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Hypertension Knowledge and Treatment Initiation, Adherence, and Discontinuation Among Adults in Chennai, India: a Cross-Sectional­ Study

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Hypertension Knowledge and Treatment Initiation, Adherence, and Discontinuation Among Adults in Chennai, India: a Cross-Sectional­ Study Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from Hypertension knowledge and treatment initiation, adherence, and discontinuation among adults in Chennai, India: a cross-sectional study Nikkil Sudharsanan ,1,2 Mohammed K Ali,3,4 Margaret McConnell5 To cite: Sudharsanan N, Ali MK, ABSTRACT Strengths and limitations of this study McConnell M. Hypertension Introduction A substantial share of urban Indians with knowledge and treatment diagnosed hypertension do not take regular treatment, ► We provide some of the first evidence on hyperten- initiation, adherence, and potentially due to poor knowledge of hypertension discontinuation among adults sion knowledge and beliefs, especially regarding consequences and treatment options. We describe in Chennai, India: a cross- blood pressure medications, among adults with di- hypertension knowledge and beliefs, treatment patterns, sectional study. BMJ Open agnosed hypertension in a major Indian city. and reported reasons for treatment non- use among adults 2021;11:e040252. doi:10.1136/ ► We also link individuals’ hypertension knowledge to with diagnosed hypertension in Chennai, India. bmjopen-2020-040252 reported treatment behaviour to determine if more Methods We collected data on 833 adults ages 30+ knowledgeable individuals are more likely to take ► Prepublication history for with physician diagnosed hypertension using a door- to- this paper is available online. daily hypertension treatment. door household survey within randomly selected wards To view these files, please visit ► The primary limitation of our study is that it is based of Chennai. We described the proportion of individuals the journal online (http:// dx. doi. on a non- probability sample of individuals from a who were not taking daily medications and their reported org/ 10. 1136/ bmjopen- 2020- single city in India and may not be generalisable to reasons for not doing so. Next, we described individuals’ 040252). all urban Indians with hypertension. knowledge of hypertension consequences and how to ► Our study was not designed to estimate the causal Received 11 May 2020 control blood pressure (BP) and assessed the association effect of individuals’ knowledge and beliefs on blood Revised 15 October 2020 between knowledge and daily treatment use. pressure outcomes and is best interpreted as hy- Accepted 22 December 2020 Results Over one quarter (28% (95% CI 25% to 31%)) of pothesis generating. diagnosed individuals reported not taking daily treatment. The largest proportion (18% (95% CI 16% to 21%)) were individuals who had discontinued prior treatment use. http://bmjopen.bmj.com/ The primary reason individuals reported for non- daily negative consequences of hypertension and is use was that their BP had returned to normal. Just 23% one of the most cost- effective ways of reducing © Author(s) (or their (95% CI 20% to 26%) of individuals listed BP medications mortality.2–4 BP control is especially pressing employer(s)) 2021. Re- use as the most effective way to reduce BP; however, these permitted under CC BY- NC. No individuals were 11% points (95% CI 4% to 19%) in urban India, since over 30% of adults over commercial re- use. See rights more likely to take daily medications. Conversely, 43% the age of 30 are hypertensive and this prev- and permissions. Published by (95% CI 40% to 47%) of individuals believed that BP alence is expected to increase substantially as BMJ. 5–7 1 medications should be stopped from time to time and the population ages. Indeed, recent obser- Heidelberg Institute of Global on October 2, 2021 by guest. Protected copyright. Health, Heidelberg University, these individuals were 15% points (95% CI −0.21 to vational studies have found that improving Heidelberg, Germany –0.09) less likely to take daily treatment. While awareness BP control has the potential to result in large 2LEAD at Krea University, of the consequences of hypertension was poor, we found population- wide improvements in mortality Chennai, India no evidence that it was associated with taking daily in urban India and similar contexts.8 9 3 Department of Family and medications. Despite the widespread availability of anti- Preventive Medicine, Emory There were large gaps in consistency of Conclusions hypertensive medications,10 several recent University, Atlanta, GA, USA BP medication use which were strongly associated with 4 Hubert Department of Global knowledge about BP medications. Further research is studies have found that BP treatment use Health, Rollins School of Public needed to identify whether