PAGE 118

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

DECEMBER 2012

Factors affecting medication adherence in patients with hypertension

Papatya Karakurt, RN, PhD, and Ma gret Kas ikc i, RN, PhD
The aim of this study descriptive study was to evaluate concordance with medication and those factors that affect the use of medicine in patients with hypertension. Data were collected using a questionnaire completed by 750 patients with hypertension between December 25, 2003, and April 30, 2004, in an outpatient hypertension clinic in Erzincan, Turkey. It was found that 57.9% of the patients did not use their medicines as prescribed. Forgetfulness, aloneness, and negligence were ranked as the top three reasons for this non-concordance, accounting for almost half (49.3%) of all patients with hypertension studied; price (expensive medicines) accounted for another quarter (26.5%). A statistically signicant relationship with non-concordance was found for age, education level and profession. Patients lack of knowledge related to the complications of hypertension was also found to have a statistically signicant relationship with not taking medicines as prescribed. Gender, location of residence and salary were not found to be statistically related to concordance. These results indicate the need to educate patients with hypertension on how to use their medicine regularly and indicate also the target populations for this. (J Vasc Nurs 2012;30:118-126)

Hypertension is the most common cardiovascular disease in the world. It affects a major portion of the adult population, raising morbidity and mortality rates in both developed and developing countries. The World Health Organization (WHO) records oneeighth of all deaths as being caused by hypertension and hypertension, which ranks it third as a cause of mortality worldwide.1,2 Although the prevalence of hypertension in the adult population as a whole averages 10% 20%, in people aged 50 or older this gure rises to 40% 50%.3 Recent studies have demonstrated that the prevalence of hypertension in Europe is 60% higher than that of the United States and Canada.4,5 As for Turkey, the prevalence of hypertension in the population over 40 years of age ranges between 20% and 38%, according to region.3 Based on the average of the 3 blood pressure measurements, hypertension was dened in this study as systolic blood pressure $140 mm Hg and/or diastolic blood pressure $ 90 mm Hg and/ or current antihypertensive medication use as reported on the baseline study questionnaire.6 The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines are evidence-based recommendations that integrate epidemiological and clinical trial evidence about the health benets associated with antihypertensive therapies into patient management decisions.4 The most recent JNC guidelines (JNC7) recommend maintaining a target blood pressure (BP) of < 140/90 mm Hg in patients with hypertension to reduce heart disease risk.7
From the Erzincan University School of Health, Erzincan, Turkey; Atat urk University, Faculty of Health Sciences, Fundamentals of Nursing Department, Erzurum, Turkey. Corresponding author: Papatya Karakurt, RN, PhD, Assistant Professor, Erzincan University School of Health, 24100 Erzincan, Turkey (E-mail: papatyademirci@hotmail.com). 1062-0303/$36.00 Copyright 2012 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2012.04.002

It may rst be useful rst to briey discuss the terminology used with medicine taking. This concept has undergone three key changes over the last few decades, recognized terminologically in the names "compliance", "adherence," and "concordance." Compliance is traditionally assumed to refer to doctors desire for patients to comply with their instructions about taking medicine. Adherence refers to the range of behaviors (regarding medication dosing or compliance with dietary recommendations) shown by an individual in response to medical advice or any health advice. The term adherence is now preferred over the earlier term compliance because it recognizes patient choice, as opposed to passive obedience to the physician. An even better term, however, is concordance, which implies a negotiated agreement between patient and physician or other healthcare professionals, and therefore implies patient involvement in the treatment process.8-10 Hypertension is one of the leading health problems among adult populations both in terms of its frequency and complications.11-13 Many factors may affect adherence to medication in patients with hypertension. One such factor is the number of medicines used to treat hypertension and other chronic illnesses, such as chronic obstructive pulmonary disease (COPD), diabetes, osteoarthritis and osteoporosis. Hypertension and those comorbidities are likely to increase the number of medicines an individual requires, thus increasing the risk of nonconcordance with treatment.12-14 Despite the many complications, hypertension is not given due attention as a health problem, neither by physicians nor by nurses or patients.3 Although diagnosis and treatment of hypertension are easy, it is not, in fact, treated very effectively. The primary reason for that may be that hypertension is asymptomatic and it may not show complications for a long time. It may also stem from patients nonconcordance with their medication and nonpharmacological therapies, such as diet and exercise.13,15 The low service utilization could also be one reason for a generally low public awareness of hypertension.16 The majority of patients with hypertension, especially those living in rural areas, are unaware of their hypertensive condition and do not seek treatment.3 Unfortunately, in Erzincan, in eastern Turkey, the location for this

