The association between personality types and medication adherence among adult hypertensive patients

OBJECTIVE: To investigate the prevalence of adherence to antihypertensive medication and its association with personality types among adult hypertensive patients. DESIGN AND METHODS: This was a cross-sectional study, which used the Big Five Inventory to assess personality types and Morisky Medication Adherence Scale (MMAS-8) to measure antihypertensive medication adherence, among a convenience sample of 301 hypertensive primary-care patients. Chi square tests, t-tests, correlations and regression techniques were used to examine associations between variables. RESULTS: The mean MMAS-8 score was 5.00 ñ 1.69. Most respondent (60%) demonstrated low adherence (score <6) with only 7% achieving high adherence (score = 8). Persons who scored highly for neuroticism were less likely to be adherent [OR = 0.30; (0.10-0.88)], as were the employed compared to the unemployed [(OR = 0.34; (0.14-0.86)]. In contrast, older persons demonstrated higher adherence levels [(OR = 1.06 (1.01-1.11)]. Regression model variables accounted for 13% of variance in antihypertensive adherence. CONCLUSIONS: This sample demonstrated low antihypertensive adherence; lowest for those high on the neuroticism scale, the employed and younger participants. This implies personality type should be considered in managing chronic diseases to identify clients requiring intervention, thereby improving control, reducing morbidity and enhancing efficient use of scarce resources. Efforts are also needed to address other risk factors that impact adherence.

The use and misuse of antihypertensive medications [abstract]

The primary aim of the study was to evaluate the use and misuse of antihypertensive medications. "Use" is defined as the stringent adherence to prescribed therapy and to the instructions of the healthcare provider. "Misuse" is the alteration of prescribed therapy by the patient, who fails to comply with/adhere to the prescribers instructions. "Non-adherence" is a form of misuse, in which the patient fails to conform to the prescribed drug regime. The methodology of this study entailed a review of primary literature, interviews with colleagues and the clinical experience of the researchers. Use, misuse, and non-adherence to antihypertensive medications are global issues. In the United States of America, 25 percent of hospital admissions are due to patients' misuse or non-adherence to medication therapy. Unfortunately, local statistics are unavailable for comparison. The study did conclude that, locally, problems do exist with the use and misuse of hypertensive medications. Management of medication therapy in the hypertensive patient can be achieved by a health-care team approach and patient education. (AU)

Lessons from reporting 100, 000 Jamaican electrocardiograms

The screening programme of the Heart Foundation of Jamaica has found hypertension in 71 percent of women and 47 percent of men. Of these patients, 13 percent were newly discovered hypertensives. Left ventricular hyperthrophy was present in 18 percent of hypertensive women and 27 percent of men. Inadequate control of raised blood pressure was a frequent finding. Ischaemic electrocardiographic (ECG) changes were only found in 4 percent of the 14,739 patients seen in the past two years but this is an underestimation of the prevalence of ischaemic heart disease. Arrhythmias seen over 15 years were usually benign, of sinus origin or ectopics in the absence of heart disease. Uncontrolled atrial fibrillation remains the most serious arrhythmia encountered and usually in hypertensive patients. Obesity found in 80 percent of women is a problem requiring public education. `Silent' ischaemia in diabetic and left ventricular hypertrophy indicate the need for ECG examination in all newly diagnosed patients with either condition, and annual ECGs thereafter. (AU)

Profile of Uncontrolled Hypertensive patients attending the Specialist Hypertension Clinic, University Hospital of the West Indies

The purpose of this study was to describe the knowledge of hypertension, its management, anthropometric measurements, blood pressure (BP), medication use, and current lifestyles of patients with persistent hypertension. Patients (n=80) attending the Specialist Hypertension Clinic at the University Hospital of the West Indies (UHWI) who had a baseline systolic BP> 140 mmHg and/or a diastolic BP> 90 mmHg were invited to participate in the study. Blood pressure, height, weight, waist and hip circumferences were measured. Body mass index (BMI) and waist/hip ratio (WHR) were calculated. A pretested questionannaire with 40 items eliciting demographic data, level of activity, dietary habits, knowledge of hypertension, medication compliance, use of alternative medicines, and substance use was administered to each participant. Mean BMI for men was 27.65 (95 percent CI 25.7 - 29.6); mean BMI for women was 30.89 (95 percent CI 26.1 - 35.7). In men, there was an association between BMI and WHR, r = 0.62, p<0.05, an association between BMI and diastolic BP and a negative association between BMI and activity level (r= -0.42, p<0.05). Although the majority of both men and women were classified as obese, only 12 percent of men and 7 percent of women recognized diet and overweight as contributing to high blood pressure. Reported diets tended to be high in fat, salt and meats and low in vegetables and fruits; the majority of the participants were sedentary. Medication compliance was good, with a mean of only four days of medications missed per month. These findings suggest that to lower blood pressure in this population, the use of nonpharmacologic theraphy involving lifestyle changes such as improved diet, weight loss and increased physical activity will be important.(AU)

