the role of pharmacists in hypertension management
TRANSCRIPT
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THE ROLE OF PHARMACISTS IN HYPERTENSION MANAGEMENT
R. C. Jagessar*1, A. Ali
2, K. Agard
2, D. McGowan
2 and L. Perry
2
1Department of Chemistry, University of Guyana.
2Final Year Pharmacy Research Students, 2014-2015.
ABSTRACT
Hypertension a risk factor for heart diseases which are the causes of
death, has gained both regional and national attention over the years.
This problem developed from poor dietary practices, stressful
lifestyles, inactivity and poor health management. The objective of this
study is to investigate the perceptions many patients have about a
Pharmacist and also to educate or re-educate the health care team and
patients of the role pharmacists play in the management of
hypertension in Guyana. The sample population covers persons of
different socio-demographic backgrounds that usually visit either the
community pharmacies or are a part of the public hospital clinics. A cross-sectional
descriptive study was conducted in the three most populated Regions of Guyana: Region 4,
Region 6 and Region 10. A total of one hundred and fifty (150) hypertensive patients were
selected and ten (10) interviews in person were conducted over a four weeks period with ten
(10) Pharmacists. Fifty (50) were between the age range 51-60, Forty (40) were between the
age range 21-30, Thirty (30) were between the age range 61-70, Fifteen (15) were between
the age range 41-50, Ten (10) were older than 70 and Five (5) were between the age range
31-40. Sixty (60) of the respondents were males and ninety (90) of the respondents were
females. Sixty (60) of the respondents were of African descent, Thirty Five (35) were mixed
individuals and Fifty Five (55) were of East Indian descent. Results were statistically
analysed for mean, standard deviation (SD), significance difference within and between
groups. Some of the interviews were favourable, whilst others were unfavourable. For
example, in response to the questions, “What perceptions do Guyanese have on the general
role of the Pharmacist and the role of the Pharmacist in hypertension management ? ”, 35%
of the participants believe that the Pharmacy is mainly a business, while 65% believe it to be
an Health Care Facility with regards to hypertension management. “Are there any non-
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
SJIF Impact Factor 7.632
Volume 9, Issue 8, 190-205 Research Article ISSN 2278 – 4357
Article Received on
02 June 2020,
Revised on 23 June 2020,
Accepted on 14 July 2020
DOI: 10.20959/wjpps20208-16734
*Corresponding Author
R.C. Jagessar
Department of Chemistry,
University of Guyana.
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traditional therapies for hypertension being used in Guyana currently ? “ 45% were in favour
whilst 55% disagree. “Is the diet the biggest contributing factor that causes hypertension ?”,
70% were in favour whilst 30% were not in favour, “Can access to patient summary record
helps Pharmacists to better promote better drug therapy ? ”, 90 % of the Pharmacists were in
favour whilst 10% disagree. “What are the current procedures for community and clinical
pharmacists in dealing with hypertension cases?“. All Pharmacists (100%) agreed that the
patient‟s current blood pressure must first be interpreted. Participants have benefitted from
the survey, designed to educate and re-educate persons on the role of the pharmacist in
hypertension management. It‟s anticipated that they would make wiser alternative diet and
lifestyle choices as well as being able to take full advantage of the services and assistance of
the pharmacists.
KEYWORDS: Hypertension, hypertension management, patients, pharmacists, regions,
socio-demographic.
1.0. INTRODUCTION
The World Health Organization, WHO clearly defines hypertension or high blood pressure as
a transitory or sustained elevation of systemic arterial blood pressure to a level likely to
induce cardiovascular damage or other adverse consequences.[1-7]
This level mainly ranges
between systolic blood pressure above 140 mmHg and a diastolic blood pressure above 90
mmHg. It is caused by a number of risk factors including poor dietary practices, age, family
history, poor adherence to hypertensive medications and ethnic origin.
