THE ROLE OF PHARMACISTS IN HYPERTENSION MANAGEMENT

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Jagessar et al. World Journal of Pharmacy and Pharmaceutical Sciences

THE ROLE OF PHARMACISTS IN HYPERTENSION MANAGEMENT

R. C. Jagessar*1, A. Ali

2, K. Agard

2, D. McGowan

2 and L. Perry

2

1Department of Chemistry, University of Guyana.

2Final Year Pharmacy Research Students, 2014-2015.

ABSTRACT

Hypertension a risk factor for heart diseases which are the causes of

death, has gained both regional and national attention over the years.

This problem developed from poor dietary practices, stressful

lifestyles, inactivity and poor health management. The objective of this

study is to investigate the perceptions many patients have about a

Pharmacist and also to educate or re-educate the health care team and

patients of the role pharmacists play in the management of

hypertension in Guyana. The sample population covers persons of

different socio-demographic backgrounds that usually visit either the

community pharmacies or are a part of the public hospital clinics. A cross-sectional

descriptive study was conducted in the three most populated Regions of Guyana: Region 4,

Region 6 and Region 10. A total of one hundred and fifty (150) hypertensive patients were

selected and ten (10) interviews in person were conducted over a four weeks period with ten

(10) Pharmacists. Fifty (50) were between the age range 51-60, Forty (40) were between the

age range 21-30, Thirty (30) were between the age range 61-70, Fifteen (15) were between

the age range 41-50, Ten (10) were older than 70 and Five (5) were between the age range

31-40. Sixty (60) of the respondents were males and ninety (90) of the respondents were

females. Sixty (60) of the respondents were of African descent, Thirty Five (35) were mixed

individuals and Fifty Five (55) were of East Indian descent. Results were statistically

analysed for mean, standard deviation (SD), significance difference within and between

groups. Some of the interviews were favourable, whilst others were unfavourable. For

example, in response to the questions, “What perceptions do Guyanese have on the general

role of the Pharmacist and the role of the Pharmacist in hypertension management ? ”, 35%

of the participants believe that the Pharmacy is mainly a business, while 65% believe it to be

an Health Care Facility with regards to hypertension management. “Are there any non-

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 9, Issue 8, 190-205 Research Article ISSN 2278 – 4357

Article Received on

02 June 2020,

Revised on 23 June 2020,

Accepted on 14 July 2020

DOI: 10.20959/wjpps20208-16734

*Corresponding Author

R.C. Jagessar

Department of Chemistry,

University of Guyana.


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traditional therapies for hypertension being used in Guyana currently ? “ 45% were in favour

whilst 55% disagree. “Is the diet the biggest contributing factor that causes hypertension ?”,

70% were in favour whilst 30% were not in favour, “Can access to patient summary record

helps Pharmacists to better promote better drug therapy ? ”, 90 % of the Pharmacists were in

favour whilst 10% disagree. “What are the current procedures for community and clinical

pharmacists in dealing with hypertension cases?“. All Pharmacists (100%) agreed that the

patient‟s current blood pressure must first be interpreted. Participants have benefitted from

the survey, designed to educate and re-educate persons on the role of the pharmacist in

hypertension management. It‟s anticipated that they would make wiser alternative diet and

lifestyle choices as well as being able to take full advantage of the services and assistance of

the pharmacists.

KEYWORDS: Hypertension, hypertension management, patients, pharmacists, regions,

socio-demographic.

1.0. INTRODUCTION

The World Health Organization, WHO clearly defines hypertension or high blood pressure as

a transitory or sustained elevation of systemic arterial blood pressure to a level likely to

induce cardiovascular damage or other adverse consequences.[1-7]

This level mainly ranges

between systolic blood pressure above 140 mmHg and a diastolic blood pressure above 90

mmHg. It is caused by a number of risk factors including poor dietary practices, age, family

history, poor adherence to hypertensive medications and ethnic origin.

