Exploring adherence to hypertension medication in a rural community in Indonesia
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Globally, hypertension is attributed to more than half of deaths caused by cardiovascular events. In Indonesia, stroke is the most frequent cause of death, and hypertension is the major modifiable risk factor. One-third of Indonesian adults have hypertension but less than 10% have their blood pressure adequately controlled. Although adherence to anti-hypertensive medications is acknowledged as a cornerstone for achieving blood pressure control, little is known about medication adherence among patients in Indonesian rural and underdeveloped areas. This thesis reports on studies that explored adherence to anti-hypertensive medications in such areas with the aim of understanding how patients might be better supported. Given the scarcity of Indonesian data, the first aim of this thesis research was to explore the use of anti-hypertensive medications and the extent of non-adherence to these medications among Indonesian rural communities. This involved collecting data about the types of medications used, sources of medicine supply and use of traditional medicines for treating hypertension. Adherence to anti-hypertensive medications was measured using a validated adherence scale. The second aim of this research was to identify factors affecting adherence to anti-hypertensive medication. Both quantitative and qualitative approaches were used to identify the enabling factors of, and barriers to, the use of anti-hypertensive medications. Finally, this research aimed to identify challenges to, and strategies for, improving adherence to anti-hypertensive medications in Indonesian rural communities. The medication-taking practices of people with hypertension were revealed through a survey study of 384 people in the Bantul district, situated in the Yogyakarta province of Indonesia. It was conducted in eight rural underdeveloped villages where people generally have a low level of education (schooling) and economic status. Of the 384 participants, 203 (51%) had taken and 181 had not taken anti-hypertensive medications within the preceding 30 days. They obtained their anti-hypertensive medications from five sources: (i) community pharmacies, by purchasing the medicines without prescription; (ii) healthcare centres, by visiting a community health centre or hospital; (iii) outreach healthcare services in the villages, by visiting community health workers-based program such as the Integrated Health Post for Elderly (IHSP-Elderly); (iv) private practices, by direct dispensing from a doctor, midwife or nurse; or (v) a combination of sites (e.g. community pharmacy plus private doctor). However, only 40 of the 203 (20%) participants had received a sufficient supply of medicine during the preceding 30 days, and almost half had obtained sufficient anti-hypertensive medications for less than seven days. A validated adherence scale showed that only 42 of 203 (21%) treated participants had good adherence (Morisky Medication Adherence Scale-8 score ≥6). A higher level of hypertension knowledge predicted good adherence (OR, 7.1, p<0.01). However, a validated questionnaire to ascertain hypertension knowledge showed that only 15% of participants had a good knowledge of hypertension. Knowledge gaps were identified, particularly about the need for long-term medication, complications of hypertension and the target blood pressure. Interviews with rural villagers with hypertension revealed some misconceptions associated with non-adherence to anti-hypertensive medications (such as the belief that medications are unnecessary for hypertension) and their expectation of obtaining more information from healthcare professionals. Given the heavy workload of healthcare providers, participants expected community health workers in the villages to play a greater role in providing information to those rural villagers with hypertension. An exploratory study of the role of a community health worker-based program, that is, IHSP-Elderly, was conducted by interviewing elderly people with hypertension, community health workers and a health district officer. The interviewees reported that being healthier, having peer support and accessing free blood pressure checks were key benefits of the IHSP-Elderly. The community health workers have the potential to provide blood pressure screening and monitoring, health education and home visits for elderly patients in the villages. Therefore, the role of these frontline personnel in providing information about hypertension to patients in rural areas should be strengthened. In-depth interviews with 30 participants who had not taken anti-hypertensive medication within the preceding year revealed associations between this behaviour and all core constructs of the health belief model: (i) perceived susceptibility and severity; (ii) perceived benefits and barriers; (iii) self-efficacy; and (iv) cues of actions. These participants believed that hypertension is not a serious problem and that high blood pressure is normal for elderly people. They perceived that anti-hypertensive medications were unnecessary for them because hypertension can be easily managed by using traditional medicines. The villagers also had pragmatic reasons, such as favouring the use of traditional medicines because they were easy to obtain (e.g. from their own land), could be accessed at any time and were more affordable than anti-hypertensive medications. For some participants, this pragmatic approach also meant that anti-hypertension medications were preferable when easily accessible and affordable. Traditional medicines were used for lowering blood pressure by 263 of 384 (69%) participants; 134 (51%) used only traditional medicines for