ORIGINAL PAPER Azlin B et al.
Health Locus of Control Among Non-compliance Hypertensive Patients Undergoing Pharmacotherapy
Azlin B *, Hatta S *, Norzila Z *, Sharifa Ezat WP ** *Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia. **Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia.
Objective: This study aims to determine the association between the locus of control and social factors with compliance to anti-hypertensive pharmachotherapy. Research Design: This is a cross sectional study, conducted from 1st of June until 31st of December 2004. Two centres were involved in this study: Hospital Universiti Kebangsaan Malaysia Primary Polyclinic in Bandar Tasik Selatan, Cheras and Salak Polyclinic in Sepang, Selangor. Methods: A total of 200 patients from both study centers, who fulfilled all the inclusion criteria, were selected as respondents. This study used the Mini International Neuropsychiatric Interview (M.I.N.I) for the psychiatric diagnoses and Multidemensional Health Locus of Control (Form C) was used to assess locus of control. Results: The prevalence of non-compliance was 38.5%. The results of this study reveal a statistically significant difference between drug compliance with site where the study was conducted, age, race, gender, internal locus of control, external locus of control (chance, doctors’). No evidence for an association between patients’ education level, occupation, income, marital status, family history of hypertension, number of medication prescribed and external locus of control (powerful others) with drug compliance. Conclusion: This study suggested that drug compliance among hypertensive patients was influenced by the presence of psychosocial factors. Hence, it is important for the medical practitioners to understand all these factors while treating their patients. It should be possible to make treatment more individual.
Key words: Hypertension, Locus of control, non-compliance
Malaysian Journal of Psychiatry March 2007, Vol. 16, No. 1
Introduction blood pressure effectively and can reduce the excess risk significantly. There is now strong evidence to suggest that the anti-hypertensive drug therapy is Hypertension is one of the most common clinical effective in preventing both heart attacks and strokes conditions encountered in the primary health care [4]. Despite the existence of efficacious medications practice and it is a significant public health problem and improvements in awareness of hypertension, in many countries. Hypertensive patients comprise many patients in actual practice remain with 10% - 20% of the total population in many countries uncontrolled hypertension. and in Malaysia, it was estimated that about 14% to 25% of the population aged 15 years and above Hypertensive patients often experience poor suffered from this disease [1]. compliance to treatment, a frequent cause of uncontrolled blood pressure. Disease like Hypertension presents the largest risk for hypertension, which is chronic, frequently cardiovascular disease. As blood pressure increases asymptomatic and requires long-term medication, from normal to severe elevations, the risk for coronary this risk is especially great. Adherence to any heart disease, stroke, end stage renal disease and intervention over long periods is determined largely peripheral vascular disease increases markedly [2, 3]. by the individual’s perception of the risks, benefits, Anti-hypertensive drug therapy can reduce high and cost of the intervention [5]. The psychosocial implications of taking medication(s) on an ongoing Correspondence Dr. Azlin B, Department of Psychiatry, Faculty of Medicine, basis and the logistic demands of such treatment must Universiti Kebangsaan Malaysia, Jalan Yaacop Latif, Bandar Tun Razak, also be considered. Compliance rates for many long- Cheras, 56000 Kuala Lumpur term drug therapies have been shown to be strikingly
20 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
low, often no more than 40%-50% [6, 7, 8]. treatment and lifestyle changes. This construct focuses on expectancy beliefs for future events with respect Medication compliance has been defined in terms to health. of an agreement between patient’s behaviour of taking medications and the clinical prescription [6]. Faulty The locus of control is described on two different compliance or non-compliance with medications may dimensions, external and internal locus of control [13]. include errors of purpose, timing or dosage as well as People who have external understanding of control total or partial omission, or use of inadvertent believe that what individuals themselves do, has no combinations. Non-compliance with medications is great importance for their well-being. Instead they one of the major factors in the failure of therapeutic locate control over their own health to destiny, programs in patients having a chronic disease [6]. circumstances or other authority. Individual who Compliance to treatment is a complex and multifaceted believe that their fate is determined largely by chance issue that can substantially alter the outcomes of and not by their own actions may less likely to adhere therapy [9]. Non-compliance can contribute greatly with therapy, because they feel that their actions may to the variability observed in a drug’s therapeutic not appreciably affect outcomes [14]. effect if the clinician incorrectly attributes the patient’s worsening condition to an absence of drug activity. An internal locus of control means that people have a greater tendency to acknowledge their own role Failures of compliance with the treatment are in influencing their situation, for example, health. common [10]. Generally in Malaysia, the problem of They view their own contribution as important to blood pressure control is not lack of therapeutic their own health. The main prediction from health options but due to patients’ non-compliance. Lim locus of control theory is that internals are more likely T.O et al. in 1989 [10] found out that 26% out of 168 to engage in health promoting activities. Individuals of patients were not compliance to their medications. who believe that, in general, their actions play a large Addressing the epidemic of poor compliance with role in determining their circumstances may tend to anti-hypertensive medications will require identifying adhere to the prescribed treatment regimen because factors associated with poor adherence, including they believe that they can affect their own health [14, psychosocial and behavioral characteristics of 15] found that the more internally oriented the patient, patients. Compliance to treatment depends on many the greater the level of compliance behaviour. However, factors, and no simple explanation for non-compliance a study by De Villes et al., 1980 [16] showed that exists. Potential determinants of compliance include patient with an internal locus of control are more likely sociodemographic characteristics, specific aspects of to be engaged in preventive behaviour/ lifestyle changes. the treatment regimen (type, complexity, side effects, This study also showed that those who had greater and duration), and features of the illness or potential internal locus of control were less willing to follow illness (symptoms, duration, disability, and medically medical prescriptions and more willing to seek defined seriousness) [11]. information about their disease. People with high internal locus of control could be more motivated to Demographic factors, including educational level take actions that could lead to good health condition. and socioeconomic status, also do not consistently However at the same time comply less with prescribed appear to have much effect on compliance to therapy medical treatment. [12], although such factors do affect access to health care services in general. Along the same lines, there is There is an implicit assumption that internality is no evidence for an association between patient’s good, although there are situations when a strong belief intelligence or educational achievement and compliance in powerful others would be advantageous, for example [12]. during hospitalization for an acute illness. In situations where there is little that one can do to change health An individual’s expectation may substantially status, a chance locus of control may be most adaptive. influence compliance behaviour and change. The concept of compliance and locus of control are This variable was able to distinguish who take, and interconnected and interdependent. Locus of control who do not take, personal responsibility for their is people own understanding of control, where the health and well-being. A balanced understanding of foundation for the decisions that the patients make control gives the individuals the best condition for more or less consciously regarding compliance with managing their health, and includes the individuals’
