University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA NON-COMPLIANCE TO ANTIHYPERTENSIVE MEDICATION AMONG HYPERTENSIVE PATIENTS ATTENDING GHANA PORTS AND HARBOURS AUTHORITY CLINIC, TEMA BY JULIANA YAWOR KPODO (10239550) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that, this thesis presented for award of Masters in Public Health degree is my own work produced from research undertaken under supervision, and has not been presented for any examination in any other institution. Where references have been used, these have been cited accordingly. Juliana Yawor Kpodo ………………………… ……………………………… Signature Date Prof. Philip Baba Adongo ………………………… ……………………… (Supervisor) Signature Date i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this dissertation to my family. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am thankful to the almighty God for His faithfulness and love. I wish to express my gratitude to Prof. Philip Baba Adongo, my academic supervisor for his expert, patience and valuable time, guidance and encouragement and the HOD of department of SOBS Dr. Phyllis Dako-Gyeke for her support and assistance given me throughout the period. My sincere thanks goes to all the lectures at the Social and Behavourial Science Department for their support. Without them, this project would not have been a success. My sincere thanks goes to my beloved family, my husband and beloved children for their unflinching love, support, encouragement and prayers. I express my heartfelt gratitude to all participants who took part in the study. To all who have directly and indirectly contributed in this dissertation, accept my gratitude. iii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ARH Ayder Referral Hospital DASH Diet Approach to stop Hypertension DBP Diastolic Blood Pressure GPHA Ghana Ports and Harbours Authority HBM Health Belief Model HPT Hypertension JNC8 Joint National Committee MGH Mekelle Belief Model MOH Ministry of Health NHF National Heart Foundation OOUTH Olabisi Onabanjo University Teaching Hospital PHC Population and Housing Census SBP Systolic Blood Pressure SSA Sub-Saharan Africa STG6 Standard Treatment Guidelines WHO World Health Organization iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION............................................................................................................................ i DEDICATION............................................................................................................................... ii LIST OF ABBREVIATIONS ..................................................................................................... iv TABLE OF CONTENTS ............................................................................................................. v LIST OF FIGURES ................................................................................................................... viii LIST OF TABLES ....................................................................................................................... ix ABSTRACT ................................................................................................................................... x CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION......................................................................................................................... 1 1.1Background ........................................................................................................................... 1 1.2 Problem statement............................................................................................................... 3 1.3 Justification .......................................................................................................................... 4 1.4 General Objectives .............................................................................................................. 5 1.4.1 Specific Objectives of the study ............................................................................. 5 1.5 Research questions ......................................................................................................... 5 1.6 Conceptual framework ....................................................................................................... 6 CHAPTER TWO .......................................................................................................................... 8 LITERATURE REVIEW ............................................................................................................ 8 2.1 Epidemiology of Hypertension ........................................................................................... 8 2.2 Pathophysiology of Hypertension ...................................................................................... 9 2.3 Risk Factors Associated With Hypertension .................................................................. 10 2.4 The Symptoms of High Blood Pressure .......................................................................... 11 2.5 Management of Hypertension .......................................................................................... 12 2.6 Compliance to Medication ................................................................................................ 13 2.7 Psychosocial and Social Aspect of Hypertension and Its Management ....................... 14 2.8 Prevalence of Non-Compliance to Medication among Hypertensive Patients ............ 15 2.9 Knowledge of Patients on Hypertension and It Control ................................................ 17 v University of Ghana http://ugspace.ug.edu.gh 2.10 Factors Influencing Compliance to Anti-Hypertensive Medication ........................... 18 2.10.1 Sociodemographic Factors ....................................................................................... 18 2.10.2 Medication Related Factors ..................................................................................... 19 2.10.3 Patient Related Factors ............................................................................................ 19 2.10.4 Health Care Related Factors ................................................................................... 20 CHAPTER THREE .................................................................................................................... 22 METHODOLOGY ..................................................................................................................... 22 3.1 Introduction ....................................................................................................................... 22 3.2 Study Design and Type ..................................................................................................... 22 3.3 Study Area ......................................................................................................................... 22 3.4 Study Population ............................................................................................................... 23 3.5 Inclusion Criteria .............................................................................................................. 23 3.6 Exclusion Criteria ............................................................................................................. 24 3.7 Sample Size Determination .............................................................................................. 24 3.8 Sampling Methods ............................................................................................................. 25 3.9 Data Collection Methods and Instruments ..................................................................... 25 3.10 Quality Control ................................................................................................................ 25 3.10.1 Variables ....................................................................................................................... 26 3.10.2 Dependent Variable .................................................................................................. 26 3.10.3 Independent Variables ............................................................................................. 26 3.11 Data Processing and Analysis ........................................................................................ 27 3.12 Ethical Consideration ..................................................................................................... 28 CHAPTER FOUR ....................................................................................................................... 29 RESULTS.................................................................................................................................. 29 4.1 Introduction ..................................................................................................................... 29 4.2 Socio-demographic characteristics of respondents ............................................................. 30 4.3 Knowledge of Patient on Hypertension ........................................................................... 31 4.4 Socio-demographic characteristics associated with non-compliance with antihypertensive medication .................................................................................................. 34 4.5 Knowledge factors associated with non-compliance with antihypertensive medication ................................................................................................................................................... 36 4.6 Factors associated with non-compliance with antihypertensive medication ............... 37 vi University of Ghana http://ugspace.ug.edu.gh 4.7 Results from multiple logistic regression of factors associated with non-compliance with antihypertensive medication .......................................................................................... 40 CHAPTER FIVE ........................................................................................................................ 46 DISCUSSION ........................................................................................................................... 46 CHAPTER SIX ........................................................................................................................... 51 FINDINGS, CONCLUSION AND RECOMMENDATION ................................................... 51 6.1 Summary of Findings .......................................................................................................... 51 6.2 Conclusion ...................................................................................................................... 51 6.3 Recommendations ............................................................................................................. 52 REFERENCES ............................................................................................................................ 53 Appendix 1 Participant Information Sheet ........................................................................... 59 Appendix 2 Consent Form ...................................................................................................... 61 Appendix 3 Data Collection tool ............................................................................................ 62 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework Adapted From Andersen and Newman (2005) Based On the Health Care Utilization Model ........................................................................................................ 7 Figure 4.3 Proportion of non-compliance with antihypertensive medication among respondents33 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 2.1 Classification of Clinical Blood Pressure Levels in Adults .......................................... 11 Table 4.1 Socio-demographic characteristics of respondents (n = 386) ....................................... 30 Table 4.2 Knowledge of Patient on Hypertension ........................................................................ 32 Table 4.4 Socio-demographic characteristics associated with non-compliance with antihypertensive medication ......................................................................................................... 34 Table 4.5 Knowledge factors associated with non-compliance with antihypertensive medication ....................................................................................................................................................... 36 Table 4.6 Factors associated with non-compliance with antihypertensive medication ................ 37 Table 4.7 Factors associated with non-compliance with antihypertensive medication ................ 