Factors Influencing Blood Pressure Control and Medication Adherence Among Hypertension Patients Attending Korle-Bu Teaching Hospital

University of Ghana http://ugspace.ug.edu.
gh
SCHOOL OF PUBLIC HEALTH

COLLEGE OF HEALTH SCIENCES
UNIVERSITY OF GHANA
LEGON
FACTORS INFLUENCING BLOOD PRESSURE CONTROL AND MEDICATION

ADHERENCE AMONG HYPERTENSION PATIENTS ATTENDING KORLE-BU
TEACHING HOSPITAL
BY
AGNETA ABENA AFRIYIE-TWUMASI
(10702320)
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF
MASTER OF PUBLIC HEALTH (MPH) DEGREE
JULY, 2019
University of Ghana http://ugspace.ug.edu.gh
DECLARATION
Except for references which have been duly acknowledged, I Agneta Abena Afriyie-Twumasi
declare that this dissertation is the result of my independent work and has not been submitted for
the award of any other degree in any institution.
Signature………………………… Date:……………………..
AGNETA ABENA AFRIYIE-TWUMASI
Signature………………………… Date:………………………
SUPERVISOR: DR ANTHONY DANSO-APPIAH
i
DEDICATION
To,
Richard,
Daphne and Nathan.
ii
ACKNOWLEDGMENT
I am eternally grateful to God Almighty, for how far he has brought me. He has been faithful to
the end.
And to my supervisor, Dr. Anthony Danso-Appiah, I would say thank you for all his guidance
and supervision throughout this research.
I would also like to thank my husband, Richard Afriyie-Twumasi for all the love, encouragement
and support throughout this study.
A special thank you also goes to my boss, Dr Daniel Ankrah for all the guidance and inputs
throughout this work.
To my family and my friends especially Marianne Naana Otoo, Benewaa Kusi, Afua Oforiwaa
Agyeman, Frederick Adu-Tsini, Dr. Adwoa Agyei-Nkansah, Dr. Vincent Boima, Dr. Francisca
Zigah, and Dr. Christian Owoo, you have been amazing. I am eternally grateful.
And to my colleagues at work, thank you for all the support.
iii
ABSTRACT
Background
Hypertension, a notable risk factor for renal disease and stroke remains a significant public health
problem. It is associated with fatality, morbidity and a huge financial burden. There is insufficient
control of blood pressure despite advancements in hypertension management. Several factors
influence blood pressure control. Prescribing trends among doctors and adherence to medication
by the patient influence control of blood pressure. This study sought to assess the control of blood
pressure and medication adherence among patients with hypertension attending Korle Bu Teaching
Hospital and some contributing factors.
Methods
A cross-sectional study was conducted at Korle-Bu Teaching Hospital at the out-patient clinics of
the Department of Medicine, the Cardiothoracic Unit and the Korle Bu polyclinic targeting patients
with hypertension. A consecutive sampling approach was used to recruit patients. Structured
questionnaire was administered to obtain information on demographics, socioeconomic status,
medication and disease data. Adherence to medication was also measured using the Morinsky 8-
item adherence scale. Statistical analysis was done using STATA version 15 and a level of
significance set at 5%.
Results
Results showed that the level of blood pressure control was 56.1% and the level of medication
adherence was 49.5%. Medication adherence (AOR 1.66 p=0.03), review visits every 3 months
(AOR 2.34 p <0.001), being on a beta-blocker (AOR 0.47 p=0.01) and being on other less
commonly prescribed drugs (AOR 0.36 p=0.04) were the factors that were found to be associated
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with blood pressure control. CCB (72.3%) and diuretics (53.6%) were found to be the most
commonly prescribed medication. Physician compliance with JNC 8 was found to be 32.2%. A
proportion of 81.6% of prescribers are guided by guidelines in their selection of medication and
59.8% and 63.2% of prescribers are influenced by availability and cost of medication in their
choice of medication respectively.
v
TABLE OF CONTENT
DECLARATION ............................................................................................................................. i
DEDICATION ................................................................................................................................ ii
ACKNOWLEDGMENT................................................................................................................ iii
Abstract .......................................................................................................................................... iv
TABLE OF CONTENT ................................................................................................................. vi
LIST OF TABLES ......................................................................................................................... ix
LIST OF FIGURES ....................................................................................................................... xi
LIST OF ABBREVIATIONS ....................................................................................................... xii
CHAPTER ONE ..............................................................................................................................1
1.0 INTRODUCTION ..................................................................................................................1
1.1 Background .........................................................................................................................1
1.2 Problem statement ..............................................................................................................3
1.3 Justification .........................................................................................................................5
1.4 Conceptual Framework.......................................................................................................6
1.5 Research Questions.............................................................................................................7
1.6 Objectives ...........................................................................................................................7
CHAPTER TWO .............................................................................................................................8
2.0 LITERATURE REVIEW .......................................................................................................8
2.1 Introduction ........................................................................................................................8
2.2 Definition of hypertension ..................................................................................................8
2.3 Uncontrolled hypertension and contributing factors ..........................................................9
2.3.1 Demographic risk factors for uncontrolled hypertension ..............................................10
2.3.2 Prescriber non-adherence to treatment guidelines .........................................................11
2.3.3 Patient non-adherence to antihypertensive medications ................................................12
2.4 Commonly prescribed drugs for hypertension .....................................................................14
2.5 Cost of hypertension medications on the patient .................................................................17
CHAPTER THREE .......................................................................................................................18
3.0 METHODOLOGY ...............................................................................................................18
3.1 Design of the Study ..............................................................................................................18
vi
3.2 Study Site .............................................................................................................................18

3.3 Targeted Population .............................................................................................................19
3.3.1 Inclusion and exclusion criteria .....................................................................................19
3.4 Sampling...............................................................................................................................19
3.4.1 Sample Size Determination ...........................................................................................19
3.4.2 Sampling Procedure .......................................................................................................20
3.5 Data Collection Method .......................................................................................................21
3.6 Data management .................................................................................................................21
3.7 Pretest ...................................................................................................................................22
3.8 Confidentiality......................................................................................................................22
3.9 Statistical Analysis ...............................................................................................................22
3.10 Ethical Considerations........................................................................................................23
CHAPTER FOUR ..........................................................................................................................24
4.0 RESULTS.............................................................................................................................24
4.1 Socio-demographic features of respondents ........................................................................24
4.2 Medication and disease features of respondents ..................................................................26
4.3.1 Comparison of respondent characteristics with blood pressure control ........................29
4.3.2 Comparison of disease characteristics with blood pressure control ..............................31
4.3.3 Comparison of medication variables with blood pressure control ................................34
4.4 Contributing factors to blood pressure control .....................................................................36
4.5 Commonly prescribed anti-hypertensive medication in KBTH ...........................................36
4.6 Characteristics of Prescribers ...............................................................................................38
4.7 Familiarity of prescribers to hypertension guidelines ..........................................................40
4.8 Prescriber compliance to JNC8 guidelines...........................................................................41
4.9 Factors that guide selection of medication for the management of hypertension ................41
4.10 Factors that influence the choice of medication in the management of hypertension ....42
4.11 Patient adherence to medication and contributing factors .................................................43
4.12 Cost of medication for the management of hypertension ..................................................46
CHAPTER FIVE ...........................................................................................................................48
5.0 Discussion ............................................................................................................................48
5.1 Summary of Objectives ........................................................................................................48
vii
5.2 Findings ................................................................................................................................48

5.3 Comparison of key findings with the literature ....................................................................49
5.4 Limitations of the study........................................................................................................52
CHAPTER SIX ..............................................................................................................................54
6.0 CONCLUSION AND RECOMMENDATION ...................................................................54
6.1 Conclusion............................................................................................................................54
6.2 Recommendations ................................................................................................................55
REFERENCES ..............................................................................................................................56
APPENDIX 1: Study Questionnaire ..............................................................................................65
APPENDIX 2: CONSENT FORM ................................................................................................69
APPENDIX 3: Study Questionnaire for Prescribers .....................................................................70
APPENDIX 4: Ethical Clearance……………………………………………………..............…75
viii
LIST OF TABLES
Table 4.1 Demographic characteristics of the respondents……………………………………….25
Table 4.2 Socio-economic characteristics of respondents attending the out-patient clinic in
KBTH…………………………………………………………………………………………….26
Table 4.3 Disease characteristics of respondents attending the out-patient clinic in KBTH .........27
Table 4.4 Medication characteristics of respondents attending out-patient clinics in KBTH……28
Table 4.5 Comparison of socio-demographic characteristics of respondents with blood pressure
control……………………………………………………………………………………………30
Table 4.6 Comparison of disease characteristics of respondents with blood pressure control…..33
Table 4.7 Comparison of medication variables of respondents with blood pressure control…… 35
Table 4.8 Contributing factors to blood pressure control among respondents attending out-patient
clinics in KBTH. ............................................................................................................................37
Table 4.9 Characteristics of prescribers in the out-patient clinics in KBTH .................................39
Table 4.10 Familiarity of prescribers in KBTH to various hypertension guidelines .....................40
Table 4.11 Factors that influence the selection of medication in the management of hypertension
among prescribers in KBTH ..........................................................................................................42
Table 4.12 Factors that influence the choice of medication among prescribers in the management
of hypertension in KBTH...............................................................................................................43
Table 4.13 Comparison of medication-related problems with medication adherence of respondents
attending out-patient clinics in KBTH ...........................................................................................45
Table 4.14 Factors associated with medication adherence among respondents attending out-patient
clinics in KBTH .............................................................................................................................46
ix
Table 4.15 Cost of medication for commonly prescribed medications for the management of
hypertension in KBTH ...................................................................................................................47
x
LIST OF FIGURES
Figure 1 Conceptual framework of the factors influencing blood pressure control ....................... 6
Figure 2 Commonly prescribed anti-hypertensive medication in KBTH ..................................... 38
Figure 3 Physician compliance to JNC 8 guidelines .................................................................... 41
Figure 4 Medication related problems of respondents attending out-patient clinics in KBTH .... 44
xi
LIST OF ABBREVIATIONS
ACE Angiotensin Converting Enzyme

