F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.141856.1 Research Article Articles 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

[version 1; peer review: 1 approved, 1 approved with reservations]

 Rivera-Lozada Oriana Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-6546-3570 a 1 2 Rivera-Lozada Isabel Cristina Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 3 Bonilla-Asalde Cesar Antonio Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing b 4 5 Universidad Nacional Mayor de San Marcos, Lima, Peru South American Center for Education and Research in Public Health, Universidad Norbert Wiener, Lima, 15046, Peru Universidad del Cauca, Popayán, Cauca, Colombia Universidad Privada San Juan Bautista, Lima District, Lima Region, Peru Hospital Nacional Daniel Alcides Carrion, Callao, Peru riveraolozada@gmail.com cabonillaasalde@gmail.com

No competing interests were disclosed.

 26 9 2023 2023 12 1215 18 9 2023 Copyright: © 2023 Rivera-Lozada O et al. 2023 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Access to health services compromises therapeutic adherence in patients with arterial hypertension (HTN), which is a risk factor for cardiovascular disease and premature death. The aim of the research is to determine the influence of access to health services on adherence to antihypertensive treatment during the COVID-19 pandemic.

Methods: We included a cross-sectional analytical study. A survey was applied to 241 hypertensive patients at the Daniel Alcides Carrión Hospital, Callao-Peru. Data were analyzed using SPSS software. Absolute and relative frequencies were reported and the chi-square test was applied with a statistical significance level of p<0.05. In addition, multiple logistic regression analysis was performed using the Stepwise method.

Results: Our results show that non-adherence to treatment is associated with health expenses (ORa: 1.9 CI 95% 1.7-2.2), not receiving care due to lack of a doctor (ORa: 2.8 CI 95% 1.5-3.2), having difficulty with schedules (ORa: 3.7 CI 95% 2. 3-5.5), fear of receiving care at the hospital (ORa: 4.5 CI 95 % 2.7-6.8), trust in health personnel (ORa: 7.5 CI 95% 2.3-10.5) and considering that the physician does not have enough knowledge (ORa: 3.1 CI 95% 2.4-7.8).

Conclusion: Therapeutic adherence was associated with physician availability for care, difficulty with schedules, fear of being seen in the hospital, trust in health personnel, and waiting time.

 adherence; COVID-19; arterial hypertension; health services Universidad Privada Norbert Wiener This research was funded by competitive funds from Universidad Norbert Wiener. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 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 health 2 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 Study design, instrument and population

A cross-sectional study was carried out between September-December 2021 in patients with a medical diagnosis of HTN who were seen in the cardiology and internal medicine clinics at the Daniel Alcides Carrion National Hospital in Peru. The inclusion criteria involved people over 18 years old, totally independent of their care, with at least 6 months of treatment, reading ability, and who would agree to sign the informed consent. Patients with metabolic comorbidities that require treatment, patients with complications of HTN, patients unable to answer the survey for medical reasons, and patients who did not prefer to participate in the study were excluded. The study took as reference a population of 1200 patients, an expected adherence to the therapeutic regime of 50%, 95% confidence interval, a design effect of 1 and losses due to non-response of 20%, resulting in a sample size of 291, 241 of which met the inclusion criteria. The sampling was systematic.

The survey included sociodemographic aspects and questions on access to health services according to the Tanahashi model, 9 which considers four stages in the access process to obtain quality coverage: availability, accessibility, acceptability, contact, and effective coverage. Treatment adherence was measured using the Morisky-Green test, which included the following questions: 1. Do you ever forget to take your medication? 2. Are you careless at times about taking your medication? 3. When you feel better, do you sometimes stop taking your medication? 4. Sometimes, if you feel worse when you take the medication, do you stop taking it? We consider patients with HNT treatment adherence as those who answer the questions in the established order NO/YES/NO/NO. 12 The instruments were subjected to a reliability analysis, for which a pilot test was performed and a Cronbach’s Alpha of 0.88 was obtained for the Tanahashi model instrument, and a K-R of 0.85 for the Morisky-Green test.

