eduzhai > Helth Sciences > Nursing >

Evaluation of compliance and related factors of nephrons in Tikur Anbessa special hospital in Addis Ababa, Ethiopia in 2012

  • sky
  • (0) Download
  • 20211031
  • Save International Journal of Nursing Science 2013, 3(1): 1-6 DOI: 10.5923/j.nursing.20130301.01 Assessments of Adherence to Hypertension Medications and Associated Factors among Patients Attending Tikur Anbessa Specialized Hospital Renal Unit, Addis Ababa, Ethiopia 2012 Habtamu Abera Hareri1,*, Mesfin Abebe2 1Department of Nursing, College of Health sciences, Debre M arkos University 2Department of Nursing, College of Health Sciences, Addis Ababa University Abstract Hypertension is one of the most important preventable causes of premature mortality worldwide and it is one of the primary risk factors for heart disease and stroke. In Ethiopia 10.6% and Addis Ababa, 30% of the population has been estimated to have hypertension. Adherence to med ication therapy is an aspect of patients’ care that is often overlooked and should be evaluated as a crucial part of cardiovascular management. Institutional based cross -sectional study was conducted. Systematic sampling technique was used to select 286 study subjects. A structured standard interv iewer ad ministered questionnaire was used after some modifications and analysis was done using SPSS 16. P -value <0.05 was considered significant association. Scoring method was used to classify patients’ level of adherence. Of 286 subjects included in the study 165(57.7%) were female and mean age was 52±13 year. The adherence level of respondents to medication was 69.2%. The medication adherence was found to be better in patients who had been informed about their med icine. There was significant association between marital status, work status, Health care facilities, duration of Hypertension and its treatment and medication adherence. The rate of adherence to med ication was generally found to be low in these study p articip an ts . Keywords Hypertension, Adherence Status, Medication, Perception 1. Introduction Hypertension is an overwhelming global challenge with high morb idity and mortality rate. Analysis of the global burden of hypertension revealed that over 25% of the world's adult population had hypertension in 2000, and the proportion is expected to increase to 29% by 2025. The prevention and control of high blood pressure has not received due attention in many developing countries. Adherence to therapies is a prima ry determinant of treatment success. Poor adherence attenuates optimu m clinical benefits and therefore reduces the overall effect iveness of health systems 1, 2,4 Despite its importance, adherence to medication therapy is an aspect o f pat ients’ care that is o ften overloo ked and should be reevaluated as a crucial part o f cardiovascular man ag ement . A lthou gh reliab le, large -scale ,populationbased data on high blood pressure in SSA are limited, recent * Corresponding author: (Habtamu Abera Hareri) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved studies provide important and worrisome findings in both epidemiology and clin ical outcomes. A lthough overall hypertension prevalence is between 10%-15%, prevalence rates as high as 30%-32% have been reported in middle-inco me countries. Importantly, hypertension awareness, treatment, and control rates as low as 20%, 10%, and 1%, respectively have also been found. Rapid urbanization and transition fro m agrarian life to the wage-earning economy of c ity life continue to fuel increases in average blood pressure levels and prevalence of HTN 2, 3. The epidemiology of h igh blood pressure among adults in Addis Ababa was studied. About 20% of males and 38% of females were overweight, with 10.8 % of the females being obese. Similarly, 17% of the males and 31% of the females were c lassified as having low level of total physical activ ity. Reported use of anti-hypertensive medication, was 31.5% among males and 28.9% among females. High blood pressure is wide ly prevalent in AA and may represent a silent epidemic in this population. In Africa, 15% of the population has hypertension. Although there is shortage of extensive data, 6% of the Ethiopian population has been estimated to have HTN. Appro ximately 30% of adults in Addis Ababa have hypertension above 140/ 90mmHg or reported use of 2 Habtamu Abera Hareri et al.: Assessments