Impact of interventions on medication adherence and blood pressure control in patients with essential hypertension: a systematic review by the ISPOR medication adherence and persistence special interest group

Barriers and facilitators of habit building for long-term adherence to antihypertensive therapy among people with hypertensive disorders in Los Angeles, California: a qualitative study

OBJECTIVES

The aim of this study was to a) explore barriers and facilitators associated with medication-taking habit formation, and b) elicit feedback on the components of an intervention designed to help form strong habits for long-term medication adherence.

DESIGN

The study design was qualitative; we conducted semistructured interviews between September 2021 and February 2022.

SETTING

The interviews were conducted online, with 27 participants recruited at the Cedars-Sinai Medical Center in Los Angeles, California.

PARTICIPANTS

A purposive sample of 20 patients who were over 18 years of age, had been diagnosed with hypertensive disorder (or reported high blood pressure; >140/90 mm Hg) and who were prescribed antihypertensive therapy at the time of recruitment, along with seven providers were interviewed.

RESULTS

Contextual factors included frequent changes to prescription for regimen adjustment, and polypharmacy. Forgetfulness, perceived need for medication, and routine disruptions were identified as possible barriers to habit formation. Facilitators of habit formation included identification of stable routines for anchoring, planning, use of external reminders (including visual reminders) and pillboxes for prescription management, and extrinsic motivation for forming habits. Interestingly, experiencing medication side effects was identified as a possible barrier and a possible facilitator of habit formation. Feedback on study components included increasing text size, and visual appeal of the habit leaflet; and imparting variation in text message content and adjusting their frequency to once a day. Patients generally favoured the use of conditional financial incentives to support habit formation.

CONCLUSION

The study sheds light on some key considerations concerning the contextual factors for habit formation among people with hypertension. As such, future studies may evaluate the generalisability of our findings, consider the role of visual reminders in habit formation and sustenance, and explore possible disruptions to habits.

TRIAL REGISTRATION NUMBER

NCT04029883.

Prevalence of uncontrolled hypertension and contributing factors in Ethiopia: a systematic review and meta-analysis

Background

Uncontrolled hypertension (HTN) is a major risk factor for cardiovascular and cerebrovascular disease. The prevalence of HTN in the Ethiopian adult population is almost 20%.This study aimed to determine the prevalence of uncontrolled HTN and its contributing factors among patients with HTN in Ethiopia undergoing treatment.

Methods

Electronic bibliographic databases such as PubMed, Google Scholar, Hinari (Research4Life), Embase, and Scopus were searched for original records in the English language that assessed HTN control in Ethiopia and were available before 29 June 2023. The data were extracted using a format prepared in Microsoft Excel and exported to the software STATA 17.0 for analysis. The study protocol was registered at PROSPERO with the reference number CRD42023440121.

Results

A total of 26 studies with 9,046 patients with HTN were included in the systematic review and meta-analysis, of which 11 studies were used to assess factors contributing to uncontrolled blood pressure (BP) in patients in Ethiopia. The estimated prevalence of uncontrolled HTN in the population of Ethiopia is 51% [95% confidence interval (CI), 42%-60%]. The subgroup analysis, based on the assessment tools, region, and follow-up period, revealed that the prevalence of uncontrolled BP was highest following the guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) (89%; 95% CI: 87%-91%) and in Addis Ababa (58%; 95% CI: 40%-76%), and the lowest proportion of uncontrolled BP was in the 3-month follow-up period (34%; 95% CI: 29%-39%). The presence of diabetes mellitus showed the highest impact (pooled odds ratio: 5.19; CI: 1.41-19.11) for uncontrolled HTN. The univariate meta-regression method confirmed that the sample size, year of publication, and subgroups were not sources of heterogeneity in the pooled estimates. Egger's regression test did not indicate the presence of publication bias.

Conclusion

More than half of the hypertensive patients in Ethiopia have uncontrolled BP. Diabetes mellitus, advanced age, male sex, and the presence of comorbidities are among the factors contributing to uncontrolled HTN in Ethiopia. The concerned bodies working in this area should implement interventional strategies and recommendations that might be helpful in achieving optimal BP in hypertensive patients.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023440121, PROSPERO (CRD42023440121).

The effectiveness of short mobile phone text message reminders compared to usual care on medication adherence in patients with hypertension: a systematic review protocol

BACKGROUND

Poor adherence to long-term medication increases the risk of morbidity and mortality and decreases the quality of life of patients with hypertension. One strategy to improve treatment adherence is to use a short text message reminder. Although evidence indicates that such programs increase medication adherence, the extent of their effectiveness and translation into clinical practice needs to be better documented. Our systematic review will collect and analyze the available evidence for clinical practice implementation. This systematic review aimed to evaluate the effectiveness of short mobile phone text message reminders versus usual/standard care for medication adherence in patients with hypertension.

METHODS

This review will include and summarize evidence from randomized controlled trials. Adults (age > 18 years) with hypertension. The comparator group received either the usual care or standard care. It encompasses standard medical care for patients not participating in a structured and supervised intervention program such as a telemedicine program. We will include studies that assess the effectiveness of short mobile phone text message reminders in improving medication adherence in patients with hypertension compared to usual care. We will search the following databases: PubMed, EMBASE, CINAHL, SCOPUS, Web of Science, Cochrane Library Central Register of Controlled Trials, and Cochrane Library. We will include studies published in English. Furthermore, we will consider studies published from the inception of the database until April 20, 2024. At least two reviewers will independently conduct study selection, data extraction, and quality assessment. A third reviewer will determine and resolve discrepancies. We will conduct a quality assessment using the ROBIS 2 critical appraisal checklist. At least two independent reviewers will crosscheck the data synthesis.

DISCUSSION

We expect this review to provide current evidence for future studies and clinical practice concerning the impact of mobile phone text message reminders on medication adherence issues. We will publish our results in a peer-reviewed journal for publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023391236.

Adherence to pharmacological treatment in non-communicable chronic diseases in the Colombian population: Systematic review and meta-analysis

Introduction. Non-communicable chronic diseases represent the leading cause of death worldwide, and their prevalence is increasing due to the epidemiological transition. Despite the advances in their management, control rates are deficient, attributed to multiple factors like adherence to pharmacological treatment, one of the most significant and least studied in the Colombian population. Objective. To calculate adherence to treatment in Colombian patients with arterial hypertension, cerebrovascular disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, and dyslipidemia between 2005 and 2022. Materials and methods. We performed a systematic literature review and a meta-analysis of studies identified through the Medline and LILACS databases to quantitatively synthesize treatment adherence percentage. Results. Fourteen studies met the inclusion criteria, and 5,658 patients were analyzed. The treatment adherence was 59%, with significant heterogeneity among the included studies (95% CI= 46- 71%; I2 = 98.8%, p< 0.001). Higher adherence rates were observed for diabetes mellitus (79%; 95% CI = 65- 90%) and dyslipidemia (70%; 95% CI = 66- 74%). Adherence to arterial hypertension treatment was 51% (95 %; CI = 31- 72%). Conclusions. This systematic review showed low adherence to recommendations regarding pharmacological management in non-communicable chronic diseases, which can have implications for long-term clinical outcomes and disease burden.

Gender-Related Factors in Medication Adherence for Metabolic and Cardiovascular Health

This review explores the impact of gender on medication adherence in the context of metabolic and cardiovascular diseases. Optimal adherence to medication is crucial for achieving treatment goals and preventing adverse outcomes in chronic diseases. The review examines specific conditions such as type 2 diabetes, hypercholesterolemia, arterial hypertension, cardiovascular diseases, and heart failure. In type 2 diabetes, female sex, younger age, new drug prescription, non-white ethnicity, low education level, and low income were identified as predictors of non-adherence. Depressive disorders were also found to influence adherence. In hypercholesterolemia, women exhibited poorer adherence to statin therapy compared to men, with statin-related side effects and patient perception being significant factors. Adherence to anti-hypertensive therapy showed conflicting results, with studies reporting both higher and lower adherence in women. Limited evidence suggests that women may have poorer adherence after acute myocardial infarction and stroke. Regarding heart failure, adherence studies have shown inconsistent findings. The reasons for gender differences in medication adherence are multifactorial and include sociodemographic, disease-related, treatment-related, and psychological factors. This review emphasizes the need for further research to better understand these differences and develop gender-customized interventions that can improve medication adherence and reduce the burden of metabolic and cardiovascular diseases.

Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication

Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.

Behavioural Economics to Improve Antihypertensive Therapy Adherence (BETA): protocol for a pilot randomised controlled trial in Los Angeles

INTRODUCTION

Non-adherence to antihypertensive therapy is one of the major barriers to reducing the risk of cardiovascular disease. Several interventions have targeted higher medication adherence, yet most do not result in sustained adherence. Routinisation has emerged as a potential method for mitigating this problem, but requires high motivation during the relatively long habit formation phase. This pilot randomised controlled trial aims to test the feasibility, acceptability, and preliminary efficacy of behavioural economics-based incentives and text messages to support the routinisation of the medication-taking behaviour for promoting long-term medication adherence.

METHODS AND ANALYSIS

This study will recruit and randomly assign 60 adult patients seeking care for hypertension at the Cedars-Sinai Medical Center in Los Angeles to one of the three groups, Control (n=20), Messages (n=20) and Incentives (n=20) in a 1:1:1 ratio. All participants will receive information about the importance of routinisation and will select an existing behavioural routine ('anchor') to which they will tie their pill-taking to, and the corresponding time. Additionally, participants in the Messages group will receive daily text messages reminding them of the importance of routines, while those in the Incentives group will receive daily text messages and conditional prize drawings. The interventions will be delivered over three months. Participants will be followed for six months post-intervention to measure behavioural persistence. Surveys will be administered at baseline, month-3 and month-9 visits. Primary outcomes include: (1) electronically measured mean medication adherence during the intervention period and (2) post-intervention period; and (3) mean timely medication adherence based around the time of the participants' anchor during the intervention period, and (4) post-intervention period.

ETHICS AND DISSEMINATION

The study was approved by the Cedars-Sinai Institutional Review Board (Study ID: Pro00057764). Findings will be published in scientific peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04029883.

Persons' experiences of having hypertension: An interview study

Background

among the 1-1.5 billion persons with hypertension globally only, 20-30% have controlled blood pressure (BP). The most important problem identified is non-adherence to treatment, i.e., failure to change lifestyle and to take prescribed medication. Knowledge about the reasons for this is limited.

Objectives

The aim of the study was to explore people's experiences of having hypertension.

Design

Inductive design based on qualitative interviews.

Settings

The south of Sweden.

Participants

Twelve adults diagnosed with hypertension and treated in primary care were interviewed.

Methods

The transcribed interviews were analysed using content analysis, which rendered three categories.

Results

The individuals adapted to their diagnosis in different ways. Collaboration with the staff gave security, but the persons still perceived anxiety and uncertainty.

Conclusions

To meet the needs of people with hypertension, strategies such as person-centred counselling and care, using digital interventions, following national guidelines and starting nurse-led clinics, may be of help. These strategies can give a foundation for increased self-efficacy, which is crucial for persons to be able to change lifestyle and adhere to prescribed medication in order to achieve BP control.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

Gaps in antihypertensive and statin treatments and benefits of optimisation: a modelling study in a 1 million ethnically diverse urban population in UK

OBJECTIVES

To characterise gaps in antihypertensive treatment in people with hypertension and statin treatment in people with cardiovascular diseases (CVD) in a large urban population and quantify the health and economic impacts of their optimisation.

DESIGN

A cross-sectional population study and a long-term CVD decision model.

SETTING

Primary care, UK.

PARTICIPANTS

All adults with diagnosed hypertension or CVD in a population of about 1 million people, served by 123 primary care practices in London, UK in 2019.

INTERVENTIONS

Following UK clinical guidelines, all adults with diagnosed hypertension were categorised into optimal, suboptimal and untreated groups with respect to their antihypertensive treatment, and all adults with diagnosed CVD were categorised in the same manner with respect to their statin treatment.

OUTCOMES

Proportion of patients suboptimally treated or untreated. Projected cardiovascular events avoided, years and quality-adjusted life years (QALYs) gained and healthcare costs saved with optimised treatments.

RESULTS

21 954 of the 91 828 adults with hypertension (24%; mean age 59 years; 49% women) and 9062 of the 23 723 adults with CVD (38%; mean age 69 years; 43% women) were not optimally treated with antihypertensive or statin treatment, respectively. Per 1000 additional patients optimised over 5 years, hypertension treatment is projected to prevent 25 (95% CI 16 to 32) major vascular events (MVEs) and 7 (3 to 10) vascular deaths, statin treatment, 28 (22 to 33) MVEs and 6 (4 to 7) vascular deaths. Over their lifespan, a patient with uncontrolled hypertension aged 60-69 years is projected to gain 0.64 (95% CI 0.36 to 0.87) QALYs with optimised hypertension treatment, and a similarly aged patient with previous CVD not optimally treated with statin is projected to gain 0.3 (0.24 to 0.37) QALYs with optimised statin treatment. In both cases, the hospital cost savings minus extra medication costs were about £1100 per person over remaining lifespan.

CONCLUSIONS

Optimising cardiovascular treatments can cost-effectively reduce cardiovascular risk and improve life expectancy.

Alteration of Relative Rates of Biodegradation and Regeneration of Cervical Spine Cartilage through the Restoration of Arterial Blood Flow Access to Rhomboid Fossa: A Hypothesis

We found the logical way to prove the existence of the mechanism that maintains the rates of biodegradation and regeneration of cervical spine cartilage. We demonstrate, that after we restore access to arterial blood flow through cervical vertebral arteries to rhomboid fossa it causes the prevalence of regeneration over biodegradation. This is in the frames of consideration of the human body as a dissipative structure. Then the recovery of the body should be considered as a reduction of the relative rates of decay below the regeneration ones. Then the recovery of cervical spine cartilage through redirecting of inner dissipative flow depends on the information about oxygen availability that is provided from oxygen detectors in the rhomboid fossa to the cerebellum. Our proposed approach explains already collected data, which satisfies all the scientific requirements. This allows us to draw conclusions that permit reconsidering the way of dealing with multiple chronic diseases.

Digital medicines for adherence support: A conceptual framework and qualitative study of adherence among chronically ill patients

Digital medicine programs (DMPs) are emerging technologies that use sensor-enabled medicine to detect when patients have taken their medication and then provide feedback about adherence. We use qualitative methods to understand how patients change their behavioral patterns while participating in a DMP intervention. An influence diagram outlining the factors hypothesized to affect adherence in DMPs constructed from prior scientific research and expert input was created. Subsequently, we conducted semi-structured interviews with 10 patients to see if their experience supported the relationships outlined in the model. We identified three pathways by which DMPs are likely to change behavior around medication adherence: (1) providing patients and providers with accurate, personalized information about adherence; (2) improving patient-provider interactions by structuring them around this information; and (3) facilitating routines and habits for medication use. Chronically ill patients often fail to adhere to drug regimens. Patients in a DMP intervention used the DMP-provided information to better understand drug efficacy and collaborated with their physician to develop adherence strategies. DMPs can promote medication adherence among patients who are willing to use them and may be most effective if physicians are active partners in the DMP.

Medication Adherence and Blood Pressure Control: A Scientific Statement From the American Heart Association

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

Assessing the effectiveness and implementation of a chronic disease self-management programme in faith-based organisations in Barbados: protocol for a cluster randomised parallel trial

INTRODUCTION

In the COVID-19 environment of reduced patient interaction with the healthcare system, evidenced-based self-care of chronic disease is vital. We will evaluate the effect of an online chronic disease self-management programme (CDSMP) plus medication adherence tools on systolic blood pressure (SBP) (primary aim) and, seek to understand the barriers and facilitators to implementation of this modified CDSMP in faith-based organisations (FBOs) (secondary aim).