21 Azlin B et al.
own capacity, their perception of support and their Lumpur and Salak Polyclinic at Sepang, Selangor. The confidence in others [18]. Locus of control was also HUKM Primary Polyclinic Bandar Tasik Selatan is related to indicators of health and resilience. Internal located about five kilometers from the main HUKM locus of control is associated with health behaviour building. It is a primary health care clinic of HUKM such as physical fitness, smoking and alcoholism and that covers areas 10 km around the center. It is situated high levels of psychological distress were related to an in a 5-storey shop houses at Bandar Tasik Selatan external locus of control [18, 19]. Commercial area. This primary health care clinic operates five days in a week, from Monday till Friday. Objectives Every day it has 2 sessions of clinic, morning and afternoon. The purpose of this study was to investigate the relationship between anti-hypertensive drug Bandar Tasik Selatan, is a district of Cheras, Kuala compliance with health locus of control. The results Lumpur, and has a total population of 11,304. Of of the study may contribute to increase the awareness these, 5944 (52.6%) are Chinese, followed by 4365 of health care providers particularly physicians on the (38.61%) Malays and 995 (8.8%) Indians (Population issue of compliance and may aid to develop strategies and Housing Census, 2000). There are about 5826 for improvement of compliance. We also would (49.2%) males and 6016 (50.8%) females in this area. specifically determine the sociodemographic data and Bandar Tasik Selatan is an urban area, situated about locus of control among compliance and non-compliance 20km from the heart of Kuala Lumpur. It is also a hypertensive patients at Primary Polyclinic Bandar commercial area for Cheras. Among the population, Tasik Selatan and Salak Polyclinic. some of them were doing their own business, working at private companies or with the government agencies. Research Hypothesis The other center involved with this study is Salak Our research hypothesis would be (i) hypertensive Polyclinic, which is situated in Sepang district, in patients with high internal external locus of control are Selangor. It is a government polyclinic that is under the non-compliance to anti-hypertensive pharmaco- management of Ministry of Health, Malaysia. Salak therapy, (ii) hypertensive patients with advanced age Polyclinic is located about 48 kilometers from HUKM. have poor compliance to anti- hypertensive It provides primary health services to the community pharmacotherapy, (iii) female hypertensive patients in Salak. It has a family physician with three medical have better compliance to anti-hypertensive officers to run the clinics. This polyclinic operates five pharmacotherapy as compared to male patients, (iv) to six days in a week (it operates half day on Saturday hypertensive patients with low education level are if it is a ‘working Saturday’). It is a walk-in clinic. non-compliance to anti-hypertensive pharmacho- Every day it has 2 sessions of clinic, morning and therapy, (v) unemployed hypertensive patients have afternoon session’s time. However the chronic illness poorer compliance to anti-hypertensive pharmaco- patients are given regular appointments. therapy than the others. The total population was 57,336. Of these 27,478 Methodology (53.0%) are Malays, followed by 13,262 (25.6%) Chinese and 11,075 (21.37%) Indians (Population Background and Housing Cencus, 2000). This area is a rural area, majority of the populations works a farmer or at the This study is a part of the IRPA project (IRPA 06- palm oil or rubber plantations. As this place is near to 02-02-0028-PR0014/06-06), titled “To identify the the new Kuala Lumpur International Airport, many psychosocial factors of non-compliance among of the younger generation find their employment patients with hypertension undergoing pharmaco- there. therapy”. The IRPA project is a 4-centres study, involving centers in Kuala Lumpur, Selangor and Study Design Kelantan. Due to logistic and time constraint, this study was conducted at the Hospital Universiti This is a cross sectional study conducted at HUKM Kebangsaan Malaysia Hospital (HUKM) Primary Primary Polyclinic in Bandar Tasik Selatan and Salak Polyclinic, Bandar Tasik Selatan, Cheras, Kuala Polyclinic in Sepang from the first week of July 2004
22 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
to the last week of December 2004. Asthma and Chronic Obstructive Pulmonary Disease, (v) blood pressure of 200/120 mmHg or more, and (vi) Sampling and Sample Size those who refused to participate in the study.
The sample population was all the hypertensive Study Instruments patients who attended the HUKM Primary Polyclinic in Bandar Tasik Selatan and Salak Polyclinic in Sepang Biodata and sociodemographic data during the study period. The variables included the name, age, sex, marital status, occupation, total household monthly income, The sample size was determined using Epiinfo highest academic qualification, hypertension history 2000 Statistical Package which was based on the (i.e.duration of hypertension and family history of power of study of 80% with alpha-level of 0.05 (95% hypertension), history of smoking, alcohol intake, confidence interval). Assuming and expected frequency body mass index measurement and vital signs. of poor compliance towards anti-hypertensive Mini international Neuropsychiatric interview pharmachotherapy in the population was around (M.I.N.I) 26% [10]; the sample size was calculated to be around The Mini International Neuropsychiatric Interview 197. (M.I.N.I) is a short structured diagnostic interview developed jointly by psychiatrists and clinicians in The author had to divide her time to attend both the United States and Europe. It was designed as a clinics. To reduce the sampling bias the author attended brief structured interview for the major Axis I the polyclinics on alternate days. Universal sampling psychiatric disorders in DSM-IV and ICD-10 was used in the recruitment process. All new and old psychiatric disorders. The diagnosis is available in hypertensive patients who came for their appointments lifetime and 12 months version. M.I.N.I is designed to at the time of the author presence at the respective meet the need for a short but accurate structured polyclinics were approached. All the consecutive psychiatric interview that can be use in a variety of patients underwent the initial screening and all the cultures, for epidemiological and clinical research subjects who fulfilled the inclusion criteria were selected purposes. It can be administered in a relatively short for this study. The patients were explained about the time (approximately 15 minutes). study and written permission was obtained from them. They were assured of their anonymity and the Multidimensional Health Locus of Control confidentiality of the data obtained. A coding system (MHLC) scales ñ Form C was used to identify the subject. The inclusion and The construct of Health Locus of Control was derived exclusion criteria were shared with the major IRPA from the Social Learning Theory developed by Rotter study. Inclusion criteria includes: (i) patients were in 1966 [15]. This theory proposed that an individual learns on the basis of his or her history of reinforcement. diagnosed to have essential hypertension, (ii) patients The individual will develop general and specific must be aged 40 years old and above, (iii) patients were expectancies. Through a learning process individuals on anti-hypertensive pharmacotherapy for at least 3 will develop the belief that certain outcomes are a months, (iv) patients agreed to participate in the IRPA result of their action (internals) or a result of other project and could give written informed consent, (v) forces independent of themselves (externals). From patients who have sufficient command of the Malay the social learning theory Rotter developed the Locus and English language and (vi) patients who could read of Control Construct, consisting of an Internal and and write. Exclusion criteria includes: (i) pregnancy, External rating scale. (ii) patients who were diagnosed to have secondary hypertension, (iii) there was no renal impairment Wallston et al. in 1978 [13] subsequently (serum creatinine > 125 mmol/L) within the last six developed the MHLC scale. The instrument later has months of recruitment date, (iii) there was no impaired become the most popular locus of control measure in liver function tests (> 3 times the upper limit of normal research on health behaviour [21]. It measures range), (iv) concomitant disease such as Diabetes generalized expectancy beliefs with respect to health Mellitus, Ischaemic Heart Disease, Congesttive along 3 dimensions, namely the: (i) Internal HLC is the Cardiac Failure, Cerebrovascular Accidents, Bronchial extent to which one believes that internal factors are
