AMBO UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF PHARMACY

AN ASSESSMENT OF ADHERENCE OF PATIENTS TO ANTI-HYPERTENSIVE

MEDICATION AND FACTORS FOR NON-ADHERENCE IN OROMIA REGION ADAMA
REFERRAL HOSPITAL,ETHIOPIA

BY
REMEDAN ANUWER

SENIOR RESEARCH PAPER SUBMITTED TO THE AMBO UNIVERSITY MEDICINE

AND HEALTH SCIENCES COLLEGE SCHOOL OF PHARMACY IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR BACHELOR OF SCIENCE DEGREE IN
PHARMACY

i
 ABSTRACT
Backg
round:Hypertension (HTN), or high blood pressure (systolic blood pressure >140 mmHG and
diastolic blood pressure >90 mmHg) is an over whelming global challenge which ranks third as a
cause of disability-adjusted life-year. Hypertension causes 7.1 million premature deaths each year
worldwide and accounts for 13% of all deaths globally(7). There are effective medical therapies
for hypertension management; but the problem of non-adherence to medical treatment remains a
challenge for the medical professionals and social scientists. Poor adherence to anti-hypertensive
therapy is one of the biggest obstacles in therapeutic control of high blood pressure and usually
associated with bad outcome of the disease and wastage of limited health care resources.
Objective: The objective of this study is to assess the magnitude of adherence and factors for non
adherence related to anti-hypertensive treatments in hypertensive patients visiting Adama
Referral Hospital.
Methodology: An institution based cross-sectional study was conducted from at Adama Referral
Hospital to assess patient adherence towards antihypertensive therapy at ARH on hypertensive
patients who are attending medical OPD. The data was collected by using a pre-tested structured
questionnaire after translated to local language, in exit interview method immediately after the
patient have got the service, and the collected data was processed and analyzed by using a
computer software package and presented by table.
Result: There were 96 respondents during the study period, from 96 respondents
42(43.75%) were males and the rest were females. Among the respondents 33.34% were >
64 years old and only 9.37% is between 15-24 years and 6.6% were students. Regarding the
educational level larger proportions of respondents were read and write,and only 12.5% of the
study population primary groups. From the study population 45.83% of the respondents were
orthodox and only 3.12% were other. 29.16% of the respondents had an income of 100-800 birr
per month
Conculsion: The overall research finding shows that 96 respondent of hypertensive patients in
Adama Refferal Hospital 44.8%was non adherent to the prescribed medication. There were a
number of perceived problem of patients with hypertension .This include prolonged duration of
treatment, adverse effect of medication and old age or disability,economic problem and use of
social drugs.
.

ACKNOWLEDGEMENT
i
Firstly I deeply acknowledge Collage of Medicine and Health Sciences and School of Pharmacy
for providing such a chance of study and offering technical support and assigning advisor timely.

I greatly delight in appreciation of Ato Muluneh for his unreserved structure advice and
comments on each segment of proposal and providing technical assistant.

All Adama Refferal hospital and college Librarians deserve great thanks for their help in showing
the available literatures in the library beyond their duties

I greatly thanks to Adama Referral Hospital administrators and staffs who are given background
information in doing this study proposal in the compound.

Finally, it gives me a great honor to thank my parents, families and best friends who gave me
continuous support and inspiration throughout my study in Adama.

TABLE OF CONTENTS

ii
ABSTRACT..................................................................................................................................................i

ACKNOWLEDGEMENT...........................................................................................................................ii

LIST OF TABLES.......................................................................................................................................v

ABBREVIATION ......................................................................................................................................vi

CHAPTER ONE1.1 INTRODUCTION..................................................................................................vii

1.1 Background.......................................................................................................................................1

1.2 STATEMENT OF THE PROBLEM...............................................................................................2

1.3 Significance of the study....................................................................................................................3

CHAPTER TWO: LITERATURE REVIEW..............................................................................................4

CHAPTER THREE......................................................................................................................................6

OBJECTIVES OF THE STUDY.................................................................................................................6

3.1 GENERAL OBJECTIVE:..................................................................................................................6

3.2 SPECIFIC OBJECTIVES:.................................................................................................................6

CHAPTER FOUR: METHOD AND MATERIALS.................................................................................7

4.1 – Study area........................................................................................................................................7

4.2 STUDY DESIGN AND PERIOD.....................................................................................................8

4.3POPULATION....................................................................................................................................8

4.3.1SOURCE POPULATION............................................................................................................8

4.3.2 STUDY POPULATION..............................................................................................................8

4.3.3 INCLUSION & EXCLUSION CRITERIA................................................................................8

4.4 SAMPLE SIZE DETERINATION....................................................................................................8

4.5 STUDY VARIABLES:......................................................................................................................8

4.6 PRE-TEST..........................................................................................................................................9

4.7 DATA COLLECTION PROCEDURE AND INSTRUMENT..........................................................9

4.7.1 Data collection instruments.........................................................................................................9

4.7.2 Data Collection Procedure...........................................................................................................9

4.8 DATA PROCESSING AND ANALYSIS.......................................................................................10

iii
 4.9 ETHICAL ISSUES CONSIDERATION.........................................................................................10

4.10 LIMITATION OF THE STUDY...................................................................................................10

