Role of perceived spousal social support in medication adherence among hypertensive patients attending family medicine clinic in federal teaching hospital, ido-ekiti, Nigeria

Background: There abound many strategies to control hypertension, however, many patients still have diffi culty adhering to medications and this results to poor Blood Pressure (BP) control. And because the condition requires life long treatment, many patients need additional effort from their spouses. The spouse shares intimacy with patient and is the chief source of social support that provides fi nancial assistance, reminds and encourages medication use, shows concern and interest by discussing issues related to the disease. Therefore, exploring the role of perceived spousal social support in medication adherence will help the physician and other stakeholders harness the gains of this association to achieving BP control, prevent complications and death. Objectives: To determine the relationship between Perceived Spousal Social Support (PSSS) and Medication Adherence (MA) among hypertensive patients attending Family Medicine Clinic in Federal Teaching Hospital, Ido-Ekiti, Nigeria. Materials and methods: It was a hospital based cross sectional analytical study carried out among 298 hypertensive patients aged between 18 and 65 years between June and August 2016 at the Family Medicine Clinic of the Federal Teaching Hospital, Ido Ekiti. Data collection was done using pre-tested, semi-structured questionnaire on sociodemographic characteristics, blood pressure measurement, Morisky Medication Adherence Scale (MMAS-8) for medication adherence and a 4-point Likert Social Support questionnaire for compliance to measure the perceived spousal social support. Data was analysed using SPSS IBM version 17.0. Results: The mean age of respondents was 56.0 ± 8.5 years. Overall, there was a statistically signifi cant relationship between PSSS and MA (χ2 = 17.93, p < 0.001). Gender and PSSS were found to be independent predictors of MA. Conclusion: Spousal social support impacts positively on medication adherence, therefore exploring this social resource will improve MA and the management outcomes of hypertension. Research Article Role of perceived spousal social support in medication adherence among hypertensive patients attending family medicine clinic in federal teaching hospital, ido-ekiti, Nigeria Ekundayo OO1*, Elegbede OT2, Gabriel-Alayode OE2, Agboola SM2, Shabi OM2, Bello IS2,3, Omosanya OE2, Ajetunmobi OA2 and Fashola AM2,4 1Emergency Department, University Hospitals of Morecambe Bay, Furness General Hospital, United Kingdom 2Family Medicine Department, Federal Teaching Hospital, Ido-Ekiti, Nigeria 3Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria 4African Field Epidemiology Network (AFENET), Nigeria Received: 28 August, 2020 Accepted: 11 September, 2020 Published: 14 September, 2020 *Corresponding author: Dr. Ekundayo OO, Emergency Department, University Hospitals of Morecambe Bay, Furness General Hospital, United Kingdom, Tel: +2348022808534, +447459666171; E-mail: https://www.peertechz.com


Introduction
Thoits defi ned social support as -emotional, informational and practical assistance from signifi cant others, such as family members, friends or co-workers, and that support actually may be received or simply perceived to be available when needed [1]. Spousal social support is the degree to which interpersonal relationship with one's spouse or partner serve the purpose of providing emotional, informational or instrumental support for an individual [2]. Medication adherence is the extent to which a person's behaviour of taking of medications, following a dietary plan, and/or executing lifestyle with respect to the timing, dosage, frequency, and duration of a prescribed medication conforms with the agreed recommendations by a health care provider [3]. In a meta analytical study on social support and adherence to treatment in hypertensive patients, functional social support was associated with medication adherence [4]. Danielle and colleagues in a qualitative analysis of peer reviewed journals on the association between different types of support and medication carried out among Americans reported that, practical/tangible support such as fi nancial support was associated with high medication adherence [5]. A cross-sectional survey using self-reported questionnaire also found that cumulative perceived functional spousal support such as fi nancial support for drug purchase, having someone to talk to about hypertension, showing concern, interest in one's spouse and reminding patients to use drugs lower the odds of high blood pressure [6]. Though the association between family social support, hypertension and medication adherence have been widely studied, there is, however paucity of data specifi cally on the role spouses play in medication adherence among hypertensive patients, therefore this study will serve as a template and encourage more researches in this area so as to reduce the morbidity and mortality among this group of people. This study identifi ed the role of perceived spousal social in medication adherence among hypertensive patients in Ekiti State, Nigeria.