Hypertension, for several decades, has been globally recognized as the most prevalent

cardiovascular disease with potent complications such as coronary heart disease, stroke,

sudden cardiac death, congestive cardiac disease, renal insufficiency and dissecting aortic

aneurysm. It remains a major public health issue in many developing countries including

Guyana.[8]

Recently, it was estimated that approximately 972 million adults are living with

high blood pressure and in 2002, it was named „the number one killer‟ by the World Health

Organization (WHO) in the World health report. The proportion of the world‟s population

with high blood pressure, or uncontrolled hypertension, fell modestly between 1980 and

2008. However, because of population growth and ageing, the number of people with

uncontrolled hypertension rose from 600 million in 1980 to nearly 1 billion in 2008 (World

health Organization).


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Approximately100, 000 persons are treated for hypertension annually with 15, 000 being new

cases.[6]

Concerns were raised for Guyanese who continuously consume approximately 10

grams of salt per day, contrary to the prescribed four to six grams, since the intake of high

levels of salt is one of the main contributing factors to hypertension.[8]

This condition can exist as Primary or Secondary hypertension. Approximately 90-95% of

adults are reported with Primary or Essential hypertension while Secondary hypertension

accounts for 5-10% of the cases.[1-7]

Primary hypertension is described as an asymptomatic

condition but also appears to be the outcome of an interaction between complex genetic and

environmental factors, whereas secondary hypertension is caused by a specific underlying

mechanism which involves the kidneys or endocrine system.[1-7]

The manual blood pressure monitor is composed of an inflatable pressure bag (the band)

attached to a sphygmometer, pump and stethoscope. In most cases a normal blood pressure

reading is considered to be 120mmHg systolic and 80mmHg diastolic, however, a blood

pressure reading above 140mmHg systolic and 90mmHg diastolic may be an indication of

hypertension.

This condition is also referred to as the “silent killer” since many individuals partake in their

daily activities without displaying any signs or symptoms for years. However, it can be easily

detected and managed by health personnel‟s including the Pharmacist. “Community

pharmacists are the most accessible of all health care professionals and are located in nearly

every community and neighborhood” which is very convenient for many patients.[8]

Moreover, It is becoming more common for community pharmacists to work directly with

specific physicians who refer patients to them. In these collaborative relationships,

pharmacists may measure blood pressure, adjust dosages and alter the antihypertensive

regimen via protocols.[9-12]

In addition, a number of authors have also suggested that non-physician health personnel

such as pharmacists can provide many services traditionally offered only by physicians. Since

the adequate care of hypertensive patients depends on use of antihypertensive drugs, more

professional involvement of well-motivated and trained pharmacists should benefit

hypertensive patients.[9]

Therefore, improvements in innovative techniques involving the

Pharmacist such as patient education, blood pressure monitoring, drug therapy and


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compliance assessment will improve the health in hypertensive patients and also minimize

the number of cases reported annually.

The implication and management of hypertension is a cause for concern for virtually all

Guyanese, as the number of persons affected by this disease has reached staggering heights.

This paper will seek to outline the role that Guyanese pharmacists can play in hypertension

management.

The purpose of the study is to educate/ re-educate doctors, pharmacists, patients and patient

care givers of the role pharmacists can play as it relates to hypertension management. It will

provide information to the target group about alternative treatment and management regimens

for hypertension. Providing resource materials for persons studying at tertiary institutions is

another aspect of this research.

Guyana is a sovereign state on the northern mainland of South America and is also part of the

Caribbean region. Guyana (83,000 square miles) is bordered by the Atlantic Ocean to the

north, Brazil to the south and southwest, Suriname to the east and Venezuela to the west13

.

Fig 1.0.

