Jurnal Penelitian Sains 26 (1) 2024: 26116(117-123)
* Corresponding Author: email: [email protected]
https://doi.org/10.56064/jps.v26i1.947
Naskah diusulkan: 28 Februari 2024; Naskah disetujui: 22 April 2024
p-ISSN: 1410-7058 e-ISSN: 2597-7059 © 2024 JPS MIPA UNSRI
26116-117
Jurnal Penelitian Sains
Journal Home Page: http://ejurnal.mipa.unsri.ac.id/index.php/jps/index
Adherence and clinical outcomes of hypertensive patients in rural areas
after receiving home pharmacy care interventions
Yopi Rikmasari
1
*, Ensiwi Munarsih
2
, and Hafiza Alfionita
2
1
Departement Clinical Pharmacy and Social Behaviour Administrative,
2
Program Studi S1 Farmasi, Sekolah Tinggi Ilmu
Farmasi Bhakti Pertiwi, South Sumatera, Indonesia.
Kata kunci:
hypertension,
adherence,
home pharmacy care,
rural areas
ABSTRAK: Kepatuhan masih menjadi masalah yang menjadi perhatian dalam pengobatan
hipertensi, sehingga diperlukan intervensi yang tepat untuk mengatasi kondisi tersebut.
Penelitian ini bertujuan untuk mengetahui pengaruh home pharmacy care terhadap kepatu-
han minum obat dan outcome klinis. Penelitian ini merupakan pilot study menggunakan
metode quasi eksperimental pre and post design with control di fasilitas pelayanan kesehatan
primer daerah perdesaan dengan melibatkan 40 pasien hipertensi yang dibagi menjadi dua
kelompok masing-masing 20 pasien pada kelompok kontrol dan perlakuan. Kuesioner MGLS
digunakan untuk menilai kepatuhan minum obat dan outcome clinis dengan menilai tekanan
darah. Data dianalisis menggunakan statistik deskriptif, uji bivariat menggunakan chi-square,
Mann Whitney, uji t berpasangan, dan uji Wilcoxon signed ranks-test. Pada awal dan akhir
penelitian tidak terdapat perbedaan tingkat kepatuhan pengobatan pada kelompok kontrol
(p=0,701) sedangkan pada kelompok intervensi terdapat perbedaan yang sign ifikan
(p=0,009). Tekanan darah sistolik pada kelompok kontrol (p=0,000) dan kelompok interven-
si (p=0,004) menunjukkan adanya perbedaan, sedangkan tekanan darah diastolik pada
kedua kelompok tidak terdapat perbedaan. Selain itu, tidak terdapat perbedaan pencapaian
target tekanan darah antar kelompok (p=0,522). Temuan dalam penelitian ini adalah home
pharmacy care berpotensi meningkatkan kepatuhan pengobatan di daerah pedesaan namun
belum berdampak pada penurunan tekanan dan pencapaian target terapi.
Keywords:
hypertension,
adherence,
home pharmacy care,
rural areas
ABSTRACT: Adherence is still a significant problem in the treatment of hypertension, so ap-
propriate interventions are needed to overcome this condition. This study aims to determine
the effect of home pharmacy care on medication adherence and clinical outcomes. This re-
search is a pilot study using a quasi-experimental pre- and post-design with control in primary
health care facilities in rural areas involving 40 hypertensive patients divided into two
each 20 patients in the control and treatment groups. The MGLS questionnaire measured
treatment adherence and clinical outcome by assessing blood pressure. Data were analyzed
using descriptive statistics, bivariate tests using chi-square, Mann Whitney, paired t-test, and
Wilcoxon signed ranks-test. At the beginning and end of the study there was no difference in
the level of treatment adherence in the control group (p=0.701) while in the intervention
group there was a significant difference (p=0.009). Systolic blood pressure in the control
group (p=0.000) and the intervention group (p=0.004) showed a difference, while there was
no difference in diastolic blood pressure in the two groups. In addition, there was no differ-
ence in achieving blood pressure targets between groups (p=0.522). The findings in this
study are that home pharmacy services have the potential to increase medication adherence
in rural areas but have not had an impact on reducing pressure and achieving targets.
