Hypertension is a global health problem affecting over 1 billion people worldwide. Poor adherence to antihypertensive medication regimens is a major challenge for controlling blood pressure. Factors contributing to non-adherence are multi-faceted and include patient-related issues like lack of education on hypertension and its complications, therapy-related challenges like complex dosing protocols and side effects, and health system problems like poor doctor-patient communication. Improving medication adherence requires addressing the underlying causes through patient education, building trust in the doctor-patient relationship, simplifying treatment plans, and utilizing mobile tools and family support.

1. Hypertension
“Non-Adherence to medication”
Dr. Ameel Toma
Cardiologist
College of Medicine
University of Duhok 17/3/2021

2. Hypertension:
• By 2010, the worldwide prevalence of hypertension was
estimated at 31.1%, affecting 1.39 billion people.
• Rapidly rising prevalence in low and middle–income countries.

3. Complications
of
hypertension :
Silent killer

6. Inadequately treated patients ?
Indeed, the survival of treated hypertensive patients
not at goal
is similar to that of an untreated hypertensive patient
suggesting that a lot of efforts are made for little
benefit.

7. Treatment of hypertension:
2 major factors contribute to hypertension control in
treated patients:
1-Prescription of an adequate number and dose of prescribed BP
medications .
2 -Adherence with therapy.

8. Successful control !
Among treated hypertensive adults,
• roughly 50% were controlled in high-income countries
• 25% in low-middle–income countries.

9. Case scenario:
• 50 years old male, obese, FH= hypertension
• One year ago Bp 170/90 , given treatment , improved
• Stopped his medication ?!
• Presented now with severe headache, minor stroke
• Bp 200/100

10. Not taking medication ?

11. ADHERENCE
‘The extent to which a person's behavior
[in] taking medication following a diet, and
executing lifestyle changes, corresponds
with agreed recommendations from a
health care provider’
- World Health Organization -2003

12. • The Term COMPLIANCE has come into
disfavor
passively
because it suggests that a person is
following a doctor's orders, rather
than actively collaborating in the treatment
process.
• Adherence, on the other hand, requires the
person's agreement to the recommendations for
therapy.

13. Adherence to medication:
1. Initiation: time from prescription until the first dose of the
medication is taken. 5-20% never do !!
2. Implementation: the extent to which a patient’s actual dosing
corresponds to the prescribed dosing regime
omitting dose, time
3. Discontinuation (non-persistance): most common problem
-50% of patients stopped treatment after 1 year
- especially newly treated and <40

14. Is this a major problem?

15. Poor adherence to treatment of chronic diseases is
a worldwide problem of striking magnitude
50%
... or lower depending on country
“Adherence to long term therapy”, WHO2003

17. Vicious circle !

18. Payors “get it”: Non-adherence comes at a cost
Source: Medication Adherence Leads to Lower Healthcare Use and Costs Despite Increased Drug
Spending,
Health Affaires,
2011

20. Is it only forgetfulness !

21. Adherence, Is it easy ?

22. Perceptions of hypertension treatment(study)
• It is difficult to accept that hypertension is a chronic condition and see it as
a physiological reaction to stress
• It is a temporary illness.
• Denial : deny the HT, deny need for treatment
“If there is high blood pressure, I do not want to know... thinking of that
makes me anxious... I am healthy because I feel healthy”

23. • Self-adjustment: modify their doctor instructions, can treat their self,
can stop treatment,
• Side effect:
“The doctor found that I have blood pressure.
The pill caused heartburn so I stopped taking it.”

25. Etiology
of
adherence:

26. 1. SOCIAL AND ECONOMIC DIMENSION
1-Cultural and lay beliefs about illness and treatment
2-Cost (health insurance !)
3-Low health literacy (TV, newspaper)
4-Lack of family or social support
5-Unstable living conditions;
6-Certain work schedule.
7-Limited language proficiency

27. 2. HEALTH CARE SYSTEM :
1-Doctor-patient relationship
2-Doctor communication skills
3- Long wait times .
4- Volume dependent care and not patient centered care.

28. 5- Clinician burn out !
suboptimal communication,
overworked and burned out
clinicians can adversely affect
the effectiveness of health care

29. Substitution of medication ??

30. 3. CONDITION-RELATED DIMENSION
1.
2.
3.
Chronic conditions
Lack of symptoms
Severity of symptoms

31. 4. THERAPY-RELATED DIMENSION
1. Complex protocol
2. Time to benefit
3. Treatment changes
4. Treatment failure
5. Treatment duration
6. Side effects

32. 5. PATIENT-RELATED FACTORS:
the most important factor
1. Denial of the diagnosis.
2. Do not perceive the impact of asymptomatic disease on their
health.
3. Lack of Knowledge about hypertension and its complications.
4. Use of alternate medicine.
5. Suboptimal treatment and development of side effects.
6. Future discounting

33. Future discounting:
Individuals who discount the future at higher rates appear less likely
to engage in preventive health behaviors including taking medications
for chronic conditions.

34. Where to put the blame ?!
Patient or health-care provider ? Prof. Leslie (Harvard)

35. Patients need to be supported not blamed
“Adherence to long term therapy”, WHO2003

36. Patient –doctor relationship:
Thus,
• ‘did you take your medication(s)?’
• ‘why don’t you follow a low-salt diet?’ are less effective
Better use:
• ‘are you having any problems with your medications such as they’re
too costly or cause unpleasant adverse effects?’
• ‘how does a low-salt diet affect you?’
• ‘what are some of the difficulties you have with a low-salt diet’?

37. Patient –doctor relationship:
May be ! Certainly ,not like this ?

38. Patient –doctor relationship
Trust is the critical currency in most human interactions and this
applies especially to healthcare.
The patient must have confidence that their clinician is competent and
has their best interests specially in management decisions.

40. Possible solution:
• Patient education ( disease, complications)
• Improving Doctor –patient relationship(patient centered therapy)
• Improving communication skills
• Drug dosage: simple as possible, single pill combination
avoid initial high doses(assoc. with SE).
• Using mobile app. Reminder
• Using pill box

43. In our community:
• Doctor-patient-family relationship (rely on it)
• Pharmacist ?
• Health system and authorities?

44. Take home message:
• Hypertension is a global problem with major complication.
• Poor adherence to medication is a major contributor for poor control
of hypertension.
• Silent disease– poor adherence--- silent killer.
• Try to identify the cause for poor adherence.
• The key solutions are related to educating patients, family and
improving doctor-patient relationship.
• Treat the patient ,not only the disease.

45. Thank
you