of Adherence to Hypertension M edications and Associated Factors among Patients Attending Tikur Anbessa Specialized Hospital Renal Unit, Addis Ababa, Ethiopia 2012 anti-hypertensive medication Th is indicates an urgent need for strategies and programmes to prevent and control high blood pressure, and pro mote healthy lifestyle behaviors primarily among the urban populations of Ethiopia1,4. A WHO report estimates that adherence to antihypertensive medications ranges from 52% to 74% when adherence is defined as possession of a med ication at least 80% of the time. It also identified non adherence to medical treatment as a major public health concern, especially in patients with chronic conditions, e.g. hypertension. It is now evident fro m WHO data that coronary heart disease and cerebrovascular disease are increasing so rapidly that they will rank Nu mber one and five respectively as causes of global burden by the year 2020. In Africa only 5-10% have a blood pressure control of hypertension of<140/ 90 mm Hg5, 6. The number of adults with hypertension in 2025 was predicted to increase by about 60% to a total of 1.56 b illion. According to the WHO, mo re than 80% o f deaths from hypertension and associated cardiovascular diseases now occur in lo w and middle -income countries and this is particularly co mmon among people of lo w socio-economic status7,8. In spite of many advances made in adherence research, non-adherence rates have remained nearly unchanged in the last decades. Poor adherence is associated with bad outcome of the disease and wastage of healthcare resources 1, 9 2. Objective The objective of this study was to assess adherence and associated factors of adherence to medication among hypertensive patients attending Tikur Anbessa Specialized Hospital renal unit, Addis Ababa, Ethiopia 2012. 3. Methods The study was conducted in Tikur Anbessa specialized Hospital renal un it in Addis Ababa, Ethiopia. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia (CSA), Addis Ababa city has a total population of 3,384,569. It lies at an alt itude of 7,546 feet (2,300 meters). The area was selected because it is central referral hospital that provides organized hypertension follows up care. The study period was from September 2011 to May 2012. A cross-sectional study design was conducted in Tikur Anbessa specialized Hospital renal unit. Source population was all hypertensive patients during the study period. Study subjects were all HTN patients who fulfilled the inclusion criteria 3.1. Sampling and Sample Size Study was carried on total of 1700 patients attending Tikur Anbessa Specialized hospital. Out of this 286 were selected by systematic rando m technique down the list. The first study subject was selected by simple random technique using lottery method. Every other two patients were interviewed when they came for follow up at renal unit fro m the registration list of patients 3.2. Data Collection and Processing A structured standard interviewer administered questionnaire was used after some modificat ions. The questionnaire was initially prepared in English and then translated in to Amharic version. The A mharic version was again translated back to English to check for consistency of mean ing. During data collection supervision was carried out and daily checking of the collected data was made by principal investigator. To assure data quality, data collectors were recru ited; training and orientation were given to data collectors and supervisor. About 5% of the data were verified by the principal investigator during the initial stage of data collection and appropriate instruction was given to the data collectors and supervisor. Supervisor and principal investigator were closely followed the data collection process at the spot. Data were entered to Epi-info version 3.5.1 and analyzed by using SPSS 16.0 software. 3.3. Operational Definitions Rudd (2000) suggests adherence is the willingness and ability of the individual to follow the clinical prescription. Medicine related adherence: to receive all the prescribed med ications regularly in the last month. Diet-related adherence: to consume a lo w-fat and low-sodium d iet and increase vegetables and fruits; exercise-re lated adherence: to exercise 30 minutes/days at least three times a week; Substance-related adherence: not to smoke (either never smoked or stopped smoking), decreas e coffee taking and stop alcohol. The adherence score for each item was obtained by calculating the mean(10). A cut-off point was set at 3 and the respondents were categorized in to adherence and non adherence groups, the respondents with a score of 3 and above were considered as adherent and a score of below 3 were considered as non-adherent. 