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      Factors Associated with Adherence to Anti-Hypertensive Treatment in Pakistan

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          Abstract

          Objectives

          Poor adherence is one of the biggest obstacles in therapeutic control of high blood pressure. The objectives of this study were (i) to measure adherence to antihypertensive therapy in a representative sample of the hypertensive Pakistani population and (ii) to investigate the factors associated with adherence in the studied population.

          Methods and Results

          A cross-sectional study was conducted on a simple random sample of 460 patients at the Aga Khan University Hospital (AKUH) and National Institute of Cardiovascular Diseases, Karachi, from September 2005–May 2006. Adherence was assessed using the Morisky Medication Adherence Scale (MMAS), with scores ranging from 0 (non-adherent) to 4 (adherent). In addition to MMAS, patient self-reports about the number of pills taken over a prescribed period were used to estimate adherence as a percentage. AKU Anxiety and Depression Scale (AKU-ADS) was incorporated to find any association between depression and adherence. At a cut-off value of 80%, 77% of the cases were adherent. Upon univariate analyses, increasing age, better awareness and increasing number of pills prescribed significantly improved adherence, while depression showed no association. Significant associations, upon multivariate analyses, included number of drugs that a patient was taking ( P<0.02) and whether he/she was taking medication regularly or only for symptomatic relief ( P<0.00001).

          Conclusions

          Similar to what has been reported worldwide, younger age, poor awareness, and symptomatic treatment adversely affected adherence to antihypertensive medication in our population. In contrast, monotherapy reduced adherence, whereas psychosocial factors such as depression showed no association. These findings may be used to identify the subset of population at risk of low adherence who should be targeted for interventions to achieve better blood pressure control and hence prevent complications.

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          Most cited references34

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          Concurrent and predictive validity of a self-reported measure of medication adherence.

          Adherence to the medical regimen continues to rank as a major clinical problem in the management of patients with essential hypertension, as in other conditions treated with drugs and life-style modification. This article reviews the psychometric properties and tests the concurrent and predictive validity of a structured four-item self-reported adherence measure (alpha reliability = 0.61), which can be easily integrated into the medical visit. Items in the scale address barriers to medication-taking and permit the health care provider to reinforce positive adherence behaviors. Data on patient adherence to the medical regimen were collected at the end of a formalized 18-month educational program. Blood pressure measurements were recorded throughout a 3-year follow-up period. Results showed the scale to demonstrate both concurrent and predictive validity with regard to blood pressure control at 2 years and 5 years, respectively. Seventy-five percent of the patients who scored high on the four-item scale at year 2 had their blood pressure under adequate control at year 5, compared with 47% under control at year 5 for those patients scoring low (P less than 0.01).
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            Helping patients follow prescribed treatment: clinical applications.

            Low adherence to prescribed medical regimens is a ubiquitous problem. Typical adherence rates are about 50% for medications and are much lower for lifestyle prescriptions and other more behaviorally demanding regimens. In addition, many patients with medical problems do not seek care or drop out of care prematurely. Although accurate measures of low adherence are lacking for many regimens, simple measures, such as directly asking patients and watching for appointment nonattendance and treatment nonresponse, will detect most problems. For short-term regimens (< or =2 weeks), adherence to medications is readily achieved by giving clear instructions. On the other hand, improving adherence to long-term regimens requires combinations of information about the regimen, counseling about the importance of adherence and how to organize medication taking, reminders about appointments and adherence, rewards and recognition for the patient's efforts to follow the regimen, and enlisting social support from family and friends. Successful interventions for long-term regimens are all labor-intensive but ultimately can be cost-effective.
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              Medication adherence: a key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients.

              Patients' adherence to antihypertensive drug regimens is a complex but important factor in achieving blood pressure control and reducing adverse cardiovascular outcomes. Approximately one half of patients with hypertension adhere to prescribed medications, and fewer than one in three patients have controlled blood pressure. Several recent studies have highlighted the importance of patient medication adherence and have outlined factors that affect patient compliance with prescribed therapy. On the basis of published studies, a conceptual framework of factors that affect patient adherence is presented. Recognizing patient nonadherence to medical therapy as a factor leading to poor blood pressure control and adverse outcomes remains a key challenge for clinicians caring for patients with hypertension.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS ONE
                plos
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2007
                14 March 2007
                : 2
                : 3
                : e280
                Affiliations
                [1 ]Medical College, Aga Khan University, Karachi, Pakistan
                [2 ]Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
                [3 ]National Institute of Cardiovascular Diseases, Karachi, Pakistan
                [4 ]Department of Family Medicine, Aga Khan University, Karachi, Pakistan
                James Cook University, Australia
                Author notes
                * To whom correspondence should be addressed. E-mail: philippe.frossard@ 123456aku.edu

                Conceived and designed the experiments: UA. Analyzed the data: UA SH. Wrote the paper: UA SH. Other: Designed and conducted the study and had equal participation: MA KA RS SH. Overall supervisor of the project, helped at all steps: PF. Was involved in study design, data analysis and review of the manuscript: MI AA DS.

                [¤a]

                Current address: Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kindgom

                [¤b]

                Current address: Department of Surgery, Yale University, New Haven, Connecticut, United States of America

                Article
                06-PONE-RA-00430R1
                10.1371/journal.pone.0000280
                1805684
                17356691
                c524f8e2-8429-4a12-8212-c63cd1fd178c
                Hashmi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                : 4 December 2006
                : 13 February 2007
                Page count
                Pages: 8
                Categories
                Research Article
                Cardiovascular Disorders
                Mental Health
                Public Health and Epidemiology
                Non-Clinical Medicine/Health Economics
                Non-Clinical Medicine/Health Policy

                Uncategorized
                Uncategorized

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