Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence
Identifieur interne : 000296 ( Pmc/Corpus ); précédent : 000295; suivant : 000297Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence
Auteurs : Irene A. Kretchy ; Frances T. Owusu-Daaku ; Samuel A. DanquahSource :
- International Journal of Mental Health Systems [ 1752-4458 ] ; 2014.
Abstract
Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for the development of mental health disorders particularly anxiety and depression. For Ghanaian patients with hypertension, the interaction between hypertension and symptoms of anxiety, depression and stress remains largely unexplored. To fill this knowledge gap, the study sought to ascertain the prevalence and role of these negative emotions on anti-hypertensive medication adherence while taking into account patients’ belief systems.
The hospital-based cross-sectional study involving 400 hypertensive patients was conducted in two tertiary hospitals in Ghana. Data were gathered on patient’s socio-demographic characteristics, anxiety, depression and stress symptoms, spiritual beliefs, and medication adherence.
Hypertensive patients experienced symptoms of anxiety (56%), stress (20%) and depression (4%). As a coping mechanism, a significant relation was observed between spiritual beliefs and anxiety (
The study has demonstrated the need for clinicians to pay attention to negative emotions and their role in medication non-adherence. The recommendation is that attention should be directed toward the use of spirituality as a possible mechanism by which negative emotions could be managed among hypertensive patients.
Url:
DOI: 10.1186/1752-4458-8-25
PubMed: 24987456
PubMed Central: 4077111
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PMC:4077111Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence</title><author><name sortKey="Kretchy, Irene A" sort="Kretchy, Irene A" uniqKey="Kretchy I" first="Irene A" last="Kretchy">Irene A. Kretchy</name><affiliation><nlm:aff id="I1">Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</nlm:aff></affiliation><affiliation><nlm:aff id="I2">Department of Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, College of Health Sciences, Legon, Ghana</nlm:aff></affiliation></author><author><name sortKey="Owusu Daaku, Frances T" sort="Owusu Daaku, Frances T" uniqKey="Owusu Daaku F" first="Frances T" last="Owusu-Daaku">Frances T. Owusu-Daaku</name><affiliation><nlm:aff id="I1">Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</nlm:aff></affiliation></author><author><name sortKey="Danquah, Samuel A" sort="Danquah, Samuel A" uniqKey="Danquah S" first="Samuel A" last="Danquah">Samuel A. Danquah</name><affiliation><nlm:aff id="I3">Department of Psychology, University of Ghana, Legon, Ghana</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24987456</idno><idno type="pmc">4077111</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4077111</idno><idno type="RBID">PMC:4077111</idno><idno type="doi">10.1186/1752-4458-8-25</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000296</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000296</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence</title><author><name sortKey="Kretchy, Irene A" sort="Kretchy, Irene A" uniqKey="Kretchy I" first="Irene A" last="Kretchy">Irene A. Kretchy</name><affiliation><nlm:aff id="I1">Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</nlm:aff></affiliation><affiliation><nlm:aff id="I2">Department of Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, College of Health Sciences, Legon, Ghana</nlm:aff></affiliation></author><author><name sortKey="Owusu Daaku, Frances T" sort="Owusu Daaku, Frances T" uniqKey="Owusu Daaku F" first="Frances T" last="Owusu-Daaku">Frances T. Owusu-Daaku</name><affiliation><nlm:aff id="I1">Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</nlm:aff></affiliation></author><author><name sortKey="Danquah, Samuel A" sort="Danquah, Samuel A" uniqKey="Danquah S" first="Samuel A" last="Danquah">Samuel A. Danquah</name><affiliation><nlm:aff id="I3">Department of Psychology, University of Ghana, Legon, Ghana</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Mental Health Systems</title><idno type="eISSN">1752-4458</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for the development of mental health disorders particularly anxiety and depression. For Ghanaian patients with hypertension, the interaction between hypertension and symptoms of anxiety, depression and stress remains largely unexplored. To fill this knowledge gap, the study sought to ascertain the prevalence and role of these negative emotions on anti-hypertensive medication adherence while taking into account patients’ belief systems.</p></sec><sec><title>Methods</title><p>The hospital-based cross-sectional study involving 400 hypertensive patients was conducted in two tertiary hospitals in Ghana. Data were gathered on patient’s socio-demographic characteristics, anxiety, depression and stress symptoms, spiritual beliefs, and medication adherence.