|Year : 2018 | Volume
| Issue : 3 | Page : 197-202
Family functioning and adherence to medication: A study of hypertensive in a tertiary hospital, South Western Nigeria
Abayomi O Ayodapo1, Kehinde Fasasi Monsudi2, Olusegun Emmanuel Omosanya3, Olayide Toyin Elegbede3
1 Department of Family Medicine, Federal Medical Centre, Birnin-Kebbi, Kebbi State, Nigeria
2 Department of Ophthalmology, Federal Medical Centre, Birnin-Kebbi, Kebbi State, Nigeria
3 Department of Family Medicine, Federal Medical Centre, Ido-Ekiti, Ekiti State, Nigeria
|Date of Web Publication||17-Jul-2018|
Abayomi O Ayodapo
Department of Family Medicine, Federal Medical Centre, Birnin-Kebbi, Kebbi State
Source of Support: None, Conflict of Interest: None
Background: Hypertension is one of the most important risk factors for coronary heart disease, stroke, heart failure, and end-stage renal disease. It remains an important public health challenge, despite effective medical therapies for its management, patients' poor adherence remains a global problem. Aim: The main objective of this study is to determine the relationship between family functioning and medication adherence among hypertensive, attending a tertiary care center in South-West Nigeria. Materials and Methods: This was a descriptive cross-sectional study. The systematic sampling method was used to select 420 patients attending the outpatient clinic of the tertiary hospital. Relevant data were collected using interviewer-administered pretested semi-structured questionnaires. Results: Four hundred and twenty people participated in the study. The mean age of respondents was 60.97 ± 11.28 years, and a slight female preponderance (M:F = 1:1.7). Three hundred and forty-nine (83.1%) were married, 273 (65.0%) were from a monogamous family and 375 (89.2%) had a family size of >4. More than half of the study participants had a functional family (66.4%) and were adherent (61.2%) to their medication. Increased medication adherence proportion was observed in patients with a functional family. Adherence to medication is three times (odds ratio = 2.585, 95%CI = 1.636, 4.084) higher among patients with functional family. Conclusion: The structure and nature of family relationships, both of which determines family functioning, are important to medication adherence. A functional family enhances adherence to medication. Primary care physicians should create a positive treatment alliance with their patients to better family functioning.
Keywords: Adherence, family function, hypertension, medication, tertiary hospital
|How to cite this article:|
Ayodapo AO, Monsudi KF, Omosanya OE, Elegbede OT. Family functioning and adherence to medication: A study of hypertensive in a tertiary hospital, South Western Nigeria. CHRISMED J Health Res 2018;5:197-202
|How to cite this URL:|
Ayodapo AO, Monsudi KF, Omosanya OE, Elegbede OT. Family functioning and adherence to medication: A study of hypertensive in a tertiary hospital, South Western Nigeria. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jan 29];5:197-202. Available from: http://www.cjhr.org/text.asp?2018/5/3/197/236893
| Introduction|| |
Hypertension is the most prevalent health problems among adult patients requiring long-term therapy, but its recognition and treatment are still suboptimal., Hypertension is a major risk factor and a powerful predictor of cardiovascular morbidity and mortality with proven benefit after treatment. Therefore, control of hypertension will protect against stroke and congestive cardiac failure.
Previous studies , reported that more than half of the hypertensive patients do not take any medication despite the availability of safe and effective medication, why more than half of those on treatment have blood pressure >140/90 mmhg threshold.
The goal blood pressure control is important in the management of hypertension and prevention of complications. Good control, however, depends on adherence to medication, good dietary, and lifestyle modification.
Adherence to medication is a critical factor in the continued health and well-being of patients with hypertension. Adherence involves patient acceptance of treatment recommendations arrived at, through shared decision making. Improving adherence to medication has been the major concern of physicians worldwide. Adherence to treatment for high blood pressure is influenced by a number of factors, some of which are modifiable., Several studies have noted demographic disparities regarding medication adherence,, but there is a need to explore the relationship of family variables-structure and functioning to outcome. The concept of family is highly relevant to the outcome of management of chronic illness like hypertension. Some family characteristics have been linked to poor chronic disease process; outcomes and a greater understanding of these factors in hypertension management give a better results. Social support is an important factor in immune, endocrine, and cardiovascular functioning; recovery from illness and injury; and health maintenance.