4.11 DESSIMINATION OF RESULT..................................................................................................10

4.12 OPERATIONAL DEFINITION....................................................................................................11

CHAPTER FIVE: RESULTS.........................................................................................................................12

CHAPTER SIX: DISCUSSION...................................................................................................................5

CHAPTER SEVEN: Conclusion and Recommendation..............................................................................7

7.1 Conclusion..........................................................................................................................................7

7.2 Recommendation................................................................................................................................7

REFERENCES.............................................................................................................................................8

APPENDIX A: QUESTIONNAIRE.........................................................................................................11

LIST OF TABLES

iv
Table 1- Socio-demographic data of the respondants who are on Antihypertensive medication at
Adama Referral Hospital,Oromia Region,East Shewa Ethiopia March
2014………………………………………………………………………………
Table 2- Number of respondents that uses social drugs who are on antihypertensive medication
at Adama Refferal Hospital,Oromia Region,East Shewa Ethiopia March
2014…………………………………………………………………………………
Table3- Number of respondent that uses contraindicated substance and engage in exercise on
antihypertensive medication at Adama Refferal Hospital, Oromia Region, East Shewa Ethiopia
March 2014………………………………………………………………………
Table 4- Some perceived problems of respondents which lead to the non adherents of the
respondents on antihypertensive medication at Adama Refferal Hospital,Oromia Region,East
Shewa Ethiopia March 2014…………………………………………………..
Table 5- Association of educational level and lack of sufficient information on knowledge of
adherence on hypertensive patient at Adama Refferal Hospital,Oromia Region,East Shewa
Ethiopia March 2014………………………………........................
Table 6- Association between socio-demographic data and non adherent hypertensive patient at
Adama Refferal Hospital,Oromia Region,East Shewa Ethiopia March
2014………………………………………………………………………………………
Table 7. Treatment related factor of respondent wich lead to the non adherents of the respondents
on antihypertensive medication at Adama Refferal Hospital,Oromia Region,East Shewa Ethiopia
March 2014………………………………………………………………

v
 ABBREVIATION
BSc : Bachelor of Science
CBE : community based education
CMHS: Collage of Medicine and Health Sciences
FMOH – Federal Ministry of Health
HTN: Hypertension
AU : Ambo University
ARH : Adama Referral Hospital
SES – Socio Economic Status
TPA : Total Physical Activity
UNICEF - United Nations International Children’s Fund
WHO : World Health Organization
OPD: outpatient department

vi
 CHAPTER ONE: INTRODUCTION

1.1 Background
Hypertension has no cure therefore; patients are expected to take medications for life. Drug treatments
of hypertension demands that patients comply with their medications as prescribed and they should
return for a refill when medications are exhausted. They should honour their appointments for follow up
visits with clinician and adopt health actions that are recommended to lower their blood pressure (18).
Medication adherence has been defined in terms of an agreement between the patient's behavior of taking
medications and the clinical prescription (1). Faulty adherence or non-adherence with medications may
include errors of purpose, timing or dosage as well as total or partial omission, or use of inadvertent
combinations. Non-adherence with medications is one of the major factors in the failure of therapeutic
programs in patients having a chronic disease (1).

In the available literature, the magnitude of non-adherence with medications prescribed for patients with
hypertension was 16.7% (2). Generally, the adherence of patients decreases with time and it is lower in
long-term medications than in short-term medications. In depressive patients, adherence was shown to be
68% after 3 weeks of treatment, but this percentage decreased after 6, 9 and 12 weeks to 63%, 50% and
40% respectively (3). An adherence study conducted with short-term medications revealed an overall
incidence of non-adherence of 26% (4). Ensuring patients’ adherence with antihypertension medications
and lifestyle modifications to prevent complications of hypertension remains a major challenge to public
health in many developing countries.

Non-adherence with treatment is the most important single reason for uncontrolled hypertension. Several
factors, which may be patient or health system related, continue to militate against adherence behaviour.
Thus it is essential to identify such factors and develop strategies to improve adherence. It is true that the
possible factors of non-adherence may vary from country to country and may contribute to the variations
that exist among the reported values of non-adherence. With regard to the possible factors of non-
adherence that are related to the patient, the disease, the drugs prescribed, the physician and the treatment
environment (5,6).

1
1.2 STATEMENT OF THE PROBLEM
In line with the global realities, Hypertension sufferers’ non adherence to their pharmacological regimen
and frequent lifestyle changes result in uncontrolled hypertension that leads to different life threatening
organ complications such as cardiovascular, renal and cerebro-vascular diseases (16). In order to mitigate
the effects of the disease in populations, it is essential to improve adherence among sufferers of the
disease by identifying underlying factors in order to mitigating against adherence behavior and
developing effective interventions to overcome identified factors (17). Factors affecting adherence
behavior are unique to individuals and specific, and also, studies done in other countries were not applied
to the circumstances surrounding the Adama Referral Hospital. However, this study was attempt to
identify factors affecting drug treatment and lifestyle modification adherence and provide possible
recommended strategies that could improve adherence for both drug treatment and lifestyle
modifications with involving hypertension patient those who visit Adama Referral Hospital.
Therefore, there is a great need of organized research that is closely linked to the patient compliance
towards their anti-hypertensive treatment to improve the adherence to therapy and healthy lifestyle
modification.