1 INTRODUCTION
he prevalence of hypertension in low-middle-
income countries continues to increase [1]. In
Indonesia, the prevalence of hypertension increased
from 25.8% in 2013 to 34.1% in 2018 [2]. Globally,
hypertension is the main cause of disability-adjusted
life-years and the leading cause of death, with 10.4
million deaths per year [3]. Cardiovascular disease
morbidity and mortality risk are directly correlated
with blood pressure; therefore, antihypertensive
drug therapy is recommended to reduce the risk of
cardiovascular events and death in patients with
high blood pressure [4]. In patients prescribed med-
T
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26116-118
ication by a doctor, the adequacy of the number and
dose of antihypertensive drugs and medication ad-
herence are the main factors for controlling blood
pressure [5]. Treatment adherence is when pa-
tients take medication according to a doctor's pre-
scription [6].
The level of patient adherence to medication is a
problem in the treatment of hypertension. The per-
centage of adherence of hypertensive patients to
treatment in a systematic review and meta-analysis
was reported to be 45.2% [7]. Five dimensions inter-
act with each other in influencing adherence: so-
cial/economic, health system, condition-related,
therapeutic, and patient factors [8]. Differences in
adherence to the treatment of hypertension patients
in urban and rural areas are due to variations in
demographic, economic, and social-environment
characteristics. Studies in several countries show
findings of different adherence levels in urban and
rural communities, including in China, the compli-
ance rate in urban areas is better than in rural; in
Brazil, compliance in rural areas is better; and in
Columbia, there is no difference between the two
regions [9 - 11]. In Indonesia, adherence to the
treatment of hypertensive patients in urban areas is
slightly better than in rural areas in national reports
of primary health research. However, many studies
show that the level of adherence to the treatment of
hypertensive patients varies in each service facility's
primary health. The proportion of taking antihyper-
tensive medication regularly in residents ≥18 years
in rural areas is 51.27% taking the medication regu-
larly, 35.8% not taking the medication regularly, and
not taking the medication 12.93%. Reasons for non-
compliance that can be identified are feeling
healthy, not taking regular medication, taking tradi-
tional medicine, often forgetting, not being able to
buy regular medicines, and medicines not being
available [2].
Interventions to improve patient adherence to
treatment in primary health care facilities can be
carried out through home pharmacy care, which is
carried out through pharmacists conducting patient
visits and accompanying patients for pharmacy ser-
vices at home with the patient's or family's consent
[12]. Previous studies have reported that home
pharmacy care can improve medication adherence
[13], improve the level of knowledge, adherence,
clinical outcomes, and quality of life of hypertensive
patients [14], dan lower blood pressure and improve
quality of life [15]. However, even though home
pharmacy care has shown promising results, modifi-
cations to home pharmacy care activities targeted at
specific groups need to be made according to the
characteristics of each region. Based on the descrip-
tion above, we conducted a pilot study on the influ-
ence of home pharmacy care by modifying the edu-
cation of hypertensive patients in rural areas in
communities with primary education to improve
adherence and clinical outcomes.
2 METHODS
Research design
This research is a pilot study using a quasi-
experimental pre and post design with control in
primary healthcare facilities in rural Musi Rawas Re-
gency, South Sumatra Province. All patients had
signed informed consent to participate in this study.
Implementation of Home Pharmacy Care
Home pharmacy care in this study was defined as an
intervention by making direct visits to the patient's
home for 10-20 minutes, carried out on the 15th day
after receiving the drug. The intervention was car-
ried out by final semester students of the Bachelor of
Pharmacy study program, who had received training
and assistance from pharmacists. The control group
received standard services, while the intervention
group received standard services and home phar-
macy care, as shown in Table 1. Standard services in
the form of providing information on drugs used by
patients include drug names, properties, and direc-
tions for use. The medication reminder card con-
tains columns for the name of the drug, indication,
rules for use, and hours of drug administration as
well as checklist columns that the patient must fill in
after taking the medication and providing education
using leaflets adopting leaflets issued by the Ministry
of Health of the Republic of Indonesia. Patient com-
pliance was measured using the MGLS question-
naire and clinical outcomes of systolic and diastolic
blood pressure and blood pressure target achieve-
ment at the beginning and end of the study.