The concept of family is highly relevant to self-care, and a recent framework published by Grey et al. outlines the relationships among family factors, individual, and family self-management of chronic illness. Family functioning is often understood as a precursor to effective self-care in chronic illness population. Many educational interventions fail because the family and social contexts in which the individual with chronic illness like hypertension is to perform self-care have not been taken into account. To achieve effective patient teaching outcomes, the family should be made to be part of the teaching plan. For example, if the wife of a patient with hypertension does all the cooking in the home, it is important to include her in diet modification. Obviously, it will be difficult for a wife to be supportive of her husband's blood pressure treatment program if she does not understand the reasons for the recommendations and the consequences of not carrying them out. Involving family members may be an important future source of support for the patient as he/she works at behavioral change. The above cannot be achieved if there is a dysfunctional family.
Family functioning is defined as the extent to which a family operates as a unit to cope with stressors. In light of the exceedingly large number of patients who are nonadherent to medical practice, practical support is a potentially important target of interventions to reduce health care costs and improve health. Hence, this study is aim at finding a relationship between family functioning and medication adherence among patients with hypertension attending a tertiary hospital in South-Western, Nigeria.
| Materials and Methods|| |
This was a descriptive cross-sectional study conducted over a 4-month period in the general outpatient department of tertiary hospital in South-western, Nigeria. This tertiary level healthcare facility provides medical care and serves as referral center for other health institutions in the state and environs.
The participants were hypertensive patients aged 18 years and above, and have been on treatment for at least 6 months, excluding those with complications of hypertension, pregnant women, and critically ill patients.
A minimum sample size was statistically determined for the study using a medication adherence prevalence rate of 45.8% as reported by Kabir et al., with the confidence interval of 95% and standard error of 5% as 381. This was increased to 420 given an attrition value of 10%. Systematic random sampling technique was used to recruit participants among the hypertensive patients attending the clinic.
Pretested semi-structured questionnaire drafted in English Language and translated in Yoruba (local language) and back-translated into English was used to obtain relevant information on characteristics of respondents and knowledge about hypertension.
Adherence was determined using Morisky medication adherence scale, a 4-item self-report scale developed by Morisky et al., with a high reliability and validity, which has been particularly useful in chronic conditions such as hypertension. It measures both intentional and unintentional adherence based on forgetfulness, carelessness, stopping the medication when feeling better, and stopping medication when feeling worse. The advantages of this over other methods of measurement include its simplicity, speed, cheapness, and validity of use.
The family APGAR scale, a five-item validated scale of family functioning, was used to measure a family member's perception of the family function. The total score ranged from 0 to 10. The family APGAR score for each subject was calculated by summing the scores of the five items on the scale: the higher the score, the higher the level of perceived functionality of the family. The 3-point scale was interpreted as, (1) “functional family” (7-10 points), (2) “moderately dysfunctional family” (4–6 points) and (3) “severely dysfunctional family” (0–3 points). For the purpose of this study, the 3-point family APGAR scale was dichotomized into two categories, these being “functional family” (7–10 points) and “dysfunctional family” (0–6 points). Family APGAR has been widely used to study the relationship of family and problems in family practice offices. Smilkstein  found that there were agreements between family APGAR scoring and clinician assessment.
Blood pressure was measured using an appropriate cuff-sized Accosson ® mercury sphygmomanometer and Littmann stethoscope. First appearance of sound was used for systolic, and a phase 5 Korotkoff sound (disappearance of sound) was used to measure diastolic blood pressure.
Data collected were entered into and analyzed with SPSS 20 software (SPSS Inc., Chicago, IL, USA). Frequency tables and diagrams in the form of charts were generated for relevant variables. Means, standard deviations (SDs), proportions, and percentages were determined as appropriate. The means and SD were calculated for continuous variables while categorical variables were summarized using proportions. Test of significance was done using Pearson's Chi-square test and Student's t-test as appropriate. P ≤ 0.05 was taken to be statistically significant.
Ethical approval was obtained from the Institution Ethical review and Research Committee of our hospital. Informed verbal and written consent was obtained from the participants before the administration of questionnaires.
| Results|| |
The sociodemographic characteristics of the 420 participants in the study are presented in [Table 1]. The mean age of respondents was 60.97 ± 11.28 years. Majority were females (63.1%), married (83.1%) and above 45 years of age (82.1%). Most of the participants (65.0%) were from a monogamous family but still enjoy the tremendous support of extended family system as all respondents had a number of external dependents. Lower social class (class IV and V) constitute 43.3% while, 38.5% had tertiary/postgraduate education.