Vol. XXX No. 4

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

PAGE 119

study, there have not been any common hypertension awareness programs. Patients tend to become aware of their hypertensive condition only after they have an examination in a health center, which they may only undergo when impelled to by another health problem (related or otherwise). This may be another reason for why hypertension is not treated effectively. Hypertension is not the only disease that can be present for a long time without symptoms. For example, type 2 diabetes is also often latent and may in fact be the cause of or associated with hypertension (metabolic syndrome).13,16 It has been estimated that about 40% 60% of patients with hypertension are estimated to fail to adhere to the prescribed treatment.7 Previous research showed that 50% of patients with hypertension stop their medication during a 12-month surveillance period and another 30% of patients underuse and accumulate their medicines.17 A worldwide assessment by WHO has suggested that countries show a great variety with respect to their capacity for treating hypertension. The Association of Diastolic Blood Pressure with Stroke and with Coronary Heart Disease was involved in a major investigation that included nine major prospective observational studies. A total 420,000 subjects in 167 countries were followed up for 6 25 (mean 10) years.18,19 Some 61% of the countries scanned did not have a national hypertension guide available, and in 45% of the countries studied, physicians were not trained for hypertension treatment. In 25%, antihypertensive medicines were deemed expensive, and in 8% 12%, necessary medicines were not available at primary healthcare centers.19 A good relationship among the physician, nurse and patient is essential for patient medicine concordance.13 Patients with hypertension should have the necessary knowledge for their care, be able to dene hypertension, evaluate risk factors and appreciate the signicance of lifelong medical control.12,13 A nurse expects her patients to use the prescribed medicine, recognize the name of the drug, know about dosing, frequency, and probable side effects and their minimization.13,20 The best way to evaluate concordance in patients with hypertension would be long-term observation. It is, however, difcult to evaluate concordance in the case of hypertension because patients live at home and treatment is part of their daily life.21 The aim of medicine therapy is to decrease the hypertensionrelated morbidity and mortality as much as possible without reducing the quality of life. Blood pressure values targeted may vary from one patient to another.14 Medicine therapy should be individualized, and factors such as age, race, history of hypertension and target organ risks should be taken into account.22 Side effects and comorbid diseases should also be kept in mind.17 Nurses should follow up the patients to learn whether they are complying with the treatment plan, or not.3

Sample
For this study, convenience sampling was employed.23 Patients were recruited from the outpatient hypertension clinic of Erzincan State Hospital, Turkey. Outpatient clinic records were examined, and it was found that a total of 882 patients with hypertension had been followed up in this center in the year 2003. Because the number of patients for the year 2004 was unclear, the 2003 data were accepted as the universe of the study, and 85% of this gure included in the study as the sample group. The inclusion criteria were:

 Diagnosis of hypertension for at least 1 year (prior to the study),  Receipt of a specied (antihypertensive) medicine for at least 6 months,  Volunteering to give verbal communication and cooperation.
In total, 750 patients with hypertension and meeting the criteria were thus involved in the study. Those people were asked to complete the questionnaire during their outpatient appointment, the data being collected between December 25, 2003 and April 30, 2004.

Data collection
A questionnaire form was used for collection of the data. Data were collected by using face-to-face interview technique. Literate patients were informed about the questionnaire, and they were asked to complete it. For illiterate patients, the content of the questionnaire was read out and the form was completed according to the patient reports by the researcher. The interviews lasted 5 10 minutes on average.

Instruments
Questionnaire. The questionnaire used in this study was developed by the researcher especially for this study with questions constructed by investigators because no local scales existed to address medication use for hypertension. It was based on an analysis of the relevant literature and consisted of a total of 15 items: 6 items were related to the sociodemographic characteristics of the patients (age, gender, educational status, occupation, location of residence, and monthly income); 7 items concerned hypertensive prole (duration of disease, subjects knowledge of the existence of a special diet, exercise of the diet, awareness of complications of hypertension, attendance of follow-up visits, regular blood pressure measurement, and comorbid diseases); and 2 items aimed to determine medication status and the factors affecting it (adherence, and reasons for non-adherence, listed viz. forgetfulness/aloneness/negligence, poverty, old age/inactivity, dislike of medicine, transportation difculties, disturbance and failure to use multiple medicines together). The items about sociodemographic characteristics of the patients, the hypertensive condition, and nature of medicine use were expressed as multiple-choice questions. The concepts of forgetfulness, aloneness, negligence were grouped together because they were expressed in the pilot study by almost all subjects. Subjects understood that forgetfulness referred to failing to

METHODS

The study
Aim. The aim of this study was to evaluate adherence with medication and those factors which affect the use of medicine in patients with hypertension.

