Pharmacological approach to management of hypertension

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The aetiology and impact of hypertension on patients’ quality of life

The aetiology of hypertension is unknown. However, there are factors that predispose a person to hypertension. These are referred to as risk factors. For primary hypertension the risk factors are stress, excessive cigarrette smoking, consumption of alcohol, sodium and saturated fat, obesity and lack of excercise (Addo et al 2007:1012; Halanych, Safford, Kertesz, Pletcher, Kim, Person, Lewis & Kiefe 2010:532; Maher et al 2011:1061. The risk factors for secondary hypertension are diseases and conditions, such as, age and race (Lewis et al 2011:741). Worldwide, almost 6.0% of deaths are caused by complications of hypertension and it also impacts physically, socially, financially and psychologically on patients’ quality of life (Saleem et al 2011:834).

Treatment adherence

The WHO defines treatment adherence as the extent to which a patient’s behaviour of taking medications, following a diet and/or executing lifestyle changes, corresponds with the recommendations of the health care provider (Chobanian et al 2003:1213; Lilley et al 2011:386). Generally, treatment adherence is higher among patients with acute conditions. This is because the treatment is taken for a short period of time and the patient expects the acute condition to be cured after a limited period of adhering to his/her treatment regimens. However, in patients with chronic conditions, such as hypertension, adherence is lower because the treatment has to be taken every day for the duration of the patient’s life. Therefore, patients could discontinue their medication within six months of taking them as they might regard swallowing drugs to be tiresome.

Tools for the measurement of patients’ adherence to anti-hypertension treatment

Different tools have been used to measure patients’ adherence to anti-hypertension medication. The methods of measuring adherence can be divided into direct (objective) and indirect (subjective) ones. Adherence to medication, pertains to records indicating whether the patient had taken the prescribed doses at the correct times or not. The challenge is that it is difficult to measure adherence accurately because there is no best measuring tool for medication adherence as each one has its advantages and disadvantages (Osterberg & Blaschke 2005:488). The following are some of the measuring instruments that were used in this study: the 8-item Morisky Medication Adherence Scale, fivepoint Likert scale and retrospective medication record reviews.

Five point Likert scales

In a five point Likert scale, the patient must rate him/herself on a scale of 0-5 for each item. The scores are, strongly agree-5, moderately agree-4, agree-3, strongly disagee2, moderately disagree-1, disagree-0. The same is done for all the items and then the total score is obtained by adding all the scores selected by the patient. It is objective, simple and easy to score if the participants are literate. But if the patient is illiterate the five points might be difficult to differentiate the parameter of agree and moderately agree, strongly agree. For illiterate persons, the three point scale is easier to rate, agree-3, disagree-2 and don’t know-1.

Factors influencing patients’ anti-hypertension treatment adherence contextualised within the major tenets of the HBM

The HBM has been adapted to describe characteristics and perceptions of patients with hypertension at QECH and how their perceptions influence their behaviour to adhere to the prescribed anti-hypertensive treatment regimens. Patients will follow a behaviour in fear of/or avoidance of the pending threat or for an expected benefit resulting from a specific behaviour. In the process of following the behaviour a benefit will follow, such as, a reduced blood pressure reading. This benefit will be perceived by the patient since there will be no dizziness, heart palpitations and headaches, associated with hypertension. With the patients’ perceived susceptibility, regarding a chance of getting a condition, and/or complications, and the benefit he/she might be more likely to adopt a behaviour to minimise complications and get some expected benefits.

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MODIFYING FACTORS INFLUENCING TREATMENT ADHERENCE; DEMOGRAPHIC AND PSYCHOSOCIAL VARIABLES

The patients with hypertension in developed and developing countries experience specific problems related to the nature of the disease and the patients’ perceptions of the condition. Since they are centered on the patients’ characteristics and individuals’ perceptions, they are referred to as patient-centered factors that influence antihypertension treatment adherence. These characteristics and individuals’ perceptions form a basis or a frame of reference upon which their life decisions, actions and/or behaviours are grounded, which might be associated with their intentions and behaviours to adhere to anti-hyertensive treatment regimen. The factors which influence treatment adherence are associated with demographic variables, such as gender, age, tribe, religion, and psychososiol variables such as educational level, occupational and marital status.

