Original Article
Rev. Latino-Am. Enfermagem 2014 May-June;22(3):491-8 DOI: 10.1590/0104-1169.3447.2442
www.eerp.usp.br/rlae
Knowledge about hypertension and factors associated with the non-adherence to drug therapy1
Mayckel da Silva Barreto2 Annelita Almeida Oliveira Reiners3 Sonia Silva Marcon4
Objectives: to identify the degree of knowledge of people with hypertension concerning the disease and to verify the factors associated with the non-adherence to anti-hypertensive drug therapy. Method: Cross sectional study, involving 422 people. Data collection took place at their homes, between December 2011 and March 2012, through interviews using the following instruments: Medication Adherence Questionnaire (MAQ-Q), Medication Regimen Complexity Index (MRCI) and a guide with questions related to sociodemographic profile, satisfaction with healthcare service and knowledge about the disease. Results: 42.6% did not adhere to the drug therapy and 17.7% had poor knowledge about the disease. Factors associated with the nonadherence were: complex drug therapy, poor knowledge about the disease and dissatisfaction with the healthcare service. Conclusion: The findings reinforce that the complex drug therapy prescriptions, little knowledge about the disease and dissatisfaction with the healthcare service have influence on the process of non-adherence to anti-hypertensive drug therapy. Descriptors: Hypertension; Medication Adherence; Risk Factors; Health Knowledge, Attitudes, Practice; Nursing.
1
Paper extracted from master’s thesis “Non compliance drug treatment in individuals with arterial hypertension in Maringá – Paraná” presented to Universidade Estadual de Maringá, Maringá, PR, Brazil. Supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), process # 485807/2011-4.
2
Doctoral student, Universidade Estadual de Maringá, Maringá, PR, Brazil. Professor, Faculdade de Filosofia Ciências e Letras de Mandaguari,
3
PhD, Associate Professor, Departamento de Enfermagem Médico-Cirúrgica, Universidade Federal do Mato Grasso, Cuiabá, MT, Brazil.
4
PhD, Associate Professor, Centro de Ciências da Saúde, Universidade Estadual de Maringá, Maringá, PR, Brazil.
Mandaguari, PR, Brazil.
Corresponding Author: Mayckel da Silva Barreto Faculdade de Filosofia Ciências e Letras de Mandaguari Rua Renê Táccola, 152 Centro CEP: 86975-000, Mandaguari, PR, Brasil E-mail:
[email protected]
Copyright © 2014 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
492
Rev. Latino-Am. Enfermagem 2014 May-June;22(3):491-8.
Introduction Systemic
Method when
Cross sectional, descriptive study, involving people
not controlled, is still being a significant medical
with SAH, undergoing outpatient care treatment at the
and social problem in developed and developing
Primary Healthcare Service in a city located in the South
countries. Even knowing the efficacy, effectiveness
region of Brazil, which had 25 primary healthcare units
and efficiency of many available preventive and
(UBS) and 65 teams of the Family Health Strategy (ESF)
control measures, the negative effects caused by
at the time of data collection. For the purposes of this
the
research, the area covering the 23UBS located within
disease
Arterial
will
Hypertension
probably
continue
(SAH),
for
decades,
representing one of the biggest social and health related challenges .
the perimeter of the city was used by convenience. The size of the sample was calculated based on the
(1)
One of the main causes of the negative effects
total of people with SAH registered in the city (40,073).
caused by SAH is the non-adherence to hypertensive
It was assumed that 50% of people could have the
treatment, as well as the late diagnosis and the prolonged
characteristic of interest (non-adherence)(6), estimation
asymptomatic course of the disease, which resulted in
error of 5%, and a confidence interval of 95%. 10%
the development of studies in the area(2-5). Estimates
more was added for possible losses, resulting in a
point out that the degree of the non-adherence to the
stratified and randomly selected sample of 422 people,
treatments of Chronic Diseases (CD) worldwide ranges
with a distribution that was proportional to the total
from 25% to 50% .
number of people with SAH registered in each UBS of
(6)
The non-adherence to the drug therapy in cases of
the urban area.
CD, usually verified through the Morisky-Green-Levine
As inclusion criteria, the following was considered:
test(7), is considered a complex and multi determined
to be 18 years old or more and to have started drug
event associated with low socioeconomic levels, complex
therapy for at least one year, since the interruption
prescription regimens and dissatisfaction with the
of antihypertensive treatment occurs more often in
healthcare service, which are factors that prevail among
the first months after it starts, with 11% to 22% of
the population with SAH(4,8-11).
the cases occurring in the first year(6). Seventeen
Another explanation for the high rate of non-
people were excluded, including two women who used
adherence is that many patients do not understand the
antihypertensive drugs only during pregnancy and 15
disease and the drug therapy. The asymptomatic course
people with a psychiatric diagnosis of acute mental
of the SAH contributes to this lack of understanding
disorder because they tend not to adhere to the therapy
and, as a result, many people believe that the disease
due to the own nature of the disease, besides the fact
is intermittent and can be treated exclusively with
that many of them relied on other people to properly
non-medication therapies, such as stress relief or
take the continuous use medication.
homemade medication(10). The
non-adherence
obtained from the City Health Council with records of the
to the SAH treatment and the patient’s knowledge
people with SAH, who were given a number. Through an
about the disease and therapeutic regimen has been
electronic draw, those people who would be interviewed
reported(4-6,10).
requires
were selected. If the selected person did not meet the
for
further
relationship
For data collection, a list divided by UBS was firstly
between
However,
evidence
relationship
the
inclusion criteria or if they refused to participate in the
healthcare professionals to act more effectively, by
research, the next person on the list was automatically
proposing and implementing actions that meet the
invited to participate in the study, and this was repeated
real needs of this population, it is necessary to identify
for up to three times.