Concerning Client adherence towards antihypertensive treatment, specific studies do almost not exist in
our local setting. Taking this into consideration this study was attempt to answer the following question:
What are the reasons for non-adherence with the drugs among hypertensive patients visiting Adama
Referral Hospital?

2
1.3 Significance of the study
The results of the study may contribute to increase the awareness of health care providers
particularly physicians on the issue of adherence and may aid to develop strategies for
improvement of adherence.

This study was also sought to examine various factors responsible for adherence and non-
adherence in the research context and elucidate relationships existing between them. Such
information would assist health care professionals to manage hypertension appropriately. It
would also assist policy makers in developing context specific and relevant policies capable of
improving the management of hypertension in the clinics. Ultimately, it is envisioned that the
implementation of effective strategies would lead to improved adherence, increased levels of
controlled blood pressure and reduced occurrences of complications.

The main aim of this study is to add to the existing body of knowledge about factors affecting
adherence to hypertension medication and lifestyle modifications necessary to maintain
hypertension control, and to propose strategies that was assist policy makers and clinicians with
hypertension management decisions.

1
 CHAPTER TWO: LITERATURE REVIEW

An early study showed that adequate control of hypertension was associated with taking at least
80% of a prescribed regimen (19).
Adherence with pharmacological and non pharmacological treatment of hypertension has various
benefits for the individuals, the health care systems and the society at large in the case of cost
saving since it reduces the incidence of complications and the need for additional medications
(20). This is particularly crucial in a public financed health care system such as Ethiopia.

Various factors affect patients’ adherence with anti-hypertension medications. a study done in
Seychelles adherence was relatively high in particularly with skilled occupations, those who were
health conscious and those who regularly honoured their clinic appointments. This study showed
that adherence magnitude with antihypertension medications was 71.57% (21). The same study
showed magnitudes of factors of non adherence with medications were forgetfulness (18.81%),
carelessness (16.83%), use of alternative remedies (12.87%), medication side effects (9.9%) and
belief that medications are ineffective (5.94%)(21). A study conducted in Finland reported that
Perceived problems concerning hypertension, negative attitudes and experiences are very
common among hypertensive patients in primary health care. Factors like lack of motivation
(72%), difficulties to accept being hypertensive (66%), carelessness (63%), lack of information
(56%), and hopelessness and adverse effects (33%) were reported (22).

According to study done in Pakistan at a cut-off value of 80%, 77% of the cases were adherent.
Upon univariate analyses, increasing age, better awareness and increasing number of pills
prescribed significantly improved adherence, while depression showed no association. Significant
associations, upon multivariate analyses, included number of drugs that a patient was taking
(P<0.02) and whether he/she was taking medication regularly or only for symptomatic relief
(P<0.00001) (14).

Adherence with life modifications and avoidance of non recommended behaviours are necessary
to control blood pressure. Study on Seychelles reported magnitudes of non adherence to engage
in physical exercise (50%), eat vegetables (7.84%), try to lose some weight (53.94%), stop smoke
(15.84%), stop alcohol drink (21.57%), reduce salt intake (24.51%), and stop eating a meal high
in animal fat (28.35) (21).

2
Reported magnitudes of adherence for antihypertension medications in different countries were
as follows; in Malaysia was 44.2% (23), in Gambia 27% (24), in Egypt 74.1% (14), and in
Scotland 91% (25).

.As the research conducted in Sub-Saharan Africa indicated, age-standardized prevalence of

hypertension was 19.3% (95%CI: 17.3–21.3) in rural Nigeria, 21.4% (19.8–23.0) in rural Kenya,
23.7% (21.3–26.2) in urban Tanzania, and 38.0% (35.9–40.1) in urban Namibia. In individuals
with hypertension, the proportion of grade 2 (≥160/100 mmHg) or grade 3 hypertension
(≥180/110 mmHg) ranged from 29.2% (Namibia) to 43.3% (Nigeria). Control of hypertension
ranged from 2.6% in Kenya to 17.8% in Namibia. Obesity prevalence (BMI ≥30) ranged from
6.1% (Nigeria) to 17.4% (Tanzania) and together with age and gender,body mass index
independently predicted blood pressure level in all study population (27).

A study conducted in Gondar north Ethiopia showed that only 64.6% of the study subjects were
found to be adherent to their treatment. Majority of the respondents (76.8%) were knowledgeable
about HTN and its treatment. The multivariate logistic regression showed that as the distance
from the hospital decreased, the adherence to treatment of HTN got improved (AOR = 2.02, 95%
CI = 1.19, 3.43). Those who have controlled HTN had a significantly higher chance of being
adherent to their treatment (AOR = 2.93, 95% CI (1.73, 4.96). The odds of adherence to anti-
HTN treatment among knowledgeable Clients was 6 times (AOR = 6.21, 95%CI = 3.22, 11.97)
higher than the odds of adherence among HTN patients who were not knowledgeable. The odds
of adherence among study participants with no or one co-morbidity were 2.5 and 2.68 times
higher than the odds adherence among those who had two co-
Morbidities (adjusted OR= 2.50,95% CI 1.01, 6.21) or more than two co-morbities (adjusted
OR =2.68, 95% CI 1.07, 6.71), respectively (28).