</p></sec><sec><title>Results</title><p>Hypertensive patients experienced symptoms of anxiety (56%), stress (20%) and depression (4%). As a coping mechanism, a significant relation was observed between spiritual beliefs and anxiety (<italic>x</italic><sup>2</sup> = 13.352, <italic>p</italic> = 0.010), depression (<italic>x</italic><sup>2</sup> = 6.205, <italic>p</italic> = 0.045) and stress (<italic>x</italic><sup>2</sup> = 14.833, <italic>p</italic> = 0.001). Stress among patients increased their likelihood of medication non-adherence [odds ratio (OR) = 2.42 (95% CI 1.06 – 5.5), <italic>p</italic> = 0.035].</p></sec><sec><title>Conclusion</title><p>The study has demonstrated the need for clinicians to pay attention to negative emotions and their role in medication non-adherence. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Ment Health Syst</journal-id><journal-id journal-id-type="iso-abbrev">Int J Ment Health Syst</journal-id><journal-title-group><journal-title>International Journal of Mental Health Systems</journal-title></journal-title-group><issn pub-type="epub">1752-4458</issn><publisher><publisher-name>BioMed Central</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24987456</article-id><article-id pub-id-type="pmc">4077111</article-id><article-id pub-id-type="publisher-id">1752-4458-8-25</article-id><article-id pub-id-type="doi">10.1186/1752-4458-8-25</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes" id="A1"><name><surname>Kretchy</surname><given-names>Irene A</given-names></name><xref ref-type="aff" rid="I1">1</xref><xref ref-type="aff" rid="I2">2</xref><email>iakretchy@yahoo.com</email></contrib><contrib contrib-type="author" id="A2"><name><surname>Owusu-Daaku</surname><given-names>Frances T</given-names></name><xref ref-type="aff" rid="I1">1</xref><email>owusudaakus@yahoo.co.uk</email></contrib><contrib contrib-type="author" id="A3"><name><surname>Danquah</surname><given-names>Samuel A</given-names></name><xref ref-type="aff" rid="I3">3</xref><email>samdanqua@yahoo.com</email></contrib></contrib-group><aff id="I1"><label>1</label>Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</aff><aff id="I2"><label>2</label>Department of Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, College of Health Sciences, Legon, Ghana</aff><aff id="I3"><label>3</label>Department of Psychology, University of Ghana, Legon, Ghana</aff><pub-date pub-type="collection"><year>2014</year></pub-date><pub-date pub-type="epub"><day>21</day><month>6</month><year>2014</year></pub-date><volume>8</volume><fpage>25</fpage><lpage>25</lpage><history><date date-type="received"><day>6</day><month>5</month><year>2014</year></date><date date-type="accepted"><day>19</day><month>6</month><year>2014</year></date></history><permissions><copyright-statement>Copyright © 2014 Kretchy et al.; licensee BioMed Central Ltd.</copyright-statement><copyright-year>2014</copyright-year><copyright-holder>Kretchy et al.; licensee BioMed Central Ltd.</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/4.0"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0">http://creativecommons.org/licenses/by/4.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><self-uri xlink:href="http://www.ijmhs.com/content/8/1/25"></self-uri><abstract><sec><title>Background</title><p>Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for the development of mental health disorders particularly anxiety and depression. For Ghanaian patients with hypertension, the interaction between hypertension and symptoms of anxiety, depression and stress remains largely unexplored. To fill this knowledge gap, the study sought to ascertain the prevalence and role of these negative emotions on anti-hypertensive medication adherence while taking into account patients’ belief systems.</p></sec><sec><title>Methods</title><p>The hospital-based cross-sectional study involving 400 hypertensive patients was conducted in two tertiary hospitals in Ghana. Data were gathered on patient’s socio-demographic characteristics, anxiety, depression and stress symptoms, spiritual beliefs, and medication adherence.</p></sec><sec><title>Results</title><p>Hypertensive patients experienced symptoms of anxiety (56%), stress (20%) and depression (4%). As a coping mechanism, a significant relation was observed between spiritual beliefs and anxiety (<italic>x</italic><sup>2</sup> = 13.352, <italic>p</italic> = 0.010), depression (<italic>x</italic><sup>2</sup> = 6.205, <italic>p</italic> = 0.045) and stress (<italic>x</italic><sup>2</sup> = 14.833, <italic>p</italic> = 0.001). Stress among patients increased their likelihood of medication non-adherence [odds ratio (OR) = 2.42 (95% CI 1.06 – 5.5), <italic>p</italic> = 0.035].</p></sec><sec><title>Conclusion</title><p>The study has demonstrated the need for clinicians to pay attention to negative emotions and their role in medication non-adherence. The recommendation is that attention should be directed toward the use of spirituality as a possible mechanism by which negative emotions could be managed among hypertensive patients.