Hypertension, for several decades, has been globally recognized as the most prevalent
cardiovascular disease with potent complications such as coronary heart disease, stroke,
sudden cardiac death, congestive cardiac disease, renal insufficiency and dissecting aortic
aneurysm. It remains a major public health issue in many developing countries including
Guyana.[8]
Recently, it was estimated that approximately 972 million adults are living with
high blood pressure and in 2002, it was named „the number one killer‟ by the World Health
Organization (WHO) in the World health report. The proportion of the world‟s population
with high blood pressure, or uncontrolled hypertension, fell modestly between 1980 and
2008. However, because of population growth and ageing, the number of people with
uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008 (World
health Organization).
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Approximately100, 000 persons are treated for hypertension annually with 15, 000 being new
cases.[6]
Concerns were raised for Guyanese who continuously consume approximately 10
grams of salt per day, contrary to the prescribed four to six grams, since the intake of high
levels of salt is one of the main contributing factors to hypertension.[8]
This condition can exist as Primary or Secondary hypertension. Approximately 90-95% of
adults are reported with Primary or Essential hypertension while Secondary hypertension
accounts for 5-10% of the cases.[1-7]
Primary hypertension is described as an asymptomatic
condition but also appears to be the outcome of an interaction between complex genetic and
environmental factors, whereas secondary hypertension is caused by a specific underlying
mechanism which involves the kidneys or endocrine system.[1-7]
The manual blood pressure monitor is composed of an inflatable pressure bag (the band)
attached to a sphygmometer, pump and stethoscope. In most cases a normal blood pressure
reading is considered to be 120mmHg systolic and 80mmHg diastolic, however, a blood
pressure reading above 140mmHg systolic and 90mmHg diastolic may be an indication of
hypertension.
This condition is also referred to as the “silent killer” since many individuals partake in their
daily activities without displaying any signs or symptoms for years. However, it can be easily
detected and managed by health personnel‟s including the Pharmacist. “Community
pharmacists are the most accessible of all health care professionals and are located in nearly
every community and neighborhood” which is very convenient for many patients.[8]
Moreover, It is becoming more common for community pharmacists to work directly with
specific physicians who refer patients to them. In these collaborative relationships,
pharmacists may measure blood pressure, adjust dosages and alter the antihypertensive
regimen via protocols.[9-12]
In addition, a number of authors have also suggested that non-physician health personnel
such as pharmacists can provide many services traditionally offered only by physicians. Since
the adequate care of hypertensive patients depends on use of antihypertensive drugs, more
professional involvement of well-motivated and trained pharmacists should benefit
hypertensive patients.[9]
Therefore, improvements in innovative techniques involving the
Pharmacist such as patient education, blood pressure monitoring, drug therapy and
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compliance assessment will improve the health in hypertensive patients and also minimize
the number of cases reported annually.
The implication and management of hypertension is a cause for concern for virtually all
Guyanese, as the number of persons affected by this disease has reached staggering heights.
This paper will seek to outline the role that Guyanese pharmacists can play in hypertension
management.
The purpose of the study is to educate/ re-educate doctors, pharmacists, patients and patient
care givers of the role pharmacists can play as it relates to hypertension management. It will
provide information to the target group about alternative treatment and management regimens
for hypertension. Providing resource materials for persons studying at tertiary institutions is
another aspect of this research.
Guyana is a sovereign state on the northern mainland of South America and is also part of the
Caribbean region. Guyana (83,000 square miles) is bordered by the Atlantic Ocean to the
north, Brazil to the south and southwest, Suriname to the east and Venezuela to the west13
.
Fig 1.0.
Fig. 1.0.: Map of Guyana. www.worldatlas.com/webimage/countrys/samerica/gy.htm.