Design
This study has a descriptive design.

PAGE 120

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

DECEMBER 2012

remember to take medicine as prescribed, aloneness referred to the subject living by herself or himself, and negligence referred to a lack of care (just not bothering about her or his medicine); disturbance, meanwhile, referred to (real or perceived) side effects of the medication.

DISCUSSION
Although hypertension can often be easily treated with medicine, many patients are not aware that they have high blood pressure. It is very important that antihypertensive therapy be explained to patients with hypertension, including the name, rationale, dosage, and side effects of all medicines. Teaching patients with hypertension the importance of taking medicine as prescribed is also vital. Because they may not feel any physical symptoms of hypertension, patients may easily forget or feel that there is no need to take their medicine as prescribed. Nurses should reinforce that medicines must be taken as prescribed regardless of any absence of symptoms. Teaching patients about behavioral changes as described is also a very important task for nurses.12,27 Reviewing the demographic data (Table 1), it was found that 53.6% of the patients were aged 50 69. Although this result is consistent with Oliveria et al28 (45.1%), Mellen et al29 (39%), and M endez-Chac on et al30 (male 55.5%, female 52.4%), it is not consistent with that of Bakoglu and Yetkin31 (29.1%). In this study, 78.0% of the patients were females. Similarly, and Y ur ugen33 (67%), LahHacalioglu et al32 (50.3%), Unsar 34 35 denpera et al (59.4%), Osamor and Owumi (65.2%), and other studies36-40 have also reported higher rates of hypertension in females. After puberty, males tend to have higher BP readings. After menopause, women tend to have higher levels of BP than men of a similar age.41 After the age 50, hypertension is more prevalent in women, though the reason for that is not clear.12,13 Table 2 shows the disease-related characteristics of patients with hypertension. It was found that 43.6% of patients had been suffering from hypertension for 1 5 years. Similarly, gures for patients suffering from hypertension for 1 5 years were reported by Bakoglu and Yetkin31 (51.3%), Leung et al42 (n = 7), and Hunt et al39 (37.1%). This frequent result of 1 5 years may be associated with the fact that hypertension is an asymptomatic disease.15 In the relatively poor province of Erzincan, Turkey, the limited utilization of health services and lack of health screening might account for hypertension remaining undiagnosed or asymptomatic for a long time. By providing hypertension awareness programs, nurses can alert people about relevant risk factors for hypertension and direct them to appropriate prevention and management options. It was found that 47.3% of the study participants did not comply with their diet (Table 2). Kyngas and Lahdenpera,43 reported that 12% of patients in Finland do not comply with their diet. In another study published in the United States, the patients concordance rate with the recommended diet is 35%.29 In another study, it was shown that 10.5% of patients stated that monitoring BP as the most important factor in keeping to a diet.28 Although the present result is consistent in this respect with this of Mellen et al,29 it is not consistent with those of Kyngas and Lahdenpera,43 or Oliveria et al.28 This result may be associated with the likelihood of patients not having had adequate and balanced nutrition before the disease, that they found keeping a diet difcult, and/or that training by medical staff was insufcient. It was found that the great majority of patients (99.1%) do not know about the complications of hypertension at all (Table 2). This is not congruent with Oliveria et al28 (3.1%). To alert the population to the relevant risk factors for hypertension and direct

Ethical considerations
Written consent was obtained from the institution where the study was conducted. All patients with hypertension were informed about the purpose and benets of the study.24-26 Participants were assured that they had the right to withdraw from the study at any stage. Participant anonymity and condentiality were assured.

Data analyses
Data were analyzed using the Statistical Package for the Social Science for Windows 11.0 (SPSS Inc., Chicago, Illinois). Descriptive statistics were computed for patients characteristics. Chi-square testing was used to determine any relationships between sociodemographic characteristics and adherence, and between disease characteristics and adherence.