Study area and design
This study was conducted among adult hypertensive patients 18- The clinic has seven consulting rooms with a semi-detached 10-bedded ward for short inpatient admission.

Sample size estimation
The sample size of 298 was determined using the formula [8]. The minimum sample size was 271 and with the addition of an attrition rate of 10%, it came to 298 respondents for the study.

Sampling method
Systematic random sampling technique was used to recruit subjects among hypertensive patients attending the clinic.
In the General Outpatient medical record of the hospital, 15 hypertensive patients attended the clinic daily, which translated to 75 patients per week using the lower limit and 900 within the 12-week period of the study. A sampling interval (K) was calculated using the formula: K = N / n Where: N = total number of patients and n = calculated sample size. Therefore K = 900 / 298 = 3.
Every 3rd hypertensive patient who met the inclusion criteria was enrolled for this research and fi ve patients were recruited daily. In selecting the fi rst participant each day, balloting technique was used in which three small papers were rolled, one was labelled 'Yes' and the other two had 'No' written in them. Using the balloting system for the fi rst three hypertensive patients on the attendance list for each day, the patient who picked 'Yes' was seen fi rst, thereafter, every 3 rd hypertensive patient was enrolled until the required number for the day was attained. For selected participants who declined to participate, he or she was given appropriate treatment, but was not included in the study. The next patient on the list was then selected for study. This was repeated every clinic day until the sample size was completed. The case fi le of each of the selected participants was tagged using a red colour code to prevent a second recruitment. By the end of the 12 -week period, the required number of subjects (n= 298) was attained.

Research protocol
Four bilingual (English and Yoruba) research assistants who were; two junior resident doctors and two nurses were recruited and trained by the researcher for two days for the purpose of pretesting and sorting of participants, data collection and questionnaire administration during the study.
A written informed consent was obtained by the researcher from willing participants using the information sheet as guide. The researcher also assured them of confi dentiality of the information provided. On daily basis, the nursing research assistants sorted out the clinical records of all hypertensive patients and applied the inclusion criteria. The selected patients were invited into a seminar room where the researcher introduced them to the study, screened them for exclusion criteria and took informed consent. Those who did not meet the criteria or declined consent were not included in the study, but were given treatment as appropriate. Using the sampling technique, fi ve participants were recruited per day.
The respondents were then given the routine medical care for hypertension and thereafter the researcher documented the socio-demographic and the BP of participants using section A and B of the questionnaire. The participants were then led to a consulting room where a junior resident conducted an exit interview on them using the MMAS-8 questionnaire for medication adherence in section C and Perceived Spousal Social Support Scale to determine the level of Perceived Spousal Social Support in section D. sensitive in detecting BP control at p value of < 0.05 [10]. The tool has been particularly useful in chronic conditions such as hypertension and has been used in Nigeria [11]. Each response was scored 'Yes' or 'No' as 0 or 1 respectively except item number 5 in a reverse code response. For instance, if item 5 = 0 Item 5r = 1 (high adherence). Item number 8 also had a standardised code as explained in the tool. The scoring scale has a range of 0 to 8. The medication adherence level scores for individuals were calculated and summed up to give the total adherence score as low adherence (< 6), medium adherence (6 to < 8) and high adherence as (8). Section D was the perceived spousal social support questionnaire used to assess the level of the perceived spousal support. It is a 4-point Likert-type adapted from the Social Support questionnaire for compliance, which has been used in Nigeria [12].

Participants' selection and collection of background information
The four domains of the PSSS were combined in a construct such that the higher the score, the stronger the level of PSSS.
The maximum score was 12 and 4 was the minimum with PSSS score of < 5, 5 to 8 and 9-12 as Poor PSSS, Fair PSSS and Strong PSSS respectively.