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2.0 RESEARCH, DESIGN AND METHODOLOGY
2.1 Research Design
The design for this study is cross-sectional in nature, the qualitative and quantitative
approaches of this research design were taken in order to fully examine and find the
perceived role of the pharmacist in hypertension management along with the status of
hypertension in Guyana. A Cross- sectional study is “a study in which a statistically
significant sample of a population is used to estimate the relationship between an outcome of
interest and population variable as they exist at one particular time.[14]
Since it was
impossible for the researchers, within the constraints of time and money to collect
information from all pharmacists and hypertensive patients, a sample population was chosen
to participate along with the data from existing records from the records department of the
Georgetown Public Hospital Cooperation. Those pharmacists who give their consent were
interviewed at their place of work or any other convenient place. Within this research, a total
of five (5) research questions were created after numerous information was gathered on the
topic. These research questions later formed a guide in creating a questionnaire and interview
which were used to provide the answers to the questions asked. The hypertensive patients
were selected from three hospital clinics and three community pharmacies and they were
asked to participate in filling the questionnaire.
Qualitative research is an inquiry approach useful for describing trends and explaining
relationships among variables.[15]
While a qualitative approach has proven useful to acquire
findings of this study, the quantitative approach was also necessary, as it allowed researchers
to acquire and use statistical data during the investigation.
In this study, the independent variable refers to the services offered by pharmacists and the
dependent variable is the perception of the general public on the role of the pharmacists. The
study has determined a link between how the services offered by the pharmacists have
influenced what the population perceives their role to be.
Table 2: Table showing the Overview of the Research Design.
Study type Cross-sectional Study
Study Length 4 weeks
Study Location Region 10, Region 4 and Region 6
Participant Demographic Hypertensive patients between ages 35 to 75
Number of participants 160
Participant Recruitment Strategy Selective
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Research Instrument Questionnaire and Interview
Method of Data collection Questionnaire and interview
Unit of Analysis Bio-statistical methods
2.2 Assumptions
The following are assumptions that were made for the study.
The target group chosen is relevant to the study.
The instruments used for data collection are reliable and valid.
The information provided to target group after study will effect change in their attitudes
towards the role of the pharmacist in hypertension management also towards treatment
options and goals.
2.3. Limitations of the Study
The limitations of the studty are that the findings of the study are limited to the Regions and
group of people who make up the sample population and therefore cannot be generalized to
all of Guyana. In addition, the findings are limited to the responses provided by the
respondents and this may be subject to the Hawthorne effect, since participants are aware that
they are taking part in a study and this may subdue their typical response.
2.4. Variables: The Independent Variables were: Patient perception of hypertension, blood
pressure reading, Lifestyle and role of the Pharmacist. The Dependent variable is
hypertension.
2.5. The Population
The population for this study comprised of ten (10) Pharmacists and one hundred and fifty
(150) hypertensive patients collectively from the study area of region four (4), region six (6)
and region ten (10) of Guyana. This study population is relevant, as it takes into consideration
the more populated regions of Guyana as well as the fact that the areas are most convenient
for the researchers. Also persons from these areas have definite access to health care facilities
and professionals which include the pharmacist. The bio-data revealed that of the one
hundred and fifty (150) participants, Fifty (50) were between the age range 51-60, forty (40)
were between the age range 21-30, thirty (30) were between the age range 61-70, fifteen (15)
were between the age range 41-50, ten (10) were older than 70 and five (5) were between the
age range 31-40.
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The additional information this section provided were the ethnicity and gender of the patient.
From the responses, it was seen that sixty (60) of the respondents are males and ninety (90) of
the respondents are females. Additionally, sixty (60) of the respondents are of African
descent, thirty five (35) are mixed individuals and fifty five (55) are of East Indian descent.
Thus, it is seen that majority of the sample population is African females between the age
range 51 and 60.
Pharmacists: Ten well qualified pharmacists from established agencies and organizations
that have been practicing for a minimum of five (5) years made up the sample population. As
expected these pharmacists gave valuable insight on the perception of the profession as well
as the expected conduct of the pharmacist as a whole.
Patients: A purposeful sample method was utilized to achieve a study population that mimics
the distribution ratio of the country‟s population in these three regions. With 67% (100
participants) of the population being from region four, 20% (42 participants) from region six
and 13% (28 participants) from region ten. Hypertensive patients from one hospital blood
pressure clinic and one community pharmacy in each region were respectively employed.