23 Azlin B et al.
responsible for health/ illness, (ii) External - Powerful Definition of Variables are given. (i) Hyper- Others HLC is the belief that one’s health is determined tension is defined as an adult aged 18 years old and by powerful others, (iii) External – Chance HLC above with systolic pressure of 140mm Hg and above measures the extent to which one believes that health and diastolic pressure of 90mm Hg and above, (ii) Non / illness is a matter of fate, luck or chance. For this compliance is the degree to which the patient does not study, the researcher decided to use the MHLC scale conform to the medical advice regarding lifestyle, - Form C after discussion with the scale author, Mr. dietary changes, keeping follow-up appointments Wallston himself through email. Consent to use the and taking prescribed treatment.In the treatment of scale was obtained from him. Form C is designed to be hypertension, a minimum compliance of 80% is condition specific and can be used when studying generally needed to achieve an adequate reduction in people with an existing health / medical conditions. blood pressure [10]. For this study medication The word ‘condition’ in each item can be replaced with compliance is based on the pill counting, the compliance whatever condition (e.g., arthritis, hypertension, ratio is then calculated using the formula below: diabetes, etc.) Compliance ratio: Z/T It has 18 items with two 6 item subscales and two 3 item subscales. The items consist of 6 item subscales X = known fixed number of tablet dispensed of internality, 6 item subscales of chance externality, Y = residual number of tablets in the container after 8 3 item subscales of powerful-doctors externality and weeks. 3 item subscales of powerful-other people externality. Z = number of tablet that have been removed from the All items are arranged on 6 point Likert scales ranging container and Presumably consumed, => X-Y = Z from “1 = strongly disagree” to “6 = strongly agree”. T = number of tablets which should have been No items need to be reversed before the summing and consumed for a particular dose regime over the 8 all the subscales are independent of one another. The weeks period. alpha reliabilities for the subscales of Form C to be the following: (1) Internal: 0.85- 0.87, (2) Chance: 0.79 – A ratio of 0.8 (80%) to 1.2 (120%) are used as the 0.82, (3) Doctors: 0.71, and (4) Other people: 0.70- criteria for adequate drug compliance [12], (iii) 0.75 Educational level of the subjects was classified into the number of years of education received, (iv) Monthly People can be both “internal” and “external” at the family income referred to combination of husband same time. Above the median internality score could and wife monthly income. In unemployed widow, be called “high internals” and those below could be called “low internals”. However being “low internal” widower or divorcee, referred to the income of his/her may not be the same as being “external”. The English own obtained from any source like monthly pension, version of this questionnaire was translated to the welfare department or the income of the children that Malay language and then back translated to English. they were staying with, (v) Race was referred to Malay, Chinese, Indian and others, (vi) Health Locus Methods of Control (HLC) referred to the degree to which individuals believe that their health is controlled by internal or external factors, (vii) External Locus of The researcher approached the subjects while they Control referred to belief that one’s outcome is under waited to be seen by the doctors. They were told of the control of powerful others or is determined by fate, the purpose of the study and reassured that confidentiality will be maintained. After the patient luck and chance, (vii) Internal Locus of Control had fulfilled the inclusion criteria, written consent was referred to belief that ones outcome is directly the obtained. Subsequently, the Multidimensional Health result of ones behaviour. Locus of Control questionnaire was administered to the respondents. Minimal explanation was given to Data Analysis some of the respondents. The respondent was then interviewed by the researcher using the M.I.N.I. It Data was analyzed using the Statistical Package for was recommended that the screening schedule be used Social Sciences (SPSS) Version 12.0. The relationships to make diagnostic formulation of any psychiatric between the study parameters were analyzed using problems the appropriate statistical test.
24 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
Table 1: Socio-demographic characteristics of respondents
Variables n (%)
Sites HUKM Primary Polyclinic 119 (59.5) Salak Polyclinic 81 (40.5)
Age 40-49 71 (35.5) 50-59 87 (43.5) 60-69 34 (17.0) 70-79 7 (3.5) 80-89 1 (0.5)
Gender Male 97 (48.5) Female 103 (51.5)
Race Malay 136 (68.0) Chinese 55 (27.5) Indian 9 (4.5)
Marital Status Single 7 (3.5) Married 182 (91.0) Widowed/ Divorced 11 (5.5)
Education None 9 (4.5) Primary 51 (25.5) Secondary 114 (57.0) Tertiary 26 (13.0)
Occupation Employed & own business 104 (52.0) Unemployed 35 (17.5) Retired 61 (30.5) Total monthly income < RM1500 115 (57.5) > RM1500 85 (42.5)
Family history of Hypertension Yes 152 (76) No 48 (24)
Number of medication prescribed 1 131 (65.5) 2 57 (28.5) 3 12 (6.0)
Smoking Yes 21 (10.5) No 160 (80.0) Ex-smoker 19 (9.5)
Alcohol Yes 13 (6.5) No 187 (935)