Blood pressure estimation
The researcher used Accosson® brand of Mercury Sphygmomanometer to measure the blood pressure of participants in sitting position using the left arm with a stethoscope and appropriate blood pressure cuff after at least 208 https://www.peertechz.com/journals/archives-of-community-medicine-and-public-health Citation: Ekundayo  The blood pressure cuff was at the level of patient's heart and the forearm was rested on a table, the brachial pulse was palpated in the antecubital fossa of the arm, and the cuff was infl ated to 20mmHg above the point at which the brachial pulse disappeared. The cuff was defl ated and the pressure at which the pulse re-appears was noted (rough systolic

Data analysis
The were adherent (medium and high adherence).
Overall, there was a statistically signifi cant relationship between perceived spousal social support and medication adherence (2 = 17.93, p < 0.001). It was found that the stronger the PSSS, the better the medication adherence.
Majority of respondents, 43.9% whose spouses were not very helpful fi nancially had low medication adherence and this was statistically signifi cant (2 = 20.08, p < 0.001). In the same vein, more than half, 52.0% of respondents whose spouses were not very helpful in reminding them to use their medications had low medication adherence and this was statistically signifi cant (2 = 24.73, p < 0.001).
Gender and perceived spousal social support were independent predictors of medication adherence among the respondents. The female gender was about 13 times more likely to achieve medication adherence than the male counterpart.
Similarly, it was demonstrated that participants with strong spousal social support were 7 times more likely to achieve medication adherence Tables 1-6.

