Qualitative Nursing Research
RisingKing
Qualitativedocument.pdf
© 2010 Tsiantou et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.
Patient Preference and Adherence 2010:4 335–343
Patient Preference and Adherence Dovepress
submit your manuscript | www.dovepress.com
Dovepress 335
O r i g i n A L r e s e A r c h
open access to scientific and medical research
Open Access Full Text Article
DOI: 10.2147/PPA.S12326
Factors affecting adherence to antihypertensive medication in greece: results from a qualitative study
Vassiliki Tsiantou1
Polina Pantzou2
elpida Pavi1
george Koulierakis2
John Kyriopoulos1
1Department of health economics, national school of Public health, Athens, greece; 2Department of sociology, national school of Public health, Athens, greece
correspondence: Vassiliki Tsiantou national school of Public health, Department of health economics, Alexandras Ave 196, 11521 Athens, greece Tel +30 210 64 35 328 Fax +30 210 64 49 571 email [email protected]
Introduction: Although hypertension constitutes a major risk factor for cardiovascular morbidity and mortality, research on adherence to antihypertensive treatment has shown that at least 75%
of patients are not adherent because of the combined demographic, organizational, psychological,
and disease- and medication-related factors. This study aimed to elicit hypertensive patients’
beliefs on hypertension and antihypertensive treatment, and their role to adherence.
Methods: Transcripts from semistructured interviews and focus groups were content analyzed to extract participants’ beliefs about hypertension and antihypertensive treatment, and attitudes
toward patient–physician and patient–pharmacist relationships.
Results: Hypertension was considered a very serious disease, responsible for stroke and myocardial infarction. Participants expressed concerns regarding the use of medicines and the
adverse drug reactions. Previous experience with hypertension, fear of complications, system-
atic disease management, acceptance of hypertension as a chronic disease, incorporation of the
role of the patient and a more personal relationship with the doctor facilitated adherence to the
treatment. On the other hand, some patients discontinued treatment when they believed that
they had controlled their blood pressure.
Conclusion: Cognitive and communication factors affect medication adherence. Results could be used to develop intervention techniques to improve medication adherence.
Keywords: hypertension, medication adherence, patient compliance, doctor–patient commu- nication, antihypertensive medicine
Introduction Nonadherence to treatment medication, especially in chronic diseases, is a complicated
issue affecting patients’ health, health expenditure, and recourses’ utilization.1,2
A number of studies, both qualitative and quantitative, examine the factors that are
believed to explain variations in adherence in other chronic diseases.3–5 Based on such
findings, interventions have been designed to improve patient compliance.6
Research on health behaviors, such as medication adherence, has resulted in
the formulation of specific psychological theories addressing patients’ beliefs and
roles. Leventhal and colleagues’ Self-Regulatory Model (SRM)7 suggests that when
individuals face a health threat, they form both cognitive and emotional representations
of the disease, which act in parallel to influence associated health behaviors. Cognitive
representations comprise of beliefs on illness identity, antecedent causes, consequences,
timeline, and cure-control,8 whereas the emotional representations comprise individual’s
emotional reaction to the disease. Furthermore, individual’s beliefs about treatment have
been proposed as another determinant to understand the way in which patients make
Patient Preference and Adherence 2010:4submit your manuscript | www.dovepress.com Dovepress
Dovepress
336
Tsiantou et al
decisions about their treatment.9 Finally, different aspects
of doctor–patient communication have been examined as
potential predictors of medication adherence.10
Hypertension is the medical condition where the
systolic blood pressure is more than 140 mm Hg and the
diastolic blood pressure is more than 90 mm Hg.11 It is a
chronic disease which is considered to be one of the major
public health problems and a significant cardiovascular risk
factor. According to the World Health Organization (WHO),
each year, at least 7.1 million people die as a result of
increased blood pressure.12 For the treatment of hypertension,
a broad range of antihypertensive medications are currently
available, as well as Therapeutic Lifestyle Changes such as
weight reduction, increased physical activity, and reduction
of dietary salt intake, which have proven to be important
in disease management.13 Although there is evidence that
increased blood pressure can actually be controlled with
the cardiovascular risk factor being thus reduced,14 75% of
patients diagnosed with hypertension cannot achieve full
control of their blood pressure.13 Poor blood pressure con-
trol is associated with higher healthcare resource utilization
and costs15 and increased risk of cardiovascular diseases.