As a research done at Addis Abeba reported about 52% of the males and 36% of the females
were classified as having a high (vigorous) level of TPA. Overall, 10.7%, 95% CI (9.7, 11.6)
adults reported regularly adding salt to their plate. About 13.5% of the males and less than 1% of
the females reported 'current' cigarette smoking, while 11% of the males were 'current daily'
smokers. Significantly higher (P < 0.001) proportion of males (18.6%) than females (2.1%)
reported current khat (Cata edulis Forsk) chewing (29).
3
A single study done in Yirgalem Hospital, south Ethiopia on chronic illnesses showed that
compliance magnitude of antihypertension regimens in adult population was 40% and lack of
money was the major factor associated with treatment compliance which accounted 83% among
other factors (30).

We do not know about the magnitude of adherence and non adherence of anti-hypertension
treatments and life style modifying regimens at the study area. Different result may be expected
by this study.

4
CHAPTER THREE: OBJECTIVES OF THE STUDY

3.1 General Objective

The general objective of this study will be to assess the magnitude of adherence and factors
related to anti-hypertensive treatments in hypertensive patient Adama Referral Hospital.

3.2 Specific Objective

1.To describe the magnitudes of adherence and non-adherence of hypertensive patient towards
antihypertensive drugs and life style modifying regimens

2. To assess the factors related to adherence and non-adherence of anti-hypertensive drugs

and life style modifying regimen

5
 CHAPTER FOUR: METHOD AND MATERIALS

4.1 Study Area

Adama town is one of the capital city of Oromia regional state, East Shewa zone and located
99Km far from Addis Ababa. There are different governmental and non-governmental institution
in town such as 8 health Center, one referral hospital, one general hospital, 50 private clinics, and
105 pharmacies.

The study was conducted in Adama hospital medical college on patients who have hypertension
cases. Adama hospital medical college was established & started its full function in 1965. The
hospital is now providing several health service including diabetes and hypertension for the
community

4.2 Study and Design

In this research, the study design was an institution based descriptive cross-sectional study and
the study was conducted from March 19th to May 23rd, 2014.

4.3 Population
4.3.1 Source Population

The source populations for the study was all hypertensive and cardiac patients attending at
Adama Referral Hospital of medical OPD for treatment follow up & life modifying services
during the study period.

4.3.2 Study Population

The study populations were those adult hypertensive patients who are on anti-hypertensive
treatment and life style modifying service follow up, strong enough and willing to respond or
impartial to respond during their exit (exit interview) from outpatient department of Adama
Referral Hospital during the study period.

6
4.3.3 Inclusion and Exclusion criteria
All hypertensive people who was attending medical OPD during the study period and volunteer
will be included. People who are unable to give response for an informed consent will be
excluded; like all pediatric age groups less than fifteen (< 15) years, all critically sick, all groups
who will not committed to respond (refusals), all groups who have weak perception to express
and all mentally ill or psychiatric patients.

4.4 Simple Size Determination

In this research, a convenience sampling techniques was used to select the study population. The
sample was selected because of their convenience.

The data was conducted in short period of time for around one two month with exit interview
method from accessible population who are used the service.

4.5 Study Variable

Independent Variable:
 Socio demographic characteristics, such as:
 Age
 Sex
 Occupational status
 Educational status
 Religion
 Ethnicity
 Income
 Marital Status
 Address /accessibility/

Dependent Variable :
 Adherence towards antihypertensive treatment and lifestyle modifying service
 Non-adherence towards antihypertensive treatment and lifestyle modifying service

7
 CHAPTER FIVE: RESULTS
There were 96 respondents during the study period, from 96 respondents 42(43.75%) were male and the rest
Were female among the respondents 33.34% were >64 years old and only 9.37% is between 15-24 years and
10.42% were farmers and daily labors.
Regrading the educational level larger proportions of respondents were read and write(28.13%) and only
12.5% of the study population primary groups. From the study population 45.83% of the respondents
were orthodox and only 3.12% were catholic. 29.16% of the respondents had an income of 100-800 birr
per month.
.
Table 1. Socio demographic characteristics of respondents in ARH Adama, Ethiopia, June, 2014
Female(%) Male (%) Total (%)
Age 15-24 5(5.2%) 4(4.17%) 9(9.37%)
25-49 14(14.58%) 11(11.46%) 25(26.04%)
50-64 16(16.67%) 14(14.58%) 30(31.25%)
>64 19(19.8%) 13(13.54%) 32(33.34%)
Total 54(56.25%) 42(43.75%) 96(100%)
Marital Married 20(20.83%) 14(14.58%) 34(35.41%)
status Single 9(9.38%) 11(11.46%) 20(20.8
4%)
Divorced 8(8.33%) 7(7.29%) 15(15.62%)
Widowed 17(17.71%) 10(10.42%) 27(28.13%)
Total 54(56.25%) 42(43.75%) 96(100%0
Religion Protestant 9(9.36%) 8(8.34%) 17(17.72%)
Orthodox 26(27.08%) 18(18.75%) 44(45.83%)
Muslim 18(18.75%) 14(14.58%) 32(33.
3%)
Catholic 1(1.04%) 2(2.08%) 3(3.12
%)
Total 54(56.25%) 42(43.75%) 96(100%)
Educational Illiterate 8(8.33%) 7(7.3%) 15(15.63%)
level Read and 17(17.71%) 10(10.42%) 27(28.13%)
Write
Primary 6(6.25%) 6(6.25%) 12(12.5%)
Secondary 12(12.5%) 5(5.2%) 17(17.7%)
Above secondary 11(11.46%) 14(14.58%) 25(26.04%)
Occupation Housewif 13(13.54%) - 13(13.54%)
e
Employed 8(8.33%) 12(12.5%) 20(20.83%)
Farmer 3(3.13%) 7(7.3%) 10(10.43%)
Daily labor 4(4.17%) 6(6.25%) 10(10.42%)
Merchant 9(9.38%) 9(9.37%) 18(18.75%)
8
 other 17(17.7%) 8(8.33%) 25(26%)
Total 54(56.25%) 42(43.75%) 96(100%)

