DETERMINANTS OF ADHERENCE TO TREATMENT AND NUTRITIONAL COUNSELLING AMONG HYPERTENSIVE PATIENTS IN A SECONDARY HEALTH FACILITY IN SOUTH-WESTERN

Abodunrin Olugbemiga L 1 , Ojo Olufemi R 2 , Onifade Bolatito T 2 and Ojofeitimi Ebenezer O 1 . 1. Department of Community Medicine, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso. 2. State Specialist Hospital, Asubiaro, Osogbo, Osun state. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (7), 895-905 896 Introduction:-Hypertension, a leading cause of mortality and the third largest cause of disability is poorly controlled worldwide. It is estimated that almost one half of patients drop out entirely from treatment within one year and the failure to control hypertension takes an unacceptable hold on patients and their families (Akinkugbe, 1996).
Nigeria is experiencing urbanization and modernization which causes changes in diet and physical activities particularly in the cities. Like many other developing countries as a result of increased longevity and improvement in the standard of living as well as the influence of the western lifestyle such as cigarette smoking and alcohol consumption, hypertension has assumed a major public health dilemma. As a result, risk factors for hypertension such as sedentary lifestyle, obesity, consumption of fatty food and resultant dyslipidemia are highly prevalent sometimes in epidemic proportion (Bovet et al 2008, WHO 2003.
A major factor accounting for inadequate treatment of hypertension is poor adherence to both drugs treatment and nutritional diet as instructed by the physicians.
The nutritional transition, which is accompanied by equal rapid changes in levels of physical activity sedentary occupations, increased use of labour-saving devices at work and home is on the increase. This brings about changes in income profiles and body composition which in most cases leads to obesity (Barry and Pelletier, 2001;F.A.O., 2001). The role of nutrition in disease control is undeniable and diet is one of the most effective non pharmacological strategies and studies evidenced that healthy nutrition has beneficial effects on cardio metabolic parameters, but behaviour change and maintenance are not easy because the greatest responsibility in dietary adherence is on the patients. Poor adherence nutrition is especially common when a patient has poor knowledge, understanding and perception of his/her health condition or when a complex or/and expensive anti-hypertensive drug regime is prescribed sometimes also with unusual side effects.
It is usual to consider patients to be sufficiently compliant with their treatment when they take at least 80% of their prescribed anti-hypertensive drugs. In outpatients, adherence to anti-hypertensive medication ranges from 20% to 80% (Martin U andNwankwo 1990, Crammer J. A. 1998). However, a review of World Health Organization, 2002, found that in developed countries adherence to long term therapies including hypertensive therapy in the population is around 50% and is as lower in low income countries including Nigeria.
Adopting unhealthy lifestyle and non-adherence with prescribed dietary habit is associated with uncontrolled hypertension as well as the risks of developing complications (Campell et al 2006). Adherence with hypertensive to medication and dietary life style has been shown to reduce the risk of stroke and coronary heart disease by estimate of a 42% and 31% respectively, (Law et al 2003). Studies also revealed that nutritional therapy improves life expectancy and quality of life.
It was revealed that two-thirds of patient who died from stroke had a history of hypertension. It is suggested that prevention of stroke in these populations should include control of high blood pressure where an adherence to quality hypertensive therapy is important ( Little has been documented on the cause of poor adherence due to financial constraint, ignorance etc, therefore this study aimed to investigate the facts affecting adherence to medication and nutrition counseling among hypertensive patients in State Specialist Hospital, Osogbo.
The aim of this study is to assess the factors affecting adherence to medication and nutritional counseling among hypertensive patients in State Specialist Hospital, Osogbo.