4. Results The total study sample was 286 hypertensive patients, with the response rate of 100%. Socio demographic Characteristics of the study sample are presented in Table 1. The study consisted of 165(57.7%) females. The mean age of the respondents was 52±13.03years. Majority of the respondents 177(61.9%) were orthodox by religion and 195(68.2%) were married. Out of the respondents 99(34.6%) attended tertiary school educational level and 103(36.0%) respondents were governmental employed. Eighty three (29%) o f respondents have income ≥3000 Ethiopian Birr (ETB) and 57(19.9%) d id not have regular income and live with support from others. As regard informat ion on Hypertension and Patients’ Condition Table 2. Of the respondents 80(28%) had blood pressure ≥160/100mmHg .Concerning health status, more International Journal of Nursing Science 2013, 3(1): 1-6 3 than half of the respondents 158(55.2%) considered their health status as fair. Majority of the respondents 180(62.9%) gone to governmental hospital to receive health care service most of the time and 186(65%) were hypertensive for five or 60% more years and 178(62.2%) were on hypertensive treatment 40% for the same period. Near to t wo third of respondents BMI 196(68.5%) were on one to two antihypertensive 20% med ications. Of the respondents 124(43.4%) never read written informat ion about their medications and 235(82.2%) 0% study subjects were understood very well the information Normal BMI Overweight Obese provided by health care givers about their medicat ion. Table 1. Socio demographic Charact erist ics of respondent s on treatment in Tikur Anbessa specialized Hospital renal unit, Addis Ababa, Ethiopia 2012 (n=286) Variables Alternative responses Number % Age in years 20-39years 40-59years 51 17.8 144 50.4 ≥60 years 91 31.8 Tot al 286 100 Male 121 42.3 Sex Female 165 57.7 Tot al 286 100 Amhara 100 35.0 Ethnic group: Oromo 70 24.5 Gurage 49 17.1 Tigire 38 13.3 Others* 29 10.1 Tot al 286 100 Single 30 10.5 Marital status Married 195 68.2 Widowed 32 11.2 Divorced 29 10.1 Tot al 286 100 Ort ho dox 177 61.9 Religious Catholic 17 5.9 Muslim 49 17.1 Prot estant 43 15.1 Tot al 286 100 Educat ion al level Illit erat e Primary school Secondary school 56 19.6 47 16.4 84 29.4 Tertiary school 99 34.6 Tot al 286 100 Governmental employee 103 36.1 Work status Private business House wife 69 24.1 49 17.1 Non-employed 59 20.6 Ret ired 6 2.1 Tot al 286 100 No regular income 57 19.9 Monthly income <999birr 1000-1999birr 2000-2999birr 30 10.5 44 15.4 72 25.2 ≥3000birr 83 29.0 Tot al 286 100 Others*=Gamo,Silte, Adiya, Sumale Other families*=children and parents Fi gure 1. BMI of respondent s (N=286) Related to respondents’ perception of hypertension Table3, fro mthe total study participants 235(82.2%) had low perception of risk of developing hypertension complications and 194(67.8%) had high perception that hypertension is sever. Related to Motivators to adhere to medication as indicated in Table 4, about 150(52.4%) respondent were not motivated to adhere to medication where as others were motivated. Table 2. Information on Hypertension and patient conditions in Tikur Anbessa specialized Hospital renal unit, Addis Ababa, Ethiopia 2012 (n=286) Items BP Alternative responses Number % ≤139/89 112 39.2 140/90-159/99 ≥160/100 Tot al 94 32.8 80 28.0 286 100 Excellent 61 21.3 Your health Status Good Fair 24 8.4 158 55.2 Poor 43 15.4 Tot al 286 100 Private Hospital 18 6.3 Health care Go v ernment al Ho spit al 180 62.9 Health center 39 13.6 Private clinic 30 10.5 More than one Tot al 19 6.6 286 100 Less than two years 31 10.8 Duration of HTN T wo to four years 69 24.1 Five or more years 186 65.0 Tot al 286 100 Less than two years 64 22.4 Duration of HTN Rx T wo to four years 44 15.4 Five or more years 178 62.2 Read written information about your prescription medicines Tot al Not at all So met imes Oft en Tot al 286 100 124 43.4 105 36.7 57 19.9 286 100 Understand the in fo rmat ion provided about your medicine Somewhat Very well Tot al 51 17.8 235 82.2 286 100 