 Procedures and statistical analysis

Data were collected in Excel 2010 format and analyzed using SPSS 21.0 software. Descriptive analysis included frequency distribution for sociodemographic, adherence variables, and dimensions of health care access. For the bivariate analysis, contingency tableswere performed and p-values were calculated using the chi-square test. The level of statistical significance was established with a value of p<0.05.

Next, a multiple logistic regression analysis was performed, using the Stepwise method, where the indicators that showed a value of p<0.05 in the bivariate analysis were added step by step. The regression equations were elaborated until no more indicators were found to contribute to the model. The advantage of this method lies in the continuous evaluation of the predictors included in the model, so that the indicator that is explained by the remaining one is eliminated.

 Ethical aspects

This study was conducted following the guidelines of the Declaration of Helsinki 1964 and its subsequent amendments. In addition, the study was approved by the Research Ethics Committee of the Hospital Daniel Alcides Carrion oficio N 2131 2021-HNDAC of the Callao region, Peru. All the participants in the study signed the informed consent form before their participation and their identity was anonymized for the elaboration of the database, so their integrity was not violated.

 Results Descriptive and bivariate analysis according to adherence to antihypertensive treatment in the study sample

A total of 241 adult patients with a diagnosis of hypertension were analyzed, of whom 65.15 % (n=157) were female and 72.61 % (n=175) were 60 years of age or older. In addition, 52.28% (n=126) were married or cohabitant. Likewise, only 4.15% (n=10) had a university education. On the other hand, 21.99% (n=53) were not affiliated to the Public Health Insurance Scheme (SIS), 26.14% (n=3) indicated that they spent on medical consultations and 64.73% (n=156) spent on medicines. The bivariate analysis of the sociodemographic characteristics according to adherence is shown in Table 1.

Descriptive and bivariate analysis according to adherence to antihypertensive treatment in adult patients with arterial hypertension treated at the Daniel Alcides Carrion National Hospital between September and December 2021.
Characteristics n % Adherence to antihypertensive treatment p-value 1
Non-adherent (%) Adherent (%)
n=224 (92.94) n=17 (7.06)
Gender 0.625
Female 157 65.15 145 (92.4) 12 (7.6)
Male 84 34.85 79 (94.1) 5 (6.0)
Age 0.117
168-37 9 3.73 9 (100.0) -
38-59 57 23.65 56 (98.3) 1 (1.8)
≥ 60 175 72.61 159 (90.9) 16 (9.1)
Civil status 0.285
Single 39 16.18 37 (94.9) 2 (5.1)
Married or cohabitant 126 52.28 114 (90.5) 12 (9.5)
Widowed or divorced 76 31.54 73 (96.1) 3 (4.0)
Schooling 0.313
Never attended school 6 2.49 6 (100.0) -
Elementary school 49 20.33 48 (98.0) 1 (2.0)
High school 139 57.26 125 (90.6) 13 (9.4)
College 47 19.50 44 (93.78) 3 (6.3)
Occupation 0.571
Homemaker 144 59.75 132 (91.7) 12 (8.3)
Student 4 1.66 4 (100.0) -
Laborer or tradesman 16 6.64 16 (100.0) -
Employee 13 5.39 13 (100.0) -
Unemployed 64 26.56 59 (92.2) 5 (7.8)
Employment status 0.361
Pensioner 65 26.97 63 (96.9) 2 (3.1)
Independent 57 23.65 52 (91.2) 5 (8.8)
Dependent 9 3.73 9 (100.0) -
Unemployed 110 45.64 100 (90.9) 10 (9.1)
Family income 0.004
≤ $750 73 30.29 71 (97.3) 2 (2.7)
$751-1500 84 34.85 76 (90.5) 8 (9.5)
>$1500 39 16.18 32 (82.1) 7 (18.0)
Does not report 45 16.87 45 (100.0) -
Public Health Insurance (SIS) 0.824
Subsidy 183 75.93 171 (93.4) 12 (6.6)
Semi-contributory subsidy 2 0.83 2 (100.0) -
Independent insurance 3 1.24 3 (100.0) -
Does not have SIS 53 21.99 48 (90.6) 5 (9.4)
Spends on consultations 0.143
No 178 73.86 168 (94.4) 10 (5.6)
Yes 63 26.14 56 (88.9) 7 (11.1)
Spends on medicines 0.002
No 85 35.27 85 (100.0) -
Yes 156 64.73 139 (89.1) 17 (10.9)
Residence 0.287
Family 98 40.66 93 (94.9) 5 (5.1)
Rented 31 12.86 29 (93.6) 2 (6.5)
Inherited 54 22.41 47 (87.0) 7 (13.0)
Owned 58 24.07 55 (94.8) 3 (5.2)

