Doctor-Patient Communication to Improve Adherence to Anti- Hypertensive Treatment

Background: Non-adherence to medication increases patient’s risk of morbidity, mortality and economic wastage of scare medical resources. This study was conducted to assess the role of doctor-patient communication and duration of consultation, as tools to improve adherence to hypertension treatment. Methods: Data of this cross-sectional study were collected by face to face interview and document review at Combined Military Hospital (CMH), Dhaka among 253 conveniently recruited hypertensive patients attending outpatient department during July 2016 to June 2017. Mean-age of the respondents was 49.2 (±10.4) years, mostly married male (54.9% male, 95.3% married). Mean consultation duration experienced by the respondents was 5.3 (± 1.3) minutes. Among the participants, 63.64% experienced effective communication, 66% were adherent and 34% were non-adherent to medication. Among the respondents with effective communication, 92.5% were adherent to medication. On the contrary, among the respondents with ineffective communication, 80.4% were non-adherent. Results: Duration of consultation had significant association with adherence to hypertension treatment (p<0.001). Association between communication and adherence to medication was highly significant (p<0.001). Binary logistic regression revealed that respondents were 3.23 times more adherent to medication with favorable response to the item‘Doctor gave me as much information as I wanted’ (p = 0.041); and 10.24 times with favorable response to the item‘Doctor checked to be sure that I understood everything’(p=0.006). Patients’ faithfulness in carrying out prescription and proscriptions correctly, depends on the adequacy and accuracy of patient’s knowledge of what they were supposed to do and on their motivation. Conclusion: Thus, it is necessary to formulate interventions to scale up communication skill of the physicians, and devise effective ways to educate patients on medication of chronic diseases. Further studies on characteristics of consultation to make it motivating and more effective may be conducted.


Introduction
Hypertension is a condition with a tremendous economic and public health impact which contributes to disability, increase health care costs and mortality. 1t affects up to 37% of global adult population and is estimated that 7.1 million deaths are due to hypertension. 2 Although the management and control of hypertension reduces morbidity and mortality, paradoxically the percentage of patients with controlled hypertension has been reported to vary between 5.4% and 58% only worldwide. 3ne of the major causes of this global hypertension threat is failure to take medication as advised.
Poor adherence attenuates optimum clinical benefits and therefore reduces the overall effectiveness of health systems.In developing countries, when taken together with poor access to health care, lack of appropriate diagnosis and limited access to medicines, poor adherence is threatening to render futile any effort to tackle chronic conditions, such as diabetes, depression, hypertension, TB and HIV/AIDS. 2t is axiomatic that effective care of patients requires both technical expertise -that is diagnosis and treatment, and interpersonal or psychosocial skill.The latter comprise the physician-patient relationship, patient education, counseling and the caring function.The psychosocial components are particularly important in the outdoor management of patients with chronic diseases, because effectiveness of treatment for conditions like hypertension, diabetes mellitus and heart diseases depends largely on patients faithfulness in carrying out instructions correctly. 4Nikita Sabherwal et al in Delhi, India, found 62% of the patients had experienced ineffective communication by the doctor. 5Various study findings clearly emphasize its abysmal lack in practice and the over-reaching need for the doctors to establish effective communication with the patients.Findings across 106 studies in a meta-analysis by Haskard-Zolnierek K et al the association between physician communication and patient adherence is positive and significant (p< .001). 6e WHO defines adherence as "the extent to which the persons behavior (Including medicationtaking) corresponds with agreed recommendations from a healthcare provider". 7It includes the initiation of the treatment, implementation of the prescribed regime, and discontinuation of the pharmacotherapy.It is noted that the adherence rate of less than 75% with short-acting antihypertensive drugs increase the risk of cardiovascular complications. 8Donald E Morisky et al in a study found 32.1% low adherers, 52.0% medium adherers, and only 15.9% high adherers. 9cept a qualitative study on communication skill of intern-doctors by Rahman A, no other study could be found in the context of Bangladesh; exposing a gap in knowledge of communication skill of service providers in Bangladesh. 10 There are a number of factors that predict patient adherence to treatment, but only the relationship between doctor-patient communication and adherence to treatment has been focused in this study.The objective of this study was to determine the link between doctor-patient communication, and adherence to anti-hypertensive treatment.Thus, this study will help to identify weaknesses and strengths in communication skills of the physicians with the patient, its relation to adherence to treatment, and potential areas for further improvement.

