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Sci Rep
Sci Rep
Scientific Reports
2045-2322
Nature Publishing Group UK London

39266562
70710
10.1038/s41598-024-70710-1
Article
Non-adherence to appointment follow-up and its associated factors among hypertensive patients in follow-up clinics in South Gondar hospitals
Yirga Gebrie kassaw gebriekassaw27@gmail.com

1
Mekonen Getu Sisay 4
Hiruy Endalk Getasew 3
Shiferaw Kirubel 2
Bantie Berihun 1
1 https://ror.org/02bzfxf13 grid.510430.3 Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
2 https://ror.org/02bzfxf13 grid.510430.3 Department of Integrated Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
3 grid.449044.9 0000 0004 0480 6730 Department of Adult Health Nursing, College of Health Science, Debremarkos University, Debremarkos, Ethiopia
4 Department of Public Health in Mekane Eyesus Primary Hospital, Debre Tabor, Ethiopia
12 9 2024
12 9 2024
2024
14 213366 2 2024
20 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Hypertension is a persistent systemic Blood Pressure reading of 140/90 mm Hg or greater which is a preventable cause of cardiovascular disease morbidity and mortality. To assess non-adherence to appointment follow-up and its associated factors among Hypertensive patients in the follow-up clinics in South Gondar Hospitals 2023. Institutional-based cross-sectional study design was employed in hospitals in South Gondar from January to February to assess missed appointment follow-up and its associated factors among Hypertensive patients in follow-up clinics. There is one comprehensive specialized hospital and 9 primary hospitals in this zone. Using simple random methods four hospitals were selected by lottery method. The sample was calculated by using the single population proportion formula. The collected data was entered into Epi data version 3.1 and exported to Statistical Package for Social Sciences version 26 for analysis. Bivariate and multivariable logistic regression analysis was performed to determine the association factors. A total of 401 hypertensive patients on hypertensive follow-up were involved with a response rate of 95.02%. Age ranged from 25 to 86 years with a median age of 58.47 years. Of the total of participants, 211 (52.6.) were rural residents. Among the total hypertensive patients in the hypertensive follow-up clinic, 39.2% were non-adherent for their appointment follow-up. Living far from follow-up health facility (AOR: 2.53; 95% CI 1.349–4.743), absence of perceived symptoms (AOR: 4.98; 95% CI 2.888–8.590), patient complaints Pill burdens (AOR: 3.50; 95% CI 2.108–5.825), and poor Awareness about complication of hypertension (AOR: 2.62; 95% CI 1.471–4.673) were significantly associated with missing of their appointment follow-up for the most hypertensive patients. The prevalence of non-adherence to medical follow-up in hypertension is high as compared to different national health policy recommendations. Distance from the health facility, absence of perceived symptoms, Pill burdens, and lack of knowledge about complications of hypertension were significantly associated with Missed appointment follow-up in Hypertensive patient.

Keywords

Non-adherence
Appointment follow-up
Hypertension
Follow-up
Care
Subject terms

Health services
Medical ethics
Patient education
Public health
issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Background

Hypertension is a persistent systemic Blood Pressure reading of 140/90 mm Hg or greater which is a preventable cause of cardiovascular disease morbidity and mortality1. It is the main cause of death worldwide and the leading cause of disability2,3. Hypertensive heart disease is a major public health issue worldwide4,5. It is a rising public health problem in sub-Saharan Africa6.

In Ethiopia, a systematic and meta-analysis study showed the prevalence of hypertension is expected to reach up to 30%7. Cardiovascular diseases are the leading cause of mortality in Ethiopi8,9. Which urges to consider CVDs as a priority public health problem10. Hypertension affects many aspects of the patient’s life including physical and mental such as attitudes, beliefs, and experiences11. Poor blood pressure control and its associated complications developed due to low lifestyle modifications3. Though patients had a good adherence to antihypertensive medications blood pressure may not controlled due to poor adherence to appointments and low lifestyle modification12. High blood pressure can be controlled by taking regular antihypertensive drugs for the long term, but requires lifelong adherence to appointment follow-up, and a healthy lifestyle13. Even though hypertension diagnosis is simple blood pressure control remains difficult due to nonadherence to follow-up and treatment14.