RESULTS
It was established that 27.2% of the patients with hypertension participating in the study were aged between 60 69 years; 78.0% were female; 45.4% were illiterate (unable to read or write); 60.8% lived in the urban areas of the province; and 66.1% had a monthly income of less than 350 YTL (New Turkish Liras) (Table 1). Table 2 shows that 43.6% of the patients had been hypertensive for 1 5 years, 94.4% knew of a special diet for hypertension, and 47.3% did not comply with their diet. According to the results of the study, it was found that 31.1% of the patients attended follow-up visits once a month (Table 2). It was found that 57.9% of the patients did not use their medicines as prescribed. The primary reasons for nonconcordance were forgetfulness/aloneness/negligence for 49.3%, high cost for 26.5%, and old age/inactivity for 16.3% (Table 3). As shown in Table 4, 33.9% of patients aged 70 79 took their medicine as prescribed, which indicated a statistically signicant difference in comparison with younger patients (P < 0.01). The difference between the groups was found to be statistically signicant (P < 0.01). It was found that 38.3% of the patients with a monthly income less than 350 YTL and 55.6% of patients with a monthly income more than 801 YTL used their medicine as prescribed, which pointed to a statistically insignicant difference between the groups (P > 0.05). As shown in Table 5, it was found that the patients suffering from hypertension for 11 years or more generally took their medicine as prescribed, and the difference between groups on this factor was insignicant (P > 0.05). In addition, 57.1% of the patients who were aware of the complications of their diseases used their medicine as prescribed. Statistical analysis revealed this to be a highly signicant difference (P < 0.001). It was identied that this difference stemmed from the group who do not know the complications of the disease.

Vol. XXX No. 4

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

PAGE 121

TABLE 1 DEMOGRAPHICS Demographics (n = 750) Age (years) Under 49 5059 6069 7079 Older than 80 Gender Female Male Educational status Illiterate Literate Primary School Graduate Secondary or High School Graduate University Graduate Occupation Housewife Retired Worker Civil servant Unemployed Others (Farmer, tradesman, etc.) Place of living Urban County Village Monthly Income Less than 350 YTL 351500 YTL 501650 YTL 651800 YTL More than 801 YTL TOTAL Number %

TABLE 2 CLINICAL CHARACTERISTICS OF THE PATIENTS Characteristics of Disease (n = 750) 160 198 204 155 33 585 165 340 112 238 49 11 569 72 11 13 8 77 456 52 242 496 188 34 23 9 750 21.3 26.4 27.2 20.7 4.4 78.0 22.0 45.4 14.9 31.7 6.5 1.5 75.9 9.6 1.4 1.7 1.1 10.3 60.8 6.9 32.3 66.1 25.1 4.5 3.1 1.2 100.0 Number %

Duration of Disease Less than 1 year 53 15 years 327 610 years 208 11 years and over 162 Whether they know there exists a special diet Yes 708 No 42 Number Exercising the diet (n = 708) Yes 373 No 335 Awareness about complications of hypertension Yes 7 No 743 Attending follow-up visits When I feel ill 183 Several times a month 68 Once a month 233 Once every 3 months 138 Once a year 128 Having blood pressure measured regularly Regular 347 Irregular 403 Comorbid diseases Yes 584 No 166
*Percentages are calculated per n = 708.

7.1 43.6 27.7 21.6 94.4 5.6 %*

52.7 47.3 0.9 99.1 24.4 9.1 31.1 18.4 17.0 46.3 53.7 77.9 22.1

them to appropriate prevention and management, the government and health professionals might conduct hypertension awareness programs. They could also organize health-screening programs. This result showing 46.3% of patients to have their blood pressures measured regularly is similar to the rate of 33.5% reported by Marshall et al,44 in Australia. This result is consistent with others in this respect. According to the proles of patients regarding the medicines they use, it was found that more than a half the patients (57.9%)

did not use their medicine as prescribed (Table 3). Among the reasons for nonconcordance, the grouping of forgetfulness, aloneness, and negligence (49.3%) took the rst place. This ratio was only 10% in the study carried out by Kyngas and Lahdenpera.43 A study conducted in United States found that 90.6% of patients were concordant with their medicine regime.28 Regarding cost, Rose et al45 found that 42% of patients reported that they were not able to nance expensive medicine. Regarding issues around multiple medicines, in a large-scale study of medication adherence among 2,325 patients with hypertension, only 39% of patients maintained therapy with one or more antihypertensive drugs throughout the 10-year follow-up period.46 Another

PAGE 122

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

DECEMBER 2012

TABLE 3 MEDICINE-TAKING CHARACTERISTICS OF PATIENTS Medicines status (n = 750) Taking medicine as prescribed Yes No Reason for not taking medicine as prescribed Forgetfulness-aloneness-ignorance Poverty Old age-inactivity Disgusted Lack of transportation possibilities Disturbance (medicine side effects) Failure to use multiple medicines together Number %

316 434

42.1 57.9

Number 370 199 122 49 48 34 23

%* 49.3 26.5 16.3 6.5 6.4 4.5 3.1

*Patients gave more than one response. The percentages are calculated per n = 845.