Fig. 1.0.: Map of Guyana. www.worldatlas.com/webimage/countrys/samerica/gy.htm.

http://www.worldatlas.com/webimage/countrys/samerica/gy.htm


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2.0 RESEARCH, DESIGN AND METHODOLOGY

2.1 Research Design

The design for this study is cross-sectional in nature, the qualitative and quantitative

approaches of this research design were taken in order to fully examine and find the

perceived role of the pharmacist in hypertension management along with the status of

hypertension in Guyana. A Cross- sectional study is “a study in which a statistically

significant sample of a population is used to estimate the relationship between an outcome of

interest and population variable as they exist at one particular time.[14]

Since it was

impossible for the researchers, within the constraints of time and money to collect

information from all pharmacists and hypertensive patients, a sample population was chosen

to participate along with the data from existing records from the records department of the

Georgetown Public Hospital Cooperation. Those pharmacists who give their consent were

interviewed at their place of work or any other convenient place. Within this research, a total

of five (5) research questions were created after numerous information was gathered on the

topic. These research questions later formed a guide in creating a questionnaire and interview

which were used to provide the answers to the questions asked. The hypertensive patients

were selected from three hospital clinics and three community pharmacies and they were

asked to participate in filling the questionnaire.

Qualitative research is an inquiry approach useful for describing trends and explaining

relationships among variables.[15]

While a qualitative approach has proven useful to acquire

findings of this study, the quantitative approach was also necessary, as it allowed researchers

to acquire and use statistical data during the investigation.

In this study, the independent variable refers to the services offered by pharmacists and the

dependent variable is the perception of the general public on the role of the pharmacists. The

study has determined a link between how the services offered by the pharmacists have

influenced what the population perceives their role to be.

Table 2: Table showing the Overview of the Research Design.

Study type Cross-sectional Study

Study Length 4 weeks

Study Location Region 10, Region 4 and Region 6

Participant Demographic Hypertensive patients between ages 35 to 75

Number of participants 160

Participant Recruitment Strategy Selective


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Research Instrument Questionnaire and Interview

Method of Data collection Questionnaire and interview

Unit of Analysis Bio-statistical methods

2.2 Assumptions

The following are assumptions that were made for the study.

The target group chosen is relevant to the study.

The instruments used for data collection are reliable and valid.

The information provided to target group after study will effect change in their attitudes

towards the role of the pharmacist in hypertension management also towards treatment

options and goals.

2.3. Limitations of the Study

The limitations of the studty are that the findings of the study are limited to the Regions and

group of people who make up the sample population and therefore cannot be generalized to

all of Guyana. In addition, the findings are limited to the responses provided by the

respondents and this may be subject to the Hawthorne effect, since participants are aware that

they are taking part in a study and this may subdue their typical response.

2.4. Variables: The Independent Variables were: Patient perception of hypertension, blood

pressure reading, Lifestyle and role of the Pharmacist. The Dependent variable is

hypertension.

2.5. The Population

The population for this study comprised of ten (10) Pharmacists and one hundred and fifty

(150) hypertensive patients collectively from the study area of region four (4), region six (6)

and region ten (10) of Guyana. This study population is relevant, as it takes into consideration

the more populated regions of Guyana as well as the fact that the areas are most convenient

for the researchers. Also persons from these areas have definite access to health care facilities

and professionals which include the pharmacist. The bio-data revealed that of the one

hundred and fifty (150) participants, Fifty (50) were between the age range 51-60, forty (40)

were between the age range 21-30, thirty (30) were between the age range 61-70, fifteen (15)

were between the age range 41-50, ten (10) were older than 70 and five (5) were between the

age range 31-40.


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The additional information this section provided were the ethnicity and gender of the patient.

From the responses, it was seen that sixty (60) of the respondents are males and ninety (90) of

the respondents are females. Additionally, sixty (60) of the respondents are of African

descent, thirty five (35) are mixed individuals and fifty five (55) are of East Indian descent.

Thus, it is seen that majority of the sample population is African females between the age

range 51 and 60.

Pharmacists: Ten well qualified pharmacists from established agencies and organizations

that have been practicing for a minimum of five (5) years made up the sample population. As

expected these pharmacists gave valuable insight on the perception of the profession as well

as the expected conduct of the pharmacist as a whole.

