Journal community pharmacy

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Original Research

The eﬀect of an educational intervention on patients’

knowledge about hypertension, beliefs about medicines,

and adherence

C. Magadza, M.Sc.(Pharmacy)

a

, S.E. Radloﬀ, Ph.D.

b

, S.C. Srinivas,

Ph.D., PGDHE

a,

*

a

Faculty of Pharmacy, Rhodes University, Grahamstown, 6140, Eastern Cape, South Africa

b

Department of Statistics, Rhodes University, Grahamstown, 6140, Eastern Cape, South Africa

Abstract

Background:The burden of chronic noncommunicable diseases continues to rise in South Africa, leading to high rates of morbidity and mortality. The control of hypertension is far from optimal because of factors such as inadequate patient understanding of the condition and its therapy, as well as poor adherence to prescribed regimens.

Objective:This study investigated the effect of an educational intervention on selected hypertensive participants’ levels of knowledge about hypertension, their beliefs about medicines, and adherence to antihypertensive therapy. Method:Participants took part in an educational intervention that provided them with information about hypertension and its therapy through presentations, monthly meetings, and a summary information leaflet. The participants’ levels of knowledge about hypertension and its therapy as well as their beliefs about medicines were measured using interviews and/or self-administered questionnaires. Levels of adherence were assessed using pill counts, self-reports, and punctuality in collecting medication refills. Paired t tests for dependent samples were performed to compare the participants’ levels of knowledge about hyperten-sion and its therapy, beliefs about medicines, and levels of adherence to antihypertensive therapy before and after the educational intervention.

Results:There were significant increases in the participants’ levels of knowledge about hypertension and its therapy (P ! .0001). Most of the parameters used to indicate beliefs about medicines were significantly modified in a positive manner (P ! .01 for concerns about medicines, P ! .01 for beliefs about the harmful nature of medicines, and P ! .01 for the necessity-concerns differential).

Conclusion: Results of this study show that the educational intervention led to an increase in the

participants’ levels of knowledge about hypertension and a positive inﬂuence on their beliefs about medicines. Despite these positive changes, adequate time is required before anticipated behavioral changes, such as increased adherence, can be observed.

Keywords:Hypertension; South Africa; Educational intervention

* Corresponding author. Tel.:þ27 46 603 8396; fax: þ27 46 636 1205. E-mail address:[email protected](S.C. Srinivas).

Research in Social and

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Introduction

Chronic noncommunicable diseases (CNCDs) accounted for 60% of global deaths, 80% of which occurred in low- and middle-income coun-tries in 2005. South Africa is one of the 23 countries accounting for 80% of the deaths caused by CNCDs in the developing world during this

period.1-3 Noncommunicable diseases are the

main cause of death in South Africa, even with the existence of the HIV/AIDS pandemic.4-6

An example of a noncommunicable disease that is prominent throughout the world is hypertension, the control of which is far from optimal.4,7-9The ﬁrst National Demographic and Health Survey carried out in South Africa in 1998 showed that 13% of the male and 16% of the female populations were hypertensive.10The Eastern Cape Province’s Equity Project Report for the period 1997-2000 showed the prevalence of hypertension at 15% in the urban and 12% in the rural adult populations of the Province. The Bisho district had the highest number of hypertensive patients on treatment in the Eastern Cape Province.11

Studies have shown that patients’ beliefs about diseases and therapies affect health-related behav-ior, such as adherence to therapy.12-17These be-liefs are shaped by an interplay of numerous factors, such as demographics, personality, cul-tural norms, socioeconomic status, and knowl-edge of the condition as well as its therapy.18,19 Demographics, cultural norms, personality, and the socioeconomic status of patients are either dif-ficult or impossible to alter. One way of positively influencing patients’ beliefs about medicines is increasing their levels of knowledge about their

diseases and therapies through educational

interventions.

