Understanding the role of educational interventions on medication adherence in hypertension: A systematic review and meta-analysis
Introduction
Hypertension is a chronic medical condition in which the blood pressure of the arteries is elevated. It is diagnosed when there is persistent rise (measured on two occasions) of ≥140 mmHg in systolic blood pressure (SBP) and/or ≥90 mmHg in diastolic blood pressure (DBP) among individuals without diabetes, and ≥130 mmHg SBP and/or ≥80 mmHg DBP among individuals with diabetes.1,11,32,53 It is often referred to as the silent killer and accounts for one-eighth of the global death burden ranking as the third cause of mortality globally.37,53,65 The complications of hypertension include chronic kidney diseases, heart failure, and stroke; these occur more frequently in blacks than whites.33,40,41 However, these complications have mainly been attributed to poor adherence to pharmacological and lifestyle management.66
In developed countries, the incidence rate of non-adherence among patients suffering from chronic diseases is as high as 50%.14,27 In comparison to developing countries, the non-adherence rates are much higher (93.3%) owing to the scarcity of health resources and inequalities in access to health care.34,65 Medication non-adherence has been associated with an increased risk for poor health, adverse clinical problems, and mortality.30 Hence, non-adherence could be a detrimental factor in achieving optimal health outcomes.20 In a systematic review of 21 reviews, the authors reported that higher financial status and better socioeconomic position have a positive impact on medication adherence in hypertension and other cardiovascular disorders.19,34 Also, adherence is low in very old and very young persons.19 For employment and education, the evidence of its impact on medication adherence is uncertain even though a positive relationship exists resulting in poor health.19,36,61,64,68 However, the benefits of medication adherence include improved survival, enhanced quality of life and lower risk of hospitalization.2,14,42
Even though excellent clinical outcomes are associated with medication adherence, failure to effectively educate the patients leads to an incomplete understanding of the disease or drug regimens.16,29,46 This ineffective education may result in continuous adoption of cultural and religious beliefs, influencing people's attitudes to medication3,13,14 leading to lack of adherence. Therefore, improving health literacy on medication through education can reduce untoward beliefs by targeting the benefits of medication adherence.
Health education can be given to individuals or groups using varieties of approaches. An individual approach may consist of counselling, clinic consultation, and on-site visits whereas the group approach may involve lectures, seminar groups, panel discussions and workshops.54 Face to face education is a common approach that promotes engagement, improves trust and enhances patient participation during education.68 This is because the face to face approach enhances the assessment of patient's needs and reduces barriers to medication adherence.68 Similarly, other modes of health education delivery include appropriate usage of educational materials such as booklets, books, handouts, and videos.54
A number of studies have evaluated the effects of educational interventions such as oral, printed material or combination of verbal and written materials on improving adherence to the management and treatment of hypertension.9,22,57 However, the existing literature does not research the effect of the different educational methods on medication adherence in hypertension based on a large amount of pooled data. Pooled quantitative evidence comparing the effect of educational methods remains scarce. Previous reviews have evaluated interventions on medication adherence in chronic diseases and have not focussed on hypertension alone.15,21,45,50,60,63 This systematic review is related to the study of Tan et al.60 However, unlike the study by Tan et al.,60 our work makes a novel contribution to the literature by focusing on the different methods of education. The educational methods considered in this review were printed, verbal (face-face and telephone counselling), videos and pictorial with or without electronic (emails) on medication adherence among individuals with hypertension.
A comprehensive search conducted in Cochrane and Prospero found no systematic review of the effect of different methods of educational intervention on medication adherence in hypertension. Therefore, this systematic review identifies and critically appraises studies to provide a comprehensive summary of the best evidence on the effect of the different methods of educational interventions on medication adherence in the management of hypertension. With the review focussing on the self-management concept of managing chronic diseases, the findings may inform the use of appropriate strategies to improve medication adherence in hypertension.
Section snippets
Methods
The study followed the Cochrane guidelines for conducting systematic reviews25 and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.43
Search results and description of included studies
The search yielded 3392 papers, and it included abstracts from conference presentations, discussions on management of hypertension and various reviews about improving hypertension. After adjustment for duplicates, 738 studies were left. Following the screening of titles and abstracts, 701 articles were removed because they were irrelevant to the review question. The final result was 37 papers. Twenty-five studies were excluded for a number of reasons and 12 papers met the inclusion criteria of
Discussion
Medication adherence is crucial in the management of individuals with hypertension, and 12 studies have adequately evaluated the potential effects of educational interventions in improving medication adherence. A meta-analysis of the 9 studies4,18,35,38,49,52,55,67 showed that educational interventions were minimally effective in improving medication adherence compared to standard care at healthcare facilities (Fig. 5). Particularly, verbal education was more effective than combined methods
Conclusion
Despite low to moderate quality of evidence, the findings of this review suggest that educational interventions can improve health literacy and consequent adherence to medication adherence among individuals with hypertension. While some individuals with hypertension may have a change of behaviour to adhere to their medication from a verbal educational approach only, others will benefit from both verbal and printed materials. In addition, frequent follow-ups can significantly influence
Authors' contribution
Study design: AGA, EK; Article search: AGA, MBI; Results: AGA, MBI; Discussion; AGA, EK MBI; Drafting of the article: AGA; EDITING; EK, MBI
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This study was presented as part of the first author's Master of Science in Clinical Nursing thesis to King's College London. This Master programme was co-sponsored by the King's College London and Commonwealth Scholarship Commission through the Commonwealth Shared Scholarship Scheme. We sincerely thank the editors, the anonymous reviewers and Shirley Ama Gyamfuah (Sacred Heart Hospital, Carlow, Ireland) for their insightful comments.
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