CHAPTER V:DISCUSSION
LIMITS AND DIFFICULTIES
Ensuring patient adherence to antihypertensive medications in
order to prevent complications remains a major challenge to public health in
many developing countries. Poor adherence to treatment is the single most
important reason for uncontrolled hypertension, serious complications and
wastage of health care resources [7].
Our main objective was to assess adherence level and its
associated factors to antihypertensive treatment among adult hypertensive
patients followed-up at the YGH. All five specific objectives were achieved by
the end of this study. However some technical difficulties were witnessed which
included: lack of an adequate secluded area at certain times to carry out
interviews privately, incomplete or missing information on patient medical
records, dealing with some patients presenting with comorbidities affecting
their quality of life like stroke, heart failure, gout or diabetic neuropathy
and making participant understand each item of the questionnaires. The study as
a whole has the following limits:
1) The study was carried out in the YGH and so the results
obtained cannot be used to generalize the adherence levels in the Centre
region. More data has to be collected from various hospitals and clinics in
order to bring out a general trend in adherence levels.
2) The research did not investigate adherence levels in
patients suffering from a mental handicap or disease.
3) Refusal of some patients to participate in the study.
v Sociodemographic and socioeconomic
characteristics
Our study sample comprised 175 participants whose average age
was 60.1 #177; 11.1 years. The 60 years and above age group was the most
represented (48%; n = 48). Our results are in line with the previous
literature[1,106-108]. However, in Ethiopia, Ambaw et al.
found in 2012 that the ]40-60[ years age group was predominant at
51.70%[7].Mbouemboue et al. had a similar finding where the
most represented age group was between ]45-65] years old at
57.10%[16]. Nonetheless, what these studies have in common is
that there is a general incremental trend in the prevalence of hypertension in
adults aged 25 and above.
The sex ratio was 1.2 in favor of males (54.90%). Several
authors have reported a similar finding[1,101,102,110].In a
2012 study carried out in Cameroon on 2,120 persons, Dzudie et al. reported
that HBP was more frequent in the male population (50.10%) than in the female
population (44.60%)[28].However other authors reported a
female predominance: Ambaw et al. in 2012 in Ethiopia
at63%[7]; Mbouemboue et al. in 2016 inCameroonat
54.76%[16]; Akoko et al. in 2017 in Cameroon at
55.70%[20]; andEssomba et al. in 2017 in Cameroon
at64.60%[19] and the latter author suggested that a possible
reason for this female predominance is that women take their health issues more
seriously compared to men.
The majority of the participants lived in an urban setting
(88.60%). The YGH is located in the heart of the capital city of Cameroon and
therefore patients who go there for consultations are mostly city
dwellers.Ambaw et al. in 2012 in Ethiopia had a similar finding at
76.60%[7]; and Behnood-Rod et al. in 2016 in Iran had
97.50%[107].
Most participants in our study went through secondary
education (42.29%). Our results were in line with the previous literature
[16,19,20,103,110,111]. This research was undertaken in an
urban setting where basic education is promoted and secondary education
institutions are very much present. Other authors reported lower levels of
education.Tufon et al. in 2014 in Cameroon had 65% of participants whohad
primary level of education possibly because the study site was conducted in a
rural setting[18]; Hussain et al. in 2011 in Bangladesh had
51.70% with primary level of education or below[104].
The majority of our study population (84.60%) spent less than
1 hour to the reach the YGH. The reason for this was that most patients lived
in neighboring quarters. Ambaw et al. in 2012 in Ethiopia had a similar result
where 39.30% spent 30 minutes to reach the hospital and 60.70% spent more than
30 minutes[7].
Only 10.90% of our study population had a health insurance. A
similar result is observed in a study by Mbouemboue et al. in 2016 in Cameroon
who had 8.60%[16]. Thiscould be primarily because of the fact
that health insurance isnot mandatory in the current health-care system, and in
partbecause of the lack of awareness on the benefits of healthinsurance. On the
contrary,Behnood-Rod et al. in 2016 in Iran had 87.80% of participants with
health insurance[107]. A reason for this high record could be
that health insurance is fully integrated into Iranian healthcare systems and
thus easy access to health services.
v Clinical and therapeutic characteristics
Our study revealed that 57.70% of the study population had a
controlled BP. This was higher than what was reported in previous literature.
Mbouemboue et al. in 2016 in Cameroon had 48.57%[16]; Akoko et
al. in 2017 in Cameroon had 42.1%[20]; Behnood et al. in 2016
in Iran had 43.6%[107]; Okwuonu et al. in 2015 in Nigeria had
33%[110]. A reason for the high level of BP control in our
study is that patients are given regular appointments especially upon treatment
initiation in order to appreciate therapeutic efficiency. Physicians comply
with treatment guidelines to change or intensify antihypertensive therapy if BP
remains uncontrolled with pharmacotherapy.
The most frequently associated pathology to HBP was heart
failure at 24.57%. Essomba et al. in 2017 in Cameroon had diabetes at
86.60%[19]; Behnood-Rod et al. in 2016 in Iran had ischaemic
heart disease at 10%[107]; Boima et al. in 2015 in Ghana and
Nigeria had diabetes or renal comorbidities at 27.73%[111];
Hedna et al. in 2015 in Sweden had ischaemic heart disease at 16.4%.
