Non-compliance and its associated factors among hypertensive patients taking anti-hypertensive treatment visiting Gimbi general hospital,Western Ethiopia:cross-sectional study

Objective: Hypertension is defined as a persistent systolic blood pressure reading of 140 mm Hg or greater and/or a diastolic blood pressure reading of 90 mm Hg or greater. Poor adherence to anti-hypertensive therapy is one of the biggest obstacles in therapeutic control of high blood pressure and usually associated with bad outcome of the disease and wastage of limited health care resources. The study was aimed to assess the patient compliance and associated factors of anti-hypertensive treatments Result: The study showed that the overall level of compliance was 106(83.46%) and non-compliance level was 21(16.54%). Among 127 respondents 52 (40.95%) were males and 75 (59.05%) were females. Majority of respondents 113(88.98%) were taking treatments as prescribed and 106(83.36%) had regular follow up. In this study 45 patients never forget to take their medication and 82(64 57%) respondents were stopped their medication due to different reason from this, 64(34.8%) were due to improvement from illness and 37(20.1%) due to lack of money.


Introduction
Hypertension is defined as a persistent systolic blood pressure reading of 140 mm Hg or greater and/or a diastolic blood pressure of 90 mm Hg or greater. It causes 7.1 million premature deaths each year worldwide and accounts for 13% of all deaths globally (1,2).
Analysis of the global burden of hypertension revealed that over 26% of the world's adult population had hypertension in 2000 (3). In Africa, 15% of the population has hypertension (4). About 6% of the Ethiopian population has been estimated to have HTN (5).
Non-compliance with medications is one of the major factors in the failure of therapeutic programs in patients having a chronic disease. In the available literature, the magnitude of non-compliance with medications prescribed for patients with hypertension was 16.7% (6,7).
The compliance of patient's decreases with time and it is lower in long-term medications than in short-term medications. Ensuring patients' compliance with anti-hypertension medications and lifestyle modifications to prevent complications of hypertension remains a major challenge to public health in many developing countries (8,9).
Non-compliance with treatment is the most important single reason for uncontrolled hypertension. With regard to the possible factors of non-compliance,the magnitude of noncompliance is expected to be high in Ethiopia, particularly study area (10,11).
Hypertension has no cure therefore; patients are expected to take medications for life.
They should honor their appointments for follow up visits with clinician and adopt health actions that are recommended to lower their blood pressure (12).
Compliance with treatment of hypertension has various benefits for the individuals, the health care systems and the society at large in the case of cost saving since it reduces the incidence of complications and the need for additional medications (13). This is particularly crucial in a public financed health care system such as Ethiopia. There are effective medical therapies for hypertension management. However, only 37% of hypertensive patients were reported to have their blood pressure controlled (14).
The problem of non-adherence to medical treatment remains a challenge for the medical professions and social scientists. As a result, substantial numbers of patients do not get the maximum benefit of medical treatment, resulting in poor health outcomes, lower quality of life and increased health care costs. In spite of many advances made in adherence research, non-adherence rates have remained nearly unchanged in the last decades (7,15,16).
Poor adherence to anti-hypertensive therapy is one of the biggest obstacles in therapeutic control of high blood pressure. Failure to adhere causes medical and psychological complications of the disease, wastes health care resources and erodes public confidence in health systems (16,17).
In line with the global realities, Hypertension sufferers' noncompliance to their pharmacological regimen and frequent lifestyle changes result in uncontrolled hypertension that leads to different life threatening organ complications such as cardiovascular, renal and cerebro-vascular diseases (18).
Despite, HTN is a difficult disease for adherence to treatment, specific studies are almost not exists in Gimbi. Little has been documented about the adherence status and associated factors in Ethiopia (19). Therefore, the main aim of this study was to add the existing body of knowledge about factors affecting compliance to hypertension medication and lifestyle modifications and to propose strategies that will assist policy makers and clinicians with hypertension management decisions.

Patients And Methods
Study setting and study period A hospital based cross sectional study was conducted at GGH from March 5,to April 5, 2018. The hospital delivers diversified health services and clinics including the emergency services, eye clinic, dental clinic, mother and child health (MCH) , laboratory, X-ray, and follow up of chronic disease.

Study participants and eligibility criteria
All hypertensive people who were attending medical OPD during the study period and patients who agreed to participate in the study were included. People who are unable to give response for an informed consent, Patients less than 15 years of age, critically ill patients and mentally ill or psychiatric patients were excluded. Data collection process and management Data was collected using questionnaire which was developed after reviewing different literature. The respondents were encouraged to answer the questions within the time they devoted as much as possible and the data was collected through daily follow up. Every effort was made to choose a site for interviewing that allow the interviewer to be seat out of sight and at a sufficient distance from the health institute to avoid interviews being over heard each other. Five percent of the sample was pre-tested to check acceptability and consistency of data collection tool two weeks before the actual data collection.