Hypertensive patient non-adherence with medical appointments and treatment is a big challenge encountered by healthcare providers15. Adherence to antihypertensive drugs is a key component to managing blood pressure but it is a worldwide problem in the treatment of chronic disease16. Missed outpatient appointments are a barrier to the sustainability of hypertensive patient care17. Non-adherence with follow-up and antihypertensive therapy is commonly associated with poor treatment outcomes18. Missed hospital appointments are a challenge to healthcare systems around the world19. Blood pressure control remains unsatisfactory in the world only 60% of treated hypertensive patients accomplish therapeutic goals20. A review of medical records in chronic disease suggests that the majority of patients (67%) missed their original appointments in South Africa21. In the study conducted in Nigeria, 16.7% of hypertensive patient missed more than 30% of their scheduled medical appointments22.

Missed appointment follow-up in hypertensive clients may be patient-related or healthcare-related23. It is the risk for all-cause morbidity and mortality, especially in patients with chronic conditions like cardiovascular disease24.

Although hypertension is modified, the blood pressure of most patients in hypertensive follow-up remains uncontrolled due to different factors23. Most hypertensive patient develops complications due to this persistent uncontrolled blood pressure. Non-adherence to medical appointments and antihypertensive drugs were the main determinants of uncontrolled blood pressure17. The rate of discontinuation of antihypertensive medication within 1 year ranges from 29.4 to 64.1%25. Similarly in Ethiopia, non-adherence to antihypertensive medication varies from 16.5 to 41.5% with a pooled prevalence of 34.9%26. However, there is no study showing the status of medical appointment follow-up adherence for hypertensive patients on follow-up. Therefore this study was conducted to assess the magnitude of missed follow-up and related factors.

Method

Study design and setting

An institutional-based cross-sectional study design was employed in hospitals in south Gondar from January to February to assess missed appointment follow-up and its associated factors among Hypertensive patients in follow-up clinics.

There is one comprehensive specialized hospital and 9 primary hospitals in this zone. Using simple random methods, four hospitals (Debretabor Comprehensive Specialized Hospital, Adiss Zemen Primary Hospital, Mekane Eyesus Primary Hospital, and Andabet Primary Hospital) were selected by a lottery method.

The sample was calculated by using the single population proportion formula. By assuming the prevalence of adherence to 50%, with a 5% margin of error, 95% CI, and 10% non-response rate the total sample size was calculated to be 422. Every second hypertensive patient who visited the facility’s outpatient departments was selected by using a systematic random sampling method.

Source of population

All hypertensive patients on follow-up in South Gondar.

Inclusion criteria

All hypertensive patients on follow-up > 18 years old, and who had a minimum of 10 visits.

Exclusion criteria

The patient is critically ill and incapable of communicating during the data collection period and lost the chart.

Data collection tool and procedure

A structured questionnaire was used for data collection which was adapted from different related literature2,3. Data were collected both in a face-to-face interview using a structured questionnaire and chart review after the patient finished his follow-up visit.

The tool includes Socio-demographic characteristics of the participants, health-related information, and reasons behind missed appointment follow-up. Missed appointment follow-ups are taken out of every ten clinic appointments. No missing appointments and 1–3 missing appointments were considered adherent to medical follow-up while missing follow-up greater than 3 missed out of every ten clinic appointments considered non-adherence to appointment follow-up15.

Measures and definitions

Non-adherence to appointment follow-up was defined as missing more than 3 out of 10 medical appointments.

Adherence to appointment follow-up include no appointment missing and 1–3 missing out of 10 medical appointments15,22.

Data quality control and analysis

The questionnaire prepared in English was translated into the local language, Amharic, and then to ensure consistency, it was retranslated to English. The training was given to data collectors on the content of data collection tools, ways of approaching the interviewee, and chart review.

Data processing and analysis procedure

After data collection, data were first checked and coded. Then collected data was entered into Epi data version 3.1 and exported to Statistical Package for Social Sciences (SPSS) version 26 for analysis. Descriptive statistics were presented by using text, tables, and figures. Bivariate and multivariable logistic regression analysis was performed to determine the association factors. Binary logistic regression was done to identify the association between each variable with the outcome variable appointment follow-up categorized into adherent and non-adherent. Then after, the Variable that had a p-value < 0.25 in binary logistic regression became a candidate for multivariate logistic regression. Homer and Lemeshow's test was checked for model goodness of fit. During the analyses, a 0.05 P-value, and a 95% confidence interval (CI) were used. Factors p-value < 0.05 were considered as predictors of the outcome variable.

Ethics approval

The study was carried out after a letter of approval was obtained from the ethical review committee of the regional review board of Amhara Public Health Institution (accordingly declarations of Helsinki. (Ref.No APHI/V/M/T-E-03/1730) and All methods were carried out according to these guidelines. A formal letter was provided to selected hospitals in south Gondar hospitals preceding data collection. Since most of the participants unable to read verbal informed consent was obtained from each study participant. Data was used only for the purpose of study.

