|Year : 2013 | Volume
| Issue : 1 | Page : 28-34
Study the impact of clinical pharmacist provided patient counseling on hypertension management in rural Indian population
Katta Venkatesh Ramanath, Katti Ravi Venkappa
Department of Pharmacy Practice, Sri Adichunchanagiri College of Pharmacy, B. G. Nagara, Mandya District, Karnataka, India
|Date of Web Publication||9-May-2013|
Katta Venkatesh Ramanath
Sri Adichunchanagiri College of Pharmacy, B. G. Nagara, Mandya District - 571 448, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: To assess the patient counseling provided by clinical pharmacist on hypertension management in a rural population.
Materials and Methods: It is a prospective, randomized and interventional study conducted over a period of 9 months. The envelop randomization method was adopted to group the patients into control and intervention.
Results: A total of 200 hypertensive patients were approached. Out of which 95 patients consented to participate and only 90 patients completed the study. Among these hypertensive patients, 65 were men and 25 women. The knowledge, attitude and practices (KAP) score at baseline was 47.76 ± 7.33 in control and 47.20 ± 5.82 in the intervention group, respectively. The same in the third follow-up was found to be 35.96 ± 3.54 in control and 31.56 ± 1.95 in the intervention group, respectively. The P values were 0.691 at the baseline, 0.060 in first follow-up, 0.001 in second follow-up, and < 0.001 in third follow-up. Mean score of various domains (recall, access, and regimen screens) to medication adherence showed a significant improvement. The P values of adherence to medication regimen at baseline and third follow-up was 0.974 and 0.329, respectively. The overall comparison of quality of life (QoL) scores showed a large improvement (suggestive significance) from baseline (P = 0.494) to final follow-up (P = 0.51).
Conclusion: This study shows that the involvement of clinical pharmacists in rural hypertension management has a positive impact in creating awareness about the disease, drugs and its usage, and its effect on quality of life.
Keywords: Control and intervention group, diastolic blood pressure, hypertension, knowledge attitude and practice, medication adherence, patient counseling, quality of life, systolic blood pressure
|How to cite this article:|
Ramanath KV, Venkappa KR. Study the impact of clinical pharmacist provided patient counseling on hypertension management in rural Indian population. Arch Pharma Pract 2013;4:28-34
|How to cite this URL:|
Ramanath KV, Venkappa KR. Study the impact of clinical pharmacist provided patient counseling on hypertension management in rural Indian population. Arch Pharma Pract [serial online] 2013 [cited 2019 Aug 19];4:28-34. Available from: http://www.archivepp.com/text.asp?2013/4/1/28/111579
| Introduction|| |
Cardiovascular diseases have emerged as an important health problem in India. High blood pressure (BP) is a major risk factor for health and better control can lead to the prevention of 1.5 million annual deaths in India. Epidemiological studies demonstrate that prevalence of hypertension is increasing rapidly among the urban and rural population of India. ,
In chronic diseases like hypertension, the patient needs to take lifelong medication with single or two drugs while some may be on polypharmacy. In the Indian rural setup, majority of the patients are illiterate and have poor health literacy which may lead to misuse of drugs, improper usage, drug-induced disorders or failure of ongoing treatment. In order to overcome this problem, rational use of medication process has to be adopted by introducing "patient counseling". 
Repeated interaction with patients or counseling either verbally or nonverbally or both helps to increase medication adherence behavior, minimize drug-related problems, reduce the cost by correct maintenance of health and increase patient satisfaction.  The pharmacist has noteworthy/immense responsibility in counseling the patients with chronic illnesses like hypertension. 
The goals of chronic disease care were to enhance functional status, minimize distressing symptoms, prolonged life through secondary prevention and enhance quality of life (QoL). Understanding the levels of knowledge, attitude and practice will allow for a more efficient process of awareness creation among the people and illustrate the areas in which the patient must need an education and training. ,,,,,,
Brief Medication Questionnaire (BMQ), a medication adherence measurement questionnaire, is used to assess the reported medication adherence behavior of patients. BMQ consists of four sections: Regimen screen, belief screen, recall screen and access screen. All these BMQ screens consisted of a positive and negative screen. 
People with hypertension have a poor QoL than normotensives. Therefore, QoL (i.e. SF-36v2™ Health Survey questionnaires) measurements are being increasingly recognized as an important tool for the assessment of medical outcomes of chronic diseases. 
Therefore, the present study was undertaken in rural hypertensive patients to know the knowledge, attitude and practices (KAP), medication adherence, and QoL.
| Materials and Methods|| |
The study was conducted in the medicine unit of Adichunchanagiri Hospital and Research Centre, B. G. Nagara, Mandya District, Karnataka, India which is a rural tertiary care 750-bedded teaching hospital.
