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Jun 7, 2012 - Objetivos: Analisar a adesão de pacientes ao tratamento anti-hipertensivo realizado em uma Unidade Básica de Saúde (UBS), assim como.
Original Article

Factors associated with adherence to antihypertensive treatment in a primary care unit* Fatores associados à adesão ao tratamento anti-hipertensivo em unidade básica de saúde Factores asociados con la adhesión al tratamiento antihipertensivo en unidad de salud Márcia Simonia Demoner1, Edivan Rodrigo de Paula Ramos2, Eliane Ramos Pereira3 ABSTRACT

Objectives: To analyze the adherence of patients to antihypertensive treatment conducted in a Primary Care Unit (PCU), as well as the related factors of low adherence to this therapy. Methods: A quantitative, descriptive exploratory study of hypertensive patients interviewed in a PCU, using the Morisky-Green Test for assessing adherence or nonadherence with antihypertensive treatment. Results: A prevalence of 64% of patients who were nonadherent to antihypertensive therapy was identified, and this was significantly related to the variables of: age, occupation, obesity, lack of other chronic disease, lack of employment, continuous use of prescription drugs, misunderstanding of the medical recommendations, and ignorance of the name of antihypertensive medication use. Conclusion: We found a high prevalence (64%) of patients nonadherent to therapy, that was significantly associated with users who were: in the youngest age group, working, and presenting with overweight or obesity. Keywords: Patient compliance; Hypertension/therapy; Antihypertensive agents; Health education

Resumo

Objetivos: Analisar a adesão de pacientes ao tratamento anti-hipertensivo realizado em uma Unidade Básica de Saúde (UBS), assim como os fatores relacionados à baixa adesão a essa terapia. Métodos: Estudo de natureza quantitativa, exploratório descritivo com amostra de 150 pacientes hipertensos entrevistados em uma UBS, utilizando-se o Teste de Morisky-Green para avaliação da adesão ou não ao tratamento anti-hipertensivo. Resultados: Uma prevalência de 64% de pacientes não aderentes à terapia anti-hipertensiva foi identificada que esteve significativamente associada às variáveis: faixa etária, ocupação, obesidade, ausência de outra doença crônica, falta de emprego de medicamentos de uso contínuo, incompreensão das recomendações médicas e o desconhecimento do nome do medicamento anti-hipertensivo utilizado. Conclusão: Constatou-se elevada prevalência de 64% de pacientes não aderentes à terapia que, foi significativamente associada aos usuários de faixa etária mais jovem, que trabalham, com sobrepeso ou obesidade. Descritores: Cooperação do paciente; Hipertensão/terapia; Anti-hipertensivos; Educação em saúde

Resumen

Objetivos: Analizar la adhesión de pacientes al tratamiento anti-hipertensivo realizado en una Unidad Básica de Salud (UBS), así como los factores relacionados a la baja adhesión a esa terapia. Métodos: Estudio de naturaleza cuantitativa, exploratoria descritiva realizado con una muestra de 150 pacientes hipertensos entrevistados en una UBS, utilizándose el Test de Morisky-Green para la evaluación de la adhesión o no al tratamiento anti-hipertensivo. Resultados: Fue identificada una prevalencia del 64% de pacientes no adherentes a la terapia anti-hipertensiva que estuvo significativamente asociada a las variables: grupo etáreo, ocupación, obesidad, ausencia de otra enfermedad crónica, falta de empleo de medicamentos de uso contínuo, incomprensión de las recomendaciones médicas y el desconocimiento del nombre del medicamento anti-hipertensivo utilizado. Conclusión: Se constato una elevada prevalencia del 64% de pacientes no adherentes a la terapia que, fue significativamente asociada a los usuarios Del grupo estáreo más joven, que trabajan, con sobrepeso u obesidad. Descriptores: Cooperación del paciente; Hipertensión/terapia; Antihipertensivos; Educación en salud

* Study extracted from the research of conclusion of course of specialization entitled “Characterization of adherence to drug therapy of hypertensive patients in a primary health care unit” – presented to the Postgraduate Course in Clinical Pharmacology, University Center, Maringá – CESUMAR – Maringa (PR), Brazil. 1 Degree in Nursing. Specialist in Clinical Pharmacology. Universidade Maringá – CESUMAR – Maringá (PR) Brazil. 2 Master’s in Pharmaceutical Sciences. Adjunct Professor, Universidade Maringá – CESUMAR – Maringá (PR) Brazil. 3 Post-Doctorate in Nursing. State University of Rio de Janeiro – UERJ – Rio de Janeiro (RJ), Brazil; Associate Professor, School of Nursing, Universidade Federal Fluminense – UFF-Niterói (RJ) Brazil. Corresponding Author: Márcia Simonia Demoner R. Eurico Batista de Oliveira Junior, 417 – Parque da Gávea Maringá, PR – CEP: 87053-336 E-mail: [email protected]

Received article 02/11/2011 and accepted 07/06/2012

Acta Paul Enferm. 2012;25(Special Issue 1):27-34.