Patients’ beliefs about their illnesses are based on previous experiences, usually of acute condi-tions.13,16-18,20Patients often expect that taking of medicines is likely to result in the curing of their con-dition. This is reﬂected by the cessation of symptoms eliminating the perceived need for therapy.13,16 However, chronic conditions require patients to take medication and alter their lifestyles for the rest of their lives. Added to this, asymptomatic con-ditions such as hypertension do not have any indica-tors that patients can use to perceive the beneﬁt of their therapy.21-24 Patients who are not aware of the nature of their conditions and the roles played by therapy may use their medication incorrectly.13 One of the main reasons for inadequate health out-comes such as uncontrolled blood pressure is poor

adherence to therapy.25-29An increase in patients’ levels of knowledge about a health condition and its therapy can also lead to a change in beliefs about the condition and its medicinal therapy, which in turn may result in patients taking a more active role in the management of their conditions.13,30-33

Patients hold beliefs about all medicines in general (general beliefs) and about medicines that have been specifically prescribed for them (specific beliefs). General beliefs are those held by patients about the prescribing habits of doctors and the harmful nature of medicines. With regard to specific beliefs about medicines, patients consider the bene-fits (necessity), as well as the risk, that is, the undesirable effects of a prescribed regimen (con-cerns), when deciding whether or not to follow the advice of health care providers (HCPs).12,14,15,31,34 High levels of the perceived necessity of medicines can lead to improved adherence, whereas high levels of concern about therapy can lead to poor adher-ence.12,15,34-36 An interaction of these 2 factors is

known as the necessity-concerns diﬀerential

(NCD). A high NCD indicates that patients believe that the need for their medication to maintain their health overrides their concerns about the discomfort that they may experience from the medication. An NCD value of 0 indicates that the level of concern about and the perceived level of necessity of the med-ication bear the same weight for the patient.37_The NCD has been shown to be a stronger predictor of patients’ adherence to therapy compared with fac-tors such as type of illness and demographics.12,15

The aim of this study was to determine the eﬀect of an educational intervention on the levels of knowledge about hypertension and its therapy, beliefs about medicines, and adherence levels of a selected group of hypertensive individuals.

Method

This study was conducted at Rhodes Univer-sity, which is in the Bisho Region of the Eastern Cape Province of South Africa. The study was approved by Rhodes University ethics committee. Hypertensive Rhodes University support staﬀ members on medicinal therapy (Table 1) were in-vited to participate in the study from the following departments of the university: housekeeping, grounds and gardens, catering, and engineering. Invitation was through letters distributed by the heads of the departments. Signed informed con-sent was obtained from all participants, most of whom had low literacy levels and whose home

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language was isiXhosa (native language spoken by most of the people of South Africa’s Eastern Cape Province).

The participants took part in a 6-month educational intervention comprising 3 compo-nents: presentations, a summary information leaflet, and individual monthly meetings with the researcher. During the presentations, all the participants met, and different topics were ad-dressed. There were 4 presentations addressing the following topics: (1) the nature of hypertension, (2) antihypertensive medicines, (3) adherence, and (4) the recommended diet and lifestyle for hyper-tensive patients. After all the 4 presentations had been given, participants were given a summary information leaflet, which highlighted the main aspects addressed during the presentations. This leaflet was available to all participants in both English and isiXhosa. During the individual meetings with the researcher, participants had an opportunity to ask questions relating to their hypertension and its therapy. The meetings were held on a monthly basis and during these meetings the researcher also measured the participants’ levels of adherence to their antihypertensive therapy. The researcher would also revisit the

topic most recently presented with those partici-pants who had not been able to attend that particular ‘‘presentation.’’

The participants’ levels of knowledge about hypertension and its therapy were measured using one-on-one interviews before and after the educa-tional intervention, and self-administered ques-tionnaires during the intervention period. Before each presentation, participants were given

self-administered questionnaires (pre-intervention

questionnaires) with questions on the topic being addressed on that day. This was done to de-termine the participants’ baseline levels of knowl-edge about that particular topic. The participants then completed the same questionnaire at the next

presentation (postintervention questionnaires),

the objective being to measure how much they understood from the previous presentation. From the second to the fourth presentation, participants completed 2 questionnaires before the presenta-tion. The first was the postintervention question-naire for the previous presentations topic and the second, the pre-intervention questionnaire for the topic to be addressed that day. The participants completed the postintervention questionnaire for the final topic during their next individual meeting with the researcher after the final presentation. The summary information leaflets were given to the participants after they had completed the final postintervention questionnaire.