addressing beliefs can improve among individuals diagnosed with hyper- Health, Emory University, Atlanta, 7 11 12 daily treatment use among individuals with diagnosed tension in India is low. For example, GA, USA among adults in New Delhi and Chennai with 5Department of Global Health hypertension. and Population, Harvard T.H. diagnosed hypertension, only an estimated 7 Chan School of Public Health, 18%–37% reported taking medications. Boston, MA, USA INTRODUCTION Similarly, a recent national study found that Hypertension is the leading modifiable risk just 31% of hypertensive adults living in Correspondence to 1 Dr Nikkil Sudharsanan; factor for mortality worldwide. Controlling urban areas reported taking hypertension 11 nikkil. sudharsanan@ uni- blood pressure (BP) through daily, low- treatment. These studies reveal substantial heidelberg. de cost, medications substantially reduces the treatment gaps among urban Indians with Sudharsanan N, et al. BMJ Open 2021;11:e040252. doi:10.1136/bmjopen-2020-040252 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from diagnosed hypertension yet the potential reasons behind by a Chennai- based research organisation that locally this pattern remain unclear. recruited survey teams and conducted all interviews in Knowledge of the importance and most effective ways Tamil, the local language. We used a geographically strat- of controlling BP is critical for initiating and adhering to ified quota sampling approach to identify respondents.23 hypertension treatment.13–16 Individuals may not initiate We started with randomly selecting 50 of Chennai’s 200 or adhere to treatment if they are not fully aware of the wards with weights proportional to share of the Chennai negative consequences of uncontrolled hypertension. population living in the ward as of the 2011 census. Alternatively, individuals may understand the importance Within selected wards, enumerators selected a random of BP control, but not know that taking medications daily starting street; if the starting street was primarily commer- is the most effective way of controlling BP. Limited qual- cial, enumerators moved to parallel streets until they itative evidence from India suggests that individuals with reached a street with residential homes. Enumerators hypertension are not aware of the link between hyperten- then used a door- to- door two- step procedure to identify sion and stroke and heart disease, and while individuals eligible individuals. Enumerators first asked a household are generally aware of the importance of healthy lifestyle respondent if anyone aged 30 and above in the house- habits, they do not necessarily understand the specific and hold had physician- diagnosed hypertension, and only if most effective ways of controlling BP.17 18 These largely confirmed, conducted the main interview. We attempted qualitative studies have focused more on knowledge of to enroll an approximately equal number of men and preventative measures than knowledge of BP medications women and older and younger adults within each ward. and did not link knowledge to medication adherence. Enumerators interviewed only one respondent per house- We investigate the potential reasons behind low hyper- hold—selected by the enumerator to best balance the age tension treatment among adults diagnosed with hyper- and sex distribution of respondents within the ward—if tension in Chennai—India’s sixth most populous city. We multiple individuals reported having hypertension. If begin by estimating the share of individuals that do not no one in the household reported having hypertension, take daily treatment. We then divide our sample between enumerators moved on to the next household. Enumer- those who never initiated treatment, those who take treat- ators repeated this procedure until they reached their ment but irregularly, and those who took treatment in the target sample of 15–20 individuals per ward. Households past but have since discontinued it. Among these individ- were only visited once and not recontacted. Of approxi- uals, we report the most commonly stated reasons for mately 1243 individuals approached, 833 (67%: 420 men, not taking daily treatment. Next, we describe individuals’ 413 women) agreed to participate. Survey teams collected knowledge of hypertension consequences and treatment surveys at multiple times during the day and on weekends and assess whether individuals who are more knowledge- to ensure that the sample contained both working and able are also more likely to take daily treatment. Findings non- working individuals. from this work will inform the development of effective interventions by exploring modifiable pathways that may Measurements http://bmjopen.bmj.com/ be responsible for poor BP management in urban India Survey teams administered a questionnaire collected and similar contexts. digitally on handheld tablets to
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