study conducted in Turkey showed that only 31.1% of patients were receiving pharmacological treatment.40 In a study performed in Turkey, 41.0% of individuals with high blood pressure were aware of their situation and 54.5% of these received hypertensive treatment.47This nursing diagnosis, which can also be dened as "nonconcordance to treatment and demands," can be associated primarily with a failure or inability to comprehend essential health behavior on the part of patients, and a failure in building awareness through necessary training on the part of administrators and professionals. A major reason for this failure may be that nearly half the patients were illiterate and a large proportion of the literate patients had received only elementary education. To provide concordance with medication, it may be necessary to include a family member or other relative who is able to support the patient with respect to communication, clinical inertia and attitudes toward concordance with medication. Because health behaviors and cultural beliefs may affect adaptation to disease, these factors may be another cause of nonconcordance with medicine. According to the literature, nonconcordance with medicine may be due to forgetting to take medicine, exercising long-term treatment, difculties in using multiple medicines, high medicine costs, side effects, and difculties of follow-up visits.12,14,48 Often, because patients may not feel any physical symptoms of hypertension, they may forget to take their medicine or feel that there is no need to take it regularly.12 According to the statistics of 1993, in Turkey, only 34% of patients with hypertension used their medicine as prescribed.14

Because the leading factor group preventing patients from taking their medicine as prescribed was found to be forgetfulness/aloneness/negligence, useful techniques should be established by patients to eliminate these, such as, setting an alarm clock, leaving the medicine somewhere where it is easily seen, etc., which will help them to remember. Patients should pay attention to their diets, they should be given education concerning this, and more extensive studies should be carried out. Nurses looking after the patients with hypertension should be informed about the results of the study concerning their trainer and consultant roles. Among patients with hypertension, those aged 70 and over were found to use their medicines less regularly than members of other age groups and this difference is highly signicant (33.9 % P < 0.01) (Table 4). This result is congruent with the study of Jassim Al Kahaje et al38 on older patients (36.9 %) in Bahrain. Because many elderly people suffer from more than one disease they may receive more than one medicine, sometimes up to 8 15 medicines. Further complicating that circumstance, the decline in the psychomotor abilities of patients aged 70 and over may reduce their independence and lead to difculties in concordance.49 In addition, a comorbid chronic disease or use of other medicine in addition to antihypertensive medicines may lead to difculties in using additional medicine for hypertension. A highly signicant difference was established between the educational level and taking medicine as prescribed (P < 0.01, Table 4). Oliveria et al28 found that concordance with medication rises with the level of education. This study produces similar results. Although no signicant difference is observed between the location of residence and taking medicine as prescribed, patients with hypertension living in villages seemed to take their medicine less regularly (34.0%, P > 0.05) (Table 4). A high number of patients report that medicine is expensive in the study by Rose et al.45 This result may also stem from the difculties of transportation in winter conditions for patients who live in rural areas, and because they are busier in summer. It was found that 61.7% of the patients with a monthly income of 350 YTL or more and 53.2% of the patients with a monthly income of 351 500 YTL did not use their medicine as prescribed, which pointed to a statistically insignicant difference between the groups (P > 0.05) (Table 4). Although no signicant difference was observed between monthly income and taking medicine as prescribed, the WHO survey revealed that medicines are found to be expensive in 25% of 167 countries antihypertensive.19 In this respect, it may be agreed that there is a close correlation between the health and the socioeconomic conditions of the patients. Although no signicant difference was observed between duration of hypertension and taking medicine as prescribed, it was found that the patients with a longer history of hypertension (50.6%) tended more to take their medicine as prescribed (P > 0.05; see Table 5). It was found that medication was the most important factor in high BP monitoring for 46.7% of patients.28 That the emergence of disease complications leads patients to take their medicines more regularly and the nature of the disease requires constant follow up may also be relevant here. In this study, the difference between knowing the complications and

Vol. XXX No. 4

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

PAGE 123

TABLE 4 DISTRIBUTION OF MEDICINE TAKING CHARACTERISTICS AS PRESCRIBED ACCORDING TO PATIENTS DEMOGRAPHIC CHARACTERISTICS Whether the patients taking their medicine as prescribed Yes Demographic Characteristics Age (years) Under 49 5059 6069 7079 Older than 80 TOTAL Gender Female Male TOTAL Educational status Illiterate Literate Primary school graduate Secondary or High School graduate University graduate TOTAL Place of living Urban County Village TOTAL Monthly income Below 350 YTL 351500 YTL 501650 YTL 651800 YTL Over 801 YTL TOTAL Number % Number No % TOTAL Number %

