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INTRODUCTION
Arterial hypertension is one of the leading causes of death in
the world (5 - 13% of global mortality). Suboptimal blood pressure
control due to poor adherence is cited as the main reason for high
mortality [1,2,3]. The World Health Organization (WHO) defines
patient adherence as the willingness to adjust their behavior (in
terms of respect for therapy, diet, lifestyle and implementation of
diagnostic procedures) to the agreed recommendations of the health
worker [1,4,5]. On the other hand, poor adherence implies refusal or
inadequate use of medications, unadapted lifestyle or diet, refusal
or inadequate implementation of diagnostic procedures. Poor
adherence can be primary (the patient is unable to meet the agreed
recommendations) and secondary (there is an intention not to follow
the agreed recommendations or they are inadvertently violated due to
demographic, social, psychological or clinical variables) [1,4,5].
Patient adherence is negatively affected by: treatment complexity,
drug side effects, imbalance between established medical guidelines
and own beliefs, poor patient-physician communication, patient
dissatisfaction with health system, socioeconomic factors,
socio-demographic factors, high treatment costs, and lack of medical
insurance [3]. The absence of manifest symptoms in the initial phase
of the disease, younger age and low level of education were
identified as the most constant etiological factors.
A large number of studies indicate the ubiquitous poor adherence of
patients with arterial hypertension. It is estimated that one third
of patients are fully compliant with the recommended treatment,
another third sometimes in compliance, while a last third is never
compliant with the recommended treatment. Suboptimal blood pressure
control due to poor adherence leads to 54% of cerebrovascular
incidents and 47% of ischemic heart disease. Adherence can be
assessed in two ways, in direct contact with patients or by
reviewing medical records. Interventions to improve adherence
include supportive measures, reviewing drug needs, and improving
communication with the patient [1,4,5,6,7,8].
OBJECTIVE
The study aimed to assess the influence of socio-demographic
factors and the duration of high blood pressure on the adherence of
patients with arterial hypertension.
METHOD
The research was performed as a cross-sectional study in a period
of seventeen months, from 02/01/2019. to 07/01/2020. The study
sample consisted of 170 individuals, heterogeneous socio-demographic
and health characteristics selected by random selection. Criteria
for inclusion of respondents in the study were: arterial
hypertension for at least twelve months, age between 40 and 69
years, completed primary school. Excluded from the study were:
people over 69 and under 40, with arterial hypertension lasting less
than twelve months. Data were collected through a general and
specific questionnaire. The general questionnaire collected
socio-demographic data (age, gender, place of residence, level of
education, employment status).
The Adherence in Chronic Diseases Scale (ACDS) was developed by a
group of authors from Poland with the aim of assessing the adherence
of patients with chronic diseases. It consists of 7 questions, ie
five questions about adherence and two questions about
doctor-patient communication. To each question, respondents have
five offered answers that are scored with a score of 0-4. The total
score <21 corresponds to low adherence, while the score 21-26 speaks
in favor of moderate adherence. A score> 26 confirms the high
adherence of the respondents [9,10]. Descriptive statistical methods
were used for data analysis: arithmetic mean, standard deviation and
percentages. An x2-independence test was used to determine
statistical significance. The significance level is set to 95%
confidence interval. The results are presented textually, tabularly
and graphically.
RESULTS
The study included 170 respondents. Among them were 88 (51.8%)
women and 82 (48.2%) men. The largest number of participants in the
study was aged 60-69 years, 72 (42.4%) respondents. The mean age of
the study population was 58 ± 7.9 years. 84 (49.4%) participants in
the research lived in the village, and 86 (50.6%) in the city. 17
(10.0%) respondents completed primary school, 108 (63.5%) secondary
school. There were 45 (26.5%) respondents with a university degree.
81 (47.6%) respondents were employed, 89 (52.4%) were unemployed
(Table 1).
Table 1. Socio-demographic characteristics of
research participants
35 (20.6%) subjects had arterial hypertension for 1 - 5 years,
and 30 (17.7%) for 6-10 years. Arterial hypertension lasting 11 - 14
years was found in 40 (23.5%) respondents. The largest number of
participants in the study had arterial hypertension lasting over 15
years, 65 of them (38.2%). Low adherence was verified in 40 (23.5%)
subjects, moderate in 72 (42.4%), while 58 subjects (34.1%) had high
adherence.
High adherence was found in 22 (26.8%) men and 36 (40.9%) women. The
sex of the participants in the study did not have a statistically
significant effect on adherence (p=0.06). 2 (5.0%) subjects aged
40-49 years, 9 (15.5%) subjects aged 50-59 years and 47 (65.3%)
subjects aged 60-69 years had high adherence. Statistically
significantly higher adherence was found in participants in the
study aged 60-69 years (p<0.05). Strong adherence was confirmed in
23 (27.4%) respondents living in rural areas and 35 (40.7%)
respondents residing in the city. The place of residence of the
study participants did not have a statistically significant effect
on adherence (p=0.08). Only 1 (5.9%) respondents with completed
primary school had high adherence. Strong adherence was found in 38
(35.2%) respondents with a high school diploma and 19 (42.2%)
respondents with a university degree. Statistically significantly
lower adherence was found in participants in the study with
completed primary school (p<0.05). High adherence was verified in 32
(39.5%) employed respondents and 26 (29.2%) unemployed respondents.