25 Azlin B et al.
Table 2: Frequency distribution of study population by socio-demographic variables
Variables HUKM Primary Polyclinic Salak Polyclinic n=119 n=81 Numbers (%) Numbers (%)
Age 40-49 37 (31.1) 34 (42.0) 50-59 51 (42.9) 36 (44.4) 60-69 26 (21.8) 8 (9.9) 70-79 4 (3.4) 3 (3.7) 80-89 1 (0.8) 0 (0.0)
Gender Male 64 (53.8) 33 (40.7) Female 55 (46.2) 48 (59.3)
Race Malay 65 (54.6) 71 (87.7) Chinese 51 (42.9) 4 (4.9) Indian 3 (2.5) 6 (7.4)
Marital Status Single 6 (5) 1 (1.2) Married 105 (88.2) 77 (95.1) Widowed/ 8 (6.7) 3 (3.7) Divorced
Total Monthly Income
Education None 3 (2.5) 6 (7.4) Primary education 22 (18.5) 29 (35.8) Secondary education 73 (61.3) 41 (50.6) Tertiary education 21 (17.6) 5 (6.2)
Occupation Employed 65 (54.6) 39 (48.1) Unemployed 24 (20.2) 11 (13.6) Retired 30 (25.2) 31 (38.3)
26 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
Ethical Consideration The mean age for HUKM Primary Polyclinic was The study was done after approval by the Ethics 54.67 (SD± 8.47), while for Salak Polyclinic was Committee of Faculty of Medicine, Universiti 52.54 (SD± 7.62). There was a significant difference Kebangsaan Malaysia and Research Committee of in age between HUKM Primary Polyclinic and Salak Psychiatry Department, Faculty of Medicine, Polyclinic (t = 1.85, d.f = 198, p = 0.071 (p<0.05)). Universiti Kebangsaan Malaysia. Distribution of the sex shows that Salak Polyclinic Respondents were not forced to participate but had more female respondents (59.3%), whereas did so voluntarily. The purpose of the study was HUKM Primary Polyclinic had more male respondents explained to the respondents and written permission (53.8%). Both centers had majority of Malays was obtained from them. Those who were found to respondents, however HUKM Primary Polyclinic have psychiatric disorder were referred to the nearest had more Chinese respondents (42.9%) as compared psychiatric clinic for further evaluation and to Salak Polyclinic (4.9%). Most of the respondents management. (88.2%) were married at both study centers.
Results The majority of the respondents at the Salak Polyclinic (77.8%) had total monthly income less than A total of 205 patients who attended the Primary RM1500.00, whereas majority of the respondents at Polyclinic of HUKM in Bandar Tasik Selatan and HUKM Primary Polyclinic (56.3%) had total monthly Salak Polyclinic (122 and 83 patients respectively) income more than RM1500.00. Respondents at HUKM Primary Polyclinic were more educated as were approached to participate in the study. However 61.3% had at least secondary level of education and only 200 hundreds patient qualified for the study. 17.6% had received tertiary education. Meanwhile at Out of 5 patients excluded from the study, 2 had Salak Polyclinic only 50.6% had secondary education difficulties understanding the interview and and only 6.2% had tertiary education. questionnaires because of language problems, 1 was . later diagnosed to have Diabetes Mellitus and another 2 patients refused to participate in the study. Thus Psychiatric Morbidity among Respondents the response rate was 97.5% out of 205 respondents. Psychiatric diagnosis Sociodermographic Characteristics of the Tables 3 shows that anxiety disorders are the most Respondents common (70.0%) type of disorder with Panic disorder as the most common form of anxiety disorder (40.0%). Table 1 shows the sociodemographic characteristics Only one respondent had agoraphobia without panic of the respondents. Approximately 80.0% of them disorder (10.0%). were in the age group of 40-59 years old and only 4.0% in the group of 70-89 years. The mean age was 53.81 Table 3: Distribution of Psychiatric diagnosis of (SD±8.19) years. The gender distribution was almost the patients using M.I.N.I equal between male (48.5% out of 200 respondents) and female (51.5%). Majority of the respondents Diagnosis Total Cases Percentage(%) were Malays (68.0% out of 200), followed by Chinese (27.5%) and only 4.5% were Indians. Most of the Dysthymia 3 30.0 respondents were married (91.0%) and had secondary Panic Disorder 2 20.0 without Agoraphobia education level (57.0%). Half of the respondents were employed (52.0%) and had total monthly income Panic Disorder with 2 20.0 less than RM1500.00 (57.5%). Majority of them Agoraphobia (76.0%) had family history of hypertension and were on one type of anti-hypertensive medication (65.5%) Social Phobia 2 20.0 Table 2 shows the frequency distribution of socio-demographic variables of the respondents. For Agoraphobia without 1 10.0 both study centers, the age groups were within 40-59 Panic disorder years old, however HUKM Primary Polyclinic had Total 10 100.0 more elderly respondents, aged 60 and above (26.0%).
27 Azlin B et al.
Descriptions of Health Locus of Control (HLC) Table 7: Relationship of drug compliance among Respondents between respondents at HUKM Primary In this study, the median for internal locus is 30. polyclinic and Salak Polyclinic As described by the questionnaire author, the median Variables HUKM Primary Salak split was allowed, thus those above the median could Polyclinic Polyclinic be called “high internals” and those below could be N (%) N (%) called “low internals”. Table 4 shows that majority of the respondents had low internality (59.0%). Drug compliance Table 4. Frequency of health locus of control among respondents Yes 57(46.3) 66(53.7) No 62(80.5) 15(19.5) Variables N (%) Chi-square (continuity correction) = 21.559; d.f = 1;p value <0.0001 (p<0.05) Internal High 82 (41.0) Relationship of drug compliance between Low 118 (59.0) respondents at both study sites
Table 5 shows that majority of respondents at HUKM Table 7 shows that Salak Polyclinic respondents had Primary polyclinic had low internal (60.1%) as good drug compliance (53.7%) as compared to compared to respondents from Salak Polyclinic. HUKM Primary Polyclinic respondents (46.3%). However there was no significant relationship between About 80.5% of the non-compliers were from HUKM the study sites and internal locus of control (p>0.05) Primary Polyclinic. There was a significant association between the sites where this study was Table 5: Frequency of locus of control between conducted and drug compliance with a probability of respondents at HUKM Primary Polyclinic and p< 0.05. Salak Polyclinic Drug compliance and age Variables HUKM Primary Salak Polyclinic There was a significant difference in age between Polyclinic compliance and non-compliance of pharmacotherapy n=119 N (%) n=81 N (%) among respondents with hypertension undergoing pharmacotherapy (p<0.05). Table 8, shows that Internal majority of the respondents aged 60 and above are not High 48(58.5) 34(41.5) compliant to the prescribed medication (52.4%). Low 71(60.1) 47(39.9) Table 8: Relationship between drug compliance Chi-square (continuity correction) = 0.007 d.f= 1 and age p=0.932 (p>0.05) Relationship Between Sociodemographic Drug compliance Factors and Drug Compliance among Patients with Hypertension Undergoing Age Yes No Pharmacotherapy Frequency of drug compliance 40-59 103 (65.2%) 55 (34.8%) Table 6, shows the majority of the respondents (61.5%) had good drug compliance. Only 38.5% of the 60 and above 20 (47.6%) 22 (52.4%) respondents did not compliant to the prescribed medications. Chi-square (continuity correction) =3.616, d.f.= 1 p value = 0.038 (p <0.05) Table 6: Frequency of drug compliance of respondents Drug compliance and gender There was a significant difference in the drug Drug compliance N (%) compliance between male and female (p<0.05). Female respondents (68.9%) were more compliant to the Yes 123 (61.5) medication as compared to male respondents (53.6%) No 77 (38.5) (table 9).