About 3 weeks after the summary information leaﬂets had been given to the participants, they completed the self-administered questionnaires for all the topics (post-post-intervention question-naires) to determine if availability of written information led to a further increase in the participants’ levels of knowledge about hyperten-sion and its therapy. Mean and standard de-viations were calculated for the diﬀerent levels of knowledge obtained using the interviews and self-administered questionnaires.

The interview and self-administered question-naires used to measure levels of knowledge about hypertension and its therapy were adapted from diﬀerent sources.8,13,38-42 _{The interview questions} used to measure knowledge about hypertension and the questions from the self-administered

ques-tionnaires have been included as Appendixes 1

and 2, respectively. The questions were designed to convey key concepts of hypertension in a simple format to be easily understood by participants with low literacy levels. Depending on the baseline interview responses, the issues to be addressed

during the educational intervention were

Table 1

Antihypertensive medicines used by the participants Generic name

of medicinea

Number of participants who took the medicine HCTZ 30 Perindopril 15 Atenolol 6 Nifedipine 5 Furosemide 4 Reserpine 4 Verapamil 4 Hydralazine 3 Indapamide 2 Amlodipine 1 Lisinopril 1 Combinations Enalapril and HCTZ 2 Amiloride and HCTZ 1 Bisoprolol and HCTZ 1 HCTZ, hydrochlorothiazide.

a_{The participants received their medicines from}

a public sector primary health care facility in Grahams-town, South Africa.

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determined. The interview questions of this study have been published elsewhere.43

Beliefs about medicines were measured using

the Beliefs about Medicines Questionnaire

(BMQ), which measures both speciﬁc and general beliefs about medicines, each section having 2 subsections. These are named ‘‘necessity’’ and ‘‘concerns’’ for the speciﬁc beliefs section and ‘‘overuse’’ and ‘‘harmful’’ for the general beliefs

section.37 Respondents indicate the extent to

which they agree or disagree to statements on the questionnaire according to a Likert 5-point scale. The scores for the 4 subsections necessity (n), concerns (c), overuse (o) and harmful (h) are calculated separately. The NCD is obtained by subtracting the concerns score from the necessity score. This study’s participants completed the BMQ before and after the educational interven-tion. Mean and standard deviation values were calculated for ‘‘n,’’ ‘‘c,’’ ‘‘o,’’ ‘‘h,’’ and NCD.

The participants’ levels of adherence to their therapy were measured using self-reports, pill counts, and the participants’ punctuality in col-lecting their medication reﬁlls. The dates when the participants collected their reﬁlls were available

from their health passports.aMean and standard

deviation values were calculated for the partici-pants’ levels of adherence to therapy. The formu-las for calculating adherence using the 3 diﬀerent methods are listed as follows:

Using the pill count method, the percentage adherence was calculated as:

%adherence score¼ ½ðamount of medication

actually taken during a specified time period amount of medication that should

have been taken during that time periodÞ 100Oðamount of medication that should have been taken during the specified periodÞ The amount of medication that should have been taken was calculated based on the number of days since the last pill count and the dosing instructions given by the HCPs. The amount actually taken was calculated by subtracting the present amount from the total amounts of med-ication that should have been received during the

speciﬁed period. Those who had taken less than the prescribed amount of medication scored a negative percentage, whereas those who took extra, scored a positive percentage. The ideal score was 0%. Therefore, the closer to 0% the adherence level was, the more adherent the participant.

Using the punctuality in collecting reﬁlls method, percentage adherence was calculated as:

½number of times when refills were collected on time during a specified periodOtotal number of times when refills should have been collected during that period 100 Percentage self-reported adherence, based on the 14 interview questions addressing adherence, was calculated as:

½number of responses to questions; during the interview that reflected the ideal behaviourO14 100

Although at the beginning of this study there were 69 participants, some of them lost interest in the study and others did not attend some of the monthly individual meetings or did not complete some of the questionnaires. As a result, not all the participants’ data were admissible for statistical analysis. By the end of the study, there were 45 participants who met the admissibility criteria listed below.

Admissibility criteria

Participants who were interviewed both before and after the educational intervention. Participants who completed the BMQ both

before and after the educational intervention. Participants who had adequate data obtained from at least 1 of the 3 methods used to mea-sure levels of adherence, that is, pill counts, punctuality in collecting prescription reﬁlls, and self-reports. Adequate data were enough data to be able to calculate adherence for each period of the study using at least 1 of these 3 methods.

a

Health Passport: a book where all details about the patient’s visits to public health care centers are recorded. The patient keeps this book. This is a system used in the public health sector in South Africa.

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Participants who completed all 3 self-adminis-tered questionnaires (pre-, and post-post-intervention) used to determine levels of knowledge about hypertension.

Participants who either attended the presenta-tions, or met with the researcher to discuss, all 4 topics: ‘‘hypertension,’’ ‘‘antihypertensive medication,’’ ‘‘adherence,’’ and ‘‘diet and lifestyle.’’

With regard to calculation of adherence, only 28 (62.2%) participants had data available from all the 3 methods. Adherence levels were, there-fore, calculated and reported separately for each method, using the number of participants with

enough admissible data for that particular

method.

Statistical analysis

The postintervention measurements were per-formed 1 month after the entire educational intervention was complete. t Tests for dependent samples were performed, at 95% level of signiﬁ-cance, to compare the participants’ levels of knowledge about hypertension, their beliefs about medicines, and adherence levels before and after the educational intervention. The probability of committing a type II error denoted by b was de-termined for adherence levels. Estimates of the ef-fect size of the tests (d) with 95% conﬁdence

intervals (CI) were determined44 for levels of

knowledge about hypertension, beliefs about med-icines, and adherence levels. Cronbach’s alpha (CA) was used to test the internal consistency of the BMQ.45,46

Results

The demographic characteristics of the 45

participants are shown in Table 2. Tables 3-5

show the mean and standard deviation percentage scores for the participants’ levels of knowledge, beliefs about medicines, and adherence levels, respectively, before, during, and after the educa-tional intervention.

The pre-intervention self-administered ques-tionnaire (Appendix 2) completed when the topic of antihypertensive medicines was presented, showed that 13 (28.9%) of the participants knew that medicinal therapy does not cure hyperten-sion. A signiﬁcant increase in this number to 35 (77.8%) was reﬂected in the post-post-interven-tion quespost-post-interven-tionnaires (P ! .0001). The pre-interven-tion quespre-interven-tionnaires also showed that 18 (40%)

participants knew that their medicines alone, without lifestyle measures, were insuﬃcient for controlling their blood pressure. This number increased signiﬁcantly to 36 (80%) in the post-post-intervention questionnaires (P ! .0001).

The participants’ levels of knowledge about hypertension and its therapy increased signiﬁ-cantly, indicating that they knew more about their condition after the educational intervention when compared with the beginning (P ! .0001). There was a signiﬁcant increase in knowledge demonstrated by the responses to the post-post-self-administered questionnaires (P ! .0001).

Participants believed that their antihyperten-sive medicines were necessary to prevent their condition from worsening and to maintain their health. This was indicated by the high mean ‘‘n’’ score of 21.3 3.46 before the educational

inter-vention which increased to 21.4 3.9 after the

educational intervention (Table 4). The increase

was, however, not statistically signiﬁcant

(P O .05). At the beginning of the study, 33

Table 2

Demographic characteristics of study participants

Characteristic Number of participants Percentage Gender Female 34 76 Male 11 24 Age (yr) 30-40 2 4 41-50 22 49 51-60 21 46 Race Black 41 91 White 1 2 Colored 3 7 Home language English 2 4 isiXhosa 39 87 Afrikaans 4 9 Language proﬁciency English 29 64 isiXhosa 41 91 Afrikaans 8 18 isiZulu 2 4 Number of years of formal education 1-4 4 9 5-7 9 20 8-12 30 67 O12 2 4

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(73.3%) participants believed that without their antihypertensive medicines they would be very ill and this number increased signiﬁcantly to 40

(88.9%) after the educational intervention

(P ! .005).

Table 6 shows the results of the dependent

t test analyses performed to test for diﬀerences

in the participants’ beliefs about medicines before and after the educational intervention. The effect sizes for comparisons on concerns, the NCD and harmful beliefs about medicines supported signif-icant intervention effects because the 95% CI did not contain zero. The effect sizes for comparisons on necessity and overuse beliefs about medicines indicate the absence of meaningful intervention effects in these instances, because the 95% CI contained zero.

There were also concerns raised regarding the potential undesirable eﬀects of these medicines. The mean concerns score decreased signiﬁcantly

after the educational intervention from

17.91 4.04 to 15.58 4.37 (P ! .01). Although

35 (77.8%) participants agreed that they were worried about the long-term eﬀects of their medi-cines before the educational intervention, this number decreased signiﬁcantly to 23 (51.1%) after the educational intervention (P ! .001). Before the educational intervention, 36 (80%) partici-pants admitted to worrying about becoming too dependent on their medicines, but this number

decreased significantly to 25 (55.6%) after the ed-ucational intervention (P ! .001). The significant decrease in the level of concern about undesirable effects of antihypertensive medication after the ed-ucational intervention was also reflected by the

signiﬁcant increase in the NCD from 3.4 4.0 to

5.9 5.0 (P ¼ .01) as shown inTables 4 and 6. With regard to general beliefs about medicines, the mean score for participants’ beliefs about the prescribing habits of doctors (‘‘o’’) was 14 3.3 before and decreased to 13.1 3.1 after the educa-tional intervention. The decrease was, however, not statistically signiﬁcant (P O .05). After the ed-ucational intervention, there was a signiﬁcant de-crease (P ! .01) in the mean score of participants’ beliefs about the harmful nature (‘‘h’’) of medi-cines (pre-intervention: 11.1 2.6, postinterven-tion: 9.5 3.0).

There were 37 (82.22%) participants with data admissible for calculating adherence levels using pill counts, 36 (80%) using punctuality in collect-ing reﬁlls and 45 (100%) uscollect-ing self-reports. The mean percentage adherence level using pill counts

was 15.27% 18.61 before the educational

inter-vention, which decreased to 16.87% 13.91

dur-ing the educational intervention (P O .05) and increased to 12.28 % 11.17 (P O .05) after the educational intervention (see earlier formula for the calculation of adherence levels using the pill count method). The participants were punctual in collecting their antihypertensive medications,

on average, 63.38% 30.07 of the time before

the educational intervention. This ﬁgure increased

to 66.88% 32.17 during (P O .05) and to

74.59 % 31.26 of the time after the educational

intervention (P O .05). The overall increase

shown by this method was statistically signiﬁcant (P ! .05). Before the educational intervention, the participants reported a mean adherence level of 81.78 % 13.36 which increased to 83.56% 10.69 after the educational intervention (P O .05).

The pre- and postintervention CA values45,46 were all in the acceptable range and all above

Table 3

Participants’ levels of knowledge about hypertension and its therapy

Method of measuring levels of knowledge Period of the study Interviews Self-administered questionnaires Pre-intervention 55.4% 16.0 63.3% 14.7 Post-intervention 80.4% 11.9 70.5% 14.3 Post-post-intervention N/A 83.5% 11.8

Values are given as mean standard deviation per-centage scores.

Table 4

Participants’ beliefs about medicines

Sub-sections of the BMQ

Period of the study n c NCD o h

Pre-intervention 21.3 3.46 17.9 4.0 3.4 4.0 14.0 3.3 11.1 2.6 Post-intervention 21.4 3.9 15.6 4.4 5.9 5.0 13.1 3.1 9.5 3.0

n, necessity; c, concerns; NCD, necessity-concerns diﬀerential; o, overuse; h, harmful. Values are given as mean standard deviation percentage scores.

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0.71. The CA analysis was performed to test the internal consistency reliability of the BMQ section addressing participants’ speciﬁc beliefs, the sec-tion addressing general beliefs about medicines and the whole questionnaire.

Discussion

Educational interventions create opportunities for patients to better understand their conditions and the role of therapies. Through patient educa-tion, misconceptions that patients have about their therapy can be cleared.14,17Patients’ beliefs about medicines are not static, and at times these beliefs are because of patients’ misunderstanding of the role of medicinal therapy.12,18,31,44Educational in-terventions can positively modify patients’ beliefs which in turn can lead to a change in patient behav-ior.4,47-49_{In this study, the participants’ levels of} knowledge about hypertension and its therapy in-creased signiﬁcantly, indicating that they learned more about their condition than what they knew at the beginning. This increase in knowledge is ex-pected to have led to a change in the participants’ beliefs about medicines.

The postintervention self-administered ques-tionnaires showed a mean score of 70.52%, which demonstrates that the participants did not retain all the information they learned during the pre-sentations and individual monthly meetings. The post-post-intervention mean score from the self-administered questionnaires was 83.5%. The sum-mary information leaflets significantly increased the amount of information retained by the par-ticipants (P ! .0001). The significant increase in the participants’ levels of knowledge about hyper-tension and its therapy is in line with previous findings, which show that patient education pro-grams can be used to increase patients’ knowledge about hypertension.47,50

In a study similar to the

present one, hypertensive individuals took part in an educational intervention, which resulted in a signiﬁcant increase in their levels of knowledge about hypertension when measured four months after the educational intervention.50

The conceptual model of illness used by the black population in South Africa is at variance with the biomedical model of illness. The biomedical model lacks consideration of the role of social, religious, and magical factors in illness and treatment. These

are paramount features of the Ngunib model of

illness.51,52_{The Western society also used to hold} beliefs about the supernatural world, but with modernization, most of the Western community no longer holds these beliefs. The black population of South Africa is gradually shifting in the same di-rection. This is evidenced by the larger emphasis placed on the traditional belief system by the rural population than by the urban population.51 Educa-tional interventions can lead to a greater acceptance of the biomedical concept of illness and medicines, which is of greater importance in managing chronic conditions, such as hypertension.

Statistical analyses of the participants’ beliefs before and after the educational intervention showed that they developed a more positive attitude toward their antihypertensive medica-tions and toward all medicines in general. The changes in the participants’ level of perceived necessity of antihypertensive medication and the beliefs about the prescribing habits of doctors were not significant (P O .05). However, they were favorable, that is, the mean necessity score (n) increased and the score for the belief that doc-tors overprescribed (o), decreased. The NCD increased significantly and the level of concern about undesirable effects of antihypertensive agents decreased significantly, as did the scores for the beliefs about the harmful nature of all

medicines in general (Tables 4 and 6). These

Table 5

Participants’ levels of adherence

Method of measuring adherence Period of the study Pill counts

(n¼ 37) Punctuality in collecting reﬁlls (n¼ 36) Self-reports (n¼ 45) Pre-intervention 15.27 18.61 63.38% 30.07 81.78% 13.36 Intervention 16.87 13.91 66.88% 32.17 N/A Post-intervention 12.28 11.17 74.59% 31.26 83.56% 10.69 Values are given as mean percentage adherence standard deviation.

b

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changes in the beliefs about medicines are consis-tent with other studies, which suggest that educa-tional interventions can lead to the modiﬁcation of patients’ attitudes toward therapy.13,30-32,53 One study suggests that hypertensive patients’ at-titude and behavior can be altered by providing patients with information and ensuring that they understand the nature of hypertension.13Another study proposes that patient counseling should ad-dress beliefs about medication use and physical activity restrictions, as perceptions of these health behaviors may have signiﬁcant impact on how pa-tients adhere to therapy and live with their conditions.53

Previous studies have reported signiﬁcant in-creases in adherence levels owing to educational interventions.12,17,18,54In the present study, slight increases in adherence levels were recorded. Al-though increase in adherence levels was not statis-tically signiﬁcant in the current study, this is not

an uncommon occurrence.13 One reason for the

lack of statistical signiﬁcance could be that chang-ing behavior is a process that occurs over a long

period.47,55 The postintervention measurements

were performed 1 month after the entire educa-tional intervention had been completed. This might not have been suﬃcient time for adequate behavior changes to occur. In 1 study where im-provements in adherence levels and health-related parameters were observed after an educational in-tervention, the postintervention measurements were performed after a period ranging from 23 to 77 weeks.54

The number of participants used in a study affects the power of statistical tests. That is, the sample size can lead to the acceptance of the null hypotheses that there was no significant change in a parameter when significant changes did actually occur. In this study, the sample size (45 partici-pants) might not have been sufficient for signifi-cant changes in adherence levels to be observed.

This is supported by the high b values

(0.49 % b % 0.94) obtained for the paired t tests performed to compare the adherence levels before and after the educational intervention.56,57

The CA analysis that was used to test the internal consistency reliability of the BMQ showed values above 0.70, indicating that the data obtained using this instrument provided a reliable measure of participants’ beliefs about medicines.46

Limitations of the study

The interview and self-administered question-naires used to the measure levels of knowledge about hypertension and its therapy were designed with diﬀerent numbers of items and scales, there-fore validity tests could not be performed on them.

It is possible that there was repeat measure-ment bias since the same self-administered ques-tionnaire was given to the participants 3 times (p, post-, and post-post-intervention). The re-sponses on the third occasion may not have been the participants’ individual responses, but what they heard from their colleagues during informal discussions in their various work places. However, it is possible that this bias is limited because the participants did not receive the questionnaires they had completed to take home and therefore could not use these to discuss and compare their responses. Another factor is that the participants completed the questionnaires as individuals and did not have the opportunity to share answers with one another. Because the self-administered questionnaires were in the form of multiple choice or true/false response options, guessing was also an unavoidable possibility.

It was a challenge for the investigator to meet with all the participants every month. At times, some of them would be too busy to settle down long enough for their tablets to be counted. A common occurrence was that participants forgot

Table 6

Comparing participants’ beliefs about medicines

Statistical Parameters

Scores from the beliefs about medicines questionnaire

n c NCD o h tvalues 0.21 3.13 3.11 1.58 2.94 Pvalues .835 .003a _.003a _.121 _.005a Eﬀect size (d) (95% CI) 0.03 (0.32, 0.26) 0.47 (0.16, 0.77) 0.46 (0.77, 0.15) 0.24 (0.06, 0.53) 0.56 (0.13, 0.74)

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to bring their medication and health passports to these monthly meetings even though appoint-ments were made in advance. There were also some participants who lost interest in the study and would avoid meeting with the researcher (Fig. 1).

The self-report and pill count methods used to measure adherence had the potential for being influenced by the participants.58-64For example, a participant might have deliberately not pre-sented all their medication for counting during the monthly meetings. Another example of partic-ipants’ influence is during the interviews when they could have reported what they believed the investigator wanted to hear, rather than their ac-tual behavior. Data obtained from measuring ad-herence using punctuality in collection of refills did not guarantee that the medication was used as directed or used at all.64

Conclusion

This study shows that pharmacist-initiated educational interventions to increase patients’ knowledge about their condition positively mod-iﬁed their beliefs about medicines. Such changes are expected to result in increased adherence

levels, but adequate time is required before anticipated behavioral changes can be observed. Acknowledgments

The authors thank Rhodes University’s JRC Research Grant awarded to Srinivas SC for funding this study. Professor Santy Daya, Dr Sirion Robertson, the 3 reviewers and the editor of this journal are acknowledged for their feed-back on earlier drafts of this manuscript. All participants and managers who supported this study are gratefully acknowledged.

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120 Invitation letters sent out

Participants who signed the consent form and completed the BMQ (n=84)

Baseline participants (n=69) Pilot study(n=5)

Not Hypertensive (n=4) No longer employees of the university (n=1)

Stopped anti-hypertensive therapy by themselves (n=2)

Instructed to stop anti-hypertensive therapy by HCP (n=2)

Lost interest (n=1)

Participants who were included in the final statistical analysis (n=45) Did not meet admissibility criteria

(n=13)

No longer employees at University (n=4) Passed away(n=1)

Participants who met eligibility criteria (n=74)

Participants who did not met eligibility criteria (n=10)

Participants who were not included in the final statistical analysis (n=26)

Participants who resumed anti-hypertensive therapy (n=2)

Participants who met the admissibility criteria

(n=43)

(n = number of participants)

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4. Steyn K. Director’s report for the chronic diseases of lifestyle unit 2002-2006. Med Res Counc; 2002. (personal communication).

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Appendix 1

Interview knowledge questions

1. What do you think high blood pressure means?

2. Do you know what the suitable blood pres-sure is?

3. Do you know what will happen if your blood pressure is not controlled?

4. Do you think that if you feel ﬁne then your blood pressure is also ﬁne?

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5. Do you think your tablets alone are enough to control your blood pressure without you changing your lifestyle, for example what you eat?