METHODS

We will conduct an unblinded cluster randomised trial in FBOs throughout Barbados. Eligibility: Persons ages 35-70 years; a previous diagnosis of hypertension or currently on antihypertensive therapy and the occurrence of two or more blood pressure readings above 130 mm Hg (systolic) or 80 mm Hg (diastolic) on the day of recruitment. Persons not known to have hypertension but who have two or more blood pressure readings at or above 130 mm Hg (systolic) or 80 mm Hg (diastolic) on two recruitment days at least 1 week apart will also be eligible. The unit of randomisation is a church cluster which consists of 7-9 churches. We will perform block randomisation to assign 24 clusters to intervention or control. The intervention has three components: modified CDSMP workshops, distribution of medication pill boxes and use of social media (WhatsApp V.2.0) to encourage medication adherence. Controls will receive one didactic lecture only. We will determine the mean changes in SBP levels for the intervention group versus controls and compare differences in outcomes 6 months' post intervention using mixed effects regression models.

ETHICS AND DISSEMINATION

This project has received ethical approval from the Institutional Review Board of the University of the West Indies in Barbados. Dissemination will use peer-reviewed publications, policy briefs to government and guidelines to leaders of FBOs. We aim to increase the proportion of patients with controlled hypertension and inform implementation of self-management programmes in small populations.

TRAIL REGISTRATION NUMBER

NCT04437966.

Mindfulness-based interventions for medication adherence: A systematic review and narrative synthesis

OBJECTIVE

Inadequate medication adherence is a significant limitation for achieving optimal health outcomes across chronic health conditions. Mindfulness-based interventions (MBIs) have been increasingly applied to promote medical regimen adherence as MBIs have been shown to improve patient-level barriers to adherence (i.e., depressive symptoms, cognitive impairment, stress). The purpose of this review is to investigate the state of research regarding MBIs targeting medication adherence in chronic illnesses and to identify evidence gaps to inform future studies.

METHODS

The search reviewed 5 databases (e.g., PubMed, PsycINFO, Embase, CINAHL, Proquest Thesis/Dissertations) to identify trials that quantitatively evaluated the effect of MBIs on medication adherence. Study abstracts and full texts were screened identifying eligible studies, and findings were summarized using a narrative synthesis.

RESULTS

A total of 497 studies were reviewed; 41 were eligible for full text review and 9 were included in narrative synthesis: seven were RCTs and two were pre-post designs. Study quality varied, with five rated moderate or high risk for bias. Clinical populations tested included living with HIV (k = 3), cardiovascular disease (k = 3), psychological disorders (k = 2), and men who underwent a radical prostatectomy (k = 1). Four studies found significant improvements in medication adherence, however only two of these studies had low risk of bias.

CONCLUSIONS

Research on MBI's for medication adherence is developing, but the effectiveness of MBIs remains unclear due to the nascent stage of evidence and methodological limitations of existing studies. Researchers should prioritize rigorous experimental designs, theory-driven investigations of behavioral mechanisms, and the use of objective measurements of adherence.

The impact of antihypertensive treatment initiation on health-related quality of life and cardiovascular risk factor levels: a prospective, interventional study

Background

Effective prevention and treatment of hypertension is one of the most potential interventions in terms of preventing cardiovascular deaths and disabilities. However, the treatment control is often poor. This may be partly explained by the impact of hypertension diagnoses and treatment on health-related quality of life. Quality of life is also an important outcome for a hypertensive patient. Most of the previous studies on health-related quality of life in hypertension have concentrated on patients with treated hypertension and less is known about the initiation of medication and the first treatment year.

Methods

In this interventional study, we followed 111 primary care patients with newly diagnosed hypertension in real world primary care setting in Finland for 12 months.

Results

We found significant decrease in both systolic and diastolic blood pressure levels, as well as modest decrease in cholesterol levels and alcohol consumption. However, the health-related quality of life also slightly deteriorated during the first treatment year.

Conclusions

Our study shows that the initiation of hypertension treatment results in cardiovascular risk decrease among newly diagnosed Finnish hypertensive patients, but it is accompanied by small negative impact on health-related quality of life. However, the deterioration in health-related quality of life is of small magnitude and earlier research demonstrates several measures to enhance treatment and avoid impairment in health-related quality of life.

Trial registration ClinicalTrials NCT02377960 (Date of registration: 04/03/2015).

A qualitative exploration of the impact of knowledge and perceptions about hypertension in medication adherence in Middle Eastern refugees and migrants

Background

Objectives

Methods

Results

Conclusion

Impact of a mobile phone app on adherence to treatment regimens among hypertensive patients: A randomised clinical trial study

BACKGROUND

Hypertension is one of the most prevalent long-term diseases seen in many countries, including Palestine. Patients with poorly controlled blood pressure are more likely to develop several complications. Therefore; it is imperative to control their blood pressure by improving their adherence to the treatment regimen.

AIM

The objective of this study was to evaluate the impact of using a mobile phone app on the level of adherence to treatment regimens among hypertensive patients in the Gaza Strip.

METHODS AND RESULTS

This study used an experimental design with a pre and post-intervention assessment. Using the Hill-Bone compliance to high blood pressure therapy scale, 191 participants completed the study: 94 in the control group and 97 in the intervention group. The intervention group used a phone app which reminds participants to take their medication, reminding them about their follow-up appointments and sending educational information about hypertension management. After 3 months of intervention, the level of adherence to treatment was reassessed. Results showed that participants in both groups showed a significant improvement in adherence levels, with higher improvements in the intervention group in the total score as well as all three domain scores: adherence to medication, diet and keeping appointments.

CONCLUSION

The use of a mobile phone app resulted in improvements in adherence to hypertension treatment. Thus, this study confirms the potential effectiveness of mobile technology in improving treatment adherence in hypertension and an opportunity to reduce cardiovascular mortality and morbidity. However, wider adoption has to be accompanied by ongoing evaluation and integration in public health systems.

The association between social support and medication adherence in patients with hypertension: A systematic review

Background:

Medication adherence is a primary determinant of treatment success in hypertensive patients. One of the challenges for healthcare providers that has received little attention is the impact of patients’ social supports on medication adherence.

Objective:

This review evaluates the impact of patients’ social supports on medication adherence in hypertensive patients.

Methods:

A systematic review methodology was used. Pubmed, CINAHL, Embase, and PsycINFO databases were searched systematically for relevant articles. The outcome measure in the studies was medication adherence in hypertension.

Results:

From 1155 articles, 238 were retained for further assessment, and finally, 14 met the inclusion criteria. Statistically significant positive associations between medication adherence and social support were found in nine studies (p<0.05).

Conclusions:

This review evaluated the impact of social support on medication adherence and highlighted gaps in the literature regarding the impact of social support on adherence. Family members or peer support may promote better adherence in some patient groups. This review suggests that healthcare providers may need to consider whether patients have appropriate social supports in place which will assist them adhering to and benefiting from treatment recommendations.

Effectiveness of motivational interviewing on medication adherence among Palestinian hypertensive patients: a clustered randomized controlled trial

BACKGROUND 

This trial aimed to evaluate the effectiveness of motivational interviewing (MINT) among medication non-adherent hypertensive patients attending primary healthcare centres in Gaza Strip.