2.6. The Instruments
In this study the researchers used both a questionnaire and an interview. The questionnaires
were administered to the hypertensive patients at hospital clinics and blood pressure testing
customers at community pharmacies. These instruments were selected as the most
appropriate for collecting the relevant data required to answer the research questions posed
for this study. The instruments were constructed by the researchers and were used to gather
data on hypertension and the perception of the population on the role of the pharmacist in
hypertension management.
The interview was carried out on reputable pharmacists in Guyana so as to gain valid
information on the expected code of conduct for pharmacists when dealing with hypertension
cases and the proposed role of the pharmacist in general.
2.7. Description of the Instruments
Questionnaire
Structurally the questionnaire consisted of five sections, A, B, C, D, E respectively. The
sections relating to bio data and general hypertension knowledge implemented close-ended
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questions while sections C, D and E relating primarily to the core of the research and the
research questions implemented the use of a modified 5 point Likert rating scale of orderable
discreet variable, that is, an instrument that comprises of statements that permit responses to
be graded along an agree-disagree continuum.[16]
The questionnaire comprised 30 items. As a data collecting instrument, “a questionnaire is a
means of eliciting the feelings, beliefs, experiences, perceptions, or attitudes of some sample
of individuals.[17]
”
It is most times “a very concise, preplanned set of questions designed to yield specific
information to meet a particular need for research information about a pertinent topic.[17-18]
Interviews
Additionally, the interview contained four open-ended questions. An interview is a direct face
to face attempt to obtain reliable and valid measures in the form of verbal responses from one
or more respondents.[17]
Structured questionnaires and semi-structured interviews are often used in mixed method
studies to generate confirmatory results despite differences in methods of data collection,
analysis and interpretation. Questionnaires can provide evidence of patterns amongst large
populations, qualitative interview data often gather more in-depth insights on participant
attitudes, thoughts, and actions.
3.0. Results and Analyses: The results obtained are shown in Tables 1.0 to 6.0.
Statistical analyses are shown in Tables 7.0 to 11.0.
Table 1.0.
Study Population Name of Region Number of Participants
Region 4 Demerara/Mahaica 100
Region 6 East Berbice/Corentyne 30
Region 10 Upper Demerara-Berbice, Linden 20
Pharmacists 10
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Table 2.0. The pharmacy is a health care Facility.
Questions Responses
The pharmacy is a
health care Facility A D SD SA
Region 4 A 20 20 0 0
Region 4 B 40 0 8 12
Region 6 15 3 0 12
Region 10 10 2 6 2
Mean with
Standard
Deviation
21.25 ± 13.15 6.25 ± 9.25 3.5 ± 4.12 6.5 ± 6.40
Table 3.0.: Pharmacists are drug specialists and should hold authority on all drugs.
Questions Responses
Pharmacists are drug
specialists and
should hold authority
on all drugs
Region 4 A 20 4 4 12
Region 4 B 40 0 0 20
Region 6 15 3 9 3
Region 10 12 0 2 6
Mean with Standard
Deviation 21.75 ± 12.60 1.75 ± 2.06 3.75 ± 3.86 10.25 ± 7.5
Table 4.0.
Questions Responses
Pharmacists have the authority to
question a doctor’s prescription.
Region 4 A 24 16 0 0
Region 4 B 36 24 0 0
Region 6 12 18 0 0
Region 10 4 16 0 0
Mean with Standard deviation 19 ± 14 18.5 ± 3.79 0 ± 0 0 ± 0
Table 5.0.
Questions Responses
Pharmacists are only responsible
for country pills and dispensing
Region 4 A 12 0 28 0
Region 4 B 16 0 44 0
Region 6 9 0 21 0
Region 10 6 0 14 0
Mean with Standard Deviation 10.75 ± 4.27 0 ± 0 26.75 ± 12.84 0 ± 0
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Table 6.0.