Majority 257 (61.2%) had good adherence and 279 (66.4%) had functional family. Out of the 279 respondents with functional family, 197 (70.6%) respondents had good adherence and 82 (29.4%) respondents had poor adherence. Good adherence was found in 60 (42.6%) of the respondents with dysfunctional family while, 81 (57.4%) had poor adherence [Figure 1].
Marital status, type of family, family size, family function, and blood pressure were found to be significantly associated with adherence to medication (P = 0.017, 0.000, 0.001, 0.000, and 0.007, respectively) [Table 2].
|Table 2: Relationship between socio-demographic characteristics and medication adherence|
Click here to view
The mean systolic BP and the mean diastolic BP was lower in respondents with good adherence with means of 140.93 ± 19.648 and 83.23 ± 10.666, respectively. In poor adherent respondents, the mean systolic BP and mean diastolic BP was 149.87 ± 22.677 and 88.13 ± 13.407, respectively. There were statistically significant association between the mean BP and adherence status [Table 3].
|Table 3: Relationship between respondents' adherence status and mean blood pressure|
Click here to view
| Discussion|| |
The mean age of the hypertensive patients in this study was 60.97 + 11.28 years. The mean age was higher than that reported by Kabir et al., and Akpa et al., in Kano and Port Harcourt, respectively. The difference may be due to the less crowded population of our study area, small sample size and the difference in methodology used for the study. Our study area is nonindustrialized town with one tertiary Health Institution and two financials Bank. Nevertheless, the mean age of the hypertensive patients in Nigeria was lower when compared with that of 70 years reported in the study done in Europe. This may be explained by the stress Nigerians are exposed to early in life compared to their European counterpart. In this study, 64.5% (271) of the participants were over the age of 55 years. This is consistent with the fact that the prevalence of hypertension increases with age in most populations, and the prevalence is highest in individuals over the age of 50 years.,,
Our study found that 89.2% had a family size of 5 and above. This is not surprising because in Nigeria and most West African countries, a family is traditionally extended vertically to include other generations, such as grandparents; and horizontally to include other relatives, such as brothers or sisters who do not live with them. Furthermore, the nuclear family may also be extended through the acquisition of >1 spouse (polygamy). However, it is worthy of note that this is fast changing as the ties of kinship binding individuals to their extended family progressively weakens with increasing urbanization. But surprisingly, our study showed 65% are in a monogamous family setting. The higher percentage of respondents with large family size (89.2%) despite been in a monogamous setting, may mean they are practising an extended family system. This may translate to enjoying a high degree of traditional social support from either members of his nuclear or extended family or both. In Africa generally and West Africa in particular, people are shielded from untoward effects of circumstances by support from families and friends.
Another finding of this study was that respondents with small family size had good adherence. Having a small family size place less financial burden on the family income, hence funds will be available to take care of the sick in the family. The government of Nigeria in the recent time advocates for small family size in the National Health Insurance Scheme by registering only four children per family under the scheme. This is consistent with findings of Kabir et al., Also studies from Bangladesh  and India, by WHO found that adherence was related to the standard of living of the people. When the family is not too large it is most likely the standard of living will be good. These findings were also corroborated by Saman et al., in their study on factors associated with adherence to antihypertensive treatment in Pakistanis.
We also found that marriage in a monogamous setting is associated with adherence. DiMatteo reported in his study  that, whereas living alone, for example, might put a patient at slightly increased risk for nonadherence to medication, living in a family that is in conflict may increase risk of nonadherence considerably.
Also, worthy of note is the fact that our study further stresses the importance of functional family background and strong family support as very important factor influencing medication adherence among hypertensive patients as reported in other studies., Functional family existed in 66.4% of our respondents, and a statistically significant association was found between family function and medication adherence. The family has been recognized by the WHO as the primary social agent in the promotion of health and wellbeing with tremendous influence on health behavior. Our study further reiterates this assertion as respondents with functional family adhered to their antihypertensive medications. The odds of adherence to medication among respondents with functional family in this study were 3 times higher than the odds of adherence among participants with dysfunctional family.
Patients who are supported in their adherence efforts are much more likely to maintain blood pressure control. Blood pressure control was associated with adherence behavior, as shown in this study. Those that are adherent has significantly lower blood pressure. This was also reported by Casson et al., Morris et al., and DiMatteo et al.
| Conclusion|| |
Type of family, size of family, marital status, and nature of family relationships (family functioning) were important to medication adherence. Hence, assessing type and quality of a patient's relationships in medical treatment of hypertension by managing physician is underscored.
Limitation and area for further study
The cross-sectional approach and short-term or one-time assessments of family functioning and perceptions were a limitation of this study. Longitudinal studies that examine the family and medication adherence trajectory over time and the reciprocal relationships between the medication adherence and changes in family functioning would be more informative.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, et al.