28 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
Table 9: Relationship between Drug compliance Drug compliance and occupation and gender Table 12 shows that there was no significant difference between the drug compliance and occupation (P Drug compliance >0.05). Majority of the non-compliance (40.4%) Sex were employed and had own business. Yes No Table 12: Relationship between drug compliance Male 52 (53.6%) 45 (46.4%) and occupation Female 71 (68.9%) 32 (31.1%) Drug compliance Occupation Chi-square (continuity correction) = 4.328 d.f. = 1 p= 0.037 (p<0.05) Yes No
Drug compliance and race Employed & 62 (59.6%) 42 (40.4%) There was a significant difference between the drug Business compliance and race with a probability of p < 0.05. Chinese respondents had high non-compliance Unemployed 60 (81.0%) 14 (18.9%) (52.7%) rate to the drug prescribed as compared to other races (table 10). Retired 40 (65.6%) 21 (34.4%)
Chi-square = 0.617 d.f. = 2 p=0.735 (p>0.05) Table 10: Relationship between drug compliance and race Drug compliance and education level Table 13 shows that there was no significant difference Drug compliance between drug compliance and education level of the Race respondents (p>0.05). Respondents with no formal Yes No education (44.4%) had high non-compliance to the drug prescribed. Malay 90 (73.2%) 46 (33.8%) Table 13: Relationship between drug compliance Chinese 26 (47.3%) 29 (52.7%) and education level Indian 7 (77.8%) 2 (22.2%) Drug compliance Chi-square= 6.965 d.f = 2 p= 0.031 (p<0.05) Education Level Yes No Drug compliance and marital status Although single respondents had high compliance No Formal 5 (55.6%) 4 (44.4%) (85.7%) rate to the drug prescribed, there was no Education significant difference in marital status with drug compliance (p>0.05) (table 11). Primary 32 (62.7%) 19 (37.3%) Education Table 11: Relationship between drug compliance and marital status Secondary 70 (61.4%) 44 (38.6%) Education Drug compliance Marital Status Tertiary 16 (61.5%) 10 (38.5%) Yes No Education
Single 6 (85.7%) 1 (14.3%) Chi-square = 0.168 d.f. = 3 p=0.983 (p>0.05) Married 112 (61.5%) 70 (38.5%) Drug compliance and monthly income Table 14 shows that there was no significant difference Others 5 (45.5%) 6 (54.5%) between drug compliance and total monthly income Chi-square = 2.930 d.f. = 2 p=0.231 (p>0.05) (p>0.05). Respondents with total monthly income
29 Azlin B et al. ofmore than RM1500.00 had high non-compliance Drug compliance and medication prescribed (43.5%) as compared to the others. Frequency number of type of medication prescribed between respondents at HUKM Primary Polyclinic Table 14: Relationship between drug and Salak Polyclinic compliance and total monthly income
Drug compliance Table 16 shows that there was significant difference Total Monthly between HUKM Primary Polyclinic and Salak Income Yes No Polyclinic for the number of type of medication prescribed (p<0.05). HUKM Primary Polyclinic had
YES 92 (60.5%) 60 (39.5%) 1 82 (62.6%) 49 (37.4%)
NO 31 (64.6%) 17 (35.4%) 2 34 (40.4%) 23 (59.6%)
Chi-square (continuity correction) = 0.111 3 7 (41.7%) 5 (58.3%) d.f.= 1 p= 0.739 (p>0.05)
Chi-square = 0.199 d.f = 1 p=0.739 (p>0.05) Table 16: Frequency number of type of medication prescribed at both study sites Relationship between drug compliance and drug group Table 18 shows that respondents between drug groups Study Sites Number of Type had no difference in drug compliance. There was no Of Meditation significant difference between the drug groups and HUKM Salak Prescribed drug compliance (P>0.05). Primary Polyclinic Polyclinic Relationship between Locus of Control and Drug Compliance among Patient with Hypertension 1 69 (52.7%) 62 (47.3%) Undergoing Pharmacotherapy 2 39 (68.4%) 18 (31.6%) 3 11 (91.7%) 1 (8.3%) Internal locus of control Table 19 below shows that respondents with high Chi-square = 10.784 d.f = 2 p=0.005 (p<0.05) internal locus of control (50.6%) had high drug non-
30 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
Table 18: Relationship between drug compliance and drug group
Drug Group Medication Compliance N Mean SD
Yes No
Ace inhibitor 7 (53.8%) 6 (46.2%) 13 0.538 0.518 Beta-Blocker 53(61.6%) 33 (38.4%) 86 0.616 0.489 Calcium Antagonist 14(70.0%) 6 (30.0%) 20 0.700 0.470 Diuretics 5 (62.5%) 3 (37.5%) 8 0.667 0.500 Alpha-blocker 3 (75.0%) 1 (25.0%) 4 0.625 0.517 Ace inhibitor & 5 (62.5%) 3 (37.5%) 8 0.458 0.509 Beta-Blocker Diuretics & 11(44.0%) 14(56.0%) 25 0.846 0.375 Beta-Blocker Calcium Antagonist 11(84.6%) 2 (15.4%) 13 0.4 0.516 & Beta-Blocker Ace inhibitor & 4 (40.0%) 6 (60.0%) 10 0.800 0.447 Diuretics Angiotensin & 1 (100.0%) 0 (0.0%) 1 1 - Diuretics Ace inhibitor & 7 (58.3%) 5 (41.7%) 12 0.636 0.504 Beta-Blocker & Diuretics F = 0.02 df = 1 p = 0.960 (p > 0.05) Table 19: Relationship between drug compliance and locus of control
Locus of Control Drug compliance chi-square D.F P value Yes (%) No (%)
Internal Low 80 (67.8%) 38 (32.2%) 4.192 1 p=0.041 High 43 (52.4%) 39 (47.6%) compliance. There was significant different between drug compliance with the internal locus of control. External locus of control ñ chance subscale Table 20 shows that the t test between drug compliance and drug non-compliance for the external locus of control (chance) subscale for the MHLC was statistically significant at 5% level (p<0.05) Table 20: Comparison of external locus of control- chance subscale of MHLC scores between drug compliance and non-compliance group
Drug compliance No Yes n=77 n=123 Mean score 13.69 16.55 Standard Deviation 8.13 7.24 t=2.594 d.f = 198 p=0.01(p<0.05)
31 Azlin B et al.
External locus of control ñ doctorsí subscale Table 23: Relationship between blood pressure Table 21 shows that the t test between drug compliance and drug compliance and drug non-compliance for the external locus of control (doctors’) subscale for the MHLC was Drug compliance statistically significant at 5% level (p<0.05). Blood Pressure Yes No Table 21: Comparison of external locus of control –doctors’ subscale of MHLC scores between Control 105 (65.2%) 56 (34.8%) drug compliance and non-compliance Uncontrolled 18 (46.2%) 21 (53.8%) Drug compliance Chi-square (continuity correction) = 4.047 df = 1 p = 0.044 (p<0.05) No Yes Discussion Mean 14.09 16.16 Overall the response rate was good (97.5%). Only a Standard Deviation 3.721 2.631 small percentage of subjects (2.75%) were excluded. As the subjects excluded were only a small number; it t= 4.606 d.f= 198 p<0.001 (p<0.05) is unlikely to have bias in selection of cases.