Nonadherence to antihypertensive medication is the main
reason for failure to control blood pressure among those
under treatment.16
In Greece, although there is no nationwide data available
for the prevalence of hypertension, it is estimated that 25%
of the adult population are suffering from it.11 Moreover, it
is estimated that 40% of hypertensive adults are unaware
of their condition, and 25% of those receiving treatment do
not succeed in controling their blood pressure.11 Other stud-
ies have shown that awareness and control of hypertension
and blood pressure is lower in Greece compared with other
countries.17,18
In addition, few studies have been conducted in Greece
investigating the issue of adherence to treatment. The aim
of the present study was to investigate the factors affecting
antihypertensive medication adherence in Greece.
Methods study design Semistructured interviews and focus groups were conducted
in order to elicit data from people with hypertension.
Semistructured interviews were preferred for those attending
the Hypertension Centers (HCs) (Group A), allowing the inves-
tigators to approach them individually, as HC attendees were
of older age. Older age is related to sensory loss that interferes
with reception of the spoken message. People with sensory
loss thus frequently experience communication problems.19
One-to-one semistructured interviews could overcome this
problem, which might otherwise influence older age partici-
pants’ ability to participate effectively in focus groups. Focus
groups were preferred for the group of younger participants
(Group B), aged between 40 and 50 years, who were not or
usually were not attending the HC, suffer from sensory loss.
The age criterion was based on the available data regarding
hypertension prevalence in Greece.20 According to these
data, diagnosed hypertensive patients younger than the age
of 40 years represent less than 1.6% of the total number of
hypertensive patients. Although it would be really hard for
these patients to be identified, we decided to have this age
criterion of hypertensive patients older than 30 years in case
we could not find anyone between the ages of 30–40 years.
In the case of focus groups, the lower limit was increased,
from 30 to 40 years of age, because it was impossible for us
to identify hypertensive patients between the ages of 30–40
years among the registered hypertensive patients. Fieldwork
was conducted during the period May–July 2008.
Participants and settings Group A participants were recruited from HC established
in hospitals of the greater Athens area. Three HCs were
purposively selected in order to reflect different geographic
and socioeconomic regions. Two were established in public
hospitals, and the third was established in an insurance fund
hospital. In each center, the physician in charge assisted
researchers to recruit patients.
Participants had to meet the following inclusion criteria in
order to participate in the study: (a) being aged above 30 years,
(b) receiving antihypertensive treatment for at least 1 year,
and (c) speaking the Greek language fluently.
When patients who met the inclusion criteria attended
the HC, on a specific day, an invitation letter was given
to them by their physician explaining the purpose and the
methodology of the study. In total, 25 patients accepted to be
interviewed. Interviews were conducted, immediately after
patients’ medical examination in a private room in the HC,
provided for the purposes of this study.
All interviews were facilitated by two researchers
(psychologist [PP] and co-moderator [VT]). All interviews
were anonymous and were audio taped, after participants’
consent.
For Group B participants, the inclusion criteria were as
follows: (a) being aged between 40 and 50 years, (b) receiving
antihypertensive treatment for at least 1 year, (c) not consult-
ing an HC, and (d) speaking the Greek language fluently.
Patient Preference and Adherence 2010:4 submit your manuscript | www.dovepress.com Dovepress
Dovepress
337
Adherence to antihypertensive treatment
Recruitment for Group B participants was made with
convenience and purposive sampling. A telephone invitation
survey among 200 registered hypertensive patients was
conducted in order to identify those who met the inclusion
criteria and were willing to attend the focus group sessions.
In total, 18 patients (50% female) accepted to participate.
Similar to semistructured interviews, participants were
informed about the aims of the study, the methodology, and
were assured of anonymity and confidentiality.
Two focus groups were organized, one comprising of
9 males and the other comprising of 9 females, in order to
facilitate group dynamics and achieve higher homogeneity.21
Each group was moderated by an experienced psychologist
and a co-moderator whose primary responsibility was to
take notes during sessions. Both researchers met after each
session in order to assess the procedure and identify crucial
elements for the interpretation of the data.
Focus groups took place at the Department of Health
Economics, National School of Public Health in Athens.
