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Family Practice Vol. 21, No. 2 Oxford University Press 2004, all rights reserved.

Doi: 10.1093/fampra/cmh202, available online at www.fampra.oupjournals.org

Printed in Great Britain

Why hypertensive patients do not comply with


the treatment
Results from a qualitative study
Juan J Gascna, Montserrat Snchez-Ortuob, Bartolom Llorc,
David Skidmored and Pedro J Saturnoa,c for the Treatment
Compliance in Hypertension Study Group

Introduction

efficacy, in patients under care, is attenuated mainly by


patient non-compliance with medication and lifestyle
advice.3 In fact, it has been estimated that only 60% of
patients take medication as prescribed.4
Given the broad scope of the problem, everincreasing attention has been devoted to identifying
factors which contribute to non-compliance.5 To date,
the majority of studies in this field have been carried
out in Anglo-Saxon contexts and have been focused on
establishing, from the medical care perspective, the factors
related to non-compliance; however, fewer studies have
focused on the patients points of view. The last suggest
that patients non-compliance could be associated with
reservations about drugs and lack of necessary knowledge
on which to build an understanding of the condition and
treatment.68
We, therefore, decided to explore patients opinions
and expectations concerning hypertension and its
treatment in another socio-cultural settings. To address

Hypertension is the single most common and most


important risk factor for cardiovascular disease.1
Despite improvements in the detection and treatment
of hypertension since the 1970s, recent survey results
illustrate that the condition continues to contribute,
significantly, to mortality and morbidity in adults and
that it is often poorly controlled in clinical practice.2
Similarly, other studies suggest that the treatments

Received 19 March 2003; Revised 22 October 2003; Accepted


3 November 2003.
aDepartment of Preventive Medicine and Public Health,
bDepartment of Basic Psychology and Methodology,
cDepartment of Nursing, University of Murcia, Espinardo
30100, Murcia, Spain and dDepartment of Health Care Studies,
Manchester Metropolitan University, Hathersage Road,
Manchester M13 OJA, UK; E-mail: gasconjj@um.es

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Gascn JJ, Snchez-Ortuo M, Llor B, Skidmore D and Saturno PJ for the Treatment Compliance
in Hypertension Study Group. Why hypertensive patients do not comply with the treatment.
Results from a qualitative study. Family Practice 2004; 21: 125130.
Background. Medical non-compliance has been identified as a major public health problem in
the treatment of hypertension. There is a large research record focusing on the understanding
of this phenomenon. However, to date, the majority of studies in this field have been focused
from the medical care perspective, but few studies have focused on the patients point of view.
Objective. Our aim was to identify factors related to non-compliance with the treatment of
patients with hypertension.
Methods. We use a qualitative study in which data were gathered from seven focus group
discussions conducted in MarchMay 2001. Patients were identified as non-compliant, using the
MoriskyGreen test, at two primary health care centres of the Spanish National Health Service.
Results. A complex web of factors was identified that influenced non-compliance. Patients had
fears and negative images of antihypertensive drugs. The data also revealed a lack of basic
background knowledge about hypertension. The clinical encounter was viewed as unsatisfactory
because of its length, few explanations given by the physician and low physicianpatient
interaction.
Conclusions. Most of the factors related to poor compliance have implications for patient
management. Knowing patients priorities regarding the most important aspects of care that
have high potential for low compliance may be helpful in improvement of the quality of
hypertensive patient care.
Keywords. Hypertension, patient compliance, physicianpatient relations.

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this issue, we designed a qualitative study, based on the


focus groups technique, intended to provide an in-depth
perspective about poor compliance in hypertension.9

BOX 1

Focus group interviewing guide

1. How did you find out that you had high blood pressure?
2. How do you feel about having high blood pressure?

Methods

3. What have you been told about high blood pressure and
its treatment?

Participants
The target population comprised non-compliant hypertensive patients who were diagnosed with and receiving
treatment for hypertension. Inclusion criteria were:
anyone between the ages of 18 and 80 years, being
treated with antihypertensives for 3 months, being
non-compliant and having sufficiently good physical and
mental health to participate. Detailed information about
the type of antihypertensive or duration of treatment
could not be collected.