External locus of control- powerful others subscale The respondents’ age ranged from 40 to 81 years The t test between drug compliance and drug non- old, with the mean age of 53.81 (SD± 8.19). About compliance for the external locus of control (powerful 80% of respondents were aged 60 years old or less. others) subscale for the MHLC was statistically not HUKM Primary Polyclinic had more respondents significant (p>0.05) (table 22). aged 60 and above (26.0%) as compared to Salak Polyclinic (13.6%). There is a possibility that the Table 22: Comparison of external locus of elderly at the rural area has lead a healthier life style control –powerful others subscale of MHLC as compared to the elderly at the urban site, thus they scores between drug compliance and non- hardly had an illness. This finding may also be due to compliance the high awareness of the elderly in the urban area to seek treatment, whereas the elderly in the rural area Drug compliance rarely came for treatment as they always attribute the illness to the ageing process. Another possibility was No Yes that in the rural area, most of the elderly lived with their n=77 n=123 spouse or on their own. As their children lived and worked in town, there was nobody that could bring Mean score 9.32 9.67 them to the clinic. The lower number of respondents in age group 60 years old and above could also be due Standard Deviation 4.26 3.90 to exclusion of respondents with concomitant medical illness. t=0.637 d.f.= 198 p=0.525 (p>0.05) The gender distribution was almost equal between male (48.5%) and female (51.5%) respondents. This Relationship between Blood Pressure and Drug finding was consistent with the statistics from the Compliance among Patient with Hypertension Population and Housing Census of Malaysia (2000), Undergoing Pharmacotherapy which revealed the distribution of gender at both study sides were also almost equal. As most of the respondents Table 23 shows that there was a significant difference were in the middle age group, majority of them were between blood pressure and drug compliance (P<0.05). married (91.0%) and few were not. It shows that respondents with uncontrolled blood pressure (53.8%) had high drug non-compliance as The ethnic composition of Malaysia comprised compared to respondents with control blood pressure. 65.1% of Malays, 32.0% of Chinese and 7.7% of
32 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
Indians (Population and Housing Census of Malaysia, with most of them were from Salak, Sepang (77.8%). 2000). In this study, majority of the respondents were HUKM Primary Polyclinic is a semi- government Malays (68.0%), followed by Chinese (27.5%) and clinic where the service charge was much higher as Indian (4.5%). In Sepang district, the Malays compared to the fully subsidized government clinic constituted 53.0% of the population, followed by like Salak Polyclinic. Thus majority who came to Chinese (25.6%) and Indian (21.37%). In this study, HUKM Primary Polyclinic were employed and had majority of the respondents of Salak Polyclinic were higher income. Malays (71%), while the others were Chinese (4.9%) and Indian (7.4%). This finding was not consistent About 76% of the respondents had family history with the distribution of ethnic population in the of hypertension and were mostly on single drug district of Sepang, which this clinic served. The treatment (65.5%). In this study only 5% of the possible reason could be that the Chinese and Indian respondents were found to have depressive and anxiety preferred to seek treatment from a nearby hospital at disorders. The prevalence of emotional disorders was the other district, which was fully equipped and a 5.8% at HUKM Primary Polyclinic and 3.7% at Salak doctor can treat them. There were only one Family Polyclinic. The prevalence of psychiatry morbidity in Physician and two doctors based at Salak Polyclinic. this study is low if compared to earlier studies in Besides running an out patient clinic at Salak Polyclinic, Malaysia. Maniam T [22] found the prevalence of routinely the doctors’ need to visits the other health emotional disorders in an urban private general practice center of Sepang District. Thus most of the time the was 29.9%, while Varma SL and Azhar MZ [23] found Medical Assistant would treat the patients and the low prevalence of depression (13.2%) and anxiety doctor only treat the complicated cases. The other disorders (6.1%) in a primary health setting in reason they could not be included in this study is Kelantan. The prevalence of emotional disorders was because of the language barrier. Majority of the higher in the urban areas as compared to rural area. respondents at HUKM Primary Polyclinic were This could be explained by life at the urban area are Malays (54.6%), followed by Chinese (42.9%) and more hectic and stressful. In this study M.I.N.I was Indian (2.5%). This finding was also not consistent used as a tool to determine the presence of psychiatric with the distribution of ethnic population in the disorder and unfortunately it could not detect district of Cheras that this clinic served. According to adjustment disorders as in SCID, thus it attribute to the Population and Housing Census of Malaysia lower prevalence of psychiatry disorder. (2000), Cheras district comprised of Chinese (52.58%), followed by Malays (38.61%) and Indian (8.8%). Patient compliance that is adherence to the regimen Even though the Chinese population utilizing health of care recommended by the doctor and persistence services in HUKM Primary Polyclinic is high, most with it over time has been a common concern in medical of them could not be included in this study because of practice for a long time. Compliance was seen as an the language barrier. active, intentional and responsible process whereby patients work to maintain their health in accordance Most of the respondents (57.0%) in this study with health regimens and in collaboration with health had at least secondary education. Only 13.0% had care professionals (20). Poor compliance with drug attended tertiary education. Those with tertiary treatment is a barrier to effective management of education and presumably with high income would hypertension. prefer to seek treatment at private health center where the clinic environment is more comfortable and less The measurement of medication compliance crowded. continues to be a key methodological problem, particularly in terms of the most valid measurement Most of the respondents were employed or owned of medication compliance [25]. Direct and indirect a business (52.0%). Salak Polyclinic had more methods of assessing compliance and non-compliance respondents whom were retired from their job (38.3%) can be made: direct methods include those by which as compared to HUKM Primary Polyclinic (25.2%). the drug can be identified in the patient; the indirect The reason could be that, after the retirement they methods include those where there is an assessment would prefer to stays in their hometown. They also as whether the patient is likely to have taken the would choose to live in the rural area where life is less medication. Examples of assessing compliance include: stressful and not so costly. Majority of the respondents (1) direct methods, such as: a. blood drug level had total monthly income less than RM1500 (57.5%) monitoring, b. measurement urinary excretion of the
