Compliance and Non-Compliance with Antihypertensive

Treatments from the Patient Perspective

SUMMARY

Health service providers, patients, relatives and the overall population Their work out hypotheses about the causes Influencing the compliance and non-compliance of medical prescriptions.  The scientific literature presents a wide group of Influencing factors in compliance or non-compliance of the medical treatment Involving components of psychosocial, medical character and of the physician-patient relationship.  The World Health Organization stressed the effect of socioeconomic factors and of Those related to the system or equipment rendering health services.  The present paper was Aimed at ascertaining-through a qualitative research technique the causes That Affect or Contribute to the Compliance With The antihypertensive treatment from the perspective of the persons Suffering esta disease.  The results pointed to questions That Have to do With The organization of health services, the single personality configurations of the patient, some características of the treatment, the economic resources to carry out the dietary treatment and the networks of family backup Necessary to assume the role of the patient.  For Contributing to controlling blood hypertension and to quality medical care, the Aspects related to the health service organization Should be addressed in a priority way.

Key words: Primary health care, hypertension, therapeutical adherence, compliance With The treatment.

INTRODUCTION

The issue of noncompliance with medical indications from patients is a problem reported by most health professionals.  Especially great difficulties in meeting the long-term treatment to be followed by patients with chronic conditions such as diabetes, hypertension, bronchial asthma, AIDS and other listed.

There are many causes attributed to manifestations of this problem.  It could be said that all providers of health professionals linked or not to care work sector, patients, family members and the general public make their own answers about the causes that influence compliance or otherwise of the requirements medical, based on personal experiences or criteria derived empirically from clinical practice.

The authors dedicated to studying the issue posed by the existence of a large group of influential factors in compliance or noncompliance of medical treatment involving components of psychosocial, medical (characteristics of the disease and the treatment itself) nature and relationship medical paciente.1-5

In the doctor-patient relationship is patient satisfaction in the process of interaction with health professionals and the characteristics of the communication established between these, especially with your doctor.  The communication allows the patient to understand the information being given on prescription or recommendation, which is a first step for you to accept and recordarla.6

The group of factors having an essentially medical nature is related to the characteristics of the therapeutic regimen, including a distinction is made, the complexity of treatment, where the degree of behavioral change required is highlighted, changes in habits or demand for new behavioral patterns, duration and type of treatment, curative, preventive or rehabilitative.  The adhesion decreases as therapy lengthens and curative and rehabilitative treatments have higher rates than preventivos.1 The cost-benefit of the treatment regimen may be relevant, since costs can be diverse: economic, social, work, family, emotional, while profits are directed toward the belief that the disease is cured.

Acute or chronic, and the presence of symptoms of pain or discomfort in varying the degree of compliance: With respect to the nature of the disease, the role of the type of disease is highlighted.  It has been found that acute diseases with bothersome symptoms occur more compliance, while chronic disease and asymptomatic presented the menores.1

Finally, a set of factors called psychosocial aspects related, first, with the patient's beliefs associated with perceived severity of the disease, estimating their own risk of becoming ill or perceived vulnerability, on the other hand stands the belief of the person to be able to execute the necessary response and finally the belief that the response will be more effective than the costs incurred in the conduct.  There is also the motivation of the patient's health, including his interest in health and everything associated with it, the characteristics of their cognitive processes especially memory and the types of coping used to the disease.

The social and family support can help to increase enforcement of the requirements to encourage keeping the medical regimen, equally, strengthening the family and significant others can facilitate this.  When recommendations include changes in lifestyles, supporting and strengthening other relatives may be particularly necessary to initiate and sustain change.

