Factors Affecting Treatment Compliance of Hypertensive Patients in Erbil City

Dler H. Ismael/ B.Sc, M.Sc. Adult Nursing department, College of Nursing, Hawler Medical University, Erbil, Iraq. Chnar S. Qadir/ B.Sc, M.Sc, Adult Nursing department, College of Nursing, Hawler Medical University, Erbil, Iraq. E. mail:dler.hamad@yahoo.com ةصلاخلا ةیفلخ ثحبلا : تابقعلا نم ربتعی جلاعلاب ضیرملا مازتلا مدع نإ حاجنل ةیسیئرلا يف مدلا طغض عافترا ةرطیسلا مدعو مدلا طغض عافترا جلاع ملاعلا ءاحنأ عیمج . فدھلا : لاثتما يف ةرثؤملا لماوعلا ىلع فرعتلاو جلاعلل ىلإ مدلا طغض عافتراب باصملا ضیرملا لاثتما ىوتسم مییقت ىلإ ةساردلا فدھت م يف ِّ مدلا طغض عافترإ نیب ئِّیس مِازتلإ يف مُھاسُی ضیرملا لیبرأ ةِنید ةیجھنملا : ىلع تیرجا ةیعطقم ةسارد ٢٠٠ ماع يف مدلا طغض باصم ضیرم ٢٠١٤ فادھلا قیقحت ضرغل ةنابتسا میمصت مت تانایبلا عمجلو ، ةیصخشلا ةلباقملا للاخ نم ىضرملا نم تامولعملا عمج متو ةساردلا . جذومنل لاثتملااو ةیفارغومیدلا تامولعملا كلذ ىلع نایبتسلاا لمشو جلاع مت مدلا طغض لیلحت تانایبلا لامعتساب ءاصحلإا يفصولا يجاتنتسلااو جئاتنلا : ىلإ تْراشأ ةِساردلا ةجیت 45 نم ٪ مدلا طغض عافترا ىضرم تناك لاثتملاا جلاعلل نأ نیح يف 55 مھنم ٪ لاثتملاا مدع . يسیئرلا لماعلا لاثتملاا مدعل وھ نایسنلا . كانھ ناك ةقلاع ةیونعم نیب لاثتملاا ىوتسم رمعلاو (P = 0.000) سنجلاو ، (P = 0.003) میلعتلا ىوتسمو (P = 0.000) ةدمو ، جلاعلا (P = 0.000) ، ةدمو مدلا طغض عافترا (P = 0.003 نیب ةیلاع ةیباجیإو ةمھم ةقلاع كانھ ناكو لاثتملاا و ةدئاف عنام و جلاعلا نم و و جلاعلا نم ضرملا ةدش و تافعاضملل ضرعتلا . اریخأ ىوقأ رشؤم وھ ریكذت للاخ نم نم ةحیصنلا رمملا تاض . جاتنتسلاا : بسح ةساردلا جئاتن فصن نم رثكأ نأ مدلا طغض عافترا ىضرم مازتللاا مدع جلاعلل تایصوتلا : جلاعلل لاثتملاا ىلع مدلا طغض عافترا ىضرمل يمیلعت جمانرب ءاطعإ تاضرمملا نأ بجی ةیسیئرلا تاملكلا : لیبرأ ةنیدم ،لاثتملااو ،مدلا طغض عافترا Abstract Background and objectives: Non-compliance to treatment is the major obstacles to the success of the treatment of hypertension and poor control of hypertension in worldwide. The objective of this study was to assess the level of compliance to treatment and identified factors contributing to poor compliance among hypertensive in Erbil city. Materials and Methods: a cross sectional study design was undertaken among 200 hypertensive in 2014, to collect the data, patients who met the inclusion criteria were selected and questionnaires were filled through interviewing. The questionnaire including demographic information and compliance to treatment, data analysis though descriptive and inferential statistical tests. Result: shows that 45% of hypertensive patients were compliance to the treatment while 55% of them were noncompliance. Major factor for non-compliance is forgetfulness. There was a significant association between level of compliance and age (p=0.000), gender (p=0.003), level of education (p=0.000), duration of treatment (p=0.000), and duration of hypertension (p= 0.003) .also there was highly significant and positive relationship between compliance and benefit of treatment, barrier of treatment, severity of disease and susceptibility to complication. Finally the strongest predictor was reminder (cues of action) by advice from nurses. Conclusion: According result of the study more than half of hypertensive patients were not compliance to treatment Recommendation: Nurses should give education program to hypertensive patients about treatment compliance