The first session had a duration of 2 hours 8 minutes and the
second 2 hours 22 minutes. Comfortable chairs, beverages,
and snacks were offered in order to create a pleasant
atmosphere and lighten the burden of the long duration of
the focus group. Focus group sessions were tape-recorded,
after participants’ written consent.
content and questions According to standard methodology, open-ended questions
and probes were predetermined for use during the semistructured
interviews and the focus groups. These were based on the
review of the relevant literature, taking into consideration the
recommendations of the research team. Questions and probes
fell within four research topics (see Table 1): perceptions and
beliefs about hypertension, perceptions and beliefs toward
antihypertensive treatment, patient—physician relationship,
and patient—pharmacist relationship. Commencing ques-
tions in each research topic were general, capturing par-
ticipants’ beliefs in hypertension and treatment. Probes were
more specific in order to elicit the opinion, experience, and
behavior of the participant. Only demographic information
was collected by a purpose-made short questionnaire.
Analysis All interviews and focus group recordings, as well as notes
kept by the focus group co-moderator, during the sessions
were fully transcribed. Transcriptions were analyzed using
content analysis,22 without using any qualitative data
software. Each researcher (PP and VT) separately studied
the transcriptions and the notes kept by the co-moderator,
identified the emergent themes and keywords, and categorized
the findings according to the four research topics. Then, the
research team met in order to compare the findings, interpret
results, and formulate conclusions. Demographic data were
analyzed using MS Excel 2007.
Results Group A comprised of 25 participants aged between 47 and
79 years (mean age, 63.7 years), whereas the 18 participants
in Group B were aged between 40 and 50 years (mean age,
44.6 years; Table 2). Participants did not differ significantly
in relation to gender. Group A participants were more likely
(84%) to be under medication treatment for co-morbidities
than their Group B counterparts (66.7%); however, this
difference did not reach statistical significance.
Perceptions and beliefs about hypertension Hypertension was considered a very serious disease
responsible for even more dangerous medical conditions such
Table 2 Demographic characteristics of the participants
Characteristics Semistructured interviews (Group A) N = 25
Focus groups (Group B) N = 18
Mean, N (%) Mean, N (%)
gender Male 12 (48%) 9 (50%) Female 13 (52%) 9 (50%) Age (mean) 63.7 44.6 no. of patients receiving additional medication for other conditions
21 (84%) 12 (66.7%)
Table 1 Topics and subtopics of the qualitative study
No Main topics Subtopics
1 Perceptions: beliefs about hypertension
• risk factors • complications • sources of information • symptoms and disease diagnosis
2 Perceptions: beliefs about antihypertensive treatment
• Attitudes and beliefs towards drugs in general
• Adverse drug reactions • Factors influencing adherence to
antihypertensive treatment • Adherent characteristics
3 Patient–physician relationship
4 Patient–pharmacist relationship
• Dispensing/recommending medications
Patient Preference and Adherence 2010:4submit your manuscript | www.dovepress.com Dovepress
Dovepress
338
Tsiantou et al
as stroke and myocardial infarction. Stress, anxiety, limited
physical activity, and unhealthy diet emerged as the perceived
most important risk factors of hypertension.
• “Hypertension has very serious consequences, you can have a stroke … it is very bad”. (Group A, female)
• “… Cardiovascular diseases and death. This is what I am thinking when I hear hypertension. If you don’t control
it you will die”. (Group B, female)
• “I believe that stress is the major factor that makes all of us or at least most of us suffering from hypertension”
(Group B, male)
• “It is not only stress, but the way of life in general”. (Group B, male)
sources of information The main sources of information were the physician or the
pharmacist, the media, the Internet, and people who suffered
from hypertension. However, participants admitted that their
physician was the most trusted source. Participants were
interested in further information for two reasons: to achieve
a better understanding of their doctor’s advice and to check
the validity of this advice.
• “My doctor gave me some information, but I search information through Internet too, so I can cross-check
what he says”. (Group A, male)
• “… mainly my doctor and some books. But usually I talk with people who also suffer from hypertension, I feel
more comfortable discussing with them” (Group A,
female)
• “There are TV programs about health, but I always discuss everything I hear with my doctor” (Group B,
male)
symptoms and disease diagnosis Although hypertension was associated with well-recognized
symptoms, such as headaches and dizziness, participants
often did not seek health care, at least until those symptoms
became unbearable.