Ethnicity Oromo 18(18.75%) 16(16.67%) 34(35.42%)

Amhara 22(22.91%) 18(18.75%) 40(41.66%)
Gurage 10(10.42%) 5(5.21%) 15(15.63%)

Other 4(4.17%) 3(3.12%) 7(7.29%)

Total 54(56.25%) 42(43.75%) 96(100%)
Address Adama 36(37.5%) 29(30.21%) 65(67.71%)
place of town
Walanchit 2(2.08%) 1(1.04%) 3(3.12%)
residence
other urban area 4(4.17%) 4(4.17%) 8(8.34%)
rural area 12(12.5%) 8(8.33%) 20(20.83%)
Total 54(56.25%0 42(43.75%) 96(100%)
Monthly <100 16(16.67%) 9(9.38%) 25(26.05%)
income 100-800 20(20.83%) 8.33%) 28(29.16%)
801-1200 11(11.46%) 14(14.58%) 25(26.04%)
>1200 7(7.29%) 11(11.46%) 18(18.75%)
Total 54(56.25%) 42(43.75%) 96(100%)

9
 In this study 35.41% of respondents were married and 15.62% of respondents were divorced.most of
the respondents (67.71%) were come from Adama town and minors were from walanchit town(3.12%).
From the study population the numbers of social drugs user were higher for alcohol users
than others which includes khat and cigarette. Social drug users from the study population
are 37.
Table 2. Number of respondents that uses social drug in ARH, Adama, Ethiopia,
June, 2014
Social drugs Total No (%)
Alcohol 30(31.25%)
Khat 18(18.75%)
Cigarette 10(10.42%)
Total 58(60.42%)

Table3. Number of respondent that uses contraindicated substance and engage in

exercise in ARH,Adama,Ethiopia,june,2014

Total No(%)
Animal fat 16(16.3%)
Salt intake 19(19.7%)
Exercise 23(24%)

From the study population the number of salt intake were higher than eating a meal high in animal
fat. Also number of respondent engage in exercise are 24%.

1
 There were also some problems of patients which contribute to non-adherence of the
patients. These were lack of money, use traditional medicine, negligence and forgetfulness.
Table4. some perceived problems of respondents which lead to the non adherents of the
respondents, ARH, Adama, Ethiopia, june.2014
Perceived problems No of respondents that were non-
adherence due
Lack of money 38
Negligence 13
Forgetfulness 19
Use of traditional medicine 7

.Number of patients that were non adherents due to lack of money, forgetfulness, negligence,
and use of traditional medicine were 38, 19, 13, and 7 respectively. Majority of respondents
were non adherent due to lack of money.

Table5. Association of educational level and lack of sufficient information on knowledge

of adherence in ARH, Adama, Ethiopia, June, 2014
Educational Total Lack of sufficient
level number information
Illiterate 15 9
Read and write 27 12
Primary 12 6
Secondary 16 7
Above secondary 26 10
P-value= 0.751
The statistical association between educational level and lack of sufficient information on
knowledge adherence was (p=0.751). Majority of respondents lack of sufficient knowledge (6)
were from read and write. Also another educational level such as illiterate, primary, secondary,
and above secondary number of patients that lack of sufficient knowledge on adherents were
3(3.1%), 2(2.1%), 2(2.1%), and 2(2.1%) respectively.

Table 6. Association between socio-demographic data and non-adherent in ARH, Adama,

Ethiopia, June, 2014.

2
 Age Total Respondents that were
number Non-adherent
14-25 9 0
26-49 25 9
50-64 30 16
>64 32 19
P-value=0.02

Monthly Total number Respondents that were non-

income adherent
<100 27 21
100-800 25 11
801-1200 26 11
>1200 18 1

P-value= 0.001

In this study there is significant association between varaible because they had p-values less
than 0.05. Majority of respondents under low monthly income were non adherent to their
medication. In this study also there were an association between age and adherence(p=0.02).
Also majority of patients >64 ages were non adherents to their medication.

