|Year : 2017 | Volume
| Issue : 3 | Page : 102-108
Knowledge, attitude, and adherence to nonpharmacological therapy among patients with hypertension and diabetes attending the hypertension and diabetes clinics at Tertiary Hospitals in Kano, Nigeria
Sanusi Abubakar1, Lawan Umar Muhammad1, Abdulazeez Ahmed2, Fatima Idris1
1 Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||16-Jan-2018|
Dr. Abdulazeez Ahmed
Department of Otorhinolaryngology, Bayero University/Aminu Kano Teaching Hospital, Kano
Background: Hypertension and diabetes are among the leading noncommunicable diseases (NCDs) in the world. The etiology and prognosis of these diseases are markedly influenced by environmental stress and lifestyle choices. Prevention and effective control of these conditions largely depend on patients' cooperation and commitment to lifestyle modification. Materials and Methods: A cross-sectional descriptive study was carried out among 51 patients with hypertension only, 27 patients with diabetes only, and 27 patients with both hypertension and diabetes attending specialist clinics at Aminu Kano Teaching Hospital and Murtala Muhammad Specialist Hospital both in Kano, using a semi-structured interviewer-administered questionnaire after selection of patients by systematic sampling. The data were analyzed with Minitab statistical software version 12 (Minitab Inc. Pennsylvania, US), qualitative and quantitative variables were summarized using percentages and means, respectively, while associations between categorical variables were assessed using Chi-squared test at a significance level of ≤0.05. Results: About 86.3% of the patients with hypertension only, 88.9% of patients with diabetes only, and 74% of patients with both hypertension and diabetes were aware of the various components of nonpharmacological therapy for NCDs; this ranged from the knowledge of the diseases and knowledge about lifestyle modifications. About 13.8% of the respondents with hypertension only had good knowledge of hypertension prevention, whereas 62.8% had fair knowledge and 23.5% had poor knowledge of hypertension prevention, respectively. Although majority (74.5%) of our hypertensive patients and 77.8% of patients with both hypertension and diabetes, had a positive attitude toward nonpharmacological therapy. Conclusion: This study showed that a great percentage of our patients with NCDs had very poor knowledge of the different components of nonpharmacological therapies.
Keywords: Diabetes, hypertension, Knowledge, lifestyle, nonpharmacologic therapies
|How to cite this article:|
Abubakar S, Muhammad LU, Ahmed A, Idris F. Knowledge, attitude, and adherence to nonpharmacological therapy among patients with hypertension and diabetes attending the hypertension and diabetes clinics at Tertiary Hospitals in Kano, Nigeria. Sahel Med J 2017;20:102-8
|How to cite this URL:|
Abubakar S, Muhammad LU, Ahmed A, Idris F. Knowledge, attitude, and adherence to nonpharmacological therapy among patients with hypertension and diabetes attending the hypertension and diabetes clinics at Tertiary Hospitals in Kano, Nigeria. Sahel Med J [serial online] 2017 [cited 2020 Feb 20];20:102-8. Available from: http://www.smjonline.org/text.asp?2017/20/3/102/223170
| Introduction|| |
Worldwide, noncommunicable diseases (NCDs) kill over 35 million people each year, representing nearly two-third of the world's death. The term NCDs refer to a group of conditions that are not mainly caused by an acute infection, result in long-term health consequences, and often create a need for long-term treatment and care. These conditions include hypertension leading to cardiovascular diseases, diabetes, cancers, and chronic lung illnesses among others. Many NCDs can be prevented by reducing common risk factors such as tobacco use, harmful alcohol use, physical inactivity, and eating unhealthy diet. More than 80% of NCDs-related deaths are in low- and middle-income countries and nearly a third of those deaths occur before age 60. The probability of dying between ages 30 and 70 years from the four main NCDs is 20%. Research has shown that cardiovascular diseases account for most NCD deaths (17 million people) annually, followed by cancer (7.6 million), respiratory disease (4.2 million), and diabetes (1.3 million). These four diseases are regarded as the most prominent NCDs, and interestingly they share common modifiable risk factors of which tobacco is the most implicated. NCDs continue to be important public health problems in the world and are responsible for a sizeable chunk of mortality and morbidity that occur globally.