Research subject
A total of 40 hypertensive patients were included,
divided into 2 groups, namely 20 patients in the con-
trol group and 20 patients in the intervention group.
The inclusion criteria were defined as adult patients
≥ 18 years old, with a diagnosis of essential hyper-
tension without comorbidities or complications and
receiving antihypertensive drugs ≤ 2 kinds of drugs,
not health workers, patients with uncontrolled blood
pressure at the start of the study, and willing to par-
ticipate in the study by filling out informed consent.
The number of sample members, each 10 to 20, can
Yopi R., dkk. / Adherence and clinical outcomes … JPS Vol. 26 No. 1 Apr. 2024
26116-119
be used in experimental research using control and
treatment groups [16].
Research Instruments
Socioeconomic data were obtained from question-
naires covering age, gender, education, working
status, monthly income, marital status, weight, and
height, plus lifestyle data, namely diet, and exercise.
Therapeutic data and clinical conditions were ob-
tained from the patient's medical records, including
the amount of antihypertensive, duration of illness,
and blood pressure.
Treatment adherence was measured using the
MGLS questionnaire. The questionnaire is valid and
reliable for respondents in Indonesia, with Cronbach
alpha = 0.651, test-retest = 0.45, and r = 0.58. A
score of 1 is given for a "yes" answer and a "0" for a
"no" answer. High compliance for a score of 0, mod-
erate compliance for a score of 1-3, and low compli-
ance for a score of 4 [17].
Data analysis
Descriptive statistics summarize the socioeconomic,
therapeutic, and clinical characteristics based on
urban and rural area criteria. Continuous variables
are reported using the mean with a standard devia-
tion. The control and treatment groups were identi-
fied for the uniformity of sociodemographic and
therapeutic characteristics using the bivariate test
using chi-square and Mann-Whitney. Differences in
adherence and blood pressure were analyzed using
the paired t-test, and Wilcoxon signed ranks-test.
Differences in blood pressure control in the two
groups were analyzed using the chi-square test. Sig-
nificance is set at p-value <0.05. All statistical tests
use SPSS version 26.
3 RESULTS AND DISCUSSION
Patient Characteristics
Table 2 shows that the sociodemographic character-
istics, lifestyle, therapy, and blood pressure of the
control and intervention groups are homogeneous
in all variables (p-value> 0.050). The homogeneity
of the two groups showed that the research subjects
were on the same basis when they started the inter-
vention.
Sociodemographic characteristics show that most
of the patients are aged ≥ 60 years (65%), female
(62.5%), primary school education (60%), retired/not
working (62.5%), monthly income < 1,000,000 IDR,
married 70.0% and normal BMI (67.5%). These data
are similar to previous studies which reported the
characteristics of hypertension patients in rural are-
as, dominated by the elderly, female sex with prima-
ry school education, and patients who were not
obese. The difference is that there are jobs where
working patients are more prone to hypertension
[18]. The prevalence of hypertension increases with
age, female gender, low level of education, and not
working [2]. Hypertension occurs with age, with a
prevalence of> 60% in > 60 years. Increasing the
population at an advanced age and adopting an ir-
regular lifestyle, body weight increases are associat-
ed with this incident [5].
Most patients did not receive a diet (72.5%) and
did not exercise (55.0%). A healthy food diet is rec-
ommended for hypertensive patients by consuming
vegetables and fruits, foods containing whole grains,
polyunsaturated fats, and dairy products. Consump-
tion of foods high in sugar, saturated fat, and trans
fat must be reduced. Moderate-intensity aerobic ex-
ercise such as walking, jogging, biking, yoga, or
swimming for 30 minutes 5-7 days per week is rec-
ommended. Weight control is aimed at avoiding
obesity [19].