77 86 94 51 8 316

48.1 43.4 46.1 33.9 24.2 42.1

83 112 110 104 25 434 x2 = 20.643 SD = 8

51.9 56.6 53.9 66.1 75.8 57.9 P < 0.01

160 198 204 155 33 750

100.0 100.0 100.0 100.0 100.0 100.0

249 67 316

42.6 40.6 42.1

336 57.4 98 59.4 434 57.9 x2 = 0.799 SD = 2 P > 0.05 218 71 114 27 64.1 63.4 47.9 55.1

585 165 750

100.0 100.0 100.0

122 41 124 22 7 316

35.9 36.6 52.1 44.9 63.6 42.1

340 112 238 49 11 750

100.0 100.0 100.0 100.0 100.0 100.0

4 36.4 434 57.9 2 x = 20.815 SD = 8 P < 0.01 246 53.9 28 53.8 160 66.0 434 57.9 x2 = 10.7 SD = 6 P > 0.05 306 100 12 12 4 434 x2 = 13.529 SD = 8 61.7 53.2 35.3 52.2 44.4 57.9 P > 0.05

210 24 82 316

46.1 46.2 34.0 42.1

456 52 242 750

100.0 100.0 100.0 100.0

190 88 22 11 5 316

38.3 46.8 64.7 47.8 55.6 42.1

496 188 34 23 9 750

100.0 100.0 100.0 100.0 100.0 100.0

PAGE 124

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

DECEMBER 2012

TABLE 5 DISTRIBUTION OF MEDICATION CHARACTERISTICS AS PRESCRIBED ACCORDING TO THE PATIENTS CLINICAL CHARACTERISTICS Whether the patients taking their medicine as prescribed Yes Hypertensive characteristics Duration of disease Less than 1 year 15 years 610 years 11 years and longer TOTAL Awareness of complications Yes No TOTAL Frequency of follow-up visits When felt ill Several times a month Once a month Once every 3 months Once a year TOTAL Regular blood pressure control Regular Irregular TOTAL Comorbid diseases Yes No TOTAL Number % Number No % TOTAL Number %

22 126 86 82 316

41.5 38.6 41.4 50.6 42.1

31 58.5 201 61.4 122 58.6 80 49.4 434 57.9 x2 = 8.234 SD = 6 P > 0.05 3 42.9 431 65.4 434 57.9 x2 = 19.948 SD = 4 P < 0.001 108 59.1 37 54.4 126 54.1 81 58.7 82 64.1 434 57.9 x2 = 6.577 SD = 8 P > 0.05 147 42.4 287 66.7 434 57.9 x2 = 66.972 SD = 4 P < 0.001 352 60.3 82 49.4 434 57.9 x2 = 6.688 SD = 2 P < 0.05

53 327 208 162 750

100.0 100.0 100.0 100.0 100.0

4 312 316

57.1 34.6 42.1

7 743 750

100.0 100.0 100.0

75 31 107 57 46 316

40.9 45.6 45.9 41.3 35.9 42.1

183 68 233 138 128 750

100.0 100.0 100.0 100.0 100.0 100.0

200 116 316

57.6 33.3 42.1

347 403 750

100.0 100.0 100.0

232 84 316

39.7 50.6 42.1

584 166 750

100.0 100.0 100.0

taking medicine as prescribed was also found highly signicant (P < 0.001). The patients in current study showed that increases in the duration of the disease may affect concordance with medication. The complications of hypertension may increase the duration of the disease. To avoid complications, patients with hypertension should be directed to be more careful in complying with their medications. A statistically signicant difference was shown between regular BP measurement and taking medicine as prescribed

(P < 0.001; Table 5). This ratio was 57.6% in our study. This result suggests that those patients who have their BPs measured regularly tend to take their medicine as prescribed as well. In a study performed in Europe, a third of hypertensives were receiving treatment, 36.5% of these individuals were on regular medication, and 56% were aware of their situation.50 Another signicant difference established is that in comparison with patients who suffer from multiple diseases, those who do not suffer from any diseases other than hypertension take their

Vol. XXX No. 4

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

PAGE 125

medicine as prescribed (Table 5). This ratio was 50.6% in our study. This may be due to an increase in patient dislike of medicine and more frequent emergence of side effects, because comorbid diseases probably necessitate the use of more than one medicine. Complications related to hypertension such as myocardial infarction, cerebrum vascular complications, peripheral vascular disorders, and kidney failure, however, ensure that patients access their medications more effectively.

Study limitations
The results of this study can not be generalized to all patients with hypertension beyond the sample. The sample was drawn from one outpatient clinic in the eastern part of Turkey. As the nonprobability sampling method was employed, it was difcult to control for biases. Besides, the instrument used had been designed especially for this study, and outcomes were assessed by the investigator. The questionnaire used by the current study was not plotted. This study demonstrated that the majority of the patients with hypertension included in this study did not use their medicines as prescribed. Forgetfulness, aloneness and ignorance ranked rst place among reasons for nonconcordance with medication, followed by the cost of medication.