43 ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Noncompliance to antihypertensive medication is a big public health problem to the management of high blood pressure and predisposes majority of the hypertension patients to cardiovascular complications. According to World Health Organization (WHO) report, the problem of uncontrolled blood pressure, which is estimated to be 52-74% of patients, is largely because of poor compliance to prescribed antihypertensive medication. The purpose of this study was to determine the prevalence and factors influencing noncompliance to antihypertensive medications among hypertensive patients of Ghana Ports and Harbours Authority Clinic, Tema. Method: A cross sectional survey was conducted between May 2019 and June 2019. A sample of 392 patients diagnosed of hypertension and on medication for not less than six months were selected by consecutive sampling. Data was retrieved through face-to-face interview using a structured questionnaire. The Donald Morisky medication adherence scale was adopted to design questions relating to antihypertensive adherence. The association between the exposure variables and noncompliance was analyzed by using multiple logistic regression and tested with Chi Square reporting crude and adjusted odd ratios with their 95% confidence intervals. Results: Data was collected from 386 patients between the ages 24 to 84 years with an average age of 53.4. The prevalence of noncompliance to antihypertensive medication was 57.2% among hypertensive patients at GPHA clinic (p = 0.57, 95% CI = 0.52 – 0.62). Age (aOR = 0.97; 95% CI = 0.93 – 0.99; p = 0.035), Marital Status, divorced (aOR = 4.98; 95% CI = 1.08 – 22.85; p = 0.039) and widowed (aOR= 5.03; 95% CI = 1.17 – 21.59; p = 0.030), Educational level, senior high (aOR = 0.07; 95% CI = 0.01 – 0.50; p = 0.008) and junior high (aOR = 0.12; 95% CI = 0.02 – 0.81; p = 0.029), Attribution of spiritual cause to hypertension (aOR = 8.05; 95% CI = 1.33 – x University of Ghana http://ugspace.ug.edu.gh 48.57; p = 0.023), Waiting time for consultation, 1 – 2 hours (aOR = 3.26; 95% CI = 1.48 – 7.18; p = 0.003) and Waiting time for drug refill, 30 minutes – 1 hour (aOR = 0.47; 95% CI = 0.25 – 0.88; p = 0.018 )‖ were found to be significant predictors of noncompliance. Conclusion: More than half of the respondents were noncompliance. Education, age and waiting time for drug refill reduce noncompliance whilst marital status and waiting time for consultation, and attribution of spiritual cause to hypertension increases noncompliance to antihypertensive medication. The Ghana Health Service should incorporate education on hypertension and importance of complying with treatment. The Ghana Ports and Harbours Authority Clinic should put in necessary measures to reduce longer waiting time for patients with hypertension seeking health service at the facility. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1Background Hypertension is a serious public health problem which is likely to cause the death of about 7.5 million people every year and comprises 12.8% of all global deaths (Boima et al., 2015; WHO, 2009). Globally, the total number of people living with high blood pressure has risen from about 600 million in 1980 to nearly 1 billion in 2008 (Boima et al., 2015). The problem of the disease is disproportionately high in Sub-Saharan Africa (SSA). In Ghana, the reported prevalence of the disease ranges from 19% to 33% in rural areas and 25.5% to 48% in urban areas (Boima et al., 2015; Bosu, 2010). Furthermore, an approximate prevalence rate of 29.9% of males and 27.6% of females with hypertension was estimated by Ghana Health Service among adult 18years and above in 2014 (Obirikorang et al., 2018). Similarly, studies conducted on hypertension in Nigeria showed the prevalence of the disease in rural areas ranged from 21% to 25% while that of urban areas ranged from 27% to 46% (Hendriks et al., 2012; Ulasi, Ijioma, & Onodugo, 2010; Ulasi et al., 2011). Best blood pressure control with levels below 140/90 mmHg due to strict compliance to antihypertensive drugs is linked with a huge decrease in cardiovascular related complications like coronary heart disease and stroke (WHO, 2011). Though there are increasing rates of hypertension in SSA, blood pressure regulation is generally worse for people living with hypertension in Sub-Saharan Africa. This poor control has been found to be a complex interaction of patient, health service provider and socio-economic factors present in the region (Boima et al., 2015; Bosu, 2010). The management of hypertension poses great challenge to both 1 University of Ghana http://ugspace.ug.edu.gh patients and health care professionals. There is no cure for hypertension, it is a disease sufferers have to live with. Thus, control of blood pressure among individuals living with high blood pressure is vital for the reduction of morbidity and death (Bader, Koprulu, Hassan, Ali, & Elnour, 2015). Compliance in the management of diseases consists of approaches to maintain or improve health as well as managing signs and symptoms of a disease. These approaches are complex behavioral processes which are strongly affected by the location in which the patient lives in, health care providers practice and health care system delivery (Miller, Hill, Kattke, & Ockene, 1997). The word compliance is synonymously used with adherence in assessing how patients follow their medical prescriptions from health care service providers. The primary aim of hypertension management is to reduce complications associated with the disease. The use of medicine is widespread and the most recent method to the management and control of hypertension. Additionally, drugs that lower high blood pressure are the common once prescribed by physician. Antihypertensive medicines contribute in achieving optimal blood pressure control as well as reducing co-occurrence of complications like renal failure. The good things associated with adherence to antihypertensive medication treatment include substantial reduction in incidence of stroke by 35%-40%, heart failure by more than 50% and myocardial infarction by 20%-25% (Li et al., 2016). Thus, hypertensive patients strict compliance to antihypertensive medication is one of the most important factors affecting the management of hypertension and its associated consequences in relation to quality of life and complications (Bader et al., 2015). In Ghana, a report shows that high blood pressure management among people living with hypertension is mostly poor as a result of non-compliance to antihypertensive therapy (Boima et al., 2015; Obirikorang et al., 2018). Thus, improvement in compliance to antihypertensive 2 University of Ghana http://ugspace.ug.edu.gh treatment is essential to preventing unfavorable outcomes in persons living with hypertension (Agbor et al., 2018). Thus, this study seeks to determine the prevalence of non-compliance to antihypertensive treatment, assess the level of knowledge on hypertension and identify factors influencing non-compliance to antihypertensive medication among Hypertensive patients of the Ghana Ports and Harbors Authority Clinic, Tema. 1.2 Problem statement Hypertension is a key health concern. It poses a serious threat to sufferers which include heart attack, heat failure and stroke if left uncontrolled (Kumar, 2013). However, there are effective interventions to manage the disease, compliance to the therapeutic management of the disease among hypertensive patients remain unsatisfactory (Ali, Bekele & Teklay, 2014). Non- compliance to medication reduces the overall effectiveness of the health care system (WHO, 2003). This unfortunate practice is prevalent particularly in the management of chronic non- communicable diseases such as hypertension which causes health outcomes and huge medical spending on drug related illness (Ali et al., 2014). It has been reported that, only 1 or 2 out of 10 people living with hypertension achieve ideal blood pressure regulation worldwide. Many of the people living with hypertension remain above recommended blood pressure targets (Guo et al., 2012; Li et al., 2016). Furthermore, this situation is worse in countries that are not developed and has inadequate accessibility to medication and health care (Ali et al., 2014). Non-compliance to therapeutic management of hypertension has disastrous effects on the client and the totality of the health delivery structure (Mbouemboue et al., 2016). Unchecked blood pressure increases the rate of occurrence of cardiovascular complications. A study conducted by Pressman and friends revealed that an increase death rate was reported among client with poor 3 University of Ghana http://ugspace.ug.edu.gh treatment compliance to those with controlled blood pressure (Pressman, Avins, Neuhaus, Ackerson, & Rudd, 2012). Uncontrolled or sub optimally treated hypertension could lead to increased rates of morbidity and mortality due to cardiovascular, cerebrovascular or renal diseases (Ali et al., 2014). Furthermore, poor compliance to antihypertensive medication is responsible for needless prescription of medicines, deteriorating of disease, increases in unnecessary hospital admissions rates as well as lengthier hospital stays leading to a substantial medical burden (Asgedom, Atey, & Desse, 2018). Hypertension is among the ten top cases that report at the outpatient department of Ghana Ports and Harbours Authority clinic. Although free medical care is readily available at the Ghana Ports and Harbors Authority Clinic, patients do not comply with anti-hypertensive therapy leading to increase in medical cost due to frequent admission and decrease in productivity. In 2017, out of 1, 507 hypertensive patients, about 104 representing 6.9% did not comply with medications (GPHA, 2017). There are few studies on noncompliance to antihypertensive treatment among hypertensive patients in Ghana (Obirikorang et al., 2018). This study seeks to determine the prevalence and factors influencing non-compliance to antihypertensive medication among hypertensive individuals in Tema. 1.3 Justification Uncontrolled hypertension is known to be a significant risk factor for cardiovascular disease. Non-compliance to treatment regimen is a barrier to better quality of life. It is thus, important to define the prevalence of non-compliance to antihypertensive medication among people living with hypertension. Though studies have been conducted in this subject area in most parts of the world, information available indicates there has not been any conducted in Tema. This therefore 4 University of Ghana http://ugspace.ug.edu.gh presents the need for research on non-compliance to antihypertensive treatment among hypertensive clients at the Ghana Ports and Harbors Authority (GPHA) Clinic at Tema. It is in this regard that this research seeks to define the prevalence of non-compliance to antihypertensive treatment among hypertensive patients. The study also seeks to determine the knowledge of patients on hypertension as well as risk factors for compliance to antihypertensive medication. Determining the prevalence of non-compliance and recognizing of these risk factors and their quantification is important to help reduce the problems of hypertension and planning for cost-effective strategies to curb the problem of noncompliance to antihypertensive medication among people living with the disease. 1.4 General Objectives The general objective of this study is to determine non-compliance to antihypertensive medication among hypertensive patients of the Ghana Ports and Harbors Authority Clinic, Tema. 1.4.1 Specific Objectives of the study 1. To determine the prevalence of non-compliance to antihypertensive medication among hypertensive patients 2. To assess the level of knowledge of patients on hypertension 3. To identify factors influencing non-compliance to antihypertensive medication 1.5 Research questions 1. What is the prevalence of non-compliance to antihypertensive medication among hypertensive patients? 2. What is the level of knowledge of patients on hypertension? 3. Which factors influence non-compliance to antihypertensive medication? 5 University of Ghana http://ugspace.ug.edu.gh 1.6 Conceptual framework The study adapts the Healthcare Utilization Model as the conceptual framework. This is in recognition of the fact that the model has tenets which are very pertinent to the study and well- suited with objectives of the study, determine the prevalence of non-compliance to medication among hypertensive patients, asses the level of knowledge patients have on hypertension, determine the factors influencing compliance to anti-hypertensive medication among hypertensive patient of Ghana Ports and Harbours Authority Clinic, Tema. According to Andersen and Newman (2005), health care utilization models classifies the aspects that influence the utilization of health services (compliance to medication) which are societal aspects, distinct aspects and health system aspects. The societal aspects are beliefs, perception and norms. The individual aspects are client’s related factors and socio demographic factors. The health system aspects are therapy-correlated factors and health care associated factors. Compliance to medication can be influenced by all these factors. 