ARB Angiotensin Receptor Blockers
ASH/ISH American Society of Hypertension/ International Society of Hypertension
BB Beta Blockers
BP Blood Pressure
CCB Calcium Channel Blockers
CTU Cardiothoracic Unit
DBP Diastolic Blood Pressure
ESC European Society of Cardiology
ESH European Society of Hypertension
IRB Institutional Review Board
JNC Joint National Committee
KBTH Korle-Bu Teaching Hospital
LMIC Low and middle-income countries
NCD Non-communicable diseases
NICE National Institute of Health and Care Excellence
OPD Out-patient department
SBP Systolic Blood Pressure
WHO World Health Organization
xii
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background
The number of cases of non-communicable diseases (NCDs) is on the upsurge in both
industrialized and third world countries (Naseem, Khattak, Ghazanfar, & Irfan, 2016). Worldwide
statistics show that 41 million people lose their lives every year from non-infectious diseases
(World Health Organization, 2018). Economically under-developed countries have 86% of these
deaths occurring in them, with about 19% attributed to elevated blood pressure, also called
hypertension (Abegunde, Mathers, Adam, Ortegon, & Strong, 2007; Banegas & Gijón-Conde,
2017; Forouzanfar et al., 2016; Lim et al., 2012; World Health Organization, 2018). Hypertension,
which was once thought to affect the affluent, and hence more common in industrialized countries,
is now higher in third world countries and its occurrence is on the rise among poor fragments of
society (van de Vijver et al., 2013).
Urbanization, aging population, and social stress have been identified to be related to the
increasing prevalence of uncontrolled blood pressure (Abegaz, Abdela, Bhagavathula, & Teni,
2018). Lifestyle changes including excessive alcohol consumption, excessive tobacco use,
decreased or no exercise and overindulgence in "Western" diets which are high in salt, refined
sugar, and unhealthy fats and oils are closely associated with the changing trend (van de Vijver et
al., 2013). According to the Demographic and Health Survey (2015) which was conducted in
Ghana, 13% of both men and women have high blood pressure or are currently taking medications
to bring down their blood pressure. Blood pressure (BP) is controlled in only 17% of these women
and 6% of these men with hypertension and on medication. It is unknown to 63% of women and
86% of men with elevated blood pressure that they are hypertensive.
1
A lot of people are oblivious they have hypertension and this is because hypertension is usually
asymptomatic and can go several years undetected (Sridhar & Srinivasa, 2018). Most detections
of elevated blood pressure are incidental. Hypertension is easily treatable but if left untreated can
cause lethal consequences such as kidney disease and stroke (Sridhar & Srinivasa, 2018). Since
there is the need to advance the control of hypertension, there has been the establishment of many
strategies for the classification and the controlling of hypertension. Organizations such as Joint
National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure,
European Society of Hypertension (ESH)/European Society of Cardiology (ESC), American
Society of Hypertension/ International Society of hypertension (ASH/ISH), National Institute for
Health and Care Excellence (NICE) and Japanese Society of Hypertension have developed
protocols for the classification and management of hypertension. The most current strategies for
the management of hypertension are the JNC 8 guidelines which were published in 2014. This
protocol can be used in diverse clinical situations (Jarari et al., 2016).
The effective management of hypertension often involves two approaches and these are a
modification of lifestyle and the use of drugs (Lecture, Chobanian, & Smithwick, 2009; Thinyane,
Mothebe, Sooro, Namole, & Cooper, 2015). It has been proven, however, that BP significantly
reduces with the adoption of certain routine adjustments like increased physical activity, low
sodium diets, weight control, and reduced alcohol consumption (Lecture et al., 2009). Medications
for the management of hypertension are prescribed to diminish the morbidity and fatality
associated with hypertension and its complexities (Jarari et al., 2016). Numerous pharmacological
drug classes are accessible for the management of hypertension. Various classes including calcium
channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, beta-blockers (BB),
2
and angiotensin receptor blockers (ARBs) and diuretics can be used as initial drug therapy (Fedila
& Tesfaye, 2015; Rimoy, Justin-Temu, & Nilay, 2008).
1.2 Problem statement
Hypertension is a severe global public health problem, contributing significantly to the load and
stress of heart disease, renal failure, stroke and untimely mortality and disability (WHO, 2013).
People living in economically under-developed countries where health systems are feeble are
mostly affected (Abegunde et al., 2007; WHO, 2013). Cardiovascular disease, a major
complication of hypertension, accounts for about 17 million fatalities annually worldwide (Lim et
al., 2012). The extent and magnitude of uncontrolled blood pressure in developing countries
remain a huge burden and a matter of concern in low resource countries (Abegaz et al., 2018).
Hypertension prevalence ranges between 19% and 54.8% among adults in Ghana ( Addo et al.,
2012).
Achieving normal blood pressure in hypertensive patients is becoming increasingly difficult
(Abegaz et al., 2018). Research and development of numerous drugs and combination therapies
have been conducted and tested in well-designed trials and the vast majority have demonstrated a
good effect in reducing blood pressure with rates of control ranging from 45% to 66% (Macedo,
Morgado, Castelo-Branco, Rolo, & Pereira, 2010). It is therefore ironic that, in spite of the
enormous developments in antihypertensive drug treatment, the proportion with unrestrained
blood pressure continues to increase (Lecture et al., 2009).
Some identified barriers to the effective regulation of blood pressure comprise some patient-related
causes, prescriber related causes and healthcare system-related factors (Odedosu, Schoenthaler,
Viera, Agyemang, & Ogedegbe, 2012). Some patient-related factors are poor compliance to drug
3
treatment, the inability of patients to change their way of life, some side effects of antihypertension
medicines and also some factors like socioeconomic status, educational levels, age and sex
(Chonbian, 2001; Odedosu et al., 2012). Some prescriber related factors are non-compliance to
management protocols, failure to augment treatments when therapeutic goals are not achieved and
also their failure to highlight modifications in lifestyles to the patient (Odedosu et al., 2012). Some
healthcare system barriers include the availability of medications and also the cost-intensive nature
of medications (Odedosu et al., 2012).
The suitable use of antihypertensive treatment at the correct doses, frequencies, and duration have
been proven to lessen the danger of cardiovascular accidents (Abegaz et al., 2018). Suboptimal
pharmacotherapy has been identified as one of the reasons for inadequate control of hypertension
(Filippi et al., 2009; Thinyane et al., 2015). Also, in low-income countries, hypertension drug cost
is a significant barricade to antihypertensive medication access and adherence (Kayima,
Wanyenze, Katamba, Leontsini, & Nuwaha, 2013). Poor adherence to therapy accounts for two-
thirds of uncontrolled blood pressure among hypertensive patients (Addo, Sencherey, & Babayara,
2018).
Worldwide, there has been the development of several guidelines which have served as reference
standards for prescribers in the control of hypertension (Jarari et al., 2016). Many clinicians have
developed their prescribing patterns based on their clinical experience in treating patients with
hypertension. Therapeutic inertia, which Lebeau et al. (2014) define as the reluctance of healthcare
providers to add on to treatment when therapeutic goals are not met, is also observed as the main
cause of uncontrolled hypertension.
4
1.3 Justification
Many patients being managed for hypertension do not have their blood pressures within blood
pressure targets. Uncontrolled blood pressure makes patients susceptible to serious long term
effects including cardiovascular diseases and subsequent onset of renal and vascular damage
(Gudmundsson et al., 2005). Although there has been a massive improvement in the control of
blood pressure, data still indicate that there are still many "care gaps" in the management of
hypertension (Campbell, McAlister, & Quan, 2013).
In Ghana, although there is extensive literature on uncontrolled hypertension ( Addo et al., 2012;
Bosu, 2010; Sarfo et al., 2018), further studies that will explore the factors that influence blood
pressure control are still needed. This is because the issue of uncontrolled blood pressures still
continues to be a major problem.
Investigation of the factors influencing BP control including prescribing trends in the
pharmacologic management of hypertension in Korle Bu Teaching Hospital is the main objective
of this research. The outcomes of this study will give insights into the extent of blood pressure
control and its contributing factors and how effectively hypertension is being managed through the
trends of prescribing medications in the Korle Bu Teaching Hospital. Also, various factors that
affect the compliance to medications would be identified in the study.
5
1.4 Conceptual Framework
Figure 1 Conceptual framework of the factors influencing blood pressure control
Hypertension patients have several factors contributing to BP control. There are patient, physician
and healthcare system-related causes that influence the control of blood pressure. Socio-
demographic characteristics like age, socioeconomic status, sex, and occupation and the level of
literacy of patients can also affect blood pressure control. Some patient-related factors include poor
adherence to drug therapy, medicine side-effects, patients’ incapacity to buy their medications and
the inability of patients to engage in lifestyle modifications. Some physician-related problems
include non-compliance to treatment strategies, therapeutic inertia and also their failure to
emphasize lifestyle modifications. Some healthcare system factors include medications cost, the
accessibility of medications and the availability of an effective health insurance system. The
6
healthcare system factors also affect the physician factors and these, in turn, affect the patient-
related factors. Patient-Related factors also affect physician factors. These patient, physician and
healthcare system factors have an overall effect on blood pressure control of patients.
1.5 Research Questions
1. What proportion of patients with hypertension has their blood pressure controlled?
2. What factors contribute to blood pressure control among these patients?
3. Which drugs are most commonly prescribed for the management of hypertension?
4. What is the level of adherence among patients on antihypertensive therapy?
1.6 Objectives
The main objective of this study was to assess blood pressure control and associated factors among
hypertension patients attending Korle Bu Teaching Hospital.
Specific objectives:
1. To determine the proportion of patients with their blood pressure controlled.
2. To determine contributing factors to blood pressure control among these patients.
3. To describe the most commonly prescribed drugs for hypertension.
4. To assess patient adherence to medication.
7
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 Introduction
This section focuses on the information gathered during the literature review phase of this study.
It provides an overview of uncontrolled hypertension and contributory factors.
2.2 Definition of hypertension
Hypertension has been known to increase the risk of cardiovascular morbidity and mortality and
this risk is modifiable (Gu, Yue, & Argulian, 2016; Zhou, Xi, Zhao, Wang, & Veeranki, 2018).
Clinical definition for hypertension is a repeated systolic blood pressure (SBP) value of higher
than or equals 140 mm Hg and or a diastolic blood pressure (DBP) value of higher than or equals
90 mm Hg (Williams et al., 2018). Hypertension is said to be uncontrolled when SBP and DBP
readings are still higher than or equals 140 mm Hg and 90 mm Hg respectively, although the
patient is on antihypertensive medications (Tesfaye et al., 2017). Hypertension, according to global
statistics was estimated to be 1.13 billion in 2015 ( Zhou et al., 2017), and is likely to increase to
over 1.5 billion by 2025 (Jarari et al., 2016; Misra et al., 2017), with a frequency of over 150
million in central and eastern Europe (Williams et al., 2018). This increasing prevalence of
hypertension presents a significant health burden due to the associated morbidity and mortality
(Kanj, Khalil, Kossaify, & Kossaify, 2018).
Overall, adult hypertension prevalence is about 30 to 45% (Chow et al., 2013). This proportion is
high and consistent worldwide without regard to the country’s income levels. Low, middle and
high-income countries are all affected by this high prevalence (Chow et al., 2013). Developed
nations have an absolute prevalence of hypertension to be 37.3% compared to a proportion of
22.9% in developing nations (Mittal & Singh, 2010). Hypertension has also been known to be very
8
common with advanced age and proportions above 60% have been reported in adults aged 60 years
and above (Chow et al., 2013). Most studies in Ghana have reported a crude prevalence of
hypertension between 25% and 48% employing a threshold blood pressure reading of 140/90
mmHg (Bosu, 2010).
Uncontrolled hypertension, irrespective of antihypertensive treatment, is still among the most
compelling public health challenges (Daugherty et al., 2011; Rahman, Williams, & Al Mamun,
2017), and it expressively upsurges the danger of chronic conditions like heart failure, myocardial
infarction, renal diseases and stroke (Elperin, Pelter, Deamer, & Burchette, 2014; Mpande et al.,
2016). It is therefore essential to optimize and regulate blood pressure in patients with hypertension
to decrease the morbidity and fatality associated with hypertension in these patients (Jiang et al.,
2014; Kumara, Perera, Dissanayake, Ranasinghe, & Constantine, 2013). Factors associated with
uncontrolled hypertension include age, race, comorbidities, cost of medications, non-adherence to
medications and recommendations, increased body mass index (BMI) and suboptimal
pharmacotherapy (Abegaz, Tefera, & Abebe, 2017; Aronow et al., 2011; Dave et al., 2013;
Gosmanova & Kovesdy, 2015; Krousel-Wood, Muntner, Islam, Morisky, & Webber, 2009; Nasir
et al., 2010).
2.3 Uncontrolled hypertension and contributing factors
Advances in the development of medications for hypertension which have influenced increased
availability and use of these medications have led to a decrease in cardiovascular events
(Rosendorff et al., 2007). Studies have however reported that in spite of the number of drugs
prescribed to patients, blood pressure control remains poor (Ghobain, Mohammed Alhashemi et
al., 2016; Lecture et al., 2009). Results from various national surveys indicate blood pressure
control in up to only one-third of patients with and on drug treatment for, hypertension (Cutler et
9
al., 2008; Ostchega, Dillon, Hughes, Carroll, & Yoon, 2007). This observation indicates the
contribution of other concomitant factors to blood pressure control (Cortez-Dias et al., 2013).
In high-income countries, less than 27% of hypertensive patients and less than 10% in low-income
countries have their blood pressure controlled (Chobanian et al., 2003). In a recent study in
Cameroun, 24.6% of hypertension patients who were on drug treatment had controlled blood
pressure (Dzudie et al., 2012). Another Cameroonian study reported that 36.82% of hypertension
patients were with controlled blood pressure and about 30% of these patients had severe
hypertension (Menanga et al., 2016). Hypertension control rates have been reported to be 29-53%
in the United States and 30-50% in Europe (Go et al., 2013; Kearney, Whelton, Reynolds, &
Whelton, 2003). South Africa, Tanzania, and Ethiopia have reported 46.9%, 47.7% and 41.9% as
hypertension control rates respectively (Adebolu & Naidoo, 2014; Ambaw, Alemie, Wyohannes,
& Mengesha, 2012; Maginga et al., 2017). Another study by Tesfaye, (2015), showed that 59.9%
of patients had uncontrolled hypertension in Addis Ababa.
Three factors have been noticed to be the cause for the fiasco to control blood pressure despite
effective therapy. These are insufficient titration of therapy, patient non-adherence and resistant
disease (Rose, Berlowitz, Orner, & Kressin, 2007).
2.3.1 Demographic risk factors for uncontrolled hypertension
Gender, age and metabolic factors such as BMI and high triglyceride levels are found to be linked
to uncontrolled hypertension (Chu et al., 2015; Daugherty et al., 2011; Rahman et al., 2017).
Urbanization has been significantly connected with a risen jeopardy of hypertension but a study in
Cameroun showed no variance in blood pressure control among rural and urban dwellers
10
(Menanga et al., 2016) and this is aligned with other research conducted in Africa (Riha et al.,
2014)
Health insurance status was also not significantly associated in studies conducted both in
Cameroun and Tanzania (Maginga et al., 2017) but other United States researches have proven
that uninsured hypertension patients are at lower odds of blood pressure control (Duru, Vargas,
Kermah, Pan, & Norris, 2007).
In Addis Ababa, certain factors have shown significant association with blood pressure control
and some of these factors include medication adherence status, family history of hypertension,
habitation (rural and urban dwellers), BMI, inactive lifestyle, number of pills in regimen and the
duration of treatment (Tesfaye, 2015).
Other studies have also shown that no sociodemographic characteristics were significantly related
with blood pressure control, however, obesity and increased prices of medication was related to
decreased odds of blood pressure control in this study (Maginga et al., 2017).
2.3.2 Prescriber non-adherence to treatment guidelines
Surveys of prescribing practices are one of the pharmaco-epidemiological techniques providing an
impartial depiction of prescribing practices (Abdulameer et al., 2012a). These studies can also
provide helpful information for the improvement of suitable and effective use of drugs in hospitals
(Mohd, Mateti, Konuru, Parmar, & Kunduru, 2012) and also serve as an effective means to
measure and appraise the prescribing approach of doctors (Mishra, Kesarwani, & SS, 2017).
Treatment guidelines aid in clinical decision making, reduce variations in practice and also help in
the appraisal of the quality of healthcare (Abdulameer et al., 2012a; Jarari et al., 2016). Health
practitioner prescribing habits, which includes the reluctance to adhere to treatment guidelines, has
11
been noted to be a non-drug related issue related to inadequate blood pressure control (Elliott,
2008). Reasons for non-adherence to management strategies may include lack of knowledge of
their existence, the complexity of the guidelines and having divergent views regarding the
guidelines (Bharatia, Chitale, & Saxena, 2016; Odedosu et al., 2012). An example is seen in the
research by Hyman et al. (2000), in which up to about 30% of doctors did not endorse treatment
in patients with SBP and DBP of 140-160 mm Hg and 90-100 mm Hg respectively.
A number of protocols for the classification and management of hypertension have been
established due to the need to control hypertension. These include the ESC/ESH Guidelines for
the managing of arterial hypertension, the ACC/AHA Hypertension Guidelines and the JNC 8
Hypertension Guidelines (Whelton et al., 2018; Williams et al., 2018).
A lot of patients would need more than one medication to attain adequate reduction of their blood
pressure. A study conducted in Zimbabwe revealed that 35% of prescriptions complied with
guidelines whereas other studies in Malaysia revealed that 85.3% of treatments were compliant
with guidelines (Basopo & Mujasi, 2017). Compliance with guidelines in clinical practice has been
shown to improve treatment outcomes and in this case, better blood pressure control (Jeschke et
al., 2009).
2.3.3 Patient non-adherence to antihypertensive medications
Adherence to medicine can be defined as the degree to which patients comply with medication
regimen as approved by healthcare providers (Blaschke, Osterberg, Vrijens, & Urquhart, 2012).
Patients diagnosed with and on treatment for hypertension are described as adherent when they
take up to about 80% of their prescribed medications daily (Nair et al., 2011). A WHO report
indicates that adherence to antihypertensive medication is between 52% to 74% (Sabaté, 2003).
12
Adherence to prescribed antihypertensive medications is, however, vital in the regulation of blood
pressure and the achievement of a reduced odds of cardiovascular events (Abegaz et al., 2017).
This is established in the study by Mazzaglia et al., (2009), in which newly diagnosed patients with
up to 80% medication adherence had 38% reduced risk of cardiovascular events as related to those
with lower adherence. Non-adherence to antihypertensive medications is, therefore, a rising worry
due to its association with adverse outcomes (Abegaz et al., 2017). Medication adherence is
generally inclined by several issues (van Der Laan et al., 2017) which the WHO classifies into
patient-related, economic-related, condition-related, therapy-related and health system-related
factors (Sabaté, 2003).
Patient-related contributors to non-adherence to antihypertensive medications include the lack of
belief that they have been diagnosed with hypertension and that the drugs could cure their
hypertension (Elliott, 2008). Other patients, who do not deny the existence of hypertension, fail to
recognize the impact of a seemingly asymptomatic condition on the danger of conditions such as
coronary heart diseases (Burnier & Egan, 2019). Economic-related factors include a low level of
health literateness, lack of societal support and drug cost (Elliott, 2008). The presence of multi-
morbidity, resulting in the complex regimens with several medications, and unacceptable side
effects of medications are examples of condition-related and therapy-related factors to non-
adherence respectively (Burnier & Egan, 2019; Gupta et al., 2017; Kim et al., 2007; Lowry,
Dudley, Oddone, & Bosworth, 2005). Poor patient-healthcare provider relationship and
inconsistencies in the availability of antihypertensive medications have also been identified as
examples of health-system related factors leading to medication non-adherence (Gellad, Grenard,
& Marcum, 2011). Studies indicate that patients who have confidence in their healthcare providers
and are involved in the selection of their therapies tend to stick more to their medications as
13
compared to patients who are not (Naik, Kallen, Walder, & Street, 2008; Roumie et al., 2011).
Medication nonadherence is also an identified factor affecting the control of hypertension (Abegaz
et al., 2018). There has been increased responsiveness of the subject of medication adherence
(Vrijens, Antoniou, Burnier, & Sierra, 2017). Almost 50% of patients on antihypertensive
medications quit taking their medications under one year in a study by Vrijens, Kristanto,
Urquhart, & Burnier,(2008). Adherence is a key therapeutic issue and goes beyond pill
consumption (Simpson et al., 2006). Adherence comprises of three major constituents which
should be measured distinctly. These components are; initiation, application, and perseverance.
Non-adherence happens when a patient does not start taking drugs on a new prescription, take it
as prescribed or be persistent with the treatment (Vrijens et al., 2012). In previous studies, 28% of
patients failed to fill prescriptions when new medications were prescribed (Fischer et al., 2010),
40% had withdrawn their treatment within a year and 4% never started treatment (Blaschke et al.,
2012). Medication non-adherence comes with some economic burden as well. In the United States,
the association between non-adherence and related costs is a nonstop series with poor medication
adherence causing poor health results, amplified service utilization and healthcare costs which are
indirectly handed on to the patient (Iuga & Mcguire, 2014). Further studies conducted by Boima
et al., (2015) indicate that medication adherence in Ghana is 72.5%. Other studies have reported
different adherence rates. One study reported the level of adherence to be 56% (Maginga et al.,
2017), while another reported an adherence level of 65.1% (Lee, Wang, Liu, Morisky, & Wong,
2013)
2.4 Commonly prescribed drugs for hypertension