There is no established mechanism for community-wide data collection in Nigeria for many NCDs, and most of the figures for Nigeria are derived from hospital and community studies. However, the World Health Organization estimated that NCDs will account for 24% of total deaths in 2014 and predicts that by 2030, deaths from NCDs in Sub-Saharan Africa (SSA) will surpass those for deaths due to infectious diseases and by that year, deaths from NCDs are expected to account for 42% of all deaths in SSA, up from approximately 25% in 2014.
Researchers have estimated that raised blood pressure (BP) currently kills 9 million people every year, and it is estimated that by 2025, up to 1.56 billion adults worldwide will be hypertensive. Raised BP is estimated to cause 7.5 million deaths, which accounts for 57 million disability-adjusted life years (DALYs). On the other hand, by 2013, the global prevalence of diabetes was 8.3% prevalence (i.e, 382 million people are affected) and this is projected to become 592 million by 2035.
This rapidly increasing prevalence of NCDs in the past few decades has resulted in significant changes that have occurred in the pattern of health and disease distribution in many developing countries. These changes may occur due to the effect of social, economic, and technological development as well as from special public health and population programs. This has resulted in the transition from the densely challenging communicable diseases to silently damaging NCDs, and this phenomenon is tagged epidemiologic transition.,
Nonpharmacologic therapy (comprising patients education and lifestyle modifications) is accepted as an essential measure in the prevention and control of both hypertension and diabetes. Nondrug therapies are set of measures other than drug therapy which helps to prevent, reduce the risk, and treat some conditions. These are in the form of lifestyle modification which conceptually refers to the pattern of an individual's behavioral choices and practices with respect to daily activities that are related to elevated or reduced risk of hypertension and diabetes or serve as adjunct to their treatment. Patient self-management education, as well as lifestyle changes for diabetes (Type 2) will include the prescription of a healthy diet, regular exercise, management of stress and avoidance of tobacco, weight management, cessation of alcohol consumption, and smoking. This will be in conformity with the global initiatives to address NCDs started in 2000, with the adoption by the World Health Assembly of its resolution 53.17, in which the Assembly endorsed the global strategy for the prevention and control of such diseases. The strategy rests on three pillars: surveillance, primary prevention, and strengthened health care. The efficient use of nonpharmacologic therapies will be strong components of primary prevention. Medical adherence has been defined as the “active, voluntary, and collaborative involvement” of the patient in a mutually acceptable course of behavior to produce a therapeutic result., This definition implies that the patient has a choice and that both patients and providers mutually establish treatment goals and the medical regimen. Medication adherence is defined as “the extent to which the medication-taking behavior of a patient corresponds with agreed recommendations from a health-care provider. It is an important factor in achieving disease control, particularly for chronic conditions such as diabetes and hypertension.
While several studies have been conducted on pharmacological management of NCDs and adherence thereof , particularly in the developed world, there is a dearth of information on the knowledge, attitude, and adherence to nonpharmacological management by hypertensive and diabetic patients attending tertiary health institutions in Nigeria. The general objectives of this study are to assess the knowledge, attitude, and adherence to nonpharmacological therapy among patients with hypertension and diabetes attending the hypertensive and diabetic clinics at Aminu Kano Teaching Hospital (AKTH) and Murtala Muhammad Specialist Hospital (MMSH), Kano, Nigeria.
| Materials and Methods|| |
Kano State is located in the northwestern part of the country with its capital as Kano city. Two hospitals in Kano metropolis were selected for the study: AKTH is a tertiary hospital, and MMSH is the oldest and largest hospital in the walled ancient city of Kano State. AKTH has staff strength of 1443 with a bed capacity of 500. The average monthly turnover of patients with diabetes and/or hypertension at the study site during the study period is 348. However, this figure may vary widely due to recurrent industrial action by health-care workers. While MMSH has a bed capacity of about 250 with a monthly patient turnover of about 18,000 and staff strength of about 1000.
