Access to health services and its influence on adherence to treatment of arterial hypertension during the COVID-19 pandemic in a Hospital in Callao, Peru: A cross-sectional study

Introduction

Non-communicable diseases (NCDs) are the cause of 71% (41 million) deaths per year worldwide, with cardiovascular diseases being the leading cause.¹ Arterial hypertension (HTN) is one of the main risk factors for the development of cardiovascular disease and is the leading cause of premature death worldwide, making it a threat to public health² despite the fact that early detection, treatment and adequate control make it possible to reduce its morbidity, mortality and complications.³ This mainly affects middle- and low-income countries, complicating the achievement of the Sustainable Development Goals (SDGs), especially the reduction of premature deaths from NCDs by 33% by 2030.⁴

In Peru, according to the Demographic and Family Health Survey 2020 -ENDES 2020 - the prevalence of arterial hypertension in the population aged 15 years and older is 16.4%, with notorious differences between males (21.3%) and females (12%),⁵ where 68% of the population with the disease received treatment.⁶ In this sense, hypertension control involves risk identification, appropriate treatment, lifestyle changes and adherence to treatment.⁷

Adherence was defined according to the World Health Organization (WHO): “The degree to which a person’s behavior - taking medication, following a dietary regimen, and making lifestyle changes - corresponds to the agreed-upon recommendations of a health provider”.⁸ Currently, adherence to treatment is an important point for the successful control of HTN.⁹ However, Latin America registered heterogonous percentages associated mainly to low incomes and limitations to access to health care.¹⁰ Guzman-Tordecilla et al.¹¹ reported medication adherence range between 46-94%. In the case of Peru, previous studies report that less than 50% of the population has optimal blood pressure levels and adherence to treatment. This situation makes them vulnerable to the development of complications such as acute myocardial infarction, stroke, among others.^12–15

In this sense, non-adherence to pharmacological treatment is a serious public health problem for the control of arterial hypertension, thus challenging health systems to improve their range of services.¹⁶ In a current context of lessons learned from the COVID-19 pandemic, it is necessary to build services networks that answer to the needs of care and facilitate access to establishments with equity and quality, guaranteeing comprehensive health care in order to contribute to universal access of the population to establishments and that these act efficiently to face prevalent health problems, such as hypertension, thus protecting people’s lives. Health services must be actively involved and implement innovative strategies to ensure and effective and quick answer to recover the space lost during the COVID-19 pandemic.¹⁷

Likewise, the control of hypertension can be affected by the limitations of health systems and the patient’s personal factors.⁷ The literature mentions that access to health services can be explained thanks to facilitating elements and personal, geographic, economic, and health system barriers, among others.^18,19 Our paper considers Tanahashi’s definition of access to health care: “the interaction between specific aspects of service provision and the population that is influenced both by the characteristics of the health system and by the population’s resources and capacities to recognize needs and seek care”.⁹

Due to the great global impact of HTN and its complications, in addition to the partial or total interruption in access and provision of health services for non-communicable diseases in the world caused by the COVID-19 pandemic,²⁰ it is more necessary than ever to ensure access to care for patients with HTN, since there has been a neglect of diseases other than those caused by the coronavirus from the beginning of 2020.²¹ This is a challenge for weak health systems and for countries with limited resources, as it implies having policies that guarantee quality and equitable care that favors adherence to treatment and control of the disease.²²

Peru is a country with an economy in transition that is facing important structural challenges, as well as epidemiological, demographic, technological and health risk changes, leading to the increase of chronic noncommunicable diseases that emphasize health inequities and health impacts on vulnerable populations.²³ If we add the slowdown in health interventions to the situation described above as a result of the COVID-19 pandemic, all this raises challenges to the health system, where the approach to arterial hypertension and other chronic noncommunicable diseases becomes a sentinel indicator from the perspective of public health and the management of health services, becoming an expression of the good or bad that might result from the control strategies applied by the health system.²⁴

Even though several factors that contribute to nonadherence to antihypertensive treatment have been postulated,^25–27 it is important to develop studies to determine the influence of the determinants of access to health services on adherence to treatment, in order to prevent complications of the disease, in addition to having an impact on improving the Peruvian health system. Therefore, the aim of the present study was to determine the influence of access to health services on adherence to antihypertensive treatment during the COVID-19 pandemic.