The majority of drugs screened in this study were CCBs
(31.90%) present as fixed-dose monotherapy. Hedna et al. in 2015 in Sweden had
62.10% drugs acting on the renin-angiotensin system in their
study[108]. The reasons for this is that CCBs are first-line
treatment for primary hypertension in patients over the age of 55and black
patients of African[3,68,71,74]. CCBs are also readily
available locally mainly as generics thus facilitating a wider access of
antihypertensives.
The mean monthly drug cost of participants was
14,543FCFA.Mbouemboue et al. in 2016 in Cameroon had a lower average monthly
cost of9,811FCFA per patient per month. The average drug cost was higher in our
study because the majority of drugs prescribed were specialty medications
(88.60%) which are more expensive than their generic counterparts.
v Adherence characteristics
Our study revealed that 32.60% were high adherers; 40.60% of
participants were medium adherers; and 26.90% were low adherers according the
Morisky medication adherence scale.Mbouemboue et al. and Akoko et al.reported
dissimilar figures in their respective studies [16,20].High
adherers were low in a similar study by Behnood-Rod et al. where 49.60% showed
low adherence to antihypertensives, 33.90% had moderate adherence and 16.40%
showed high adherence [107].These figures varied mainly
because of the different methodologies used in assessing adherence.The ultimate
goal of health care intervention is to encourage good adherence of patients to
their antihypertensive drugs. This will have the effect of controlling their BP
thence preventing complications.
v Factors associated with poor adherence
After bivariate analysis 10 variables were found to be
significantly associated with poor adherence (living singly, first cycle
secondary education, trip duration of one hour or more, medium socioeconomic
status, uncontrolled BP status, presence of handicap, monotherapy, taking
medications in the evening, presence of side effects, and knowledgeable about
hypertension). 9 variables persisted after multivariate analysis with logistic
regression (first cycle secondary education, living singly, trip duration of
one hour or more, middle socioeconomic status, uncontrolled BP status, presence
of handicap, monotherapy, presence of side effects, and taking medications in
the evening.
Patients who had a 1st cycle secondary education
were more associated with a poor level of adherence compared to those who had
other educational levels (p=0.0209; OR=3.0287). This was similar
to findings by Mbouemboue et al. in 2016 in
Cameroon[16];Hussain et al. in 2006 in
Bangladesh[104]; and Boima et al. in 2013 in Nigeria and Ghana
also reported insufficient levels of education[111]. Patients
with insufficient background of the disease will have the tendency to neglect
medication adherence and thus be subject to high BP setbacks.
We noted that 66.30% of participants lived as a couple either
legally married or not. Other authors reported similar results
[7,16,18-20,103,106,110,111].Patients who were single were
more associated with a poor level of adherence(p=0.0003; OR=4.6623). Lo et al.
reported in 2016 in China reported a similar finding[109].
Living singly could encourage forgetfulness about drug taking and neglect of
appointments with physicians as opposed to patients living as couples.
Patients who lived 1 hour or more away from the hospital were
more associated with poor therapeutic adherence(p=0.008; OR=7.3925). A similar
finding was gotten from Ambaw et al. in 2012 in Ethiopia[7].
Patients living far away from health centres have the tendency of absenting
from their medical appointments. This can create a breach in patient follow-up,
foster poor adherence and lead to uncontrolled BPs.
Middle socioeconomic status was more associated with a poor
level of adherencecompared to the low and high statuses(p=0.006; OR=2.6814).
Patients in this socioeconomic class usually have difficulties purchasing their
medications which were predominantly specialties and therefore expensive.In
this light, health care providers should promote the prescription of generic
drugs which are affordable and accessible.
Of the 74 participants having an uncontrolled BP, 86.49% had
poor therapeutic adherence.Patients with an uncontrolled BP were more
associated with poor therapeutic adherence than those with a controlled
BP(p<0.001; OR=5.5704). Boima et al. had a similar finding
[111].This association therefore confirms that poor adherence
to antihypertensive medication is responsible for the increasing prevalence of
hypertension.
In our study, 18.29% had a form of handicap of which 16.57%
were physical handicaps. A similar finding was obtained by Mbouemboue et al. in
2016 in Cameroon (18.1%) but with only sensory
handicap[16].Patients with a handicap were more associated
with poor therapeutic adherence compared to those without(p=0.0117; OR=4.1222).
Mbouemboue et al. had a similar finding[16]. Any form of
handicap affects a person's quality of life and also normal medication taking.
Patients with a handicap go through extra challenges in order to correctly take
their medications as prescribed. They therefore need assistance from family and
friends to improve adherence.
Patients who experienced side effects were more associated
with poor therapeutic adherence compared to those who did not experience it
(p<0.0001; odds ratio=11.5143). Lin et al. reported a similar
finding[102]. It is important for physicians to address
medication side effects in patients promptly. This will prevent therapeutic
gaps which are likely to occur in the presence of these side effects. Drug
changes or dosages are therefore imperative in this case.
Patients who took their medications in the evening were more
associated with poor therapeutic adherence compared to those who took their
drugs at other times(p=0.0399; odds ratio=2.5452). Patients are more likely to
forget when told to take drugs in the evening before bedtime. Daily duties
associated with physical and mental stress deter patients from medication
taking thus constituting a hindrance to good adherence.
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