Clinical practice procedures for the control of hypertension endorse a stepwise method for the
commencement of drug treatment (Thinyane et al., 2015). There is clinical proof to suggest that
14
dropping of blood pressure by the use of antihypertensive drugs decreases the danger of
myocardial infarction (MI), heart failure, stroke and final stage renal disease in patients with
hypertension (James et al., 2014). Several classes of antihypertensive drugs that may be used for
initial therapy in the control of hypertension exist and these drugs have proven to reduce
complications of hypertension (Rimoy et al., 2008). Some of these classes include diuretics,
calcium channel blockers (CCB), beta-blockers (BB) and inhibitors of the renin-angiotensin
system.
There are several medications for managing hypertension. These medicines usually belong to one
of several classes. Some patients are put on one medication which is usually referred to as
monotherapy and others are put on two or more medications referred to as Polytherapy. Several
studies have shown differences in the medications that have been commonly prescribed for
hypertension control.
A drug assessment research on a prescription pattern among hypertensive patients showed that
34.6% of patients were prescribed monotherapy to regulate their blood pressure. This was followed
by two drug combinations which made up 18.4% and then three-drug combinations which made
up 11.8% of prescriptions. A few patients, about 3%, were put on four-drug combinations
(Romday, Gupta, & Bhambani, 2016). In another study, monotherapy made up 38% of
prescriptions. The dual and triple-drug therapy also constituted 38% and 18% respectively. Very
few prescriptions contained more than three drugs and these made up 6% of the prescriptions
(Basopo & Mujasi, 2017). In another study, monotherapy was found in 20.8% of prescriptions and
Polytherapy in 79.2% (Abdulameer et al., 2012b). A study by Sridhar & Srinivasa, (2018) also
revealed that Polytherapy was more preferred to monotherapy. Polytherapy made up 54.96% of
prescriptions while monotherapy made up 45.04%

15
There have been variations in the frequently prescribed drugs for the management of hypertension.
According to Romday et al., (2016), diuretics were the most commonly prescribed drug (10.2%)
and followed by calcium channel blockers (7.6%) and then ACEI and ARBs which made up 6.6%
and 5.6% respectively of the drugs on monotherapy. In another study, calcium channel blockers
(CCB) were mostly prescribed followed by beta-blockers (BB). CCBs made up 41.97% of
prescriptions and BBs made up 25.3% of prescription (Rachana, 2014). In another study in
Zimbabwe, beta-blockers and calcium channel blockers made up 19.3% and 17.9% of
prescriptions (Basopo & Mujasi, 2017). Some studies have also reported BBs as most commonly
prescribed. BBs made up 85.9% of prescriptions and this was followed by ACEI which made up
69.6%. Diuretics, angiotensin receptor blockers (ARB) and CCBs made up 24%, 7.9%, and 18.8%
respectively (Abdulameer et al., 2012b). Sridhar & Srinivasa, (2018) also reported BB as the most
commonly prescribed medication making up 37.07%. CCB followed at 27.41% and ACEI and
ARBs made up 18.15% and 17.37% respectively. Menanga et al., (2016) also indicate that CCB
which made up 74.64% of prescriptions was most commonly prescribed and this was followed by
thiazide diuretics which also made up 71.98% and then ACEI which also made up 62.76% of
prescriptions.
Amlodipine turned out to be the most prescribed drug followed by atenolol and telmisartan.
Amlodipine constituted 37.3% of prescriptions, atenolol 19.43% and telmisartan 8.03% (Rachana,
2014). In the study by Abdulameer et al., 2012a, the most common BB prescribed were metoprolol
which made up 66.8% and atenolol which made up 12.5%. Perindopril and enalapril were the most
common ACEI prescribed which made up 55.3% and 10.2% respectively. The common diuretics
prescribed in this study were hydrochlorothiazide (HCT) and furosemide which also constituted
10.2% and 12.8% respectively. Telmisartan and losartan also made up 4.5% and 2.2% of
16
prescriptions respectively. Diltiazem which made up 10.5% was the most common CCB
prescribed, followed by amlodipine which made up 7.3% (Abdulameer et al., 2012b). A study by
Urade, Bende, Shamkuwar, & Satpute (2016) showed that 58.68% of patients on anti-hypertensive
medication were on amlodipine, followed by atenolol which was consumed by 12.67% of patients.
Enalapril, losartan, and ramipril were consumed by 7.04%, 3.73% and 1.87% of patients
respectively.
The mean number of drugs per prescription has been reported to be 2.09 ±0.78 (Abdulameer et al.,
2012b). Further studies also reported the average quantity of drugs per prescription to be 2.7±1.4
(Morgado, Rolo, Pereira, & Castelo-Branco, 2010).
2.5 Cost of hypertension medications on the patient

