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Irregular treatment of hypertension in the former Soviet Union
  1. Bayard Roberts1,
  2. Andrew Stickley1,2,3,
  3. Dina Balabanova1,
  4. Martin McKee1
  1. 1European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Stockholm Centre on Health of Societies in Transition (SCOHOST), Södertörn University, Huddinge, Sweden
  3. 3Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
  1. Correspondence to Bayard Roberts, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK; bayard.roberts{at}lshtm.ac.uk

Abstract

Background The USSR failed to establish a modern pharmaceutical industry and lacked the capacity for reliable distribution of drugs. Patients were required to pay for outpatient drugs and the successor states have inherited this legacy, so that those requiring long-term treatment face considerable barriers in receiving it. It was hypothesised that citizens of former Soviet republics requiring treatment for hypertension may not be receiving regular treatment.

Aims To describe the regularity of treatment among those diagnosed with hypertension and prescribed treatment in eight countries of the former Soviet Union, and explore which factors are associated with not taking medication regularly.

Methods Using data from over 18 000 respondents from eight former Soviet countries, individuals who had been told that they had hypertension by a health professional and prescribed treatment were identified. By means of multivariate logistic analysis the characteristics of those taking treatment daily and less than daily were compared.

Results Only 26% of those prescribed treatment took it daily. The probability of doing so varied among countries and was highest in Russia, Belarus and Georgia, and lowest in Armenia (although Georgia's apparent advantage may reflect low rates of diagnosis). Women, older people, those living in urban areas, and non-smokers and non-drinkers were more likely to take treatment daily.

Conclusions A high proportion of those who have been identified by health professionals as requiring hypertension treatment are not taking it daily. These findings suggest that irregular hypertension treatment is a major problem in this region and will require an urgent response.

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Introduction

Access to many basic medications in the Soviet Union was limited, at least outside the major cities, first because the USSR was unable to develop a modern pharmaceutical manufacturing sector (importing many drugs from its satellite states in eastern Europe or from India), and second, because it lacked the distribution system to ensure that its population had regular access to medications.1 From the 1960s onwards these problems were exacerbated by the progressive diversion of money to other sectors (such as space exploration and the military), with the health sector funded on the ‘residual principle’, receiving only what was left after other priorities were met.2

We hypothesised, on the basis of persistently high mortality from disorders amenable to medical care,3 that there may be an ongoing problem in providing continuing treatment for those with chronic disorders. We selected hypertension, the most common of these disorders, for study. Until the 1960s, patients with hypertension were often treated only when symptomatic, reflecting both the side effects of the drugs then available and a lack of awareness of the benefits of regular treatment.4 In the West this situation was transformed by the development of new, safer drugs, initially thiazide diuretics and then beta-blockers and ACE inhibitors, as well as the publication of trials showing that regular treatment of asymptomatic individuals markedly reduced the risk of complications and, in particular, stroke.5 Since then, a substantial body of research has accumulated on the importance of regular treatment,6 including both clinical research, such as that demonstrating the benefits of regular treatment in reducing cerebral lesions,7 and epidemiological studies undertaken in many settings in developed and developing countries that have identified the importance of improving regular adherence as a means of reducing morbidity and mortality.8–10 Treatment should be taken at least daily as, although there is some variation within classes of drugs,11 12 the half life of the common preparations is well under 24 h.

We thus first assessed the extent to which those who had been diagnosed as having hypertension and had been prescribed treatment were taking it regularly; and second, explored which factors were associated with not taking medication regularly.