6 University of Ghana http://ugspace.ug.edu.gh Figure 1: Conceptual Framework Adapted from Andersen and Newman (2005) Based On the Health Care Utilization Model 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Epidemiology of Hypertension Worldwide in 2008, almost 40% of adults aged 25 years and beyond had been diagnosed with hypertension. The number of people with the condition rose from 600 million in 1980 to 1 billion in 2008 (WHO, 2011). In 2012, World health statistics approximated the occurrence of high blood pressure to be 29.2% in males and 24.8% in females. Almost 90% of males and females who do not have high blood pressure by 55 and 65 years will be diagnosed of having high blood pressure when get to age of 80–85years. High blood pressure affect countries of low-income population and not restricted to rich population. In 2004, out of 58.8million death worldwide, 7.5million was as a result of hypertension (Kumar, 2013). Through the WHO regions, the occurrence of elevated blood pressure was highest in Africa (46% for both sexes). Men and women have high rates of elevated blood pressure in the Africa region (WHO, 2013). Hypertension is not a disease of people in first world countries but second and third world countries are at a higher threat of developing and dying from hypertension (Kumar, 2013). Between 2000 and 2025, WHO approximate there will be an increase in patients detected with hypertension from about 60% to 1.56 billion with the largest proportion being Asian. Hypertension is not as much common in Asia as to western countries but the larger Asian populace results in a significantly bigger number of persons affected. In China and India, the total sum of hypertensive patients is anticipated to rise more than 800 million by 2025. The total increments for India and China are (95.3 million) and (117.6 million) respectively. However, in 2010, approximately 200 million people were hypertensive, which indicated, one in every five 8 University of Ghana http://ugspace.ug.edu.gh persons was hypertensive (Chun-Na et al., 2013). About 77.9 million people (1 out of every 3) adults have hypertension in United States. Among adults age 20 and above in the Unites States, for Non-Hispanic whites 33.4% of men and 30.7% of women are hypertensive (American Heart Association, 2016). In other developed countries, the commonness of hypertension in Europe ranges from 9% to 20% in the adult population and 44% up to 60% in the elderly (Magrini, & Reggiani, 2011). A methodical review on research done in Ghana on hypertension reveals, the prevalence of high blood pressure in Ghana (BP ≥ 140/90 mmHg ± antihypertensive treatment) ranged from 19% to 48% between studies (Bosu, 2010). A cross sectional study conducted in rural Delhi indicated the frequency of hypertension in adults to 14.1% (Kishore, Gupta, Kohli, & Kumar, 2016). In Ghana, a study on high blood pressure reveal the frequency of hypertension to be approximately 54.6 % in the city and 19.3 % in the village communities (Addo et al., 2012). Also, a study carried out in rural communities Hohoe Municipality, Ghana among adults also found the prevalence of hypertension to be 25.4% (Incoom et al., 2017). 2.2 Pathophysiology of Hypertension Hypertension is a multifactorial systemic chronic disorder through functional and structural macro vascular and microvascular alterations. Macro vascular alterations are featured by arterial stiffening, disturbed wave reflection and altered central to peripheral pulse pressure amplification. Microvascular alterations, including altered wall-to-lumen ratio of larger arterioles, vasomotor tone abnormalities and network rarefaction, lead to disturbed tissue perfusion and susceptibility to ischemia (Yannoutsos, Levy, Safar, Slama, & Blacher, 2014). 9 University of Ghana http://ugspace.ug.edu.gh Blood pressure has two readings, the ―systolic and diastolic pressures‖. Systolic pressure (the first and top figure) is the force against the artery walls as the heart reduces in size to pump blood. The diastolic pressure (the last and lower reading) is created as the heart rest between each beat (AHA, 2016). Hypertension is grouped into two classes, primary HPT and secondary HPT, which accounts for (95%) and (5%) of hypertensive cases respectively. The cause of primary hypertension is not known and usually begins in the later stages of life often has a link with high salt consumption, and overweight has an association with family history (Delacroix, Chokka, & Worthley, 2014). Persistently raised blood pressure is term as hypertension (WHO, 2011). Every heart beats pumps blood into the vessels. The greater the force the tougher the heart has to push blood (WHO, 2013). 2.3 Risk Factors Associated With Hypertension Hypertension predispose one to risk factors and cause of cardiovascular and end organ damage diseases (myocardial infarction, chronic kidney disease, ischemic and hemorrhagic stroke, heart failure and permanent disability) (Yannoutsos et al., 2014). It need a holistic approach to manage the condition. The accompanied risk factors of hypertension are older age, family history, overweight/obesity, increase salt intake, abuse of alcohol and tobacco , lack of exercise, stress, lack of potassium consumption and diabetes (Ali, Bekele & Teklay, 2014; Yannoutsos et al., 2014; Bosu, 2010). The compounded adverse health complications of hypertension is a result of other health condition which predisposes people with hypertension to high chances of complications like stroke, kidney failure and heart attack (NHF, 2016). 10 University of Ghana http://ugspace.ug.edu.gh 2.4 The Symptoms of High Blood Pressure Majority of people suffering from hypertension experience no symptoms. The popular perception that patients with hypertension experience symptoms always in not so, majority of hypertensive patient have no symptoms. Most times hypertension present with symptoms like headache, difficulty in breathing, dizziness, chest pain, palpitations and nosebleeds. It is serious to overlook such symptoms. Hypertension requires lifestyle modification because of it seriousness. Hypertension needs to be monitored because it is a silent killer (WHO, 2013). Table 2.1 Classification of Clinical Blood Pressure Levels in Adults Diagnostic category Systolic (mmHg) Diastolic (mmHg) Optimal <120 And <80 Normal 120-129 and/or 80-84 High-normal 130-139 and/or 85-89 Grade 1 (mild) 140-159 and/or 90-99 hypertension Grade 2 (moderate) 160-179 and/or 100-109 hypertension Grade 3 (severe) ≥180 and/or ≥110 hypertension Isolated systolic >140 And <90 hypertension Blood pressure is measured with an electronic, mercury and aneroid device. The use of an affordable and reliable electronic device is recommended by WHO (NHF, 2016). 11 University of Ghana http://ugspace.ug.edu.gh 2.5 Management of Hypertension After one has been diagnosed, hypertension can be managed by either practicing a healthy lifestyle or taking medications. The goal of the healthy lifestyle is to control risk factors such as abuse of alcohol and tobacco, exercising and minimizing salt intake. The healthy lifestyle to be adopted are consuming more fruits and vegetables, low salt intake, physical activity, avoid smoking, avoiding excessive intake of alcohol and regular checking of blood pressure (WHO, 2011). The use of programmed sphygmomanometers is an accepted way to measure blood pressure in primary care because it does not need training which is usually required with manual blood pressure measurement (Myers et al., 2011). In addition, blood pressure devices are connected with user-bias which is attributed to terminal number preference, wrong korotkoff understanding, threshold evasion and improper deflation speeds (Hezelgrave & Shennan, 2012). It also increases the number of measurement that can be done (Pickering et al., 2005). Clinic measurement is the recommended method to monitor blood pressure during treatment (NICE, 2011).The target clinic blood pressure in those less than 80 years is 140\90 mmHg but 150\90 mmHg for people older than 80 years of age. After diagnosis of hypertension, it is important to counsel all patients on lifestyle modification and adherence to treatment. Anti-hypertensive medication therapy is normally initiated in people with sustained systolic blood pressure of 160 mmHg and above or sustained diastolic blood pressure of 100mmHg and above. In those with sustained systolic pressure between 140 and 159mmHg or sustained diastolic blood pressure between 90 and 99mmHg, the decision to start drug therapy is dependent on the presence or absence of cardiovascular disease target organ damage or an estimated increased cardiovascular risk (Williams et al., 2004). 12 University of Ghana http://ugspace.ug.edu.gh 2.5.1 Lifestyle Modification and Hypertension Most studies have shown that lifestyle modification either as an adjuvant to drug therapy or alone in the treatment increases the chances of attaining a controlled blood pressure (Chobanian et al., 2003). Lifestyle modification in chronic disease management like hypertension involve dietary intervention to halt hypertension (DASH) diet, increase exercise, moderation in alcohol intake and stopping smoking. The DASH diet is a pleasant dietary schedule that lowers blood pressure and it is acceptable for the whole population. The diet is rich in fiber, fruits and vegetables. It also contains monounsaturated fats (but high in polyunsaturated fats) and solution. The DASH diet decreases the systolic blood pressure by 2-8mmHg which is very significant in the management of hypertension (Champagne, 2006) Other components of lifestyle modifications are minimizing alcohol intake and stopping of smoking. Alcohol intake at 2.5-4.9g\day is in connection with a 14 – 25% reduction in cardiovascular risk compared with staying away from alcohol. The intake of large quantity of alcohol is also linked to high risk for cardiovascular disease (Ronksley et al., 2011). 2.6 Compliance to Medication Medication compliance is the extent to which patients take their mediations as instructed by their health care practitioners. WHO report stated that, the leading cause of persistent high blood pressure which is approximately 52–74% of client is as a result of poor compliance to prescribed antihypertensive medication. Non-compliance has been a big problem among individuals with hypertension and has been attributed as one of the main reasons to uncontrolled blood pressure 13 University of Ghana http://ugspace.ug.edu.gh (Bader, Kprulu, Hassan, Ali & Elnour, 2015). Noncompliance with reduced persistence in taking anti-hypertensive medication results in a poor blood pressure control, worse clinical outcome and higher health care cost (Hill, Miller & DeGest, 2010). High blood pressure has no cure and medications are supposed to be taken for life and also to adhere to review date with their doctors. The main aim of medication is to bring blood pressure down and eventually minimize danger of developing problems. Adherence to drug treatment and adjustment is very effective in the controlling of high blood pressure and benefits the individual, health delivery systems, and the society at large by improving their lifestyle and prevent complications as well as early deaths (Demisew, Mahmud & Kechalew, 2018). Causes of noncompliance general fall into two broad groups, intentional and unintentional. Averagely 31% of patients reported unintentional non-compliance and 9% reported intentional noncompliance (Lowry et al., 2005). Unintentional non-compliance happens when patients are ready to follow to the approved treatment but hindered from doing so by factors that are outside their control. Lowry et al., (2005) further that, typical instances are not remembering or difficulties in understanding the instructions, challenges with using the treatment, patients not being able to pay for the medication or simply forgetting to take it. Controlling high blood pressure normally depends on country-specific rules such as the Joint National Committee (JNC8) and the Ghana Standard Treatment (STG6) Guidelines (MOH, 2010). 2.7 Psychosocial and Social Aspect of Hypertension and Its Management The social and psychosocial aspects influenced the health and wellbeing of the individual. The social elements of health example, pay, edification, and accommodation have an adverse effect on behavioral risk issues and may predispose one to having high blood pressure. Example, not working or on any income have an effect on stress levels which later predispose one to 14 University of Ghana http://ugspace.ug.edu.gh hypertension (WHO, 2011). The social and psychosocial aspects are part of our wellbeing to attain good health. Kretchy and colleagues conducted a study to assess psychosocial factors that affects patients’ opinion and familiarity of adverse effects of medication, and management of experiences and effect on drug adherence behavior. The findings of their study showed that, they experience reaction such as shivers, recurrent urination, persistent bouts of hunger, erectile dysfunction, and faintness, easily fatigued. The results again showed that, there was a significant association between depression, anxiety, stress and side effects were observed. Drug adverse reaction significantly rises the chance of individuals to be non-compliance with social influences, media impacts and attitudes of principal caregivers (Kretchy, Owusu-Daaku, Danquah & Asampong, 2015). Adverse social factors are often associated with a poor lifestyle including unhealthy diet, lack of exercise, smoking, and consequently an increased majority to abdominal obesity and the so-called metabolic syndrome. This raises the risk of developing hypertension in vulnerable persons. The effect of psychosocial stress on hypertension control has been studied in numerous areas. A study from Sweden shows that work pressure at the workplace could affect blood pressure increase, and is high among men than in women (Nilsson, 2009). Another study conducted to determine the relationship between social involvement and high blood pressure in Japan, a country with a more numbers of high blood pressure revealed that, exercise can be a way that links social involvement and high blood pressure and therefore suggested that, increasing social participation activity, particularly those involving horizontal organizations was important (Yazawa et al., 2016). 