It is a prospective randomized controlled study. The envelop randomization technique was used to group the patient into control and intervention.
The study was conducted over a period of 9 months starting from June 2010 to February 2011.
Ethics committee approval was taken (Ref. no: AIMS/EC/601/2010-11, Dated: June 22, 2010) prior to the study from institutional ethics committee (Adichunchangiri Institute of Medical Sciences, B.G.Nagar, Mandya District, Karnataka, India).
- Hypertensive patients above 18 years of age.
- Hypertension alone or with less than 4 co-morbidities. For example, hypertension (HTN) with diabetes mellitus (DM), asthma and chronic obstructive pulmonary disease (COPD).
The hypertensive patients visiting the medicine department of tertiary care hospital (AH and RC: Adichunchanagiri Hospital and Research Centre) were enrolled after taking their consent and divided into two groups, that is, control and interventional group by envelope randomization technique. The enrolled patients were briefed about the study and informed (orally, telephonically as well as by envelop reminders) to come for the first follow-up after 1 month from the date of the enrolment and thereafter, every 30 days for the remaining two follow-ups to know their health status. Education materials like patient information leaflets on disease and drugs (amlodipine, atenolol, enalapril, losartan, metoprolol, nifedipine, ramipril, verapmil) were prepared in English and local language, that is, Kannada and validated. Patient satisfaction questionnaire was also prepared by consulting the hospital clinical pharmacists. The leaflets were distributed/given to the patients for better disease management. The disease information leaflet contained information like definition of disease, reasons, signs, symptoms, and management. The drug information leaflet consisted of drug name, brand name, dose and usage information, side effect, storage, and precaution.
- Pregnant/lactating hypertensive patients.
The control and intervention group patients were interviewed and their socio-demographic details (e.g., previous history, income, habits, previous medication, etc.) were collected and entered in a well-designed data collection form along with systolic and diastolic blood pressure (SBP and DBP), and body mass index (BMI). Control group patients were not counseled at the baseline but, their KAP, Medication adherence (BMQ) and QoL were assessed using their respective questionnaires. The answers given by them were recorded and the same method was carried out in first, second, and third follow-up. The control group was counseled at the third follow-up. Whereas, the intervention group patients were counseled (verbal and nonverbal/written) on various aspects like disease, drugs, life style modifications (e.g., low salt intake, exercise/walking, etc.) and their management during all the three follow-ups, and patient satisfaction towards the clinical pharmacist who provided patient counseling services was collected in a questionnaire. In each follow-up and at the baseline, the patient's SBP and DBP were noted/measured in both the groups.
Statistical analysis methods like, level of significance (5%) for continuous measurements was done with Mean ± S.D. (Min-Max), and categorical measurements with Number (%). Student's t-test (two tailed, independent) was used for continuous scale between two groups. Intergroup analysis was performed on metric parameters. Mann-Whitney U test was used to find the significance between two groups' parameters on non-interval scale. Pearson's correlation method used between KAP, BP with QOL analysis.
| Results|| |
A total of 200 patients were approached during the study period and were informed about the study and its procedure briefly. Out of which only 95 patients agreed to participate. The remaining, that is, 105 people were not interested in the study due to unknown reasons (e.g. distance from study site, unable to come for follow-up, financial problems, etc.). Out of 95 patients, 90 completed all the three follow-ups and 5 dropped out.
[Table 1] shows the distribution of sociodemographic details. There were 34 (75.6%) males in control and 31 (68.9%) in intervention group. Similarly, there were 11 (24.4%) female patients in the control and 14 (31.1%) in the intervention group. Majority of patients belonged to the age group of 61-70 years, that is, 17 (37.8%) in control and 15 (33.3%) in intervention group; followed by 51-60 years, that is, 12 (26.7%) in control and 11 (24.4%) in intervention group. The smoking habit of the study patients showed that there were 16 and 10 smokers in control and intervention group, respectively. Overall, the smoking habit was similar in both the groups. The percentage of alcohol consumption habit among the study patients was 17.8 and 22.2 in control and intervention group, respectively.
[Figure 1] and [Table 2] shows the KAP score. The P values at baseline, first, second, and third follow-up was found to be 0.691, 0.060 (suggestive significance), 0.001, and < 0.001 (strongly significant), respectively. This clearly showed that there is a positive impact of pharmacist provided counseling.