4. Have you found it easy to follow the instructions?

The focus group interview


In order to elicit information on the patients perspective
of their condition, their treatment and the relationship with
the provider, pre-determined, open-ended questions were
arranged by way of a guided interview. Topics for the
guided interview were determined by a review of the
relevant literature and in consultation with colleagues
(psychologists and GPs). The interview form covered four
domains: the diagnosing of hypertension; the patients

6. What do you and the doctor usually talk about in the


surgery?
7. When you have taken medication, how has it been for you?
8. What kind of problems do you encounter when taking the
medication?

understanding of the condition; perception of the


relationship between patient and health care provider;
and any difficulties in following the treatment (Box 1).
All focus groups were facilitated by two of the authors
(MSO and PPF) who represent different backgrounds
(psychology and medicine).
Each session began with introductions and a brief
explanation of the reasons for the study and of its
confidentiality. The same set of questions was posed for
each group, although not strictly in the same order.
Participants were encouraged to talk freely and, if they
brought up relevant points spontaneously, the order of the
questions was varied to maintain the flow of the session.
Data analysis
With patients permission, sessions were videotaped and
later transcribed verbatim. The analysis was inductive
and followed established conventions for ensuring that
the process was grounded in the data rather than
reflecting a pre-determined analytic framework.11 The
analysis followed several stages. (i) In order to obtain an
overall impression, the transcripts were read repeatedly
by seven researchers (JJG, MSO, BL, DS, PJS, PPF
and JJA), who represent three disciplines (medicine,
psychology and sociology). (ii) The seven researchers
identified, independently, emergent themes. This
process was iterative, with new data used to assess the
integrity of the developing analysis. (iii) The researchers
met to compare analysis and an on-going dialogue
between the researchers contributed to the shaping of
the definite categories. (iv) To validate the categories,
they were compared with established concepts in
published research in this field from the initial literature
review. (v) JJG and MSO examined each interview line
by line to identify relevant text units to be categorized
according to the established underlying categories. To
ensure compatibility of text categorizing, the two

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Procedure
In order to determine whether or not the patient was
compliant, a telephone survey was first conducted
among 267 hypertensive patients, identified from clinic
and computer records from two primary health care
centres in Murcia (Spain). The MoriskyGreen test10
was used in this survey. Those patients who scored 1
point in the test were considered to be non-compliant
and hence potential participants (n = 146).
Letters were sent to patients, identified as noncompliant, asking them if they would be prepared to help
with some research on patients experiences of
hypertension. Approximately 1 week later, they were
contacted by telephone in order to ascertain their
commitment to attend and to remind them of the session.
An average of 20 patients at a time was contacted by
telephone to participate in each focus group until no new
themes or ideas were emerging (n = 141). A total of
44 patients, 24 men and 20 women, participated in the
seven focus groups sessions where conventional
consent and confidentiality procedures were followed.
Group size varied from three to 11, and sessions lasted
4080 min. We felt that our participants might be
diffident in discussing issues related to their health in
the presence of the opposite sex and therefore decided
to have separate male and female groups. The venues
selected for the focus groups were neutral, being located
neither in university nor hospital premises.

5. Is there anything you would like to say about the care you
have received whilst attending the surgery?

High blood pressure: factors related to compliance with treatment

researchers analysed three transcripts jointly and the


others separately. Disagreements between the two
researchers were resolved by discussion. The analysis
was finalized when all relevant text could be categorized.
The researchers checked the plausibility of the data
interpretation and ensured that the qualitative data
analysis was systematic and verifiable, as recommended
by experts.9 As we aimed to find aspects related to noncompliance, our analysis focused on negative rather
than positive outcomes.

Results

Beliefs and attitudes towards antihypertensive drugs


Fears were expressed about the long-term use of
antihypertensive medication and the possibility of being
stuck with it for the rest of ones life. Negative feelings
were elicited in many cases, as antihypertensives were
perceived as being damaging and not good for the body.
The adverse effects of drugs were issues of concern to
most subjects. In addition, we identified remarks indicating that the information on medicines provided in leaflets
was frightening and difficult to understand.
I was afraid of the medication, because I was told
that once I started to take it I would have to take it
all my life. (Participant 2; focus group 2)
I think that has to be damaging to some part of my
body. (Participant 6; focus group 7)
I dont like them (medicines), they have lots of side
effects, they can make you sick I think that I might
get worse instead of better. (Participant 1; focus
group 2)
I read the whole leaflet but I dont understand
anything, and even the doctor doesnt explain it.
(Participant 1; focus group 4)
I dont even want to read the leaflet, if I did I would
never take any medication. (Participant 4; focus
group 2)
When analysing the accounts participants gave of the
medication that they were currently taking, we found
that some patients thought that it was perfectly safe not
to take it from time to time and some admitted that
they did not always take medication as prescribed.
Sometimes this was simply because they forgot it,
especially if the drug had to be taken at regular intervals
throughout the day. We also found that many patients
regarded drug taking as conditional to the symptoms
they were experiencing and, basically, because they felt