p-value estimated by chi-square test, with a significance level of p<0.05.

Regarding the characteristics and availability of health services, 66.8 % (n=161) responded that they did not receive care because the physician was not available. In addition, when asked about the timely care received, 32.78% (n=79) reported not having received timely care for their consultations or examinations (29.88%, n=72). Finally, 46.89 % (n=113) responded that they did not receive any information about their disease. The bivariate analysis of the characteristics and availability of health services according to adherence is shown in Table 2.

Descriptive and bivariate analysis of the characteristics and availability of health services according to adherence to antihypertensive treatment in adult patients with arterial hypertension treated at the Daniel Alcides Carrion National Hospital between September and December 2021.
Characteristics n % Adherence to antihypertensive treatment p-value 1
Non-adherent (%) Adherent (%)
n=224 (92.94) n=17 (7.06)
Considers the environment clean 0.004
Does not know 1 0.41 1 (100.0) -
No 60 24.9 50 (83.3) 10 (16.7)
Yes 180 74.69 173 (96.1) 7 (3.9)
Considers the bathrooms clean 0.329
Does not know 11 4.56 9 (81.8) 2 (18.2)
No 189 78.42 177 (93.7) 12 (6.4)
Yes 41 17.01 38 (92.7) 3 (7.3)
When going to the physician's office, blood pressure is checked with a sphygmomanometer 0.168
Does not know 4 1.66 4 (100.0) -
No 4 1.66 3 (75.0) 1 (25.0)
Yes 200 82.99 184 (92.0) 16 (8.0)
Not reported 33 13.69 33 (100.0) -
Did not receive care because the physician was not available <0.001
Does not know 3 1.24 1 (33.3) 2 (66.7)
No 161 66.8 154 (95.7) 7 (4.4)
Yes 77 31.95 69 (89.6) 8 (10.4)
Would prefer to be seen in the afternoon shift <0.001
Does not know 4 1.66 4 (100.0) -
No 180 74.69 174 (96.8) 6 (3.3)
Yes 57 23.65 46 (80.7) 11 (19.3)
Received timely attention for consultations 0.193
No 79 32.78 71 (89.9) 8 (10.1)
Yes 162 67.22 153 (94.4) 9 (5.6)
Received timely attention for exams 0.184
Does not know 4 1.66 3 (75.0) 1 (25.0)
No 72 29.88 65 (90.3) 7 (9.7)
Yes 165 68.46 156 (94.6) 9 (5.5)
Knows the laboratory service 0.024
Does not know 17 7.05 14 (82.4) 3 (17.7)
No 55 22.82 55 (100.0) -
Yes 169 70.12 155 (91.7) 14 (8.3)
Received any information about the disease by a non-medical source ( broadcast media, family, and friends) 0.200
Does not know 13 5.39 11 (84.6) 2 (15.4)
No 113 46.89 103 (91.2) 10 (8.9)
Yes 115 47.72 110 (95.7) 5 (4.4)

p-value estimated by chi-square test, with a significance level of p<0.05.