METHODS AND RESULTS 

A clustered randomized controlled trial was run among 355 hypertensive participants; who were identified as non-adherent by a self-reported adherent scale and were recruited from 10 centres by two stages cluster random sampling approach (five centres were randomly allocated to each group). Standard of hypertension care was provided to 173 participants, parallel to 182 one who received their standard of care including non-blinded MINT sessions for 3 months. The change in medication adherence status was the primary outcome and within-patient changes of systolic blood pressure (SBP), diastolic blood pressure (DBP), self-efficacy and intrinsic motivation were the secondary outcomes. Data were collected via an interview-based structured questionnaire and were analysed by generalizing equation estimation model adjusting for covariates. The results showed a significant improvement in medication adherence status among participants in the intervention group (n = 159) [OR= 6.28; 95% confidence interval (CI): 3.20, 12.33; P < 0.001] compared with those in the control group (n = 151). Moreover, there were significant drops in both SBP (OR = 0.18; 95% CI: 0.06, 0.55; P = 0.002) and DBP (OR = 0.26; 95% CI: 0.09, 0.76; P = 0.013) and significant positive changes in both within-patient's self-efficacy (OR = 15.4; 95% CI: 3.9, 60.6; P < 0.001) and intrinsic motivation (OR = 31.7; 95% CI: 13.9, 71.9; P < 0.001).

CONCLUSION 

Standard of care including MINT is an effective client-centred approach which promoted medication adherence, decreased mean blood pressure, and improved self-efficacy and intrinsic motivations among hypertensive patients.

Longitudinal analysis of safety and medication adherence of patients in the Fingolimod patient support program: a real-world observational study

The Fingolimod Patient Support Program (F-PSP) is an interprofessional specialty pharmacy service designed to ensure responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to evaluate the safety and medication adherence of patients who joined the F-PSP between 2013 and 2016. Sociodemographic and medical characteristics, patient safety data (patient-reported symptoms, discontinuations due to adverse events (AEs), repeated first-dose monitoring), and medication adherence (implementation, persistence, reasons for discontinuation, influence of covariates, barriers and facilitators) were described. Sixty-seven patients joined the F-PSP. Patients reported a high frequency of symptoms. Due to AEs, 7 patients discontinued fingolimod, 3 took therapeutic breaks, and 1 reduced the regimen temporarily. Three patients repeated the first-dose monitoring. Patients had a high medication adherence over the 18-month analysis period: implementation decreased from 98.8 to 93.7%, and fingolimod persistence was 83.2% at 18 months. The patients’ level of education, professional situation, and living with child(ren) influenced implementation. Patients reported more facilitators of medication adherence than barriers. The F-PSP seems valuable for supporting individual patients (ensuring responsible use of fingolimod and inviting patients for shared-decision making) and public health (indirectly gathering real-world evidence).

Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: Meta-analysis of randomized controlled trials

AIM

To assess the effects of self-management interventions on systolic blood pressure, diastolic blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension.

BACKGROUND

Effective treatment of hypertension may require the practice of self-management behaviours. However, evidence on effects of self-management interventions on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension is lacking.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

CINAHL, Cochrane Library, Embase, Ovid-Medline, PubMed, Scopus, Web of Science and other sources were searched to October 2020.

REVIEW METHODS

Data were analysed using Comprehensive Meta-Analysis 2.0 and quality assessment was done using ROB 2.0. The pooled effect sizes were reported as Hedges' g values with corresponding 95% confidence intervals using a random-effects model.

RESULTS

Twelve randomized controlled trials met our inclusion criteria. The results revealed that self-management interventions significantly decreased blood pressure and increased self-efficacy and medication adherence in older adult patients with hypertension, with no significant effect on body mass index.

CONCLUSIONS

Self-management interventions have considerable beneficial effects in older adults with hypertension. Health care providers should implement self-management interventions to strengthen the patient's role in managing their health.

Adherence to triple-component antihypertensive regimens is higher with single-pill than equivalent two-pill regimens: A randomized controlled trial

Abstract

Using a single‐pill combination (SPC) for hypertension (HTN) treatment resulted in better adherence and persistence than a free‐equivalent combination in previous observational studies. The aim of this study is to confirm superior adherence with a triple‐component SPC compared with an equivalent two‐pill regimen in a randomized controlled trial (RCT) using a medication event monitoring system (MEMS). This is a multicenter, open‐label, RCT. Subjects were persons with HTN whose clinic blood pressure was not adequately controlled (systolic >140 mmHg or diastolic >90 mmHg) with a dual combination. Eligible patients were randomized to either the triple‐component SPC (olmesartan/amlodipine/hydrochlorothiazide 20/5/12.5 mg) group or the equivalent two‐pill (olmesartan/hydrochlorothiazide 20/12.5 mg + amlodipine 5 mg) group and maintained for 12 weeks. Primary outcomes were the difference in percentage of doses taken (PDT) and percentage of days with the prescribed dose taken correctly (PDTc) between the single‐ and two‐pill therapy groups, calculated from MEMS data. From 8 hospitals, 145 patients with HTN were randomized. The single‐pill group had significantly higher PDT and PDTc than the two‐pill group: median (25–75 percentile) PDT 95.1 (86.7–100.0) versus 92.1 (73.0–97.3); and PDTc 91.0 (79.4–96.5) versus 88.6 (69.2–96.3%), P = 0.04 for both by the Wilcoxon rank sum test. The single‐pill combination of the triple‐component antihypertensive regimen showed better adherence than the equivalent two‐pill therapy. Reducing pill burden by means of a single‐pill combination is an effective strategy for enhancing adherence to multiple‐agent antihypertensive therapy.

Prevalence of non-adherence to antihypertensive medication in Asia: a systematic review and meta-analysis

Background Hypertension and its associated complications are one of the leading causes of morbidity and mortality in Asia. Racial disparities in terms of treatment outcomes among hypertension patients have been reported in literature with Asian patients resulting in poorer treatment outcomes. Non-adherence to antihypertensive therapy is frequently associated with poor treatment outcomes. Aim of the review The aim of this review was to estimate the prevalence of non-adherence to antihypertensive medications among patients with hypertension residing in Asia. Method PubMed, Google Scholar, MEDLINE, Embase, Scopus, CINHAL and Cochrane library were searched for studies published between 2000 and 2019 involving hypertensive patients. Studies investigating the prevalence of medication non-adherence in Asian countries, rated either good or fair on National Institute of Health quality assessment tool and published in English language were included in our review. Data were extracted by one author and checked by another using a structured and pilot-tested data extraction sheet. A random-effects meta-analysis was performed using STATA version 14.3®. Results Sixty-Six studies from 22 Asian countries including 2,532,582 hypertensive patients were included. Mean (± SD) age of participants was 58(± 6) years. Overall, the estimated prevalence of non-adherence to antihypertensive medication in Asia was 48% (95% CI: 41-54, P = 0.001). The rate of non-adherence was higher among females 49% (95% CI: 41-56, P = 0.001) compared to males 47% (95% CI: 40-53, P = 0.001). As per the region, the highest prevalence of non-adherence was found in South Asia 48% (95% 44-51, P = 0.877) followed by East Asia 45% (31-59, P = 0.001) and the Middle East 41 (95% 30-52, P = 0.001). Similarly, higher rate of non-adherence was observed in low and lower middle-income countries i.e. 50% (95% CI: 47-54, P = 0.220) as compare to upper-middle and high-income countries i.e. 37% (95% CI: 25-49, P = 0.001) and 44% (95% CI: 29-59, P = 0.001) respectively. Conclusion The prevalence of non-adherence to antihypertensive medication is high in Asia. This may partly explain poor treatment outcomes and incidence of higher mortality rate in Asia frequently reported in the literature. There is a need to implement appropriate policies and clinical practices to improve medication adherence.

When less is more: Can reduced health monitoring improve medication adherence?