Respondents' employment did not have a statistically significant
effect on adherence (p=0.09) (Table 2).
Table 2. Influence of sociodemographic factors on
the Adherence in Chronic Diseases Scale index
According to hi square test or Fisher test; Low
adherence; ***Intermediate adherence; ****High adherence.
High adherence was found in 3 (8.6%) subjects with
arterial hypertension for 1 - 5 years, 5 (16.7%) subjects with
arterial hypertension for 6 - 10 years, 6 (15.0%) subjects with
arterial hypertension for 11 - 15 years and 44 (67.7%) subjects with
arterial hypertension for> 15 years. Statistically significantly
higher adherence was found in participants in the study with
arterial hypertension for more than 15 years (p<0.05) (Table 3).
Table 3. Influence of duration of arterial
hypertension on subjects adherence to Adherence in Chronic Diseases
Scale index
According to hi square test or Fisher test; Low
adherence; ***Intermediate adherence; ****High adherence.
DISCUSSION
High adherence was detected in 38.3% of study participants. A
study by a group of authors from Ethiopia found full adherence in
31.4% of respondents. Similar results were obtained in studies
conducted in China 21.3–35.2%, Ghana and Nigeria 33.3%, Kenya 31.8%,
Palestine 36.2% and Nepal 35.4%. A slightly more significant
percentage of high adherence was verified by studies in Italy 48.6%,
Brazil 52.9%, the United Arab Emirates 54.4%, the United States
57.6% and Pakistan 77.0%. A study by a group of authors from Korea
verified adequate adherence in 81.7% of respondents. Differences in
the availability and quality of health care are cited as a possible
reason for differences in adherence in the mentioned research
[3,11,12]. In our study, there was no statistically significant
influence of gender on the adherence of the subjects.
A significant number of studies did not identify gender as a
statistically significant factor in the adherence of the
respondents, but it emphasizes a slightly higher adherence in
females. The lack of gender differences in adherence in adolescents
is explained by the fact that parents take responsibility for
adhering to the therapeutic regimen in this age group. The better
adherence observed among young women arises as a consequence of
earlier cognitive maturation. The need for social desirability (the
desire to meet social expectations) and a better perception of the
disease in women may contribute to the observed differences.
[13,14]. The study verified a statistically significantly higher
adherence in people aged 60-69 years. Numerous studies have
identified aging as a statistically significant factor in increasing
patient adherence. A middle-aged person often inadvertently violates
the therapeutic protocol due to lifestyle factors, social or
psychological variables. Elderly patients devote more time to the
treatment regimen and use a number of aids such as tablet boxes and
a calendar. In addition, older people often have comorbidities and
show greater concern for their health. Possible unintentional
reduction of adherence in persons over the age of eighty occurs as a
consequence of cognitive and physical deficiencies [1,5,15,16]. The
research did not detect the existence of a statistically significant
influence of place of residence on the adherence of the respondents.
A study by a group of authors from Bangladesh found statistically
significantly lower adherence in people residing in rural areas.
Poor adherence of the rural population occurs as a result of lower
socio-economic status, poorer access to health care, lack of
specialist services and frequent changes in health care staff [15].
A judge from a group of authors from Australia determined a distance
of more than 10 kilometers from the nearest health facility as an
independent predilective factor of poor adherence [17].
The study noted the existence of statistically significantly lower
adherence in study participants with completed primary school.
Studies by a group of authors from Ethiopia, Pakistan, Poland, Ghana
and Nigeria have found a negative impact of lower education on the
adherence of subjects with arterial hypertension. Low income,
unemployment, lack of awareness about the complications of
hypertension and the importance of optimal blood pressure control
are cited as possible reasons [3,9,10]. A study conducted in Ghana
indicates that a low level of education may play an important role
in a patient’s decision to replace antihypertensive therapy with
herbs and spiritual healing [18]. The study noted the existence of
statistically significantly higher adherence in respondents who were
employed. Studies by a group of authors in Iran found a
statistically significant weakening of adherence in unemployed
respondents with limited access to medicines. Participants in the
low-income study were 18.5 times more likely to have poor adherence
than respondents whose incomes were average [3,6]. The study
detected a statistically significant increase in adherence with
prolonged hypertension. A study conducted in China detected the
duration of hypertension for an independent predictor of quality
adherence [3]. Prolonged duration of hypertension is often
accompanied by comorbidities but also an increase in awareness of
the importance of optimal blood pressure control. Research by
authors from Ethiopia has determined the negative impact of
prolonged hypertension on the adherence of patients [19].
Participants in the study with a duration of hypertension of five or
more years were more than five times more likely to have poor
adherence compared to subjects in whom hypertension was diagnosed
less than two years ago. With the stabilization of blood pressure, a
significant number of patients are considered cured. In addition,
long-term use of drugs burdens patients and leads to inadequate use
or discontinuation of antihypertensive therapy [3,19]. A study by a
group of authors from Malaysia did not establish a statistically
significant association between the duration of hypertension and
adherence [20]. According to the same, problems with adherence occur
in the first six months after the introduction of antihypertensive
therapy and persist for up to 4 years. At the end of this period, no
statistically significant differences in therapeutic adherence were
verified [20].
CONCLUSION
Adherence of the subjects was statistically significantly
affected by age, educational status and duration of arterial
hypertension. Place of residence, employment status and gender of
respondents do not show a statistically significant impact.
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