33 Azlin B et al.
drug and (2) indirect methods, such as: a. asking the transportation for the patients as the bus/taxi station patient or other people, b. pill counts, c. clinical was quite far from the polyclinic. The polyclinic judgement of the doctor, d. presence of side effects and environment was also not conducive for the patients e.electronic monitoring. as the clinic was always crowded, noisy and the waiting area was small, thus most of the time patients To date there was no gold standard allowing did not have a place to sit. At HUKM Primary precise measurement of compliance. However the Polyclinic, patients had long waiting time before and electronic monitoring with Medication Event during appointments with their doctor. They were Monitoring System (MEMS) can be considered as the only able to see the doctor based on appointments. best existing system for measurement of medication Patients who defaulted were asked to make a new compliance. This method provides information about appointment. the regularity of drug use, specific drug use patterns, such as erratic drug use, drug holidays and information On the other hand, Salak Polyclinic was cozier and about over and under consumption. Unfortunately less hectic. It was less crowded and had a large waiting this method was too costly to be practiced over here. area with comfortable chairs. It also had ample parking area and a bus station just outside the polyclinic area. In this study, the counting pill method was adopted Patients had shorter waiting time before and during and it was done manually. Every patient was given appointments. The patients were allowed to see their more medication than required for the period under doctors/medical assistant if they missed the study. The pills were counted without the knowledge appointments. Long waiting times before and during of the patients, before they were given to them. The appointments with their physician are major reasons patients were then reminded to return the left over for patients to fail to keep subsequent appointments, medication during the subsequent follow up. The and these factors are also likely to affect compliance tablets left in the container were counted when returned. to medications [12]. Therefore part of the success of this study depended on the trust of respondents to be truthful of their The relationship between the patient and his or compliance. During this study, we noted that patients her health care practitioners may affect drug compliance who wanted to avoid showing that they had missed [26, 27, 28]. Specific physician practices and continuity doses did not return the unused medication. of care may be important [12]. Compliance can be improved by good relationships between the client In Malaysia, a few studies on drug compliance and the health care provider [24]. These studies stress have been conducted [10], where their drug compliance the importance of enabling individuals to take an active was measured by the pill-counting method. The study part in planning their care together with the health care showed 26.0 % of patients were non-compliant. The personnel.At Salak Polyclinic, the relationship between usual reported range of non-compliance with the health staff and the patients were close. Most of medication is 25-50% [25]. In this study; the prevalence the health staffs live around the polyclinic area and of non-compliant to the medication was 38.5%. This know most of the attendees. The doctors and medical can be considered relatively low. The reason for this assistant in this polyclinic are well known among the may be that medications have developed a great deal residents as most of them are local people and have during the last decades, do not have so many side been giving services for many years as compared to effects and are more effective than before. those in HUKM Primary Polyclinic. Most of the time at HUKM Primary Polyclinic, different doctors would HUKM Primary Clinic respondents had higher see the patients because the doctors were postgraduate rate (52.1%) of non-compliance to the medication students. A friendly environment and good prescribed as compared to Salak Polyclinic (18.5%). relationship between the health care provider and the There was a significant association between these respondents at Salak Polyclinic might have contributed groups when tested statistically. There were few to the better compliance to treatment in these reasons that can be attributed to this significant respondents. association. This significant difference may be explained by the logistic differences between these two study Relation between compliance and socio- sites. HUKM Primary Polyclinic was temporarily demographic factors differs from different studies. situated in a five-storey shop lot building at a busy Monane M. et al. [29] in their study found that commercial area. However, there was lack of public increased compliance was associated with advanced
34 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY
age (85 years and older). Bohari H et al. [30] in their they would forget to take their medication. The other study found that age had no influence on compliance. reason is that the Chinese community has strong However Aziz A.M.A et al. [31] in their study found beliefs in their traditional medicine, they like to take that older age group was statistically significant to be herbs, ginseng and other type of traditional medicine non-complier to the prescribed medication. In this instead of drug treatment. study there was a significant association between age and drug compliance, with the majority of the In this study there was no significant association respondents of the older age group (60 years and between drug compliance with marital status, above) was noted to be non-compliant to the prescribed educational level, income or family history of medication. The reason for this may be that the elderly hypertension. Although there was no significant have memory problem and become forgetful, relationship between educational level and drug complexity of drug regimen and have encountered compliance, the respondents who never had formal more medication side effects. Drug compliance among education, showed to have high non-compliance rate the elderly may be compromised by an increased to the medication prescribed. The reasons for this may number of prescribed medications, by decreased social be that they were illiterate, had less knowledge and support, and by the increased incidence of memory understanding about the illness. Respondents with problems in the population [32]. income less than RM1500 had good compliance. There is a possibility that this group of people could The majority of the respondents at HUKM not afford to fall sick, as they need to earn a living. If Primary Polyclinic, lived in the city and had jobs, thus they fall sick they cannot work and have to spend they were busy with earning their livelihood hence money on the treatment. Thus, it is better for them they forgot their medication and clinic appointments. to comply with the medication in order to prevent Unlike respondents from Salak Polyclinic where life complications of the disease. was less hectic, they had more time to come for their appointments. The service and medication fees were This study also found that there was no significant much higher at HUKM Primary Polyclinic as compared association between drug compliance with the number to Salak Polyclinic where the clients enjoyed fully of prescribed medications. However, respondents subsidized medical treatment. However, in this study with monotherapy had better drug compliance. The there was no significant relationship between drug reason for this may be due to the availability of novel compliance with occupational status. anti-hypertensives that have fewer side effects and simple dosing regimen. Most of the respondents at Shea et al. [33] studied patients’ compliance with both study sites were put on monotherapy treatment. medication and reported men’s compliance to be Most of the respondents at HUKM Primary Polyclinic poorer than women’s. However Bohari et al. [30] were put on novel anti-hypertensives such as showed that female patients had decreased compliance. indapamide, ibersartan or perindropril, which have In this study, there was a significant association fewer side effects. Unfortunately they were found to between drug compliance and gender.Female be less compliance to the prescribed medication. respondents (57.7%) were found to be more compliant Interestingly, respondents at Salak Ployclinic showed to the medication as compared to male respondents better compliant to the medication although most of (42.3%). them were on conventional antihypertensive such as metoprolol, nifedipine and chlorothiazide. This is Increased compliance was associated with white because themajority of the patients at Salak Polyclinic race [29]. Meanwhile Aziz A.M.A [31] in their local were put on monotherapy. study found that race was not seen to have influence on compliance. In this study, there was a significant In this study also, respondents with high internal association between drug compliance and race. The locus of control were found to be non- compliant to Chinese (52.7%) were found to be non-compliant to the medication. There was a significant difference in the prescribed medication as compared to the other the relationship between high/low internal locus of major races. The reason could be that, the majority of control with drug compliance. This is a contra finding, the Chinese in this study came from the urban area with the fact that a person with high self-efficacy (94.4%). Based on the demographic data, most of believes that he or she is able to adhere to certain them ran their own business or worked with the behaviour, such as remembering to take pill as private sector, thus due to being busy earning a living prescribed. However, the finding was consistent with