• “I knew that I had high blood pressure but I had never gone to a doctor, until I couldn’t bear the pain of the
headaches” (Group A, male)
• “I was feeling a constant pressure in my head, so I decided to consult a doctor …” (Group B, female) When symptoms were mild, participants were usually
referring to a pharmacist. If symptoms were more intense,
they were looking for a specialist mainly an internist or a
cardiologist.
• “I was not feeling well, so I went to a pharmacist to measure my blood pressure …” (Group B, female)
• “One day, I felt very strange, like having a heart attack or stroke; I was so scared that I went to the hospital …” (Group B, male)
• “I had strong headaches and because my father had also hypertension, I went to a cardiologist” (Group A,
female)
Participants’ perceptions and beliefs toward antihypertensive treatment Attitudes and beliefs towards drugs Concerns and fear were expressed by the majority of
participants regarding the use of medicines. Some of them
expressed the opinion that the long-term use of medicines
will have an impact on their immune system.
• “In general, I avoid taking medicines. If the decision is on me I will not take any drugs …” (Group A, male)
• “… Some years ago I was suffering from spondylolisthesis and my doctor prescribed anti-inflammatory, and then my
blood pressure was 18 to 19”. (Group A, female)
• “… I have taken so many drugs that I have destroyed my immune system …” (Group A, female)
• “… I don’t like it (taking drugs) at all, because you try to fix one thing and something else goes wrong …” (Group A, female)
• “Yes, but so many drugs? Don’t all of these end up in the liver? For how long can it (the liver) bear all these? … and it is only one. I don’t know, I am a little afraid”.
(Group B, female)
Adverse drug reactions Adverse drug reactions were an issue of great concern for
the majority of study participants. Some of them had stopped
their treatment because they were afraid of the possible
side effects. Avoidance of getting to know the possible side
effects was also one of the reasons given for not reading the
information leaflet of the drug.
• “… If I read (in the leaflet) that the drug has adverse drug reactions and this or that can happen to me, I stop
the treatment …” (Group A, male) • “If you read about side effects you should not take any
medicine. However, I have prevented some reactions
because I had read the information leaflet” (Group A,
male)
• “I don’t read the side effects, because then I think that I suffer from all these reactions” (Group B, female)
Patient Preference and Adherence 2010:4 submit your manuscript | www.dovepress.com Dovepress
Dovepress
339
Adherence to antihypertensive treatment
• “I usually read the side effects, but I can’t understand everything … I trust my doctor who prescribes it. If something goes wrong I believe that I will understand
it” (Group B, male)
Factors influencing adherence to antihypertensive treatment The level of adherence among participants ranged. Previous
experiences regarding hypertension and the fear or
knowledge that they could suffer from a complication if they
did not control their blood pressure were important reasons
for medication adherence.
• “I didn’t know what it means to have high blood pressure for years and what this can cause to you …” (Group A, male)
• “… because I have read and I know what can happen to me if I do not follow the treatment” (Group A,
female)
• “… I take the pill every day, because I am afraid” (Group B, female)
• “… my neighbor had a stroke 5 years ago and he hasn’t recovered yet. I see all these and I follow my treatment
because I am afraid that this will happen to me too”.
(Group B, male)
• “… I am afraid of what will happen to me because of the hypertension, there is also the heredity”. (Group B,
male)
In addition, systematic disease management, especially
in HC, was a signif icant factor influencing treatment
adherence.
• “Here (in the HC) I have a program and I come regularly for my blood pressure …” (Group A, male)
• “First of all, it is very important that I come here regularly and I have a program, an antihypertensive program,
and since I’ve started taken my pills nothing has gone
wrong …” (Group A, male) Another important factor affecting adherence was the
acceptance of the disease and the adoption of the patient’s
role. Most of the participants, especially the younger ones
who participated in focus groups, were hesitant and negative
to the idea of taking a medicine for their whole life. The
sooner they perceived hypertension as a chronic disease, the
more adherent they became.
• “… at first I was really stressed. I didn’t want to believe that I will receive an antihypertensive treatment, why
me? I was feeling really sad, it was like killing me …” (Group B, male)
• “I believe that it is tragic to take a medication for the whole of your life, I can’t stand it. I believe that it is
the beginning of the end, the beginning of taking more
drugs …” (Group B, male) Sometimes, acceptance of the disease led to the change
of patient’s lifestyle.