WHO proposes five interacting dimensions that influence adherence.  In addition to factors related to treatment with the disease and the patient, which appear repeatedly in the literature referred to above, is included and highlights the influence of socioeconomic factors and those related to the system or equipment rendering health services.  Notes that while, socioeconomic status, not detected as a predictor of adherence, a considerable effect is attributed to issues such as poverty, illiteracy and unemployment.  Regarding the health care system, point the consequences of poorly developed health services, gaps in the distribution of medicines, poor ability of the system to educate patients and provide follow-up and to gain the support of community.7

This paper aims to explore the factors influencing compliance or non-medical indications for control of hypertension from the perspective of the patients themselves.  Research was conducted through a technique of qualitative research the causes that affect or contribute to the fulfillment of antihypertensive treatment, referred directly by people with the disease, assuming that his experiences in the daily performance sick of his role as a source of reliable and indisputable information.

METHODS

The nominal group technique was used.  This technique allows to collect spontaneous, clear and organized information reported by the subjects of the research on a specific topic regardless of their age and education.  It is easy to apply and management by the investigators and yields data that can systematize and solidify through techniques priorización.8

Nominal eight hypertensive patients groups were formed in two municipalities of Havana's Revolution Square and Cerro, chosen from differences in living conditions that exhibit so that it could consider the impact on compliance medical indications of socioeconomic factors type.  Groups were also formed in the town Jiguaní Granma province, in order to obtain information from another region.

Four groups were organized with patients adhere to treatment or compliant (in this paper we use the terms interchangeably adherence and compliance) for a total of 29 participants and four non-adherent or non-compliant patients, which included 24 patients.  The study was conducted in institutions of primary and tertiary care level.  The groups at each institution were conformed as follows:

Adhering to treatment:

Group 1. Policlinico "Edor of Kings".  Jiguaní Municipality.  Granma.
Group 2: Polyclinic "Revolution Square".  Municipality Plaza.
Group 3: Polyclinic "ramp".  Plaza de la Revolution.
Group 4: National Institute of Cardiology and Cardiovascular Surgery.

Not adhering to treatment:

Group 1: Polyclinic "Abel Santamaría". Cerro municipality.
Group 2: Polyclinic "Revolution Square".  Plaza de la Revolution.
Group 3: Polyclinic "ramp".  Plaza de la Revolution.
Group 4: Polyclinic "Edor of Kings".  Jiguaní Municipality.  Granma.

Procedures

Essential hypertensive patients offices corresponding to the health areas were cited and were previously administered a questionnaire to assess their adherence to antihypertensive treatment, which is called immediately, in order to form groups bonded and unbonded.

They were asked to express their agreement to participate in the activity before starting the group work sessions.  Attended a facilitator and a rapporteur, who recorded in writing interventions, the final list of prioritized causes and other observations of interest group dynamics.  In some cases participated with members of the research team, the doctor and the nurse's office to which patients belonged to support the activity.  At the end of the working session worksheets where each participant recorded his thoughts and thanked the group for their collaboration were collected.

Group work session was held only in premises with the conditions required for proper development of the activity.  Was developed and validated previously subjected to answer the question and discussion to the group of patients adhered and similarly proceeded with the question for the group not attached.

The next steps in the development of sessions with each group were followed: 8

1. Writing ideas into silence by each participant.
2. Registration written on a blackboard of all ideas generated by the group.
3. Reduction of ideas, eliminating those that were repeated.
4. Collective discussion of ideas.
5. Rounds prioritization of ideas to form a prioritized list of ideas.

The final list of prioritized causes the result of the activity of all groups was integrated and summarized in a list summary Causes influencing treatment compliance, referred by subscribers patients and a list summary Causes influencing the non-compliance treatment, referred by patients not stuck.  Those factors that were prioritized by several groups of patients were identified.

RESULTS

The results of all the expressed, discussed and then prioritized ideas, which constituted causes of performance or breach of indicated medical treatment for the control of blood pressure (HBP) reported by patients in the health areas are presented is found matches factors considered as causes of behavior adopted by patients in various nominal groups and health areas ( Box 1 and Box 2 ).