Therapeutic data shows that most patients re-
ceive monotherapy, 85% using amlodipine, and the
remaining 15% use a combination of amlodipine and
captopril. Most patients received 1-5 years of thera-
py (52.5%), and the condition of blood pressure SBP
≥ 160 mmHg and DBP ≥ 100 mmHg 75%%. A study
reported that monotherapy drugs in primary health
care facilities were dominated by monotherapy at
89.93%, with the most widely used drug, amlodipine.
In contrast, in antihypertensive drugs, 10.07% com-
bined with drugs often used a combination of am-
lodipine and hydrochlorothiazide. This study also
reported that most of the patients had uncontrolled
blood pressure (75.51%) [20].
Overcoming uncontrolled blood pressure re-
quires intervention with an appropriate population-
based strategy that focuses on ensuring patients
have a place of health care for routine checks, opti-
mizing adherence, and minimizing therapeutic iner-
tia associated with high blood pressure control [21].
Interventions to improve medication adherence in
hypertensive patients can be performed at the doc-
tor, patient, drug therapy, and healthcare system
levels [22].
Effect of Home Pharmacy Care Intervention
on Compliance and Clinical Outcome
Table 3 shows that the treatment adherence level in
the control group experienced a slight change ∆of
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26116-120
±SD 0.10±1.21, but the change was insignificant
(p=0.701). Unlike the intervention group, there was
a significant increase in adherence ∆±SD 0.70±1.08
(p=0.009). This value indicates that home pharmacy
care interventions performed on patients affect med-
ication adherence in people living in rural areas.
Various factors can cause nonadherence to
treatment, and interventions should be focused on
the existing causes. Nonadherence is caused by poor
economic status, low education, unemployed, and
high medical costs; interventions can be focused on
family support, health insurance, and an uninter-
rupted drug supply. Non-compliance caused by the
unavailability of consultation time and poor relation-
ship between patients and health workers, interven-
tions can be carried out with the participation of
health workers, including pharmacists, in education-
al programs. Inadequate patient knowledge and
skills in managing symptoms and treatment, percep-
tion of health risks related to disease, and active par-
ticipation in disease management therapy monitor-
ing, can be overcome with behavioral interventions
and motivation to improve relationships, education
on disease management and self-management im-
provement as well as memory aids and reminders
take medicine [8].
Interventions made to improve compliance must
consider these factors. Home pharmacy care in this
study combined various educational materials with
medication reminder cards. In addition to overcom-
ing the lack of consultation time at service facilities,
it increases good relations between patients and pa-
tient motivation. Educational material delivered to
patients in leaflet media adopts leaflet material pub-
lished by the Ministry of Health of the Republic of
Indonesia, including education about hypertension,
risk factors, and complications, how to control blood
pressure, and how to regulate diet [23]. Pharmacist
intervention in primary health care through home
pharmacy care is a manifestation of clinical pharma-
cy services that have been regulated in pharmacy
service standards in order to provide benefits for
patients in ensuring the safety, effectiveness, and
affordability of medical expenses, increasing under-
standing in managing and using drugs, avoiding
drug reactions undesirable outcomes and resolve
drug use problems in certain circumstances [12].
Before the intervention, all patients in the control
and intervention groups had blood pressure that had
not reached the expected therapeutic target. There
was a significant decrease in systolic blood pressure
in the control group (p=0.000) and the intervention
group (p=0.004). In contrast, diastolic blood pres-
sure did not decrease significantly in the control
group (p=0.265) or the intervention group
(p=0.167). However, it was found that the decrease
in diastolic blood pressure in the intervention group
∆±SD 3.60±11.20 was slightly better than the con-
trol group ∆±SD 3.05±11.87. The improvement in
systolic blood pressure in the intervention group
cannot be ascertained due to the provision of home
pharmacy care. The control group also experienced
the same thing. Likewise, there was no significant
difference in diastolic blood pressure before and
after the intervention. However, if seen from the
percentage of patients in the intervention group,
there were more in controlled conditions (50%) than
in the control group (35%).