Patients: A purposeful sample method was utilized to achieve a study population that mimics

the distribution ratio of the country‟s population in these three regions. With 67% (100

participants) of the population being from region four, 20% (42 participants) from region six

and 13% (28 participants) from region ten. Hypertensive patients from one hospital blood

pressure clinic and one community pharmacy in each region were respectively employed.

2.6. The Instruments

In this study the researchers used both a questionnaire and an interview. The questionnaires

were administered to the hypertensive patients at hospital clinics and blood pressure testing

customers at community pharmacies. These instruments were selected as the most

appropriate for collecting the relevant data required to answer the research questions posed

for this study. The instruments were constructed by the researchers and were used to gather

data on hypertension and the perception of the population on the role of the pharmacist in

hypertension management.

The interview was carried out on reputable pharmacists in Guyana so as to gain valid

information on the expected code of conduct for pharmacists when dealing with hypertension

cases and the proposed role of the pharmacist in general.

2.7. Description of the Instruments

Questionnaire

Structurally the questionnaire consisted of five sections, A, B, C, D, E respectively. The

sections relating to bio data and general hypertension knowledge implemented close-ended


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questions while sections C, D and E relating primarily to the core of the research and the

research questions implemented the use of a modified 5 point Likert rating scale of orderable

discreet variable, that is, an instrument that comprises of statements that permit responses to

be graded along an agree-disagree continuum.[16]

The questionnaire comprised 30 items. As a data collecting instrument, “a questionnaire is a

means of eliciting the feelings, beliefs, experiences, perceptions, or attitudes of some sample

of individuals.[17]

”

It is most times “a very concise, preplanned set of questions designed to yield specific

information to meet a particular need for research information about a pertinent topic.[17-18]

Interviews

Additionally, the interview contained four open-ended questions. An interview is a direct face

to face attempt to obtain reliable and valid measures in the form of verbal responses from one

or more respondents.[17]

Structured questionnaires and semi-structured interviews are often used in mixed method

studies to generate confirmatory results despite differences in methods of data collection,

analysis and interpretation. Questionnaires can provide evidence of patterns amongst large

populations, qualitative interview data often gather more in-depth insights on participant

attitudes, thoughts, and actions.

3.0. Results and Analyses: The results obtained are shown in Tables 1.0 to 6.0.

Statistical analyses are shown in Tables 7.0 to 11.0.

Table 1.0.

Study Population Name of Region Number of Participants

Region 4 Demerara/Mahaica 100

Region 6 East Berbice/Corentyne 30

Region 10 Upper Demerara-Berbice, Linden 20

Pharmacists 10


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Table 2.0. The pharmacy is a health care Facility.

Questions Responses

The pharmacy is a

health care Facility A D SD SA

Region 4 A 20 20 0 0

Region 4 B 40 0 8 12

Region 6 15 3 0 12

Region 10 10 2 6 2

Mean with

Standard

Deviation

21.25 ± 13.15 6.25 ± 9.25 3.5 ± 4.12 6.5 ± 6.40

Table 3.0.: Pharmacists are drug specialists and should hold authority on all drugs.

Questions Responses

Pharmacists are drug

specialists and

should hold authority

on all drugs

Region 4 A 20 4 4 12

Region 4 B 40 0 0 20

Region 6 15 3 9 3

Region 10 12 0 2 6

Mean with Standard

Deviation 21.75 ± 12.60 1.75 ± 2.06 3.75 ± 3.86 10.25 ± 7.5

Table 4.0.

Questions Responses

Pharmacists have the authority to

question a doctor’s prescription.

Region 4 A 24 16 0 0

Region 4 B 36 24 0 0

Region 6 12 18 0 0

Region 10 4 16 0 0

Mean with Standard deviation 19 ± 14 18.5 ± 3.79 0 ± 0 0 ± 0

Table 5.0.