Materials and Methods
This cross-sectional study was conducted at Combined Military Hospital, Dhaka among 253 conveniently recruited hypertensive patients, attending outpatient department during July 2016 to June 2017.The data were collected by face to face interview and document review.Study involved quantitative method of data collection with component of qualitative data collection.Assuming proportion of patient's adherence to treatment for chronic condition as p (0.15), 5% margin of error (d) and confidence level of 95% (z ∞/2 = 1.96), the minimum sample size was 196. 7inally, a sample of 253 was recruited.'Interview' of all the respondents was conducted to identify the contributing factors for skipping prescriptions and proscriptions.Participants, who were diagnosed as case of hypertension at least six months before recruitment into the study, receiving antihypertensive treatment, age 18 years or above and willing to participate were recruited.
Physicians involved in treating and communicating with patients were military doctors with specialization in internal medicine and/or cardiology.Communication skill of the clinicians, as perceived by the respondents was determined by using 'Communication Assessment Tool' (CAT). 11he CAT with 15 items, asked the respondents to rate different dimensions of communication and interpersonal skills of the physician using a 5-point Likert Scale (1=Poor, 2=Fair, 3=Good, 4=Very good, 5= Excellent).The first 14 questions focused specifically on the physician's interpersonal and communication skills.The last question concerned about patient interaction with the staffs.The 'Cronbach's Alpha' for the original CAT was 0.98.Any score above 3 was considered as 'Effective' and below 3, as 'Ineffective' communication. 11igher score signified better communication.
The 8-item, 'Morisky's Medication Adherence Scale (MMAS-8)' was administered to the respondents to determine the self-reported adherence level to antihypertensive medication (Cronbach's Alpha= 0.83). 12he first seven items were 'Yes/No' responses, while the last item was a 5-point Likert response.Every 'negative' response of the first 7 items scored 'one' and every positive response scored 'zero' (Except question no-6, for which the scoring was reverse).For question no-8, score obtained from 0 to 4 in Likert scale was divided by 4 to get a score out of value of one.Finally, all scores are summed up to get a total score out of eight.Higher scores indicated better adherence.Any score equal and above six was classified as adherent and below six as non-adherent respectively. 12Data were analysed using SPSS.Descriptive statistics, and inferential statistics, like ttest, One way ANOVA, Chi Square test and binary logistic regression were performed.Level of significance for this study was chosen 5%.Research protocol was approved by Ethical Review Board (Directorate General Medical Services, Bangladesh Armed Forces).Participation in the study was on voluntary basis.Privacy and confidentiality of data were strictly maintained.

Results
In this study, mean-age of the participants was 49.2 (±10.4)years, majority were male (54.9%), belonged to age category 41-50 years (30.8%),95.3% married, 44.3% were house wife, 30.8% had higher secondary qualification and 39.1% had family income within range of Tk 25,001 to 50,000 (table I).Mean consultation duration as expressed by the respondents was 5.34 (± 1.31) minutes.More than half of the respondents (57.3%) experienced a consultation duration between 3 minutes to 5 minutes.(figure 1) In this study, using 'Communication Assessment Tool' (CAT), 63.6% and 36.4% of the patients were found to have experienced 'effective' and 'ineffective' communication respectively.
Relation of gender (p< 0.005), and occupation (p< 0.01) with communication was statistically significant (table II).In this study, it was tried to explore the level of adherence for each CAT-item from patients' revealed that respondents were 3.23 times more adherent to medication with favorable response to the item-'Doctor gave me as much information as I wanted' (p = 0.041); and 10.24 times more adherent with favorable response to the item-'Doctor checked to be sure I understood everything' (p=0.006)(table IV).
This study unfolded that 66% of the respondents were adherent to anti-hypertensive medication, rest 34% were non-adherent.Respondents who perceived effective communication were also more adherent to medication (92.5%); whereas, the respondents who experienced ineffective communication, were comparatively less adherent to medication (19.6%).where 66.1% of the respondents showed adherence and 33.9% showed nonadherence to anti-hypertensives.Hossian SZ et al in a study in Dhaka Medical College Hospital found 55.47% patients were adherent to anti-hypertensive treatment. 14This study suggests that rate of patient's adherence to anti-hypertensive medication in Dhaka CMH was relatively higher than other studies conducted in Bangladesh.
Mean consultation time as expressed by the respondents was 5.3 (± 1.3) minutes.More than half of the respondents (57.3%) experienced a consultation time with the physicians for 3 minutes to 5 minutes.7] Consulting time varies greatly between countries.For example, in Great Britain, average consultation lengths for general practitioners are between 5 and 8 minutes, 18 whereas in the United States and Sweden, they are 10 to 20 minutes or more. 19 Binary Logistic Regression analysis revealed that respondents were 3.23 times more adherent to medication with favorable response to the item-'Doctor gave me as much information as I wanted' (p = 0.041); and 10.24 times more adherent with favorable response to the item-'Doctor checked to be sure I understood everything' (p=0.006).This result indicated that more exchange of information between the doctor and the patient, and taking feedback by the doctor to reconfirm that messages exchanged were understood by the patient play important role in patients understanding, motivation and adherence to the treatment.

Conclusion
It can be inferred from the findings of this study, that adherence to medication among other factors, significantly depends on effective communication between the doctor and the patient.It is necessary to formulate interventions to scale up communication skill of the physicians, and devise effective ways of patient education on chronic diseases and medication.Further studies on communication skill of the clinicians, and characteristics of consultation that render any communication as effective should be conducted.

Figure 1 :
Figure 1: Duration of Consultation experienced by the study sample (n = 253)

Figure 2 :
Figure 2: Mean Plot in ANOVA shows that with increase in duration of consultation, there are increases in score of communication skill as perceived by the respondents.

Table I :
Demographic characteristics of study sample (n= 253)

Table II :
Association of demographic variables to level of Doctor-Patient Communication (n = 253)

Table III :
Association between categories of consultation-duration and mean 'score in communication skill' in one-way ANOVA (n=253)

Table IV :
Association between categories of consultation duration and mean 'score in communication skill' in Tukey's Post Hoc Test (n=253)

Table IV :
Logistic Regression Analysis of item-wise score of Communication Assessment Tool (CAT) (n = 253)

Table V :
Parameter Estimates in Binary Logistic Regression contrasting Non-Adherent group versus groups of other variables those were found significant in Chi Square test (n = 253) this study, Communication Assessment Tool (CAT) items -'Doctors Treat with Respect', 'Greeting and Feeling of Comfort', and 'Showing Care and Concern' scored means above 3(3.17± 0.748, 3.04 ± 0.668, 3.03 ± 0.60 respectively).Lowest mean-score (2.55 ± 0.638) was obtained in item-'Staffs Treated with Respect'.This result indicated that an important source of gap in communication might be lack of support from the paramedics, and auxiliary staffs.