2.8 Prevalence of Non-Compliance to Medication among Hypertensive Patients Compliance to high blood pressure drugs is one of the significant issues influencing hypertension management consequence in relation to quality of living and complications. A study carried out 15 University of Ghana http://ugspace.ug.edu.gh in United Arab States intended to evaluate the analysts of non-compliance to antihypertensive medications showed that, non-compliance to antihypertensive medicine was reported by 45% of patients (Bader et al., 2015). Ayder Referral Hospital (ARH) and Mekelle General Hospital (MGH) conducted a prospective cross-sectional study to investigate antihypertensive medication noncompliance revealed that, quarter of (26.4%) of the study respondent were found to be compliant to their medication (Ali, Bekele & Teklay, 2014). A cross sectional study conducted in Ethiopia to assess the prevalence of adherence to antihypertensive treatment and associated factors showed that 37% of the patients were non-adherent (Demisew et al., 2018). Another cross sectional study conducted to evaluate the adherence to treatment of hypertension patients attending community health centers in a rural area in Vietnam showed that prevalence to nonadherence to antihypertensive was 50.2% (Nguyen, Schulling-Veninga, Nguyen, Vu, Wright & Postma, 2017). A descriptive study conducted among Palestinian hypertensive patients showed that, low compliance to antihypertensive medication was 54.2% (Al-Ramahi, 2015). A study meant to determine the factors of compliance to hypertension medicine based on health belief model (HBM) among hypertensives in a rural area of the Ardabil city revealed that, 76% of the patients were non-compliant to the medication (Kamran, Sadeghieh, Biria, Malepour & Heydari, 2014). A hospital study conducted in southwest Ethiopia showed the prevalence of noncompliance to hypertensive medication as 38.2% (Asgedom, Atey & Desse, 2018). A cross sectional study carried out in Aligarh showed that the prevalence of antihypertensive noncompliance was 76.3%‖ (Khwaja, Ansari & Mehnaz, 2017). A community-based study carried out in Cameroon revealed that 67.7% of the participants were non-compliant to their medication (Adidja, Agbor, Aminde, Ngwasin, Ngu & Aminde, 2018). 16 University of Ghana http://ugspace.ug.edu.gh 2.9 Knowledge of Patients on Hypertension and It Control In Bhagalpur, a study was carried out among individuals who have hypertension revealed that, 66 (33.9%) patients knew that antihypertensive medications may sometime cause hypotension. Most patients identified that excessive salt intake (93.0%), alcohol (90.5%) and being overweight were the risk factors of hypertension (Shrestha, Adhikari, Poudel, Thapaliya, Kharal, Bastakoti, Bhatta, 2016). A cross sectional descriptive study was conducted to assess hypertensive patients knowledge on hypertension in Sri Lanka showed that, the patients believed that heart is affected while 26% mentioned that kidneys could be affected by poor controlled hypertension. 64% believed that both tablets and lifestyle modifications were the useful strategies for controlling hypertension. Approximately 76.0% stated that reducing body weight is effective in managing hypertension while 81.1% accepted that salt reduction as another method. Only 45.0% of participants agreed that increased intake of fruits and vegetables would improve control of hypertension. The findings therefore concluded that, the patients had insufficient information on hypertension (Kisokanth et al., 2016). A study carried out to evaluate the knowledge and level of consciousness of the disease among hypertensive persons visiting the outpatient clinic of Olabisi Onabanjo University Teaching Hospital (OOUTH) showed that, 52.4% of the partakers were aware that hypertension was the common non-communicable disease in Nigeria. About one in 10 patients (11.4%) know that hypertension does not present with any signs and symptoms, while 37% did not know that hypertension can predispose one to develop renal failure. About (35.4%) of the patients knew that hypertension treatment is for life (Familoni, Ogun, & Aina, 2004). A cross sectional descriptive survey conducted in Cape Coast, Ghana revealed that, the hypertensive patients surveyed demonstrated inadequate knowledge in 17 University of Ghana http://ugspace.ug.edu.gh the reasons, symptoms, risk factors, avoidance and management of hypertension (Anowie & Darkwa, 2015). 2.10 Factors Influencing Compliance to Anti-Hypertensive Medication 2.10.1 Sociodemographic Factors Some socioeconomic factors that influence noncompliance of patients to hypertensive medicine. A study piloted by Bader and colleagues in United Arab States revealed that, socioeconomic factors such as sex and number of children were associated predictors of non-adherence to antihypertensive medication (Bader et al., 2015). A prospective study conducted in Ayder Referral Hospital, Northern Ethiopia showed that the place of patient residence was related to non-compliance to hypertensive treatment (Ali, Bekele & Teklay, 2014). A descriptive cross sectional study done among Palestinian patients with high blood pressure showed that, sociodemographic factors has a relationship with low levels of medication adherence among younger age (<45 years), staying in a rural area compared with a urban area and evaluating health status as very good, good or poor compared with excellent (Al- Ramahi, 2014). A cross sectional study carried out in Aligarh among hypertensive patients revealed that, gender, education and higher social class has a strong relationship with adherence to medication (Khwaja et al., 2017). A hospital-based cross-sectional study conducted in Northwest Ethiopia revealed that, respondents aged 60 years and above were noncompliance to hypertensive medication (Teshome, Bekele, Habitu & Gelagay, 2017). 18 University of Ghana http://ugspace.ug.edu.gh 2.10.2 Medication Related Factors The findings of a research conducted in the United Arab States also showed that, admissions, quantity and medications prices, medication supposed usefulness and use of traditional preparations were the therapy associated factors to adherence of antihypertensive medication among hypertensives (Bader et al., 2015). A hospital based cross sectional study conducted in southwest Ethiopia showed that, getting free medication and combination of antihypertensive medications were inversely associated with antihypertensive medication adherence (Asgedom et al., 2018). A community-based cross- sectional study conducted in Cameroon came up with multiple daily doses and adverse drug effects as predicted of nonadherence to anti-hypertensive medication (Adidja et al., 2018) 2.10.3 Patient Related Factors A cross sectional study conducted among hypertensives in United Arab States revealed that, patient related factors such as forgetfulness, method of identifying medication and poor awareness of hypertension complications were factors related with non-compliance to the antihypertensive medications (Bader et al., 2015). A cross sectional study conducted in Ethiopia to assess the prevalence of adherence to antihypertensive treatment and associated factors showed results that agree with findings obtained (Bader et al., 2015). They also found that, forgetfulness was associated with noncompliance and in addition found that, the perceived severity of the disease by the patient influenced adherence to the medication (Demisew et al., 2018). Another cross sectional study conducted to measure the compliance to treatment of hypertension patients attending community health centers in a village in Vietnam from a qualitative technique revealed that, knowing the of complications associated with hypertension was the main cause for 19 University of Ghana http://ugspace.ug.edu.gh compliance to treatment (Nguyen et al., 2017). A descriptive cross sectional study conducted among Palestinian hypertensive clients revealed forgetfulness, fear of getting used to medication, drug reaction, and not in agreement with treatment had a statistically significant association with lower levels of medication adherence (Al-Ramahi, 2015). The results indicating forgetfulness is almost the same to the findings obtained in the study (Bader et al., 2015; Demisew et al., 2018 and Adidja et al., 2018). A cross-sectional study was undertaken in a rural area of the Ardabil city revealed that, participants who exercise frequently and those who do not smoke were less more compliant to hypertension treatment when compared to participants with sedentary lifestyle and smoking (Kamran et al., 2014). A hospital based cross sectional study conducted in southwest Ethiopia showed that, patients who took alcohol were inversely associated with antihypertensive medication adherence (Asgedom et al., 2018). 2.10.4 Health Care Related Factors There is health care related issues associated with compliance to hypertensive medications among patients. The health care related issues related with compliance to hypertensive treatment in a study piloted by Bader and colleagues in the Arab States were frequent checkup, education and counselling, regular of altering medication by physicians and awareness of physician directives (Bader et al., 2015). A prospective cross sectional study conducted in Ayder Referral Hospital, Northern Ethiopia identified that lack of social help from the prehypertension stage of blood pressure and existence of hypertensive heart disease were found to reduce adherence to hypertensive treatment (Ali, Bekele & Teklay, 2014). Findings from a study conducted by Demisew and colleagues in Ethiopia is similar to results obtained (Ali et al., 2014; Asgedom et al., 2018). They also found that, the presence of comorbidity like the presence of heart disease 20 University of Ghana http://ugspace.ug.edu.gh were factors strongly affecting medication adherence among hypertensive (Demisew et al., 2018; Asgedom et al., 2018). A cross sectional study carried out in Aligarh among hypertensive patients revealed that, duration of hypertension was strongly related with adherence to medication (Khwaja et al., 2017). A community-based cross-sectional study carried out in Cameroon revealed that financial constraints in getting medication, was a predictor to nonadherence to anti-hypertensive medication (Adidja et al., 2018). Chapter Summary In conclusion, several studies by researchers have showed findings on non-compliance to high blood pressure drugs and knowledge on hypertension among hypertensive patients. This study also seeks to determine the prevalence of non-compliance to medication among hypertensive patients, knowledge of patients on hypertensive and determine the factors influencing compliance to anti-hypertensive medication among hypertensive patient of Ghana Ports and Habours Authority Clinic, Tema. 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter is a brief description of the study design, study area, study population, sampling method and detailed sample size calculation, data collection, data management and analysis, ethical issues and anticipated study limitations 3.2 Study Design and Type The study was a cross sectional survey. Cross sectional design was most suitable since it employs collection of both outcome and exposure information at the same time. 3.3 Study Area The study was conducted in Ghana Ports and Harbors Authority clinic (GPHA) located in Tema in the Greater Accra Region of Ghana. .It is among the top public health facilities offering services to the people of Tema and neighboring communities. Tema is located 25kilomters east of the capital city, Accra in the greater Accra Region the capital of the Tema metropolitan district. Tema metropolis is one of the 26 districts in Greater Accra Region and a vibrant commercial and industrial city. The metropolitan shares boundaries with Ashiaman municipal, Adenta municipal district and Ledzokuku Krower municipal district to the west. To the east, with Kpone Katamanso district and to the north with Dangme west district and south with Gulf of Guinea The population of Tema metropolis was estimated at 403,934 projection from 2010 population census (GSS PHC., 2012), making it the second largest populated district in the Greater Accra Region. The estimated 2016 population of Tema Metropolis is 351,616 as 22 University of Ghana http://ugspace.ug.edu.gh projected from the 2010 Census, making it the second largest-population of the ten districts in the Greater Accra Region, after Accra Metropol.is. Tema has 25 communities. The GPHA clinic located in community 2 started operating in the year 1985 as a cargo clinic and responds to the health needs of workers and their dependents. With time, the clinic was expanded to accommodate staff of other organizations in various port departments as well as individuals who could afford services rendered by paying directly. Average daily outpatient attendance ranges from 100-150 patients. Apparently, the clinic is equipped with four trained medical doctors and a visiting cardiologist and orthopedic surgeon. The main services provided by the clinic include; outpatient services, ultrasound, cardiology, laboratory services, in-patient services, orthopedic services and management of some non-communicable illnesses of which hypertension is included. 