4 Habtamu Abera Hareri et al.: Assessments of Adherence to Hypertension M edications and Associated Factors among Patients Attending Tikur Anbessa Specialized Hospital Renal Unit, Addis Ababa, Ethiopia 2012 Table 3. Perceptionsof respondents in Tikur Anbessa Specialized Hospital renal unit, Addis Ababa, Ethiopia 2012(n=286) Variable P ercept io n Tot al Perception of Risk P ercept ions of sev erit y High N (%) 51(17.8) 194(67.8) Low N (%) Number % 235(82.2) 286 100 92(32.2) 286 100 Table 4. Cues to action of respondents in T ikur Anbessa Specialized Hospital renal unit (n=286) Addis Ababa, Ethiopia 2012 Variables Cues to act ion (Mot ivat ion ) Not motivated Mot iv at ed Tot al Num ber % 150 52.4 136 47.6 286 100 Table 5. Association of Medication adherence by selected characteristics, among hypertensive patients in Tikur Anbessa Specialized Hospital renal unit, AA, Ethiopia 2012 Variables Marital status Single Married Widowed Divorced Tot al Current work Non-employed House wife Private business Ret ired Governmental emp. Tot al Read written Oft en Not at all/ Sometimes Tot al Understand information Very well Not at all/Somewhat Tot al Health care Private Hospital Gov. Hospital Health center Private clinic More than one Tot al Duration of Diagnosis <2 years 2 to 4 years 5 / more years Tot al Duration of Rx <2 years 2 to 4 years 5 / more years Tot al Cues to action Not motivated Mot iv at ed Tot al Medication adherence Adherent N (%) Non-adherent N (%) 18(6.3) 145(50.7) 21(7.3) 14(4.9) 198(69.2) 12(4.2) 50(17.6) 11(3.8) 15(5.2) 88(30.8) 47(16.4) 35(12.3) 32(11.2) 3(1.0) 81(28.3) 198(69.2) 12(4.3) 14(4.9) 37(12.9) 3(1.0) 22(7.7) 88(30.8) 46(16.1) 152(53.1) 198(69.2) 11(3.9) 77(26.9) 88(30.8) 169(59.1) 29(10.1) 198(69.2) 66(23.1) 22(7.7) 88(30.8) 9(3.1) 131(45.9) 22(7.7) 27(9.4) 9(3.1) 198(69.2) 9(3.1) 49(17.3) 17(5.9) 3(1.0) 10(3.5) 88(30.8) 17(5.9) 39(13.6) 142(49.7) 198(69.2) 14(4.9) 30(10.5) 44(15.4) 88(30.8) 32(11.2) 33(11.5) 133(46.5) 198(69.2) 32(11.2) 11(3.8) 45(15.8) 88(30.8) 93(32.5) 105(36.7) 198(69.2) 57(19.9) 31(10.9) 88(30.8) COR(95%CI) AOR(95%CI) 1.61(.573,4.509) 3.11(1.402, 6.888)* 2.05(.730,5.734) 1.00 1.49(.520, 4.262) 2.00(1.330, 6.744)** 2.303(.804, 6.594) 1.00 1.06(.483, 2.344) 0.68(.312, 1.479) 0.23(.118, 0.459)* 0.27(.051, 1.440) 1.00 1.08(.449-2.582) 0.75(.328-1.730) 0.28(.130, .606)** 0.28(.049,1.643) 1.00 2.12(1.039, 4.320)* 1.00 1.30(.562, 3.006) 1.00 1.94(1.042, 3.622)* 1.00 1.71(.855, 3.414) 1.00 1.11(.306, 4.037) 2.97(1.139, 7.746)* 1.44(.478, 4.323) 10.00(2.243,44.574)* 1.00 0.96(.224, .095) 1.44(.469, .406) 1.01(.282, .616) 6.31(1.173,33.962)* * 1.00 1.00 1.07(.456, 2.511) 2.66(1.213, 5.821)* 1.00 0.96(.313, 2.953) 0.11(.013, .955)** 1.00 3.00(1.295, 6.950)* 2.96(1.630, 5.360)* 1.00 3.81(1.264, 1.510)** 0.33(.033, 3.357) 1.00 1.00 2.08(1.236, 3.488)* 2.84(1.470, 5.499)** (*COR, Statistically significant but lost in AOR) and (**AOR= statistically significant), p<0.05 International Journal of Nursing Science 2013, 3(1): 1-6 5 Adhere nce Fro m the total study participants 198(69.2%) were adherent to medicat ion regimen where as the rest were not. Married respondents were 2 t imes more likely to adhere to anti-hypertensive med ication compared to divorced AOR=2.00, 95%CI: 1.330-6.744, P=0.008. Respondents who had private business were 72% less likely to adhere to med ication co mpared to governmental emp loyed AOR=0.28, 95% CI: 0.130-0.606, P=0.001. Respondents who attended most of the time private clinic to receive health care were 6 times more likely to adhere to med ication than who attended more than one health care facilities AOR=6.34,95%CI: 1.173-33.962, p=0.032. Respondents with the duration of diagnosis of five or more years were 89% less likely to adhere to treat ment when co mpared to with diagnosis of hypertension less than two years AOR=0.11, 95% CI: 0.013-0.955, P=0.045. Those with treatment duration between two to four years were 4 times more likely to adhere to treat ment co mpared to<2years AOR=3.81, 95% CI: 1.264-11.510, P=0.018. Motivated respondents were 3 times more likely to adhere to the med ication compared to those not motivatedAOR=2.84, 95% CI 1.470-5.435, P=0.002 (Table 5) 5. Discussion In this study awareness of the negative consequence of non- adherence to antihypertensive drug therapy(17.8% Vs 48%), patients attending private hospital(3.1% Vs34.1%) had low level of adherence and