Regarding accessibility, 24.48% (n=59) reported a travel time of more than 40 minutes, and the most frequently used means of transportation was the bus (78.42%, n=189). A total of 82.57% (n=199) responded that they considered that the health personnel were trained to provide care. Likewise, 58.51% (n=141) responded that they had had difficulties with administrative procedures, where the most common problem was the availability of the service (50.62%, n=122), while the least common was the lack of authorization of the service (0.41%, n=1).

On the other hand, it was found that 55.19 % (n=133) considered inadequate the time they had to wait from the time they requested their appointment until they received care. Similarly, 49.8% (n=120) reported having waited more than 60 minutes to be seen on the day of their appointment and 39% (n=94) reported not having received timely care. Regarding the economic aspect, it was found that the median loss in soles for attending a consultation was 30.00 (RIQ=20). On the other hand, 33.2% (n=80) mentioned that they pay for the consultation or service received and 13.28% (n=32) have missed their appointment or care due to monetary limitations. Finally, 82.57% (n=199) bought medicines for their treatment and 46.47% (n=112) expressed not having complied with taking such medicine due to economic precariousness. Table 3 shows the bivariate analysis of the accessibility of health services according to adherence.

Descriptive and bivariate analysis of accessibility to health services according to adherence to antihypertensive treatment in adult patients with arterial hypertension treated at the Daniel Alcides Carrion National Hospital between September and December 2021.
Characteristics n % Adherence to antihypertensive treatment p-value 1
Non-adherent (%) Adherent (%)
n=224 (92.94) n=17 (7.06)
Time delay from residence to hospital 0.624
0-40 min 182 75.52 170 (93.4) 12 (6.6)
>40 min 59 24.48 54 (91.5) 5 (8.5)
Means of transportation <0.001
Walking or cycling 14 5.81 10 (71.4) 4 (28.6)
Taxi or motorcycle taxi 31 12.86 26 (83.9) 5 (16.1)
Bus 189 78.42 182 (96.3) 7 (3.7)
Own car 5 2.07 5 (100.0) -
Other 2 0.83 1 (50.0) 1 (50.0)
Care staff trained to provide care 0.435
Does not know 22 9.13 19 (86.4) 3 (13.6)
No 20 8.30 19 (95.0) 1 (50.0)
Yes 199 82.57 186 (93.5) 13 (6.5)
Had difficulty with administrative procedures 0.002
Not remember 1 0.41 1 (100.0) -
No 99 41.08 99 (100.0) -
Yes 141 58.51 124 (87.9) 17 (12.1)
Kind of difficulty in requesting care 0.010
Difficulty with dates and times and availability of the service 90 37.34 78 (86.7) 12 (13.3)