• “… after this (the diagnosis of hypertension) the whole perspective about my diet changed …” (Group B, male)
Adherence characteristics Adherence to treatment was easier if the medication
were received in the morning. In this case, the majority
of participants had associated their medication with their
breakfast or had invented different tricks in order to
remember it.
• “I take it during breakfast, I am used to it now” (Group A, female)
• “I take it every morning, I set the alarm clock in order to remember it, you have to associate it with something,
otherwise you forget it” (Group B, male)
Most of the participants admitted during weekends
they received their medication some hours later than the
appropriate, believing that this was an “innocent” tactic,
although their doctor had warned them for the opposite.
• “At the weekends I take my pill 3 hours later … I don’t believe it does any harm. On the contrary, three
hours more sleep is good because our organism is calm
when we are sleeping. When we wake up we need the
pill …” (Group B, female) The drug substance also seemed to be an important factor
affecting adherence when its effects interferes with patients’
activities.
• “I take one pill every morning. But, because it is diuretic, when I go out I do not take it …” (Group A, male) Finally, some of the participants mentioned that they
stopped the treatment from time-to-time when they no longer
suffered from symptoms or when they believed that they had
controlled their blood pressure.
• “If my blood pressure is at good levels, I can’t see the reason to take it (the pill). I am afraid to take it because
it might cause hypotension to me”. (Group A, female)
• “… When I have symptoms I follow my treatment, when I feel good I don’t ….” (Group B, female)
• “I stopped the treatment for a period, just to see what will happen, if I will get better … but it didn’t work” (Group B, male)
Patient Preference and Adherence 2010:4submit your manuscript | www.dovepress.com Dovepress
Dovepress
340
Tsiantou et al
Patient–physician relationship The majority of participants considered the relationship
with their physician of great importance. Good atmosphere
during consultation and physician’s time spent on giving
advice and answering questions were mentioned as the most
important characteristics of a “good” doctor. Distant and
formal behavior of physician could be a reason for changing
the doctor for some participants.
• “I appreciate my doctor very much, he explains everything to me. He doesn’t care only about prescribing.
He practices real medicine. (Group A, male)
• “First of all they really seem to care about me. They listen to my questions and wishes and I understand it”
(Group A, male)
• “I stopped consulting my first doctor because of his behavior. I don’t know, this was probably because of
his age, he was old, but the distance between me and
the physician was big. I wanted to ask something and I
hesitated, and when I did so his answers were yes or no,
nothing more ….” (Group B, female) Good communication and a rewarding behavior of the
physician as well as a high level of confidence also seemed
to facilitate adherence.
• “If I have good results, then my doctor congratulates me” (Group A, female)
• “I believe that the doctor should inspire you confidence, then you will follow the treatment and if the doctor is
strict you will comply ….” (Group A, female) • “I feel gratitude; the whole team here works for me”.
(Group A, male)
Patient–pharmacist relationship Regarding patient–pharmacist relationship, participants
trusted their pharmacist’s advice on taking the appropriate
medication when they concerned a minor health condition
such as a sore throat or a cold. For more serious conditions
such as hypertension, they trusted only their physician for
prescribing a drug. Still, participants consult their pharmacist
for additional information on treatment, such as whether they
should take the drug before or after dinner.
• “… I don’t want to take medicines if my doctor hasn’t prescribed them …” (Group A, female)
• “(I trust the pharmacist) … for simple things like throat, nose and things like these. For more serious conditions I
consult the doctor …” (Group A, male) • “I could trust my pharmacist for something simple like
a sore throat. In that case I could consult the pharmacist
instead of the physician” (Group B, male)
• “I will ask the pharmacist for additional information, for example if I should take my medication before or after
dinner, things like that” (Group A, male)
• “… the pharmacist is not a doctor. The pharmacist sells drugs” (Group B, female)
Participants from the insurance fund HC referred to drug
cost as another reason for not seeking pharmacist’s advice
on taking the appropriate medication.
• “… These are expensive (the antihypertensive drugs). How can I pay for these without a prescription? I am a
pensioner and my pension is low” (Group A, female)
• “… my doctor has prescribed all the drugs I take … I can’t take it without a prescription, I am a pensioner and … you understand …” (Group A, female)
Discussion Research on the adherence of antihypertensive treatment has
shown that patient’s nonadherence to medication is related
with a mix of demographic, organizational, psychological,
and disease- and medication-related variables.23,24 Thus,
investigating patients’ beliefs regarding hypertension itself
and antihypertensive treatment, as well as communication
factors that affect adherence, can have a great impact
on designing effective interventions in order to improve
treatment adherence.