Methods

Results

Discussion

In this study, non-adherence to antihypertensive treatment reached 92.94%, this predominance of non-adherence to treatment in hypertensive patients was also reported in a study on therapeutic adherence in patients with chronic diseases, where Bertoldo et al.²⁹ found that 38% of patients did not comply with treatment, highlighting hypertensive patients with 75% non-adherence. However, this high percentage found does not coincide with the general acceptance of therapeutic adherence which is between 50 and 70% and differs from the 37.4% adherence reported by Quintana et al.³⁰ or the 43.9% reported by Martinez³¹ using, in both cases, the same instrument.

Likewise, it differs from Peruvian studies where the Morisky-Green test was also used, such as that of Carhuallanqui et al.³² who found 37.9% adherence and that of Fernández-Arias¹⁴ who found 57.4% adherence in hypertensive patients. However, the low adherence rate coincides with that found by Rosas-Chávez³³ in an observational study, where they determined a 15% adherence rate, although it is still above the percentage found in the present study, this low adherence is a sample of the heterogeneity of this phenomenon in Peru, probably related to cultural, demographic and educational factors, considering that both studies were carried out in different hospitals in Lima and Callao.

On the other hand, in the United States, lack of adherence to antihypertensive treatment affects approximately 75% of patients, which implies that they do not achieve optimal blood pressure control. In addition, studies carried out in recent years show that about 50% of hypertensive patients are unable to comply with a hygienic-health regimen and to adhere correctly to pharmacological treatment, especially when these measures last for more than 1 year.³⁴

Likewise, the evidence reviewed suggests that sociodemographic characteristics such as gender and age, among others, seem to be related to adherence.²⁵ This does not coincide with the findings of this study, since none of the sociodemographic characteristics studied was significantly associated with adherence, with the exception of family income (p=0.004), where the results showed a greater number of adherent patients (9.5%) among those with an income of between 751 and 1500 dollars. Despite the above, the percentage remains low; and expenditure on medications (p=0.002) where 100% non-adherence was found among those who do not spend on medications, probably due to the fact that those who spend on their health tend to take better care of themselves. The findings of Ruiz-Alejos et al.²⁶ and Martínez et al.²⁶ show that arterial hypertension predominates in the male gender, in contrast to this study, which found a predominance in the female sex (65.15%).

On the other hand, in order to study the reasons for this low adherence to antihypertensive treatment, Tanahashi suggested the need to focus attention on access to health services to identify the population that does not have access or has difficulty in doing so and to redirect actions towards them to improve primary care coverage.³⁵ This is all the more important because of the asymptomatic nature of hypertension and, therefore, in many cases it is detected as a finding in a routine examination and most patients are unaware that they suffer from hypertension,³⁶ so early detection of hypertension is crucial in Peru and relies mainly on routine blood pressure control in patients who come for consultation. However, this is not consistent with what was found in this study, because although 82.99% of patients had their blood pressure checked at the time of consultation, it was not found that receiving such control was significantly associated with adherence (p=0.168). It also differs from what was reported by Gabert et al.,²⁷ in that study, which also refers to the scarcity or deterioration of resources and personnel to carry out an adequate diagnosis, as in the present study, since the unavailability of the physician to provide care (p<0.001), as well as the availability of the services (p=0.001), not knowing the location of some services such as the laboratory (p=0.024) and the hygienic state of the environments where care was received (p=0.004) were associated with therapeutic adherence.

In addition, adherence may also be compromised by the patient’s confidence in receiving care and his or her relationship with the health care provider,³⁷ demonstrating that fear of receiving care in the hospital is associated with adherence (p<0.001).

It is important to mention the importance of patient follow-up after the first visit to control the progression of the disease and reduce the possible risk factors that the patient presents, taking into account the cardiovascular risk, which should also be evaluated at the first visit. Carrying out the aforementioned can be complicated by the availability of patients who work or fulfill obligations that demand a large part of their day,³⁸ this coincides with what was found in this study, since the timetable difficulty was associated with adherence (p<0.001) as well as the waiting time to receive an appointment (p=0.018) and to be seen on the scheduled day (p=0.014).