Lack of information, difficulties with dates, availability of the service 22 9.13 20 (90.9) 2 (9.1)
None 88 36.5 88 (100.0) -
Others (delayed appointments, lack of money to transport, and unkind hospital staff treatment) 32 13.28 29 (90.6) 3 (9.4)
No answer 9 3.73 9 (100.0) -
Lack of information 0.984
No 213 88.38 198 (93.0) 15 (7.0)
Yes 28 11.62 26 (92.9) 2 (7.1)
Non-authorization of service 0.783
No 240 99.59 223 (92.9) 17 (7.1)
Yes 1 0.41 1 (100.0) -
Difficulty of dates and times <0.001
No 116 48.13 115 (99.1) 1 (0.9)
Yes 125 51.87 109 (87.2) 16 (12.8)
Personal financial aspects 0.017
No 239 99.17 223 (93.3) 16 (6.7)
Yes 2 0.83 1 (50.0) 1 (50.0)
Service availability 0.001
No 119 49.38 117 (98.3) 2 (1.7)
Yes 122 50.62 107 (87.7) 15 (12.3)
Additional procedures 0.494
No 235 97.51 218 (92.8) 17 (7.2)
Yes 6 2.49 6 (100.0) -
Does not know 0.783
No 240 99.59 223 (92.9) 17 (7.1)
Yes 1 0.41 1 (100.0) -
None 0.001
No 153 63.49 136 (88.9) 17 (11.1)
Yes 88 36.51 88 (100.0) -
Other/which 0.631
No 238 98.76 221 (92.9) 17 (7.1)
Yes 3 1.24 3 (100.0) -
They were last appointment was requested/ 0.072
1-3 days 112 46.47 108 (96.4) 4 (3.6)
4-6 days 23 9.54 22 (95.7) 1 (4.4)
7-9 days 106 43.98 94 (88.7) 12 (11.3)
Considers waiting time to be adequate 0.018
Does not know 1 0.41 1 (100.0) -
No 133 55.19 118 (88.7) 15 (11.3)
Yes 107 44.40 105 (98.1) 2 (1.9)
Waiting time on the day of appointment 0.014
≤60 min 121 50.21 115 (95.0) 6 (5.0)
61-180 min 72 29.88 69 (95.8) 3 (4.2)
>180 min 48 19.92 40 (83.3) 8 (16.7)
Received timely care 0.009
Does not know 7 2.90 5 (71.4) 2 (28.6)
No 94 39.00 84 (89.4) 10 (10.6)
Yes 140 58.09 135 (96.4) 5 (3.6)
Attending the consultation is a financial loss 0.042
No 218 90.46 205 (94.0) 13 (6.0)
Yes 23 9.54 19 (82.6) 4 (17.4)
How much is the economic loss estimated 30 [20-40] 30 [20-40] 35 [25-55] 0.508
A family member keeps company to the consultation 0.343
No 191 79.25 176 (92.2) 15 (7.9)
Yes 50 20.75 48 (96.0) 2 (4.0)
Amount lost by the person accompanying to the consultation 30 [20-40] 27.5 [17.5-40] 45 [40-50] 0.130
Any payment for consultation 0.469
No 161 66.80 151 (93.8) 10 (6.2)
Yes 80 33.20 73 (91.3) 7 (8.8)
Did not attend due to lack of money 0.619
Does not know 1 0.41 1 (100.0) -
No 208 86.31 192 (92.3) 16 (7.79
Yes 32 13.28 31 (96.9) 1 (3.1)
Purchased medicines for treatment 0.049
No 42 17.43 42 (100.0)
Yes 199 82.57 182 (91.5)
Did not take the medicines due to lack of money 0.290
No 129 53.53 122 (94.6)
Yes 112 46.47 102 (91.1)
Health services care have been denied in the last year <0.001
Does not know 28 11.62 21 (75.0)
No 194 80.50 184 (94.9)
Yes 19 7.88 19 (100.0)