Box 1. Relationship of ideas nominal groups prioritized as causes of compliance, hypertensive patients referred by adhering

1. There are medicines at the pharmacy.  (4)	20. Comply treatment accuracy.
2. be disciplined.  (4)	21. Comply medical orientations.
3. improve health.  (2)	22. Having control oriented diet.
4. Have an interest in compliance.	23. Do not self-medicate.
5. By having controlled hypertension.	24. Willingness.
6. The organization on of the person.	25. Help from the family.
7. Feel good and not have complications.	26. Willingness to do the treatment.
8. Want to live more and better quality of life.	27. Avoid trouble.
9. Treatment is not as complex.	28. Take medications at the same time.
10. There are medical in the office.	29. Visit the medical and nurse at home if the patient fails.
11. No cause problems or concerns to the family.	30. Knowledge of the disease.
12. Health is more important.	31. ensure quality of life.
13. Good medical attention.	32. Excellent relationship with physicians.
14. Good treatment of the doctor and family nurse.	33. Ease of doing exercises.
15. Interest for feeling good.	34. POWER SUPPLY guaranteed.
16. You have to watch.	35. Maintain health.
17. The treatment is good.	36. It isn’t hard to comply.
18. Meet the severity of uncontrolled hypertension.	37. Exercises.
19. Attend the consultation, the checkup.

The numbers in parentheses indicate the number of nominal groups involved.

Box 2. Relationship of ideas nominal groups prioritized as causes of treatment failure, hypertensive patients referred by not adhering

1. You do not have enough money to do the diet.  (4)	12. Lack at the pharmacy of a drug (timely).
2. They are irresponsible.  (3)	13. Despreocupaci meet ng treatment when it feels good.
3. No tracking the m edical.  (2)	14. Failure to attend controls by patients.
4. It has many problems to solve at home.  (2)	15. strict diet.
5. Because est to control.  (2)	16. It forgets.
6. Appear s annoying íntomas scary.  (2)	17. Lack of inter és to meet treatment.
7. Lack of will.  (2)	18. The work is very complicated and does not remember taking medications.
8. Problems in the family and the work you miss pills.  (2)	19. It’s unto tired of taking so many pills.
9. Difficulty in getting the drug.	20. Lack of discipline.
10. The drug depresses.	21. Not always the m edical oriented properly.
11. No fixed medical.

The numbers in parentheses indicate the number of nominal groups involved.

DISCUSSION

Factors contributing or no treatment compliance reported by the patients themselves are summarized in matters having to do with: the organization of health services, personality configurations 9 treatment characteristics, availability of financial resources and family support.

Patients who adhere to treatment considered as important aspects of the health system, among them the fact that no medicines at the pharmacy (Priority idea into four nominal groups) are highlighted.  Patients felt that the Cuban health system guarantees the existence of drugs requiring treatment for hypertension control.  They also stated that affects treatment compliance positive relationship with your doctor and nurse, proper communication with my health, had a good assessment of treatment and care provided and highlighted as an important guarantee medical care when needed.

From the psychosocial point of view the role of the family stands out as social support network that encourages compliance, both from the standpoint of emotional and material support as well as the patient appreciates its role within the family group and want with your good health state to protect their integrity and functioning.

From a medical perspective aspects that relate to treatment characteristics were prioritized.  The patients felt that the treatment is relatively easy to meet, is operative and the need for controlled hypertension as a medical condition in good health encourages compliance in this respect lies a psychological factor, the motivation for good health.

Most of the factors prioritized by the patients had a personological nature, are psychological configurations that modulate the behavior of the individual towards a salutogenic behavior in relation to their disease, such as discipline, interest and organization.  These ideas described by the patients pointed to a matter of great importance in adherence: personal involvement and active, conscious and voluntary participation of the patient in compliance from a set of personal predispositions and are being disciplined (factor very consistent to be prioritized in four nominal groups), volitional effort, interest, organization of the person, the arrangement of so compliance staff capacity self.