Result

Socio-demographic characteristics of the participants

A total of 401 hypertensive patients on hypertensive follow-up were involved with a response rate of 95.02%. Age ranged from 25 to 86 years with a median age of 58.47 years. Of the total participants, 72.8% were above 50 years old and 211(52.6%) were rural residents. (Table 1).Table 1 Socio-demographic distribution of study participants (hypertensive patients on follow-up) in south Gondar Ethiopia 2023 (N = 401).

Variable	Category	Frequency	Percentage	
Sex	Male	205	51.1	
Female	196	48.9	
Age	 ≤ 50 years old	109	27.2	
 > 50 years old	292	72.8	
Marital status	Single	37	9.2	
Married	252	62.8	
Divorced	25	6.2	
Widowed	87	21.7	
Education status	None	107	26.7	
Primary	120	29.9	
Secondary	102	25.2	
Tertiary	73	18.2	
Residency	Urban	190	47.4	
Rural	211	52.6	

Health-related information

Of all hypertensive patients, only 66.1% controlled their blood pressure. Among the total hypertensive patient in the hypertensive follow-up clinic, 39.2% were non-adherent for their appointment follow-up in ten consecutive appointments (Fig. 1). More than half (53.6%) of the participants had health insurance and 38.9% had medical comorbidity. (Table 2).Fig. 1 Number of missed appointments out of 10 appointments. (Note non-adherence = miss greater than 3 appointments out of 10 appointments2. So both green parts in the chart are considered adherent for appointment follow-up.

Table 2 Health-related information of Hypertensive study participants living in south Gondar Ethiopia 2023(N = 401).

Variable	Category	Frequency	Percentage	
Blood pressure status	Controlled	265	66.1	
Uncontrolled	136	33.9	
Any medical comorbidity	Yes	156	38.9	
No	245	61.1	
Treatment duration	 ≤ 5 years	207	51.6	
 > 5 years	194	48.4	
Health insurance	Yes	215	53.6	
No	186	46.4	
Mode of communication Appointment	Verbal	154	38.4	
Written	134	33.4	
Both	113	28.2	
Interval of each appointment	1 month	163	40.6	
2 month	175	43.6	
3 month	63	15.7	
Number of missed appointment in 10 months	None(adherence)	137	34.2	
1–3 (adherence)	107	26.6	
 > 3 (non- adherence)	157	39.2	
Self-treatment practice	Yes	154	38.4	
No	247	61.6	
Non-adherent to appointment	Yes	157	39.2	
No	244	60.8	

Reasons behind non-adherence to appointment follow-ups

The absence of symptoms is a common reason to miss hypertensive follow-up. Of the total participants, 60.8% of the participants responded that the absence of perceived symptoms was the reason why they missed their medical appointment in hypertensive follow-up. Around half (49.6%) of hypertensive patients complain of pills burden. Most of the hypertensive patient had no reminders for their appointment. (Table 3).Table 3 Reasons behind non-adherence to appointment follow-up study participants hypertensive patients on follow-up in south Gondar Ethiopia 2023 (N = 401).

Reason	Category	Frequency	Percentage	
Pills burden	Yes	199	49.6	
No	202	50.4	
Lack of time for visit	Yes	170	42.4	
No	231	57.6	
Absence of reminder	Yes	135	33.7	
No	266	66.3	
Fear of cost	Yes	197	49.1	
No	204	50.9	
Perceived home distance	Near	119	29.7	
Far	190	47.4	
Not sure	92	22.9	
Perceived symptoms	Yes	157	39.2	
No	244	60.8	
Lack of proper instructions for follow‐up	Yes	201	50.1	
No	200	49.1	
Aware of consequences of missed appointments	Yes	225	56.1	
No	176	43.9	
Aware of complications of hypertension	Yes	214	53.4	
No	187	47.6	

Factors associated with non-adherence to appointment follow-up in Hypertensive patients on follow-up clinic

Hypertensive patients who had no symptoms were five times more likely to miss their hypertensive follow-up than patients who had symptoms [AOR = 4.98; 95% CI = (2.888, 8.59)]. Those hypertensive patients who complained of pill burdens [AOR = 3.50, 95% CI = (2.108, 5.825)] were 3.5 times more likely to miss their appointment follow-up than those who did not complain. (Table 4).Table 4 Bivariate and multivariable logistic regression output on the association between non-adherence to appointment and its factor on hypertensive follow-up south Gondar (N = 401).