Methods

This study took advantage of a series of nationally representative population-based surveys of a total of 18 428 respondents in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2001 which were part of the Living Conditions, Lifestyles and Health Project. Details of the methods used in these surveys have been described elsewhere.13 Surveys were conducted in each country in the autumn of 2001 using standardised methods. Each sought to include representative samples of the population aged 18 years and over, although a few small regions had to be excluded from sampling in Georgia (eg, South Ossetia, 3% of the population), Moldova (eg, Trans-Dniester Republic, 15% of the population) and the Russian Federation (eg, Chechnya, 2% of the population) due to the presence of separatist movements or ongoing military actions. Individuals in the armed forces and prisoners were excluded from the samples. Other exclusion criteria (with variations among countries) included being mentally disabled, institutionalised, hospitalised or homeless, or suffering from heavy alcoholic intoxication. The aim was to sample at least 2000 respondents in each country, but to reach 4000 in the Russian Federation and 2500 in Ukraine to reflect the larger and more regionally diverse populations in these two countries. Samples were selected using multi-stage random sampling with stratification applied by region and rural/urban settlement type. Primary sampling units were selected with a probability in proportion to population size based on population lists of administrative units (approximately 50–200 primary sampling units per country). Within each primary sampling unit, households were selected by random sampling from a household list (Armenia) or by standardised random route procedures (other countries) in which a starting address is randomly selected and, taking alternate left- and right-hand turns at road junctions, every n-th address is selected. One person was chosen from each selected household (nearest coming or last birthday). If after three visits (different days and times) there was no one at home, the next household on the route was selected. Pre-specified quota control was used in Belarus, Kazakhstan, Moldova and Ukraine (a combination of region, area, gender, age and/or education level), and sampling repair procedure (based on area, gender, age and education) was used in Georgia and Russia. Face-to-face interviews were conducted by trained fieldworkers in the respondents' homes. The questionnaire was developed and piloted in consultation with country representatives. Quality control procedures included re-interviews to assess the work of the interviewers and the interviewers' supervisors, a carefully designed data entry mask, and checks on the data for any evidence of biased sampling or inconsistency. Response rates varied between 71% and 88% among countries (calculated on the basis of the total number of households for which an eligible person could be identified). This study was approved by the ethics committee of the London School of Hygiene and Tropical Medicine and was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

The questionnaire covered a range of demographic, socioeconomic, lifestyle and health characteristics which have been detailed elsewhere13 14). Demographic characteristics included sex, age, marital status and educational level. Social factors included settlement type (rural/urban), living conditions, health service utilisation, concern about crime, social capital (eg, levels of trust, sources of support, and membership of groups and organisations) and political attitudes. Economic characteristics included income source, employment status, household assets and perceived household economic status (a five-point range from very good to very bad). Lifestyle and health factors included diet, tobacco and alcohol consumption, daily exercise, symptoms relating to cardiovascular disease, general health (a four-point range from good to bad), physical fitness (ability to walk a kilometre) and psychological distress (using a range of 12 symptoms, with scores of <3 symptoms and >9 symptoms considered low and high psychological distress scores, respectively).

Our key outcome measure was derived from two questions: whether an individual had ever been told by a doctor that their blood pressure was too high; and whether they were taking medication for hypertension several times per day, once per day, several times a week, month, year or less, or never. In the absence of data on their current blood pressure, we assumed that all those who had been told they had hypertension and prescribed treatment by a doctor had the disorder (this is consistent with our knowledge of how the health systems operate) and that all those who were taking medication less than daily were receiving irregular, and therefore inadequate treatment.

To explore which factors were associated with irregular treatment, variables which may have a plausible link with treatment adherence were selected for inclusion in the analysis. These included the country; demographic variables of sex, age group, marital status, education and settlement type; economic variables of employment status and self-assessed economic status (which has been found to be a much better predictor of health-related behaviours in transition countries compared with measures such as income15); health-related variables (general health, physical fitness and psychological distress); and alcohol and tobacco consumption (as it is plausible that money used to purchase these products could displace expenditure on essential medicines).

Logistic regression was used for the analytical purpose of exploring which factors were associated with someone who had been prescribed treatment for hypertension but was taking that treatment less than once a day. Bivariate analysis was first conducted to generate proportional ORs indicating associations of the selected variables with irregular treatment. Multivariate analysis was then conducted of all the variables in order to adjust for the influence of the other variables given that some of the putative explanatory variables are themselves correlated. A full model was first used in the multivariate analysis, in which all the variables were entered. A final model was then developed using backward stepwise regression to eliminate variables with proportional ORs that were not statistically significant (p<0.05). The remaining variables were inferred to have a statistically significant association with irregular treatment for hypertension and to be of most value for the study. Data were adjusted for the sampling design effect. The final model was also statistically significant (p<0.01). The variance in irregular treatment explained by the final model was low at 0.15. Data were analysed using Stata V.11.

