 82.3%) were Senior Civil Servants [Table 1].
|Table 1: Sociodemographic characteristics of Federal Civil Servants attending Federal Staff Hospitals and Clinics in Abuja; November 2013–June 2014 (n = 424)|
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69.1% (293/424; 69.1%) of the patients were found nonadherent whereas 131/424 (30.9%) were adherent to treatment [Figure 1]. The average systolic was 144.7 mmHg whereas the average diastolic reading was 89.4 mmHg at the time of the interview. Up to 242/424 (57.1%) of respondents had uncontrolled blood pressure at the time of the interview.
|Figure 1: Distribution of Federal Civil Servants with hypertensive attending Federal Staff Hospitals and Clinics, Abuja by adherence status to antihypertensive drugs; November 2013–June 2014 (n = 424)|
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Patients who had been on antihypertensive drugs for <5 years were 1.7 times more likely to be nonadherent, compared to patients who had been on drugs for 5 years or more (95% CI: 1.1–2.5). Patients who experienced any adverse effects from their drugs were 1.8 times more likely to be nonadherent (95% CI: 1.2–2.9). Patients who took alternative drugs were 2.0 times more likely to be nonadherent compared to those who did not take alternative drugs (95% CI: 1.2–3.2). Those whose drugs got exhausted before the next clinic appointment were 8.4 times more likely to be nonadherent (95% CI: 4.8–14.7) compared to patients whose drugs did not get exhausted. Patients who received counseling for <5 min were 2.6 times more likely to be nonadherent (95% CI: 1.6–4.3) compared to patients counseled for 5 min or more. Patients whose last visit to the hospital was 3 months or more were 2.2 times more likely to be nonadherent compared to those whose last visit was <3 months (95% CI: 1.4–3.4). Patients who bought their drugs in the pharmacy and open market were 2.5 times more likely to be nonadherent compared to those who bought their drugs in the hospital alone (95% CI: 1.6–3.8) [[Table 2] and [Table 3]].
|Table 2: Sociodemographic factors associated with nonadherence to antihypertensive drugs among Federal Civil Servants attending Federal Staff Hospitals and Clinics, Abuja; November 2013–June 2014 (n = 424)|
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|Table 3: Drug-related and health service delivery factors associated with nonadherence to antihypertensive drugs among Federal Civil Servants with hypertensive attending Federal Staff Hospitals and Clinics in Abuja; November 2013–June 2014 (n = 424)|
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Further analysis using multiple logistic regressions was performed to evaluate the relationship between multiple factors and nonadherence to antihypertensive drugs. When controlling for other variables in the model, Junior Civil Servants had a significantly higher chance of nonadherence (95% CI: 1.1–7.7). Those whose drugs got exhausted before the next clinic appointment had a 5.9 times likelihood of nonadherence (95% CI: 2.8–12.5). In addition, patients whose total time spent counseling was <5 min had a 1.8 times higher chance of nonadherence (95% CI: 102–3.2) [Table 4].
|Table 4: Independent factors for nonadherence to antihypertensive drugs among Federal Civil Servants in Abuja (n = 424)|
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| Discussion|| |
In this study, the level of nonadherence to antihypertensive drugs among Federal Civil Servants attending Federal Staff Hospitals and Clinics was found to be high. This is lower to a finding in a previous study conducted in Bangladesh, which showed that the level of nonadherence among study participants was up to 85%. The result in this study is, however, higher than what has been reported in other studies: Kano 45.8%, Ethiopia 35.4%, and Zambia 17%. This study was conducted among Federal Civil Servants living in an urban setting. It may be that the participants in this study led busier life styles because of their occupation and where they lived. The studies that had the lower levels of nonadherence mentioned above were conducted among the general population.
In this study, the grade level, exhaustion of drugs before the next clinic appointment, and counseling received for <5 min were independent factors associated with nonadherence to antihypertensive drugs among Federal Civil Servants in Abuja.
Junior Civil Servants were found more likely to be nonadherent compared to Senior Civil Servants in this study. A possible reason may be that Junior Civil Servants had lower incomes compared to Senior Civil Servants which may make the drugs less affordable to them. In addition, Junior Civil Servants are younger compared to Senior Civil Servants. Previous studies have shown that older patients tend to be more adherent to treatment., Patients whose drugs got exhausted before their next clinic appointment were more likely to be nonadherent compared to those whose drugs did not get exhausted. In Kano, similar results were obtained. It is possible that patients who do not refill their drugs in good time means that they are not taking their prescribed drugs as they should. Patients counseled for <5 min were more likely to be nonadherent compared to patients who were counseled for 5 min or more. This result is similar to the Zambian study, where being counseled for more than 5 min about how to take medication was associated with decrease in the level on nonadherence. “Patient-centered” communication between patients and healthcare providers contributes to increase in patients’ understanding about their illnesses and adherence to treatment.
The limitations of the study were: recall bias; information may not have been given accurately by the respondents. There was the possibility of willful misstatements by respondents as the information given by them could not be independently verified.
In conclusion, being a Junior Civil Servant, having drugs exhausted before the next clinic appointment and total time spent counseling <5 min were independent factors associated with nonadherence to antihypertensive drugs in this study. Recommendation of this study to Federal Staff Hospitals and Clinics is as follows: for the healthcare staff to take note of hypertensive Junior Civil Servants as potential patients who may not adhere to drugs. Counseling techniques should be specially created for this subgroup of Civil Servants with greater emphasis on adherence to drugs. Support groups can be created to ensure that Junior Civil Servants are informed about the importance of adherence to treatment and this may in turn motivate them to take better care of their health.
For the staff to stress the importance to patients about refilling their antihypertensive drugs on as soon as they are exhausted. This may be achieved during clinic visits. Patients can be counseled before seeing their doctors after vital signs are taken. Special health messages either visual, audio and counselling can be given to stress the importance of refilling drugs in good time.
Improving the communication techniques between patients and hospital staff about hypertension and its management may be achieved by training healthcare staff in counseling techniques specific for hypertensive disease. Other communication techniques apart from one on one counseling can be adopted such as fliers, showing mini documentaries about the importance of adherence to antihypertensive drugs and the consequences of not taking the drugs. All patients with hypertension should be counseled for 5 min or more before or after seeing the doctor. Medication nonadherence to antihypertensive drugs constitutes a major problem in the management of hypertension.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]