Table 4 shows that there was no difference in
blood pressure control in the control group and the
intervention group (p=0.522). However, in the in-
tervention group, it was found that patients with
controlled blood pressure were 50% more than the
control group, 35%. JNC VIII recommends that pa-
tients receiving hypertension treatment achieve their
target blood pressure. Target blood pressure for pa-
tients under <60 years, namely <140/90 mmHg, and
those under≥ 60 years, or <150/90 mmHg. Target
blood pressure for patients with diabetes mellitus
and patients with CKD, namely < 140/90 mm Hg
[24]. The findings in this study showed that home
pharmacy care did not affect clinical outcomes.
Previous studies have reported positive results
through home pharmacy care interventions for med-
ication adherence, level of knowledge, clinical out-
comes, and quality of life [13] [14] [15]. In this study,
home pharmacy care affected adherence but did
not affect clinical outcomes, but the direction of im-
provement was visible. The factors influencing blood
pressure control consist of complex internal and ex-
ternal factors. One study reported that blood pres-
sure control was related to age, partner status, salt
consumption, coffee consumption, stress, and anti-
hypertensive drugs [25].
The causal factors for failure to normalize blood
pressure are very complex, including not having
health insurance, lack of access to health services,
absence of health care facilities for routine control,
failure to diagnose hypertension (failure to assess
high blood pressure without showing symptoms,
blood pressure measurement) inaccurate, failed to
recognize hypertension), therapeutic inertia of the
clinician (failure to treat asymptomatic hypertension,
failure to start treatment when hypertension is pre-
sent, failure to intensify therapy in patients whose
blood pressure is above the therapeutic target), in-
adequate patient education, absence of shared deci-
sion making, lifestyle recommendations and inade-
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26116-121
quate counseling, low adherence to lifestyle modifi-
cations and adherence to prescribed antihyperten-
sive drugs, no monitoring and reporting of blood
pressure from home, low awareness of patients and
health care providers about pressure targets blood
and no systematic follow-up [21]. Pharmacists can
improve clinical outcomes in chronic diseases in-
cluding hypertension disease [26]. Pharmacist-led
interventions improved BP control and medication
adherence through education, counseling, or a
combination of both [27]. Verbal educational inter-
ventions can improve health literacy and conse-
quent adherence to medication among individuals
with hypertension. Frequent verbal educational in-
terventions can enhance patient engagement, par-
ticipation as well as promote medication literacy and
adherence [28].
The study's limitations were that a pilot study was
conducted on a small number of samples; compli-
ance measurement was carried out using a self-
reported questionnaire which could lead to memory
bias—a small of the possible influencing factors and
blood pressure using data from medical records.
Subsequent studies were carried out longer with
scheduled home pharmacy care, modified educa-
tional materials, and in a larger population.
4 CONCLUSION
Home pharmacy care affects patient adherence. Sis-
tolic blood pressure in both groups decreased, so it
cannot be ascertained that the decrease in blood
pressure was due to the effect of the intervention.
The decrease in diastolic blood pressure was better
in the intervention group, and the desire for blood
pressure was more pronounced in the intervention
group but not significant. The findings in this study
demonstrated that home pharmacy treatment im-
proves adherence and does not affect reducing
blood pressure and achieving blood pressure targets
in rural areas.
ACKNOWLEDGEMENT
We want to thank Sekolah Tinggi Ilmu Farmasi
Bhakti Pertiwi Palembang Indonesia.