</p></sec></abstract><kwd-group><kwd>Hypertension</kwd><kwd>Negative emotions</kwd><kwd>Medication non-adherence</kwd><kwd>Spirituality</kwd><kwd>Ghana</kwd></kwd-group></article-meta></front><body><sec><title>Background</title><p>As disease burdens shift from infectious to non-communicable diseases, hypertension is a principal precursor to cardiovascular diseases and a main cause of death globally [<xref ref-type="bibr" rid="B1">1</xref>,<xref ref-type="bibr" rid="B2">2</xref>]. About 80% of these deaths were recorded in low- and middle- income countries and projections indicate that the highest non-communicable mortality rates would be recorded in these countries by 2020 [<xref ref-type="bibr" rid="B3">3</xref>]. Hypertension affects approximately 25% of urban and 20% of rural Ghanaian populations [<xref ref-type="bibr" rid="B4">4</xref>] and 11% - 42% of Africans [<xref ref-type="bibr" rid="B2">2</xref>,<xref ref-type="bibr" rid="B5">5</xref>-<xref ref-type="bibr" rid="B7">7</xref>]. A global hypertension prevalence of 26% is projected to ascend to 29% by the year 2025 [<xref ref-type="bibr" rid="B8">8</xref>].</p><p>Like patients with other chronic medical conditions, hypertensive patients experience many profound emotions which increase their risk for the development of mental health disorders particularly anxiety and depression [<xref ref-type="bibr" rid="B9">9</xref>,<xref ref-type="bibr" rid="B10">10</xref>]. Imperative to the management of hypertension is the need for patients to adhere to pharmacological and non-pharmacological therapies and these negative emotions may adversely influence their adherence behaviour [<xref ref-type="bibr" rid="B11">11</xref>].</p><p>Anxiety and lower adherence rates have been observed for asthma, heart failure, haemodialysis and contraceptive use [<xref ref-type="bibr" rid="B12">12</xref>-<xref ref-type="bibr" rid="B15">15</xref>], although Kim et al. [<xref ref-type="bibr" rid="B16">16</xref>] noticed greater adherence among the majority of their patients with anxiety disorder.</p><p>Depression is a burdensome disease of global importance [<xref ref-type="bibr" rid="B17">17</xref>] and although prevalent, it is mostly undiagnosed in patients with hypertension [<xref ref-type="bibr" rid="B18">18</xref>]. Some relationship has been observed between depression and non-adherence to medical therapy [<xref ref-type="bibr" rid="B19">19</xref>,<xref ref-type="bibr" rid="B20">20</xref>] and a high number of prescribed medications were listed as one of the contributing factors for the development of depressive symptoms in hypertension [<xref ref-type="bibr" rid="B21">21</xref>]. However not all studies successfully showed a relationship between depressive symptoms and adherence [<xref ref-type="bibr" rid="B14">14</xref>,<xref ref-type="bibr" rid="B22">22</xref>].</p><p>The stress of having a chronic medical condition may potentially influence medication adherence behaviour; yet, earlier studies on emotional determinants of adherence have largely focused on depression and anxiety [<xref ref-type="bibr" rid="B12">12</xref>,<xref ref-type="bibr" rid="B14">14</xref>]. In clinical settings, stress has repeatedly been used as a euphemism for negative emotions, particularly to address undesirable psychiatric diagnostic labelling [<xref ref-type="bibr" rid="B23">23</xref>]. Stress negatively influenced medication adherence behaviour in HIV/AIDS [<xref ref-type="bibr" rid="B24">24</xref>] and acute coronary syndrome [<xref ref-type="bibr" rid="B25">25</xref>]. Empirical evidence showed the importance of stress in the onset and worsening of essential hypertension [<xref ref-type="bibr" rid="B26">26</xref>], yet there is a dearth of information associating stress and medication adherence in hypertension management.</p><p>Drawing a causal relationship between anxiety, depression and stress, in hypertension and medication adherence may be difficult [<xref ref-type="bibr" rid="B19">19</xref>]; but on the other hand, overlooking the association may further decrease attempts to manage the burden of medication non-adherence. For Ghanaian patients with hypertension, this interaction between hypertension and symptoms of anxiety, depression and stress remains largely unexplored and incompletely understood in terms of its prevalence and effect on medication adherence. To fill this knowledge gap, the study sought to ascertain 1) whether hypertensive patients exhibited symptoms of anxiety, depression and stress; 2) whether individuals experiencing anxiety, depression and stress symptoms were more likely to be non-adherent than patients without these symptoms; and 3) whether patients’ belief systems had a relationship with anxiety, depression and stress symptoms.</p></sec><sec sec-type="methods"><title>Methods</title><sec><title>Study design and setting</title><p>A hospital-based cross-sectional study design was used. The study was carried out at the two major teaching hospitals in Ghana; Korle-Bu Teaching Hospital (KBTH), Accra and Komfo Anokye Teaching Hospital (KATH), Kumasi. The description of the study site has previously been reported [<xref ref-type="bibr" rid="B27">27</xref>].