The antihypertensive effects of the Jamaican Cho-Cho (Sechium edule)

The experiments reported in this study constitute a preliminary investigation into the possible hypotensive effect of the Jamaican Cho-Cho (Sechium edule). Experiments were conducted in a random and blind fashion on two sub species of Sechium edule. Both the pulp and the peel were examined for hypotensive activity. Water-soluble extracts were prepared from these components of the fruit and injected into anaesthetised rats. Various cardiovascular parameters were measured including heart rate, mean arterial pressure (MAP) and several ECG intervals. We report that all extracts tested produced a fall in blood pressure with little change in ECG intervals. Extract B produced the least change in heart rate with a fall in MAP of approximately 23 mmHg. Changes in heart rate with all extracts appeared to be minimal as an ED25 value could only be determined for extract A, and ED10 values could not be evaluated for extracts C and D. The mechanism(s) by which these extracts produce their hypotensive effects could not be determined in these preliminary experiments. However, it appears not to involve direct effects on cardiac tissue. This conclusion is based on the finding that it took a minimum of 10 to 15 seconds for the hypotensive action to manifest post bolus. Future experiments will be aimed at delineating the mechanism(s) involved in decreasing MAP.(Au)

A five-year evaluation of intervention in diabetes care in Trinidad and Tobago [see comments]

AIMS: To evaluate an intervention to improve diabetes care in government-run health centres in Trinidad and Tobago over 5 years. METHODS: A cross-sectional survey of 690 subjects with clinical diabetes attending nine health centres was carried out in 1993. The intervention was: reports to the Ministry of Health, dissemination of management guidelines and annual training workshops for healthcare staff. Re-evaluation was through a survey of 1579 subjects with diabetes, attending 23 health centres in 1998. RESULTS: Comparing 1993 with 1998, foot examinations in the previous year increased from 38 (6 percent) to 346 (22 percent) and fundoscopy from 6 (1 percent) to 139 (9 percent). For subjects attending for 1 year or less, 34/96 (35 percent) had dietary advice recorded in 1993 compared with 77/143 (54 percent) in 1998. Exercise advice was recorded for 3/96 (3 percent) in 1993 and 48/143 (34 percent) in 1998. In 1993, 329 (48 percent) were taking chlorpropamide but this fell to 57 (4 percent) in 1998. Glibenclamide use increased from 214 (31 percent) to 856 (54 percent) and gliclazide from 4 (1 percent) to 205 (13 percent). In 1993, 198/338 (56 percent) of hypertensive subjects were taking Brinerdin, this fell to 56/829 (7 percent) in 1998 while use of thiazide diuretics, methyldopa and angiotensin-converting enzyme (ACE) inhibitors increased. There were no changes in indicators of metabolic control, blood pressure control or body weight. CONCLUSIONS: Use of audit data to inform health policy and practice, linked with educational interventions, may modify patterns of care in government-run primary care health centres in a middle-income country with a high prevalence of diabetes. (AU)

A 4-year evaluation of blood pressure management in Trinidad and Tobago

This paper reports a 4-year evaluation of government primary care services in Trinidad and Tobago. The sample included 16 primary care health centres in Trinidad and Tobago with cross-sectional surveys of adult attenders in 1994 and 1998. Data were obtained from clinic records including details of processes of care, drug utilisation and blood pressure (BP) control. Intervention following the initial survey was by means of reports to the Ministry of Health and annual training workshops for medical officers. Data were analyzed for 1759 adult attenders at study clinics (981 in 1994 and 778 in 1998). Most attenders had blood pressure recorded (96 percent in 1994 and 98 percent in 1998). Among 1176 subjects with hypertension (BP > or = 160/95 mm Hg or treated with drugs) the proportion with dietary advice ever recorded increased from .139/662 (21 percent) in 1994 to 185/514 (36 percent) in 1998, and recording of exercise advice increased from 36 (5 percent) in 1994 to 99 (19 percent) in 1998. Among subjects treated with drugs, use of Brinerdin decreased from 191/625 (31 percent) in 1994 to 29/486 (6 percent) in 1998, while use of diuretics, beta-blockers, calcium antagonists and ACE inhibitors increased. The proportion of patients with blood pressure adequately controlled (<160/95 mm Hg) was 338 (51 percent) in 1994 and 297 (58 percent) in 1998 (odds ratio 1.39, 95 percent confidence interval 0.96 to 2.00). An audit study used to inform health care policy, staff training and clinical practice may contribute to improving processes of hypertension management in a middle-income country like Trinidad and Tobago.(Au)