3.4 Study Population The study population was made up patients diagnosed of hypertension and on medication for not less than six months in the GPHA clinic reporting at the outpatient department. 3.5 Inclusion Criteria The study included patients of all age diagnosed with hypertension in the GPHA clinic. These same patients were on medication for not less than six months. Also, patients on anti- hypertensive medication reporting with co-existing medical conditions like malaria, diabetes, injuries among others were included in the study. 23 University of Ghana http://ugspace.ug.edu.gh 3.6 Exclusion Criteria The study did not include patients on medication for less than six months. Also, patients who refused to consent for reasons pertinent to them were excluded from the study. Pregnant women and clients with Pregnancy Induced Hypertension (PIH) were also excluded from the study. 3.7 Sample Size Determination ―The sample size was estimated on the following assumptions;  Anticipated proportion of adherence is 58.6 % in a study conducted by (Obirikorang et al., 2018) in Ghana  Standard normal deviate (Zα) of 1.96 at 95% confidence level.  Desired precision of the estimate is plus or minus 5%=0.05 With reference to these assumptions, the sample size was calculated using the formula by Cohran (1977) Where: N= number of hypertensive to be sampled Z= Standard normal deviate (α). P= expected coverage. d= degree of precision Assuming confidence level of 95% (for α= 0.05, Z= 1.96), expected coverage (P) of 58.6% (0.586) and degree of precision ±5% (d= 0.05), the minimum number of respondents was; = = 372.76=373 Non-response rate of 5% (0.05) gives 0.05 x 373 = 18.65=19 24 University of Ghana http://ugspace.ug.edu.gh Adding 19 to the sample size (n) of 373 gives, (i.e. 19+ 373= 392) Hence, the sample size desired for the study is 392. 3.8 Sampling Methods Hypertensive clinic is held twice a week at GPHA clinic. Averagely there is 60—100 patient a day. Data was collected within 4 weeks that is 8 times in the month. A daily target of 50 patents was recruited into the study. This number was arrived by dividing 8 by the sample size of 392. Consecutive sampling method was used to select patients for interview. With reference to the inclusion and exclusion criteria, patients were approached to seek their consent to participate in the study. 3.9 Data Collection Methods and Instruments Data was composed through face-to-face interviews using an organized questionnaire. The questionnaire was in four sections. One section focused on socio-demographic features such as sex, religion, age, marital status, educational level of eligible participants, section two was based on knowledge on hypertension, and section three on compliance to medication and factors influencing compliance to anti-hypertensive medication. The Donald Morisky medication adherence scale was adopted to design question relating to anti-hypertensive adherence. This scale is an 8-item based tool coded into 1 and 0 where 1 depicts ―yes” whiles 0 depicts “no”. A score of seven and above indicate high adherence. Low adherence is a score of 6 and below. 3.10 Quality Control For data assurance and quality, data collection tools was validated through pre-testing. Pretesting was done in a hospital outside the study district. This helped avoid misinterpretation of questions and allow modification of ambiguous questions. In addition, respondents’ information was kept 25 University of Ghana http://ugspace.ug.edu.gh privately during and after data collection. Research assistants were trained for a week prior to actual data collection. At the end of each data collection session, validation of questionnaires was done and errors corrected. Questions were translated into local language or any language suitable for the participants if participant cannot read, speak or understand English language. Data was entered twice into EpiData 3.1 twice for validity. Data and data entry template was coded to prevent typographical errors during data entry. Finally, there was regular monitory by field supervisors at the hospital to ensure that, research assistance adhere to guidelines. 3.10.1 Variables Two main variables was considered in this study, thus dependent variable and independent variable. 3.10.2 Dependent Variable The dependent variable in the study was noncompliance to hypertensive treatment. This was measured using the 8-item Morisky medication adherence scale. 3.10.3 Independent Variables Independent variables in the study are; Demographic factors; Sex, Educational level, Socio-economic status. Age Religion Beliefs 26 University of Ghana http://ugspace.ug.edu.gh Waiting time for consultation Waiting time for drug refill Comorbidity Duration of condition Knowledge on hypertension Overall knowledge of respondents on hypertension was dichotomized into two levels (inadequate and adequate knowledge). A respondent was deemed to have adequate knowledge if he or she indicated that hypertension was inherited and had no cure and that antihypertensive medication control hypertension. Anything short of these was deemed as inadequate knowledge. 3.11 Data Processing and Analysis Data collected was sorted, coded and entered twice in separate computers using EpiData Version 3.1 and later exported to Stata version 15 for analysis. Descriptive analysis such as frequencies was conducted on categorical variables whiles, mean and standard deviation was conducted on continuous variables. Graphs and percentages were used to report on sociodemographic characteristics, knowledge on hypertension and proportion of participants adhering to anti- hypertensive medication. The Morisky Medication scale was used to assess adherence in that, scores was summed to create an overall adherence score with possible score range of 0-8. Scores of 6 and above were considered as high adherence whilst scores below 6 were considered as low levels of adherence. Chi square test was conducted to determine association between adherence to anti-hypertensive medication and some socio-demographic characteristics. As a way of determining the strength of association and factors influencing adherence to medication, logistic regressions, thus simple and multiple logistic regressions was used with adherence as the dependent variable. A p-value of <0.05 was considered statistically significant. 27 University of Ghana http://ugspace.ug.edu.gh 3.12 Ethical Consideration Ethical clearance was sought from the Ghana Health Service (GHS) Ethics Review Committee (ERC). Approval was sought from the medical director of the GPHA clinic. Written consent was sought from eligible participants after explaining the benefits and risks involved in participation. Also participants were made to understand that, participation is purely voluntary and can opt out at any time and this did not affect service delivery at the facility. 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents results from the analysis of the data collected. The chapter would be presented in seven sections. Section one provides a descriptive statistics of socio-demographic characteristics of respondents. Section two reports the knowledge patients have on hypertension. Sections three, four, five, six and seven report prevalence of non-compliance with antihypertensive medication among respondents, socio-demographic characteristics associated with non-compliance with antihypertensive medication, knowledge factors associated with non- compliance with antihypertensive medication, factors associated with non-compliance with antihypertensive medication, Results from multiple logistic regression of factors associated with non-compliance with antihypertensive medication. Out of a total of 392 questionnaires retrieved, 386 had clean and complete data after entry and cleaning. The results below shows the analysis of data from these 386 respondents. 29 University of Ghana http://ugspace.ug.edu.gh 4.2 Socio-demographic characteristics of respondents The minimum age of hypertensive patients in this study was 24 with a maximum age of 84. The average age of respondents was 53.4 years ± 9.3SD. Males formed 58.0% of the respondents and Christians were the majority (80.3%). Most of the hypertensive patients were married (74.3%). A majority of the respondents had senior high education or higher (64.1%), 36.7% of whom had up to senior high school and the rest (27.4%) had up to tertiary education. Nearly 40% of respondents had income level above GH ₵ 1500 per month. Most of these hypertensive patients have lived with the condition for more than three years (77.5%), 22.8% of whom have lived with the disease for more than nine years. Table 4.2 Socio-demographic characteristics of respondents (n = 386) Variables Frequency Percent (%) Gender Male 224 58.0 Female 162 42.0 Religion Christianity 310 80.3 Muslim 64 16.6 Traditional 10 2.6 Other 2 0.5 Marital status never married 35 9.1 Married 287 74.3 Divorced 26 6.7 co-habiting 10 2.6 widow/widower 28 7.3 30 University of Ghana http://ugspace.ug.edu.gh Table 4.2 contd. Socio-demographic characteristics of respondents (n = 386) Variables Frequency Percent (%) Educational level no formal education 14 3.6 Primary 18 4.7 junior high school 106 27.5 senior high school 142 36.7 Tertiary 106 27.4 Income level 100 – 500 40 10.4 501 – 1000 104 26.9 1001 – 1500 86 22.3 > 1500 156 40.4 Duration of condition 1 - 3 years 87 22.5 4 - 6 years 117 30.3 7 - 9 years 94 24.4 above 9 years 88 22.8 4.3 Knowledge of Patient on Hypertension Assessing the knowledge of patients on hypertension, responses of respondents are shown in table 4.2. About 53% indicated inheritance as the cause of hypertension whereas 50.5% cited lack of exercise as the cause of hypertension. Unhealthy diet was reported by 59.1% of the respondents as the cause of hypertension. Majority of respondents (81.1%) knew stroke as a complication of hypertension and 77% of the respondents indicated that hypertension had no cure. 31 University of Ghana http://ugspace.ug.edu.gh Upon asking respondents any knowledge they have about antihypertensive medication, 70.2% stated that ―they control BP‖ whereas 20.7% could not provide any response. Overall knowledge of respondents on hypertension was dichotomized into two levels (inadequate and adequate knowledge). Most respondents (70.5%) had inadequate knowledge as against 29.5% who had adequate knowledge. Table 4.3 Knowledge of Patient on Hypertension Variables Frequency Percent (%) Causes of hypertension Inheritance 203 52.6*** lack of exercise 195 50.5*** Aging 189 48.9*** unhealthy diet 228 59.1*** Spiritual 33 8.6*** Other 96 24.9*** don't know 31 8.0*** Complications of hypertension Stroke 313 81.1*** heart failure 242 62.7*** heart attack 239 61.9*** renal failure 198 51.3*** Cure for hypertension yes 88 22.8 No 298 77.2 Adverse effects of antihypertensive medication Yes 241 62.4 No 145 37.6 ***multiple response 32 University of Ghana http://ugspace.ug.edu.gh Table 4.3 contd. Knowledge of Patient on Hypertension Variables Frequency Percent (%) Any knowledge about hypertensive medication they control BP 200 70.2 make you better 17 5.9 good drug 5 1.8 sexual weakness 4 1.4 no response 160 20.7 Overall knowledge inadequate knowledge 272 70.5 adequate knowledge 114 29.5 ***multiple response 4.4 Prevalence of non-compliance with antihypertensive medication among respondents Out of the 386 respondents, 57.2% were non-compliant with their antihypertensive medication (p = 0.57, 95% CI = 0.52 – 0.62) with (Morisky score > 0). Figure 4.3 Proportion of non-compliance with antihypertensive medication among respondents 33 University of Ghana http://ugspace.ug.edu.gh 4.4 Socio-demographic characteristics associated with non-compliance with antihypertensive medication Table 4.4 shows results from chi-square and simple logistic regression of socio-demographic characteristics associated with non-compliance with antihypertensive medication. Age, marital status (p = 0.009), educational level (p = 0.002), income level (p = 0.003), duration of condition (p < 0.001) were found to show statistically significant association with non-compliance with antihypertensive medication among respondents. The table also shows crude-odds ratios of these associations which are further interpreted in section 4.7. Table 4.4 Socio-demographic characteristics associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Gender 0.131 Male 121(54.0) 103(46.0) 1.0 