their hypertension (i.e. they did not take anti-hypertensive medications). Among traditional medicine users, a lower educational level was associated with the behaviour of not taking anti-hypertensive medications. Vegetables and fruit, such as cucumber and watermelon, as well as homemade herbal medicines were commonly used as a primary means of managing high blood pressure. The research did not identify any socio-demographic variables that predicted the use of traditional medicines. Their uses were not associated with the level of hypertension knowledge. Overall, this thesis research reveals that most rural villagers with hypertension living in Indonesian underdeveloped villages have poor adherence to anti-hypertensive medications. By combining the findings from quantitative and qualitative studies, the research identifies the following key factors affecting adherence to hypertensive medication, according to the World Health Organisation’s multidimensional adherence model: (i) patients’ knowledge and beliefs about hypertension and the use of hypertension medication; (ii) self-efficacy in managing hypertension; (iii) access to an adequate supply of anti-hypertensive medications; (iv) information and recommendations regarding hypertension medication; and (v) support from family and community health workers within the villages. Despite the presence of misconceptions and misbeliefs, patients expected to receive more detailed information. The distance from healthcare facilities and a lack of consultation with healthcare providers raise the need to improve patients’ self-management skills to manage their blood pressure. Only a few rural villagers reported having access to an adequate supply of anti-hypertensive medications. These findings indicate that rural villagers need support in terms of adequate information, self-management skills, functional social support and accessible anti-hypertensive medication. Targeted interventions for these rural villagers should aim at encouraging the support needed and addressing the potential barriers identified. The finding that good knowledge significantly predicts good adherence suggests a need to provide adequate information for rural villagers with hypertension. Information about medicines was rarely provided during a clinical encounter, and recommendations from healthcare providers about long-term adherence to medication were lacking. Despite the potential of community pharmacists being front-liners in providing information, only a few participants regarded them as the main source of medicine information. Although the opportunity existed for community health workers and family members to support rural villagers, their limited knowledge about hypertension may preclude an increased role in providing information. Therefore, in response to the findings in this research, a simplified written information leaflet for patients was developed. The ‘Blood Pressure Action Sheet’ (BP Action Sheet) was a purpose-designed sheet to inform each patient about his/her target blood pressure, how to achieve the target, key facts about hypertension and sources of support in the local setting. The tailored BP Action sheet provides space to record blood pressure readings measured by healthcare workers (including community health workers) as they monitor the patient. A qualitative study was conducted to canvass feedback on the BP Action Sheet via individual telephone interviews with patients, community health workers in the villages and healthcare professionals in the community health centres. Most participants commented that the information provided in the BP Action Sheet was important, easily understood and well presented. Both patients and healthcare workers supported the use of the BP Action Sheet in practice, particularly by patients who had joined the existing hypertension program supervised by the community health centre. Suggestions for refinement of the BP Action Sheet included a more colourful print to attract attention and the need to provide additional information, such as the role of traditional medicines in the management of hypertension. Community health workers who could explain the information in the BP Action Sheet in their local language were regarded as playing a key role in improving patients’ understanding of the information in the sheet as well as encouraging patients to have their blood pressure monitored regularly. Overall, patients and healthcare workers valued the BP Action Sheet as a way to provide information about hypertension, to monitor patients’ progress towards achieving their target blood pressure and to facilitate patient-centred communication involving healthcare providers, community health workers and patients. The BP Action Sheet has potential to be a low-cost strategy to improve management of hypertension in Indonesian rural areas. This thesis research provides first-hand information about poor adherence to anti-hypertensive medications among Indonesian rural villagers. Poor adherence was associated with poor knowledge about hypertension, high self-efficacy for the use of traditional medicines, a lack of access to an adequate supply of medications and a lack of tailored information. Strengthening the role of community health workers in local villages, increasing patient participation in programs to achieve their blood pressure target and providing healthcare support systems in primary healthcare are important aspects for promoting adherence to medication and improving management of hypertension for these rural people. This research has developed the BP Action Sheet aimed at supporting patients in Indonesian rural communities. The potential benefits of the BP Action sheet in clinical practice should be evaluated further.
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