As the prevalence of chronic diseases rises, improving self-management has become an important determinant of the productivity of healthcare delivery. Recently, Mexico's largest healthcare provider began issuing automatic-refill prescriptions to stable hypertensive patients, thus reducing the frequency of health monitoring from 30- to 90-day intervals. Exploiting this change, I find that less monitoring implies no drawbacks in health outcomes and actually improves self-management of disease by increasing medication adherence when baseline monitoring is relatively frequent. The number of days when patients are out of medication between fillings falls by 2.2 days-an improvement in adherence of 6.4%. Furthermore, patients appear to value being on a low-frequency regime as they improve adherence in order to remain on it, suggesting that lower monitoring could be used as a "reward" to promote medication adherence or, potentially, other health behaviors. Finally, I find evidence of positive spillovers on adherence, as clinic congestion falls.

Impact of patient knowledge on hypertension treatment adherence and efficacy: A single-centre study in Poland

Introduction: Recent studies show that treatment of arterial hypertension is unsuccessful. This is due to the patients' insufficient knowledge of about the therapeutic methods and the consequences of not treating arterial hypertension. Objectives: The aim of the study was to evaluate the patients' knowledge concerning therapeutic options, prophylaxis, and complications of arterial hypertension. The study also assessed the effect of such knowledge on hypertension treatment adherence and efficacy. Patients and Methods: The survey included 488 patients (250 female and 238 male), aged over 18 years, diagnosed with and treated in outpatient and inpatient settings at selected healthcare institutions in Poland. A custom-made questionnaire, based on references on this subject, was the key tool in the present study. Information about the course of the disease and evaluation of hypertension treatment efficacy was based on the patients' medical records. Results: The study found that 54.7% of the subjects had good knowledge about arterial hypertension, 40.0% had average knowledge, and 5.3% had poor knowledge. The extent of knowledge about the disease was significantly dependent on the level of education and the place of receiving medical care (p< 0.05). Good knowledge was significantly associated with controlled blood pressure, number of antihypertensive drugs used, frequency of hospitalization, as well as with medication adherence, and healthy lifestyle behaviours (p< 0.05). Conclusions: More than half of the patients presented good knowledge but a large group still had poor knowledge, especially patients with a low level of education and with hypertension treated at a general practitioner's clinic. The results of our study clearly show that knowledge about arterial hypertension affects medication adherence and healthy lifestyle behaviours and improves hypertension treatment efficacy.

Effectiveness of a targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: A cluster randomised controlled trial

Aim

To assess the effects of a targeted and tailored pharmacist‐led intervention among patients with type 2 diabetes (T2DM) who are nonadherent to antihypertensive drugs.

Methods

A cluster‐randomised controlled trial was conducted in 10 community health centres (CHCs) in Indonesia among T2DM patients aged ≥18 years who reported nonadherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS‐5). Patients in CHCs randomised to the intervention group received a tailored intervention based on their adherence barriers (eg, forgetfulness, lack of knowledge, lack of motivation and/or other drug‐related problems) using a simple question‐based flowchart at baseline and 1‐month follow‐up. Patients in control CHCs received usual care. Primary outcome was the between‐group difference in change in MARS‐5 score from baseline to 3‐month follow‐up. Secondary outcomes included changes in patients' blood pressure and their medication beliefs. Differences in difference in primary and secondary outcomes between groups were assessed using general linear models.

Results

In total, 201 patients were screened for eligibility, 113 met the inclusion criteria and participated, and 89 (79%) patients had complete follow‐up. Forgetfulness (42%) and lack of knowledge (18%) were the most common adherence barriers identified at baseline. The intervention improved medication adherence by 4.62 points on the MARS‐5 scale (95% CI 0.93 to 8.34, P value = 0.008). There were no significant changes in blood pressure levels and beliefs about antihypertensive drugs.

Conclusion

A tailored low‐cost pharmacist‐led intervention aimed at nonadherent T2DM patients resulted in an improvement in medication adherence to antihypertensive drugs. There were no significant changes in secondary outcomes.

Assessing Barriers to and Level of Adherence to Hypertension Therapy among Palestinians Living in the Gaza Strip: A Chance for Policy Innovation

Introduction

Hypertension is a major health concern, especially in low-income countries. Nonadherence and poor or no persistence in adhering to hypertension treatment regimens result in uncontrolled high blood pressure, increasing rates of mortality and morbidity, and preventable healthcare costs. The aim of this study was to assess the level of adherence and barriers to treatment regimens among hypertensive patients living in the Gaza Strip, Palestine.

Methods

A convenience sample of 648 participants completed the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The great majority of participants (n = 521, 80.4%) was highly adherent to their treatment regimen, 123 participants (18.98%) were classified as moderately nonadherent, and 4 (0.62%) participants were classified as highly nonadherent to their hypertension treatment regimen. Participants of this study showed the highest adherence rate to the domain of medication adherence (mean of 1.42 out of 4) followed by appointment keeping (mean 1.8), while they were least adherent to diet (mean of 2.18). The greatest three barriers to adherence to the recommended treatment regimen reported by participants were inability to exercise, inability to resist fast and fried food, and inability to keep themselves away from salty foods.

Conclusion

Overall adherence to medication in Gaza was surprisingly good in patients with a diagnosis of hypertension for at least one year. However, adherence to lifestyle advice or dietary regimes remains poor. A combination of interventions using low-cost mobile technology, combined with face-to-face interventions by healthcare professionals, can be applied to improve adherence to hypertension treatment regimens in order to reduce the consequences of uncontrolled blood pressure.

The Effect of Contextualized Racial and Gendered Stressors, Social Support, and Depression on Hypertension Illness Perceptions and Hypertension Medication Adherence in Young African American Women With Hypertension

BACKGROUND

Poor adherence to hypertensive medication has been suggested to be a major contributor to uncontrolled hypertension (HTN) in African Americans. The impact that social determinants have on the various patient-level factors, including HTN beliefs, mental well-being, and social support, may provide insight into the development and tailoring of culturally targeted interventions, thus improving adherence.

OBJECTIVE

The aim of this study was to examine the relationships of exposures to contextualized racial and gendered stressors, social support, and depressive symptoms with HTN illness perceptions and blood pressure (BP) medication adherence.

METHODS

Participants (N = 85) were hypertensive African-American women aged 18 to 45 years (mean [SD], 39.2 [5.4] years) recruited from the community setting and outpatient medical clinics in a large metropolitan city. Hypertension illness beliefs were assessed using the 8-item Brief Illness Perception Questionnaire ("How much does your blood pressure affect your life?") and medication adherence was assessed with the 7-item Adherence to Refills and Medication Scale ("How often do you forget to take your BP medicine?"). Logistic regression analyses were performed to examine the associations with medication adherence and linear regression analyses were performed to examine the associations of continuous variables and HTN illness perceptions.

RESULTS

The sample was predominantly nonadherent (81.2%). In the adjusted multivariable regression model, systolic BP (odds ratio, 0.95; P = .05) and the "Consequence" dimension of HTN beliefs (odds ratio, 0.76; P = .02) were associated with medication adherence. In the adjusted linear regression model, systolic BP (β = 0.22, P < .01) and depressive symptoms (β = 1.11, P < .01) were associated with HTN illness beliefs.

CONCLUSIONS

Assessing beliefs and the mental well-being before initiating BP medications is essential for adherence and BP control.

A systematic review of interventions using health behavioral theories to improve medication adherence among patients with hypertension

Medication adherence is a major problem in the treatment of hypertension. Approximately half of the patients who use antihypertensive medications are not adherent. Several interventions have endeavored to improve medication adherence among patients with hypertension, and some have used health behavioral models/theories. However, the quality and effectiveness of using health behavioral models/theories in improving medication adherence among patients with hypertension remain unknown. The main aim of this systematic review was to describe study characteristics and types of health behavioral models/theories used in interventions for improving medication adherence among adults with hypertension. PubMed, Scopus, Ovid MEDLINE, CINAHL, and PsycINFO databases were searched for randomized clinical trial interventions using any health behavioral models/theories published in English from 1979 to 2019. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers searched, screened abstracts and articles, extracted data, and assessed the risk of bias and the use of the model/theory using the Theory Coding Scheme. A total of 11 articles were included in this systematic review. Two studies reported significant improvement in medication adherence. The Self-Regulation Model and Social Cognitive Theory were the most common types of models/theories. Nine studies used a single model/theory, and four studies measured the constructs of a model/theory. Risk of bias was good (n = 4) and fair (n = 5) in interventions. Using health behavioral models/theories may be an efficient way for health care professionals to improve adherence to medications among patients with hypertension. More interventions with rigorous designs are needed that appropriately utilize health behavioral models/theories for improving medication adherence among adults with hypertension.

