Academic journal article Bulletin of the World Health Organization

Compliance with Medication among Outpatients with Uncontrolled Hypertension in the Seychelles

Academic journal article Bulletin of the World Health Organization

Compliance with Medication among Outpatients with Uncontrolled Hypertension in the Seychelles

Article excerpt

Introduction

Treatment of hypertension has been shown to reduce cardiovascular morbidity and mortality[1, 2]. Uncontrolled hypertension has been attributed to patients' failure to follow properly a prescribed drug regimen in approximately half the cases[3, 4], thus reducing both the effectiveness and the cost-effectiveness of treatment[5] and leading to avoidable hospitalization[6] and increased rates of coronary events[7]. Compliance with treatment is therefore important since hypertensive patients are often asymptomatic and medication is required over a long period. Few studies have examined compliance with antihypertensive treatment in developing countries, although the appropriate management of hypertension is an economically affordable means to control cardiovascular diseases in countries with limited resources[8], where hypertension is becoming a major health problem[9-11]. Currently, in the adult population of the Seychelles (Indian Ocean) the prevalence of high blood pressure is 32%; one third of hypertensives are receiving medication and only half of these have their blood pressure under control [11, 12]. To investigate the extent of compliance among patients with medically treated hypertension we chose riboflavin (vitamin B2), a natural and nonteratogenic constituent of the diet[13], as a marker and relatively accurate indicator of compliance [14-17].

Patients and methods

The study was carried out towards the end of 1993 with the patients of ten doctors in 7 general outpatient clinics, out of the 15 which provide ambulatory medical care in the Seychelles. Participation was solicited and obtained from 223 consecutive patients with uncontrolled hypertension, none of whom was taking vitamin supplement preparations. Uncontrolled hypertension was defined as a diastolic blood pressure [greater than or equal to] 90 mmHg despite medication. Patients with a diastolic blood pressure > 115 mmHg required immediate and intensive treatment, and for this reason were not included in the study. The protocol was approved by the Ministry of Health of the Seychelles. Medical consultation and medication were free of charge, as for all inhabitants of the Seychelles. At the time of the first visit (No. 1), the study patients received riboflavin to be taken once every morning (1 tablet of 10 mg, Hanseler AG, Herisau, Switzerland), in addition to their usual antihypertensive medication. All participants received their medication at the pharmacy of the primary health care centre, as usual. Data about clinical characteristics, socio-demographic features, degree of literacy, health habits, history of hypertension, and duration of antihypertensive treatment were obtained by interview. Literacy was evaluated by the ability to read a local newspaper in at least one of the three national languages. Study patients were invited for a follow-up visit (No. 2) after an arbitrary period of 21[+ or -]3 days. Patients were not informed that a special procedure (urinary examination) was to be performed on visit No. 2.

At the time of visit No. 2, the blood pressure was measured and patients were asked about the number of antihypertensive pills taken daily, which was compared with the treatment prescribed by the doctor. Results were "concordant" when the daily number of pills prescribed and taken were similar, or else "non-concordant". Compliance with medication was estimated by testing for the presence of metabolites of riboflavin in the urine, which was collected at the time of visit No. 2. This test was carried out by the treating doctors, after special training using an UV light source according to the method described by Jones[18]. Patients were excluded from the study if visit No. 2 was not within the 21[+ or -]3-day period or not between 9 a.m. and 2 p.m. or if they were hospitalized in the interval, or had made an extra visit and had the treatment changed. Rates of compliance within categories of variables were compared using the chi-squared and trend tests. …

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