Table of contents :

CHAPTER 1 INTRODUCTION AND BACKGROUND INFORMATION
- 1.1 INTRODUCTION
- 1.2 BACKGROUND INFORMATION ABOUT HYPERTENSION AND PATIENTS’ ADHERENCE TO THEIR ANTI-HYPERTENSIVE TREATMENT REGIMENS
  - 1.2.1 Hypertension as a health problem
  - 1.2.2 Systems and factors that regulate the blood pressure
  - 1.2.3 Technique for measurement of blood pressure
  - 1.2.4 The five phases of blood pressure readings and their sounds
  - 1.2.5 Variations in blood pressure readings
  - 1.2.6 Primary hypertension
  - 1.2.7 Secondary hypertension
  - 1.2.8 Complications of hypertension
    - 1.2.8.1 Cerebral complications
    - 1.2.8.2 Ocular complications
    - 1.2.8.3 Cardiovascular complications
    - 1.2.8.4 Renal complications
  - 1.2.9 The management of hypertension
  - 1.2.9.1 The non-pharmacological approach to management of hypertension
  - 1.2.9.2 Pharmacological approach to management of hypertension
  - 1.2.9.2.1 The WHO approach to hypertension management
- 1.3 STATEMENT OF THE PROBLEM
  - 1.3.1 Purpose of the study
  - 1.3.2 Specific objectives
  - 1.3.3 Significance of the study
- 1.4 THEORETICAL FRAMEWORK: THE HEALTH BELIEF MODEL
  - 1.4.1 The importance of a theoretical framework
  - 1.4.2 Origin and contributions of the Health Belief Model
  - 1.4.3 Components of the Health Belief Model
CHAPTER 2 LITERATURE REVIEW
- 2.1 INTRODUCTION
  - 2.1.1 Purpose of the literature review
- 2.2 HYPERTENSION
  - 2.2.1 The aetiology and impact of hypertension on patients’ quality of life
  - 2.2.2 Treatment adherence
  - 2.2.3 Tools for the measurement of patients’ adherence to anti-hypertension treatment
  - 2.2.3.1 The 8-item Morisky Medication Adherence Scale (MMAS-8)
  - 2.2.3.2 Five point Likert scales
  - 2.2.3.3 Retrospective medication record reviews
  - 2.2.4 Models of adherence
  - 2.2.5 Factors influencing patients’ anti-hypertension treatment adherence contextualised within the major tenets of the HBM
- 2.3 MODIFYING FACTORS INFLUENCING TREATMENT ADHERENCE: DEMOGRAPHIC AND PSYCHOSOCIAL VARIABLES:
CHAPTER 3 RESEARCH DESIGN AND METHOD
- 3.1 INTRODUCTION
- 3.2 RESEARCH DESIGN
  - 3.2.1 Study setting
  - 3.2.2 Study population
  - 3.2.3 Sample
  - 3.2.3.1 Sampling design
  - 3.2.3.2 Sampling frame
  - 3.2.3.3 Selection and calculation of sample size
  - 3.2.3.4 Sampling
  - 3.2.3.5 Sample selection procedure
  - 3.2.4 Research instrument
  - 3.2.4.1 The structured interview schedule
  - 3.2.5 Data collection procedure
  - 3.2.5.1 Pre-testing the research instrument
  - 3.2.5.2 Refinement of the research instrument
  - 3.2.5.3 Recruitment and training of the research assistants
  - 3.2.5.4 Data collection technique
- 3.3 VALIDITY AND RELIABILITY
  - 3.3.1 Validity of the research design and instrument
  - 3.3.1.1 Validity of the structured interview schedule
  - 3.3.1.2 Internal validity
  - 3.3.1.3 External validity
  - 3.3.1.4 Face validity
  - 3.3.1.5 Content validity
Chapter 4 Data analysis and discussion
Chapter 5 Conclusions, limitations and recommendations