</p></sec><sec><title>Participants</title><p>Two hundred (200) hypertensive outpatients each were recruited from KBTH and KATH. Eligibility to participate in the study was based on the following: A diagnosis of hypertension only or hypertension with other co-morbid conditions, reporting prescription of at least one antihypertensive medication for a minimum of two months and an age of at least eighteen years. The sample did not include pregnant women (because of the possibility of gestational hypertension which may resolve after delivery), newly diagnosed patients as well as the physically and mentally incapacitated [<xref ref-type="bibr" rid="B27">27</xref>].</p></sec><sec><title>Measures</title><p>After informed written consent, a standardized quantitative assessment tool was used to collect data concurrently from the hypertensive patients attending KBTH and KATH between May and October, 2012. The information gathered covered three areas: i) demographic characteristics; ii) anxiety, depression and stress measures using the Depression Anxiety Stress Scale (DASS) – 21 [<xref ref-type="bibr" rid="B28">28</xref>]; iii) medication adherence behaviour using the Morisky Medication Adherence Scale [<xref ref-type="bibr" rid="B29">29</xref>]; and iv) the Spiritual Perspective Scale [<xref ref-type="bibr" rid="B30">30</xref>]. Participants were asked about their age, sex, place of residence, religious affiliation, marital status, educational level, and duration of hypertensive diagnosis.</p><p>The DASS is a 21 item self-report inventory that measures the negative emotional states of depression, anxiety and stress. Each of the three scales comprised seven items with related content. The depression subscale assessed dysphoria, hopelessness, devaluation of life, self-depreciation, and lack of interest/involvement, anhedonia, and inertia. The anxiety subscale measured autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress subscale measured relaxation difficulty, nervous arousal, agitation, irritability and impatience. Participants were requested to use a 4-point severity/frequency scale to rate the extent to which they had experienced each negative state over the past week. Reliability for the three scales is 0.71 for depression, 0.79 for anxiety and 0.81 for stress [<xref ref-type="bibr" rid="B28">28</xref>]. The DASS anxiety subscale has a correlation coefficient of 0.81 with the Beck Anxiety Inventory whereas the DASS depression subscale had 0.74 with the Beck Depression Inventory [<xref ref-type="bibr" rid="B31">31</xref>,<xref ref-type="bibr" rid="B32">32</xref>].</p><p>The MMAS is an 8-item scale used to measure medication adherence behavior in hypertensive patients and responses are categorized as low adherence (<6), medium adherence (6 - < 8), and high adherence (8). Low and moderate scores were grouped as poor adherence levels [<xref ref-type="bibr" rid="B33">33</xref>].</p><p>The ten-item SPS measured the belief perceptions of participants relating to spiritually-related interactions. Scores above or below the mean respectively represented high and low spiritual involvement. The SPS has consistently been reliable with Cronbach’s alpha above 0.90 [<xref ref-type="bibr" rid="B34">34</xref>].</p></sec><sec><title>Analysis</title><p>The data gathered from the study were analyzed with the Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were used to represent the characteristics of participants. Anxiety, depression and stress, and medication adherence as well as the level of spirituality were evaluated using chi-square tests and logistic regression models.</p></sec><sec><title>Ethics</title><p>Ethical clearance from the institutional ethics committees for KBTH and KATH were obtained before conducting the study. The ethical approval codes are NMIMR-IRB CPN 044/10-11and CHRPE/AP/022/12 respectively.</p></sec></sec><sec><title>Results and discussions</title><sec><title>Sample characteristics</title><p>A summary of the sample characteristics (mean and standard deviation) of the hypertensive patients are presented in Table <xref ref-type="table" rid="T1">1</xref>. Approximately 63% were women, 33% were 50 to 59 years old, 64% were married, 90% were Christians and 54% had a minimum of a secondary school education. Of these approximately 80% had had hypertension for ≥ 10 years, 42% had co-morbidities and diabetes accounted for 60% of these. Anxiety, depression and stress were not reported in the co-morbid health conditions. This is to be expected as negative emotions are usually not included in the co-morbidities reported by patients [<xref ref-type="bibr" rid="B35">35</xref>]; and may partly be due to the lack of adequate medical information being given to the patients. This finding is however interpreted bearing in mind the limitation that those co-morbidities were self-reported and not obtained from the clinicians or from the patients’ health records.