adherence to medication in motivated patient(36.7% Vs 65.7%) were lo w co mpared to study conducted in southwestern Nigeria 16. This can be explained by the findings of the respondents related to perception of risk was very low (17.8%) in this study groups. Low Perception of negative consequence and lack of reminders could lead to non- adherence. Patients with hypertension for five or mo re years were 88% less likely to adherent to treatment which is lo wer than studies conducted in India showed 1.71 times more adherent compare to these who were not adherent 17.This could be related to sympto m free nature of the disease, lack of knowledge and continuous reminders. It is important to provide continuous awareness and reinforcement to those groups of patients in this study groups to improve their adherence status. The health care team, especially nurses should emphasis on the awareness creation related to hypertensive complications. There by increase adherence behavior of their patients. In general, lack of organized continuous health education concerning hypertens ion management might be the cause for non-adherence among these patients. Hypertension is one of the mostly prevalent chronic diseases in the world 5, 11, 12. In study conducted in Bra zil showed that Adherence to treatment is the most important factor to an effect ive blood pressure control. Non-adherence to medication is a major factor to non- control of blood pressure in more than two-thirds of hypertensive individuals 13. It was identified 69.2% o f respondents in this study was adherent to medication wh ich is significantly lower compared to expected index of 80% medicat ion adherence 5, 10, 13,14. It is also lower than prev ious studies done in Kuwait 88.6%, Nigeria 75%, India 73%, and Turkey 72% were adherent15, 16, 17, 18.. This might be due to better access and care to patients in these countries. This could also be related to low level of education and low leve l of awa reness related to risk of hypertension complications. Failure to adhere by hypertensive patients to medications can lead them to poor blood pressure control and increased risk of co mplications. The relat ion between age and med ication adherence was found in studies conducted in New Orleans USA and Iran 19, 20. In this study there was no association between age of respondents and med ication adherence. In this study even though there was no significant association between sex and adherence level, females were mo re adherent than males (40.9% Vs 28.3%). This find ing is in line with a study done in Gonder University Hospital (65% Vs 35%) 1.Th is can be explained by the fact that; men are burdened by the outdoor activities which make them busy and make them forget their med ications. Alcohol consumption, a co mmonly p ractice by males, could also be a barrier for their treat ment adherence. 6. Conclusions and Recommendations The adherence to med ication was generally low in these hypertensive patients. It was indicated in this study that patients had low perception of risk of co mplication of hypertension which was reflected by low leve l of adherence. Factors such as marital status, work status, Health care facilit ies, duration of HTN and its treat ment were associated with medicat ion adherence. The medication adherence was found to be better in patients who had been informed about their med icine. The present study will provide base line informat ion that will enable to exp lore the problem at wide range by conducting further more research in different segment of populations. Health professionals must educate hypertensive patients about their disease with specific emphasis on its causes, the severity of the disease, their med ications and the consequences of non-adherence with treatment. They need to stress the importance of ad herence with their hypertension treatment despite the absence of symptoms. It is necessary to stress the benefits of their treatment and their risks of developing complications. The present study will p rovide base line informat ion that will enable to exp lore the problem at wide range by conducting further more research in different segment of populations, to investigate the problem in better way and design interventional activities accordingly. ACKNOWLEDGEMENTS 6 Habtamu Abera Hareri et al.: Assessments of Adherence to Hypertension M edications and Associated Factors among Patients Attending Tikur Anbessa Specialized Hospital Renal Unit, Addis Ababa, Ethiopia 2012 This research was funded by Addis Ababa University. Moreover, we would like to thank the study participants and data collectors for their fully participation and responsible data collection. (2003): The National High Blood Pressure Education Program Coordinating Committee. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension; 42: 1206-1252. REFERENCES [1] Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved Abere D, Getahun A, Solomon M , Zelalem B. (2012): Adherence to antihypertensive treatment and associated factors among patients on follow up at University of Gondar Hospital, Northwest Ethiopia. BM C Public Health; 12:282. [2] Ronan O’Carroll, M artin D, M arie J, Cathie S. (2010): Improving adherence to medication in stroke survivors (IAM SS): a randomized controlled trial: study protocol. BM C Neurology; 10(15). [3] Cooper RS, Amoah AG, M ensah GA. (2003): High blood pressure: the foundation for epidemic cardiovascular disease in African populations. Ethn Dis.; 13(2); S48-52. [12] Chockalingam A, Campbell NR, Fodor JG. (2006) : Worldwide epidemic of hypertension. Can J Cardiol.; 22(7); 553-5. [13] Rachel G, Bastos B, Nereida Kilza da Costa L. (2006): Adherence rates of hypertension treatment in Brazil and around the world. Rev Bras Hiperten; 13 (1); 35-38. [14] Jae-Hyun P, Youngsoo S, Sang-Yi L, Sang III L. (2008): Antihypertensive drug medication adherence and its affecting factors in South Korea. Int J Cardiol;128( 3) ; 392-398 [15] Amal M Al-M ehza, Fatma A Al-M uhailije, M aryam M Khalfan, Ali A Al-Yahya. (2009): Drug compliance among hypertensive patients: an area based study. Eur J Gen M ed.; 6(1); 6-10. [16] Kazeem B Yusuff, Abdrahman A.( 2007): Assessing patient adherence to anti-hypertensive drug therapy: can a structured pharmacist-conducted interview separate the wheat from the chaff? The Inter J of Pharmacy Practice; 15: 295–300. [4] Fikru T, Peter B, Stig W. (2009): Population based prevalence [17] Subhasis B, P. Sankara Sarma(2011): Adherence to of high blood pressure among adults in Addis Ababa: antihypertensive treatment and its determinants among urban uncovering a silent epidemic. BM C Cardiovascular Disorders; slum dwellers in Kolkata, India. Asia-Pacific J of PH. 9(39). ht tp ://ap h.sagep ent /early /.abst ract ? [5] Sabate E. (2003): Adherence to long term therapies: Evidence for action. Geneva, Switzerland: WHO; 35(3); 207 [6] Seedat YK. (2000): Hypertension in developing nations in sub-Saharan Africa. J Hum Hypertens; 14(10-11); 739-47. [7] Kearney PM , Whelton M, Reynolds K, Muntner P, Whelton PK, He J. (2005): Global burden of hypertension: analysis of worldwide data. Lancet; 365(9455); 217-23. [8] World Health Organization (2003). Adherence to long-term therapies: evidence for action. Geneva: World Health Organization. Accessed on12/2/2012. [9] Hashmi SK, Afridi M B, Abbas K, Sajwani RA, Saleheen D, Frossard PM , Ishaq M , Ambreen A, Ahmad U. (2007): Factors Associated with Adherence to Anti-Hypertensive Treatment in Pakistan. PLoS ONE; 2(3); e280. [10] Carpenter R. (2005): Perceived threat in compliance and adherence research. Nursing Inquiry; 12(3); 192-199. [11] Aram V Chobanian, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, M aterson BJ, Oparil S. [18] Ana do lu Kar di yol Derg: The assessment of adherence of hypertensive individuals to treatment and lifestyle change recommendations. Hypertensive individuals and lifestyle 2009; 9: 102-9. [19] Krousel-Wood M A, Islam T, M untner P. (2008): M edication adherence in older clinic patients with hypertension after Hurricane Katrina: implications for clinical practice and disaster management. Am J M ed Sci.; 336(2); 99-104. [20] Negin H, Narges R (2004): Determinant factors of medication compliance in hypertensive patients of Shiraz, Iran: archives of Iranian medicine; 7(4); 292 - 296. [21] Helvi K.(1999): Compliance of patients with hypertension and associated factors in Finland population. JAN; 29(4): 832-839. [22] Lawrence J, M ichael W. Brands, Stephen R. Daniels, Njeri K, Patricia J. (2006): Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association; 47: 296-308.

... pages left unread,continue reading

Document pages: 6 pages

Please select stars to rate!


0 comments Sign in to leave a comment.

    Data loading, please wait...