The present study is the first in Greece, which examined
hypertensive patients’ beliefs about hypertension and
antihypertensive medicines, as well as patients’ behaviors
concerning treatment adherence. It also examined patient–
doctor relationship and its impact on adherence. Finally, the
study examined patients’ beliefs about the role of pharma-
cists. In general, results are consistent with findings from
other qualitative studies on antihypertensive medication
adherence.25,26
The majority of participants considered hypertension as
a very serious disease and were afraid and anxious about
potential serious consequences on their health in case of
failure to manage the disease. These negative feelings toward
hypertension represent a finding that differs from those of
other studies, where hypertension was found to be considered
a less important disease with well-recognized symptoms.23
Further research based on theoretical models like SRM is
required so that Greek patients’ beliefs about hypertension
is further explored.
Stress emerged as one of the main risk factors of hyperten-
sion. Even though participants acknowledged the importance
of this factor, stress was believed to be inevitable, and this
situation was attributed to the modern way of living.
Patient Preference and Adherence 2010:4 submit your manuscript | www.dovepress.com Dovepress
Dovepress
341
Adherence to antihypertensive treatment
Participants were being informed about hypertension
from a plethora of sources, but they trusted mainly their
physician. Furthermore, they were feeling comfortable
to discuss about hypertension with other hypertensive
patients. This finding was also confirmed during the focus
group sessions where participants were interested in sharing
their experiences and discussing their health problem with
each other.
Participants reported that they attend different health
care facilities depending on the severity of symptoms.
This behavior reflects the characteristics of the health care
system in Greece and the way it is organized. In the absence
of integrated primary care with a gate-keeping system,
patients seek care and advice of the pharmacists when it
concerns minor health conditions while they face limited
or no barriers at all in accessing and choosing health care
providers. This enables them to visit a specialist as often as
they wish without referral from a general practitioner.
Based on the results of our study, the factors that
influence medication adherence concern the management
of the disease, the treatment characteristics, and the patient–
physician relationship. The systematic disease management
includes regular appointments with the physician and
intense counseling in order for the patient to be aware
of the complications of uncontrolled blood pressure.
Treatment characteristics, such as the time of receiving the
medicine, the number of doses, and the drug substance,
were reported as influential factors. These characteristics,
which may be considered minor, are really important for
patient compliance and have been identified in other studies
as well.23,25–27
Although an association between adherence and
demographic characteristics such as age and gender could
not be established due to the nature of the study, it seems
that younger adults in Greece face greater difficulty in
the acceptance of the disease and consequently in adher-
ing to treatment. Age-related illness perception, with the
elderly being more adherent, has also been reported in
other studies.27 Building on the results of the present study,
a longitudinal quantitative survey would be useful in order
to further explore – confirm or reject – the aforementioned
finding.
Results suggest that the major factor affecting positive
medication adherence is a good doctor–patient relation-
ship. A physician who encourages and rewards patients, and
most importantly, spends quality time with them in giving
information and providing explanations about the disease and
treatment contributes significantly in patients’ compliance.
This finding is consistent with a number of previous studies that
have established the importance of this relationship.23,25,26
In contrast, pharmacist–patient relationship seems that
it did not affect medication adherence among study partici-
pants. However, a finding worthwhile to be further researched
is the role of cost of drugs in adherence because this was
a matter of great concern for a number of participants,
especially those attending insurance funds HC. Cost and
particularly level of co-payment has been identified as an
important factor associated with adherence to pharmaceutical
treatment.28
Perceptions of personal risk and outcome expectancies, as
well as redefinition of self concept or social role, have been
proven to create a “teachable moment” for risk-reducing
health behaviors.29,30 In our study, participants do create a
“teachable moment” about hypertension, by cognitively
escalating the severity of their symptoms. Previous experi-
ences regarding hypertension, either personal or those of
friends and family, and knowledge about the complications of
the disease were major determinants of a teachable moment.
Nevertheless, due to organizational factors, participants
seem to adopt a risk-reducing health behavior (ie, visit an
HC) only at a very late stage. A primary intervention stage
should be identified, and early prevention strategies should
be adopted so that hypertensive patients benefit at an earlier
prohypertension stage rather than waiting until they are
diagnosed with hypertension.