INTRODUCTION
Hypertension is an important public health challenge worldwide.Prevention, detection, treatment, and control of this condition should receive high priority.Hypertension is defined as an average systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater 1,2 .It is a silent killer disease, a time bomb in both the developed and developing nations of the world.It is bone of the most significant risk factors for cardiovascular (CV) morbidity and mortality resulting from target-organ damage to blood vessels in the heart, brain, kidney, and eyes 3. The World Health Organization (WHO) has estimated that the high blood pressure cause 7.1 million deaths annually, accounting for 13% of all deaths globally 4 .
Uncontrolled hypertension is caused by non adherence to the antihypertensive drugs, patients understanding their drug regimens help to improve their adherence, thus will help prevent the complications of hypertension which are debilitating and if not prevented can increase the burden of a disease that is already on the increase 5 .Non-adherence to prescribed drugs schedule has been continues to be a major problem in the world over.Studies on this subject show that adherence is about 50% for medications in chronic diseases including hypertension and much lower for lifestyle prescriptions 6 .
Poor adherence to long-term therapies severely compromises the effectiveness of treatment making this a critical issue in population health both from the perspective of quality of life and health economics.Interventions aimed at improving adherence would provide a significant positive return on investment through primary prevention of risk factors and secondary prevention of adverse health outcomes 7 .
Little studies has been documented on the cause of poor compliance, therefore this study aimed to assess factors affecting treatment compliance which guided by the use of Health Belief Model variables among hypertensive patients in Erbil city .The findings of this study will be used to increase the scientific knowledge base to the scientific world, also, the findings will be used to in practice with the aim of planning interventions to improve patient compliance to antihypertensive therapy to reduce the impact of hypertension and complications.

PATIENTS AND METHODS:
A cross sectional study design was used to assess factors affecting treatment compliance among hypertensive patients in General Teaching Hospitals in Erbil city.To find out the factor affecting on patients compliance for treatment, a non probability (purposive) sample was used to select among hypertensive patients who are using antihypertensive treatment according to the following criteria patients who agreed to participate the study, medical diagnosis of hypertension, age more than 18 years old and have been taking antihypertensive treatment for at least past one month ago.Data were collected through the use of questionnaire; it was developed by the researcher that adapted health believes model and review literature .It was modified based on advice of experts to applicable and specific to hypertension.The questionnaire consist of demographic data of the patients such as age, gender, level of education, marital status, residential area and medical data include number of medication, duration of treatment per year , duration of disease, frequency of medication intake per day.
Treatment compliance was composed of 8 items, each item are rated four point scales (never, rarely, sometime and regularly).The total score for each patient could range from 8 (minimum) and 32 (maximum).Lower scores would reflect compliance to treatment.Also, the questionnaire highlighted perception of severity; perception of susceptibility; perception of benefits; perception of barriers and cues to action each part consist of five items that participants were asked to respond: (1) strongly agree, (2) agree, (3) disagree and (4) strongly disagree 8 .Data analysis was performed using SPSS 19 version information was summarized using frequency tables and cross tabulations.The chi-square test was used to compare proportions; bivariate correlation (Pearson correlation) analysis was done.Multivariate analysis was done using Linear Multiple regression to obtain strongest predictor variable between variables of HBM (health believe model), P-value of equal or less than 0.05 was considered a statistically significant.Table 1.revealed that the 200 hypertensive patients were assessed.There were 66% male and 34 % female with a mean age of 58.07±12.39age range from (≤45->65) years and (65.5%) were illiterate in contrast (7%) of them their education was secondary school.More than half of patients were had no family history of hypertension.Concerning measurement of blood pressure the highest percentage (47%) of patients had hypertension stage I (>160/>100 mmHg) while lowest percentage (2%) had normal blood pressures (<120/<80).Most of hypertensive patients their duration of disease were less than ten years.More than half of them used one medication per day for more than ten years.HBM (health believe model) ** High significant Table 5.The findings revealed that there were relationship between the compliance and perceived benefit(r = 0.225; P= 0.001), perceived barrier to treatment (r = 0.321; P = 0.000), severity of disease (r= 0. 315; P = 0,000) and perceived susceptibility to complication (r = 0.286; P= 0.000) .Also, there were relationship between the benefit to treatment and barrier to treatment (r = 0.52; P= 0.000), severity of disease (r = 0.47; P= 0.000), susceptibility to complication (r = 0.81; P= 0.000) and cues of action (r = 0.31; P= 0.000) .Moreover, there were relationship between barrier to treatment and severity of disease (r = 0.78; P= 0.000), susceptibility to complication (r = 0.62; P= 0.000) and cues of action (r = 0.34; P= 0.000).Furthermore, there were relationship between the severity of disease with susceptibility to complication (r = 0.40; P= 0.000) and cues of action (r = 0.96; P= 0.000).Finally there were relationship between susceptibility to complication and cues of action (r = 0.34; P= 0.000) Table 6.illustrate that the there was a significant association between highest percentage (84%) participants who were in the age group of more than 65 years which had higher treatment compliance compared to lowest percentage (41%) were age group of less than 45 years .Also, the study revealed that there was a significant association between gender and treatment compliant, male had higher proportion of treatment compliant (63.7%) than female (38.3%).Moreover, there was statistically significant proportion observed between treatment compliance and level of education, (70%) participants had no formal education which higher proportion of treatment compliance compared to lowest percentage (9.8%)those with primary school education.Furthermore, the result of study shows that there was a significant proportion between duration of treatment and treatment compliance; highest percentage (65.8%)patients had disease from less than 10 years which higher treatment compliance as compare lowest percentage (42%) patients had the disease from more than 10 years.