(5,12)
.
this
the
Moreover,
in
order
the patients who do not adhere to the treatment and
their
characteristics,
and
the
reasons
why
this occurs.
After
obtaining
the
addresses
and
telephone
numbers of the people selected, which took place at the UBS, the data collection was conducted and
Based on the above, the present study was aimed
happened during the period from December 2011 and
at: identifying the degree of knowledge of people with
March 2012, through home visits with the use of a
arterial hypertension about the disease and verifying the
semi-structured guide composed of questions related
factors associated with the non-adherence to the anti-
to the sociodemographic profile, health monitoring and
hypertensive drug therapy.
knowledge about the disease, which was completed by
www.eerp.usp.br/rlae
493
Barreto MS, Reiners AAO, Marcon SS. the researcher. The economic level was defined on the
It was chosen to use the MRCI because it is a
basis of the Economic Classification Criteria of Brazil
comprehensive instrument, which includes three different
(Brazilian Association of Research Companies – ABEP)
dimensions of the construct related to the adherence
which is based on the educational level and consumer
(dose intake, behavior related to the medication and
goods and is used to estimate the spending power of
clinical outcome), provides the same effectiveness as
people and families. In this study, the eight possible
the concomitant use of other instruments and enables
levels (A1-A2-B1-B2-C1-C2-D-E) were grouped into two
easier and quicker application(13).
levels A/B and C/D/E.
Independent variables
Procedures and data analysis
The knowledge about the disease was verified
The dependent variable was the non-adherence
using 10 questions, with dichotomous answers (yes/
to the hypertensive drug therapy. An instrument of
no)(8). Through the instrument, people who answers
indirect evaluation was used for its measurement, the
all the questions correctly receive a score 10 (100%)
Medication Non-Adherence Questionnaire (MAQ-Q) of
and those who answer them all incorrectly receive a
the Qualiaids team, developed to address the act (if the
zero. Similarly to another study(10), the knowledge was
person takes their medication and how much they take),
considered satisfactory for those with scores equal or
the process (how they take the medication), and the
above seven (70%) and dissatisfactory for the others in
result of adherence (in this case, if the blood pressure
this investigation.
is controlled)
.
As for the complexity of the drug therapy, this was
(13)
The developed and validated instrument(13) takes
assessed through the Medication Regimen Complexity
into account the statement of the participant as a source
Index (MRCI), a valid instrument(14) in which the final
of information and has three questions, the two first
score is obtained by adding the scores of the three
being based on the last seven days, 1) On which days
sections – A, B and C – and the higher the score, the
of the week you did not or you did take more than at
more complex the drug therapy(14). The first section has
least one pill of this medication?; 2) On these days, how
information about dosage ways; the second, about the
many pills you did not take, or took more than it was
frequency of doses; and the third, additional information
prescribed?; 3) How was your blood pressure when you
such as specific times, breaking or crushing the pill and
last measured it?. It is important to note that there was
concomitant use with food.
no time restriction for this last question.
The
satisfaction of the user with the healthcare
The answers resulted in a combined measurement,
service was estimated based on eight questions, two
in which only the people who reported to have taken
being related to the structure and access to the service,
between 80% and 120% of the prescribed dosages
three to the assistance, treatment and care provided by
were considered adherent. These values are obtained by
the professionals at the UBS, two to the satisfaction with
multiplying the number of pills taken by the number of
the treatment and with the doctor, and one to the general
times, and dividing it by the number of pills prescribed
satisfaction. The score scale of answers is the Likert
multiplied by the number of times. Finally, the result is
type with four possible alternatives, one representing
multiplied by one hundred.
maximum satisfaction and four, total dissatisfaction.
Adherence was also conditioned to the adequate
After obtaining the average scores, the median divided
intake, that is, without “breaks” (not taking any
the sample into groups of “more satisfied” and “less
medication for one day), “change of time” (taking the
satisfied”, as used in another study(4).
correct dose, but at wrong times), “change of dose”
The information was entered into an Excel for
(increasing or reducing the amount of the medication
Windows 2007® spreadsheet and later statistically
or between medications), “erratic intake” (not taking
analyzed through the software Statistical Analysis
the medications in various days and times), “half
System
adherence”
(taking
medication
correctly
SAS®.
The
variables
of
interest
were
and
dichotomized. In the logistic regression of the type
another incorrectly), “partial interruption” (stopping
Stepwise Backward Elimination, all the variables were
taking one or more of their medications), “interruption”
inserted and after the application of the tests, only the
(not taking any dose of all medications in the last seven
variables with statistical significance with p10 years
78
18.49
107
25.35
185
Yes
108
25.60
150
35.54
258
No
72
17.06
92
21.80
164
p %
Gender
0.14
Age
0.64
Race
0.33
Marital status
0.64
Level of education
0.52
Economic level*
0.91
Time since diagnosis
0.64
Comorbidities
0.40
Medication Regimen Complexity Index
0.02†
Low
91
21.56
155
36.73
246
High
89
21.09
87
20.62
176
Satisfaction with healthcare service
0.00†
Satisfied
70
17.81
156
39.70
226
Dissatisfied
98
24.94
69
17.55
167
Yes
123
29.14
224
53.09
347
82.23
No
57
13.51
18
4.26
75
17.77
Satisfactory knowledge
0.00†
*Based on the Economic Classification Criteria of Brazil (Brazilian Association of Research Companies – ABEP) †p-significant value in the logistic regression model Stepwise Backward Elimination
Regarding the characteristics, the majority of the
already presented comorbidities (61.14%). However,
studied people were female (59.48%), elderly (63.25%),
none of these characteristics had significant association
Caucasian (70.14), married (68.96%), with low level of
with the outcome of interest (p