Medication costs have always proven to be a hindrance to active management of hypertension
(Rachana, 2014). The treatment of hypertension requires spending money and time over several
years to avoid developing other problems as a result of the disease among those affected (Bakare
et al., 2014). The rising occurrence of hypertension and the persistently increasing cost of its
management have an influence on the prescribing patterns among physicians and also on treatment
by the patient (Rachana, 2014). In a case study in Ibadan, Nigeria, it was discovered that the
economic load of hypertension management was significant, in that, about half of the patients spent
10% or more of their earnings on healthcare expenditures (Ilesanmi, Ige, & Adebiyi, 2012). Further
research conducted in a tertiary hospital in Lagos, Nigeria, showed that the cost of the
antihypertensive prescription was average $44 with a minimum cost per month being $2 depending
on the medications that are prescribed for the patient (Osibogun & Okwor, 2014)
17
CHAPTER THREE
3.0 METHODS
3.1 Design of the Study
A cross-sectional research design was adopted for the data collection on prescriber practices and
adherence to treatment guidelines, patient adherence to treatment and factors influencing blood
pressure control among patients visiting the out-patient clinics at the Department of Medicine,
Korle Bu polyclinic and the Cardiothoracic Unit (CTU) of Korle Bu Teaching Hospital (KBTH).
The collected data were by the administration of a structured questionnaire to prescribers and
eligible patients attending the OPD clinics between April 2019 and June 2019. Additional data
extraction methods were used to collect data from patient case notes.
3.2 Study Site

This study took place at the Korle-Bu Teaching Hospital (KBTH), a tertiary hospital in Accra. It
is situated about three kilometers west of the Centre of Accra in the Ablekuma Constituency. It is
reputable in providing tertiary healthcare for all Ghanaians and also providing facilities to school
and train health professionals, conduct research and provide specialist services to patients in Ghana
and also to foreigners. The hospital has a 2000 bed capacity and 17 clinical and diagnostic
departments.
The department of medicine runs a physician specialist clinic, a cardiology clinic and a renal clinic
four days in a week. Averagely, the physician specialist clinic sees about 180 patients weekly, the
cardiology clinic also sees about 60 patients every week and the renal clinic also sees about 80
patients every week. It is projected that between 40% to 60% of these patients have hypertension.
18
At the Cardiothoracic Unit (CTU), the cardiology clinic runs 2 days per week. Averagely, 150
patients report every week to the clinic and an estimate of about 80% have hypertension.
At the Korle Bu polyclinic, averagely 300 patients are seen daily and it is estimated that 14% to
20% of these patients have hypertension. All patients with hypertension report to these
departments with those needing specialist care reporting to the department of medicine and CTU
making these sites suitable for this study.
3.3 Targeted Population

This research included all adults with hypertension who reported for review at the out-patient
department of the Department of medicine, Korle Bu polyclinic and Cardiothoracic Unit of the
Korle Bu Teaching Hospital. All patients' folders were screened for eligibility when they reported
to the various OPD clinics before the start of the clinic.
3.3.1 Inclusion and exclusion criteria
Patients aged 18 years with a hypertension diagnosis for more than six months and currently taking
medications for the management of hypertension were involved in the research. Patients with co-
morbid conditions and currently taking medications for hypertension were also included in the
study. Pregnant and lactating mothers with a diagnosis of hypertension were excluded and also
patients who did not agree to the study were also excluded in the study.
3.4 Sampling
3.4.1 Sample Size Determination
Using the Cochran's (1977) formula, the minimum required sample size for this study was
estimated as
19
𝑍𝛼2⁄ ×𝑃 ×(1−𝑃)
2
𝑛= 𝑒2
Where:
n = minimum required sample size
α = Significance level = 5%
𝑍𝛼2⁄ = z-score at 95% confidence level of sided test =1.96

2
p = Proportion of medication adherence (Boima et al., 2015) = 72.5% = 0.725
q = Proportion of medication non-adherence = 1 – 0.725= 0.275
e = margin of error = 0.05
1.962 × 0.725 × (1 − 0.725)

𝑛= = 306.3 ≈ 307
0.052
Hence, a minimum sample size of 307 patients was to be used. A sample size of 321 was used in
this study.
3.4.2 Sampling Procedure
Consecutive sampling technique was used to sample all eligible patients who met the criteria for
inclusion when they reported to the out-patient department (OPD) clinics of the various
departments. Every eligible patient was selected until the sample size was achieved. Selected
participants who did not consent to this research were replaced. All participants were made to
consent to the study.
20
3.5 Data Collection Method

Structured questionnaires were administered to each participant by trained research assistants.
Demographic characteristics such as gender, age, ethnicity, religion, marital status, and
educational level were obtained. Data on socioeconomic status such as occupation and income
level were also obtained. Disease data such as blood pressures at first, last and current visits, and
the presence or absence of co-morbid conditions were extracted from the case notes. Also, drug
data such as the name of drug and type of therapy (monotherapy, polytherapy, and fixed-dose
combinations) were extracted from case notes. The cost of drugs was obtained from the hospital
pharmacy and also from the NHIS medicines list 2018. Adherence to medication was also
measured using the 8 item Morisky scale (Morisky, Green, & Levine, 1986).
Additional questionnaires were also administered to prescribers who consented to the study.
Information such as their ages, their years of practice, their specialty and their designation was
obtained. Self-developed questions to assess their compliance with JNC8 guidelines was asked.
Other questions to also assess the factors that guide their selection of drugs and also factors that
influence their medication selection was also asked.
3.6 Data management

Information from completed questionnaires was entered into Microsoft Excel as was coded on the
questionnaire. The entries were double-checked for wrong entries and necessary corrections made.
The data were then imported into STATA version 15 for analysis. Consistency checks were run
on certain variables using frequencies, cross-tabulations, and conditional tabulations. All data
cleaning was done in STATA version 15.
21
3.7 Pretest
Questionnaires were pretested with 20 patients who met the criteria for inclusion before the start
of the study at the Mamprobi Polyclinic. These participants were not involved in the study. The
pretest was used to tackle all mistakes and omissions in the questionnaire.
3.8 Confidentiality
All study participants were allocated a unique study code and all patient and prescriber data were
coded.
3.9 Statistical Analysis

Data collected were imported into STATA version 15. All variables were named appropriately and
their various labels appropriately defined. Descriptive statistics were performed on categorical
variables and the results shown in tables as frequencies and percentages while that of the
continuous variables were shown as means and standard deviation. The Pearson chi-squared test
of association was used to determine any associations between the outcome variable and the
independent variables. Univariate logistic regression was then run against all the variables that
showed a significant association using the chi-square test to obtain crude measures of association.
Multivariate logistic regression was then used to determine the adjusted measure of association
controlling for all other covariates.
Blood pressure control was categorized as systolic blood pressure below 140mmHg and diastolic
blood pressure below 90mmHg for adults aged less than 60 years and systolic blood pressure less
than 150mmHg and diastolic blood pressure less than 90mmHg for adults aged 60 years and above.
Level of medication adherence was obtained by calculating the composite score of the 8-item
Morisky medication adherence questionnaire. A total score of 8 was allocated for the measurement
scale with a mark above or equal 6 indicating high adherence and a score less than 6 indicating
low adherence. The level of adherence was then generated. Adherence to JNC 8 guideline was also
22
generated using a score of 6 or more out of 10 questions to signify adherence to the guideline
(Ahmad, Khan, Khan, Khan, & Atif, 2018). Cost of medication was calculated using prices from
the hospital pharmacy and also NHIS prices and the daily, monthly and yearly cost of medications
calculated accordingly. Level of significance was set at 5% and hence a p-value below 0.05 would
be measured statistically significant.
3.10 Ethical Considerations

This research was conducted according to the requirements of the KBTH IRB and Helsinki
Declaration on Human Experiments in 1964 (revised in 2000). Participants were fully informed of
the nature of the research. They were made aware that participation in this study was voluntary
and that they were at liberty to exit the study at any time with no consequence. Anonymity was
ensured using codes and access to data was restricted to the researcher and interviewers only.
Subjects who agreed to take part in the research were made to give informed consent after due
explanation and subjects who are unable to sign were made to give a thumbprint. Invasive
investigations were NOT performed, and no laboratory procedure was carried out. Collected data
were kept in locked cabinets and soft copies of data were password protected.
23
CHAPTER FOUR
4.0 RESULTS
4.1 Socio-demographic characteristics of respondents

This section describes the demographic characteristics of the respondents in the survey. A total of
321 respondents were interviewed between April 2019 and June 2019. A proportion of 58.3% of
the participants in this study were above 60 years. The respondents were made up of 222 (69.2%)
females and 99 (30.8%) males. The minimum age of the respondents was 30 years and the
maximum age was 96 years. The mean age of the respondents was 62.70 ±11.6 years. A greater
number were married (55.1%) and 24% of the respondents were widowed. Most respondents were
either unemployed (29.9%), retired (24.9%) or in the traders or artisans group (29.0%). Majority
of respondents were Christians (89.9%). Most respondents either had no income or had very low-
income levels (65.3%). An estimated 30.9% of respondents had no income. Most respondents
85.7% did not take in alcohol and 96.6% have never smoked in their life.
Table 4.1 and table 4.2 depicts the comprehensive sociodemographic characteristics of the study
population.
24
Table 4.1 Demographic characteristics of the respondents attending out-patient clinics

in KBTH
Variables Frequency Percentage

N=321 (%)
Sex
Male 99 30.8
Female 222 69.2
Age Group
<=60years 134 41.7
>60years 187 58.3
Mean age in years (SD)
62.70 (11.6)
Marital Status
Single 32 10
Married 177 55.1
Divorced 35 10.9
Widowed 77 24
Level of Education
No formal education 99 30.8
Primary(up to JHS) 104 32.4
Secondary(up to SHS) 64 19.9
Tertiary 54 16.8
Religion
Christian 282 87.9
Muslim 37 11.5
Other 2 0.6
Residence
Around KBTH 148 46.1
Far from KBTH 151 47
Outside Accra 22 6.9
Note: Due to rounding errors some percentages may not be up to 100.0%
25
Table 4.2 Socio-economic characteristics of respondents attending the out-patient clinic

in KBTH
Variables Frequency Percentage

N=321 (%)
Alcohol consumption
No alcohol 275 85.7
Sparingly 19 5.9
Occasional 22 6.9
Regular 5 1.6
Smoking status
Never smoked 310 96.6
Previous Smoker 10 3.1
Current smoker 1 0.3
Occupation
Unemployed 96 29.9
Trader/Artisan 93 29
Professional 31 9.7
Retired 80 24.9
Other 21 6.5
Income level
No income 99 30.9
Less than 500 84 26.3
500-1000 81 25.3
>1000-1500 15 4.7
>1500-2000 22 6.9
More than 2000 19 5.9
4.2 Medication and disease features of respondents

The mean systolic blood pressure of respondents was 140.7mmHg (SD± 23.7mmHg) with the
range 147mmHg. The average diastolic blood pressure of the respondents was 79.8mmHg (SD±
14.0mmHg) with the range 103mmHg. A larger percentage of the respondents (56.1%) had their
blood pressure controlled. Some respondents had been living with hypertension for more than 10
years (33.6%) and 32.7% of them had been diagnosed between 5 to 10 years. A small proportion
of 1.9% had been diagnosed for less than a year. Of the respondents, 85.0% had other
comorbidities with hypertension. Also, 62.6% of these respondents had their review visits every
26
3 months. Concerning their medications, 49.5% of the respondents were compliant with their
medications. Polytherapy that is being on more than one drug was found in 85.4% of the
respondents. Other medication and disease details are summarized in Table 4.3 and table 4.4
Table 4.3 Disease characteristics of respondents attending the out-patient clinic in

KBTH
Frequency Percentage
Variables
N=321 (%)
Blood Pressure
Uncontrolled 141 43.9
Controlled 180 56.1
Mean Systolic BP in mmHg(SD)
140.7(23.7)
Mean Diastolic BP in mmHg(SD)
79.8(14.0)
Duration of diagnosis
Less than 1 year 6 1.9
1 to 5 years 102 31.8
5 to 10 years 105 32.7
More than 10 years 108 33.6
Co-morbidity
Had no co-morbidity 48 15
Had co-morbidity 273 85
Frequency of review visit
Monthly 81 25.2
Every 2months 33 10.3
Every 3months 201 62.6
Every 6months 6 1.9
Home BP monitoring
No home BP monitoring 201 62.6
Home BP monitoring 120 37.4
27
Table 4.4 Medication characteristics of respondents attending out-patient clinics in