Questions Responses
There are effective traditional
treatment for Hypertension. A D SD SA
Region 4 A 12 16 8 4
Region 4 B 16 12 28 4
Region 6 15 3 3 9
Region 10 8 0 12 0
Mean with Standard Deviation 12.75 ± 3.59 7.75 ± 7.5 12.75 ± 10.81 4.25 ± 3.69
Key:
A: agree
D: disagree
SA: strongly agree
SD: strongly disagree
Table 7.0.
Question F-value P-value F-critical
The pharmacy is a health care Facility
Source of variation between groups 3.26 0.0594 3.490
Source of variation within groups 0.0 0.0 0.0
Table 8.0.
Question F-value P-value F-critical
Pharmacists are drug specialists and
should hold authority on all drugs
Source of variation between groups 3.490295 0.012696 5.54623
Source of variation within groups 0.0 0.0 0.0
Table 9.0.
Question F-value P-value F-critical
Pharmacists have the authority to
question a doctor’s prescription.
Source of variation between groups 3.490 0.002215 8.917591
Source of variation within groups 0.0 0.0 0.0
Table 10.0
Question F-value P-value F-critical
Pharmacists are only responsible for
counting pills and dispensing
Source of variation between groups 3.490295 0.000322 13.9635
Source of variation within groups 0.0 0.0 0.0
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Table 11.00.
Question F-value P-value F-critical
Question: There are effective traditional
treatments for Hypertension.
Source of variation between groups 1.380634 0.0295998 3.490295
Source of variation within groups 0.0 0.0 0.0
Graphs
Graph 1.0: Showing the response as it corresponds to Traditional Hypertension
Treatment.
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Graph 2.0.: Showing the response as it pertains to diet as a contributing factor of
hypertension.
3.0. DISCUSSION
The results are tabulated in Tables 1.0 to 6.0 with mean and standard deviation (SD). Tables
7.0 to 11.0. indicate the P and F values to confirm whether there is significance difference
between groups or within groups as it pertains to each research question. When the P value is
less than 0.05, there is a significance difference between the groups and within the groups. As
mentioned, several research questions were asked and these can be discussed.
“The Pharmacy is a health care Facility”. Table 2.0, addresses this. It is seen that Region
4B had the highest positive responses 40 (26.67%), followed by Region 4A with 20 (13.33%)
and the least in Region 10 (6.67%). The highest number that disagree, 20 (13.3%) was from
Region 4A, whereas the lowest of 0 (0%) was from Region 4B. Statistically, a P value of
0.0594 was obtained, indicating that there is no significance differences in the response
between regions. This was further supported with an Fvalue (3.26) < Fcritical (3.49).
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“Pharmacists are drug specialists and should hold authority on all drugs”
Again the highest value of 40 (26.6%) agreed with the above statements and these were from
Region 4B, whereas the lowest of 12 (8%), was from Region 10, Table 3.0. The highest
number that disagree, 4 (2.6%) was from Region 4A, whereas the lowest of 0 (0%) was from
Region 4B and Region 10. Statistically, a P value of 0.012696 < than 0.05 was noted. This
indicates that there wasn‟t any significant differences in responses for the selected areas.
Also, the F value (3.490295) < F critical (5.54623) and further supporting the trend in
significance difference.
“Pharmacists have the authority to question a Doctor’s prescription”
Region 4B showed the highest positive response, 36 (24%), whereas lowest number that
agree was from Region 10, 4(2.67%). The highest number that disagree, 24 (16%) was from
Region 4B, whereas the lowest number that disagree, 16 (10.6%), was from Region 4A and
Region 10. Statistically, a P-value of 0.002215 (< 0.05) was obtained, indicating that there
wasn‟t any significant differences. In addition, the F value of 3.490 is less than F critical,
8.917591, Table 9.0.
“Pharmacists are only responsible for counting pills and dispensing”
Region 4B, showed the highest positive response, 16 (10.67%), whilst Region 10 showed the
lowest, 6%, positive response. With respect to the disagree responses, zero (0%) was noted,
Table 5.0. Statistically, a P value of 0.000322 < 0.05 was obtained, Table 10.0. This was
supported by F value = 3.490295 < F critical (13.9635).