[Table 3] shows the medication adherence means scores of various domains like regimen, recall, belief and access screens in which a very good improvement can be observed. In which the P values of recall (baseline-0.439, first-0.001, second-0.030, and third-1.000) and access screens (baseline-0.696, first-0.018, second-0.089, and third-0.004) were strongly significant.
|Table 3: Comparison of medication adherence (mean score) in two groups of patients|
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[Table 4] shows the SBP of control and intervention groups with a significant improvement in the P values from the baseline (0.64) to third follow-up (0.021). Similarly, the P values of DBP showed a good improvement from 0.140 at baseline to 0.604 at third follow-up.
[Table 5] shows comparison among QoL scores of various domains like physical function, role function, body pain, general health, vitality, social function, and role emotional score. P values were found to be statistically significant when compared from baseline to third follow-up. The physical function (P values: Baseline-0.679, first-0.045, second-0.002, and third- < 0.001) and mental health score (P values: Baseline-0.366, first-0.036, second-0.021, and third- < 0.002) showed a very good and significant improvement from baseline to each follow-ups. The mental state and physical condition are strongly associated with the maintenance of QoL. This clearly showed that pharmacists play a very important key role in disease maintenance.
[Table 6] shows the overall comparison of QoL score in two groups. A greater improvement was seen in the intervention group than the control, that is, from a P = 0.494 at baseline to P = 0.51* at third follow-up. However, in second follow-up the overall QoL showed a more significant P value, that is, 0.08*** than other follow-ups.
[Table 7] shows that the patients belonging to the intervention group were completely satisfied with pharmacist provided patient counseling.
|Table 7: Patients' satisfaction for pharmacist provided patient counseling in intervention group. (Response: Yes/No)|
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| Discussion|| |
Patient counseling is one of the method/process for improving the rational use of medications which promotes awareness among people to learn about medicines and their safe use; this in turn minimizes the risks associated with drugs.
In our study, there were 65 male and 25 female patients [Table 1]. This may be because of the male patients' working environment, social habits, genetic influences, etc., Most of the patients were belonged to the age group of 51-70 years. The national demographics of hypertension survey showed that hypertension is highly prevalent among patients which are ≥ 50 years. The age group of 61-80 years and above had more number of hypertensive patients, that is, a total of 51 in both the groups (control and intervention) followed by the age group of 51-60, which had 26 hypertensive patients from both the groups. As mentioned earlier, this shows that the prevalence of hypertension is more among the elderly people. The study population showed a total of 26 active smokers and 18 alcoholics. However, overall smoking and alcoholic habits were same in both the control and intervention groups. Interestingly, this study shows that more hypertensive patients have absence of precipitating risk factors. ,
Knowledge, attitude and practices
KAP are the important parts in disease management; this study gives a clear idea about the patients' knowledge regarding disease, drugs and its usage. [Figure 1] and [Table 2] shows the comparison of KAP between the control and intervention group, in which a statistically significant result was observed at the third follow-up. At entry level, KAP analysis found that patients had a poor perception about their disease. Their attitude and practice was below average, and they had a fair idea of the symptoms of hypertension. Repeated intervention with them had made changes in their KAP. ,,
Medication adherence and BP
At baseline, low medication adherence rate was observed among the enrolled patients when compared to three follow-ups. However, repeated counseling showed that improvement in medication adherence significantly reduced the SBP and DBP of both the groups. As most of the patients were illiterate it was difficult for them to remember the name of the drug, but on repeated counseling they remembered it with the help of the strips, color, and covers of the medicines which made them adhere to their medication properly. There were few patients who missed the doses but their blood pressure was found to be under control. This may be the reason for increase in P values in diastolic when compare with the same of SBP. This study strongly suggested that there is a need of continuous education to the patients to improve their medication adherence towards disease management. The common reasons for non-adherence found in the enrolled patients were forgetfulness (regimen screen) and financial (access screen) problems.
Quality of life
QoL is a major concern in the overall health status of patients, where it shows a very good result within the medication adhered people. In some of the cases, QoL in certain domains showed an improvement. This study also showed that there was an altered QoL among some patients and the reasons were age, comorbidities, physical and mental status/psychological belief about the disease, etc., [Table 5] and [Table 6].
The overall physical and mental health, and QoL results strongly suggest that there is a need of more and more education to the rural people. The overall physical health and QoL results were found to be positive only in third follow-up [Table 6].
