healthmedicinet

This cross-sectional descriptive study of hypertensive subjects with stroke underscores the magnitude of the lack of awareness of hypertension and the suboptimal medication adherence in urban Ugandans. Nearly two-thirds of the study participants were poorly adhering to the prescribed anti-hypertensive medications following the diagnosis of hypertension.

Hypertension still remains a major independent factor of morbidity and mortality [15]. With the raising levels of non-communicable diseases in sub-Saharan Africa the morbidity and mortality from cerebro-vascular accidents is estimated to increase [3]. Correct and prompt institution of BP reduction measures has shown benefit in reducing the incidence of stroke [16–18]. The lack of adhering to the prescribed medications for hypertension and stroke awareness within our communities might be increasing the high rates of strokes in Uganda. More than half of participants were not regularly attending medical care since being diagnosed with high BP. This would have predisposes the higher BP levels, inadequate control and lack of continuous health education subsequently increasing the risk of strokes. Up-scaling of hypertension awareness campaigns and health education is therefore urgently needed to stem this trend.

There are differences in age among people who suffer strokes within the sub-Saharan region compared to those in developed countries. In our study, 42 % of the study participants were less than 60 years. Studies have reported that stroke occurs at an earlier mean age of 57 years in sub-Saharan Africa compared to 66.0 years in developed countries, with those ?45 years constituting 24 % in Africa and 8 % in developed countries [19, 20].

Antihypertensive medications are the mainstay of treatment for essential hypertension [21, 22]. Earlier studies have demonstrated that there is a significant relationship between lower medication adherence and first stroke among hypertensive patients [23–27]. In our study, 77 % of the study participants were poorly adhering to medication prior to stroke. Medication adherence is associated with improved BP control and with reductions in stroke among those at risk for stroke [24, 25]. Some of the study subjects were using concomitant herbal medications. Whereas some herbal medications have been reported to have hypotensive effects, some might interfere with hypertensive drug bioavailability and efficacy [28]. Recommending adherence to the correct drugs and dosage still remains a challenge in our settings.

Barriers to anti-hypertensive medication adherence are multi-factorial, including complex medication regimens, excessive dosing frequency or pill burden, personal behavioral factors, trust communications of the health personnel, drug side effects, complications of treatment and other co-existing medical conditions [29, 30]. Reasons reported by stroke survivors in other studies include; lack of adequate knowledge, cost of the medications, drug access, drug side effects and pill burden [31, 32]. The role of the health workers however, was not explored in this study. Health care workers need to ensure that patients understand their health condition, the importance of drug adherence and the implications of non-adherence. In Uganda, medications are typically provided for by the Ugandan government. However, during periods of drug stock-outs patients have to buy their medications out of pocket. Some hypertensive participants in our sample were poorly adhering due to financial or access reasons.

Overall, our findings suggest the need for increasing hypertension awareness and drug adherence in stroke prevention. Preliminary data from Rose et al. suggest that treatment intensification is ultimately the most effective strategy to achieve controlled BP regardless of the status of medication adherence [33, 34]. Setting up easily accessible BP measuring sites, and making treatment and support readily available, would help mitigate this upcoming scourge.

This study had important limitations including cross-sectional design and relatively small sample size. Medication adherence using patient self-reporting may introduce recall bias. Self-reported medication adherence may also be subject to social desirability bias and may lead to misclassification regarding the true prevalence of low medication adherence [35]. However adherence rates were similar to other studies and the Morisky scale is a well validated instrument that has been used for more than 25 years. Recent evidence demonstrates its correlation with pharmacy fill/refill data [36, 37]. We were also not able to assess the relationships between stroke and the co-morbidities such as diabetes mellitus, hyperlipidemia, HIV, other cardiovascular diseases, alcohol consumption, amphetamine use, cigarette smoking and level of physical activity due to the low power. No stroke severity scales were used in this study we hence did not measure the severity of the strokes in our participants. Another setback was absence of vascular imaging to classify the strokes based on the TOAST criteria, we relied on the radiologists reports which is has many setbacks. This made it difficult to accurately assess the location of strokes especially in the posterior fossa.

In conclusion, not being in routine care for hypertension and poor adherence to anti hypertensive medications are important factors among hypertensive patients admitted in the two study hospitals in Kampala, Uganda. There is an urgent need to raise the level of knowledge regarding screening for hypertension and the importance of BP control among hypertensive patients in Uganda. Increased funding to the Health Sector for the procurement of drugs and other health supplies could reduce the financial burden of out of pocket expenses met by hypertensive patients for routine care. There is also need for larger studies with a longitudinal design and more focus on lifestyle or other risk factors that may influence health behaviors and stroke risk.