Variable	Category	Appointment	COR (95% CI)	AOR(95% CI	p-value	
Adherent	Non-adherent	
Residency	Urban	135	109	1			
Rural	55	102	2.3(1.52–3.47)	1.7(.99–2.913|)	0.053	
Home distance from hospital	Near	93	26	1			
Far	92	98	3.81(2.266–6.406)	2.53(1.349–4.743)	0.004*	
Nut sure	59	33	2.01(1.088–3.677)	1.57(0.769–3.210)	0.215	
Health Insurance	Yes	143	72	1			
No	101	85	1.67(1.116–2.504)	1.44(0.856–2.414)	0.170	
perceived symptoms	Yes	132	112	1			
No	25	132	6.22(3.789–10.22)	4.98(2.888–8.590)	0.000***	
Forget the appointment	No	176	90	1			
Yes	68	67	1.93(1.263–2.939)	1.43(0.879–2.326)	0.150	
Pill burdens	No	148	54	1			
Yes	96	103	2.94(1.937–4.465)	3.50(2.108–5.825)	0.000***	
Awareness of consequences of missed appointments	Yes	168	57	1			
No	76	100	3.88(2.540–5.922)	1.50(0.849–2.644)	0.163	
Awareness of complications hypertension	Yes	167	47	1			
No	77	110	5.08(3.284–7.845)	2.62(1.471–4.673)	0.001**	
COR: Crude odds ratio, AOR: Adjusted odds ratio, CI: Confidence interval, *P < 0.05, **P = 0.001, ***P = 0.000.

Discussion

Suboptimal adherence is a key contributor to poor controlled blood pressure and the major obstacle to the effective management of hypertension27. This study aimed to assess the adherence to follow-up appointments among hypertensive patients. Hypertensive patients’ compliance with the clinic’s follow-up visits is associated with better blood pressure control23. In this study, the prevalence of missed appointment hypertensive follow-up in more than 30% of their scheduled follow-up appointments was 39.2% which was greater than the study conducted in Nigeria which was 16.7%22. This difference may be due to differences in health care systems, health cost, health coverage, sample size, method used, timing, and setting.

In this study patients who lived far from the health facilities were significantly associated with missed medical appointment follow-up which is similar to a study conducted in India and Oman, residence distance from hospital is an important predictor for missed appointments2,19. Distance from the hospital; was associated with the adherence behavior of patients28. The absence of perceived symptoms is the other reason that hypertensive patients missed appointment follow-up in this study. An individual’s illness perception may affect adherence to follow-up and treatment which is vital to prevent complications2,29,30. The findings of this study also showed pill burden is associated with poor appointment adherence. The hypertensive patients who complained of pill burdens were non-adherent to their appointment follow-up in the hypertensive follow-up clinic. Likewise, Single-pill combination therapy leads to improved treatment compared with free-equivalent combination therapy31,32. An increased number of prescribed antihypertensive drug fixed-dose combination drugs is related to the higher rate of non-adherence to treatment33. Another study revealed that adherence to polyp ill therapy was significantly higher compared to multi-pill therapy34. The finding in this study revealed that inadequate information about the complications of hypertension is a related factor in missed medical appointment follow-up in hypertension patients. Similarly, other studies showed patients’ knowledge and awareness of hypertension treatment and complications are determinant factors for effective blood pressure control35,36. Additionally, the findings show that most hypertensive patients are not aware of the risk factors, complications, and preventive measures of hypertension37.

Limitations of the study

There is a potential limitation of on sampling technique in which a simple random sampling technique was employed without considering the variation of the study population due to funding constraints and financial scarcity. Also, there is a short duration of the study period due to the nature of the study design as a limitation.

Conclusion the prevalence of non-adherence to appointment follow-up in hypertension is high as compared to different national health policies and chronic disease guidelines and recommendations which state that all hypertension patients should strictly adhere to follow-up. Distance from the health facility, absence of perceived symptoms, Pill burdens, and lack of knowledge about complications of hypertension were significantly associated with missed appointment follow-up in Hypertensive patients.

Author contributions

GK and KS participated in the conception and design of the study, obtaining funding, acquisition, analysis, and interpretation of the data, and drafting the manuscript. GS and EG participated in the conception and design of the study, obtaining funding and revising the manuscript critically. And BB participated in, the analysis and interpretation of data.

Data availability

The raw data generated in this study are not shared publically due to confidentiality but will be available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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