The efficacy and acceptability of Perindopril for the treatment of essential hypertension in a Caribbean population

Angiotensin converting enzyme Inhibitors (ACEIs) are reported to have a lower efficacy in black hypertensive patients, particularly in monotherapy. However, no studies have examined the efficacy of ACEIs in a Caribbean population. A dose titration study was performed with perindopril in the English and Dutch Caribbean islands to assess the efficacy and acceptability of Perindopril in this population. 435 patients with essential hypertension, with a diastolic BP between 95 and 125 mmHg were enrolled into this 3-month open study. Out of 333 patients who completed this study, 285 patients (69.3 per cent) were successfully controlled (diastolic BP<90 mmHg). An additional 45 (7.81 per cent) patients were controlled with the addition of hydrochlorothiazide 25 mg. Supine BP was reduced from 168.2 mmHg (+/- 1.08) systolic and 105.6 mmHg (+/- .48) diastolic to 149.12 mmHg (+/- 0.98) systolic and 91.95 mmHg (+/- 0.55) diastolic (p<0.001) after 2 months of perindopril in monotherapy. Supine BP was reduced further at the end of the 3-month treatment period to 144.3 mmHg (+/- 0.91) systolic and 88.39 mmHg (+/- 0.46) diastolic (p<0.001). There was no significant difference between the black population and the total population. Perindopril was well tolerated with a low reported incidence of cough. Withdrawal due to adverse events was also low at 2.3 per cent (10 patients). The anti-hypertensive efficacy of perindopril in a Caribbean population and more specifically, the black Caribbean population with mild to moderate hypertension, is confirmed in this study together with its clinical and biological acceptability (AU)

Control of hypertension in a General Hospital Clinic, what are we achieving? - abstract

The records of 272 hypertensive patients attending the Spanish Town Hospital during the last four months of 1982 were assessed with respected to their last clinic visit. The ages ranged from 23 to 84 years, with a peak in the 6th decade. Sixty-eight per cent had been attending clinic for more than three years; 22 percent could be categorised as WHO Grade III hypertension and 19 percent as WHO Grade II. Based on either the initial blood pressure reading or a recent value while off treatment, 26 percent of patients had mild hypertension (diastolic B.P. 95-105 mm Hg Torr), 44 percent moderate (diastolic B.P. 105-110 mm Hg Torr) and 32 percent severe (diastolic B.P. 115-130 mm Hg Torr). Eight per cent had very severe hypertension (diastolic B.P. > 130 mm Hg Torr). All but 12 of the patients had been prescribed one or more of the seven antihypertensive drugs available in the Jamaica Government Medical Service. Twenty-seven per cent of subjects were on a one daily drug regimen, 41 percent on twice daily, 29 percent on thrice daily and four times daily on greater medication frequency. Thiry-two per cent were on a single drug only, 49 percent on two drugs and 19 percent on triple drug therapy. Thirty-one per cent of patients were on reserpine-containing compounds. 0nly 38 percent of patients had blood pressure levels below 150/100mm Hg Torr on the day of last clinic attendance. If the last three visits were analysed, the figure only rose to 42 percent. Control correlation best with frequency of medications - 5.7 percent of patients on once daily drugs were well controlled; 46 percent on reserpine containing compounds were well controlled and 63 percent with strokes were now well controlled. Reviewing the patients assessed as having poorly contolled hypertension, 32 percent were thought by the investigator either to be on an inappropriate drug or to have an inadequate drug dosage. Comments on patient compliance were only recorded in 24 percent of cases if the last three clinic attendances were reviewed, and drug side-effects in 15 percent. A sub-group of 100 poorly controlled pateints were interviewed to ascertain possible reasons for this. Seventy-eight had poor drug compliance, and 42 reported drug side-effects. Other reasons for non-compliance included failure of appreciation of the need for continued treatment, failure of appreciation of the risk of untreated hypertension, belief that the pressure was normal as long as they felt well, drug non-availability in hospital pharmacies and inability to afford the transportation costs of having the precription repeated monthly. Inappropriate drug therapy, inappropriate reduction of drug dosages, and being told by medical or paramedical personnel that they no longer needed treatment were also significant problems (AU)