Satisfaction and experiences of patients taking fingolimod and involved in a pharmacy-based patient support program in Switzerland - a qualitative study

BACKGROUND

Fingolimod is an oral multiple sclerosis drug that is considered a specialty drug due to its high cost and safety issues. The Fingolimod Patient Support Program (F-PSP) is a specialty pharmacy service developed to ensure the responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to explore the satisfaction, experiences and perceptions regarding the F-PSP among patients currently involved in this program or recently withdrawn.

METHODS

A qualitative study was conducted via individual, face-to-face semistructured interviews with patients involved in the F-PSP. The interviews were audio-recorded, transcribed verbatim, coded and analyzed via thematic content analysis.

RESULTS

The main themes identified from the interviews (n = 17) were overall perception of the F-PSP, perception of the pharmacist-led consultations, perception of the tools (electronic monitor and drug intake graph), reasons to participate or potentially withdraw, and suggestions for improvements. Participants perceived the F-PSP as a reassuring support that complemented their medical care, providing a more human, personalized and person-centered approach than usual pharmacy care. Pharmacist-led consultations were valued for the medication-related and holistic support they provided. The importance of the pharmacist's attitude was emphasized. The electronic monitor was valued for promoting daily medication adherence and allowing the involvement of relatives, which reassured participants and their relatives. The participants appreciated the drug intake graph because it provided an objective overview of medication adherence, thereby reassuring, rewarding, and motivating them. The main reason to join the program was to be supported, especially with respect to medication adherence.

CONCLUSIONS

Participants were satisfied with the F-PSP, each for different reasons. Their feedback enabled the identification of measures for the optimization of the F-PSP and should facilitate its dissemination and transfer to other drugs/diseases/populations. Essential elements of generic pharmacist-led patient support programs considered valuable from the patients' perspective were identified.

Supporting self-management for people with hypertension: a meta-review of quantitative and qualitative systematic reviews

OBJECTIVES

Globally, healthcare policy promotes supported self-management as a strategy for people with long-term conditions. This meta-review aimed to explore how people with hypertension make sense of their condition, to assess the effectiveness of supported self-management in hypertension, and to identify effective components of support.

METHODS

From a search of eight databases (January 1993-October 2012; update June 2017) we included systematic syntheses of qualitative studies of patients' experiences, and systematic reviews of randomized controlled trials evaluating the impact of supported self-management on blood pressure and medication adherence. We used meta-ethnography, meta-Forest plots and narrative analysis to synthesise the data.

RESULTS

Six qualitative and 29 quantitative reviews provided data from 98 and 446 unique studies, respectively. Self-management support consistently reduced SBP (by between 2 and 6 mmHg), and DBP (by between 1 and 5 mmHg). Information about hypertension and treatment, home BP monitoring (HBPM) and feedback (including telehealth) were widely used in effective interventions. Patients' perceptions of a disease with multiple symptoms contrasted with the professional view of an asymptomatic condition. HBPM, in the context of a supportive patient-professional relationship, changed perceptions of the significance of symptoms and fostered confidence in ability to self-manage hypertension.

CONCLUSION

Our systematic qualitative and quantitative meta-reviews tell complementary stories. Supported self-management can improve blood pressure control. Interventions are complex and encompass a broad range of support strategies. HBPM (with or without telehealth) within the context of a supportive patient-professional partnership can bridge the gap between medical and lay perspectives of hypertension and enable effective self-management.

The Relationship Among Health Beliefs, Depressive Symptoms, Medication Adherence, and Social Support in African Americans With Hypertension

BACKGROUND

African Americans are disproportionately affected by hypertension and have lower medication adherence when compared to other racial groups. Antecedent factors such as beliefs surrounding hypertension, the presence or absence of social support, and depressive symptoms have not been extensively studied collectively in relation to hypertension medication adherence in African Americans.

OBJECTIVE

To determine the associations among demographic and clinical factors, depressive symptoms, hypertension beliefs, and social support with blood pressure medication adherence in middle-aged African American adults with a diagnosis of hypertension.

METHODS

A cross-sectional study of (N = 120) African Americans (mean age, 49 years; 22.5% men) with a current diagnosis of metabolic syndrome, including hypertension, who reported having and taking a prescribed blood pressure-lowering medication were included. Descriptive statistics, bivariate correlation analysis, and logistic regression using odds ratio were used to examine the effects of high blood pressure beliefs, social support, and depression on medication adherence.

RESULTS

A small but significant relationship was found between medication adherence and number of comorbidities (r = 0.19, P = .04). In a multivariate regression model, after controlling for gender, comorbidities remained associated with medication adherence (β = 0. 77, P = .04). Depressive symptoms, high blood pressure beliefs, and social support did not have a significant relationship with medication adherence.

CONCLUSIONS

Multiple comorbidities may have a positive impact upon medication adherence. Further study is needed in a larger sample of African Americans who have a diagnosis of hypertension in addition to other comorbidities requiring medication management.

The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial

OBJECTIVE

To evaluate the effects of self-management education tailored to health literacy on medication adherence and blood pressure control.

METHOD

This randomized controlled trial was conducted in 2018 with 118 elderly people with uncontrolled primary hypertension and inadequate health literacy. Self-management education was developed on the basis of the health literacy index. Medication adherence and blood pressure were assessed using 8-items Morisky Medication Adherence Scale and a mercury sphygmomanometer, respectively.

RESULTS

At baseline, there were no significant between-group differences regarding participants' demographic characteristics, medical history, and medication adherence. After the intervention, between-group comparisons adjusted for pretest scores showed a significant reduction in the mean score of systolic and diastolic blood pressure and increase adherence to medication due to intervention (P < 0.05). However, the proportions of controlled systolic and diastolic blood pressure were not statistically significant different between-group (P > 0.05).

CONCLUSION

Self-management education tailored to health literacy significantly promotes medication adherence but has no significant effects on control of blood pressure.

PRACTICE IMPLICATION

To promote adherence to antihypertensive medications, tailored patient education to Health literacy is recommended. Limited pieces of evidence are available on the effectiveness of health literacy index-based interventions, so further studies are required.

Evaluating the Role of Clinical Pharmacists in Providing Pharmaceutical Care to Improve Adherence in Hypertensive Patients at a Rural Hospital in Southern Chile: A Pilot Study

Objective:

The majority of patients who receive antihypertensive treatment do not achieve adequate blood pressure (BP) outcomes. Adherence to antihypertensive therapy contributes to adequate control of BP and is a substantial reason for therapeutic success. This study aims to evaluate the role of clinical pharmacists in improving patient adherence to pharmacological treatment and in improving BP outcomes.

Methods:

A pre- and postpharmaceutical care interventional study was provided to hypertensive patients in the Cardiovascular Health Program of the Family Health Community Hospital in rural Coelemu, Chile. Patients received pharmaceutical care in three individualized sessions over 6 months. Written educational materials including basic information on high BP were provided to each patient in every session using easy-to-understand language. BP was measured at the beginning and end of each session using an electronic tensiometer, and patients reported their adherence to therapy using indirect, self-reported measures.

Findings:

Over the study period, patients experienced average decreases in systolic and diastolic BP of 7.68 mmHg (P < 0.001) and 2.91 mmHg (P < 0.001), respectively. Patient adherence to medication, according to self-reported measures, increased from 22% to 60% over the study period.