The study population consisted of patients with either hypertension alone, diabetes alone, or patients with both hypertension and diabetes attending hypertension and diabetes outpatient clinics of AKTH and MMSH during the period of the study. A cross-sectional descriptive study was used to assess the knowledge, attitude, and adherence to nonpharmacological therapy among patients with hypertension and diabetes attending AKTH and MMSH, Kano.
The calculated sample size for the study was a total of 110 cases and using systematic sampling technique, the total number of the patients registered by the record clerks as they arrive at the weekly hypertensive and diabetes clinics. The patient attendance on the clinic day was used as the sampling frame (average of 87 patients/clinic day), and the sampling interval of one was used to recruit a sample of 110 hypertensive and/or diabetic patients over a 5-week period. During the period of the study, an average of 18–25 subjects was interviewed per clinic day for the two sites.
The Kano State Hospital Management Board Ethics Committee and the Health Research Ethics Committee of AKTH, Kano, gave approval for the study after reviewing the study protocol submitted before commencement of the study. The respective Heads of Departments where the study was conducted also gave their permission. All respondents gave their verbal informed consent before administration of the questionnaires. A semi-structured interviewer administered questionnaire was used for data collection, and it consisted of four sections; one section was dedicated to socio-demographic characteristics while the remaining sections, each were allocated to the specific objectives of the study, which were knowledge, attitude, and adherence to nonpharmacologic therapy guidelines. There were 45 questions in the knowledge section of the questionnaire, and a score of one was given for each correct response and zero for wrong answers. Respondents that scored between 0 and 15 were graded as having poor knowledge, while those that scored between 16 and 30 were graded as having fair knowledge and those that scored 31–45 were regarded as having good knowledge. Attitude was measured using the Likert scale, and maximum scores of 72 were obtainable from the section. Respondents that scored between 0 and 36 were considered as having a negative attitude and those who scored from 37 to 72 were graded as having a positive attitude. A total score of 46 points was assigned to the section on adherence and respondents that scored 0–23 were said to have poor adherence and those who scored 24–46 were considered as having good adherence.
The collected data were entered into Microsoft Excel spreadsheet and analyzed using Minitab. Microsoft Word was used to draw tables and Microsoft Excel for charts. Quantitative variables were summarized using measures of central tendency and measures of dispersion as appropriate. Chi-square test was used to determine significant association between categorical variables. P ≤ 0.05 was considered statistically significant.
| Results|| |
A total of 105 questionnaires out of 110 were filled and returned by the study participants, giving a response rate of 95%. The ages of respondents ranged between 23 to 85 years with mean age of 51±14.5 years among patients with hypertension, 46±12.7 years among patients with diabetes and 52±16.4 among those with both hypertension and diabetes. Female respondents constituted 86.3% of hypertensives and 51.8% of diabetics whereas majority of respondents (51.9%) with both hypertension and diabetes were males. [Table 1]
Majority of the respondents were of Hausa extraction, 81.5% were diabetics and 81.5% had hypertension and diabetes. More than half (64.7%) of hypertensive respondents were married while 85.2% of those with both hypertension and diabetes are also married ([Table 1]). Majority (52.9%) of the hypertensive respondents' had no formal education while 44.4% of diabetics have secondary education and 29.6% of those with combined conditions had secondary education [Table 1].
Regarding knowledge, attitude and adherence to non-pharmacological therapies, 32 (62.8%) of hpertensive respondents had a fair knowledge with 13(25.5%) of respondents having a negative attitudes towards this mode of management. However, across all respondents, there was generally a good adherence. Although fair knowledge of non-pharmacological therapy was highest among respondents with diabetes [Table 2].
