Research on the adherence of antihypertensive treatment has shown that patient’s nonadherence to medication is related with a mix of demographic, organizational, psychological, and disease- and medication-related variables.23
Thus, investigating patients’ beliefs regarding hypertension itself and antihypertensive treatment, as well as communication factors that affect adherence, can have a great impact on designing effective interventions in order to improve treatment adherence.
The present study is the first in Greece, which examined hypertensive patients’ beliefs about hypertension and antihypertensive medicines, as well as patients’ behaviors concerning treatment adherence. It also examined patient–doctor relationship and its impact on adherence. Finally, the study examined patients’ beliefs about the role of pharmacists. In general, results are consistent with findings from other qualitative studies on antihypertensive medication adherence.25
The majority of participants considered hypertension as a very serious disease and were afraid and anxious about potential serious consequences on their health in case of failure to manage the disease. These negative feelings toward hypertension represent a finding that differs from those of other studies, where hypertension was found to be considered a less important disease with well-recognized symptoms.23
Further research based on theoretical models like SRM is required so that Greek patients’ beliefs about hypertension is further explored.
Stress emerged as one of the main risk factors of hypertension. Even though participants acknowledged the importance of this factor, stress was believed to be inevitable, and this situation was attributed to the modern way of living.
Participants were being informed about hypertension from a plethora of sources, but they trusted mainly their physician. Furthermore, they were feeling comfortable to discuss about hypertension with other hypertensive patients. This finding was also confirmed during the focus group sessions where participants were interested in sharing their experiences and discussing their health problem with each other.
Participants reported that they attend different health care facilities depending on the severity of symptoms. This behavior reflects the characteristics of the health care system in Greece and the way it is organized. In the absence of integrated primary care with a gate-keeping system, patients seek care and advice of the pharmacists when it concerns minor health conditions while they face limited or no barriers at all in accessing and choosing health care providers. This enables them to visit a specialist as often as they wish without referral from a general practitioner.
Based on the results of our study, the factors that influence medication adherence concern the management of the disease, the treatment characteristics, and the patient–physician relationship. The systematic disease management includes regular appointments with the physician and intense counseling in order for the patient to be aware of the complications of uncontrolled blood pressure. Treatment characteristics, such as the time of receiving the medicine, the number of doses, and the drug substance, were reported as influential factors. These characteristics, which may be considered minor, are really important for patient compliance and have been identified in other studies as well.23
Although an association between adherence and demographic characteristics such as age and gender could not be established due to the nature of the study, it seems that younger adults in Greece face greater difficulty in the acceptance of the disease and consequently in adhering to treatment. Age-related illness perception, with the elderly being more adherent, has also been reported in other studies.27
Building on the results of the present study, a longitudinal quantitative survey would be useful in order to further explore – confirm or reject – the aforementioned finding.
Results suggest that the major factor affecting positive medication adherence is a good doctor–patient relationship. A physician who encourages and rewards patients, and most importantly, spends quality time with them in giving information and providing explanations about the disease and treatment contributes significantly in patients’ compliance. This finding is consistent with a number of previous studies that have established the importance of this relationship.23
In contrast, pharmacist–patient relationship seems that it did not affect medication adherence among study participants. However, a finding worthwhile to be further researched is the role of cost of drugs in adherence because this was a matter of great concern for a number of participants, especially those attending insurance funds HC. Cost and particularly level of co-payment has been identified as an important factor associated with adherence to pharmaceutical treatment.28
Perceptions of personal risk and outcome expectancies, as well as redefinition of self concept or social role, have been proven to create a “teachable moment” for risk-reducing health behaviors.29
In our study, participants do create a “teachable moment” about hypertension, by cognitively escalating the severity of their symptoms. Previous experiences regarding hypertension, either personal or those of friends and family, and knowledge about the complications of the disease were major determinants of a teachable moment. Nevertheless, due to organizational factors, participants seem to adopt a risk-reducing health behavior (ie, visit an HC) only at a very late stage. A primary intervention stage should be identified, and early prevention strategies should be adopted so that hypertensive patients benefit at an earlier prohypertension stage rather than waiting until they are diagnosed with hypertension.
All participants of the present study reported adherence to treatment at the time of the study, a finding initially indicating high levels of adherence in Greek hypertensive patients compared with previous studies conducted in Greece.20
Nevertheless, participants mentioned that they did not take medication at the right time, or skipped if they felt well, indicating a rather nonadherent than adherent pattern of behavior. This inconsistency perhaps shows a cognitive bias, which underline causes worth further investigation. Psychological factors like patients’ frustration due to inefficient antihypertensive treatment or the meaning of monitoring blood pressure at home or telemonitoring might have some effects on adherence. Furthermore, the detected inconsistency could represent a time-related reference: participants referred to all these behaviors regarding their pharmaceutical treatment, considering them as past behaviors and not things that they usually do in the present. In addition, this result may only be due to a volunteer effect and can be considered a methodological limitation given that, according to literature, adherence to antihypertensive treatment ranges between 50% and 70%.13
Unanimous adherence allowed the identification of the factors contributing to adherence but prevented us from exploring the factors that inhibit it (although it could well be assumed that the opposite factors can be responsible for nonadherence).
From a methodological point of view, the smaller number of participants interviewed in HC, three compared to the number of participants in the other two HCs, could be considered another limitation of the study. However, due to the qualitative methodology adopted and the fact that direct comparisons among HCs were not an objective of the study, this sample difference has a limited effect on results.
Finally, the long duration of the focus groups may be considered another limitation of the study. Although we took care to achieve a comfortable environment for participants, it is not quite sure whether they were fully engaging in the end of the discussion.