well, some claimed that they had tried to gain personal


experiences of the medicines by experimenting to see
how they felt without them. Associated with this idea
was the desire to find out about alternatives such as
reducing the prescribed dose or stopping treatment for
a while, once the blood pressure seemed to be controlled. In some cases, the length and routine nature of
the treatment caused boredom and, consequently, the
desire to drop out. Furthermore, it was also suggested
that there was more confidence in herbal or natural
remedies taken due to common knowledge than in
medicines to alleviate hypertension.
My problem is that I forget to take my medication
during the day when I dont have it right beside me.
(Participant 3; focus group 7)
Ive stopped taking the tablets when Ive felt like it,
sometimes for a fortnight or three weeks just to
see. (Participant 6; focus group 6)
If my blood pressure feels more controlled, Ive
reduced the dose myself. (Participant 3; focus
group 7)
Im really tired . . . Ive been taking medication for
thirty-one years now and Im fed up so sometimes
I say Im just going to stop taking it for a while.
(Participant 3; focus group 7)
I take lemons . . . thats what helps me the most but
the doctors dont tell you that: (Participant 5; focus
group 4)
I only take the medication because it (blood
pressure) doesnt go above 14 or 15; if they went any
higher Id just boil up some nettles and take that.
(Participant 9; focus group 6)
Beliefs and attitudes about hypertension
The fact of having high blood pressure did not seem
worrisome for patients and was often associated with
certain well-recognized familiar symptoms, as if the
absence of them meant that blood pressure was controlled.
The doctor told me your blood pressures a
bit high, 1617 . . . but I didnt think that was
important . . .. (Participant 6; focus group 3)
I have to feel sick, or have a sore neck and then Ill
have my blood pressure taken. (Participant 3;
focus group 1)
The knowledge which the majority of patients had
regarding hypertension had been acquired from
sources other than the physician, such as magazines, TV
programmes on health or talking to other people. As a
result, a strong need for further knowledge, provided by
the physician, is identified by many subjects.
Anything I know about blood pressure Ive read in
books, the doctor tells me absolutely nothing . . .

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Factors identified as influencing treatment compliance


fell into three categories: beliefs and attitudes about
antihypertensive drugs; beliefs and attitudes about
hypertension; and clinical encounters.

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I want him to tell me where high blood pressure


comes from. (Participant 4; focus group 1)

You only get to see the doctor for five minutes.


(Participant 3; focus group 1)
Theres not really any conversation, youre there
explaining whats wrong with you and he doesnt
even look at you, hes just taking notes . . . He sends
you away with a few words here is your
prescription and thats it. (Participant 7; focus
group 6)
The doctors could pay a bit more attention at least
or explain things, because sometimes they explain
it and you just dont understand . . . they should
explain it in a different way so that you can
understand. (Participant 1; focus group 2)
In the chemist they write on the box how I have
to take the medication because I cant understand
what the doctor wrote. (Participant 4; focus
group 5)
Some reported that the encounter with the physician
created nervousness and that they did not ask what they
wanted to know. It is felt that the physician did not
encourage patient interaction and did not help to create
the context that elicits the patients underlying concerns
about hypertension and its treatment.
Whenever I go to the doctor I would want to ask if
I can go running or if its OK to ride a bicycle or
not, but when I go into the surgery I dont feel
comfortable and I forget everything I wanted to
ask. (Participant 1; focus group 4)
He doesnt even give you the chance to tell him
anything or to ask questions. (Participant 2; focus
group 2)
In the consultation, the most common lifestyle
changes recommended were reductions of salt intake
and some exercise, but there were no rational explanations provided by the physician on why these changes
were beneficial. This information was considered by

They give you advice: stop smoking and take some


physical exercise, but they dont tell you, say, how
to go walking or if you can ride a bicycle or not.
(Participant 1; focus group 4)
Theyve told me hundreds of times that I have to
lose weight and I just dont know how because they
never explain how to do it. (Participant 7; focus
group 6)