DISCUSSION
The result of present study revealed the proportional of non treatment compliance was 55%.It is supported with study which showed that 51.7 % of hypertensive patients were non compliant to treatment 9 .Forget to take your medicine is most of the factor for non compliance to treatment, it is possible means should be taken to enhance patients' memory, to keep to the dosing regimen for their medications.Steps should be taken by health care professionals through counseling sessions to help patients organize their medication taking.For example, this could be achieved by planning for medication taking to correspond with certain activities, such as eating meals, or by setting alarms to go off at medicine-taking time during the initial stages of their therapy.
Also, the study showed that patients older than 65 years were more compliance than younger patients.This probably reflects the traditional emphasis on family care for the elderly in the community when the disease is more frequently associated with more severe symptoms and complications.Similar result has been observed in studies 10,11 .The result revealed that male patients were more compliant than female.This is inconsistent with another study on patients' adherence to hypertensive medication by Schoberberger in 2002 who found that the incidence of adherence was significantly lower in male patients 12 .Nevertheless, identifying groups of patients in a population that tends to have more problems with medication adherence enables more targeted efforts toward improvement, for example, from this study, male or very old patients (above 70 years old) can be targeted.
Compliance rate was higher among patients with a low level of education, this result supported by study have been observed that uneducated patients or those with lower educational level might have more trust in physician's advice.From these results, it seems that educational level may not be a good predictor of therapeutic adherence 13 .But the reverse was found in developed countries 14 , this might indicate that poor people with low education might be more easily motivated to treatment by doctors, media and colleagues in developing countries.The present study showed that compliance score was higher in those patients who had hypertension for less than 10 years.The rate of compliance was low in the newly diagnosed patients.This might partially be due to the fact that young patients are more afraid of taking a life long medication than patients in older age group.It might also be, as mentioned earlier, that the course of the disease is usually more severe in old age group 15.

CONCLUSION
The study showed that higher proportion of treatment compliant among older age, female, low level of education, lesser duration of treatment and longer duration of hypertension.There was a significant association between level of compliance and age, gender, level of education, duration of treatment, and duration of hypertension and there was highly significant and positive relationship between compliance with benefit, barrier to treatment, severity of disease and susceptibility to complication.

RECOMMENDATION:
1. Nurses should give heath education to patients about treatment compliance in discharge planning.2. Further research should be integrated qualitative study to gain deeper insight about each factor and increase mass media.

Table 2 .
shows the level of treatment compliance among hypertensive patients.Higher mean score consider non-compliance to treatment include forget to take your medicine , lack of discipline to comply dietary, not having enough time to exercise, lack of motivation to stop smoking (3.14, 2.56, 2.52,2.38)respectively.

Table 3
. Shows multivariate analysis indicated significant model fit for the data (F = 7.42 and P value = 0.000).The amount of variance in treatment compliance that is explained by the predictors is (R² = 0.16) with cues of action being the strongest predictor of treatment compliance (β = -0.181;P = 0.017).Beta coefficient indicates a negative association between cues of action and treatment compliance.Other predictor variables were not statistically associated with treatment compliance.

Table 4 .
show finding of study indicated significant model fit for the data (F = 2.33 and P value = 0.004).The amount of variance in treatment compliance that is explained by the predictors is R² = 0.05 with advice from nurse being the strongest predictor of treatment compliance (β = -0.253;P = 002).Beta coefficient indicates a negative association between advice from nurse and treatment compliance.Other variables were not statistically associated with treatment compliance.