Demoner MS, Ramos ERP, Pereira ER

28

INTRODUCTION Systematic arterial hypertension (HTN) is considered a disease of high prevalence and low control, and its inadequate treatment can lead to coronary heart disease (CHD), acute myocardial infarction (AMI), peripheral vascular disease (PVD), stroke (CVA), congestive heart failure and renal failure. Because of these consequences, HTN is responsible for about 7.6 million deaths worldwide (1-3). Epidemiological data obtained in more than 25 countries indicate that in 2025, one billion, nine hundred seventy-two million people aged 18 to 91 years will present with HTN. However, this number may be even higher, because it is an asymptomatic disease and it is therefore under diagnosed (2,4-5). In Brazil, a third of all deaths and 65% of deaths in people aged between 30 and 69 years are due to cardiovascular diseases. As for HTN, it is estimated that approximately 17 million Brazilians have the disease (2,6-7). From 2002 to 2008, HTN had a considerable increase in its incidence, and during the year of 2008, more than 19,000 deaths occurred (8). Although HTN is considered a disease of multifactorial etiology, certain risk factors are more relevant. Among these are: age, gender, race / ethnicity, overweight and obesity, excessive intake of salt and alcohol for a long period of time, sedentary lifestyle, smoking, socioeconomic factors, education and genetics (1-6,9). Because of the high morbidity and mortality resulting from complications caused by HTN, it is necessary for the patient to have adequate control of his/her blood pressure (BP) through the use of pharmacological and non-pharmacological therapies. Non-pharmacological therapy involves changes in lifestyle that emphasize the regular practice of physical activity, weight loss, a diet low in sodium and fat, no consumption of alcohol, no smoking, and stress management. Such simple measures in healthy patients may delay the onset of this disease (10). Pharmacological therapy may be performed with a variety of classes of antihypertensive medications and their combinations. These treatment groups are represented by diuretics, drugs that reduce the activity of the renin-angiotensin-aldosterone system, direct action vasodilators, beta-blockers, and sympatholytic drugs with central and peripheral action (11). Despite the arsenal of anti-hypertensive medications, health professionals continue to encounter a serious problem: the lack of adherence to therapy, whether it is medication or another treatment (12). Adherence to treatment is complex and several factors may be associated, depending on user characteristics and the disease, cultural and life habits, medication treatment,

institutional difficulties, and also, problems related to the health care team (13). Considering that HTN is a difficult disease for adherence to treatment due to the required change in lifestyle habits and active participation of the individual in antihypertensive medication therapy (2), we consider that the knowledge about adherence and these factors and their relationships can guide facilitating actions for greater adherence (1,2). Accordingly, the present study had the objectives of analyzing the adherence of patients to antihypertensive treatment performed in a Primary Care Unit (PCU), as well as factors related to poor adherence to this therapy. METHODS This was a quantitative, exploratory and descriptive study, developed in a PCU that attended to, among others, 432 patients with hypertension, in the city of Maringá (PR), within an upper middle class neighborhood, of approximately 5753 residents. This PCU has teams of the Family Health Program (FHP) services are provided by professionals from the Support Center for Family Health. The research sample consisted of 150 patients with HTN monitored by this PCU, who were selected randomly and, after being welcomed, were invited to participate in the study. The data collection occurred in the waiting room while users were awaiting medical consultation. The study sample included individuals over 18 years of age, who had hypertension treated with medications. We considered as exclusion criteria those who did not fit these categories. The participation of the subjects was voluntary, safeguarding the ethical principles of research, maintaining the anonymity and confidentiality of the interview, if they wished. Data were collected in the period between the months of May and July, 2011. The technique of structured interview was used, through the application of two instruments. The first consisted of a structured questionnaire to characterize the sociodemographic data, information about the disease, lifestyle, and references to the health team, in addition to knowledge about medication. The second instrument was the Morisky-Green Test (TMG), used to assess the degree of adherence to antihypertensive treatment (14) based on the patient self-report, constituting an instrument with the questions: Have you ever forgotten to take your medication? Are you, at times, careless regarding the time to take your medication? When you have felt good, have you ever stopped taking your medication? Have you ever failed to take the medicine when you felt ill? (15) The first analysis of adherence to antihypertensive drug therapy, as per the TMG protocol (15), was accomplished by considering the positive (yes, 0 points) and negative (no, Acta Paul Enferm. 2012;25(Special Issue 1):27-34.

Factors associated with adherence to antihypertensive treatment in a primary care unit

1 point) responses. When interpreting this test, patients reaching a score of four were considered as adherent with the treatment, and those who presented at least one ‘yes’ for an answer were considered nonadherent. The TMG analysis classified two groups of patients: adherent and nonadherent. After statistical analysis, these were distributed in absolute frequency and percentage, according to the variables obtained in the first instrument. For the statistical data interpretation, the relationship of nonadherence to pharmacologic therapy with other data collected was examined, including those related to non-pharmacologic treatment. The influence of these variables on the frequency of distribution was analyzed using the chi-square statistic or Fisher exact test, considering a significance level of p 60 years Working Yes No Marital status Single/widowed/divorced Married Children None 1 or 2 3 or more Income < 1x minimum wage 1 – 3x minimum wage > 3x minimum wage Housing Homeowner Rented/other

Patients Adherent n (%)

Non adherentn (%)

Total

p-value

13 (27.1) 41 (40.2)

35 (72.9) 61 (59.8)

48 102

0.1456

07 (50.0) 31 (32.6) 15 (41.7) 01 (20.0)

07 (50.0) 64 (67.4) 21 (58.3) 04 (80.0)

14 95 36 05

0.4375

03 (20.0) 17 (26.6) 34 (47.9)

12 (80.0) 47 (73.4) 37 (52.1)

15 64 71

0.0143*

16 (25.4) 38 (43.7)

47 (73.6) 49 (56.3)

63 87

0.0254**

15 (31.3) 39 (38.2)

33 (68.7) 63 (61.8)

48 102

0.4680

07 (41.2) 24 (40.7) 23 (31.1)

10 (58.8) 35 (59.3) 51 (68.9)

17 59 74

0.4641

10 (40.0) 28 (34.6) 03 (27.3)

15 (60.0) 53 (65.4) 08 (72.7)

25 81 11

0.7521

35 (42.2) 19 (28.4)

48 (57.8) 48 (71.6)

83 67

0.0893

*Statistically significant (p