The patient satisfaction questionnaire, about the services rendered by the pharmacist during patient counseling in the management of hypertension, showed maximum satisfaction within the intervention group. This strengthens the fact that there is a need for more and more clinical pharmacist services for the efficient management of chronic diseases.
| Conclusion|| |
This study showed that clinical pharmacist provided patient counseling has a strong positive impact in increasing the medication adherence behavior, prolonging life, and improving the QoL of rural hypertensive patients. This study also highlights that there is a need of patient counseling services for the rural population in chronic disease maintenance.
| Acknowledgment|| |
We are thankful to Dr. B. Ramesh, Principal, S. A. C. College of Pharmacy, B. G. Nagar, Mandya District, Karnataka, India for providing necessary support to conduct the study. We express our special thanks to Quality Metric's Health Outcomes Solutions (Lincoln, RI, USA) for providing the QoL questionnaire (SF-36v2™ Health Survey) in English and Kannada (License No. CT132378/OP012595), and Bonnie L. Svarstad (Professor Emerita, School of Pharmacy, University of Wisconsin - Madison, WI, USA) for permitting us to use the BMQ for our study. We are also thankful to all other staff members of the department of Clinical Pharmacy and Adichunchanagiri Hospital and Research Centre.
| References|| |
|1.||Gupta R, Gupta VP. Hypertension epidemiology in India: Lessons from Jaipur Heart Watch. Curr Sci 2009;97:349-55. |
|2.||Dighore PN, Patil PH, Kuchake VG, Maheshwari OD. Prescription patterns of antihypertensive drugs. Indian J Hosp Pharm 2009;46:78-82. |
|3.||Ramesh A. Patient counselling. In: Parthasarathi G, Nyfort-Hansen K, Nahata MC, editors. A Clinical Pharmacy Practice; Essential Concepts and Skills. Hyderabad: Universities Press; 2004. p. 43-53. |
|4.||Erhuna WO, Agbanib EO, Bolaji EE. Positive benefits of a pharmacist-managed hypertension clinic in Nigeria. Public Health 2005;119:792-8. |
|5.||Blumenthal RS. Clinical strategies for optimal hypertension management. Adv Stud Med 2005; 5:S537-42. |
|6.||Milder IE, Blokstra A, de Groot J, van Dulmen S, Bemelmans WJ. Lifestyle counselling in hypertension-related visits--analysis of video-taped general practice visits. BMC Fam Pract 2008; 14:58. |
|7.||Sekhar SM, Abraham S, Revikumar KG. Emerging trends in practice of patient counselling-Indian scenario. Indian J Pharm Prac 2008;1:6-13. |
|8.||Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Ann Fam Med 2003;1:4-7. |
|9.||Tiggelaar JM. Protocol for the treatment of essential hypertension and type 2 diabetes mellitus by pharmacist in ambulatory care clinics. Drug Intell Clin Pharm 1987;21:521-9. |
|10.||Fitzpatrick R, Fletcher A, Gore S, Jones D, Spiegelhalter D, Cox D. Quality of life measures in health care. I: Applications and issues in assessment. BMJ 1992;305:1074-7. |
|11.||Taylor J, Semchuk W, Deschamps M, Sulz L, Tsuyuki RT, Duffy P, et al. Pharmacist intervention in risk reduction study in high-risk cardiac patients: The effect of 2 methods of pharmacist training. Can Pharm J 2007; 140:116-23. |
|12.||Svarstad BL, Chewning BA, Sleath BL, Claesson C. The brief medication questionnaire: A tool for screening patient adherence and barriers to adherence. Patient Educ Couns 1999;37:113-24. |
|13.||Glanz K, Rimer BK, Lewis FM. Health behavior and health education. In: Glanz K, Rimer BK and Lewis FM, editors. Theory, Research and Practice. 3 rd ed. San Francisco: Jossey-Bass Publishers; 2002. |
|14.||Singh RB, Beegom R, Mehta AS, Niaz MA, De AK, Haque M, et al. Prevalence and risk factors of hypertension and age-specific blood pressures in five cities: a study of Indian women. Int J Cardiol 1998;63:165-73. |
|15.||Gupta R, al-Odat NA, Gupta VP. Hypertension epidemiology in India: meta-analysis of 50-year prevalence rates and blood pressure trends. J Hum Hypertens 1996;7:465-72. |
|16.||Sharma S, Khanal A, Poudel B, Sharma R, Srivastav S, Parajuli K, et al. Knowledge, attitude and practice outcomes: An effect of pharmacist provided counseling in hypertensive patients in a tertiary care teaching hospital in Western Nepal. Int J Pharm 2010;2:583-7. |
|17.||Adepu R, Ari SM. Influence of structured patient education on therapeutic outcomes in diabetes and hypertensive patients. Asian J Pharm Clin Res. 2010;3:174-8. |
|18.||Aubert L, Bovet P, Gervasoni JP, Rwebogora A, Waeber B, Paccaud F. Knowledge, attitude and practices on hypertension in a country in epidemiological transition. Hypertension 1998;31:1136-45. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]