Table 7. Treatment related factor of respondent wich lead to the non adherents of the
respondents in ARH, Adama, Ethiopia, June, 2014.
Treatment related factor Number of respondents that were non
adherence due to
Adverse effect of the drug 18
Different kind of medicine 9

3
 Prolonged duration of treatment 21
Lack of the role health worker 4

From the study population the prolonged duration of the treatment is major factor of treatment
related factor that lead non adherent of the respondets. Number of respondents that were non
adherents due treatment related factors such as adverse effect of the drug, different kind of
medicine, and lack of the role health worker were 18, 9, and 4 respectively

CHAPTER SIX: DISCUSSION

This study showed magnitude of treatment related factor of non adherence with adverse effect of
the drug (18.8%),prolonged duration of treatment (21.8%),different kind of medicine (9.3%) and
lack of role of health worker in describing about the drug were (18.8%), (21.8%), (9.3%), and

4
(4.1%)respectively. Different findings were reported. The study conducted in Seychelles showed
the magnitude of non adherence with medication side effect, use of alternative remedies and
ineffective medication were (9.9%), (12.87%), and (5.49%)(21), respectively. Also study in
finland reported as factor of non adherence with adverse effect was 33%(22).

In this study number of respondents that uses social drugs such as; alcohol,smoke cigarette and
chew chat were (31.225%), (10.42%), and (18.75%) respectively. Also this study suggests that
number patients take contraindicated substance such as animal fat and salt were (16.3%), and
(19.7%) respectively. Also number of respondents that engage in physical exercise were 24%.
In line with this study in sychelles showed magnitudes of non adherence to engage in physical
exercise (50%%), eat vegetables (7.84%), try to lose some weight (53.94%), stop smoke
(15.84%), stop alcohol drink (21.57%), reduce salt intake (24.51%), and stop eating a meal high
in animal fat (28.35) (21). In this study about 9.4% of male and 1% female reported current
cigarette smoking. Similar findings were from study in Addis Ababa reported 13.5% of the males
and less than 1% of the females were current cigarettes smoking(29).

In this study age of the patient had significant association with respondents that were non
adherent. The study conducted in ARH shows that 36.5% patients which age of >50 years were
non adherent. This is mostly because of economic problem. Age of the patient was one of
significantly associated factor with adherence. There is one study that was conducted in Pakistan
and 75% of adherent is due increasing age wich disagreed with this idea (14). But this result is
not complying with the above stated literature. This might be due to the reason that most patients
does not know the disease that they acquired earlier due to different factors.
In this study also there were no significant association between educational level and having
information on knowledge of adherence for hypertension. 9 (9.4%) of uneducated patients who
are not able to understand the warning on a tablet container as much more likely to be non-
adherent to their medication and 15.6% of respondent was lack of knowledge on adherence of
antihypertensive medication. In contrary to these a study conducted in Gondar showed that
majority of respondents(76.8%) were kowledgeable about HTN and its treatment(28). The
overall level of awareness about hypertension and its treatment was very low. Greater awareness
is associated with higher adherence people who are read and write were non-adherent.

5
Another relevant point was economic factor, according to this study majority of the respondents
were under low economic status greater than 50% of the respondents had an income of less than
800 birr per month. Also study conducted in Yirgalem showed that 83% lack of money was a
major factor associated with treatment adherence(30). In this study also there were an association
between monthly income and adherence(P=0.001). Therefore the price for treatment of the
disease was the major factor for non adherence of the respondents.

In this study total non adherence of respondents were 45.8% but study conducted in Gondar
showed that 35.2% (28), lack of knowledge on adherence (15.6%) about the disease and 39.6%
of economic problem of the patient contributed to the non adherence of the respondents. Among
the study conducted on various population of the world; in Malaysia 44.2% of the populations
were non adherent to their medication(23), study conducted in Gambia also showed that 27% of
the study populations were non adherent(24), another study conducted in Egypt showed 74.1%of
the study population were non adherent(14), other study conducted in Scotland showed 91% of
the population were non adherent(25).

CHAPTER SEVEN: CONCLUSION AND RECOMMENDATION

7.1 Conclusion
The study showed that from 96 respondent of hypertensive patients in Adama Refferal
Hospital 45.8%was non adherent to the prescribed medication. There were a number of

6
perceived problem of patients with hypertension .This include forgetfullness, negligence,
adverse effect of medication and old age or disability,economic problem, and use of
social drugs of stopping of medication.

From the above factors economical problem and negligence were the major obstacles for
the patients to be non adherent. Related to perceived problem of respondents on the
health care system, there was old age of >50 on 36.5% of the respondents were non
adherent and 44.9% of patients had problem due to cost of the medication no free service
were available for special cases in the hospital.

7.2 Recommendation
Health professionals must educate hypertensive patients about their disease with specific
emphasis on its causes, the severity of the disease, their medications and the
consequences of non-adherence with treatment.

It may be by preparing leaflet for educated patients and verbally for illiterate one.

And also the disadvantage of non adherence should be told to the patient always and
other problem on the patient’s side that could affect adherence should also be told.

The hospital should have free service for special case like for very poor patients and for
very old patients who had no sufficient income for themselves.
The hospital should prepare normal schedule for BP measurement follow up for the
respondent.