In order to determine which variables influence level of knowledge of non-pharmacologic therapy among our respondents, analysis revealed that only a positive attitude was a statistically significant factor upon the level of knowledge. Interestingly, education was not statistically significant [Table 3].
|Table 3: Factors that influence level of knowledge of non-pharmacologic therapy among respondents|
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Among all highlighted modalities for nonpharmacological therapies for hypertension, majority of respondents were mostly aware of salt restriction/exercise and least aware of use of unsaturated fats and dairy products, see [Figure 1]
|Figure 1: Shows that most of our respondents (82.4%) are aware of salt reduction as part of a non-pharmacological therapy|
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| Discusssion|| |
The respondent's ages ranged from between 23 and 85 years with a mean age of 51 ± 14.5 years among patients with hypertension, 46 ± 12.7 years among patients with diabetes, and 52 ± 16.4 years among patients with both hypertension and diabetes [Table 1].
This is close to the findings of similar studies done in Umuahia, Nigeria  and Edo State. These findings agree with an earlier report  that majority of the people with diabetes in developing countries are middle-aged, i.e., between 45 and 64 years which is quite a productive age group, when individuals are still quite productive or even getting to the peak of their careers. The heavy affectation of the middle-aged also places additional burden on the health system because of need for frequent consultations by those affected and on the economy of the country as well because of absenteeism from work, and the impact on the quality of life and DALYs of the persons affected.
Females were the majority among the respondents that had hypertension only (86.3%) and also among the respondents that had diabetes only (51.8%) [Table 1], but a slight majority of respondents (51.9%) that had both hypertension and diabetes were males. This is consistent with a previous study in Nigeria  which showed a similar pattern. It is not surprising that majority of the respondents (76.5%) that had hypertension only, 81.5% of respondents that had diabetes only, and 81.5% of the respondents that had both hypertension and diabetes were of Hausa extraction, this basically reflects the dominant social and demographic composition of the catchment area where these hospitals are located. This is also reflected by the fact that up to 98% of the respondents with hypertension only were Muslims, whereas 100% of the remaining participants with diabetes and those with both conditions were all Muslims [Table 1].
Most of the respondents were married, among those 64.7% with hypertension only, 77.8% with diabetes only, and 85.2% with both conditions. This finding is similar to that obtained in a study  conducted in Osun State, Nigeria where almost 70.7% of the respondents were married; this is not unexpected because being married is the social norm for that age group. Majority (54.9%) of the respondents with hypertension only have no formal education, whereas most of the respondents (85.1%) with diabetics only and 62.9% of the respondents with both hypertension and diabetes had some secondary school level training, respectively. The overall literacy level [Table 1] of the respondents was good and this may probably be due to the fact that the two hospitals are located in an urban setting where literacy levels are relatively higher (NDHS 2013).
About one-third (39.2%) of the respondents who had hypertension only were engaged in small scale businesses [Table 1], 33.3% of the respondents who had diabetes only were civil servants and 37% of those with both conditions were either civil servants or unemployed. This finding is quite interesting because it did not show any clustering of diabetes or hypertension in any particular social class as seen in studies from developed countries such as the Whitehall study. This finding maybe explained by the fact that the societies in most developing countries, like Nigeria, do not have or do not follow a fairly rigid ordinal class structure or stratification based on occupational and educational characteristics that used to be seen in some countries like the UK in the past.
About 86.3% of the respondents who had hypertension only, 88.9% of the respondents who had diabetes only, and 74% of patients with both hypertension and diabetes were aware of the components of nonpharmacological therapy which ranged from knowledge about the risk factors for the disease to lifestyle modifications [Table 2]. This is quite reassuring and maybe a pointer to the fact that these are chronic conditions where patient self-care is encouraged and which involves prolonged, regular contact with the health-care system that provides opportunities for repeated patient and peer education. Only about 13.8% of the respondents with only hypertension had good knowledge of nonpharmacological therapies for their condition while 22.2% of patients with both hypertension and diabetes had good knowledge [Table 2]. This tallies with findings from a survey in Gavar  region where the knowledge of nondrug control of hypertension was inadequate with cumulative mean percent knowledge score of 50.2% ± 21.5% standard deviation, only 14.8% of patients with diabetes had good knowledge of nonpharmacological therapies for their condition, which is quite low when compared to the findings from similar studies in Southern Nigeria , and Ethiopia, 72% and 77.6% of the patients with diabetes, respectively, had good knowledge of nonpharmacological therapies for their condition. The reason for the higher level of good knowledge in the latter studies may be due to the fact that the educational status of the respondents in these other studies was higher.