A set of motivational health aspects were highlighted: improving health, (prioritized into two groups) desire to live longer and quality of life, desire to feel good.  That is, they reported health needs of physical, which is revealed as a very important value for the person.  Also knowledge of the seriousness of uncontrolled disease is stressed as a prioritized idea which corroborated the importance of the knowledge and belief of the patient about the disease as a compliance flattering look.

Finally, a set of ideas described by the patients that deal with specific forms of behavior that are directly related to compliance with the guidelines given by the doctor and some behavioral resources that favor is found, for example ease exercise or habit allegedly acquired them before suffering from hypertension.

Patients who do not adhere to treatment considered as important aspects concerning the health system, which interfere compliance behavior, these issues could be gaps in the health system of care to its users.  They argue that they can not always deal with the same doctor, changes in professional attendance generates the need to repeat the history of the disease increasingly requiring attention, or not to establish an empathic connection with this, receive different orientations.  The instability of personnel attending the hypertensive patient is a contributing factor to no good treatment compliance.

It was further noted that not always properly oriented medical treatment, lack explanation, details of what action to take, the characteristics of the disease and treatment.

The difficulties in obtaining the drug was raised in this group with less consistency than in the acceding and the lack of a drug appeared in a timely manner for a period of time in a municipality of the study.

From a socioeconomic point of view appears very consistently (repeated as an idea prioritized in four nominal groups) a purely financial factor, lack of purchasing power to meet dietary requiring disease and part of treatment in most cases.  Another issue to note is the approach by patients of an overload of responsibilities within the family and work life that hinders or interferes attention to the disease and treatment.  These people prioritize other obligations before their health care.

From the medical point of view aspects that relate to treatment characteristics are prioritized.  It was observed that patients perceive as factors that interfere fulfilling some characteristics of treatment, as side effects experienced as annoying symptoms that cause fear and discomfort, even depression.  They considered that the diet is characterized by being very strict and difficult to meet, moreover, as the HTA chronic disease as extending the time of treatment, the patient feels like a burden in your life, you get tired and fails or leaves it.

Just as in the groups of patients adhered, most of the factors prioritized by the non-adherent patients had a personological nature, are psychological configurations that modulate the behavior of the individual to not salutogenic behavior in relation to their illness.

He excelled with great consistency (Idea prioritized into 3 groups of patients) than a cause that interferes compliance is the lack of individual responsibility for health, the patient is not liable to the obligations of the sick role for lack of will.  Here absence of voluntary and participatory nature of the actions that define adherence behavior manifests.  They also referred to the lack of motivation for treatment, neglect, failure to fulfill the behavioral plane of an important indication as attendance at the controls, and finally stood out with some consistency the belief that when blood pressure is controlled is not necessary treatment.  This result points to the lack of proper education of the hypertensive patient directed, inter alia, to the personal involvement which must assume responsibility before his illness, which often decreases as a function of social identification as own health personnel, roles and responsibilities inherently patients and not their doctors or nurses.

FINAL THOUGHTS

The nominal group technique was a valuable way to explore the perceptions, thoughts and opinions with hypertensive patients about the factors that modulate behaviors follow directions given by their doctors.  It can be said that the realization of nominal groups was a moment of educational intervention for these patients, who thanked the realization of such actions, which assessed poor and low for such a common disease such as hypertension, in spaces both social communication in health in national radio and television as part of health.

The main factors that contribute or not to compliance with medical treatment indicated for the control of hypertension reported by the patients themselves are summarized in matters having to do with the organization of health services, the individual personality configurations of the patient, some characteristics treatment, the economic resources available for the dietary management and social support networks available to assume the sick role.  These elements correspond to those reported in the literature reviewed, although the results of this study helped identify the peculiarities acquired in the context of health in a group of patients from different municipalities of Cuba.

Aspects related to the organization of health services that are affecting adversely the manifestations of failure hypertensives are gaps that must be addressed as a priority if we want to achieve levels of quality care and help control disease high incidence and high risk in the population.

Contribution by Uziel Perez club memberships white coat