Impact of findings on practice

  • Through the practise of pharmaceutical care, a pharmacist could complement a GP in the management of hypertension.

  • Pharmaceutical care is an effective approach to improving adherence to chronic therapies and modification of life style.

  • Pharmacists could effectively participate in health education and promotion through the practise of pharmaceutical care.

Introduction

Hypertension is still a major health problem in Nigeria. Prevention and control of hypertension remains a crucial challenge. Community pharmacists have the potential of preventing hypertension especially when the new philosophy of practice; pharmaceutical care (PC) is applied. Hypertensive patients visit community pharmacies to refill their medications and thus a pharmacist can institute a care process. PC comprises the detection, prevention and solution of drug-related problems [1].

Pharmaceutical care practice in hospital and community pharmacies in Nigeria is still nascent. In 2005, the Pharmacist Council of Nigeria (PCN) set minimum standards for the assurance of PC in Nigeria [2]. Few studies have been conducted to establish PC’s comparative advantage as well as difficulties towards pharmaceutical care implementation in Nigerian community pharmacies.

In this study, we aimed at determining the effect of a community pharmacy-based PC programme on hypertensive patients using clinical outcome (blood pressure) and humanistic outcome (quality of life) for evaluation. Other outcome measures included smoking cessation, adherence to therapy, exercise, salt restriction, alcohol moderation and self blood pressure measurement.

Method

This single site study was carried out in Port Harcourt, the capital of Rivers state and the largest oil producing state in Nigeria. As at the time of study, two hundred and thirty three pharmacies were registered in the state. The selection of the pharmacy for the study was based on its suitability. It was one of the biggest pharmacies in the city and had a pharmacist’s consulting room.

The ten-month study comprised of five months of usual care and another five months of PC, and was carried out from March 2006 to December 2006. Two pharmacists, a research pharmacist and the superintendent pharmacist of the community pharmacy conducted the study. The superintendent pharmacist received a one day training on the PC programme and the study protocol. A non-randomised, crossover design was used. Patients served as their own control. Forty hypertensive patients were registered for the study after oral consent was obtained. Patient recruited had blood pressure reading that was greater than 140/90 mmHg, were on anti-hypertensive therapy and had been diagnosed of high BP in a hospital. During the five months of usual care period, recruited patients had contact with the pharmacy either to refill their prescription or to measure their BP. The fifth month of usual care was used as baseline.

Pharmaceutical care was instituted for another five months after the usual care period and was evaluated at the end. The nine steps of good PC practice were followed, specifically, developing a pharmacist-patient relationship; collecting, analysing, and interpreting relevant information; listing and ranking drug-related problems; establishing pharmacotherapeutic outcomes with the patients; determining feasible pharmacotherapeutic alternatives; selecting the best pharmacotherapeutic solution; designing a therapeutic monitoring plan; implementing the individual regimen and monitoring plan; and follow-up [1]. Patients had face-to-face, goal-directed medication and lifestyle counselling once every month and were provided with an educational material. They were taught how to take BP readings and encouraged to buy a BP measuring apparatus. Patients who smoked were encouraged to quit smoking. They were also advised on indulging in aerobic exercise particularly to take walk or to skip in their houses at least three times a week. Adherence to salt restriction and to medication was also promoted. Medication adherence was determined by using the number of times a patient reported to have taken his medication in a month. Alcohol moderation (i.e., 20 g/day for males and 10 g/day for females) was recommended. Clinical and medication-related data were sent to the patient’s physician as the need arose. Blood pressure measured by the pharmacists, and other patient reported outcome measures (smoking, adherence to therapy, exercise, salt restriction, alcohol moderation and self blood pressure measurement) were used to access the intervention at end of pharmaceutical care period. World health organisation quality of life bref (WHOQOL-BREF) questionnaire, which was self-administered, was given to the patients at baseline and at the end of 5 months of PC intervention.

Statistical analyses were carried out using SPSS for Windows (version 11; SPSS, Chicago, IL). Data were summarized as mean ± SD, means ± SEM, median [interquartile range] or percentages. As the sample size was small, two-sample comparisons were done using non-parametric tests; Wilcoxon signed-rank tests. Comparisons of proportions were by Mcnemar’s tests. A two-tailed significance level of 0.05 was used. Administration and scoring of the WHOQOL-BREF was carried out according to the manner stipulated in the WHOQOL-BREF manual [3].

Results

Forty patients were recruited for the study. Twenty-four patients (60%) completed the study. Seventy five percent (75%) were males. They had a mean age of 51.6 ± 11.7 years. Twenty nine percent (29%) of the patients had diabetes concurrently with hypertension and another 33.3% had a family history of cardiovascular disease.

Changes in clinical outcome over 5 months are shown in Table 1. There was a significant reduction in systolic and diastolic blood pressure. The reduction in body mass index was not significant. The percentage of patients that indulged in aerobic exercise increased significantly at the end of the intervention. Patients also adhered to salt restriction, smoking cessation and alcohol moderation. Out of the subjects that completed the study, 45.8% of them learnt how to take their own blood pressure readings and purchased a BP measuring apparatus. There was a significant increase in medication adherence. In 12.5% of the subjects, drug related problems were identified. The problems identified were dysphagia caused by insulin therapy and frequent urination caused by thiazide diuretics. Patients were educated on the drug related problems they presented. Forty two percent (42%) of the subjects were referred back to their physician in order to optimise their drug therapy, as their BP was above 140/90 mmHg [4]. Details of these outcome measures are presented in Table 1.