Data processing and analysis
The data was entered in to computer using EPI-manager 4.0.2 software. Data checking and cleaning was done by principal investigator on daily basis during collection before actual analysis. Analysis was done using statistical software for social sciences (SPSS) 24.
Descriptive statistics was used to analyze data in terms of frequency and percentage.

Operational definitions
Compliance: Is defined as "the extent to which a person's behavior (taking medicines or executing lifestyle changes) coincides with medical or health advice" those taking medication daily (20,21 ).
Non-compliance: Any form of deviation from compliance like losing one appointment, missing doses, etc.(instructions not understood, ,costy,not availability of drug.) Adherence: As "the extent to which a person behaviour taking medication following diet and or executing corresponds with agreed recommendations from health care provider." Concordance: Is patients have relationship with health care professionals and discuss with treatment and about the drug openly.
Hypertension: Is defined as the persistent systolic blood pressure equal to and greater than 140 mmHg and/or persistent diastolic blood pressure equal to and greater than 90 mmHg (13).

Socio-demographic characteristics
A total of 127 study participants were interviewed making the response rate 100%. Most of the respondents were in the age range of 50-64 which make 54(42.51%) of the respondents. Majority of the respondents75 (58.9%) were females. Protestant Christians and the Gimbi towns hypertensive patients accounted for 70(55.1%) and 54(42.51%) of the respondents respectively. 54(42.51%) of the respondents were rural by resident. 73(57.5%) reported to be married and more than one third or 48(37.8%) of respondents were uneducated.

Factors associated with anti-hypertension treatments non-compliance
This study showed that among the respondents 45 (35.43%) never forget to take medication, so they were compliant to their medication. 82(64.57%) respondent that they knew stopped their regular follow up and their medication previously with different purposes. From them 64(34.8%) were due to improvement of illness.

Discussion
This study conducted to determine the levels of adherence and factors associated with non adherence to antihypertensive teatment and revealed that 83.46% were compliant.
As a study done in Seychelles showed that compliance magnitude with anti-hypertension medications was 71.57% (26). Study done in Dessie showed that about74.2% of respondents were adherent to their medication (27).
The variation that existed partly be explained by the differences in the methods employed, economical status and educational advancement and may be different definitions of compliance. In our study the level of compliance was lesser than the study done in Scotland. This might be because they are economically advanced to get needed drugs at time as well as more awareness than our countries people.
In the case of African countries all listed above reported lesser results than this study result. This might be the fact that the subjects of this study regularly visited the General hospital got instructions from their health care providers contributed their non-compliance behavior A study done in Yirgalem Hospital showed that compliance magnitude of anti-hypertension regimens in adult population was 40% and lack of money was the major factor associated with treatment compliance which accounted 83% (28).Here in this study Lack of money was reported as a limiting factor of patient compliance. This might be because antihypertension drugs are provided by money payment now a day. This finding is supported by the study done in India (29).
Urban people were more likely compliant than rural; this is may be information gap and accessibility of health facilities. Those who had high income were more likely compliant than those who low income. This might be happened because of they have enough money to buy treatment drugs.

CONCLUSION
The magnitude of adherence among hypertensive patients found to be higher.The most influential factor to non-adherence was lack of money or income and improvement of illness and longer duration of treatment.
In order to increase the magnitude of compliance to the medication health professionals must educate the patient about disease and consequences of non-adherence with treatment. Additionally, government should be ensured adequate supply of antihypertensive drugs the policy of sharing should be on the possibilities of giving antihypertensive drug free of charges.

Limitation
As limitations, the study was cross sectional and the causal effect relationship cannot be found and the follow-up period was short, thus failing to take into account any noncompliance after this time. We thank Wollega University for funding this study. We are grateful to staff members and health care professionals of GGH, data collectors and study participants for their cooperation in the success of this study.

Authors' Contributions
FB contributes in the proposal preparation, study design and analysis.GF contributed to the design of the study, analysis and write up of the manuscripts. DD and KB made a substantial contribution to the local implementation of the study. All authors read and approved the final version of the manuscript.
Ethics Approval and Consent-to-Participate Ethical clearance was obtained from the ethics review board of Wollega University.
Permission was obtained from medical director of the GGH to access hypertensive patients and conducts the study. The benefit and risks of the study was explained to each participant included in the study and written consent were obtained from each patient involved in the study.
Consent for publication: Not applicable. No individual person's personal details, images or videos are being used in this study.
Funding: The study was funded by Wollega University. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Others includes Student and Nongovernmental organization  Figure 1 Reported reasons for non-compliance to anti-hypertensive treatments, GGH, Oromia, Ethiopia, from March 5 to April 5, 2018