Questions Responses

Pharmacists are only responsible

for country pills and dispensing

Region 4 A 12 0 28 0

Region 4 B 16 0 44 0

Region 6 9 0 21 0

Region 10 6 0 14 0

Mean with Standard Deviation 10.75 ± 4.27 0 ± 0 26.75 ± 12.84 0 ± 0


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Table 6.0.

Questions Responses

There are effective traditional

treatment for Hypertension. A D SD SA

Region 4 A 12 16 8 4

Region 4 B 16 12 28 4

Region 6 15 3 3 9

Region 10 8 0 12 0

Mean with Standard Deviation 12.75 ± 3.59 7.75 ± 7.5 12.75 ± 10.81 4.25 ± 3.69

Key:

A: agree

D: disagree

SA: strongly agree

SD: strongly disagree

Table 7.0.

Question F-value P-value F-critical

The pharmacy is a health care Facility

Source of variation between groups 3.26 0.0594 3.490

Source of variation within groups 0.0 0.0 0.0

Table 8.0.


Pharmacists are drug specialists and

should hold authority on all drugs



Table 9.0.


Pharmacists have the authority to

question a doctor’s prescription.



Table 10.0


Pharmacists are only responsible for

counting pills and dispensing




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Table 11.00.


Question: There are effective traditional

treatments for Hypertension.



Graphs

Graph 1.0: Showing the response as it corresponds to Traditional Hypertension

Treatment.


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Graph 2.0.: Showing the response as it pertains to diet as a contributing factor of

hypertension.

3.0. DISCUSSION

The results are tabulated in Tables 1.0 to 6.0 with mean and standard deviation (SD). Tables

7.0 to 11.0. indicate the P and F values to confirm whether there is significance difference

between groups or within groups as it pertains to each research question. When the P value is

less than 0.05, there is a significance difference between the groups and within the groups. As

mentioned, several research questions were asked and these can be discussed.

“The Pharmacy is a health care Facility”. Table 2.0, addresses this. It is seen that Region

4B had the highest positive responses 40 (26.67%), followed by Region 4A with 20 (13.33%)

and the least in Region 10 (6.67%). The highest number that disagree, 20 (13.3%) was from

Region 4A, whereas the lowest of 0 (0%) was from Region 4B. Statistically, a P value of

0.0594 was obtained, indicating that there is no significance differences in the response

between regions. This was further supported with an Fvalue (3.26) < Fcritical (3.49).


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“Pharmacists are drug specialists and should hold authority on all drugs”

Again the highest value of 40 (26.6%) agreed with the above statements and these were from

Region 4B, whereas the lowest of 12 (8%), was from Region 10, Table 3.0. The highest

number that disagree, 4 (2.6%) was from Region 4A, whereas the lowest of 0 (0%) was from

Region 4B and Region 10. Statistically, a P value of 0.012696 < than 0.05 was noted. This

indicates that there wasn‟t any significant differences in responses for the selected areas.

Also, the F value (3.490295) < F critical (5.54623) and further supporting the trend in

significance difference.

“Pharmacists have the authority to question a Doctor’s prescription”

Region 4B showed the highest positive response, 36 (24%), whereas lowest number that

agree was from Region 10, 4(2.67%). The highest number that disagree, 24 (16%) was from

Region 4B, whereas the lowest number that disagree, 16 (10.6%), was from Region 4A and

Region 10. Statistically, a P-value of 0.002215 (< 0.05) was obtained, indicating that there

wasn‟t any significant differences. In addition, the F value of 3.490 is less than F critical,

8.917591, Table 9.0.

“Pharmacists are only responsible for counting pills and dispensing”

Region 4B, showed the highest positive response, 16 (10.67%), whilst Region 10 showed the

lowest, 6%, positive response. With respect to the disagree responses, zero (0%) was noted,

Table 5.0. Statistically, a P value of 0.000322 < 0.05 was obtained, Table 10.0. This was

supported by F value = 3.490295 < F critical (13.9635).