Conclusion:

Pharmaceutical care, including education about hypertension, healthy lifestyle habits, and adherence, was associated with improved adherence to antihypertensive drug treatment and control of BP in hypertensive patients at a rural hospital in Chile.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Non-Adherence to Prescribed Antihypertensives in Primary, Secondary and Tertiary Healthcare Settings in Islamabad, Pakistan: A Cross-Sectional Study

OBJECTIVE

This study aimed to assess the prevalence and predictors of non-adherence to antihypertensive medication among patients with hypertension attending various healthcare settings in Islamabad, Pakistan.

METHODS

A questionnaire-based cross-sectional study was conducted in selected healthcare facilities between September 2017 and December 2018. The study was conducted in primary, secondary and tertiary healthcare settings in Islamabad, Pakistan. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). Sociodemographic and clinical data of recruited patients were collected through a structured questionnaire. Binary logistic regression analysis was performed to determine covariates significantly associated with medication adherence and blood pressure control.

RESULTS

A total of 776 hypertensive patients were invited and 741 (95%) completed the questionnaire. The mean ± SD age of participants was 53.6±12.6 years; 284 patients (38.3%) had high adherence, 178 (24%) had moderate adherence and 279 (37.7%) were non-adherent to the prescribed antihypertensive therapy. Binary regression analysis revealed that old age (OR 1.783 [95% CI: 1.172-2.712]; P=0.013), being educated (OR 2.018 [95% CI: 1.240-3.284]; P=0.036), entitlement to free medical care (OR 1.369 [95% CI: 1.009-1.859]; P=0.044), treatment duration (OR 2.868 [95% CI: 1.913-4.299]; P=0.001), number of medications (OR 1.973 [95% CI: 1.560-2.495]; P=0.001), presence of any comorbidity (OR 2.658 [95% CI: 1.836-3.848]; P=0.001) and blood pressure control (OR 3.103 [95% CI: 2.268-4.247]; P=0.001) were significantly associated with good adherence. Similarly, age (OR 1.998 [95% CI: 1.313-3.040]; P=0.004), entitlement to free medical care (OR 1.498 [95% CI: 1.116-2.010]; P=0.007), treatment duration (OR 1.886 [95% CI: 1.143-3.113]; P=0.013), presence of any comorbidity (OR 1.552 [95% CI: 1.123-2.147]; P=0.008) and adherence level (OR 3.103 [95% CI: 2.268-4.247]; P=0.001) had significant association with controlled blood pressure. The following were the main reasons for non-adherence to prescribed antihypertensive medication: "don't feel need for regular use" (24.7%), "Carelessness" (13.4%) and "adverse effects" (11.2%).

CONCLUSION

The prevalence of non-adherence to antihypertensive medications was high in the study population and poor medication adherence could potentially explain poor blood pressure control. Evidence-based targeted interventions on both medication adherence and blood pressure control should be introduced and implemented for better treatment outcomes.

Health Beliefs and Medication Adherence in Omanis With Hypertension

BACKGROUND

Patients' health beliefs are essential to improve medication adherence among patients with hypertension.

OBJECTIVE

Our objective was to examine the relationship between (1) patients' beliefs about hypertension, medication, and self-efficacy and medication adherence and (2) medication adherence and blood pressure control in Oman.

METHODS

This cross-sectional study included 215 participants with hypertension. Participants completed 4 questionnaires (Arabic version) to measure medication adherence, beliefs about hypertension severity, beliefs about medication, and self-efficacy. Bivariate and multivariate logistic regression was used to conduct the analyses.

RESULTS

Higher self-efficacy (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.54-4.37), stronger beliefs about medication necessity (OR, 1.98; 95% CI, 1.21-3.23), increased age (OR, 1.06; 95% CI, 1.03-1.10), and fewer medication concerns (OR, 0.34; 95% CI, 0.20-0.57) were related to high medication adherence. Moreover, uncontrolled blood pressure was less likely in participants with high medication adherence (OR, 0.47; 95% CI, 0.24-0.93).

CONCLUSIONS

Patients' beliefs are important consideration to improve medication adherence. Clinically, patients' beliefs should be assessed, and strategies to improve medication adherence should incorporate beliefs as a key component to improve antihypertensive medication adherence. Patient education and counseling regarding hypertension and necessity and side effects of medications are important to maximize positive beliefs and improve medication adherence.

Determinants of Primary Nonadherence to Medications Prescribed by General Practitioners Among Adults in Hungary: Cross-Sectional Evaluation of Health Insurance Data

Background: Primary nonadherence to prescribed medications occurs when patients do not fill or dispense prescriptions written by healthcare providers. Although it has become an important public health issue in recent years, little is known about its frequency, causes, and consequences. Moreover, the pattern of risk factors shows remarkable variability across countries according to the published results. Our study aimed to assess primary nonadherence to medications prescribed by general practitioners (GPs) and its associated factors among adults in Hungary for the period of 2012–2015.

Methods: Data on all general medical practices (GMPs) of the country were obtained from the National Health Insurance Fund and the Central Statistical Office. The ratio of the number of dispensed medications to the number of prescriptions written by a GP for adults was used to determine the medication adherence, which was aggregated for GMPs. The effect of GMP characteristics (list size, GP vacancy, patients’ education provided by a GMP, settlement type [urban or rural], and geographical location [by county] of the center) on adherence, standardized for patients’ age, sex, and eligibility for an exemption certificate, were investigated through generalized linear regression modeling.

Results: A total of 281,315,386 prescriptions were dispensed out of 438,614,000 written by a GP. Overall, 64.1% of prescriptions were filled. According to the generalized linear regression coefficients, there was a negative association between standardized adherence and urban settlement type (b = -0.099, 95%CI = -0.103 to -0.094), higher level of education (b = -0.440, 95%CI = -0.468 to -0.413), and vacancy of the general practices (b = -0.193, 95%CI = -0.204 to -0.182). The larger GMP size proved to be a risk factor, and there was a significant geographical inequality for counties as well.

Conclusions: More than one-third of the written prescriptions of GPs for adults in Hungary were not dispensed. This high level of nonadherence had great variability across GMPs, and can be explained by structural characteristics of GMPs, the socioeconomic status of patients provided, and the quality of cooperation between patients and GPs. Moreover, our findings suggest that the use of the dispensed-to-prescribed medication ratio in routine monitoring of primary health care could effectively support the necessary interventions.

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services

This study was part of monitoring an intervention aimed at developing a general practitioner cluster (GPC) model of primary healthcare (PHC) and testing its effectiveness in delivering preventive services integrated into the PHC system. The aim was to demonstrate whether GPC operation could increase the percentage of drugs actually dispensed. Using national reference data of the National Health Insurance Fund for each anatomical-therapeutic chemical classification ATC group of drugs, dispensed-to-prescribed ratios standardized (sDPR) for age, sex, and exemption certificate were calculated during the first quarter of 2012 (before-intervention) and the third quarter of 2015 (post-intervention). The after-to-before ratios of the sDPR as the relative dispensing ratio (RDR) were calculated to describe the impact of the intervention program. The general medication adherence increased significantly in the intervention area (RDR = 1.064; 95% confidence interval (CI): 1.054-1.073). The most significant changes were observed for cardiovascular system drugs (RDR = 1.062; 95% CI: 1.048-1.077) and for alimentary tract and metabolism-specific drugs (RDR = 1.072; 95% CI: 1.049-1.097). The integration of preventive services into a PHC without any specific medication adherence-increasing activities is beneficial for medication adherence, especially among patients with cardiovascular, alimentary tract, and metabolic disorders. Monitoring the percentage of drugs actually dispensed is a useful element of PHC-oriented intervention evaluation frames.