Sexual dysfunction among females on anti-hypertensive treatment - abstract

Sexual dysfunction is a common finding among males treated for essential hypertension, and is frequently cited as a cause of non-compliance with a therapeutic regimen. Reports of sexual dysfunction among treated women have been few, and there is little appreciation of how this problem affects the female patient. The present paper focusses on 112 pre-menopausal females, age 23 to 45 years, referred for evaluation of essential hypertension either as part of a pre-immigration physical examination or for management in a general medical out-patient clinic. Seventy-five women had been on anti-hypertensive treatment in the past or were on treatment at the time of evaluation. Previously treated women were kept on their old regime, and the others were put on a stepped-care protocol. After stabilisation of their blood pressure, all patients were questioned about sexual function while on treatment. Twenty-four women admitted to some degree of sexual dysfunction, loss of libido being the most significant problem. Twelve said they would enjoy sex after activity was initiated by their consorts, but thought their pleasure was considerably diminished by treatment. Four found that sex had become distasteful but continued to please their partners. Sixteen patients reported virtually complete loss of orgasm, and eight cited failure of lubrication as a significant problem. Eleven women admitted to more than one sexual problem. Only one admitted to pre-treatment sexual dysfunction. Four patients were thought to be depressed, by the medical attendant, and three of these responded to anti-depressant therapy plus a change of anti-hypertensive drugs. Of fourteen patients followed by the same physician for more than one year, eleven considered themselves restored to normal, or near normal, sexual function by a change of drug regimen but, in all cases, 2 or more different drugs had been tried before this was achieved. Only two women admitted to discontinuing drugs because of sexual difficulties. Sexual dysfunction in treated hypertensive females would therefore appear to be a significant problem. The present study may actually underestimate its extent, as there was a preponderance of middle-class women among those admitting to dysfunction: these females are presumably more educated and articulate and perhaps less embarrassed at discussing sexual matters (AU)

Treatment of Jamaican hypertensives with atenolol and chlorthalidone

A clinical trial of the new beta-blocker Atenolol, showed that the drug is effective in the management of Jamaican hypertensives when used in combination with the diuretic Chlorthalidone. A mean fall in blood pressure of 39/31 mm Hg was achieved in 21 patients studied. The drug was administered once daily at a dose of 100 mg to 200 mg. It was suggested that a higher dose of Atenolol may be required in black patients than that conventionally used for white subjects. Pre-treatment plasma renin levels did not correlate with the sensitivity of response to Atenolol (AU)

Clinical aspects of the management of hypertension in the Caribbean

Hypertension is a major clinical and public health problem in the Caribbean. Thus, there is a great need for general guidelines in our management of the condition based upon local and international experience. A review of the clinical aspects of hypertension has been presented and attention has been focussed on the basic principles in management. It is emphasized that by using a small selected group of drugs, adequate blood pressure control can be obtained even with limited resources (AU)

Outpatient treatment trial of mild and severe hypertension

Not much is known about the feasibility or the advantages of treatment of subjects with only mild hypertension. There are also many unresolved problems in the out-patient management of hypertension of any severity. In this study an analysis is made of the results of a controlled treatment trial of 56 subjects with mild hypertension, 26 of whom were treated with active drug and 30 initially with placebo, and a treatment programme involving 81 patients with moderate or severe hypertension, all of whom received treatment with active drug. The drugs used in this study were bethanidine, debrisoquine, and guanethidine. Follow-up for 12 months or more was achieved in 87 percent of individuals admitted to the study with mild hypertension and in 80 percent with severe hypertension. Many subjects with only mildly raised blood pressure were found to have cardiac enlargement on chest x-ray (up to 45 percent) and left ventricular hypertrophy on electrocardiogram (up to 51 percent). Rapid rates of rise of blood presure were observed in many placebo-treated subjects; but good blood pressure control was achieved in 63 out of 104 patients (61 percent) receiving active drug in both the mild and the severe hypertension groups. The drugs used showed approximately equal effectiveness in controlling blood pressure (AU)