KBTH
Variables
N=321 (%)
Type of therapy
Monotherapy 47 14.6
Polytherapy 274 85.4
Fixed-dose combination
Not fixed-dose 304 94.7
Fixed-dose 17 5.3
Total no. of drugs
1 to 3 93 29
4 to 6 182 56.7
More than 6 46 14.3
Medication adherence
Non-Adherence 162 50.5
Adherence 159 49.5
Source of medications
Hospital pharmacy 30 9.3
Pharmacy around KBTH 186 57.9
Other pharmacies 27 8.4
Hospital and pharmacy around KBTH 32 10
Hospital, pharmacy around KBTH and other
26 8.1
pharmacies
Hospital and other pharmacies 6 1.9
Pharmacy around KBTH and other
14 4.4
pharmacies
OTC
No OTC use 247 76.9
OTC use 74 23.1
28
4.3.1 Comparison of respondent characteristics with blood pressure control
For patients above 60 years, 58.3% had their blood pressure under control, compared to the 41.7%
in those aged below 60 years. This difference in blood pressure control by age was, however, not
statistically significant (p=0.97). Although female respondents (71.1%) had better-controlled
blood pressure compared with their male counterparts (28.9%), the difference was not found to be
statistically significant (p=0.39). Majority of the married respondents (53.3%) had controlled
blood pressure compared to the unmarried respondents. For respondents with no formal education,
33.3% had their blood pressure controlled. Blood pressure control among respondents with some
level of education was found to be 66.7%, among which 29.4% had primary education and 20.6%
had tertiary education. Also, the majority (50.6%) of respondents with controlled blood pressure
were low-income earners of which 28.9% had no income at all. There was a slight difference in
the proportion of non-alcohol consumers and non-smokers with controlled blood pressure. The
blood pressure was controlled for 86.1% of those who did not consume alcohol and 97.2% of those
who never smoked. There was no statistically significant association between blood pressure
control and the demographic characteristics of respondents in this study. Table 4.5 presents further
details.
29
Table 4.5 Comparison of socio-demographic characteristics of respondents with blood

pressure control
Blood Pressure
Variables Uncontrolled Controlled Pearson chi2 p-value
N=141 (100%) N=180 (100%)
Age Group
<=60years 59 (41.8) 75 (41.7)
>60years 82 (58.2) 105 (58.3) 0.001 0.974
Sex
Male 47 (33.3) 52 (28.9)
Female 94 (66.7) 128 (71.1) 0.732 0.392
Marital Status
Single 14 (9.9) 18 (10)
Married 81 (57.4) 96 (53.3) 0.932 0.818
Divorced 13 (9.2) 22 (12.2)
Widowed 33 (23.4) 44 (24.4)
Occupation
Unemployed 49 (34.8) 47 (26.1)
Trader/Artisan 38 (27) 55 (30.6)
Professional 14 (9.9) 17 (9.4) 3.227 0.521
Retired 31 (22) 49 (27.2)
Other 9 (6.4) 12 (6.7)
Educational level
No formal education 39 (27.7) 60 (33.3)
Primary(up to JHS) 51 (36.2) 53 (29.4) 7.523 0.057
Secondary(up to SHS) 34 (24.1) 30 (16.7)
Tertiary 17 (12.1) 37 (20.6)
Religion
Christian 125 (88.7) 157 (87.2)
Muslim 15 (10.6) 22 (12.2) 0.221 0.896
Other 1 (0.7) 1 (0.6)
Residence
KBTH Environs 70 (49.6) 78 (43.3)
Far from KBTH 64 (45.4) 87 (48.3) 2.138 0.343
Outside Accra 7 (5) 15 (8.3)
30
Table 4.5 (continued)
Blood Pressure
Variables Uncontrolled Controlled Pearson chi2 p-value
N=141 (100%) N=180 (100%)
Alcohol Consumption
No alcohol 120 (85.1) 155 (86.1)
Sparingly 8 (5.7) 11 (6.1) 2.758 0.43
Occasional 9 (6.4) 13 (7.2)
Regular 4 (2.8) 1 (0.6)
Smoking status
Never smoked 135 (95.7) 175 (97.2)
Previous Smoker 5 (3.5) 5 (2.8) 1.444 0.486
Current smoker 1 (0.7) 0 (0)
Income level
No income 47 (33.6) 52 (28.9)
< 500 36 (25.7) 48 (26.7)
500-1000 38 (27.1) 43 (23.9) 3.835 0.573
>1000-1500 6 (4.3) 9 (5)
>1500-2000 8 (5.7) 14 (7.8)
More than 2000 5 (3.6) 14 (7.8)
4.3.2 Comparison of disease characteristics with blood pressure control
Blood pressure control was compared among respondents’ disease characteristics which included
the duration of disease or diagnosis, the presence of co-morbid conditions, frequency of review
visits, home blood pressure monitoring and their health insurance status. Comparing blood
pressure control among patients with certain co-morbidities was also assessed. From the results
obtained, a greater proportion of those who had been hypertensive for 1 to 5 years had their blood
pressure controlled (34.4%) and 32.8% of those who had been hypertensive for more than 10 years
had their BP controlled. This association was, however, not significant (p=0.29). Generally, having
a co-morbidity was not significantly associated with BP control though a greater proportion
(82.2%) with co-morbidities had their BP controlled. Of all comorbid conditions which included
31
diabetes, heart failure, ischemic heart disease, renal disease, and dyslipidemia, diabetes was the
only comorbidity associated with blood pressure control (p=0.04). A proportion of 61.1% of
respondents without diabetes had their blood pressure controlled at a 95% level of significance
(p=0.04). There was also a significant association (p=0.01) between blood pressure control and the
frequency of review visits. A proportion of 70.6% of respondents with their BP controlled had
their reviews every 3 months. Table 4.6 presents the comparison of disease characteristics with
blood pressure control.
32
Table 4.6 Comparison of disease characteristics of respondents with blood pressure

control
Blood Pressure
Variables Uncontrolled Controlled Pearson chi2 P-value
N=141(100%) N=180(100%)
Duration of diagnosis
Less than 1 year 1 (0.7) 5 (2.8)
1 to 5 years 40 (28.4) 62 (34.4) 3.740 0.291
5 to 10 years 51 (36.2) 54 (30)
More than 10 years 49 (34.8) 59 (32.8)
Co-morbidity
No co-morbidity 16 (11.3) 32 (17.8)
Co-morbidity 125 (88.7) 148 (82.2) 2.571 0.109
Monthly 45 (31.9) 36 (20)
Every 2months 18 (12.8) 15 (8.3) 11.344 0.01
Every 3months 74 (52.5) 127 (70.6)
Every 6months 4 (2.8) 2 (1.1)
Home BP monitoring
No home BP monitoring 90 (63.8) 111 (61.7)
Home BP monitoring 51 (36.2) 69 (38.3) 0.158 0.691
Health insurance
No health insurance 5 (3.5) 5 (2.8)
Health Insurance 136 (96.5) 175 (97.2) 0.155 0.694
Diabetes
No diabetes 70 (49.6) 110 (61.1)
Diabetes 71 (50.4) 70 (38.9) 4.220 0.04
Heart failure
No heart failure 123 (87.2) 159 (88.3)
Heart failure 18 (12.8) 21 (11.7) 0.090 0.765
Ischemic heart disease
No ischemic heart disease 135 (95.7) 167 (92.8)
Ischemic heart disease 6 (4.3) 13 (7.2) 1.25 0.264
Renal disease
No renal disease 129 (91.5) 168 (93.3)
Renal disease 12 (8.5) 12 (6.7) 0.389 0.533
Dyslipidemia
No dyslipidemia 101 (71.6) 123 (68.3)
Dyslipidemia 40 (28.4) 57 (31.7) 0.408 0.523
33
4.3.3 Comparison of medication variables with blood pressure control
Table 4.7 shows the comparison of medication variables with blood pressure control. There was
no significant association between the blood pressure control and the type of drug therapy, the
source of their medication and some drug classes such as calcium channel blockers, angiotensin-
converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. There was, however, a
significant association between medication adherence and blood pressure control at a 95% level
of significance (p=0.015). A proportion of 55.6% of respondents with their blood pressure
controlled was adherent to their medications and a greater proportion of those with uncontrolled
blood pressure (58.2%) was non-adherent to their medications. The total number of drugs taken
was also associated significantly with BP control at a 95% level of significance (p=0.027). Of
those with controlled BP, 51.7% were on 4 to 6 medications for both hypertension and other co-
morbid conditions. Being on a beta-blocker was also significantly associated (p=0.005) with blood
pressure control; with a greater proportion (71.1%) of respondents with controlled blood not on
any beta-blocker. BP control was also significantly related to being on other classes of drugs which
were least prescribed (p=0.009) at a 95% level of significance. Some of these classes included
centrally acting agents, vasodilators and alpha-adrenergic blockers.
34
Table 4.7 Comparison of medication variables of respondents with blood pressure

control
Blood Pressure
Variables Uncontrolled Controlled
N=141 (100%) N=180 (100%) Pearson chi2 P-value
Medication Adherence
Non adherent 82 (58.2) 80 (44.4)
Adherent 59 (41.8) 100 (55.6) 5.947 0.015
Type of therapy
Monotherapy 16 (11.3) 31 (17.2)
Polytherapy 125 (88.7) 149 (82.8) 2.183 0.14
Fixed-dose combination
Not fixed-dose 133 (94.3) 171 (95.0)
Fixed dose 8 (5.7) 9 (5.0) 0.072 0.789
Total number of drugs
1 to 3 30 (21.3) 63 (35.0)
4 to 6 89 (63.1) 93 (51.7) 7.253 0.027
More than 6 22 (15.6) 24 (13.3)
Source of medication
Hospital pharmacy 9 (6.4) 21 (11.7)
Pharmacy around KBTH 85 (60.3) 101 (56.1)
Other pharmacies 15 (10.6) 12 (6.7)
Hospital and pharmacy around
KBTH 12 (8.5) 20 (11.1) 4.743 0.577
Hospital, pharmacy around KBTH
and other pharmacies 11 (7.8) 15 (8.3)
Hospital and other pharmacies 3 (2.1) 3 (1.7)
Pharmacy around KBTH and other
pharmacies 6 (4.3) 8 (4.4)
Calcium Channel Blocker(CCB)
No CCB 36 (25.5) 53 (29.4)
CCB 105 (74.5) 127 (70.6) 0.604 0.437
Beta-Blocker(BB)
No BB 80 (56.7) 129 (71.1)
Beta-blocker 61 (43.3) 51 (28.3) 7.757 0.005
Angiotensin-Converting Enzyme
Inhibitor(ACEI)
No ACEI 87 (61.7) 122 (67.8)
ACEI 54 (38.3) 58 (32.2) 1.285 0.257
Angiotensin Receptor Blocker
(ARB)
No ARB 95 (67.4) 115 (63.9)
ARB 46 (32.6) 65 (36.1) 0.425 0.514
Diuretic
No diuretic 61 (43.3) 88 (48.9)
Diuretics 80 (56.7) 92 (51.1) 1.004 0.316
Other Classes
No other class 126 (89.4) 174 (96.7)
Other classes 15 (10.6) 6 (3.3) 6.900 0.009
35
4.4 Contributing factors to blood pressure control

In the chi-squared test of association between blood pressure control and demographic, disease
and medication characteristics, there was a significant association between frequency of review
visits and BP control, diabetes status and BP control, medication adherence and BP control, total
number of drugs taken and BP control, being on a beta-blocker and BP control and being on other
less prescribed medication and BP control. Table 4.8 illustrates the crude and the adjusted odds
ratios of these variables with their confidence intervals and their p-values.
4.5 Commonly prescribed anti-hypertensive medication in KBTH
Calcium channel blockers (CCB) and diuretics were the most prescribed drugs. CCBs were
prescribed in 72.3% of prescriptions and diuretics were also prescribed in 53.6% of prescriptions.
Among the CCBs, amlodipine was most prescribed (55.5%) whilst Bendrofluazide was the mostly
prescribed diuretic (22.7%). Beta-blockers (BB) and Angiotensin-converting enzyme inhibitors
(ACEI) were seen in 34.9% of prescriptions while Angiotensin receptor blockers (ARB) were seen
in 34.6% of prescriptions. Bisoprolol was the most prescribed BB (15.3%), Lisinopril the most
prescribed ACEI (33.0%) and Losartan the most prescribed ARB (32.4%). A very small proportion
of prescriptions (6.5%) were made of other drug classes like the alpha-blockers and the centrally
acting hypertension medication. A graphical depiction of the commonly prescribed anti-
hypertensive medication is shown in figure 2.
36
Table 4.8 Contributing factors to blood pressure control among respondents attending
out-patient clinics in KBTH
Dependent variable: Blood pressure control