Can Acupuncture Treatment of Hypertension Improve Brain Health? A Mini Review

With age, cerebrovascular and neurodegenerative diseases (e.g., dementia and Alzheimer’s) are some of the leading causes of death in the United States. Related to these outcomes is the increased prevalence of hypertension, which independently increases the development of cerebrovascular and neurodegenerative diseases. While a direct mechanistic link between hypertension and poor brain health is unknown, many hypothesize that the etiology stems from poor blood pressure (BP) and cerebrovascular regulation. This dysfunction fosters hypoperfusion of the brain, causing stress to the tissue through a nutrient mismatch, subtly damaging the brain over many years. Current Western medical treatment relies on pharmacological treatment (mainly beta-blockers, angiotensin-converting enzyme inhibitors, or a combination of the two). However, Western treatments have not been successful in mitigating brain health outcomes and are burdened with unwanted side effects and non-adherence issues. Alternatively, traditional East Asia medicine has used acupuncture as a treatment for hypertension and may offer a promising approach in response to the limitations of conventional therapy. While detailed clinical and mechanistic experimental evidence is lacking, acupuncture has been observed to reduce BP and improve endothelial function in hypertensive adults. Further, acupuncture has been shown to have specific cerebrovascular effects, increasing cerebrovascular reactivity in healthy adults, highlighting possible neuroprotective properties. Therefore, our review is aimed at evaluating acupuncture as a treatment for hypertension and the potential impact on brain health. We will interrogate the current literature as well as discuss the proposed neural and vascular mechanisms by which acupuncture acts.

Treatment of actinic keratoses and cancerization field of the face and scalp with 0.015% ingenol mebutate gel in Brazilian individuals: safety, tolerability and patients' perspectives

BACKGROUND

Actinic keratosis (AK) represents a risk of progression to squamous cell carcinoma. Ingenol mebutate gel is a novel therapeutic option for field-directed treatment.

OBJECTIVES

To evaluate the safety, tolerability and patients' perspectives, related to the therapeutic success of managing AKs on the face and scalp with ingenol mebutate gel in Brazilian individuals.

METHODS

This was an observational, retrospective and descriptive study of 68 areas of actinic keratosis on the face and scalp treated with Ingenol mebutate gel involving a total of 37 patients. The drug was applied for three consecutive days on an area of of 25 cm2 and documentation was performed on baseline and days 4, 8, 15, 60 and 180. On day 4, the composite local skin reaction score was calculated. At the end, a questionnaire was applied to evaluate patients' perspectives about the treatment.

RESULTS

Adherence was 100%, no serious adverse events were recorded and the mean composite local skin reaction score (standard deviation) was 8.61±4.22. The treatment was considered optimum by 75.68% of the patients.

STUDY LIMITATIONS

Calculation of composite local skin reaction score performed only on the fourth day.

CONCLUSIONS

Treatment with ingenol mebutate gel was considered safe and tolerable in Brazilian subjects. Patients had a maximum adherence rate and a great improvement in self-esteem. The results of this research reproduce the findings of the literature.

Association Between Medication Literacy and Medication Adherence Among Patients With Hypertension

Background: Few studies have investigated the association between medication literacy and medication adherence as well as the influence of medication literacy on medication adherence in hypertensive patients. Thus, the goal of the present study was to determine the association between medication literacy and medication adherence in hypertensive patients. Methods: A cross-sectional survey was conducted between August 2016 and December 2016. Self-administered questionnaires were completed, including a self-developed and structured socio-demographic questionnaire; a self-developed, validated, and self-reported Medication Literacy Scale for Hypertensive Patients (C-MLSHP) used for medication literacy measurement; and the Chinese Version of the Morisky Medication Adherence Scale-8 (C-MMAS-8), an eight-item validated, self-report scale for adherence measurement with a total score range of 0-8. A cut-off of 6 was applied to differentiate adherence levels, including patients with an MMAS score <6 (low adherence), MMAS score = 8 (high adherence), and MMAS score ≥6 and <8 (moderate adherence). In this study, hypertensive patients' medication literacy levels and adherence to antihypertensive agents were identified. Pearson correlation analysis was carried out to identify the correlation between medication literacy and adherence. Binary logistic regression analysis was performed with medication adherence as the outcome variable in order to confirm factors associated with medication adherence. Results: A total of 420 hypertensive patients, including 198 women and 222 men with a mean age of 60.6 years (SD = 12.4), were recruited. The mean score of hypertensive patients on the medication literacy scale was 24.03 (SD = 5.13). The mean scores of the four dimensions of knowledge, attitude, skill, and behavior on the medication literacy scale of this study were 6.22 ± 2.22, 5.04 ± 1.16, 4.50 ± 2.21, and 8.27 ± 1.90, respectively. Regarding medication adherence, the mean score of the C-MMAS-8 in this study was 4.82 (SD = 2.11). A total of 63.6% of patients presented with low adherence, 29.5% presented with moderate adherence, and 7.6% presented with high adherence. The Pearson correlation results showed that medication literacy (r = 0.342, P < 0.01) as a whole variable and the three dimensions of knowledge (r = 0.284, P < 0.01), attitude (r = 0.405, P < 0.01), and behavior (r = 0.237, P < 0.01) were significantly associated with medication adherence. Binary logistic regression analysis indicated that annual income [OR 1.199 (95% CI: 1.011-1.421); P = 0.037] and two dimensions of attitude [OR 2.174 (95% CI: 1.748-2.706); P = 0.000] and behavior [OR 1.139 (95% CI: 1.002-1.294); P = 0.046] in medication literacy were found to be independent predictors of medication adherence. Individuals with better attitudes and behavior literacy in medication literacy were more likely to adhere to the use of antihypertensive agents. Those who had higher annual incomes were more likely to adhere to the use of antihypertensive agents. Conclusion: The levels of medication literacy and medication adherence of hypertensive patients are suboptimal and need to be improved in China. The level of medication literacy in patients with hypertension could affect their adherence to antihypertensive drugs. It was suggested that hypertensive patients' medication adherence could be improved and driven by increasing the medication literacy level, especially in the attitude and behavior domains. Pertinent strategies that are specific to several dimensions of medication literacy should be developed and implemented in order to promote full medication literacy among hypertensive patients, thus facilitating optimal adherence and blood pressure control.

Antihypertensive Medication Nonpersistence and Low Adherence for Adults <65 Years Initiating Treatment in 2007-2014

Previous evidence suggests modest improvements in antihypertensive medication adherence occurred from 2007 to 2012 among US adults ≥65 years of age. Whether adherence improved over time among adults <65 years of age is unknown. We assessed trends in antihypertensive medication nonpersistence and low adherence among 379 658 commercially insured adults <65 years of age initiating treatment in 2007-2014 using MarketScan claims. Nonpersistence was defined as having no days of medication available to take during the final 90 days of the 365 days following initiation. Among beneficiaries who were persistent to treatment, low adherence was defined by having antihypertensive medication available to take for <80% of the days in the 365 days following initiation (ie, proportion of days covered <80%). In 2007 and 2014, 23.3% and 23.5% of patients were nonpersistent to treatment, respectively, and 42.3% and 40.2% had low adherence, respectively. The relative risks for nonpersistence and low adherence were lower among beneficiaries initiating treatment with an angiotensin-converting enzyme inhibitor (0.95; 95% CI, 0.94-0.97 and 0.97; 95% CI, 0.96-0.98, respectively), angiotensin receptor blocker (0.86; 95% CI, 0.85-0.88 and 0.99; 95% CI, 0.97-1.00, respectively), or multiclass regimen (0.82; 95% CI, 0.80-0.84 and 0.88; 95% CI, 0.86-0.89, respectively), prescribed 90-day versus 30-day prescriptions (0.67; 95% CI, 0.66-0.68 and 0.70; 95% CI, 0.69-0.71, respectively), or who received medications by mail versus at the pharmacy (0.93; 95% CI, 0.90-0.95 and 0.90; 95% CI, 0.88-0.92, respectively). In conclusion, several modifiable factors were associated with lower rates of both antihypertensive medication nonpersistence and low adherence among adults <65 years of age initiating treatment in 2007-2014.