Most of the respondents [82.4% - [Figure 1] overall are aware of salt reduction as part of nonpharmacological therapy, and this corresponds to the finding from a study conducted in Ethiopia where 65.3% and 87.1% of the respondents, respectively, were aware of optimal weight attainment and salt reduction as part of an approach to control hypertension.
Majority (74.5%) of the patients with hypertension only, 48.2% of the patients with diabetes only, and 77.8% of patients with both hypertension and diabetes had a positive attitude toward nonpharmacological therapy [Table 2]. This is an encouraging finding because it implies that they are amenable to taking up targeted patient education messages for behavior change toward nonpharmacological therapy which will help to improve BP/blood sugar control, and reduce most of the long-term complications associated with these conditions. These findings were also seen in other studies, where majority of the respondents had a positive attitude toward lifestyle modifications., However, this is not consistent with the findings of similar studies in a suburban Nigerian community which revealed negative attitude and inadequate practice toward lifestyle modifications among hypertensives, nor was it consistent with the findings of another study in Umuahia which reported poor attitude (56.6%) among diabetics toward dietary management.
All the respondents with hypertension only and diabetes only self-reported good adherence tononpharmacological therapy, whereas almost all (96.3%) of the patients with both hypertension and diabetes had self-reported good adherence to nonpharmacological therapy [Table 2]. This corresponds to findings in other studies, in which majority of the respondents had good practice and adherence., about 63% of the respondents with diabetes only claimed they consume vegetables ≥3 times a week as part of their nonpharmacological therapy, as against the finding in Umuahia where 44.5% reported consuming vegetables >3 times a week. This disparity could be due to the relatively better or cheaper availability of different types of vegetables in the different study areas.
Most of the respondents (85%) reported visiting the dietician only on an occasional basis; this is a worrisome finding because it is a pointer to the lack of weight given by respondents to the importance of diet in the management of their conditions. This study found a positive association (P = 0.006) between the knowledge level and the attitude of the respondents toward lifestyle modifications for their conditions [Table 3]. This finding is similar to that from a study conducted in South Africa which reported significant positive correlation (P = 0.012) between knowledge and attitude level. This is a pointer to the need to target appropriate messages to patients with these conditions in the respective health facilities.
| Conclusion|| |
The results of this study showed that a greater percentage of patients with only hypertension, only diabetes, or both hypertension and diabetes had very poor knowledge of the different components of nonpharmacological therapy even though they were generally aware of its existence. However, there was generally a higher percentage of positive attitudes among respondents toward nonpharmacological therapy. These findings buttress the need for focused and targeted health messages and patient education, especially by dieticians, pharmacists, nurses, and doctors (including the media) about the importance and benefits of nonpharmacological therapy in the management of diabetes and hypertension so as to reduce the long-term complications of these conditions.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kadiri S. Tackling cardiovascular disease in Africa. BMJ 2005;331:711-2.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.
Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, et al.
National, regional, and global trends in systolic blood pressure since 1980: Systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants. Lancet 2011;377:568-77.
International Diabetes Federation (IDF) Diabetes Atlas. 6th
Edition, Brussels; 2013.
Otaigbe BE, Ugwu RO, Dabibi OM, Obiora RN. The profile of non-communicable diseases in patients admitted into the children's medical ward of University of Port-Harcourt Teaching Hospital. Port Harcourt Med J 2008;2:204-10.
Adedoyin RA, Adesoye A. Incidence and pattern of cardiovascular disease in a Nigerian teaching hospital. Trop Doct 2005;35:104-6.
Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, et al.
Non-communicable diseases in Sub-Saharan Africa: What we know now. Int J Epidemiol 2011;40:885-901.