Limitations All participants of the present study reported adherence
to treatment at the time of the study, a finding initially
indicating high levels of adherence in Greek hypertensive
patients compared with previous studies conducted in
Greece.20 Nevertheless, participants mentioned that they did
not take medication at the right time, or skipped if they felt
well, indicating a rather nonadherent than adherent pattern
of behavior. This inconsistency perhaps shows a cognitive
bias, which underline causes worth further investigation.
Psychological factors like patients’ frustration due to ineffi-
cient antihypertensive treatment or the meaning of monitoring
blood pressure at home or telemonitoring might have some
effects on adherence. Furthermore, the detected inconsistency
could represent a time-related reference: participants referred
to all these behaviors regarding their pharmaceutical treat-
ment, considering them as past behaviors and not things that
they usually do in the present. In addition, this result may
only be due to a volunteer effect and can be considered a
methodological limitation given that, according to literature,
Patient Preference and Adherence 2010:4submit your manuscript | www.dovepress.com Dovepress
Dovepress
342
Tsiantou et al
adherence to antihypertensive treatment ranges between 50%
and 70%.13 Unanimous adherence allowed the identification
of the factors contributing to adherence but prevented us
from exploring the factors that inhibit it (although it could
well be assumed that the opposite factors can be responsible
for nonadherence).
From a methodological point of view, the smaller num-
ber of participants interviewed in HC, three compared to
the number of participants in the other two HCs, could be
considered another limitation of the study. However, due to
the qualitative methodology adopted and the fact that direct
comparisons among HCs were not an objective of the study,
this sample difference has a limited effect on results.
Finally, the long duration of the focus groups may be
considered another limitation of the study. Although we took
care to achieve a comfortable environment for participants,
it is not quite sure whether they were fully engaging in the
end of the discussion.
Conclusion In conclusion, the present study confirmed that cognitive and
communication factors—patients who were better informed,
had previous experiences of the disease, and a good rela-
tionship and communication with their physician—were
important determinants for adherence. These results could
form the basis for designing effective interventions adjusted
to the Greek reality aiming at both enhancing doctor–patient
communication and empowering the patient himself. Such
interventions have the potential to improve the adherence
of hypertensive patients’ medication and can consequently
reduce hypertension-related costs.
Acknowledgments This study was supported by NOVARTIS Hellas S.A.C.I.
We are also grateful to the physicians and all the patients
who participated in the study.
Disclosure The authors report no conflicts of interest in this work.
References 1. Mar J, Rodriguez-Artalejo F. Which is more important for the efficiency
of hypertension treatment: hypertension stage, type of drug or therapeutic compliance? J Hypertens. 2001;19(1):149–155.
2. Cramer JA, Benedict A, Muszbek N, Keskinaslan A, Khan ZM. The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. Int J Clin Pract. 2008;62(1): 76–87.
3. Myers L, Midence K. Adherence to Treatment in Medical Conditions. London, UK: Harwood Academic; 1998.
4. Rustveld L, Pavlik V, Jibaja-Weiss M, Kline K, Gossey T, Volk R. Adherence to diabetes self-care behaviors in English and Spanish speaking Hispanic men. Patient Prefer Adherence. 2009;3: 123–130.
5. Yurgin N, Boye K, Dilla T, Surinach N, Llach X. Physician and patient management of type 2 diabetes and factors related to glycemic control in Spain. Patient Prefer Adherence. 2008;2:87–95.
6. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescription for medications (Review). Cochrane Database Syst Rev. 2002;2:CD000011.
7. Leventhal H, Zimmerman R, Gutmann M. Compliance: a self-regulation perspective. In: Gentry D, editor. Handbook of Behavioral Medicine. New York, NY: Guilford Press; 1984:369–436.
8. Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognit Ther Res. 1992;16:143–163.
9. Horne R. Patients’ beliefs about treatment: the hidden determinant of treatment outcome? J Psychosom Res. 1999;47(6):491–495.
10. Berry D, Michas IC, Bersellini E. Communicating information about medication: the benefits of making it personal. Psychol Health. 2003; 18(1):127–139.
11. Hellenic Society for the study of Hypertension. Guidelines for the management of hypertension [in Greek]. Athens; 2008. Available from: http://www.hypertension.gr/pdf/guidelines-2008.pdf. Accessed Apr 15, 2010.