REFERENCE

1.Sackett DL. The magnitude of compliance and non-compliance. In: Sackett DL,
Haynes RB.(eds.). Compliance with therapeutic re-gimens. Johns Hopkins University

7
 Press, Baltimore, 1976;9-25.
2. .Contreras EM, Main CG, etal. Observancia terapeutica enla hipertension arterial.
Atencion Primaria 1995;16(8):496-500.
3. Myers ED, Branthwaite A. Out-patient compliance with antidepressant medications
Br J Psychiatry 1992;160:83-86.
4. Abula T. Patient non-compliance with therapeutic regimens and factors of non-
compliance in Gondar.Ethiopia J Health Dev. 2000;14(1):1-6.
5. Benet LZ. Priciples of prescription order writing and patient compliance instructions.
In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW. (eds.). The pharmacological
basis of therapeutics. MC. Graw-hill companies, INC., New York, 1996;1697-1706.
6. Griffith S. A review of the factors associated with patient compliance and the taking of
prescribed medicines. Br J General practice 1990;40:114-116.
7. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J: Global burden
of hypertension: analysis of worldwide data. Lancet 2005, 365(9455):217-223.
8. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL: Jones DW,
Materson BJ, Oparil S, Wright JT Jr, et al: Seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure. Hypertension 2003, 42(6):1206-1252.
9. Hajjar I, Kotchen TA: Trends in prevalence, awareness, treatment, and control of
hypertension in the United States, 1988–2000. JAMA 2003, 290(2):199-206.
10. Salako LA: Hypertension in Africa and Effectiveness of Its Management with
Various Classes of Antihypertensive Drugs and in Different Socio-Economic and
Cultural Environments. Clin Exp Hypertens 1993, 15(6):997-1004.
11. Tesfaye F, Byass P, Wall S: Population based prevalence of high blood pressure
among adults in Addis Ababa: uncovering a silent epidemic
BMC Cardiovasc Disord 2009, 9:39.

12.Ong KL, Cheung BMY, Man YB, Lau CP, Lam KSL: Prevalence, Awareness,
Treatment, and Control of Hypertension Among United States Adults 1999–2004.
Hypertension 2006, 49:69-75.
13. Primatesta P, Poulter NR: Improvement in hypertension management in England:

8
 results from the Health Survey for England 2003.
J Hypertens 2006, 24(6):1187-1192.
14. Hashmi SK, Afridi MB, Abbas K, Sajwani RA, Saleheen D, Frossard PM, Ishaq M,
Ambreen A, Ahmad U: Factors associated with adherence to anti-hypertensive
treatment in Pakistan. PLoS One 2007, 2(3):e280.
15. Balkrishnan R: The importance of medication adherence in improving chronic-
disease related outcomes: what we know and what we need to further know.
Med Care 2005, 43(6):517-520.
16. Psaty, BM, Lumley, T, Furberg, CD, Schellenbaum, G, Pahor, M, Alderman, MH &
Weiss, NS. 2003. Health outcomes associated with various antihypertensive
therapies used as first-line agents: a networkmeta- analysis.Journal of American
Medical Association 289:2534.
17. Thrall, G, Lip, GYH & Lane, D. 2004. Compliance with pharmacological therapy in
hypertension: can we do better, and how? Journal of Human Hyprtension 18: 595e
18. Greeff, D. 2006. An approach to preventing and treating hypertension through
Lifestyle modification. Professional Nursing Today 10(5): 8-22.
19. Hayne RB, Sackett DL, Gibson ES, et al. Improvementof medication compliance in
uncontrolled hypertension. Lancet, 1976; 1:1265-1268.
20. WHO. 2003a. Adherence to long-term therapies: evidence for action. Geneva:
World Health Organization
21. Thomas AE, Master of public health, University of south Africa, 2009.
Factors affecting compliance with antihypertensive drug treatment and required
lifestyle modifications among hypertenive patients on Praslin Island, Seychelles 108-114.
22. Jokisalo, E, Kumpusalo, E, Enlund, H, Halonen, P & Takala, J. 2002. Factors
Related to non – compliance with antihypertensive drug therapy.
Journal of Human Hypertension 16 (8): 577- 583.

23. Morisky DE, Green LW, Levine DM: Concurrent and predictive validity of a self-
reported measure of medication adherence. Med Care 1986, 24(1):67-74.
24. van der Sande MA, Milligan PJ, Nyan OA, Rowley JT, Banya WA, Ceesay SM,
Dolmans WM, Thien T, McAdam KP, Walraven GE: Blood pressure patterns and

9
 Cardiovascular risk factors in rural and urban gambian communities.
J Hum Hypertens 2000, 14(8):489- 496.
25. Rm Y: II M: Patterns and determinants of treatment compliance among
hypertensive patients. East Mediterr Health J 2002, 8(4–5):579-592.
26. Obarzanek, E, Proschan, MA, Vollmer, WM, Moore, TJ, Sacks, FM, Appel, LJ,
Svetkey, LP, Most-Winhauser, MM & Cutler, JA. 2003. Individual blood pressure
responses to changes in salt intake: results from the DASH-Sodium Trial. Hypertension
42:459-467.
27. Hendriks ME, Wit FWNM, Roos MTL, Brewster LM, Akande TM, et al. (2012)
Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and
Urban Communities. PLoS ONE 7(3): e32638.
28. Abere DA, Getahun A A, Solomon MW, Zelalem BM, 2012. Adherence to
Antihypertensive treatments and associated factors among patients on follow up at
University of Gondor Hospital, Northwest Ethiopia. BMC Public Health 12:282.
29. Fikiru T, Peter B, Stig W: Population based prevalence of high blood pressure among
Adults in Addis Abeba: uncovering a silent epidemic.
BMC Cardiovascular Disorders 2009, 9:39.
30. Alexander T, Enguday S, Haregwoin A, Hiwot A, Tariku B 2006.
Compliance and Factors related to treatment of chronic illness in adult population
visiting Yirgalem Hospital: 13-14.