Global burden of hypertension: Analysis of worldwide data. Lancet2 005; 365:217-23.
Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;10:348-54.
Chobanian AU, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al
. Seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. JAMA 2003;289:2560-72.
Inkster ME, Donnan PT, MacDonald TM, Sullivan FM, Fahey T. Adherence to antihypertensive medication and association with patient and practice factors. J Hum Hypertens 2006;20:295-7.
Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: Results from the health survey for England 2006. Hypertension 2009;53:480-6.
Bittar N. Maintaining long-term control of blood pressure: The role of improved compliance. Clin Cardiol 1995;18:12-6.
Svensson S, Kjellgren KI. Adverse events and patients' perceptions of antihypertensive drug effectiveness. J Hum Hypertens 2003;17:671-5.
Marentette MA, Gerth WC, Billings DK, Zarnke KB. Antihypertensive persistence and drug class. Can J Cardiol 2002;18:649-56.
Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J, et al.
Compliance with antihypertensive therapy among elderly medicaid enrollees: The roles of age, gender, and race. Am J Public Health 1996;86:1805-8.
Grey M, Knafi K, McCorkle R. A framework for the study of self-and family management of chronic conditions. Nurs Outlook 2006;54(5):278-86.
Cao X, Jiang X, Li X, Hui Lo MC, Li R. Family functioning and its predictors among disaster bereaved individuals in china: Eighteen months after the wenchuan earthquake. PLoS One 2013;8:e60738.
Kabir M, Iliyasu Z, Abubakar IS, Jibril M. Compliance to medication among hypertensive patients in Murtala Mohammed specialist hospital, Kano, Nigeria. J Community Med Prim Health Care 2004;16:16-20.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.
Saman KH, Maria BA, Kanza A, Rubina AS, Danish S, Philippe MF, et al
. Factors associated with adherence to antihypertensive treatment in Parkistans. PLoS One 2007;2:e280.
Amal S, Syed S, Abass A. Hospital admission and poor adherence to antihypertensive therapy: Is there any relationship? Int J Pharm Pharm Sci 2009;2:38-46.
Smilkstein G. The family APGAR: A proposal for a family function test and its use by physicians. J Fam Pract 1978;6:1231-9.
Akpa MR, Agomuoh DI, Odia OJ. Drug compliance among hypertensive patients in port Harcourt, Nigeria. Niger J Med 2005;14:55-7.
Mijinyawa MS, Iliyasu Z, Borodo MM. Prevalence of hypertension among teenage students in Kano, Nigeria. Niger J Med 2008;17:173-8.
Cappuccio FP, Micah FB, Emmett L, Kerry SM, Antwi S, Martin-Peprah R, et al.
Prevalence, detection, management, and control of hypertension in Ashanti, west Africa. Hypertension 2004;43:1017-22.
Zhang H, Thijs L, Staessen JA. Blood pressure lowering for primary and secondary prevention of stroke. Hypertension 2006;48:187-95.
Inev AV, Ayankogbe OO, Obazee M, Ladipo MM, Udonwa NE, Odusote K. Conceptual and contextual paradigm of the family as a unit of care. Nig Med Pract 2004;45:9-12.
National Health Insurance Scheme. Operational Guidelines. Scope of Coverage, Page 6 Section 22.214.171.124. Abuja Nigeria: National Health Insurance Scheme; 2012.
Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized controlled trials. Arch Intern Med 2004;164:722-32.
Sabate E. Defining adherence In: World Health Organisation, editor. Adherence to Long-term Therapies-Evidence for Action. Vol. 3. Geneva: World health Organization; 2003. p. 27-38.
DiMatteo MR. Social support and patient adherence to medical treatment: A meta-analysis. Health Psychol 2004;23:207-18.
Campbell TL, Bray JH. The family's influence on health. In: Textbook of Family Practice. Rackel RE, editor. 7th
ed., Vol. 6. Philadephia, PA: WB Saunder; 2007. p. 25-34.
Casson RI, King WD, Godwin NM. Markers of loss of control of hypertension. Can Fam Physician 2003;49:1323-31.
Morris AB, Li J, Kroenke K, Bruner-England TE, Young JM, Murray MD, et al.
Factors associated with drug adherence and blood pressure control in patients with hypertension. Pharmacotherapy 2006;26:483-92.
DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: A meta-analysis. Med Care 2002;40:794-811.
[Table 1], [Table 2], [Table 3]