Other authors, such as Gabert²⁷ and Owolabi³⁹ raised the availability and accessibility of adequate medications as important barriers to the management of hypertension, similar to what has been found in other studies on access to treatment in other chronic diseases, all of which coincides with the results of this study that identified as factors associated with adherence the means of transportation (p<0.001) and difficulty with administrative procedures (p=0.002). As consequence, in this study, not having received timely care was related to adherence (p=0.009).

Likewise, the family plays a fundamental role in compliance with the therapeutic regimen, providing support in seeking care and, in many cases, assuming a leadership role during treatment.³⁰ However, no significant association was found between therapeutic adherence and family or acquaintance support (p=0.428), This could be explained by the lack of specificity of the question in the Morisky-Green test, since it does not have a question directed to this point and the closest questions are marital status and a question related to the difficulty of a family member or neighbor knowing about the patient’s health, which leaves little or no information available to study this possible relationship.

The limitations of the present study include: First, the methodologic design of our study does not allow us to estimate a causal relationship. Second, we used a nonprobabilistic sampling method. This limits generalizing the conclusion because our sample could not be representative. Finally, our results cannot be extrapolated to different populations.

On the other hand, a systematic review conducted by AlGhurair et al.⁴⁰ found a consistent and significant association between economic costs and non-adherence to antihypertensive treatment. This finding reflects that healthcare expenses are strongly linked to a higher likelihood of non-adherence. Such association suggests the necessity of healthcare policies addressing the economic costs related to treatment, especially in pandemic contexts where financial difficulties may worsen.

Additionally, studies such as that of Wei et al.⁴¹ Have emphasized the importance of trust in healthcare personnel and the perceived quality of medical care in adherence to treatment for chronic diseases. Our finding that trust in healthcare personnel is positively associated with adherence reinforces this notion. Trust in healthcare providers can influence patients’ willingness to follow treatment recommendations, underscoring the importance of building trustful relationships between patients and healthcare professionals.

Furthermore, our study also identified additional factors that may affect treatment adherence, such as the perception of a clean environment, difficulties with medical procedures, and inadequate appointment scheduling. These findings align with previous research highlighting the significance of comfort and accessibility of healthcare services in treatment adherence.^42,43

The implications of our findings are significant for clinical practice and public health policies. Firstly, our results emphasize the need for interventions addressing financial barriers to access antihypertensive treatment, especially during crises like the COVID-19 pandemic. This may involve cost-reduction strategies such as subsidized health insurance programs or free access to essential medications, alongside promoting safe healthcare environments and fostering trustful communication between doctors and patients.

Regarding the study limitations, we acknowledge that the cross-sectional design used does not allow for establishing causal relationships, and the non-probabilistic sampling method may limit the generalizability of our findings. Nevertheless, these results offer valuable insights into the challenges faced by hypertensive patients during the COVID-19 pandemic and underscore the necessity of effective, patient-centered interventions to enhance treatment adherence. In summary, our findings contribute to the body of knowledge on antihypertensive treatment adherence and provide a solid foundation for developing interventions aimed at improving clinical outcomes and reducing disease burden among hypertensive patients during the COVID-19 pandemic.

Conclusions

The adherence to antihypertensive treatment evaluated in our study sample is associated with family income, medicine expenses, availability of the physician for care, means of transportation, difficulty of dates and schedules, fear of being treated in the hospital, trust in health staff, availability of services, waiting time, and receiving timely care.

The adherence to antihypertensive treatment evaluated in our study sample is associated with expenses in the consultation considers the environment clean, not receiving care due to lack of a doctor, difficult with procedures, having difficulty with schedules, fear of receiving care at the hospital, trust in health staff and considering that the physician does not have enough knowledge.

In conclusion, our study contributes to the growing body of evidence emphasizing the importance of access to healthcare services in adherence to antihypertensive treatment. Individual and systemic interventions are needed to address the identified barriers and improve treatment adherence, especially in times of public health crises such as the COVID-19 pandemic.