“There are effective traditional treatment for hypertension”

The largest positive response response was noted for Region 4B, 16 (10.67%), whereas the

lowest of 8 (5.3%) was noted for Region 10. The highest number that disagree was from

Region 4A, 16 (10.67%), whereas the lowest number of 0 (0%) was from Region 10, Table

6.0. This is also reflective in Graph 1.0. Statistically, a P value of 0.0295998 was obtained,

showing that there was no significant difference between the values. In addition, F value

(1.380634) is less than F critical (3.490295), Table 11.0. Other questions were asked and

these were.

“Are there any non-traditional therapies for hypertension being used in Guyana

currently?” Sixty eight (68) agree that there are effective treatments. Some of these

treatments were stated as eating cucumber without salt, drinking lime in warm water and


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eating or consuming juice made of bilimbee. While these non-conventional methods may

prove helpful from time to time, their precise mechanism of action is unknown. Additionally,

also in severe to uncontrolled cases these treatments only tend to be insufficient.

“Is diet the biggest contributing factor that causes hypertension?”. Most of the participants

agreed that diet is the biggest contributing factor that causes hypertension. This signifies that

although persons are aware that much caution should be taken with their diet, they somehow

still make poor dietary choices. This may be as a result of cultural norms. The Caribbean

cuisine is a combination of foods from all the various ethnic groups that now inhabit there.

Graph 1.0. shows the diet as a contributing factor of hypertension. The graph shows that the

largest number of patients that agreed, 12 (8%), was from Linden, whereas the lowest that

disagree, 0 (0%) was from both Georgetown A and Linden. The highest number that

disagree, 20(13.33%) was from Georgetown B.

“What are the current procedures for community and clinical pharmacists in dealing with

hypertension cases?” While there is no current standard operational procedure for dealing

with hypertension case, there was homogeneity in the responses of the pharmacists in how

they handle hypertension patients. It was agreed, that for known hypertensive patients,

whenever a blood pressure test is requested, the pharmacist would simply perform the test,

inquire on current medications and adherence then refill medication supply if necessary.

For new cases, after testing and recording a higher than normal reading, the pharmacist would

do a short interview on potential causes and in most cases, recommend a traditional remedy

for short term regularization. However, if the reading is indicative of Secondary Stage 2

hypertension that is a reading of more than 160 systolic and 100 diastolic, the individual is

immediately referred to the doctor.

“Can access to patient summary records help pharmacists to better promote better drug

therapy?” The responses revealed that while the majority of the pharmacists agree that this

change can lead to improved health care, a small number of pharmacists still feel this may

prove to be futile if disease states are too far progressed. In very rare cases, pharmacists admit

to administering drugs for immediate relief. One such drug is Nifedipine 10 to 20 mg

sublingually. Nifedipine is a simple effective and safe alternative drug for managing

hypertensive emergencies especially when continuous monitoring of the patient cannot be

guaranteed. This is ideal for the community pharmacist. Many countries especially England


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has now allowed community Pharmacists to access patient records. Following a study that

ultimately supported same; the practice eliminates prescribing error and possible drug

interaction.

5.0. CONCLUSION

Based on the findings, the researchers concluded that the participants of this study have

benefited from the program which was designed to educate or re-educate persons on the role

of the pharmacist in Hypertension management. The fact that the participants were

empowered with a wealth of knowledge on the scope of the pharmacist as well as better

dietary practices, it can be concluded that they are no longer in a position of ignorance

therefore we expect them to make wiser alternative diet and lifestyle choices as well as being

able to take full advantage of the services and assistance the pharmacist has to offer. The

findings of the study should encourage health officials to take a holistic view on how

pharmacist intervention can improve this current phenomenon and put workable systems in

place to correct these actions.

6.0. ACKNOWLEDGEMENT

Special thanks are extended to the pharmacists who facilitated this investigation by the filling

of the interview sheets; as well as the patients and other health professionals who participated

by filling the questionnaires. The community pharmacies that allowed access to their

customers and resources.

7.0. REFERENCES

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