p-value estimated by chi-square test, with a significance level of p<0.05.

Regarding the acceptability of health services, it was found that 88.38 % (n=213) reported that they did not feel afraid of being treated at the hospital and 96.68 % (n=233) did not feel discriminated against or rejected because of their illness. Likewise, 93.78 % (n=226) considered that the doctor had sufficient knowledge for their recovery, while 82.16 % (n=198) trusted the health personnel in general. Finally, 16.6 % (n=40) rated it as excellent, while 2.9 % (n=7) rated the medical treatment as bad. Table 4 shows the bivariate analysis of the acceptability of health services according to adherence.

Descriptive and bivariate analysis of the acceptability of health services according to adherence to antihypertensive treatment in adult patients with arterial hypertension treated at the Daniel Alcides Carrion National Hospital between September and December 2021.
Characteristics n % Adherence to antihypertensive treatment p-value 1
Non-adherent (%) Adherent (%)
n=224 (92.94) n=17 (7.06)
Fear of being treated at the hospital <0.001
Does not know 1 0.41 - 1 (100.0)
No 213 88.38 202 (94.8) 11 (5.2)
Yes 27 11.20 22 (81.5) 5 (18.5)
Felt discriminated against or rejected because of the disease 0.428
No 233 96.68 216 (92.7) 17 (7.3)
Yes 8 3.32 8 (100.0) -
It is difficult for a neighbor or family member to know about one's health 0.668
No 220 91.29 204 (92.7) 16 (7.3)
Yes 21 8.71 20 (95.2) 1 (4.8)
Treatment will control hypertension 0.646
Does not know 1 0.41 1 (100.0) -
No 10 4.15 10 (100.0) -
Yes 230 95.44 213 (92.6) 17 (7.4)
The physician will have sufficient knowledge for the recovery 0.037
Does not know 2 0.83 1 (50.0) 1 (50.0)
No 13 5.39 13 (100.0) -
Yes 226 93.78 210 (92.9) 16 (7.1)
Trusts in health staff 0.012
Does not know 30 12.45 24 (80.0) 6 (20.0)
No 13 5.39 12 (92.3) 1 (7.7)
Yes 198 82.16 188 (95.0) 10 (5.1)
Feeling about the physician's treatment 0.288
Bad 7 2.90 7 (100.0) -
Fair 20 8.30 17 (85.0) 3 (15.0)
Good 174 72.20 161 (92.5) 13 (7.5)
Excellent 40 16.60 39 (97.5) 1 (2.5)

p-value estimated by chi-square test, with a significance level of p<0.05.

It was found that 34.02% (n=82) rated the quality of care as fair or very poor, while 5.81% (n=14) rated it as excellent or very good. Likewise, the quality of treatment received was perceived as fair or very poor by 8.71% (n=21) and as excellent by 27.39% (n=66) of the respondents. In addition, 70.95 % (n=171) reported that the staff answered their questions, 95.85 % (n=231) had their disease explained to them and 97.51 % (n=235) received an explanation of the indicated treatment. It was found that 92.95 % (n=224) were satisfied with the explanation provided by the health staff. Table 5 shows the bivariate analysis of the variables according to adherence.

Descriptive and bivariate analysis of contact with health services according to adherence to antihypertensive treatment in adult patients with arterial hypertension treated at the Daniel Alcides Carrión National Hospital between September and December 2021.
Characteristics n % Adherence to antihypertensive treatment p-value 1
Non-adherent (%) Adherent (%)
n=224 (92.94) n=17 (7.06)
Quality of care 0.511
Fair or poor 82 34.02 75 (91.5) 7 (8.5)
Good 145 60.17 135 (93.1) 10 (6.9)
Excellent or very good 14 5.81 14 (100.0) -
Quality of treatment received 0.320
Fair or poor 21 8.71 19 (90.5) 2 (9.5)
Good 154 63.90 146 (94.8) 8 (5.2)
Excellent or very good 66 27.39 59 (89.4) 7 (10.6)
Staff answered the concerns 0.572
Does not know 55 22.82 52 (94.6) 3 (5.5)
No 15 6.22 13 (86.7) 2 (13.3)
Yes 171 70.95 159 (93.0) 12 (7.0)
Had any discomfort with the medication 0.598
No 186 77.18 172 (93.6) 14 (7.5)
Yes 55 22.82 52 (94.6) 3 (5.5)
Stopped taking the medication before completing treatment 0.444
No 188 78.01 176 (93.6) 12 (6.4)
Yes 53 21.99 48 (90.6) 5 (9.4)
Health staff explained about the disease 0.374
No 10 4.15 10 (100.0) -
Yes 231 95.85 214 (92.6) 17 (7.4)
Health staff explained about the treatment 0.494
No 6 2.49 6 (100.0) -
Yes 235 97.51 218 (92.8) 17 (7.2)
Satisfied with the explanation 0.500
Does not know 7 2.90 7 (100.0) -
No 10 4.15 10 (100.0) -
Yes 224 92.95 207 (92.4) 17 (7.6)

p-value estimated by chi-square test, with a significance level of p<0.05.

Multiple logistic regression analysis according to adherence to antihypertensive treatment in the study sample.

The multiple logistic regression model found an association between adherence to antihypertensive treatment and consultation costs (ORa: 1.9, CI 95% 1,7:2,2), not receiving care because the physician was not available (ORa: 2,8, CI 95% 1,5:3,2), and fear of receiving care at the hospital (ORa: 4,5 CI 95 % 2,7:6,8). Table 6 shows all the associations found.