12. World Health Organization. Preventing Chronic Diseases: A Vital Investment. Geneva, Switzerland: WHO; 2005
13. World Health Organization. Adherence to Long Term Therapies: Evidence for Action. Geneva, Switzerland: WHO; 2003.
14. McInnes GT. How important is optimal blood pressure? Clin Ther. 2004;26(Suppl A):S3–S11.
15. Paramore LC, Halpern MT, Lapuerta P, et al. Impact of poorly controlled hypertension on healthcare resource utilization and cost. Am J Manag Care. 2001;7(4):389–398.
16. Neutel JM, Smith D. Improving patient compliance: a major goal in the management of Hypertension. J Clin Hypertens. 2003;5(2):127–132.
17. Efstratopoulos A, Voyaki S, Baltas A, et al. Prevalence, aware- ness, treatment and control of hypertension in Hellas, Greece. The Hypertension Study in General Practice in Hellas. Am J Hypertens. 2006;19(1):53–60.
18. Psaltopoulou T, Orfanos P, Naska A, Lenas D, Trichopoulos D, Trichopoulou A. Prevalence, awareness, treatment and control of hypertension in a general population sample 26913 adults in the Greek EPIC study. Int J Epidemiol. 2004;33(6):1345–1352.
19. Heine C, Browning CJ. Communication and psychosocial consequences of sensory loss in older adults: overview and rehabilitation directions. Disabil Rehabil. 2002;4(15):763–773.
20. Yi a n n a k o p o u l o u E C h , P a p a d o p o u l o s J S , C o k k i n o s DV, Mountokalakis TD. Adherence to antihypertensive treatment: a critical fac- tor for blood pressure control. Eur J Cardiovasc prev Rehabil. 2005;12(3): 243–249.
21. Gibbs A. Focus Groups. Guildford, United Kingdom: University of Survey; 1997. Available from: http://sru.soc.surrey.ac.uk/SRU19.html. Accessed Jun 5, 2010.
22. Bowling A. Research methods in Health: Investigating Health and Health Services. 2nd ed. Berkshire, UK: Open University Press; 2002
23. Gascon J, Sanchez-Ortuno M, Llor B, et al. Why hypertensive patients do not comply with the treatment. Results from a qualitative study. Fam Pract. 2003;21(2):125–130.
24. Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165(10):1147–1152.
25. Benson J, Britten N. Patient’s decision about whether or not to take antihypertensive drugs: qualitative study. BMJ. 2002;325:873.
26. Bane C, Hughes C, Cupples M, McElnay J. The journey to concordance for patients with hypertension: a qualitative study in primary care. Pharm World Sci. 2007;29(5):534–540.
Patient Preference and Adherence
Publish your work in this journal
Submit your manuscript here: http://www.dovepress.com/patient-preference-and-adherence-journal
Patient Preference and Adherence is an international, peer-reviewed, open access journal focusing on the growing importance of patient preference and adherence throughout the therapeutic continuum. Patient satisfaction, acceptability, quality of life, compliance, persistence and their role in developing new therapeutic modalities and compounds to
optimize clinical outcomes for existing disease states are major areas of interest. This journal has been accepted for indexing on PubMed Central. The manuscript management system is completely online and includes a very quick and fair peer-review system. Visit http://www.dovepress.com/ testimonials.php to read real quotes from published authors.
Patient Preference and Adherence 2010:4 submit your manuscript | www.dovepress.com Dovepress
Dovepress
Dovepress
343
Adherence to antihypertensive treatment
27. Jin J, Sklar G, Oh V, Li S. Factors affecting therapeutic compliance: a review from the patient’s perspective. Ther Clin Risk Manag. 2008; 4(1):269–286.
28. Taira DA, Wong KS, Frech-Tamas F, Chung RS. Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care. Am J Manag Care. 2006;12(11): 678–683.
29. McBride C, Emmons K, Lipkus I. Understanding the potential of teach- able moments: the case of smoking cessation. Health Educ Res. 2003; 18(2):156–170.
30. Rohrer J, Anderson G, Furst J. Obesity and pre-hypertesion in family medicine: implications for quality improvement. BMC Health Serv Res. 2007;7:212.
- Publication Info 2:
- Nimber of times reviewed:
