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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, andadherence toantihypertensive 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.
Ó 2009 Elsevier Inc. All rights reserved.
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).
1551-7411/09/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.sapharm.2009.01.004
Research in Social and
Administrative Pharmacy 5 (2009) 363–375
Available online at www.sciencedirect.com
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 whichis far fromoptimal.
4,7-9
The 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.
10
The 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.
12-17
These 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.
13,16-18,20
Patients often expect that taking of
medicines is likely toresult inthe 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.
25-29
An 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 andthe perceivedlevel 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
364 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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 medicine
a
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.
365 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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.
a
Mean 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 score ¼ ½ðamount of medication
actually taken during a specified time period
Àamount of medication that should
have been taken during that time periodÞ
Â100ŠOðamount 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 periodŠ  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
behaviourO14Š  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.
366 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
Participants who completed all 3 self-adminis-
tered questionnaires (pre-, post- 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 determined
44
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 questionnaires (P !.0001). The pre-interven-
tion questionnaires 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 Æ 3.46 before the educational inter-
vention which increased to 21.4 Æ 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
367 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
(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 Æ 4.04 to 15.58 Æ4.37 (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 Æ 4.0 to
5.9 Æ 5.0 (P ¼ .01) as shown in Tables 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 Æ3.3
before and decreased to 13.1 Æ 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 Æ 2.6, postinterven-
tion: 9.5 Æ3.0).
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%) using self-reports. The
mean percentage adherence level using pill counts
was 15.27% Æ18.61 before the educational inter-
vention, which decreased to 16.87% Æ13.91 dur-
ing the educational intervention (P O.05) and
increased to 12.28 %Æ 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% Æ30.07 of the time before
the educational intervention. This figure increased
to 66.88% Æ32.17 during (P O.05) and to
74.59 %Æ 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 %Æ13.36 which increased to
83.56% Æ 10.69 after the educational intervention
(P O.05).
The pre- and postintervention CA values
45,46
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%Æ16.0 63.3%Æ14.7
Post-intervention 80.4%Æ11.9 70.5%Æ14.3
Post-post-
intervention
N/A 83.5%Æ11.8
Values are given as mean Æstandard 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 Æ3.46 17.9 Æ4.0 3.4 Æ4.0 14.0 Æ3.3 11.1 Æ 2.6
Post-intervention 21.4 Æ3.9 15.6 Æ4.4 5.9 Æ5.0 13.1 Æ3.1 9.5 Æ3.0
n, necessity; c, concerns; NCD, necessity-concerns differential; o, overuse; h, harmful.
Values are given as mean Æstandard deviation percentage scores.
368 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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.
14,17
Patients’ beliefs about
medicines are not static, and at times these beliefs
are because of patients’ misunderstanding of the
role of medicinal therapy.
12,18,31,44
Educational 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 usedby 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 Nguni
b
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
(n ¼37)
Punctuality in collecting
refills (n ¼36)
Self-reports (n ¼45)
Pre-intervention 15.27 Æ 18.61 63.38%Æ 30.07 81.78%Æ13.36
Intervention 16.87 Æ 13.91 66.88%Æ 32.17 N/A
Post-intervention 12.28 Æ 11.17 74.59%Æ 31.26 83.56%Æ10.69
Values are given as mean percentage adherence Æ standard deviation.
b
The Nguni people are the ethnic group occupying much of the Southern parts of Africa.
369 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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.
13
Another
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.
12,17,18,54
In 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
(pre-, 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
t values À0.21 3.13 À3.11 1.58 2.94
P values .835 .003
a
.003
a
.121 .005
a
Effect size (d)
(95% CI)
À0.03
(À0.32, 0.26)
0.47
(0.16, 0.77)
À0.46
(À0.77, À0.15)
0.24
(À0.06, 0.53)
0.56
(0.13, 0.74)
a
Significant difference as indicated by P value !.05.
370 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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.
58-64
For 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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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?
373 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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
, False.
374 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375
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
, False
375 Magadza et al./Research in Social and Administrative Pharmacy 5 (2009) 363–375

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