Logistic regression analysis according to adherence in adult patients with arterial hypertension seen at the Daniel Alcides Carrión National Hospital between September and December 2021.
Characteristics Adjusted OR CI 95% p-value 1
Expenses in the consultation No 1.9 1.7 – 2.2 <0.001
Yes
Considers the environment clean No 1.4 1.2 – 1.8 0.001
Yes
Not receiving care because the physician was not present No 2.8 1.5 – 3.2 <0.001
Yes
Difficulty with procedures No 1.8 1.2 – 2.8 0.035
Yes
Difficulty with dates and schedules No 3.7 2.3 – 5.5 0.040
Yes
Fear of being treated at the hospital No 4.5 2.7 – 6.8 <0.001
Yes
Trusts in health staff No 7.5 2.3 – 10.5 <0.001
Yes
Considers that the physician did not have enough knowledge to treat No 3.1 2.4 – 7.8 0.030
Yes

p-value estimated by chi-square test, with a significance level of p<0.05.

 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. 28 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. 29 or the 43.9% reported by Martinez 30 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. 31 who found 37.9% adherence and that of Fernández-Arias 14 who found 57.4% adherence in hypertensive patients. However, the low adherence rate coincides with that found by Rosas-Chávez 32 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. 33

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. 34 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, 35 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, 36 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, 37 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 Gabert 27 and Owolabi 38 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. 29 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.

Despite these limitations, the present study provides a first scope of the influence of access to health services on adherence, which will contribute evidence for larger studies.

 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.

 Data availability Underlying data

Zenodo: Access to health services and its influence on adherence to treatment of arterial hypertension during the COVID-19 pan-demic in a Hospital in Callao, Peru: A Cross-Sectional Study, https://doi.org/10.5281/zenodo.8299902. 39

This project contains the following underlying data:

DATABASE_.xlsx (dataset)

 Extended data

Zenodo: Access to health services and its influence on adherence to treatment of arterial hypertension during the COVID-19 pan-demic in a Hospital in Callao, Peru: A Cross-Sectional Study, https://doi.org/10.5281/zenodo.8299902. 39

This project contains the following extended data:

Survey (a copy of the questionnaire)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Murga Gustavo de Sujo M Estevez A : Adherencia farmacológica en pacientes hipertensos. Rev. Cuba. Med. Gen. Integr. 2020;36:982. Carhuanllanqui R Diestra-Cabrera G Tang-Herrera J : Adherencia al tratamiento farmacológico en pacientes hipertensos atendidos en un hospital general. Rev. Medica Herediana. 2010;21:21. 10.20453/rmh.v21i4.1114 Rosas-Chavez G Romero-Visurraga CA Ramirez-Guardia E : El grado de alfabetización en salud y adherencia al tratamiento en pacientes con hipertensión arterial en un hospital nacional de Lima, Perú. Rev. Peru. Med. Exp. Salud Publica. 2019;36:214–221. 31460632 10.17843/rpmesp.2019.362.4279 Tagle R Acevedo M : Objetivos terapéuticos en hipertensión arterial: metas de presión arterial en los diversos subgrupos de hipertensos. Rev. Médica Clínica Las Condes. 2018;29:21–32. 10.1016/j.rmclc.2017.12.006 Tanahashi T : Health service coverage and its evaluation. Bull. World Health Organ. 1978;56:295–303. 96953 Organizacion Mundial de la Salud: Hipertensión. OMS;2021. (accessed on 18 May 2022). Reference Source Van Der Laan DM Elders PJM Boons CCLM : Factors associated with antihypertensive medication non-adherence: A systematic review. J. Hum. Hypertens. 2017;31:687–694. 28660885 10.1038/jhh.2017.48 MINSAP: Programa del médico y enfermera de la familia. 1st ed. La Habana, Cuba: Publisher;2011. Owolabi M Olowoyo P Miranda JJ : Gaps in Hypertension Guidelines in Low- and Middle Income Versus High Income Countries: a Systematic Review. Hypertens. 2016;68:1328–1337. (accessed on 11 June 2022). 27698059 10.1161/HYPERTENSIONAHA.116.08290 PMC5159303 Rivera-Lozada O Rivera-Lozada IC Bonilla-Asalde CA : Access to health services and its influence on adherence to treatment of arterial hypertension during the COVID-19 pan-demic in a Hospital in Callao, Peru: A Cross-Sectional Study.[Dataset].2023. 10.5281/zenodo.8299902 10.5256/f1000research.155340.r210110 Reviewer response for version 1 Huancahuire-Vega Salomon 1 Referee https://orcid.org/0000-0002-4848-4767 Peruvian Union University UPeU, Lima, Peru