0 Female 100(61.7) 62(38.3) 1.37(0.91 – 2.07) 0.1 31 Religion + 0.117 Christianity 1 85(59.7) 125(40.3) 1.0 0 Muslim 31(48.4) 33(51.6) 0.63(0.37 – 1.09) 0.0 99 Traditional 5(50.0) 5(50.0) 0.68(0.19 – 2.38) 0.542 Other 0(0.0) 2(100.0) 1 Marital stat us 0.009* never married 26(74.3) 9 (25.7) 1.0 0 Married 150(52.3) 137(47.7) 0.38(0.17 – 0.84) 0.01 6* Divorced 17(65.4) 9(34.6) 0.65(0.22 – 1.98) 0.452 co-habiting 9(90.0) 1(10.0) 3.12(0.34 - 28.13) 0.312 widow/widower 19(67.9) 9(32.1) 0.73(0.24 – 2.19) 0.575 + (fisher’s exact) *(statistically significant, p<0.05 ) 34 University of Ghana http://ugspace.ug.edu.gh Table 4.4 contd. Socio-demographic characteristics associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Educationa l level 0.002* no formal education 12(85.7) 2(14.3) 1.0 0 Primary 14(77.8) 4(22.2) 0.58(0.09 – 3.76) 0.5 71 junior high school 65(61.3) 41(38.7) 0.26(0.06 – 1.24) 0.092 senior high school 65(45.8) 77(54.2) 0.14(0.03 – 0.65) 0.012* Tertiary 65(61.3) 41(38.7) 0.26(0.06 – 1.24) 0.092 Income leve l 0.003* 100 – 500 2 8(70.0) 1 2(30.0) 1.0 0 501 – 1000 67(64.4) 37(35.6) 0.78(0.35 – 1.70) 0.5 27 1001 – 1500 54(62.8) 32(37.2) 0.72(0.32 – 1.62) 0.430 > 1500 72(46.2) 84(53.9) 0.37(0.17 – 0.77) 0.009*” Duration of condition <0.001 1 - 3 years 6 5(74.7) 2 2(25.3) 1.0 0 4 - 6 years 72(61.5) 45(38.5) 0.54(0.29 – 0.99) 0.04 9* 7 - 9 years 41(43.6) 53(56.4) 0.26(0.14 – 0.49) <0.001* above 9 years 43(48.9) 45(51.1) 0.32(0.17 – 0.61) 0.001* Last blood p ressure check 11.5 ± 19.4 8.3 ± 20.1 1.01(0.99 – 1.02) 0.113 + (fisher’s exact) *(statistically significant, p<0.05 ) 35 University of Ghana http://ugspace.ug.edu.gh 4.5 Knowledge factors associated with non-compliance with antihypertensive medication Knowledge factors did not show any statistically significant association with antihypertensive medication. Table 4.5 Knowledge factors associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Cure for hypertension 0.734 Yes 4 9(55.7) 3 9(44.3) 1.0 0 No 172(57.7) 126(42.3) 1.09(0.67 - 1.75) 0.734 Adverse effects of antihypertensive medication 0.521 Yes 141(58.5) 100(41.5) 1.0 0 No 80(55.2) 65(44.8) 0.87(0.58 – 1.32) 0.521 Overall knowledge inadequate knowledge 159(58.5) 113(41.5) 0.461 1.00 adequate knowledge 62(54.4) 52(45.6) 0.85(0.55 – 1.32) 0.461 + (fisher’s exact) *(statistically significant, p<0.05) 36 University of Ghana http://ugspace.ug.edu.gh 4.6 Factors associated with non-compliance with antihypertensive medication Table 4.6 shows results from chi-square and simple logistic regression of factors associated with non-compliance with antihypertensive medication. However, from chi-square, the factors that showed statistically significant association with non-compliance were frequency of antihypertensive pills intake (p = 0.004), usage of traditional methods (p < 0.001), spiritual cause of hypertension (p = 0.001), subscription to other treatments (p = 0.001), side effects of antihypertensive pills (p = 0.002), waiting time for consultation (p < 0.001), waiting time for drug refill (p < 0.001). The table also shows crude-odds ratios of these associations which are further interpreted in section 4.7. Table 4.6 Factors associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Number of antihypertensive pills per day 1.9 ± 0.8 2.0 ± 0.8 0.84(0.65 - 1.08) 0.174 Condition after taking antihypertensive pills 0.072 Better 2 01(56.0) 158(44.0) 1.0 0 Worse 20(74.1) 7(25.9) 2.25(0.93 – 5.45) 0.0 73 + (fisher’s exact) *(statistically significant, p<0.05) 37 University of Ghana http://ugspace.ug.edu.gh Table 4.6 contd. Factors associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Challenges with acquisition of + antihypertensive pills 0.246 Yes 6(85.7) 1(14.3) 1.0 0 No 215(56.7) 164(43.3) 0.22(0.03 – 1.83) 0.1 61 Usage of traditional methods <0.001* Yes 34(82.9) 7 (17.1) 1.00 No 187(54.2) 158(45.8) 0.24(0.11 – 0.56) 0.00 1* Spiritual cause of hypertension 0.001* No 2 0(90.9) 2 (9.1) 1.0 0 Yes 201(55.2) 163(44.8) 8.11(1.87 – 35.20) 0.00 5* Any other condition 0.3 86 Yes 38(62.3) 2 3(37.7) 1.0 0 No 183(56.3) 142(43.7) 0.78(0.44 – 1.37) 0.3 87 Subscription to other treatments 0.001* Yes 37(80.4) 9(19.6) 1.0 0 No 184(54.1) 156(45.9) 0.29(0.13 – 0.61) 0.00 1* Side effects of antihypertensive pills 0.002* Yes 7 1(70.3) 3 0(29.7) 1.0 0 No 150(52.6) 135(47.4) 0.47(0.29 – 0.76) 0.00 2* Smoking habit 0.2 34 all the time 4(33.3) 8 (66.7) 1.0 0 Occasionally 12(57.1) 9(42.9) 2.67(0.61 – 11.70) 0.1 94 not at all 205(58.1) 148(41.9) 2.77(0.82 – 9.37) 0.101 + (fisher’s exact) *(statistically significant, p<0.05) 38 University of Ghana http://ugspace.ug.edu.gh Table 4.6 contd. Factors associated with non-compliance with antihypertensive medication 2 Variables Compliance χ cOR(95% CI) p-value Non- compliance Compliance (n = 221) (n = 165) p-value Alcoholism 0.064 all the time 9 (56.2) 7(43.8) 1.0 0 Occasionally 40(33.9) 78(66.1) 1.52(0.53 – 4.37) 0.4 41 not at all 134(53.2) 118(46.8) 0.88(0.32 – 2.45) 0.811 Waiting time for + consultation <0.001* less than 30mins 38(62.3) 23(37.7) 1.0 0 30 min - 1 hour 133(68.6) 61(31.4) 1.32(0.72 – 2.40) 0.3 65 1 - 2 hours 47(37.3) 79(62.7) 0.36(0.19 – 0.68) 0.002* more than 2 hours 3(60.0) 2(40.0) 0.91(0.14 – 5.85) 0.919 Waiting time for drug + refill <0.001* less than 30mins 1 35(69.2) 6 0(30.8) 1.0 0 30 min - 1 hour 75(44.6) 93(55.4) 0.36(0.23 – 0.55) <0.0 01* 1 - 2 hours 9(47.4) 10(52.6) 0.40(0.15 – 1.03) 0.059 more than 2 hours 2(50.0) 2(50.0) 0.44(0.06 – 3.23) 0.423‖ + (fisher’s exact) *(statistically significant, p<0.05 ) 39 University of Ghana http://ugspace.ug.edu.gh 4.7 Results from multiple logistic regression of factors associated with non-compliance with antihypertensive medication Table 4.7 shows the results from multiple logistic regression of factors (age, gender, religion, marital status, educational level, income level, duration of condition, last blood pressure check, number of antihypertensive pills per day, condition after taking antihypertensive pills, challenges with acquisition of antihypertensive pills, usage of traditional methods, spiritual cause of hypertension, subscription to other treatments, side effects of antihypertensive pills, smoking habit, waiting time for consultation, waiting time for drug refill that had p-values ≤ 0.2, in the simple logistic regression done earlier. The table shows crude-odds ratios and adjusted odds ratios of factors influencing non-compliance with antihypertensive medication among hypertensive patients. The odds of non-compliance with antihypertensive medication per a one year increase in respondents age was reduced by 2% (cOR = 0.98; 95% CI 0.96 – 0.99; p = 0.050) this association was statistically significant after adjusting for all other variables (aOR = 0.97; 95% CI = 0.93 – 0.99; p = 0.035). The odds of non-compliance with antihypertensive medication was reduced by 62% among married hypertensive patients as compared to those who had never married (cOR = 0.38; 95% CI = 0.17 – 0.84; p = 0.016). However, after adjusting for all other variables this association was no longer statistically significant. Rather, there was significantly increased odds of non-compliance among divorced (aOR = 4.98; 95% CI = 1.08 – 22.85; p = 0.039) and widowed (aOR= 5.03; 95% CI = 1.17 – 21.59; p = 0.030) respondents. 40 University of Ghana http://ugspace.ug.edu.gh Participants with senior high school education had reduced odds of non-compliance as compared to participants with no formal education (cOR = 0.14; 95% CI = 0.03 – 0.65; p = 0.012). After adjusting, this association found between educational level and non-compliance was still statistically significant (aOR = 0.07; 95% CI = 0.01 – 0.50; p = 0.008). However, the odds of non-compliance amongst participants with up to junior high school education turned out to be significantly lower than those without formal education (aOR = 0.12; 95% CI = 0.02 – 0.81; p = 0.029). Respondents with income level > GH₵ 1500 had significantly lower odds of non-compliance as compared to those with income levels between GH₵100 and GH₵ 500 (cOR= 0.37; 95% CI = 0.17 – 0.77; p = 0.009). However, after adjusting for other variables, income level was no longer significantly associated with non-compliance with antihypertensive medication (aOR = 0.88; 95% CI = 0.28 – 2.71; p = 0.819). Participants who lived with hypertension for 4-6 years had significantly 46 % reduction in their odds of non-compliance compared to participants who lived with the disease for 1 – 3 years (cOR = 0.54; 95% CI = 0.29 – 0.99; p = 0.049 ). Similarly, participants’ who lived with the disease for 7 – 9 years (cOR = 0.26; 95% CI = 0.14 – 0.49; p < 0.001) and those who lived with the disease for more than 9 years (cOR = 0.32; 95% CI = 0.17 – 0.61; p = 0.001) had significantly reduced odds of not complying with their antihypertensive medication. However, duration of condition did not show statistically significant association after well adjusting for other variables. Participants who did not use traditional methods of controlling their blood pressure had significantly 76% reduction in their odds of non-compliance as compared to those who used traditional methods of controlling their blood pressure (cOR = 0.24; 95% CI = 0.11 – 0.56; p = 41 University of Ghana http://ugspace.ug.edu.gh 0.001). However, this association did not show statistical significance after well adjusting for other variables (aOR = 0.36; 95% CI = 0.09 – 1.34; p = 0.128). Participants who did attributed spiritual cause to their hypertension had significantly 8.11 times the odds of non-compliance as compared to those who did not attribute spiritual cause to their hypertension (cOR = 8.11; 95% CI = 1.87 – 35.20; p = 0.005 ). However, this association was still statistically significant after well adjusting for other variables (aOR = 8.05; 95% CI = 1.33 – 48.57; p = 0.023). Participants who did not subscribe to alternative treatments had significantly 71% reduction in their odds of non-compliance as compared to those who subscribed to alternative treatments (cOR = 0.29; 95% CI = 0.13 – 0.61; p = 0.001). However, this association did not show statistical significance after adjusting for other variables (aOR = 0.91; 95% CI = 0.26 – 3.13; p = 0.876). Participants who indicated they had no side effects from their medication were less likely non- compliant as compared to those who indicated side effects from their medication (cOR = 0.47; 95% CI = 0.29 – 0.76; p = 0.002). However, this association did not show statistical significance after adjusting for other variables (aOR = 0.59; 95% CI = 0.31 – 1.11; p = 0.104). Waiting time for consultation, 1 – 2 hours, was significantly associated with non-compliance (cOR = 0.36; 95% CI = 0.19 – 0.68; p = 0.002). However after adjusting for all other variables, participants who waited for 30 minutes – 1 hour for consultation had significantly increased odds of not complying with their antihypertensive medications compared to those who waited less than 30 minutes (aOR = 3.26; 95% CI = 1.48 – 7.18; p = 0.003). 42 University of Ghana http://ugspace.ug.edu.gh Waiting time for drug refill, 30 minutes – 1 hour, was significantly associated with non- compliance (cOR = 0.36; 95% CI = 0.23 – 0.55; p < 0.001). However after adjusting for all other variables, participants who waited for 30 minutes – 1 hour to refill their antihypertensive medicines had significantly reduced odds of not complying with their antihypertensive medications compared to those who waited less than 30 minutes (aOR = 0.47; 95% CI = 0.25 – 0.88; p = 0.018 ). Table 4.7 Factors associated with non-compliance with antihypertensive medication Variables cOR (95 % CI) p-value aOR (95% CI ) p-value Gender Male 1.00 Female 1.37(0.91 – 2.07) 0.131 0.84(0.49 – 1.45) 0.530 Religion Christianity 1.00 Muslim 0.63(0.37 – 1.09) 0.099 0.55(0.26 – 1.14) 0.107 traditional 0.68(0.19 – 2.38) 0.542 0.36(0.07 – 1.89) 0.225 Other 1 Marital status never married 1.00 Married 0.38(0.17 – 0.84) 0.01 6* 1 .62(0.58 – 4.49) 0.354 Divorced 0.65(0.22 – 1.98) 0.452 4.98(1.08 – 22.85) 0.039* co-habiting 3.12(0.34 - 28.13) 0.312 11.59(0.82 - 163.28) 0.069 widow/widower 0.73(0.24 – 2.19) 0.575 5.03(1.17 – 21.59) 0.030* Educational level no formal education 1.00 Primary 0.58(0.09 – 3.76) 0.5 71 0 .36(0.04 – 3.12) 0.357 junior high school 0.26(0.06 – 1.24) 0.092 0.12(0.02 – 0.81) 0.029* senior high school 0.14(0.03 – 0.65) 0.012* 0.07(0.01 – 0.50) 0.008* Tertiary 0.26(0.06 – 1.24) 0.092 0.17(0.02 - 1.20) 0.076 *(statistically significant, p<0.05) 43 University of Ghana http://ugspace.ug.edu.gh Table 4.7 contd. Factors associated with non-compliance with antihypertensive medication Variables cOR (95 % CI) p-value aOR (95% CI ) p-value Income level 100 – 500 1.00 501 – 1000 0.78(0.35 – 1.70) 0.5 27 1.42(0.51 – 3.96) 0.502 1001 – 1500 0.72(0.32 – 1.62) 0.430 2.91(0.97 – 8.77) 0.057 > 1500 0.37(0.17 – 0.77) 0.009* 0.88(0.28 – 2.71) 0.819 Duration of condition 1 - 3 years 1.00 4 - 6 years 0.54(0.29 – 0.99) 0.04 9* 0.77 (0.37 – 1.62) 0.492 7 - 9 years 0.26(0.14 – 0.49) <0.001* 0.44(0.19 – 1.00) 0.051 above 9 years 0.32(0.17 – 0.61) 0.001* 0.66(0.28 – 1.55) 0.338 Last blood pressure check 1.01(0.99 – 1.02) 0.113 1.00(0.99 - 1.02) 0.620 Number of antihypertensive pills per day 