ACKNOWLEDGMENTS This study was funded by Atat urk Universitys Research Fund (BAP-2004/154). Responsibility for the project ties with Magret KARA KAS IKC I. The authors acknowledge the contributions of all patients who took part in the study, and clerical staff of the clinic where these data were gathered. REFERENCES
1. World Health Organization (WHO). Report. Reducing risks, promoting healthy life. Geneva: Switzerland: World Health Organization; 2002. 2. Capriotti T. Pharmacologic implications of the new JNC 7 blood pressure guidelines. Medsurg Nurs 2003;12(5):325-31. 3. Bilir N, C ol M, Kumbasar D, et al. Monitor Program for Chronic Diseases at First Stage I-Hypertension. Ankara: Onur Matbaaclk Ltd. S ti.;2003: 21-35. 4. Puras A, Sanchis C, Artigao LM, et al. Prevalence, awareness, treatment and control of hypertension in a Spanish population. Eur J Epidemiol 1998;14(1):31-6. 5. Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada and the United States. JAMA 2003;289(18):2363-9. 6. Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: Results from the chronic renal insufciency cohort (CRIC) study. Am J Kidney Dis 2010;55(3):441-51. 7. McGill JB. Optimal use of b-blockers in high-risk hypertension:A guide to dosing equivalence. Vasc Health Risk Manage 2010;6:363-72. 8. Pound P, Britten N, Morgan M, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med 2005;61(1):133-55.

9. Benson J, Britten N. What effects do patients feel from their antihypertensive tablets and how do they react to them? Qualitative analysis of interviews with patients. Fam Pract 2006;23(1):80-7. 10. Cortet B, Benichou O. Adherence, persistence, and concordance: do we provide optimal management to our patients with osteoporosis? Joint Bone Spine 2006;73:e1-7. 11. Bilir N. Social Signicance of and prevention from hypertension. Hypertension Bull 1992;2(4):55-8. 12. Black JM, Matassarin-Jacobs E. Luckman and Soresens Medical-Surgical Nursing a Psychopysiologic Approach. Fourth Edition. , Philadelphia: W. B. Saunders Company; 1993; 1267-1283. 13. DeMartinis JE. Client with hypertensive disorders: promoting positive outcomes. In: Black JM, Hawks JH, Keene AM, editors. Medical-Surgical Nursing. Philadelphia: W.B. Saunders Company; 2001:1379-98. 14. Turan F, Gencbay M, S onmez K, et al. Hypertension Diagnosis and Treatment Guide. Ankara: Ministry of Health Publications; 1999. 15. Akdemir N. Vascular system diseases and nursing care. In: Akdemir N, Birol L, editors. Internal Diseases and Nursing Care. Ankara: Sistem Ofset; 2004:465-82. 16. San A. In: Sa glker Y, editor. Improvement of Patient Education and Public Consciousness of Hypertension. Treatment of Hypertension in the IIIrd Millenium. Adana: Akg un Matbaas; 1999. 17. Hypertension. Diagnosis and Treatment Guide for First Stage by Republic Turkey Ministry of Health. Ankara: Ministry of Health Publications; 2002; 1-7. 18. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke and coronary disease. Part1. Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990;335:765-74. 19. Hypertension Treatment Declaration. J Hypertens 2004;3(1): 5-16. 20. Saounatsou M, Patsi O, Fasio G, et al. The inuence of the hypertensive patients education in compliance with their medication. Public Health Nurs 2001;18(6):436-42. 21. Lahdenpera TS, Kyngas HA. Compliance and its evaluation in patients with hypertension. J Clin Nurs 2000;9:826-33. 22. Arellano F, Jasso Soto ME. Treatment of systemic arterial hypertension. Arch Cardiol Mex 2002;72(1):254-61. 23. Polit DF, Beck CT. Nursing Research: Principles and Methods. 7 th ed. Philadelphia: PA: Lippincott Williams & Wilkins; 2004. 24. Babadag K. Ethics in studies on nursing. Nurs Bull 1995; 9(38):1-11. _ editor. Re25. Bayk A. Ethics in studies on nursing. In: Erefe I, search Principles, Processes and Methods in Nursing. _ Istanbul: Ofset Bask; 2002:27-48. 26. Ulusoy MF, Ucar H. Ethics of Research. 72. Ankara: Tasarm Ltd. S ti.; 2002:27-42. 27. Thompson JM, Mc Farland GK, Hirsch JE, et al. Mosbys Clinical Nursing. Third Edition. St.Louis: Mosby-Year Book; 1993. 28. Oliveria SA, Chen RS, McCarthy BD, et al. Hypertension knowledge, awareness, and attitudes in a hypertensive population. J Gen Intern Med 2005;20:219-25.