Competing interests: No competing interests were disclosed.

 22 2 2024 Copyright: © 2024 Huancahuire-Vega S 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This is an interesting work on the influence of access to health services on adherence to antihypertensive treatment during the COVID-19 pandemic in a Peruvian hospital. This work is well planned, uses good instruments to measure the variables, and reports important data to take into consideration so that patients can have better adherence to treatment. However, there are some aspects of the manuscript that remain unclear and imprecise, and that must be clarified and corrected:

1. In the summary, results section, 6 characteristics associated with adherence are mentioned. It is understood from the description that these associations were obtained from the regression analysis; however, in Table 6 (logistic regression) 8 associations are mentioned. Why not mention the two missing ones? (considers the environment clean, difficulty with procedures)

2. Similarly, in the results section (multiple logistic regression analysis) (page 10) only three associations are mentioned.

3. In the conclusion of the abstract and the manuscript, waiting time is mentioned as an element associated with treatment adherence, however, this result is not shown in the regression analysis.

4. In the methodology section, according to the calculation of the sample size mentioned, this was not achieved. Why was this not achieved? This should be mentioned as a limitation of the study.

5. The description of the dimensions of the instrument used to measure access to health services indicates: availability, accessibility, acceptability, contact, and effective coverage. However, there are no results for the last dimension.

6. In the results section it is mentioned that 4.5% of participants had a university education, however, table 1 indicates 57.26%

7. The report of results in tables 2 – 5 focuses on percentages according to the responses to each question of the instruments. It would be more interesting and the information in these tables would be better utilized if their description focused on the significance obtained from the bivariate analysis.

8. Why was the characteristic “expenses in the consultation” included in the multiple regression analysis if this characteristic did not show a significant association in the bivariate analysis (table 1)?

9. The data in Table 6 show the adjusted OR values. It would be interesting to show the raw ORs and mention which characteristics were considered to make the adjusted analysis.

10. The discussion section should focus in more detail on those elements or characteristics that were shown to have an influence on treatment adherence (from the regression analysis), rather than the prevalence of treatment adherence.

11. It would be interesting to add to the discussion what the implications of the results of this study would be, as well as mention other limitations of the study. For example, since the study was done during a pandemic, it was important to have information on how many of the participants had the infection.

12. The conclusion of the work mentions “family income”, “means of transportation” and “waiting time” as elements associated with adherence, however, this is not reported in the results section. These inaccuracies must be corrected in the different sections of the manuscript.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

public health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.155340.r210111 Reviewer response for version 1 Contreras Pulache Hans 1 Referee Investigación y Desarrollo, EDUNEURO, Peru, Peru

Competing interests: No competing interests were disclosed.

 17 11 2023 Copyright: © 2023 Contreras Pulache H 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

I consider this work to be adequately supported, with a noteworthy level of methodological detail. Furthermore, it is likely that this study will become a fundamental reference for education and research in Peru (given its original focus on the subject matter).

To further enrich the discussion, I suggest adding a paragraph in the discussion section that alludes to the low prevalence of treatment adherence (less than 10%) and the implications this has for future designs, specifically what parameters would be recommended for consideration regarding sample size calculations.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Public health, epidemiology.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.