Discussion
This study reveals a complex web of factors that can
influence compliance behaviour within a group of
patients diagnosed with hypertension (Figure 1).
Although all the findings are not new with respect to
previous literature, these serve to confirm what has been
found previously, in the Spanish context. At first glance,
the results indicated negative feelings towards
medicines, low awareness about the condition and
dissatisfaction with clinical encounters as barriers with
regard to following treatment advice. Some of these
factors were similar to those found in other studies on
compliance in hypertension.7,8,12,13 In the main, these
factors can be summarized in two categories: patient
and physician context related. Most of them do have
clear implications for patient management, as the
predominant view that emerges is that there is plenty
of room for improvement in the patientphysician communication. First, it is, arguably, surprising to discover
that patients with a chronic condition, such as hypertension, lack basic background knowledge about it, such as
its potential risks and why it is important to follow the
prescribed treatment even in the absence of symptoms.
So it does not seem odd that they also have lay
knowledge and beliefs on medication that can,
consequently, reduce compliance. These must be
addressed by the physician and, if this is the case,
adequate information should be provided to reduce the
fear and anxiety derived from the use of medicines, and
hence this will improve compliance. Even so, this study
shows that, in the ordinary clinical situation, patients
often fail to understand what they are told and, what
is more, without this primary basis the patient cannot
build up a rationale for the therapy.14 This aspect of the
doctorpatient relationship has been visited previously,
where it was argued that doctors offer simple
instructions on several occasions and yet the patient, due
largely to anxiety, does not receive such information.15
This puts the physician in a unique position of
responsibility and opportunity to act not only as
diagnostician but also as a qualified patient educator. In
this respect, participants in the focus groups put the
highest emphasis on physicians empathetic qualities,

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Clinical encounters
The majority of patients complained about the length of
the consultation. They claimed that little time was spent
with regard to informing; indeed most of the consultation time was used just to get the prescription. In
keeping with this, there was the perception of the
physician as always being busy, and this was mentioned
in several cases. In many cases, it was stated that
physicians did not give any spontaneous information and
asked few questions. In addition, it was emphasized that
the physician seldom made eye contact during the
consultation and spent the time just taking notes. Other
statements were made to the effect that it was difficult to
understand the physicians language or writing.

the patients to be too general and not tailored to the


individual.

High blood pressure: factors related to compliance with treatment

Factors associated with treatment non-compliance

in being interested, listening and devoting time to


patients.
An exploration of these issues may help the physician
discuss with the patient the appropriateness of the
proposed treatment and to find alternatives.
This implies that a new perspective on health care, one
which goes beyond the biomedical side of medicine, is
needed and that physicians must become more active in
their interactions with the patients and be able to
examine the patients understanding of the world. To
achieve this goal, the use of interpersonal skills training
among health professionals has been suggested.16
However, it can be argued that the time limits of
family physician consultations and resource constraints
are an obstacle to addressing the individual needs. We
consider that a practical solution could be the
integration of group visits into the family practice
routine. The meeting of several patients with the family
physician at the same time allows a more efficient use of
the family physicians consultation time and a better
interaction with patients, as the group approach may
facilitate communication, sharing concerns with the
doctor and, therefore, compliance.17
The study had some limitations. Focus group studies
have some potential disadvantages, which the researcher
should be aware of. They involve relatively small
numbers of people, which means that there is a probability of the findings not being representative of the
general population in terms of the opinions voiced.
However, this qualitative study was designed to highlight
this phenomenon, and not to measure variables. The
application of qualitative methods has provided an indepth view of a complex area of clinical care that can
promote more comprehensive and sensitive measurement of factors related to non-compliance.

All of this led to the conclusion that knowing patients


priorities regarding the most important aspects of
care that have high potential for low compliance may be
helpful in improvement of the quality in the care of the
hypertensive patient.

Acknowledgements
We thank the practice staff and the patients who
participated in the study. The Treatment Compliance in
Hypertension Study Group comprises Pedro Prez
Fernndez, MD, Jos J Antn Botella, PhD, Inmaculada
Vicente Lpez, MD, and Jos Saura-Llamas, PhD, from
the Primary Health Centres of Murcian Health Service,
Spain. This study was supported by the Executive Health
Department of the Murcias Government (EMCA
program: project number 504/2000).

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