Variables
COR (95%CI) P-value AOR (95% CI) P-value
Non-adherent 1.00 1.00
Adherent 1.74 (1.11-2.71) 0.02 1.66 (1.04-2.67) 0.03
Monthly 1.00 1.00
Every 2months 1.04 (0.46-2.35) 0.92 1.14 (0.49-2.66) 0.76
Every 3months 2.15 (1.27-3.62) 0.00 2.34 (1.35-4.07) 0.00
Every 6months 0.63 (0.11-3.61) 0.60 0.82 (0.14-5.00) 0.83
Total no. of drugs
1 to 3 1.00 1.00
4 to 6 0.5 (0.29-0.84) 0.01 0.79 (0.44-1.44) 0.45
More than 6 0.52 (0.25-1.07) 0.08 1.12 (0.47-2.67) 0.80
Diabetes
No diabetes 1.00 1.00
Diabetes 0.63 (0.40-0.98) 0.04 0.61 (0.36-1.04) 0.07
Beta blocker
No beta-blocker 1.00 1.00
Beta-blocker 0.52 (0.33-0.83) 0.01 0.47 (0.28-0.80) 0.01
Other Classes
No other class 1.00 1.00
Other classes 0.29 (0.11-0.77) 0.01 0.36 (0.13-0.97) 0.04
37
Commonly prescribed anti-hypertensive medications in KBTH

60
50
40
PERCENTAGE
30
20
10
Ramipril
Nifedipine
Carvedilol
Indapamide
Losartan
Candesartan
Methyldopa
Hydralazine
Amlodipine
Atenolol
Bisoprolol
Doxasozin
Metoprolol
Lisinopril
Frusemide
Spirinolactone
Felodipine
Bendrofluazide
Torsemide
Calcium Channel Beta Blockers Diuretics Angiotensin Angiotensin

Blockers Converting Receptor Blockers
Enzyme Inhibitors
MEDICATIONS
Percentage
Figure 2 Commonly prescribed anti-hypertensive medication in KBTH
4.6 Characteristics of Prescribers

A total number of 87 prescribers participated in the survey and this was made up of 57.5% males
and 42.5% females. The majority (58.6%) of these prescribers were between 25 and 35 years with
the range being 25 to 60 years. The years of practice differed among the prescribers with 47.1%
38
of them have practiced for 5 to 10 years and 31.0% of them have practiced for more than 10 years.
The main specialties of the prescribers were internal medicine (69.0%) and family medicine
(16.1%). A small proportion of prescriber (4.6%) did not have any specialties. Most respondents
(36.8%) were senior residents or specialists. Table 4.9 illustrates the characteristics of prescribers
in the study.
Table 4.9 Characteristics of prescribers in the out-patient clinics in KBTH
Variables
N=87 (%)
Sex
Male 50 57.5
Female 37 42.5
Age group
25-35 51 58.6
36-44 31 35.6
45-60 5 5.7
Years of practice
Less than 5years 19 21.8
5 to 10years 41 47.1
More than 10years 27 31.0
Specialty
Internal medicine 60 69.0
Family medicine 14 16.1
Other 9 10.3
None 4 4.6
Prescriber's Rank
Senior House Officer 4 4.6
Medical Officer 12 13.8
Junior Resident 25 28.7
Senior Resident/Specialist 32 36.8
Senior Specialist 6 6.9
Consultant 8 9.2
39
4.7 Familiarity of prescribers to hypertension guidelines

Several guidelines are available for the management of hypertension. Out of these guidelines,
47.1% and 37.9% of the prescribers were familiar with JNC 8 and JNC 7 guidelines respectively.
The JNC 6 and ASH/ISH guidelines were not too popular among prescribers as only 3.4% and
5.7% of prescribers were respectively familiar with them respectively. Table 4.10 shows further
details.
Table 4.10 Familiarity of prescribers in KBTH to various hypertension guidelines
Variables
N=87 (%)
JNC6 Guideline
Not familiar 84 96.6
Familiar 3 3.4
JNC7 Guideline
Familiar 33 37.9
JNC8 Guideline
Familiar 41 47.1
ESH/ESC Guideline
Familiar 22 25.3
ASH/ISH Guideline
Familiar 5 5.7
40
4.8 Prescriber compliance to JNC8 guidelines
32.2%
67.8%
Non_Adherent Adherent
Figure 3 Physician compliance to JNC 8 guidelines
Figure 3 depicts the level of compliance of prescribers to the JNC 8 guidelines
4.9 Factors that guide selection of medication in hypertension management

Several factors guide the selection of medication in the management of hypertension among
prescribers. Notably, 81.6% of prescribers are guided by guidelines in determining what
medications to use in the management of hypertension. Also, 23.0% of prescribers use their
experience from practice in the selection of medication in the management of hypertension. Other
factors such as influence from senior colleagues, patient characteristics and financial status of
patients influence the options of medications in the management of hypertension. Table 4.11 shows
details of these factors.
41
Table 4.11 Factors that influence the selection of medication in the management of
hypertension among prescribers in KBTH
Variables
N=87 (%)
Prescribing based on experience from practice 20 23.0
Prescribing based on guidelines 71 81.6

Prescribing based on experience from senior
colleagues 15 17.2
Prescribing based on other factors 3 3.4
4.10 Factors that influence the choice of medication in the management of hypertension
Table 4.12 illustrates the various factors that influence the choice of medication in the management
of hypertension by prescribers. Most prescribers are influenced by the cost of the medication and
the availability of the medication when prescribing. In this study, 63.2% of these prescribers were
influenced by the cost of medication whilst 59.8% of prescribers were influenced by the
availability of the medication when prescribing. Other factors that influence medication choice are
illustrated in table 4.12.
42
Table 4.12 Factors that influence the choice of medication among prescribers in the
management of hypertension in KBTH
Variables
N=87 (%)
Availability of medication 52 59.8
Cost of medication 55 63.2
Compelling information about medication 36 41.4
Personal preference 12 13.8
Instructions from senior colleagues 11 12.6
Other factors influencing the choice of medications 7 8.0
4.11 Patient adherence to medication and contributing factors

As illustrated in table 4.4, medication adherence was found in this study to be 49.5%. Some
patients had difficulties with regards to their medications and this affected their adherence level.
Most patients had difficulty in remembering the doses of their medication and others also had
difficulty in the number of tablets they were taking. Figure 4 shows various medication problems
among respondents attending out-patient clinics in KBTH. Among these problems difficulty to
remember doses, anxiety about long term effects of medications, unwanted side-effects,
medications causing other problems and having too many tablets were significantly associated
with medication adherence in the study. Details are illustrated in table 4.13. Table 4.14 illustrates
the crude and adjusted odds ratio of the factors associated with medication adherence.
43
Medication related problems of respondents

attending out-patient clinics in KBTH
80
70
60
50
Percentage
40
30
20
10
0
No Yes No Yes No Yes No Yes No Yes No Yes
Hard to Hard to pay for Unwanted side- Worry about long Drug causes Tablets too many
remember doses drugs effects term effects other problems
Medication related problems
Figure 4 Medication related problems of respondents attending out-patient clinics in

KBTH
44
Table 4.13 Comparison of medication-related problems with medication adherence of

respondents attending out-patient clinics in KBTH
Non-
Adherent
adherent Pearson chi2 P-value
Variables
N=162 N=159
(100%) (100%)
Hard to remember doses
Not hard to remember 84 (51.9) 136 (85.5)
Hard to remember 78 (48.1) 23 (14.5) 42.22 0.00
Hard to pay for drugs
Not hard to pay 117 (72.2) 127 (79.9)
Hard to pay 45 (27.8) 32 (20.1) 2.58 0.11
Hard to get a refill on time
Not hard to get refills 134 (82.7) 143 (89.9)
Hard to get refills 28 (17.3) 16 (10.1) 3.54 0.06
Unwanted side-effects
No unwanted side-effects 112 (69.1) 131 (82.4)
Unwanted side-effects 50 (30.9) 28 (17.6) 7.66 0.01
Worry about long term effects
No worries about long term effects 99 (61.1) 128 (80.5)
Worry about long term effects 63 (38.9) 31 (19.5) 14.57 0.00
Drug causes other problems
No problems 105 (64.8) 126 (79.2)
Other problems 57 (35.2) 33 (20.8) 8.28 0.00
Tablets too many
Not too many 74 (45.7) 111 (69.8)
Tablets too many 88 (54.3) 48 (30.2) 19.14 0.00
45
Table 4.14 Factors associated with medication adherence among respondents attending
out-patient clinics in KBTH
Dependent variable: Medication Adherence

Variables
COR(95%CI) P-value AOR (95% CI) p-value
Hard to remember doses
Not hard to remember 1.00 1.00
Hard to remember 0.18 (0.11-0.31) 0.00 0.19 (0.11-0.33) 0.00
Hard to pay for drugs
Not hard to pay 1.00 1.00
Hard to pay 0.66 (0.39-1.10) 0.11 0.79 (0.42-1.50) 0.48
Hard to get a refill on time
Not hard to get refills 1.00 1.00
Hard to get refills 0.54 (0.28-1.03) 0.06 0.75 (0.33-1.70) 0.49
Unwanted side-effects
No unwanted side-effects 1.00 1.00
Unwanted side-effects 0.48 (0.28-0.81) 0.00 0.64 (0.34-1.21) 0.17
Worry about long term effects
No worries about long term effects 1.00 1.00
Worry about long term effects 0.38 (0.23-0.63) 0.00 0.47 (0.24-0.92) 0.03
Drug causes other problems
No problems 1.00 1.00
Other problems 0.48 (0.29-0.80) 0.00 1.28 (0.62-2.65) 0.51
Tablets too many
Not too many 1.00 1.00
Tablets too many 0.37 (0.23-0.58) 0.00 0.44 (0.27-0.74) 0.00
4.12 Cost of medication for the management of hypertension

The cost of the frequently prescribed medications for the management of hypertension is
illustrated in table 4.15. These daily costs of each medication, the monthly costs and the yearly
cost of medications are also illustrated. These costs are the out-of-pocket amounts paid at the
hospital pharmacy and the amounts reimbursed by the NHIS.
46
Table 4.15 Cost of medication for commonly prescribed medications for the
management of hypertension in KBTH
NHIS NHIS NHIS
Cost/day Cost/Month Cost/Year Price/day Price/month Price/Year
Drugs Dose (GHC) (GHC) (GHC) (GHC) (GHC) (GHC)
Amlodipine 5mg 0.35 10.50 126.00 0.15 4.5 54
10mg 0.40 12.00 144.00 0.21 6.3 75.6
Nifedipine 20mg 0.55 16.50 198.00 0.12 3.6 43.2
30mg 1.10 33.00 396.00 0.39 11.7 140.4
60mg 1.60 48.00 576.00 0.78 23.4 280.8
Felodipine 5mg 2.20 66.00 792.00 0 0 0
10mg 3.20 96.00 1152.00 0 0 0
Atenolol 25mg 0.20 6.00 72.00 0.09 2.7 32.4
50mg 0.25 7.50 90.00 0.14 4.2 50.4
100mg 0.30 9.00 108.00 0.14 4.2 50.4
Bisoprolol 2.5mg 0.20 6.00 72.00 0 0 0
5mg 0.25 7.50 90.00 0 0 0
10mg 0.25 7.50 90.00 0 0 0
Metoprolol 50mg 0.70 21.00 252.00 0 0 0
100mg 1.00 30.00 360.00 0 0 0
Carvedilol 3.125mg 0.70 21.00 252.00 0 0 0
6.25mg 0.80 24.00 288.00 0 0 0
12.5mg 0.90 27.00 324.00 0 0 0
25mg 1.20 36.00 432.00 0 0 0
Bendrofluazide 2.5mg 0.20 6.00 72.00 0.05 1.5 18
Indapamide 1.5mg 2.10 63.00 756.00 0 0 0
Candesartan 8mg 1.40 42.00 504.00 0 0 0
16mg 1.80 54.00 648.00 0 0 0
Losartan 50mg 0.30 9.00 108.00 0.35 10.5 126
100mg 0.50 15.00 180.00 0.56 16.8 201.6
Lisinopril 5mg 0.40 12.00 144.00 0.15 4.5 54
10mg 0.30 9.00 108.00 0.14 4.2 50.4
20mg 0.50 15.00 180.00 0.3 9 108
Ramipril 5mg 0.30 9.00 108.00 0.35 10.5 126
10mg 0.50 15.00 180.00 0.7 21 252
Frusemide 20mg 0.25 7.50 90.00 0 0 0
40mg 0.35 10.50 126.00 0.1 3 36
Spirinolactone 25mg 0.55 16.50 198.00 0.36 10.8 129.6
50mg 0.60 18.00 216.00 0.56 16.8 201.6
100mg 0.75 22.50 270.00 1.12 33.6 403.2
Methyldopa 250mg 0.45 13.50 162.00 0.25 7.5 90
Hydralazine 25mg 2.00 60.00 720.00 0.7 21 252
Doxazosin 2mg 0.50 15.00 180.00 0 0 0
47
CHAPTER FIVE
5.0 Discussion
5.1 Summary of Objectives
The main objective of this study was to assess blood pressure control and associated factors among
hypertension patients attending Korle Bu Teaching Hospital.
5.2 Findings
In this study, the level of blood pressure control was found to be 56.1%. Also, the level of
medication adherence was found to be 49.5%. Prescriber adherence to JNC 8 was also found to be
32.18%. Frequency of review visits, diabetes status, medication adherence, the total number of
drugs taken, being on a beta-blocker and being on other less prescribed medications for the
hypertension management affected the odds of blood pressure control. After adjusting for the other
factors, medication adherence, frequency of review visits, being on a beta-blocker and being on
the other less prescribed medications for the hypertension management still significantly affected
the odds of blood pressure control.
The odds of medication adherence were affected by factors including the patient’s ability to
remember the doses of their medications, their experience of unwanted side effects, their anxiety
about the long term effects of their medications, their experience of the medication causing other
problems and the total number of tablets they take. Adjusting for other factors, a substantial
association was found between medication adherence and the patient’s ability to remember the
doses of their medication, their worry about the long term effects of their medications and the total
number of tablets they take.
In this study, 96.88% of respondents had health insurance although 14.64% of them could not
purchase their medications using health insurance. Also, 48.60% of those with health insurance
48
were able to purchase their medications on insurance and 5.92% are unable to buy their medication.
On average, the yearly cost of being on Amlodipine (CCB) and Bendrofluazide (Diuretic) is
135GHC and 72GHC respectively.
5.3 Comparison of key findings with the literature