</p><table-wrap position="float" id="T1"><label>Table 1</label><caption><p>Characteristics of study sample</p></caption><table frame="hsides" rules="groups" border="1"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead valign="top"><tr><th align="left"><bold>Variable</bold></th><th align="left"><bold>Frequency</bold></th><th align="left"><bold>Percentage</bold></th></tr></thead><tbody valign="top"><tr><td align="left" valign="bottom"><bold>Sex</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">Male<hr></hr></td><td align="left" valign="bottom">149<hr></hr></td><td align="left" valign="bottom">37.25<hr></hr></td></tr><tr><td align="left" valign="bottom">Female<hr></hr></td><td align="left" valign="bottom">251<hr></hr></td><td align="left" valign="bottom">62.75<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Age</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">< 20<hr></hr></td><td align="left" valign="bottom">1<hr></hr></td><td align="left" valign="bottom">0.25<hr></hr></td></tr><tr><td align="left" valign="bottom">20 - 29<hr></hr></td><td align="left" valign="bottom">12<hr></hr></td><td align="left" valign="bottom">3.00<hr></hr></td></tr><tr><td align="left" valign="bottom">30 - 39<hr></hr></td><td align="left" valign="bottom">20<hr></hr></td><td align="left" valign="bottom">5.00<hr></hr></td></tr><tr><td align="left" valign="bottom">40 - 49<hr></hr></td><td align="left" valign="bottom">71<hr></hr></td><td align="left" valign="bottom">17.75<hr></hr></td></tr><tr><td align="left" valign="bottom">50 - 59<hr></hr></td><td align="left" valign="bottom">130<hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">60 - 69<hr></hr></td><td align="left" valign="bottom">105<hr></hr></td><td align="left" valign="bottom">26.25<hr></hr></td></tr><tr><td align="left" valign="bottom">≥ 70<hr></hr></td><td align="left" valign="bottom">61<hr></hr></td><td align="left" valign="bottom">15.25<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Marital status</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">Single<hr></hr></td><td align="left" valign="bottom">39<hr></hr></td><td align="left" valign="bottom">9.75<hr></hr></td></tr><tr><td align="left" valign="bottom">Married<hr></hr></td><td align="left" valign="bottom">254<hr></hr></td><td align="left" valign="bottom">63.50<hr></hr></td></tr><tr><td align="left" valign="bottom">Widowed<hr></hr></td><td align="left" valign="bottom">73<hr></hr></td><td align="left" valign="bottom">18.25<hr></hr></td></tr><tr><td align="left" valign="bottom">Divorced/separated<hr></hr></td><td align="left" valign="bottom">25<hr></hr></td><td align="left" valign="bottom">6.25<hr></hr></td></tr><tr><td align="left" valign="bottom">Co-habiting<hr></hr></td><td align="left" valign="bottom">9<hr></hr></td><td align="left" valign="bottom">2.25<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Education</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">No formal<hr></hr></td><td align="left" valign="bottom">48<hr></hr></td><td align="left" valign="bottom">12.00<hr></hr></td></tr><tr><td align="left" valign="bottom">Primary<hr></hr></td><td align="left" valign="bottom">33<hr></hr></td><td align="left" valign="bottom">8.25<hr></hr></td></tr><tr><td align="left" valign="bottom">Secondary<hr></hr></td><td align="left" valign="bottom">217<hr></hr></td><td align="left" valign="bottom">54.25<hr></hr></td></tr><tr><td align="left" valign="bottom">Tertiary<hr></hr></td><td align="left" valign="bottom">102<hr></hr></td><td align="left" valign="bottom">25.50<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Religious affiliation</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">Christian (spiritual)<hr></hr></td><td align="left" valign="bottom">18<hr></hr></td><td align="left" valign="bottom">4.50<hr></hr></td></tr><tr><td align="left" valign="bottom">Christian (Charismatic/Pentecostal)<hr></hr></td><td align="left" valign="bottom">166<hr></hr></td><td align="left" valign="bottom">41.50<hr></hr></td></tr><tr><td align="left" valign="bottom">Christian (Orthodox)<hr></hr></td><td align="left" valign="bottom">174<hr></hr></td><td align="left" valign="bottom">43.50<hr></hr></td></tr><tr><td align="left" valign="bottom">Muslim<hr></hr></td><td align="left" valign="bottom">20<hr></hr></td><td align="left" valign="bottom">5.00<hr></hr></td></tr><tr><td align="left" valign="bottom">African Traditional Religion<hr></hr></td><td align="left" valign="bottom">4<hr></hr></td><td align="left" valign="bottom">1.00<hr></hr></td></tr><tr><td align="left" valign="bottom">Other<hr></hr></td><td align="left" valign="bottom">18<hr></hr></td><td align="left" valign="bottom">4.50<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Number of years of having hypertension</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">≤ 10 years<hr></hr></td><td align="left" valign="bottom">318<hr></hr></td><td align="left" valign="bottom">79.50<hr></hr></td></tr><tr><td align="left" valign="bottom">11 – 20 years<hr></hr></td><td align="left" valign="bottom">49<hr></hr></td><td align="left" valign="bottom">12.25<hr></hr></td></tr><tr><td align="left" valign="bottom">21 – 30 years<hr></hr></td><td align="left" valign="bottom">20<hr></hr></td><td align="left" valign="bottom">5.00<hr></hr></td></tr><tr><td align="left" valign="bottom">31 – 40 years<hr></hr></td><td align="left" valign="bottom">12<hr></hr></td><td align="left" valign="bottom">3.00<hr></hr></td></tr><tr><td align="left" valign="bottom">41 – 50 years<hr></hr></td><td align="left" valign="bottom">1<hr></hr></td><td align="left" valign="bottom">0.25<hr></hr></td></tr><tr><td align="left" valign="bottom"><bold>Level of adherence</bold><hr></hr></td><td align="left" valign="bottom"> <hr></hr></td><td align="left" valign="bottom"> <hr></hr></td></tr><tr><td align="left" valign="bottom">Low<hr></hr></td><td align="left" valign="bottom">323<hr></hr></td><td align="left" valign="bottom">80.75<hr></hr></td></tr><tr><td align="left" valign="bottom">Moderate<hr></hr></td><td align="left" valign="bottom">50<hr></hr></td><td align="left" valign="bottom">12.50<hr></hr></td></tr><tr><td align="left">High</td><td align="left">27</td><td align="left">6.75</td></tr></tbody></table></table-wrap></sec><sec><title>Anxiety and adherence</title><p>Anxiety was common among 225 (57%) of the hypertensive patients. This result corroborates the high prevalence of anxiety found among hypertensive patients in varied countries such as South Africa, China and Argentina [<xref ref-type="bibr" rid="B10">10</xref>,<xref ref-type="bibr" rid="B36">36</xref>,<xref ref-type="bibr" rid="B37">37</xref>]; thus showing the presence of anxiety in hypertension in spite of cultural variability. Anxiety in hypertension could result in a higher risk of morbidity and mortality as a result of hastened cardiovascular events [<xref ref-type="bibr" rid="B38">38</xref>]. Although it was not measured in the scope of the present study, the anxiety may, in part, be specifically related to the medications or to the chronic health condition [<xref ref-type="bibr" rid="B39">39</xref>]. Approximately 93% of participants poorly adhered to their anti-hypertensive medications (Table <xref ref-type="table" rid="T1">1</xref>). Although previous studies had correlated anxiety and medication adherence [<xref ref-type="bibr" rid="B12">12</xref>,<xref ref-type="bibr" rid="B14">14</xref>-<xref ref-type="bibr" rid="B16">16</xref>] the present study did not observe any significant association between anxiety and adherence (<italic>x</italic><sup>2</sup> = 3.887, <italic>p</italic> = 0.421), [(OR) = 1.6 (0.7 – 3.66), <italic>p</italic> = 0.262]; yet our findings on the prevalence of anxiety calls for clinicians to take critical action in addressing the negative emotional needs of anxious hypertensive patients (Tables <xref ref-type="table" rid="T2">2</xref>, <xref ref-type="table" rid="T3">3</xref> and <xref ref-type="table" rid="T4">4</xref>).</p><table-wrap position="float" id="T2"><label>Table 2</label><caption><p>Distribution of degree of symptoms of depression, anxiety and stress</p></caption><table frame="hsides" rules="groups" border="1"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead valign="top"><tr><th align="left" valign="bottom"><bold>Emotional condition</bold><hr></hr></th><th align="left" valign="bottom"><bold>Normal</bold><hr></hr></th><th align="left" valign="bottom"><bold>Mild</bold><hr></hr></th><th align="left" valign="bottom"><bold>Moderate</bold><hr></hr></th><th align="left" valign="bottom"><bold>Severe</bold><hr></hr></th><th align="left" valign="bottom"><bold>Extremely severe</bold><hr></hr></th></tr><tr><th align="left"> </th><th align="left"><bold>N (%)</bold></th><th align="left"><bold>N (%)</bold></th><th align="left"><bold>N (%)</bold></th><th align="left"><bold>N (%)</bold></th><th align="left"><bold>N (%)</bold></th></tr></thead><tbody valign="top"><tr><td align="left" valign="bottom">Depression<hr></hr></td><td align="left" valign="bottom">358 (89.50)<hr></hr></td><td align="left" valign="bottom">25 (6.25)<hr></hr></td><td align="left" valign="bottom">12 (3.00)<hr></hr></td><td align="left" valign="bottom">4 (1.00)<hr></hr></td><td align="left" valign="bottom">1 (0.25)<hr></hr></td></tr><tr><td align="left" valign="bottom">Anxiety<hr></hr></td><td align="left" valign="bottom">129 (32.25)<hr></hr></td><td align="left" valign="bottom">46 (11.50)<hr></hr></td><td align="left" valign="bottom">140 (35.00)<hr></hr></td><td align="left" valign="bottom">44 (11.50)<hr></hr></td><td align="left" valign="bottom">41 (10.25)<hr></hr></td></tr><tr><td align="left">Stress</td><td align="left">259 (64.75)</td><td align="left">59 (14.75)</td><td align="left">52 (13.00)</td><td align="left">26 (6.50)</td><td align="left">4 (1.00)</td></tr></tbody></table><table-wrap-foot><p>A high number of patients experienced moderate to extremely severe symptoms of anxiety (225), followed by stress (82) and depression (17).