Methodology:-
This descriptive cross sectional study was carried out in Osogbo Local Government Area, which is one of the 30 Local Government Areas in Osun State, South West of Nigeria. The target population was the adult patients within the age >18 years attending the hypertension clinic of the state-owned General Hospital, Asubiaro, Osogbo, Osun state. It is a secondary health facility receiving referrals from primary and comprehensive health centres within and outside Osogbo city. It is located within the heart of the city within reach of community members. It is fairly well staffed with health professionals and with modern equipment. The hypertension clinic which is a specialist clinic 897 runs once a week and patients are usually counseled on various aspects of modifiable risk factors such as diet and physical activities apart from medication prescription.
Ethical clearance was obtained from the state ministry of health and permission to carry out the study was gotten from the hospital management as well as the consultant in charge of the Hypertension clinic.
A systematic random sampling procedure was used to select the respondents using every other patient that meet up with the inclusion criteria on the clinic days. All adults within the age >18years, who consented, were interviewed through a self-developed but validated, pre-tested, semi-structured, interviewer-administered questionnaires. Patients who are too sick were excluded from the study. A minimum sample size of 310 was arrived at using the Lang, J. Stoekeid 1963 formula for population greater than 1,000 and taken into consideration a non-response rate of 10%. The questionnaires were manually sorted out and analyzed using statistical package for social sciences (SPSS) version 22 on the computer. Appropriate cross tabulations and test statistics were applied and the p-value set at p=<0.05.   Most of the respondents have the disease condition diagnosed within one year of data collection 231(65.6%). Majority 336(90.8%) of the patients were diagnosed at the hospital/health post while 20(5.4%) were first detected during religious medical outreaches (Christianity 16; 4.3% and Islam 4; 1.1%). More than half 238(64.3%) reported that they carried out some test while 132(35.7%) were not. Out of two-hundred and thirty eight that had the test including Chest X-ray, Blood and urine test etc even though some could not remember the exact name of the tests ( Table 3). As many as 68(18.4%) indicated they had another disease apart from high blood pressure. Considerable proportion 37(10.0%) of those that had other disease claimed they had Diabetes. Higher proportion 304(82.2%) of 899 the studied patients reported that they were counseled on their ailment while 66(17.8%) were not counseled. Majority 257(84.5%) of those that were counseled said they were counseled on diet and usage of their drugs, 195(64.2%) were counseled on low salt intake while 71(23.4%) were counseled about healthy lung and life style (Table 3)  Table 4 reveals that majority 295(79.7%) stated that they know hypertensive patients have a special diet while 75(20.3%) were not aware. The studied patients stated that they were counselled to be taking low salty food (207; 73.7%), low cholesterol (117; 41.6%), low refined sugar and starchy food (123; 43.8%); avoidance / reduction of alcohol (175; 62.1%) etc. However, 304(82.2%) reported that they were able to abide with their nutritional dictates out of which 121(32.7%) did so to avoid complication, 82(22.2%) felt it would contribute to controlling their blood pressure while 47(12.7%) said it was just because they cherish their health. Most of those that couldn't abide indicated that it was due to difficulty to change habits they have been used to (57; 15.4%). 900  Table 5 shows the patients' adherence to medication and clinic appointments. It reveals that just a little more than half 207(55.9%) were attending clinic appointments without skipping at all. Only 108 (29.2%) skipped the last 2 consecutive appointments with considerable proportion of them, 101(93.5%) claiming that it was due to forgetfulness attitude while 97(89.8%) said it was due to financial constraint. Moreover, majority 291(78.6%) of the studied patients were aware of the complications of hypertension with 227 of them (78.0%) of the patients mentioning stroke as the major complication of hypertension. Most of the respondents 298(80.5%) reported having their blood pressure measured regularly. About the same proportion 297 (80.3%) of those that do have regular blood pressure check-up were also the one that do take their medicine as prescribed by the health workers.  Table 6 demonstrates the relationship between socio-demographic characteristics and adherence to nutrition. It shows that there is significant relationship between age, sex, marital status, occupation, place of living, monthly income and religion in association with adherence to nutrition as there (P-value < 0.05) while the educational status and source of income were not statistically significant with (P-value >0.05).  Table 7 shows the relationship between socio-demographic characteristics and adherence to medications. It reveals that the age, marital status, educational status, occupation and place of living were statistically significant (p <0.05) while the variables sex, monthly income and religion were not statistically significant (p >0.05).  Table 8 reveals the relationship between social habit and adherence to medication as well as nutritional advice. It reveals that only the use of herbal medicine is statistically significant (p-0.038) while smoking and taking of alcohol were not statistically significant (p >0.05).  , 2006). This may explain the significant association between these variables and adherence to nutritional counseling with the age group greater than 60years having abide with their nutrition and those that are married abide with the proper nutrition than singles in this study. There was also a significant relationship between respondents' income and adherence to proper nutrition with more earning 10000 to 30000 naira abide to the proper nutrition as compared to those earning more income.

Results:-
Similar determinants of medication adherence as in most other studies were also found except that our study did not show that income is a statistically significant factor found in previous studies.

Conclusion and Recommendation:-
Based on the findings of this study there is need for launching a comprehensive approach involving health care providers, patients and the general public especially with the aim of educating patients on the need to abide with proper nutrition in the manner prescribed by the health practitioners. Health personnel should adhere to standards of providing adequate information through counselling as need be. However, majority of the respondents were aware of their disease state. Majority of the respondents were aware of special diet for hypertensive patients and the major factors affecting nutritional counseling are to avoid complication to control blood pressure and to keep fit and 905 healthy always. Those who did not adhere to nutritional counseling complained of financial constraint, national economic status. It is therefore necessary for health practitioners to intensify their health education and counselling of their hypertensive patients. The patient should know the importance of adherence with proper nutrition whether they have symptoms or not. They should take responsibility of their health and adhere to health instructions. Further studies on adherence by health insured patients should be carried out to negate the financial catastrophe that could have affected their adherence. Studies that may show importance of support group to improve adherence is necessary as in other chronic illnesses such as HIV and Tuberculosis.