Numerous national surveys have stated blood pressure control rates in up to one-third of patients
with hypertension and on treatment (Cutler et al., 2008; Ostchega et al., 2007). Blood pressure
control was reported in 56.1% of patients according to the findings of this survey, and this is higher
than those obtained in other studies that have been done. A study in Cameroun recorded a blood
pressure control rate of 24.6% (Dzudie et al., 2012). Another study in Cameroun also reported a
blood pressure control rate of 36.82%. Studies in South Africa, Tanzania, and Ethiopia have
reported blood pressure control rates of 46.9%, 47.7% and 41.9% respectively (Adebolu & Naidoo,
2014; Ambaw et al., 2012; Maginga et al., 2017). The higher level of blood pressure control rate
in this study could be due to the effective management of patients with hypertension in KBTH.
In this study, no significant association was recorded between the demographic characteristics of
respondents and blood pressure control. This is in line with a study by Maginga et al., (2017) which
showed that no socio-demographic characteristics were significantly related to blood pressure
control. Frequency of review visits, diabetes status, medication adherence, the total number of
drugs taken, being on a beta-blocker and other less commonly prescribed medications were,
however, significantly associated with blood pressure control in this study. The association of
medication adherence and the number of drugs taken was consistent with a study done in Addis
Ababa (Tesfaye, 2015).
49
Adherence to medication increased the odds of blood pressure control by 74% in this study.
Adjusting for other factors also showed that adherence to medication increases the odds of blood
pressure control by 66%. Also the odds of blood pressure control in patients attending review
clinics every 3 months was about two times the odds of blood pressure control in those attending
monthly review clinics. Having diabetes, however, diminished odds of blood pressure control by
37% but adjusting for other factors showed no significant association between blood pressure
control and diabetes. Being on a beta-blocker reduced the odds of blood pressure control by 48%
in this study. Other less prescribed medications like hydralazine and doxazosin also reduced the
odds of blood pressure control by 71%. Adjusting for other factors, the odds of blood pressure
control was reduced by 53% and 64% when one is put on beta-blockers or other classes of
hypertension medication respectively.
A greater proportion of prescribers were guided by guidelines in their selection of medication in
the management of hypertension. Of all prescribers who took part in the study, 81.6% of them
were guided by guidelines in the management of hypertension. Several guidelines are available for
the management of hypertension some of which include ESC/ESH, ACC/AHA, JNC 7 and JNC 8
guidelines (Whelton et al., 2018; Williams et al., 2018). There are a lot of guidelines for the
management of hypertension. A proportion of 47.1% of prescribers are familiar with JNC8
guidelines for the management of hypertension and 37.9% are also familiar with JNC 7 guidelines.
Despite their familiarity with these guidelines, only 32.2% of prescribers were adherent to the JNC
8 guidelines which is similar to another study where 35% of prescriptions were compliant with
guidelines (Basopo & Mujasi, 2017). This low level of compliance to guidelines could be due to
the fact that several guidelines are available and hence prescribers might be using what is familiar
50
to them individually and hence adherence to one particular guideline might vary from prescriber
to prescriber.
In this study, availability and cost of medications were the main factors that influenced the choice
of medications for patients with hypertension. About 60% of prescribers were influenced by the
availability of medication in their choice of medication and 63.2% of them were influenced by the
cost of medication in their choice of medication. Compelling information about the medication
also influenced the choice of medication of 41.4% of prescribers.
The mean number of drugs per prescription was found to be 2.52±1.00. Other studies have reported
similar findings. A study by Morgado et al., (2010) also reported a mean number of drugs per
prescription as 2.7±1.4. Calcium channel blockers were the most commonly prescribed drugs and
this made up 72.3% of prescriptions which is consistent with Menanga et al., (2016). This was
followed by diuretics which made up 53.6% of prescriptions. Beta-blockers and ACEIs were
equally prescribed in 34.9% of all prescriptions. Menanga et al., (2016) had a similar pattern
although the proportions were different from those in this study. Amlodipine was the most
prescribed drug amongst the CCBs. Bisoprolol was the commonly prescribed BB, Bendrofluazide
the most commonly prescribed diuretic, Lisinopril the most commonly prescribed ACEI and
losartan the most commonly prescribed ARB. Despite non-adherence to JNC 8 guidelines,
adequate blood pressure control is being achieved in the majority of patients.
Patient adherence to medication was found to be 49.5%. Other studies have reported different
adherence rates. A study by Boima et al., (2015) reported an adherence rate of 72.5% for Ghana.
Maginga et al., (2017) also reported a level of adherence of 56% and a study by Lee et al., (2013)
reported an adherence level of 65.1%. Among the factors that influenced adherence to medication,
42.4% of respondents had problems with the number of tablets they were taking and 31.5% had
51
difficulty in remembering their doses. Those who had difficulty remembering their doses had an
82% reduced odds of adhering to medication in the crude analysis.
Also, patients with concerns about the long term effects of their medication had a 62% reduced
odds of medication adherence and a 53% reduced odds of medication adherence. Patients with
concerns about the number of drugs they took also had a 63% reduced odds of medication
adherence and a 56% reduced likelihood adjusting for other factors. Patients who complained of
unwanted side-effects and those who had their medications causing other problems had a 52%
reduced odds of medication adherence in the crude analysis.
Although most medications for the management of hypertension are reimbursed on the NHIS in
Ghana, out-of-pocket payments have to be made on some of the medications. Majority (96.88%)
of the respondents had health insurance, but 14.64% of them did not get any of their medications
on insurance whereas 48.60% had all their medications on insurance. A small proportion of 5.92%
are unable to buy their medication when they are prescribed medicines not reimbursed by the
NHIS. Almost 31% of respondents had no income at all and hence having to pay for these
medications would be a big burden on them because medications are for the long term in the
management of hypertension.
5.4 Limitations of the study

This study was conducted in a tertiary facility where the majority of patients are referred for further
management and specialist attention. These patients usually come in with complications and
difficult to manage cases. An assessment of prescriber adherence to guidelines would not be
comprehensive since most of the patients started their management elsewhere before coming to
KBTH. Patients could also give wrong information with socially acceptable responses making
information and recall bias likely to occur. Most patients could also not tell exactly how much they
52
spent on their medications monthly because they were taking medications for other co-morbidities
and hence couldn't estimate the cost of only their hypertension medication.
53
CHAPTER SIX
6.0 CONCLUSION AND RECOMMENDATION
6.1 Conclusion
This study revealed a blood pressure control rate of 56.1%. Several factors were associated with
blood pressure control. Notable among these factors were medication adherence, frequency of
review visits, diabetes status, the total number of drugs taken, being on a beta-blocker and being
on other classes of less prescribed medication. This study also revealed that calcium channel
blockers were the most prescribed medication for the management of hypertension followed by
diuretics.
Prescribers in this study were aware of several guidelines for the management of hypertension
with more of them familiar with JNC 7 and JNC 8 guidelines. Adherence to JNC 8 guidelines was
found to be 32.2%. Among the factors that guide the selection of medications for patients, the
majority of prescribers were guided by guidelines followed by their experience from practice.
Availability of medication and the cost of medication were the main factors that influenced the
choice of medications for patients.
Medication adherence was found to be 49.5% with several factors influencing adherence to
medication. Patients who find it hard to remember doses, those who worry about long term effects
of their drugs and those who take too many tablets have higher odds of being non-adherent to their
medications.
A greater proportion of patients get their medications on insurance and hence may not be burdened
with cost of medications. Some hypertension medication can be expensive and they are taken for
many years. The medications given by health insurance also come at a cost to government even
though the patients do not directly feel that burden.
54
6.2 Recommendations
Considering the findings of this study, the following recommendations are being made.
Recommendations to Ministry of Health
1. Local protocols for hypertension management should be improved and frequently reviewed
to suit our setting since the majority of prescribers are guided by guidelines in their
selection of medication for patients.
2. The ministry in collaboration with the health promotion unit of the Ghana Health Service
should develop policies to ensure regular health education on adherence to medications
and also educate patients on unwanted side-effects and adverse reactions to their
medications and how to deal with them.
Recommendations to Korle-Bu Teaching Hospital
1. Prescribers need to be persistent in their efforts to assist patients reach their target blood
pressures.
2. Patients should be regularly educated on the need to adhere to their medication since this
study had a lower level of adherence compared to an earlier study done in 2015
3. Since the total number of tablets taken influenced both blood pressure control and
medication adherence, further studies on the effects of fixed-dose combinations on blood
pressure control and medication adherence should be considered.
4. Continuous professional development (CPD) should be organized for all health workers
periodically on current updates in the management of hypertension.
55
REFERENCES
Abdulameer, S. A., Sahib, M. N., Aziz, N. A., Hassan, Y., Alrazzaq, H. A. A., & Ismail, O.
(2012a). Physician adherence to hypertension treatment guidelines and drug acquisition
costs of antihypertensive drugs at the cardiac clinic: A pilot study. Patient Preference and
Adherence, 6, 101–108. https://doi.org/10.2147/PPA.S27223
Abdulameer, S. A., Sahib, M. N., Aziz, N. A., Hassan, Y., Alrazzaq, H. A. A., & Ismail, O.
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(2013). Status report on hypertension in Africa - Consultative review for the 6th Session of
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APPENDIX 1: Study Questionnaire

Patient Study Id ………………………………
Interviewer Code ………………………………
Study site ………………………………...
PLEASE UNDERLINE THE MOST APPROPRIATE ANSWER UNLESS
SPECIFIED
Section 1: Socio-Demographics of patient
1. Age at last birthday ……………….
2. Sex: [ 1] Male [ 2] Female
3. Marital Status: [ 1] Single [ 2] Married [ 3] Divorced [ 4] Widowed
[5] Co-Habiting
4. Occupation: [1] Unemployed [2] Trader / Artisan [3] Professional [4] Retired
[5] Other ……………………………………………………………………
5. Educational level: [1] No formal Education [2] Primary (up to JHS)
[3] Secondary (up to SHS) [4] Tertiary
6. Religion: [1] Christian [2] Muslim [3] Traditionalist [4] Other
7. Residence…………………………………………
8. Alcohol Consumption: [1] None [2] Sparingly (At least once every 3 or 4 months)
[3] Occasional (At least once a month) [4] Regular (At least once a week)
9. Smoking Status: [1] Never [2] Previous Smoker [3] Current Smoker
10. If current smoker: [1] Light (less than 10 sticks a day) [2] Moderate (between 10 and
20 sticks a day ) [3] Heavy (more than 20 sticks a day)
11. Income Level (GH₵): [1] No Income [2] Less Than 500 [3] 500-1000
[4] > 1000-1500 [5] >1500-2000 [6] More Than 2000
Section 2: Disease and medication data
12. Duration of Diagnosis: [1] < 1 year [2] 1 to 5 years [3] 5 to 10 years [4] >10 years
13. Home BP monitoring: [1] Yes [2] No
14. Monthly Cost of Drug(s) ………………………
15. Source of Drug [1] Hospital Pharmacy [2] Pharmacy around KBTH
[3] Other Pharmacies [4] 1 and 2 [5] 1, 2 and 3 [6] 1 and 3 [7] 2 and 3
65
16. Do You Have Any Active Health Insurance: [1] Yes [2] No
17. If Yes, which one [1] NHIS [2] Private Health Insurance
18. Do you get your medications on insurance? [1] No [2] Some of them [3] All
of them
19. Do you feel burdened buying your medication? [1] Yes [2] No
20. Are you able to buy all your medication? [1] Yes [2] No
21. OTC use: [1] Yes [2] No If yes, which OTCs…...............................................
Section 3: Adherence to Medication (MORISKY 8 ITEM MEASUREMENT SCALE ON

ADHERENCE)
22. Do you sometimes forget to take your medicines?