Table 1 Clinical and process outcome changes after PC implementation (n = 24)
Full size table

The changes after PC intervention for the four domain scores of the WHOQOL-BREF are presented in Table 2. The scores are scaled in a positive direction, with a score range of 0–100, and with higher scores denoting higher quality of life [3]. A significant increase was achieved in physical health and social relationship of the subjects after PC implementation (47.9–59.3 and 47.8–51.0 respectively). However, in the psychological health domain, there was no difference noticed after 5 months of PC intervention. There was a significant decrease from 46.3 to 40.1 in the environmental component of the WHOQOL-BREF after implementation of PC.

Table 2 Changes in quality of life of the subjects after PC implementation (n = 24)
Full size table

Discussion

Our study had limitations and the results obtained were interpreted in this light. The sample size was small and non-randomised, therefore may not represent the real population of hypertensive patients in Nigeria. Many of the subjects were educated and are of the middle class. Many patients dropped out from the study and those that completed the study did so voluntarily which may reflect stronger interest in self-management. Some of the outcome measures were based on patient’s report, which might not have been factual. Lastly, the sustainability of beneficial outcomes beyond 5 months was not assessed.

However, the study revealed that PC programme for hypertensive patients from a community pharmacy in Nigeria could produce beneficial reduction in blood pressure and improve their health related quality of life. Positive results were obtained in the various outcome measures. After PC implementation, more of the patients exercised frequently. Many of the patients became aware of salt restriction and they complied well. Evidence from clinical trials have shown that systolic BP reductions of 2–8 mmHg can be achieved with restricting sodium intake to ≤2.4 g daily [5]. The subjects also complied to alcohol moderation. Moderate alcohol consumption of two or fewer drinks daily in men and one or fewer drinks daily in women or lighter weight persons have been shown to decrease systolic BP approximately by to 2–4 mmHg [4]. Prior to the PC intervention, none of the patients knew how to take their BP readings. Forty-six percent (46%) of the subject learnt to take their BP readings and acquired a BP measuring apparatus. Home BP devices have been reported to be very useful in involving patients in their own care [6]. It is also recognised as a simple and economic tool for obtaining blood pressure profile [7]. Medication adherence by the patients also improved. There was a significant increase from 66.3% per month to 83.5% per month after PC intervention. Increase in drug compliance obtained could be attributed to the drug education given to them. Lack of knowledge has been recognised as a barrier to adherence [7]. Again, during the PC period, some patients complained of some drug related problems which included frequent urination after taking thiazide diuretic and polyphagia caused by insulin therapy. Explanations were given and the patients stated that they felt more comfortable with their medications after knowing the reason for the drug effects they experienced. Subjects who were not at BP goal were referred to their physicians for optimisation of therapy. Although the effects of these process outcomes cannot be related to the clinical outcome, they helped patients to achieve the best possible outcome from their medication. Adoption of healthy lifestyle by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hypertension [8].

The WHOQOL bref was used as a humanistic outcome to measure the effect of the 5 months PC intervention on the physical, emotional and social well being of the patients. In the physical health domain which is composed of facets like pain and discomfort; dependence on medical treatment; energy and fatigue; mobility; sleep and rest; activities of daily living and work capacity, there was a significant increase. In the Psychological health field which deals with aspects such as positive affect; spirituality; thinking, learning, memory and concentration; body image and appearance; self-esteem; and negative affect, there was no change after 5 months of PC implementation. There was an appreciable change in the social relationship domain. Items in the social relationship domain included personal relationships, sexual activity and social support. However there was a decrease in the environment domain after PC implementation. Environment domain dealt with aspects such as physical safety and security; physical environment; financial resources; home environment; health and social care etc. Since the PC program did not address the issues in the environment facets, it might explain the negative change obtained in the environment domain. In summary, PC intervention had a positive effect on the physical and social well being of the patients and no effect on their emotional health. Some other pharmaceutical care interventions have shown that pharmaceutical care improves the quality of life of hypertensive patients. For example, a study carried out in the United States reported an improvement in several quality of life scores in hypertensive subjects after pharmaceutical care implementation [9].

Any qualified Nigerian pharmacist could implement this PC program. Although not evaluated, pharmaceutical care practice gives a better job satisfaction. For PC to be a reality in Nigeria, a set of interventions seems necessary. Many Nigerian faculties of pharmacy need to include clinical courses and practise in their curricula. This will produce patient oriented pharmacists; those that take pro-active step and systematically try to identify, solve and prevent all possible drug related problems. They also need to offer pharmaceutical care practice experiences in pharmacies that are designed to prepare students for PC practice. These sites would provide students with the opportunity to observe the integration of pharmaceutical care activities into community practice [10]. Many Community pharmacies in Nigeria would need upgrade in order to offer PC. Patients’ consultation area is absent in many pharmacies. This detail in community pharmacy organizational layout is important for the provision of PC as patients do not like discussing sensitive issues over the counter. Introduction of professional fee for the extra services offered might be explored so as to motivate pharmacists to practise pharmaceutical care.

Conclusion

Pharmaceutical care programmes for hypertensive patients from a community pharmacy in Nigeria could produce beneficial reduction in blood pressure and improve their health related quality of life.