0.84(0.65 - 1.08) 0.174 0.90(0.65 - 1.25) 0.535 Condition after taking antihypertensive pills Better 1.00 Worse 2.25(0.93 – 5.45) 0.073 1.91(0.66 – 5.55) 0.235 Challenges with acquisition of antihypertensive pills Yes 1.00 No 0.22(0.03 – 1.83) 0.161 0.11(0.01 – 1.31) 0.082 Usage of traditional methods Yes 1.00 No 0.24(0.11 – 0.56) 0.001* 0 .36(0.09 – 1.34) 0.128 *(statistically significant, p<0.05) 44 University of Ghana http://ugspace.ug.edu.gh Table 4.7 contd. Factors associated with non-compliance with antihypertensive medication Variables cOR (95 % CI) p-value aOR (95% CI ) p-value Spiritual cause of hypertension Yes 1.00 No 8.11(1.87 – 35.20) 0.005* 8.05(1.33 – 48.57) 0.023* Subscription to other treatments Yes 1.00 No 0.29(0.13 – 0.61) 0.001* 0 .91(0.26 - 3.13) 0.876 Side effects of antihypertensive pills Yes 1.00 No 0.47(0.29 – 0.76) 0.002* 0 .59(0.31 – 1.11) 0.104 Smoking habit all the time 1.00 Occasionally 2.67(0.61 – 11.70) 0.194 1.71(0.27 – 10.96) 0.572 not at all 2.77(0.82 – 9.37) 0.101 1.91(0.40 – 9.07) 0.416 Waiting time for consultation less than 30 minutes 1.00 30 minutes - 1 hour 1.32(0.72 – 2.40) 0.365 3 .26(1.48 – 7.18) 0.003* 1 - 2 hours 0.36(0.19 – 0.68) 0.002* 1.91(0.72 – 5.04) 0.191 more than 2 hours 0.91(0.14 – 5.85) 0.919 1.19(0.14 – 10.19) 0.876 Waiting time for drug refill less than 30 minutes 1.00 30 min - 1 hour 0.36(0.23 – 0.55) <0.001* 0 .47(0.25 – 0.88) 0.018* 1 - 2 hours 0.40(0.15 – 1.03) 0.059 0.64(0.21 – 1.93) 0.433 more than 2 hours 0.44(0.06 – 3.23) 0.423 0.21(0.01 – 3.34) 0.270‖ *(statistically significant, p<0.05) 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION Prevalence of Non-adherence to anti-hypertensive This study identified more than half of respondents not complying with antihypertensive medications. This was higher than what was reported in the United Arab States which showed non-adherence to antihypertensive medication to be 45% (Bader et al., 2015), among Palestinian hypertensive patients with non-adherence of 45.8% (Al-Ramahi, 2015) and Vietnam, with non- adherence to be 50.2% (Nguyen, Schulling-Veninga, Nguyen, Vu, Wright & Postma, 2017). These findings including what was reported in this study were contrary to non-adherence prevalence reported in Mekelle General Hospital (MGH) where medication non-adherence stands at 26.4% (Ali, Bekele & Teklay, 2014) and 38.2% Ethiopia (Asgedom, Atey & Desse, 2018). In some communities in Ghana, four in ten adults have hypertension and one of four adults have pre-hypertension (Incoom, 2017). Prevalence of hypertension in Ghana stands at 13% and high among females compared to males (Sanuade, Boatemaa, & Kushitor, 2018). Simultaneously, prevalence of the disease practically is rising in some African countries due to uncontrolled high population , weakness in the health delivery and poor health seeking behaviors among them (Hospital, Shoa, Demisew, & Mahmud, 2018). It is imperative to ensure that patient adhere to antihypertensive treatment in preventing complications arising from hypertension. Adherence as reported is a major indicator in the management of hypertension in relation to quality life and complications (Hashmi et al., 2007). Some studies have identified much higher levels of non- adherence compared to what was stated in this study. In a rural area of the Ardabil city, studies 46 University of Ghana http://ugspace.ug.edu.gh have revealed that, 76% of the patients were not adherent to the medication (Kamran, Sadeghieh, Biria, Malepour & Heydari, 2014). In addition, in a cross sectional study conducted by Aligarh which showed that, prevalence of antihypertensive non-compliance to be 76.3% (Khwaja, Ansari & Mehnaz, 2017) and 67.7% in Cameroon (Adidja, Agbor, Aminde, Ngwasin, Ngu & Aminde, 2018). The high non-adherence as identified in this study could be explained by the low knowledge of the patients on hypertension in this study. Patients lack enough knowledge on understanding the disease and its therapy. The non-adherence could also be driven by forgetfulness to take medication, inadequate funds to buy medication and possible side effects of the drugs. Prevalence of Non-Compliance as Far as Age and Gender Are Concerned From the study, females are more likely to be non-compliant than males, reflecting in 54% non- compliance for males and 61.7% noncompliance for females. This finding is still valid when one considers the levels of compliance instead of non-compliance (46% for males and 38.3% for females). The phenomenon is that the ages of these are quite advanced and it is ideally expected that they would be able to avail time for their health (Labonte., 2004). The findings also suggest that those in the non-compliant group are younger (52.6 ) years as against (54. ) years for those who are compliant. Knowledge of patients on hypertension Control of high blood pressure remain an entrenched global health challenge particularly in African Regions. Although efficacious and effective preventive and control measures are readily available, patients do not adhere to medications (Jimmy & Jose, 2011). Knowledge on the 47 University of Ghana http://ugspace.ug.edu.gh disease is key in one, adhering to medication and secondly ensure effective management. This study identify high inadequate knowledge among hypertensive patients at the Ghana Ports and Harbour Clinic. About half of the patients (50.5%) actually know lack of exercise and unhealthy diet to be predisposes of hypertension. Consistent findings were observed in Cape Coast, Ghana where poor knowledge level on the causes, signs and symptoms, risk factors, prevention and treatment of hypertension was reported (Anowie & Darkwa, 2015). This finding is also consistent with the study conducted among the hypertensive patients in Bharatpur. In that study, it was reported that, more than half of the patients did not know that antihypertensive medications may sometime cause hypotension. Kisokanth et al., (2016) also reported low knowledge in their study where less than half of the patients know that increased consumption of fruits and vegetables would improve control of hypertension. Contrary findings were however reported by Shrestha et al., (2016) where most patients are aware that excessive salt intake (93.0%) and alcohol (90.5%) and being overweight heavily contribute to the development of hypertension. Plausible reason contributing to the low knowledge on hypertension could be due to the low adherence to antihypertensive treatment reported in this study. Similarly, most of the patients are living with the disease for 4-6 years which could indicate that most of the patient might not develop any complication which could increase their knowledge on the disease. Factors influencing non-compliance to antihypertensive Poor compliance to antihypertensive drug is the biggest obstacle in the control of high blood pressure. This study seek to determine factors responsible for the uptake of antihypertensive drugs among patients seeking health services at the Ghana Ports and Harbor Clinic. It identified marital status, level of education, spiritual cause of hypertension awareness, waiting time for 48 University of Ghana http://ugspace.ug.edu.gh consultation hours and drug refill to be major analysts of non-adherence to antihypertensive medicine. Patients who were married and widowed were more likely not to adhere to antihypertension drugs compared to patients who are single in this study. This is consistent with the study conducted in Japan (Takaki, Wang, Takigawa, & Ogino, 2007), where marital status was found to play a significant part in the managing of hemodialysis particularly medication adherence. This could imply that, married people could possibly be engaged in other activities which could take their mind of the medications. It could also be due to the fact that, married patients constitute majority in this study. Widowed patients could possibly be in emotional and psychological grip making them not to adhere to antihypertensive drugs. Patients with Junior and Senior High educations were less likely not to adhere to antihypertensive medications compared to women with no education. This is similar to what was reported by Obirikorang et al. (2018) where educational level was related with reduced odds of non-adherence to antihypertensive (Obirikorang et al., 2018). Patients with spiritual mindset as the cause of hypertension has increased odds for non-adherence compared to patients who do not. This could be attributed to the fact that, patients of this category could be Patients who believe their disease is been caused by spiritual elements are less likely to adhere to treatment. This is because; people whose understand hypertension to be caused by spiritual elements would seek spiritual remedies for the disease hence neglecting the contemporary methods. In this study, waiting time of 30 minutes to one hour and longer waiting time for drug fill have decreased odds of none-adherence to antihypertensive treatment among hypertensive patients. Although studies have not identified waiting time influencing non-adherence, Labonte and colleagues identified amount of time a patient waits to be a major factor that affects the 49 University of Ghana http://ugspace.ug.edu.gh utilization of health care services (Labonte, 2004). However, patients with 30 to one hour time for consultation were extra likely not to adhere to antihypertensive treatment. This can be attributed to the fact that, patients who wait for long could feel tired and leave health facilities. Similarly, it could also be that, patients who experience longer waiting time at the health facility will not frequently seek health services, which due to the time involve which might lead to non- adherence. These reasons directly affect waiting time at the health facility since patients have to be seen first before drug fill. This implicate varied waiting time at each point of seeking health at the hospital hence there is the need to conduct study to estimate time difference at each point of care for hypertensive patients. 50 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX FINDINGS, CONCLUSION AND RECOMMENDATION 6.1 Summary of Findings Following the analysis of the data collected from respondents it was found out that on the issue of non-compliance, females were more likely to be non-compliant than men. Nearly 58 out of a 100 of the patients are non - compliant with their antihypertensive treatment. Nearly 60% of respondents had inadequate knowledge of hypertension. Age was found to be associated with non-adherence. The odds of non-compliance with antihypertensive medication per a one year increase in respondents age was reduced by 2%. Whiles married and widowed patients have higher odds of non-adherence, JHS and SHS level educational attainment has a protective factor against non-compliance to antihypertensive medication. Attribution of spiritual elements as cause of hypertension influenced non-compliance to antihypertensive treatment. Waiting time for consultation also influence non-compliance, however, less time spent for drug fill is beneficial in compliance to antihypertensive treatment 6.2 Conclusion From the above findings, it can be concluded that majority of the respondents were non- compliant to their medication with an increased percentage in females. Inasmuch as the levels of 51 University of Ghana http://ugspace.ug.edu.gh knowledge of hypertension among respondents was low, quite a significant percentage of the respondents non-compliance was not affected by the frequencies of medication refill. Age, marital status, educational level, attribution to spiritual causes to hypertension and waiting time were significant predictors of non-adherence 6.3 Recommendations 1. There should be complete cooperation between all the health authorities in the country to encourage patient education on hypertension and counseling on treatment. 2. The Ghana Ports Harbours Authority Clinic should put in necessary intervention to reduce longer waiting time for patients with hypertension seeking health service at facilities 3. Hypertensive patients should be assisted by health professionals to develop measures to remind them to always take their medication. 52 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adidja, N.M., Agbor, V.N., Aminde, J.A., Ngwasin, C.A., Ngu, K.B., Aminde, L.N. (2018). Non adherence to antihypertensive pharmacotherapy in Buea, Cameroon: a cross-sectional community-based study. 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Kisokanth, G., Ilankoon, I.M.P.S., Arulanandem, K., Goonewardena, C.S.E., Sundaresan, K.T. Joseph, J. (2016). Assessment of knowledge on the disease, its complications and management strategies among hypertensive patients attending medical clinics at Teaching Hospital, Batticaloa Sri Lanka. Journal of the Postgraduate Institute of Singh, Medicine. 3:E30:111.doi: http://dx.doi.org/10.4038/jpgim.8097 55 University of Ghana http://ugspace.ug.edu.gh R.B., Suh I.L., Singh V.P., Chaithiraphan S., Laothoivorn P., Sy R.G., Babilinia N.A., Rahman A.R., Sheikh S., Tomhinson B., Sarraf Zadigan N. (2010). Hypertension and Stroke in Asia, prevalence, control, strategies in developing countries for prevention. J. Hum Hypertens. 