IMPROVING PATIENTS' MEDICATION ADHERENCE IN PRIMARY HYPERTENSION
Josip Čulig1,2, Jelena Bošković3, Marcel Leppée2, Vladimira Lesnikar2
1
School of Medicine, Josip Juraj Strossmayer University, Osijek, Croatia
2
Andrija Stampar Institute of Public Health, Zagreb, Croatia
3
Pharmacy Zagreb, Croatia
INTRODUCTION
Adherence is the extent to which a person's behaviour-taking medication corresponds with
agreed recommendations from a health care provider. There is a strong evidence that many
patients with chronic illnesses, including hypertension, have difficulty adhering to their
recommended treatment regimen. This leads to reduced control of the illness, reduces patient's
quality of life, and increased risk of stroke and myocardial infarction. It has been shown that
despite the availability of effective treatment less than 25% of patients treated for
hypertension achieve optimum blood pressure. Poor adherence has been identified as the main
cause of failure to control hypertension.
The determinants of adherence to antihypertensive therapy are related to drug treatment such
as drug tolerability and regimen complexity. Other potential determinants of adherence may
be related to the demographic factors (age, sex, education), the patient's perception of
disease, the health care provider's mode of delivering treatment, the relationship between
patients and health care professionals, the socioeconomic factors (price, access, supply).
The important factors of the health care providers on the patient's adherence to therapy
include: a back of knowledge and inadequate time with patient. The patient-doctor
relationship was much more studied then the patient-pharmacist relation.
AIM OF THE STUDY
The objective of this study was to investigate the adherence to medication in patients with the
primary hypertension in Zagreb. The patient-pharmacist relationship was analysed.
MATERIAL AND METHODS
Patients with diagnosed chronic diseases filled self-reported questionnaire during visit to the
pharmacy where they collect their prescribed drugs.
The questionnaire was standardized in the previous study on drug use (J.Culig, et al.
9th Congress of EACPT, Edinburgh, 2009.) The extent of adherence to medication was
estimated according to the answers on the specific questions. There were 16 reasons offered
for not taking medication as agreed. There were 634 self-reported questionnaires collected
from the 114 various community pharmacies in Zagreb. The most significant cohort was the
primary hypertension patients (357/56,3%). The relationship between patients and pharmacist
was evaluated through a part of the questionnaire.
RESULTS
There were more women than men among the study population. There was no difference
between adherent and non-adherent patients according to the sex (Table 1). Also, there was no
significant difference according to the age distribution (Figure 1). Patients with primary
hypertension (n=357) fulfilled the questionnaire. It was estimated that 39,2% (140) were
adherent, and 60,8% (217) were non-adherent (Table 2). The reasons for non-adherence are
listed in Table 3. The two leading reasons are patient forgetfullness and „ran out of pills“. The
next three are connected with treatment characteristics: drug side-effects, polypharmacy in
chronic illness and unconvinent dosing time. The defective supply of local pharmacy is
unexpectedly high on the 6th place of the list. In the middle of the list is the frequent changes
of prescribed therapy.
The patients expected more than they got from the pharmacists (Table 4). Less than half of the
patients have got adequate counselling from the pharmacists.
DISCUSSION
The adherence to long term therapy in the primary hypertension is inadequate. Most of the
studies estimated adherence to antihypertensive therapy above 50%. We found it even lower
(39,2%). Two of the most important factors contributing to poor adherence are the
asymptomatic and lifelong nature of the disease. According to the answers given in our study,
two most important factors are that patients simply forgot to take a pill and they forgot to
renew supply of drugs. It has been suggested that the interventions should be pointed to a
patient behavioural change. The patients should be provided with knowledge of importance to
sustain a medication-taking behaviour. Also, a family support might have some influence. The
side-effects of therapy, the polipharmacy, the complex dose and time regimen are still pretty
high on the list of non-adherent reasons. The health care providers should improve a quality
of communication, but also their knowledge on drugs therapy that they prescribe. There are
213 community pharmacies in Zagreb and problem with drug supply should not be the issue.
The reason why that was high on the list is probably the bad economic shape of the main
Croatian health fund. The most of strategies to improve adherence to drug treatment is dealing
with a doctor-patient relationship and with a patient behaviour change. The pharmacist as
resource in improving patient's adherence to drugs should be more exploited. According to
our results, the patient's expectation were not met. This is obviously the area for
improvement.
CONCLUSIONS
The patient's adherence to antihypertensive medication in Zagreb is low. The strategy for
better managemnt should be implemented. The pharmacist-patient relationship is important
resource that might be improved in the interventions strategies.
ACKNOWLEDGMENT
This study was funding by Ministry of Science, Education and Sports, Republic of Croatia.
Table 1. Adherent vs. non-adherent patients with chronic diseases according to sex in
Zagreb
Sex
Adherent Non-adherent Total
Male
107
151
258
Female
156
220
376
Total
263
371
634
Table 2. A percentage of adherent vs non-adherent patients with a primary hypertension in
Zagreb
Adherent Non-adherent Total
140
217
357
39,2%
60,8%
100,0%
Table 3. The reasons for not taking antihypertensive therapy
Reasons
N
%
Forgetfullness
„Ran out of pills“
Side-effects
Polypharmacy
Dosing time
Deffective supply
Away of home
Frequent changes of therapy
Well-being
Fear of potential toxic effects
Symptomatic flu
Expensiveness
Went asleep
Fear of dependancy on drug
Depressive mood
Public embarrassement
253
251
248
247
247
245
244
243
241
235
234
233
231
231
229
223
70,9
70,3
69,5
69,2
69,2
68,6
68,3
68,1
67,5
65,8
65,5
65,3
64,7
64,7
64,1
62,5
Table 4. The patients view of the patient-pharmacist relationship
Pharmacist's advise
Pharmacist always check do I take my medication at first visit
Pharmacist always informed me how to take a drug
Pharmacist always stress the importance of adherence
Pharmacist always conselled me on side-effects
Pharmacist always check do I miss a dose and why instructions
Pharmacist always check do I understand the instructions
%
61
57
46
44
42
23
140
Adherent and non-adherent patients according to the age
120
100
80
60
40
20
0
26-35
36-45
46-55
Non-adherent
56-65
Adherent
>65
Figure 1. Adherent vs. non-adherent patients with chronic diseases according to the
age in Zagreb