6. Do you know that there are some of the foods you should not eat or can only eat in small amounts because of your high blood pres-sure? Can you give examples?

7. What are the names of the tablets you are tak-ing for your high blood pressure?

8. Do you think there is a cure for high blood pressure?

9. How long are you going to be taking your tablets for high blood pressure?

10. Do you know that there are some medicines and tablets that you are not supposed to take because of your high blood pressure and the tablets you are taking for it? Appendix 2

Knowledge questions from self-administered questionnaires

High blood pressure 1. What is blood pressure?

, Pressure that builds up in your heart after a high-salt meal

, A measurement of the force of blood

against the walls of your blood vessels

, The amount of stress you can take before

your blood begins to boil

2. If you feel ﬁne then your blood pressure is ﬁne too.

, True

, False

3. What is the main cause of high blood pressure?

, Being overweight

, Stress

, Smoking

, All of the above

4. High blood pressure is a normal part of aging, so you don’t need any treatment for it.

, True

, False

5. There is no cure for high blood pressure.

, True

, False

6 .If medications can control your high blood pressure, you don’t need to change your lifestyle.

,True

,False

7. If untreated, high blood pressure can cause:

,Mental disorders

,Stroke

,Heart problems like heart attack

,Kidney failure

,All of the above

8. What is the most desirable blood pressure (mm Hg)?

,Less than or equal to 120/80

,130/85

,140/90

,160/100.

Medicines

1. List the names of your tablets for high blood pressure.

2. Tablets can cure high blood pressure.

,True

,False

3. Tablets alone are enough for keeping blood pressure under control.

,True

,False

4. If I have been taking my high blood pressure tablets, then my blood pressure will be under control.

,True

,False

5. If I make the necessary lifestyle changes, then I will not need to take any tablets for my high blood pressure.

,True

,False

6. Medicines and tablets for other diseases like ﬂu and coughs can raise my blood pressure.

,True

,False

7. I must not take other medicines, besides my tablets for high blood pressure, without ﬁrst asking the doctor, pharmacist, or nurse.

,True

,False

8. I must not take any herbs or traditional med-icines without ﬁrst asking the doctor, phar-macist, or nurse.

,True

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Adherence

1. I take my tablets for high blood pressure the way I was told by the doctor, the pharmacist or the nurses.

,All the time

,Some of the time

,None of the time

2. If I forget to take my tablets for high blood pressure today, I must take double the dose tomorrow.

,True

,False

3. If I take too much of my tablets for high blood pressure, I must:

,Just leave it and take correct dose the next day.

,Tell the doctor, nurse, or pharmacist as

soon as possible

,Not take any the next day

4. I must take my tablets for high blood pressure only when I feel sick.

,True

,False

5. I have to take my tablets for high blood pres-sure for the rest of my life

,True

,False

6. I must wait till all my tablets for high blood pressure are ﬁnished before collecting new ones.

,True

,False

7. If my medicine or tablets give me any prob-lems, for example if they make me feel sick, I should

,Just stop taking it

,Tell the nurse, doctor, or pharmacist

,Just continue taking the medication

8. Tick the reasons why you might not take your medicine or tablets. You may tick more than one reason.

,Bad taste

, Make you sick

, Diﬃcult to follow instructions

, When it is not working

, Scared of getting addicted

, No transport to get to the clinic or doctor

, Forgetting

, Other reasons

, None

Diet and lifestyle

1. The best way to prepare food if you have high blood pressure is:

, Frying

, Boiling

, Grilling

, 2 and 3

2. If you have high blood pressure, your diet must have lots of:

, Salt

, Fats and oil

, Fruits and vegetables

, Starch, for example potatoes, pap, rice 3. The best meat for people with high blood

pressure is:

,Red meat (beef)

,Chicken and ﬁsh

, Pork

4. People with high blood pressure can smoke as many cigarettes as they want.

, True

, False

5. People with high blood pressure must avoid alcohol.

, True

, False

6. Weight aﬀects blood pressure

, True

, False

7. Exercising will also help to lower your weight and blood pressure.

, True