10-11 Labonte, R. N., ed. (2004). Fatal indifference: the G8, Africa and global health. Lansdowne, South Africa : Ottawa, Canada: University of Cape Town Press ; International Research Development Centre. Lowry,K.P.,Dudley,.T.K.,Oddone,E.Z.,&Bosworth,H.B(2005). International and unintentional. nonadherence to antihypertensive medication. Annals of Pharmacotherapy, 39 (7- 8),1198-1203. Li, Y. T., Wang, H. H. X., Liu, K. Q. L., Lee, G. K. Y., Chan, W. M., Griffiths, S. M., & Chen, R. L. (2016). Medication Adherence and Blood Pressure Control Among Hypertensive Patients With Coexisting Long-Term Conditions in Primary Care Settings. Medicine, 95(20), 1–10. https://doi.org/10.1097/MD.0000000000003572 Magrini, F., Reggiani, P. (2011). Epidemiology of Hypertension in Europe. International Heart Journal. 13, 27-34 Mbouemboue, O. P., Tamanji, M. T., Gambara, R., Lokgue, Y., & Ngoufack, J. O. (2016). Determinants of therapeutic nonadherence to antihypertensive treatment : a hospital-based study on outpatients in Northern Cameroon. International Joural of Medical Science and Public Health, 5(03), 547–554. https://doi.org/10.5455/ijmsph.2016.01112015205 Miller, N. H., Hill, M., Kattke, T., & Ockene, I. (1997). The multilevel Compliance Challenge: Recommendation for a Call to Action. Circulation, 95, 1085–1090. Ministry of Health. Standard treatment guidelines. 6th ed. Accra: Yamens Press; 2010. p. 96– 122. National Heart Foundation of Australia. (2016). Guideline for the diagnosis and management of hypertension in Adults-2016. Melbourne National Heart Foundation of Australia, 2016 Myers,M.Godwin,M.,Dawes,M.,Kiss,A.,Tobe,S,&Grant,F.(2011) Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension:randomised parrel design controlled trial.British Medical Journal,342,d286- d286 doi:10.1136/bmj.d286. NICE,(2011).Hypertension Guidelines:http://guidance.nice.orgUK/CG127 Nguyen, T.B.Y., Vu, T-H., Wright, E.P., Postma, M.J. (2017) Adherence to hypertension medication: Quantitative and qualitative investigations in a rural Northern Vietnamese community. PLoS ONE 12(2): e0171203. Doi: 10.1371/journal. pone.0171203 56 University of Ghana http://ugspace.ug.edu.gh Nilsson, P.M. (2009). Adverse social factors can predict hypertension—but how? European Heart Journal. 30, 1305–1306. doi:10.1093/eurheartj/ehp131 Obirikorang, Y., Obirikorang, C., Acheampong, E., Anto, E. O., Gyamfi, D., Segbefia, S. P., … Amoah, B. (2018). Predictors of Noncompliance to Antihypertensive Therapy among Hypertensive Patients Ghana : Application of Health Belief Model. International Journal of Hypertension, 2018, 1–10. Pressman, A., Avins, A. L., Neuhaus, J., Ackerson, L., & Rudd, P. (2012). dherence to placebo and mortality in the Beta Blocker Evaluation of Survival Trial (BEST). Contemporary Clinical Trials, 33(3), 492–498. 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World Health Organisation Factsheet on Cardiovascular Disease. Geneviva, Switzerland WHO. (2013). Raised blood pressure. Global Health Observatory. Geneva. Retrieved from http://www.int/gho/ncd/risk_factors/ World Health Organization. (2009). Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. World Health Organization. (2011). Global Status Report on Noncommunicable Diseases 2010: Description of the Global Burden of NCDs, Their Risk Factors and Determinants. World Health Organization. (2013). The global brief of hypertension: WHO report on HTN. WHO. (2003). Adherence to long-term therapies. Who, 1–194. 58 University of Ghana http://ugspace.ug.edu.gh APPENDIX Appendix 1 Participant Information Sheet Title of project: Noncompliance to antihypertensive medication among hypertensive patients of Ghana Ports and Habours Authority Clinic, Tema. Principal Investigator (P.I.): Juliana Yawor Kpodo Academic Supervisor:Professor Philip Baba Adongo Study background and objectives Hypertension is defined as blood pressure reading equal to or above 140 mmHg and or diastolic blood pressure equal to or above 90 mmHg. Hypertension is one of the major public health problem which is estimated to cause about 7.5 million deaths globally on annual basis. The burden of the disease is high in Sub-Saharan Africa (SSA) with Ghana having prevalence of the condition ranging from 19% to 33% in rural areas and 25.5% to 48% in urban areas. Hypertension poses serious health problems on sufferers including heart attack, heat failure and stroke if left uncontrolled. Though there are effective interventions to manage the disease, compliance to the therapeutic management of the disease among hypertensive patients remain unsatisfactory. Non-compliance to medication is a huge burden to the world’s health care system. This unfortunate practice is widespread particularly in the management of chronic non- communicable diseases such as hypertension leading to poor health outcomes and huge medical spending on drug related morbidity. Hence this study is to help the researcher determine factors associated with non-compliance to antihypertensive among hypertensive patients among Ghana’s Port and Habour Clinic workers as this group of people stand as one of the vulnerable to hypertension. Objectives: 1. To determine the prevalence of non-compliance to medication among hypertensive. patients 2. To assess level of knowledge of patients on hypertension. 3. To assess factors influencing compliance to anti-hypertensive medication. Participation You will be required to give us an information with regards to questions in the questionnaire. The questions basically are to help the researcher elicit factors associated with compliance to antihypertensive drugs among hypertensive patients Potential Risk and Benefits Risks No risk is anticipated to occur to participants. The time of participant may be the only resource that may be taken. Benefits Determining the prevalence of non-compliance and identification of risk factors facilitating non- adherence will help address all adverse reactions associated with antihypertensive drugs among patient’s. This will go a long way to reduce non-compliance to antihypertensive drugs among patients which also will reduce the burdens associated with hypertension among people living with the condition. Confidentiality 59 University of Ghana http://ugspace.ug.edu.gh For confidentiality, participant’s names will not be taken in this study. Participants will be given privacy to go through the questionnaire. All information provided by participant will be kept confidentially from access by an external individual except for the researcher and his supervisor Willingness/voluntariness Participation in the study is solely voluntary. The participant has the right to participate and withdraw from the study at any time without coaxing. Compensation No form of compensation will be awarded to a participant for participating in the study. How to get information about the study? For further information, /clarification, contact: 1. Name of (P.I): Juliana Yawor Kpodo Tel 0242218820 Email:jaynthc@yahoo.com 2. Name of (Principal Supervisor): Prof. Philip Baba Adongo Tel 0244806015 Email: adongophilip@yahoo.com For Further Information On Ethical Issues 3. Name (Administrator of the Research Ethics Committee): Hannah Frimpong Tel +233 302681109, 0243235225, 0507041223 Email: Hannah.Frimpong@ghsmail.org 60 University of Ghana http://ugspace.ug.edu.gh Appendix 2 Consent Form "I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactory explained to me in a Language I understand (………………). I fully understood the contents and any potential implications as my right to change my mind (i.e. withdraw from the research) even after I have signed this form". I voluntarily agree to be part of this research. Name or Initials of Participant…………………………………………ID Code………………… Participant’ Signature/Thumbprint…………………… Date……………………….. INTERPRETERS’ STATEMENT (where applicable) I interpreted the purpose and contents of the Participants’ Information Sheet to the afore named participant to the best of my ability in the (………………………) language of his/her proper understanding. All questions appropriate clarification sort by the participant and answers were duly interpreted to his/her satisfaction. Name of Interpreter…………………………………….. Signature of Interpreter…………………………… Date…………………………. Contact Details: 61 University of Ghana http://ugspace.ug.edu.gh Appendix 3 Data Collection tool Project title: Non compliance to antihypertensive medication among hypertensive patients of Ghana Ports and Habours Authority clinic, Tema. Questionnaire Code: ………… Date of interview ……………………… Session 1: Bio-Data of Patients 1. Age of patient (in years) …………………………. 2. Gender 1. Male 2. Female 3. Religion 1. Christian 2. Muslim 3. Traditional 4. Other, Specify 4. Marital Status 1. Never married 2. Married 3. Divorced 4. Co-habiting 5. Widow/widower 6. Level of education 1. No formal education 2. Primary 3. JHS/Middle school 4. SHS/Technical 5. Tertiary 7. Level of income (GH 1. 100-500 Cedi) 2. 501-1000 3. 1001-1500 4. > 1500 8. Duration of condition 1. 1-3 years 2. 4-6 years 3. 7-9 years 4. Above 9years 9. When last was your blood pressure (BP) checked? (Days) …………………………. Session 2: Knowledge of Patient on Hypertension 9. What do you think 1. By inheritance is/are the cause(s) of 2. Lack of exercise hypertension? 3. Aging 4 . U n h e a l t h y d i e t 5. Spiritual 6. Other, specify 7. Don’t know 10. What do you think are 1. Stroke the complications of 2. Heart failure hypertension? 3. Heart attack 62 University of Ghana http://ugspace.ug.edu.gh 4. Renal failure 5. Other, specify 11. Do you think 1. Yes hypertension has a 2. No cure? 12. What do you know ………………………….. about antihypertensive ………………………….. drugs? ………………………….. 13. Do you think 1. Yes antihypertensive drugs 2. No could have adverse effects? Session 3: Factors influencing non-compliance to antihypertensive medication among BP patients 14. Number of Antihypertensive pills do you take a day? …………………………. 15. How often do you take 1. Everyday as prescribed your antihypertensive 2. Once a week pills? 3. Twice a week 4. Only when my BP rises 16. Do antihypertensive 1. Better drugs make you feel 2. Worse better or worse? If you chose better, move to QN. 18 17. If you feel worse, 1. Feel dizzy which of the following 2. Become weak conditions do you 3. More tired experience? 4. Other, specify 18. Do you have 1. Yes challenges with 2. No acquisition of If No, move to QN 20 antihypertensive pills? 19. If Yes to Q17 above, …………………………… can you specify the …………………………… challenge(s) 20. Do you consort to other 1. Yes traditional methods for 2. No BP control? If No, move to QN22 21. If Yes to QN20 above, …………………………… can you specify what …………………………… traditional method you use? 63 University of Ghana http://ugspace.ug.edu.gh 22. Do you think your BP 1. Yes condition is a spiritual 2. No disease? 27. Do you have any other 1.Yes condition eg. diabetics, kidney 2.No problems or any disease that requires you to continually take medicines? 28. Do you subscribe to other 1. Yes treatments (local herbs/prayer 2. No camp/annointing oil) to manage your BP condition? 29. Have you suffered any side 1. Yes effects of antihypertensive 2. No drugs ? If yes (29), please specify ………………………………. 30. Do you smoke? 1. All the time ? 2. Occasionally 3. not at all 64 University of Ghana http://ugspace.ug.edu.gh 31. Do you drink alcohol? 1. All the time 2. Occasionally 3. not at all 32. How much time do you 1. less than 30 mins spend waiting at the hospital 2. 30min- 1hr for BP consultation? 3. 1-2 hrs 4. more than 2hrs 33. How much time do you 1. less than 30 mins spend waiting at the hospital 2. 30min- 1hr for BP drug refill at the 3. 1-2 hrs pharmacy? 4. more than 2hrs Morisky 8-item Medication Adherence Questionnaire Patient Answer Question (Yes/No) 1. Do you sometimes forget to 1. Yes take your medicine? 0. No 2. . People sometimes miss taking their medicines for 1. Yes reasons other than forgetting. Thinking over the past two 0. No weeks, were there any days when you did not take your medicine? 3. Have you ever cut back or stopped taking your medicine 1.Yes without telling your doctor because you felt worse when 0.No you took it? 4. When you travelled or leave home, do you sometimes 1.Yes forget to bring along your medicine? 0.NO 5. Did you take all your medicines yesterday? 0.Yes 1.No 65 University of Ghana http://ugspace.ug.edu.gh 6. When you feel like your symptoms are under control, 1. Yes do you sometimes stop taking your medicine? 0. No 7. Taking medicine everyday is a real inconvenience for some 1.Yes people. Do you ever feel 0. No hassled about sticking to your treatment plan? 8. How often do you have 1. Never/rarely difficulty remembering to take 2. Once in a while all your medicine? 3. Sometimes 4. Usually (1= 0, 2-5 = 1) 5. All the time Score: >2 = low adherence 1 or 2 = medium adherence 0 = high adherence Donald E. Morisky, ScD, ScM, MSPH, Professor, Department of Community Health Sciences, UCLA School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA 90095-1772, dmorisky@ucla.edu Thank you for your time! Name of interviewer:…………………………………… 66 University of Ghana http://ugspace.ug.edu.gh Appendix 4 Ethical Clearance 67 University of Ghana http://ugspace.ug.edu.gh Appendix 5 Introductory letter 68