Discussion
The result of this study showed that the mean age of respondents is 56.0 ± 8.5 years and this is comparable with the work done by Ojo et al in Abeokuta, which found an overall mean age of 55.4 ±10.5 years in a study conducted among hypertensive patients [13]. In a related study to determine  the link between social support and adherence to medications among hypertensive patients, Ofoli et al reported a mean age of 56 ± 11.6 years [14]. This observation is not surprising because reports from similar studies have shown that the prevalence of hypertension increases with age in most populations [15][16][17]. However, this result is higher than that in Ibadan which reported 42.1 ± 21.6 years and in Enugu where 43.8 ± 13.7 years was noted [18,19]. This difference could be accounted for probably because these were community-based studies. Also the fact that larger participants, including the younger population in these semi-urban areas were recruited and data was collected on other CVD risk factors such as body mass index and cholesterol level which not only affect the middle aged population but also the younger people [19]. The mean age in this study was lower than 64.7 years reported in a study in Ireland [15]. This may be explained by lower life expectancy in Nigeria when compared to the developed world.
The study's fi nding of female preponderance of 70.1% is in keeping with previous reports of female dominance compared with their male counterparts in most hospital-based studies [20,21]. This fi nding supports the study in Northern Nigeria which reported that 75% of hypertensive patients were females [14]. This deduction suggests that women exhibit more health caring attitude and have enough time to visit the clinic than men, this was further supported by cross sectional studies in Spain and the US where similar fi ndings were reported [21,22].
However, in another related study on the appraisal to determine the level of BP control in a hospital-based prospective study among 207 hypertensive outpatients in Port Harcourt, South-South Nigeria, a lower female predominance of about 52% was reported [20]. This is not unrelated to the high concentration of women in the rural area where this study was conducted in contrast with the urban area like Port Harcourt where the younger ones have migrated to seventy-one percent of the  Mean MA Score ± SD 5.7 ± 2.1    [23].
Seventy percent of respondents in this study attained secondary school education and above. This is similar to 60.2% quoted by Ojo et al in Abeokuta and 63.6% by Fatusin in Ekiti [13,24]. This may be explained by the fact that like any Southwestern State of Nigeria, Ekiti indigenes are well educated. This fi nding could also be because many of the participants enjoyed the free education of the old south-western region. However, Pauline in a community-based cross-sectional descriptive social support and hypertension management study of 440 community residents in Idikan community in Ibadan reported that about 50% of the respondents had no formal education [12]. This difference is obvious going by the hospital-based nature of this study when compared with the one at Idikan, Ibadan.
Most of the participants were either civil servants or traders indicating that Ekiti State is a civil service state and that women, who are known for trading constituted the larger percentage of the study.
The income of participants in this study ranged from N 2,000 to N 200,000 ($ 5-500) while the median income was N 30,000.00 about $ 75 per month ($1 = N 400). This view was also shared by Fatusin et al who found a range of N 10,000 and N 194,000 [24]. This could be attributed to the level of education and the good occupational rate among them, bearing in mind that the monthly minimum wage of an average Nigerian is N 18,000 or $45 or less than two dollars a day [25]. However, about 63% of the respondents lived on a monthly income of ≤ N 50,000. This corroborates Ojo in Abeokuta and Rasaq in Ibadan, in which 64% of their study respondents also earned ≤ N 50,000 monthly [13,26]. Also, in a descriptive cross-sectional study of high blood pressure in a semi-urban area in Uyo, South-South Nigeria, Ekanem et al reported that majority of the participants, 45% earned between N 30,000 and N 50,000 monthly [27]. A Lagos study on the prevalence and socio-demographic profi le of hypertensive outpatients, majority, 45% of the respondents earned less than N 10,000 monthly [28]. The reason for this is probably because many Nigerians are underemployed and live from hand to mouth due to the poor economic state of the country.
The fi nding of half or 76% of the participants having strong or fair/strong spousal social support respectively lays credence to a cross sectional study on BP control and perceived social support conducted by Ojo and colleagues in Abeokuta, Southwest Nigeria in which about 79% of the respondents reported strong perceived social support [13]. This corroborates the fact that Africans have a naturally rich social support network even though could sometimes be without fi nancial capability. The strong family ties of the Yoruba culture and the rural nature of the study area could also be responsible and because the participants were in a marital relationship. A similar study done in Ibadan among the hypertensive patients reported that 93% of the subjects received some social support from family members [12]. Previous research works have also shown that in family-centered societies, people tend to gain support from family members, especially the spouse or the signifi cant other [29,30].
In this study, MMAS-8 scale was used and 22.5% of respondents were found to achieve high medication adherence, and when medium and high adherence were combined as adherent, the proportion rose to 61.1%. Ambaw and colleagues in Gondar Hospital in Ethiopia using a dichotomised version also reported adherence prevalence of 64.6% [31]. Similarly, Rasaq and colleagues in Ilorin, Southwest, Nigeria in a hospitalbased cross-sectional study among 400 hypertensive patients in a Nigerian Family practice setting found an adherence prevalence of 65.5% [26]. Conversely, in Eastern Nigeria it was as low as 43% [32]. These difference might not be unconnected with the small sample size and data collection tools used in Eastern Nigeria.
This study found an association between perceived spousal social support, its four domains and medication adherence to anti-hypertensive medications. Perceived spousal support was also an independent predictor of medication adherence. In the study of social support and adherence among hypertensives in India, social support predicted medication adherence [33].
Likewise, in a meta analytical study on social support and adherence to treatment in hypertensive patients, functional social support as looked into in this work was associated with medication adherence [4]. The likely reason for this fi nding could be that, spouses or the closest other buffer the negative effects of unsatisfactory physician-patient relationship such as too short consultations and stressful interactions with other caregivers. However, Bader and colleagues in the UAE found no such association [34].
Female gender was also found to be an independent predictor of medication adherence. This corroborates earlier work done by Lee in China which that women were reported to have higher odds of medication adherence when compared with the men [35]. Several reasons that could probably explain this are that women are more likely to receive fi nancial support from their spouses to cater for themselves among other things and so much so because they utilise health care services more than men [21,22]. However, this fi nding is in contrast with the work done by Shah which found that males are more likely to adhere to antihypertensive medications [36]. Factors associated with adherence in male patients include less causal attribution to culture, more attribution to risk factors, fewer symptoms and uncertain symptoms related to high blood pressure.
While for women, poor adherence was related to more causal attribution to balance and risk factors, less personal control, cost of multiple prescriptions due to co-morbidites [36]. Therefore, spouses should be made to know that emotional and practical spousal social support is critical to the wellbeing of their hypertensive spouses. They should be encouraged to show concern and interest in the plight of their hypertensive spouses as this will go a long way to improve medication adherence and blood pressure control.

Conclusion
Furthermore, they should also be encouraged to constantly remind their hypertensive spouses to regularly take medications as agreed on by the patient and the doctor. Efforts to harness spousal social support should be encouraged by doctors and other stakeholders in the management of hypertension. Also, once hypertension is diagnosed, the level of spousal social support and medication adherence should be determined as quickly as possible towards the achievement of BP control, prevention of complications and death.