APPENDIX A: QUESTIONNAIRE

10
Consent Form
Questionnaires to assess the magnitude of to antihypertensive treatments and
contributing factors to non-adherence related to treatment regimens.
Self introduction:
My name is ------------------. I am working as data collector in Adama referral
hospital at cardiac and hypertension follow up clinic . We are interviewing hypertensive
people here about adherence for antihypertension treatments and related factors in order
to generate information necessary for the planning of appropriate strategies
(interventions) to prevent further complications of hypertension as an outcome of non-
adherence to the treatment in the hospital. To attain this purpose, your honest and
genuine participation by responding to the question prepared is very important & highly
appreciated.
Confidentiality and Consent form
I would like you to answer some questions. Your answers are completely
confidential. Your name will not be written on this form. However your honest
answer to these questions was help us to better understand about adherence and factors
related to non-adherence for antihypertension treatments. We would greatly appreciate
your help in responding to this study. The interview was take about 10 - 20 minutes.
Would you be willing to participate?
If yes, proceed here.
If no, thank and stop

Part I.Socio-Demgraphic and Economic Data

1. Age (years) ------ 1. 15-24 □ 2. 25-49 □ 3. 50-64 □ 4. >64 □

11
2. Sex
1. Female□ 2. Male□
3 . Marital status
1. Married□ 2. Single □ 3. Divorced□ 4. Widowed□
4. Religion
1. Protestant□ 2. Orthodox□ 3. Muslim□ 4.other (Specify)
_____________________
5. Educational status
1. Illiterate□ 2. Read & write only□ 3. Primary□ 4.Secondary□ 5. Above
secondary□
6. Occupation
1. Housewife□ 2. Employed□ 3. Farmer□ 4. Daily labor□
5. Merchant□ 6.Other (specify)________
7. Ethnicity
1. Oromo 2. Amhara□ 3. Gurage□ 4. Other (specify)………………
8. Address place of residence
1. adama town□ 2. walanchit□ 3. Other urban area□ 4. Rural
area□
9. Monthly income in Ethiopian Birr
1. <100□ 2. 100-800□ 3. 801-1200□ 4. >1200□

Part II. Assessment on knowledge, perception & practice on treatment adherence.

10. Do you regularly take drugs as prescribed by health workers?

12
 1. Yes□ 2. No□
11. Did you take the full dose of the drug on previous day?
1. Yes□ 2. No□
12. Do you think proper adherence to prescribed treatment is important?
1.Yes□ 2. No□
13. If yes do you apply it?
1. Yes□ 2. No□
14. If no number 12, why?
1. Has no importance□ 2. Its rules are difficult□ 3. I have no idea□
15. Do you stop taking contra indicated substances (drinks or food such as animal fat
sugar, salt, coffee and the like)?
1. Yes□ 2. No□
16. If no, which contra indicated substances you are taking?
1. Animal fat□ 2. Salt□ 3. Coffee□ 4. Others (specify)
…………………….
17. Do you perform regular exercise?
1. Yes□ 2. No□
18. Do you drink alcohol? 1. Yes□ 2. No□
19. If yes, how frequently? 1. Always□ 2. Some times□ 3. Rarely□
22. Do you smoke cigarette? 1. Yes□ 2. No□
23. If yes, how frequently? 1. Always□ 2. Some times□ 3. Rarely□
24. Do you chew chat? 1. Yes□ 2. No□
25. If yes, how frequently? 1. Always□ 2. Some times□ 3. Rarely□
Part III. Follow up profile
26. Do you have regular follow up? 1. Yes□ 2. No□
27. If yes, how frequently?
1. <1 month□ 2. 1-3 months□ 3. >3 months□

28. How long has it been since you started the treatment?

13
 1. <2 months□ 2. 2-5 months□ 3. 5-12 months□ 4. >12
months□
29. How do you get medical services or treatment drugs?
1. Free of payment□ 2. By money payment□
30. If no for question 27, why?
A. Patient factor: 1. Lack of money□
2. Forgetfulness□ 4. Shift to herbal or traditional medications□
3. Negligence□ 5. Other (specify)

B. Treatment related factors:

1. Different kinds of medicines or regimens□
2. Adverse effects of the drugs□
3. Unpleasant odor or test of the drug□
4. Prolonged duration of treatment□
5. Lack of the role of health worker in describing about the drug□
31. How many months has it been since you stopped the treatment?
1. <1 month□ 2. 1-3 months□ 3. >3 months□
32. What are you planning now? 1. To start the treatment regimens again□
2. Not to start□
3. I have no idea about follow up□
Name of interviewer……………………………………………Sign.
………..Date……………………

14