Jane A, Charles RA, Anthony JF, Juliet C, Edwin AM. Cardiovascular diseases, diabetes mellitus and other disorders of metabolism. In: Parveen K, Michael C, editors. Kumar and Clark's Clinical Medicine. 7th
ed. Edinburgh, London: Saunders Elsevier; 2009. p. 802-5, 1038-40.
Madaki AJ. Lifestyle medicine in primary health care. Niger J Fam Pract 2012;2:39-41.
ICMR Guidelines for Management of Type 2 Diabetes. Indian Council of Medical Research, Ansari Nagar, New Delhi-110029; 2005. Available from: http://www.icmr.nic.in/per_app/per_app.pdf
. [Last accessed on 2015 Jan 30].
Delamater AM. Improving patient adherence. Clin Diabetes 2006;24:71.
Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner's Guidebook. New York: Plenum Press; 1987.
Fung V, Huang J, Brand R, Newhouse JP, Hsu J. Hypertension treatment in a medicare population: Adherence and systolic blood pressure control. Clin Ther 2007;29:972-84.
Ahmed N, Abdul Khaliq M, Shah SH, Anwar W. Compliance to antihypertensive drugs, salt restriction, exercise and control of systemic hypertension in hypertensive patients at Abbottabad. J Ayub Med Coll Abbottabad 2008;20:66-9.
A Global Brief on Hypertension. World Health Organization (World Health Day 2013). Available from: http://www.who.int
. [Last accessed on 2014 Nov 22].
Kano State Hospital Management Board. Annual Report. Statistics Office, HMB. Kano State Ministry of Health, Nigeria. 2014.
Odenigbo MA, Inya OJ. Knowledge, attitude and practices of people with type 2 diabetes mellitus in a tertiary health care centre, Umuahia, Nigeria. J Diabetes Metab 2012;3:187.
Godfrey BS, Sarah II. Hypertension-related knowledge, attitudes and life-style practices among hypertensive patients in a sub-urban Nigerian community. J Public Health Epidemiol 2010;2:71-7. Available from: http://www.academicjournals.org/jphe
. [Last accessed on 2015 Jan 30]
Fourlanos S, Varney MD, Tait BD, Morahan G, Honeyman MC, Colman PG, et al.
The rising incidence of type 1 diabetes is accounted for by cases with lower-risk human leukocyte antigen genotypes. Diabetes Care 2008;31:1546-9.
Isara AR, Omonigho L, Olaoye DO. Non-medical management practices for type 2 diabetes in a teaching hospital in Southern Nigeria. Afr J Diabetes Med 2014;22:2.
Awotidebe TO, Adedoyini RA, Rasaq WA, Adeyeye VO, Mbada CE, et al.
Knowledge, attitude and practices of exercise for blood pressure control: A cross-sectional survey. J Exerc Sci Physiother 2014;10:1-10.
Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, et al.
Health inequalities among British civil servants: The Whitehall II study. Lancet 1991;337:1387-93.
Tadevosyan A. Control of High Blood Pressure in Gavar Region: Knowledge, Attitude and Practice (KAP) Survey of Hypertensive People. Yerevan, Armenia: School of Public Health, American University of Armenia; 2013.
Abdulkadir MA, Esayas TG, Belayneh KG, Ahmed M, FromsaSeifu M, Thirumurugan G, et al.
Assessment of knowledge, attitude and practices regarding lifestyle modification among type 2 diabetic mellitus patients attending Adama hospital medical college, Oromia region, Ethiopia. Global Journal of Medical Research 2014; 4:37-48.
Okonta HI, Ikombele JB, Ogunbanjo GA. Knowledge, attitude and practice regarding lifestyle modification in type 2 diabetic patients. Afr J Prim Health Care Fam Med 2014;6:E1-6.
Al-Sinani M, Min Y, Ghebremeskel K, Qazaq HS. Effectiveness of and adherence to dietary and lifestyle counselling: Effect on metabolic control in type 2 diabetic Omani patients. Sultan Qaboos Univ Med J 2010;10:341-9.
[Table 1], [Table 2], [Table 3]