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________________________________________________
APPENDIX
Table 1. Treatment of respondents
No Control group No Intervention group
1 Provision of drug information used
includes drug name, efficacy and
rules of use
1 Provision of drug information used includes drug name,
efficacy and rules of use
2 Medication reminder card
3 Education about hypertension, risk factors and compli-
cations
4 Education on how to control hypertension
5 Education on how to regulate eating patterns
6 Opportunity to ask questions related to disease, non-
pharmacological therapy and pharmacological therapy
Yopi R., dkk. / Adherence and clinical outcomes … JPS Vol. 26 No. 1 Apr. 2024
26116-123
Table 2. Sociodemographic characteristics, lifestyle, therapy and blood pressure (n=40)
Variables n %
Respondents for each group
(n=20) p-
value Con-
trol
%
Inter-
vention
%
Age, years ≥ 18 – 45 5 12.5 2 10.0 3 15.0 0.911
a
46 – 59 9 22.5 5 25.0 4 20.0
≥ 60 26 65.0 13 65.0 13 65.0
Mean (SD) 58.50±8.80 59.00±8.87 58±8.932
Gender Male 15 37.5 7 35.0 8 40.0 1.000
b
Female 25 62.5 13 65.0 12 60.0
Education Primary 24 60.0 15 75.0 9 45.0 0.107
b
Middle school 16 40.0 5 25.0 11 55.0
Working status Working 15 37.5 7 35.0 8 40.0 1.000
b
Retired/not Working 25 62.5 13 65.0 12 60.0
Monthly income (IDR) < 1.000.000 28 70.0 16 80.0 12 60.0 0.301
b
1.000.000 - < 3.000.000 12 30.0 4 20.0 8 40.0
Marital status Married 28 70.0 13 65.0 15 75.0 0.730
b
Divorce/single 12 30.0 7 35.0 5 25.0
BMI Normal 27 67.5 12 60.0 15 75.0 0.500
b
Overweight 13 32.5 8 40.0 5 25.0
Diet Diet 11 27.5 6 30.0 5 25.0 1.000
b
Not dieting 29 72.5 14 70.0 15 75.0
Physical exercise No physical exercise 22 55.0 10 50.0 12 60.0 0.608
a
Occasionally 12 30.0 7 35.0 5 25.0
exercising regularly 6 15.0 3 15.0 3 15.0
Number of antihyper-
tensive drugs
1 34 85.0 16 80.0 18 90.0 0.382
a
2 6 15.0 4 20.0 2 10.0
Duration of illness,
years
< 1 11 27.5 5 25.0 6 30.0 0.812
a
1 - 5 21 52.5 11 55.0 10 50.0
>5 8 20.5 4 20.0 4 20.0
Blood Pressure (mmHg) SBP140-159 or DBP 90-99 10 25.0 4 20.0 6 30.0 0.715
b
SBP ≥ 160 or DBP ≥ 100 30 75.0 16 80.0 14 70.0
Abbreviations: IDR, Indonesia Rupiah; SBP, Systolic blood pressure; DBP, Diastolic blood pressure; BMI, Body Mass
Index
a
mann-whitney,
b
Chi square
Table 3. Effect of home pharmacy care on adherence, SBP and DBP
Variables
Control group
(rerata±SD) ∆±SD
p-
value
Intervention group
(rerata±SD) ∆±SD p-value
Pretest Post test Pretest Post test
Adherence 1.60±1.05 1.35±0.99 0.10±1.21 0.701
a
1.20±1.10 0.50±0.61 0.70±1.08 0.009
a
Clinical outcomes
a. SBP 172.15±16.53 148.80±22.16 23.35±14.84 0.000
a
162.50±22.90 140.20±24.16 22.30±25.43 0.004
b
b. DBP 88.70±7.51 85.65±7.29 3.05±11.87 0.265
a
88.45±9.82 84.85±7.30 3.60±11.20 0.167
a
Abbreviations: SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure
a
Paired t-test,
b
wilcoxon signed ranks-test
Table 4. Effect of home pharmacy care on blood pressure control
Variable
Controlled Uncontrolled
p-value
n % n %
Groups Control 7 35.0 13 65.0 0.522
Intervention 10 50.0 10 50.0