</p></table-wrap-foot></table-wrap><table-wrap position="float" id="T3"><label>Table 3</label><caption><p>Relationship between negative emotional characteristics and medication non-adherence</p></caption><table frame="hsides" rules="groups" border="1"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead valign="top"><tr><th align="left"><bold>Variable</bold></th><th align="left"><bold>Chi-square</bold></th><th align="left"><bold><italic>p</italic></bold><bold>-value</bold></th></tr></thead><tbody valign="top"><tr><td align="left" valign="bottom">Depression<hr></hr></td><td align="left" valign="bottom">0.004<hr></hr></td><td align="left" valign="bottom">0.950<hr></hr></td></tr><tr><td align="left" valign="bottom">Anxiety<hr></hr></td><td align="left" valign="bottom">3.887<hr></hr></td><td align="left" valign="bottom">0.421<hr></hr></td></tr><tr><td align="left">Stress</td><td align="left">5.936</td><td align="left">0.037</td></tr></tbody></table><table-wrap-foot><p>At p < 0.05, stress and not depression and anxiety significantly related with medication non-adherence.</p></table-wrap-foot></table-wrap><table-wrap position="float" id="T4"><label>Table 4</label><caption><p>A logistic regression model for negative emotional symptoms and medication non-adherence</p></caption><table frame="hsides" rules="groups" border="1"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead valign="top"><tr><th align="left"><bold>Variable</bold></th><th align="left"><bold>OR</bold></th><th align="left"><bold>95%</bold><bold>CI</bold></th><th align="left"><bold><italic>p</italic></bold><bold>value</bold></th></tr></thead><tbody valign="top"><tr><td align="left" valign="bottom">Anxiety symptoms (present: ref absent)<hr></hr></td><td align="left" valign="bottom">1.6<hr></hr></td><td align="left" valign="bottom">0.7 – 3.66<hr></hr></td><td align="left" valign="bottom">0.262<hr></hr></td></tr><tr><td align="left" valign="bottom">Depressive symptoms (present: ref absent)<hr></hr></td><td align="left" valign="bottom">0.81<hr></hr></td><td align="left" valign="bottom">0.1 – 6.29<hr></hr></td><td align="left" valign="bottom">0.837<hr></hr></td></tr><tr><td align="left">Stress symptoms (present: ref absent)</td><td align="left">2.42</td><td align="left">1.06 – 5.5</td><td align="left">0.035</td></tr></tbody></table><table-wrap-foot><p>Adjusted for demographic and clinical characteristics.</p></table-wrap-foot></table-wrap></sec><sec><title>Depression and adherence</title><p>Moderate to extremely severe levels of depressive symptoms which merit clinical attention were found in 17 (4%) study participants (Table <xref ref-type="table" rid="T2">2</xref>). This information is vital because of the increasing impact of depression on the global disease burden [<xref ref-type="bibr" rid="B17">17</xref>]. Yet, depression among hypertensive patients is usually not diagnosed [<xref ref-type="bibr" rid="B35">35</xref>]. As a consequence such patients may be denied comprehensive clinical care which takes their mental health into consideration. Contrary to other studies which observed participants with depression exhibiting a higher likelihood of medication non-adherence [<xref ref-type="bibr" rid="B16">16</xref>,<xref ref-type="bibr" rid="B20">20</xref>,<xref ref-type="bibr" rid="B40">40</xref>], this association was not observed in the current study (<italic>x</italic><sup>2</sup> = 0.004, <italic>p</italic> = 0.950) which draws the same conclusion as studies by Schweitzer et al. [<xref ref-type="bibr" rid="B14">14</xref>] and Corvera-Tindel et al. [<xref ref-type="bibr" rid="B22">22</xref>]. These studies showed no relationship between the two variables among patients with chronic heart failure. The outcome of a relationship between depression and non-adherence is likely to be inconclusive due to the small number of participants in this study exhibiting symptoms of depression. However, it is essential for clinicians to pay attention to these negative emotional symptoms because overlooking them may further decrease attempts to manage the global burden of chronic diseases.</p></sec><sec><title>Stress and adherence</title><p>Studies on emotional determinants of medication adherence have focused primarily on anxiety and depressive symptoms; however significant stressful events have been reported to be responsible for hypertension [<xref ref-type="bibr" rid="B41">41</xref>,<xref ref-type="bibr" rid="B42">42</xref>]. We reported 82 patients (20%) exhibiting moderate to severe high scores of stress symptoms which may require clinical attention and management (Table <xref ref-type="table" rid="T2">2</xref>). Similar to earlier studies on HIV/AIDS [<xref ref-type="bibr" rid="B24">24</xref>] and acute coronary syndrome [<xref ref-type="bibr" rid="B25">25</xref>], stress was associated with medication non-adherence among the study participants (<italic>x</italic><sup>2</sup> = 5.936, <italic>p</italic> = 0.037). The patients who were stressed were more likely to be non-adherent than those who had no or low stress levels [(OR) = 2.42 (1.06 – 5.5), <italic>p</italic> = 0.035]. A probable explanation is that patients showing stress symptoms may be more susceptible to the negative effects of their medications and thus may discontinue taking them. This observation further supports the need for health providers in this area to pay particular attention to medication adherence in patients who are stressed or those who could potentially be affected by stress.