35 Azlin B et al.
study done by De Vellis et al. [16] that showed that questionnaires at patients’ homes or offices and it is patient with internal locus of control are more likely recommended to translate the questionnaires to other to be engaged in preventive behaviour or lifestyle different languages such as Mandarin and Tamil. changes and seek information about the disease but These would help in getting more samples. were less willing to comply with the drug therapy. People with high internal locus of control could be Secondly, the place where the study was more motivated to take actions which lead to good conducted also influenced the results of the assessment. health, but at the same time comply less with prescribed As mentioned earlier, in HUKM Primary Polyclinic, medical treatment. the clinic setting was not suitable to be a clinic as it is located in a shop lot space. The waiting area was too This study also reveals that there was a statistically crowded and had not enough rooms to see patients. significant difference for both modalities of external Thus, there was no proper place to interview the locus of control (chance and doctors’) with drug respondents. Sometimes when the consultation rooms compliance. However there was no statistically were fully occupied, the respondents were interviewed significant difference for external locus of control in the waiting area without any privacy.The (powerful others) with drug compliance. respondents were easily distracted by the noise. There were some patients who did not appear The study results show that respondents with enthusiastic about the study despite their voluntary external locus of control (chance or doctors’), have participation, given the fact that they had completed better drug compliance. By contrast, individual who the responses in a rather short time. Thus, their reply believe that their fate is determined largely by chance may have been erratic and unreliable. Nevertheless, and not by their own actions are less likely to adhere such patients were very small in number. with the therapy, as they feel that their actions may not appreciably affect outcomes [14]. This might be Thirdly, the socio-demographic data was shared due to the fact that the majority of the respondents between the major IRPA study and the researcher were Malays and most of them were Muslim. In Islam, study. It was found that the total household income we believe in fate that is determined by God but the was not calculated properly according to the total religion itself encourages its followers to make an number of the family members. This would affect the effort and seek help to treat the illness. It is considered data interpretation later. In future studies, it is a sin not to try to find treatment for the illness. Other recommended that the number of family members reasons could be that most of the Malaysian should be included. Thus, it can give the true figures populations are obliging people; they usually have of income. Previous studies have shown that lower high confidence and respects for the doctors treating income has association with non-compliance to the them. medications.
Nevertheless, in conducting this study, the Fourthly, the urban (HUKM Primary Polyclinic) researcher was aware of its limitations. Firstly was the and rural (Salak Polyclinic) cohorts may not be relatively small sample size, which means that caution representative of the general population. Further should be applied in generalizing these findings to the studies are recommended to replicate these findings general population. It was due to: (a) the respondents using a bigger sample size. involved in this study are those who have agreed to participate in the major IRPA project. Some of the The Multidimensional Health Locus of Control patients refused to be interviewed after completing used in this study has not been used on a Malaysian countless questions from the major IRPA studies. population prior to this study; therefore its validity Most who gave consent to participate in this study for a Malaysian population is questionable, taking were those identified earlier while waiting to see the into consideration the diversity of culture and religious doctor, (b) time constraint also prevented the researcher beliefs among the study population. getting a bigger sample, as the researcher needs to divide her time to attend both clinics and run her own Many methods have been used to measure clinics at the hospital, (c) strict inclusion criteria, (d) compliance, each of which is limited by biases and the fact that only Malay and English speaking patients methodological flaws [34]. The potential effect of the were included. In future studies, it is recommended measurement itself, termed the “Hawthorne effect,” that home visits can be done to administer must be considered. This is the effect (often beneficial
36 HEALTH LOCUS OF CONTROL AMONG NON-COMPLIANCE HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY or positive) of observation itself on the outcome. References Frequently, an individual’s knowledge that he or she is under study influences behaviour and may therefore 1. Ali Osman, Rampal KG, Lubis SH. Kajian affects the compliance. Prevalens Hipertensi Di Kalangan Orang Melayu Di Kuala Selangor. Med.J.Malaysia 1984; 39:148- In this study, the researcher had the problem 150. usually encountered in compliance studies, which result in an incomplete picture of compliance, because 2. Frochlich ED, Apstein C, Chobanian AV et al. questionnaires were only received from patients The Heart in Hypertension. New England Journal who visited health providers. The patients with the of Medicine 1992; 327: 998-1008. poorest compliance do not visit the health care personnel and frequently do not participate in the 3. Chalmers J, Mac Mohan S, Mancia G et al. 1999 study. Lastly, factors such as life events and social World Health Organization- International Society support, which may influence the compliance and of Hypertension Guidelines for the Management locus of control, were not included in this study. of Hypertension. Journal of Hypertension 1999; 17 : 151-183. Conclusion 4. Collins R, Peto R, Mac Mohan S et al. Blood This study has shown that only 38.5% of the Pressure, Stroke and Coronary Heart Disease. respondents were non-compliant to the anti- Part 2, Short Term Reductions in Blood Pressure: hypertensive pharmachotherapy. It also suggests Overview of Randomised Drug Trials in their that differences in locus of control exist between Epidemiological Context. Lancet 1990; 335: 827- compliance and non-compliance respondents with 838. hypertension undergoing pharmacotherapy. It has shown that respondents with high internal locus of 5. Haynes RB, Taylor DW, Sackett DL. Com- control had poor drug compliance. There were also pliance in Health Care.Baltimore (MD): The significant differences between drug compliance with John Hopkins University Press 1979. the study sites, age, race, gender and external locus of control (chance, doctors’). 6. Sackett DL, Haynes RB.Compliance with Therapeutic Regimens.Baltimore (MD):The John There were no significant differences between Hopkins University Press 1976. compliance and no-compliance to the pharmacho- therapy in term of external locus of control (others), 7. Cooper JK, Love DW, Raffoul PR. Intentional number of medication prescribed, family history of Prescription Nonadherence (noncompliance) by hypertension, income, education level, employment the Elderly. Journal American Geriatric Society and marital status. 1982; 30:329-33.
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