PAGE 126

JOURNAL OF VASCULAR NURSING www.jvascnurs.net

DECEMBER 2012

29. Mellen PB, Palla SH, Goff DC, et al. prevalence of nutrition and exercise counseling for patients with hypertension. J Gen Intern Med 2004;19:917-24. 30. M endez-Chac on E, Santamar a-Ulloa C, Rosero-Bixby L. Factors associated with hypertension prevalence, unawareness and treatment among Costa Rican elderly. BMC Public Health 2008;8:275. 31. Bakoglu E, Yetkin A. Assessment of patients with hypertension strength for self-care. Journal of Cumhuriyet University School of Nursing 2000;4(1):41-9. _ 32. Hacalioglu N, G uraksn A, Inand T. Hypertension prevalence and relevant factors among population aged 30 and over in the vicinity of Torul Central Local Clinic in G um us hane. Turkey Clinicals Journal of Medical Sciences 1999;19(4):200-8. 33. Unsar ST, Y ur ugen B. Establishing the lifestyle factors among essential patients with hypertension visiting Hypertension Outpatients Clinic at Trakya University and examining the relation with their hypertension. Journal of Nurse 2001;1(5):22-5. 34. Lahdenpera TS, Wright CC, Kyngas HA. Development of a scale to assess the compliance of patients with hypertension. Int J Nurs Studies 2003;40:677-84. 35. Osamor PE, Owumi BE. Factors associated with treatment compliance in hypertension in Southwest Nigeria. J Health Popul Nutr 2011;29(6):619-28. 36. Knight EL, Giynn RJ, Levin R, et al. Failure of evidence based medicine in the treatment of hypertension in older patients. J Gen Intern Med 2000;15:702-9. 37. Jassim Al Khaja KA, Sequeira RP, Mathur VS. Rational pharmacotherapy of hypertension in the elderly: analysis of the choice and dosage of drugs. J Clin Pharm Therapeut 2001;26:33-42. 38. Erci B, Sayan A, Tortumluo glu G, et al. The effectiveness of Watsons Caring Model on the quality of life and blood pressure of patients with hypertension. J Adv Nurs 2003;41(2):130-9. 39. Hunt JS, Siemienczuk J, Touchette D, et al. Impact of educational mailing on the blood pressure of primary care

40.

41. 42.

43.

44.

45.

46.

47.

48. 49. 50.

patients with mild hypertension. J Gen Int Med 2004; 19:925-30. Altun B, Arici B, Nergizo glu G, et al. Prevalence, awareness, treatment and control of hypertension in Turkey (the PatenT study) in 2003. J Hypertens 2005;23(10):1817-23. Potter PA, Perry AG. Fundamentals of Nursing. Philadelphia: Mosby-Year Book, Inc.; 1997; 594-640. Leung CM, Ho GKH, Foong M, et al. Small-group hypertension health education programe:a process and outcome evaluation. J Adv Nurs 2005;52(6):631-9. Kyngas HA, Lahdenpera TS. Compliance of patients with hypertension and associated factors. J Adv Nurs 1999; 29(4):832-9. Marshall AL, Booth ML, Bauman AE. Promoting physical activity in Australian general practices: a randomized trial of health promotion advice versus hypertension management. Patient Educ Couns 2005;56:283-90. Rose LE, Kim MT, Dennison CR, et al. The contexts of adherence for African American with high blood pressure. J Adv Nurs 2000;32(3):587-94. Van Wijk BL, Klungel OH, Heerdink ER, et al. Rate and determinants of 10-year persistence with antihypertensive drugs. J Hypertens 2005;23(11):2101-7. Erem C, Hachasanoglu A, Kocak M, et al. Prevalence of prehypertension and hypertension and associated risk factors among Turkish adults: Trabzon Hypertension Study. J Pub Health 2008;31(1):47-58. Wissen KV, Litcheld M, Maling T. Living with high blood pressure. J Adv Nurs 1998;27(3):567-75. Seager LH. Drug therapy in the elderly. Special Supplement to Geriatrics Literature 1996;11-15. Costanzo S, Di Castelnuovo A, Zito F, et al. Prevalence, awareness, treatment and Control hypertension in healthy unrelated male-female pairs of European regions. The dietary habit prole in European communities with different risk of myocardial infarction-the impact of migration as a model of gene-environment interaction project. J Hypertens 2008;(26):2303-11.