</p></sec><sec><title>Relationship between spirituality and anxiety, depression and stress</title><p>Spirituality showed a significant association with lower levels of anxiety (<italic>x</italic><sup>2</sup> = 13.352, <italic>p</italic> = 0.010), depression (<italic>x</italic><sup>2</sup> = 6.205, <italic>p</italic> = 0.045) and stress (<italic>x</italic><sup>2</sup> = 14.833, <italic>p</italic> = 0.001) (Table <xref ref-type="table" rid="T5">5</xref>). These strong spiritual attributes may have enabled patients cope better with the emotional problems of having a chronic condition like hypertension. Greater spiritual well-being has been found to be associated with fewer symptoms of anxiety, depression and stress [<xref ref-type="bibr" rid="B43">43</xref>-<xref ref-type="bibr" rid="B46">46</xref>]. Most of these studies related to terminally ill patients yet, the outcome from our study has demonstrated a confirmation of the alleviating role of spirituality in emotional experiences that can be applicable to hypertensive patients and by extension, patients with other chronic conditions.</p><table-wrap position="float" id="T5"><label>Table 5</label><caption><p>Relating spirituality with depression, anxiety and stress symptoms experienced by hypertensive patients</p></caption><table frame="hsides" rules="groups" border="1"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead valign="top"><tr><th align="left" valign="bottom"><bold>Variable</bold><hr></hr></th><th colspan="2" align="left" valign="bottom"><bold>Depression</bold><hr></hr></th><th colspan="2" align="left" valign="bottom"><bold>Anxiety</bold><hr></hr></th><th colspan="2" align="left" valign="bottom"><bold>Stress</bold><hr></hr></th></tr><tr><th align="left"> </th><th align="left"><bold><italic>X</italic></bold><sup><bold>2</bold></sup></th><th align="left"><bold><italic>p</italic></bold><bold>value</bold></th><th align="left"><bold><italic>X</italic></bold><sup><bold>2</bold></sup></th><th align="left"><bold><italic>p</italic></bold><bold>value</bold></th><th align="left"><bold><italic>X</italic></bold><sup><bold>2</bold></sup></th><th align="left"><bold><italic>p</italic></bold><bold>value</bold></th></tr></thead><tbody valign="top"><tr><td align="left">Spirituality</td><td align="left">6.205</td><td align="left">0.045</td><td align="left">13.352</td><td align="left">0.010</td><td align="left">14.833</td><td align="left">0.001</td></tr></tbody></table></table-wrap><p>Some limitations are acknowledged. First, this study was conducted in tertiary hospitals only, thus the views of patients with hypertension in Ghana who seek medical care from other healthcare facilities were not obtained. Second, the use of a subjective measure of medication adherence may give wrong adherence estimations. Future studies could supplement patients’ report on adherence with objective assessments of adherence.</p></sec></sec><sec sec-type="conclusions"><title>Conclusions</title><p>Patients with hypertension manifested symptoms of anxiety, depression and stress. This implies that the patient’s hypertensive state and perhaps the need for adherence to the anti-hypertensive medications placed psychological demands on their health. Thus, although hypertension could be viewed in itself as a biomedical problem, patients’ experiences with the demands of living as hypertensives resulted in mental health problems. This illustrates the link between biomedical problems and the development of psychological disorders. Further, spirituality helped patients cope with the emotional burden of having hypertension; a chronic disease. Therefore, the need to adopt a multi-faceted perspective towards health delivery in Ghana becomes real in the purview of these findings. The involvement of clinicians, pharmacists, clinical/health psychologists, religious leaders, and nurses thus becomes important in alleviating the problem of non-adherence and invariably improving the quality of life outcomes of hypertensive patients. Attention could be directed toward the use of spirituality as a possible mechanism by which negative emotions are managed among hypertensive patients.</p></sec><sec><title>Competing interests</title><p>The authors declare that they have no competing interest.</p></sec><sec><title>Authors’ contributions</title><p>IK was involved with research concept, data collection, data analysis, interpretation of results, and writing of manuscript. FO and SD contributed to the research concept and interpretation of results. All authors reviewed and approved the final manuscript.</p></sec></body><back><sec><title>Acknowledgements</title><p>The authors wish to thank the hypertensive patients who participated in this study as well as the staff of KBTH and KATH. For their technical support, the authors are grateful to Dr. Joseph Osafo and Dr. Asamoah Kusi. This research was partially funded by the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC) as well as the University of Ghana Faculty Development Grant by Office of Research, Innovation and Development (ORID).</p></sec><ref-list><ref id="B1"><mixed-citation 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