“There are effective traditional treatment for hypertension”
The largest positive response response was noted for Region 4B, 16 (10.67%), whereas the
lowest of 8 (5.3%) was noted for Region 10. The highest number that disagree was from
Region 4A, 16 (10.67%), whereas the lowest number of 0 (0%) was from Region 10, Table
6.0. This is also reflective in Graph 1.0. Statistically, a P value of 0.0295998 was obtained,
showing that there was no significant difference between the values. In addition, F value
(1.380634) is less than F critical (3.490295), Table 11.0. Other questions were asked and
these were.
“Are there any non-traditional therapies for hypertension being used in Guyana
currently?” Sixty eight (68) agree that there are effective treatments. Some of these
treatments were stated as eating cucumber without salt, drinking lime in warm water and
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eating or consuming juice made of bilimbee. While these non-conventional methods may
prove helpful from time to time, their precise mechanism of action is unknown. Additionally,
also in severe to uncontrolled cases these treatments only tend to be insufficient.
“Is diet the biggest contributing factor that causes hypertension?”. Most of the participants
agreed that diet is the biggest contributing factor that causes hypertension. This signifies that
although persons are aware that much caution should be taken with their diet, they somehow
still make poor dietary choices. This may be as a result of cultural norms. The Caribbean
cuisine is a combination of foods from all the various ethnic groups that now inhabit there.
Graph 1.0. shows the diet as a contributing factor of hypertension. The graph shows that the
largest number of patients that agreed, 12 (8%), was from Linden, whereas the lowest that
disagree, 0 (0%) was from both Georgetown A and Linden. The highest number that
disagree, 20(13.33%) was from Georgetown B.
“What are the current procedures for community and clinical pharmacists in dealing with
hypertension cases?” While there is no current standard operational procedure for dealing
with hypertension case, there was homogeneity in the responses of the pharmacists in how
they handle hypertension patients. It was agreed, that for known hypertensive patients,
whenever a blood pressure test is requested, the pharmacist would simply perform the test,
inquire on current medications and adherence then refill medication supply if necessary.
For new cases, after testing and recording a higher than normal reading, the pharmacist would
do a short interview on potential causes and in most cases, recommend a traditional remedy
for short term regularization. However, if the reading is indicative of Secondary Stage 2
hypertension that is a reading of more than 160 systolic and 100 diastolic, the individual is
immediately referred to the doctor.
“Can access to patient summary records help pharmacists to better promote better drug
therapy?” The responses revealed that while the majority of the pharmacists agree that this
change can lead to improved health care, a small number of pharmacists still feel this may
prove to be futile if disease states are too far progressed. In very rare cases, pharmacists admit
to administering drugs for immediate relief. One such drug is Nifedipine 10 to 20 mg
sublingually. Nifedipine is a simple effective and safe alternative drug for managing
hypertensive emergencies especially when continuous monitoring of the patient cannot be
guaranteed. This is ideal for the community pharmacist. Many countries especially England
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has now allowed community Pharmacists to access patient records. Following a study that
ultimately supported same; the practice eliminates prescribing error and possible drug
interaction.
5.0. CONCLUSION
Based on the findings, the researchers concluded that the participants of this study have
benefited from the program which was designed to educate or re-educate persons on the role
of the pharmacist in Hypertension management. The fact that the participants were
empowered with a wealth of knowledge on the scope of the pharmacist as well as better
dietary practices, it can be concluded that they are no longer in a position of ignorance
therefore we expect them to make wiser alternative diet and lifestyle choices as well as being
able to take full advantage of the services and assistance the pharmacist has to offer. The
findings of the study should encourage health officials to take a holistic view on how
pharmacist intervention can improve this current phenomenon and put workable systems in
place to correct these actions.
6.0. ACKNOWLEDGEMENT
Special thanks are extended to the pharmacists who facilitated this investigation by the filling
of the interview sheets; as well as the patients and other health professionals who participated
by filling the questionnaires. The community pharmacies that allowed access to their
customers and resources.
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