[1] Yes [2] No
23. People sometimes miss taking their medicines for reasons other than forgetting. Thinking over
the past two weeks was there any days when you did not take your medicine?
[1] Yes [2] No
24. Have you ever cut back or stopped taking your medicine without telling your doctor because you
felt worse when you took it?
[1] Yes [2] No
25. When you travel or leave home, do you sometimes forget to bring along your medicine?
[1] Yes [2] No
26. Did you take all your medicines yesterday?
[1] Yes [2] No
27. When you feel like your blood pressure is under control, do you sometimes stop taking your
medicine?
[1] Yes [2] No
28. Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled
about sticking to your treatment plan?
[1] Yes [2] No
29. How often do you have difficulty remembering to take all your medicine?
[1] Never/rarely [2] Once in a while [3] Sometimes [4] Usually
[5] All the time
Adherence Score………………...
66
How much difficulty are you having in each area? [0] None [1] A little [2] A lot
30. It is hard to remember all the doses. 0 1 2

31. It is hard to pay for my drugs. 0 1 2
32. It is hard to get my refill on time. 0 1 2
33. I still get unwanted side effects from the drug. 0 1 2
34. I worry about the long-term effects of the drug. 0 1 2
35. This drug causes other concerns or problems. 0 1 2
36. I take too many tablets it bothers me. 0 1 2
67
Data extraction sheet
1. Type of therapy: [1] Monotherapy [2] Polytherapy [3] Fixed-dose

combination
2. Medication Information
Drugs ( Initial Therapy) Drugs (Current Therapy)
3. The number of drugs taken……………………….

4. BP at First Visit ……………………………
5. BP at Last Visit……………………………
6. Current BP…………………………………
7. Co-Morbidities: [0] None [1] Diabetes [2] Heart Failure [3] Ischemic
Heart Disease [4] Renal Failure [5] Stroke [6]
Others……………………….
8. Follow up visits: [1] Monthly [2] Every 3 months [3] Every 6 months [4]
Yearly
68
APPENDIX 2: CONSENT FORM
Consent for participation in a study
Factors influencing blood pressure control and adherence among hypertension patients in
Korle Bu Teaching Hospital
Thanks for showing interest in participating in this study. My name is Agneta Abena Afriyie-
Twumasi, a Master of Public Health student of the School of Public Health, University of Ghana,
Legon. I am undertaking this study to find out the prescribing practices, cost of medication and
adherence to therapy and the control of blood pressure in patients with hypertension.
I can be reached on 0208135752 or via email: agneta_ampomah@yahoo.com.
Participation in this study is absolutely voluntary. Whatever information you provide is totally
confidential, limited to the purpose of this study and will not be disclosed to anyone. You have the
right to change your mind at any time. Information about medications given should be a true
reflection of what actually pertains. If you agree to take part in this study, please append your
signature or thumbprint to indicate your consent.
……………………………… ……………………. ……………… …………….
Name of the participant, Signature/ Thumbprint & Date
…………………………………. …………………………… ………………………
Name of researcher, Signature &Date
69
APPENDIX 3: Study Questionnaire for Prescribers

Study Id……………………………
Title: Factors influencing blood pressure control and adherence among hypertension patients
in Korle Bu Teaching Hospital
This study seeks to evaluate the prescribing practices in the management of hypertension in Korle
Bu Teaching Hospital. The study also seeks to assess prescriber compliance with hypertension
treatment guidelines and also know the most commonly prescribed medication in the
management of hypertension.
Section A: Demographics
1. Sex: [1] Male [2] Female
2. Age (Years) ………………
3. How many years have you been practicing?
[1] < 5 years
[2] 5 to 10 years
[3] More than 10 years
4. Which year did you graduate?.................................
5. Where did you have your training?
[1] Accra
[2] Cape-coast
[3] Tamale
[4] Kumasi
[5] Other, please specify…………………………...
6. Specialty:
[1] Internal Medicine
[2] Family Medicine
[3] Other, please specify………………………….
7. What is your sub-specialization? ……………………………………
8. What is your rank?
[1] Senior House Officer
[2] Medical Officer
[3] Junior Resident
[4] Senior Resident/ Specialist
[5] Senior Specialist
[6] Consultant
70
Section B
Pick the answer(s) for each question that best matches your response.
Please tick (√) all that apply.
1. For adults with hypertension aged ≥ 60years, at what blood pressure would you initiate
pharmacotherapy?
[] ≥ 130/90
[] ≥ 140/90
[] ≥ 150/90
[] ≥ 160/90
[] Others, please specify……………………………….
2. What would be your target blood pressure for this patient?
[] < 130/90
[] < 140/90
[] < 150/90
[] < 160/90
[] Others, please specify…………………………….
3. For adults with hypertension aged ≤ 60 years, at what blood pressure would you initiate
pharmacotherapy?
[] ≥ 130/90
[] ≥ 140/90
[] ≥ 150/90
[] ≥ 160/90
[] Other, please specify…………………………….
[] < 130/90
[] < 140/90
[] < 150/90
[] < 160/90
71
5. For adult hypertensive patients aged ≥ 18 years with CKD and/or diabetes, at what blood
pressure would you initiate pharmacotherapy?
[] ≥ 130/90
[] ≥ 140/90
[] ≥ 150/90
[] ≥ 160/90
[] < 130/90
[] < 140/90
[] < 150/90
[] < 160/90
[] Others, please specify…………………………….
7. What drug would you give for initial therapy for essential hypertension?
[] Thiazide diuretic
[] Calcium channel blocker (CCB)
[] Angiotensin-Converting Enzyme Inhibitor (ACEI)
[] Angiotensin Receptor Blockers (ARB)
[] Combination therapy, please specify…………………………
8. What drug would you give for initial therapy for essential hypertension with diabetes?
[] Combination therapy, please specify…………………………
9. What drug would you give for initial therapy for essential hypertension with CKD?
72

[] Combination therapy, please specify………………...
10. If your blood pressure targets are not reached, which of the following would you consider
first?
[] Titrate to the maximum dose of initial therapy
[] Add on to initial therapy
[] Change therapy altogether for another option
[] Add on to initial therapy and titrate initial therapy to maximum dose at the same
time
11. Which hypertension guidelines are you most familiar with?
[] JNC 6
[] JNC 7
[] JNC 8
[] ESH/ESC
[] ASH/ISH
[] None
12. Which of the following guides your selection of medications in the management of
hypertension?
[] Experience from practice
[] Guidelines
[] Instructions from senior colleagues
[] Other, please specify……………………
13. Which of these factors influences your choice of medications?
[] Availability of medication
[] Cost of medication
[] Compelling information about the medication
[] Personal preference
[] Instructions from senior colleagues
[] Other, please specify……………………………
14. How long do you wait to intensify therapy when BP targets are not reached?
[] <1 month
73
[] 1 month
[] 2 months
[] 3 months
[] 6 months
15. Do you have any departmental protocol on the management of hypertension?
[] Yes
[] No
[] Don’t know
16. When did you last attend an update or refresher course on hypertension?
[] Never
[] Within the last 6 months
[] 6 to 12 months
[] 1 to 3 years
[] More than 3 years
74
Appendix 4: Ethical Clearance
75

Factors Influencing Blood Pressure Control and Medication Adherence Among Hypertension Patients Attending Korle-Bu Teaching Hospital

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University of Ghana http://ugspace.ug.edu.

SCHOOL OF PUBLIC HEALTH

FACTORS INFLUENCING BLOOD PRESSURE CONTROL AND MEDICATION

THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON

the award of any other degree in any institution.

AGNETA ABENA AFRIYIE-TWUMASI

SUPERVISOR: DR ANTHONY DANSO-APPIAH

Daphne and Nathan.

and supervision throughout this research.

and support throughout this study.

throughout this work.

And to my colleagues at work, thank you for all the support.

control of blood pressure despite advancements in hypertension management. Several factors

Hospital and some contributing factors.

questionnaire was administered to obtain information on demographics, socioeconomic status,

significance set at 5%.

choice of medication respectively.

3.2 Study Site .............................................................................................................................18

5.2 Findings ................................................................................................................................48

Table 4.1 Demographic characteristics of the respondents……………………………………….25

Table 4.2 Socio-economic characteristics of respondents attending the out-patient clinic in

Table 4.4 Medication characteristics of respondents attending out-patient clinics in KBTH……28

Table 4.5 Comparison of socio-demographic characteristics of respondents with blood pressure

clinics in KBTH. ............................................................................................................................37

Table 4.9 Characteristics of prescribers in the out-patient clinics in KBTH .................................39

Table 4.10 Familiarity of prescribers in KBTH to various hypertension guidelines .....................40

among prescribers in KBTH ..........................................................................................................42

Table 4.13 Comparison of medication-related problems with medication adherence of respondents

attending out-patient clinics in KBTH ...........................................................................................45

clinics in KBTH .............................................................................................................................46

hypertension in KBTH ...................................................................................................................47

Figure 2 Commonly prescribed anti-hypertensive medication in KBTH ..................................... 38

Figure 3 Physician compliance to JNC 8 guidelines .................................................................... 41

ACE Angiotensin Converting Enzyme

The number of cases of non-communicable diseases (NCDs) is on the upsurge in both

society (van de Vijver et al., 2013).

European Society of Hypertension (ESH)/European Society of Cardiology (ESC), American

Society of Hypertension/ International Society of hypertension (ASH/ISH), National Institute for

protocol can be used in diverse clinical situations (Jarari et al., 2016).

channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, beta-blockers (BB),

& Tesfaye, 2015; Rimoy, Justin-Temu, & Nilay, 2008).

1.2 Problem statement

Achieving normal blood pressure in hypertensive patients is becoming increasingly difficult

enormous developments in antihypertensive drug treatment, the proportion with unrestrained

blood pressure continues to increase (Lecture et al., 2009).

of medications (Odedosu et al., 2012).

is a significant barricade to antihypertensive medication access and adherence (Kayima,

cause of uncontrolled hypertension.

hypertension (Campbell, McAlister, & Quan, 2013).

continues to be a major problem.

Investigation of the factors influencing BP control including prescribing trends in the

pharmacologic management of hypertension in Korle Bu Teaching Hospital is the main objective

affect the compliance to medications would be identified in the study.

1.4 Conceptual Framework

Figure 1 Conceptual framework of the factors influencing blood pressure control

the inability of patients to engage in lifestyle modifications. Some physician-related problems

1.5 Research Questions

2. What factors contribute to blood pressure control among these patients?

4. What is the level of adherence among patients on antihypertensive therapy?

hypertension patients attending Korle Bu Teaching Hospital.

1. To determine the proportion of patients with their blood pressure controlled.

2. To determine contributing factors to blood pressure control among these patients.