Results

Table 1 presents the characteristics of all the study respondents. Of the 18 428 respondents, 15 138 (82%) recalled ever having had their blood pressure checked by a health professional, although this varied considerably by country (figure 1). Of those who had their blood pressure checked, 5253 (35%) had been told they had high blood pressure, of whom 5042 (96%) had been prescribed treatment by a doctor. Of those prescribed treatment, only 1323 (26%) took it at least daily. Table 2 presents the summary data by a range of potential explanatory variables for irregular treatment for hypertension, along with unadjusted ORs on their bivariate association with irregular treatment. These indicate that all of the variables show a possible association with irregular treatment, with the exception of employment status and four of the countries (Armenia, Belarus, Kyrgyzstan and Ukraine).

Table 1

Characteristics of all study respondents, by country (N=18 428)

Figure 1

Percentage of respondents who have ever had their blood pressure checked by a health professional.

Table 2

Characteristics of respondents taking blood pressure (BP) medication, and the bivariate association of these characteristics with taking blood pressure medication less than once a day

Table 3 shows the adjusted ORs in the full and final models of the multivariate analysis. The results in the final model indicate that the probability of not taking treatment daily is significantly higher than in Russia in each of the other countries except Belarus and Georgia. Men are less likely to take treatment regularly than women, while pensioners are more likely than those in younger age groups to take treatment regularly. People living in rural areas are less likely to take regular treatment than those living in urban areas. Economic variables of employment status and self-rated household economic situation show no association with the regularity of treatment. Those who rate their health as bad are more likely to take treatment regularly, with low fitness levels exerting a similar but independent effect. Those who drink or smoke are less likely to take treatment regularly, suggesting that there may indeed be some diversion of resources away from essential drugs.

Table 3

Multivariate analysis for associations of selected variables with not taking medication at least once a day for high blood pressure

It was also possible, tentatively, to explore the role of health beliefs. However, there was no significant difference between those taking treatment daily and less than daily in responses to questions on agreement with the statement ‘Keeping healthy depends upon the things that one can do for oneself’.

Discussion

To the best of our knowledge this is the first time that the scale of adherence to hypertension treatment has been assessed in a comparable way in population-based samples in different countries of the former Soviet Union. This study shows that about three-quarters of adults who have been diagnosed with, and treated for, hypertension in eight former Soviet countries are not taking treatment regularly, with potentially important consequences for their long-term health. The situation is even worse in the two central Asian republics and only appears better in Georgia because fewer people there have ever had their blood pressure checked.

Although we anticipated that many people prescribed treatment for hypertension would not be taking treatment regularly, we were surprised that the proportion was so high despite the considerable investment in modern primary healthcare in this region.16 One recent study in 20 Russian cities reported that only 46% of patients with hypertension alone and 34% of patients with hypertension and coronary heart disease did not take hypertensive treatment regularly, but it was facility-based and limited to patients attending for treatment.17

Many of the observed associations, but not all, are consistent with existing knowledge. We would expect a higher rate of adherence to treatment in Russia than in many of its neighbours as it is still the wealthiest of the countries studied and has continued to provide basic healthcare delivery to most of its citizens during a period of financing reform. Reported financial and geographical access to care and drugs is the best in the region.18

Belarus has also maintained good access to care, despite a failure to reform. The health system in Belarus maintains many features of the Soviet system, consistent with the rejection of Western economic and political models. The observation that many fewer Georgians have had their blood pressure checked is consistent with other evidence that its health system has deteriorated much more than the other countries except its neighbour Armenia,19 20 and in particular, evidence that Georgians are less likely to access healthcare than in the other countries. Those Georgians who have been diagnosed seem to be a select group that can afford regular treatment. This is supported by the observation that 34% of those in Georgia who recall having their blood pressure checked have completed higher education, compared with 24% in Kazakhstan, the next highest, and 18% in Russia.

Before seeking to interpret these findings, it is necessary to consider the study's obvious limitations. First, caution is required in interpreting these figures as those who have been diagnosed with hypertension may not be representative of all individuals who actually have it. Furthermore, we cannot assume that all those who have been told they have hypertension and have been prescribed treatment actually need it, although it is likely to be a reasonable approximation. It is possible that some individuals have adopted lifestyle changes, such as weight loss, that have removed the need for treatment, but the numbers are likely to be small. Second, as we were unable to measure blood pressure in these surveys, we can say nothing about those who have high blood pressure but are unaware of it, so our figures will inevitably underestimate the scale of the problem. Third, we were unable to ascertain whether the drugs prescribed to our subjects are actually effective in the treatment of hypertension (our earlier research on prescribing in obstetric care in Russia revealed widespread use of many ineffective treatments, a subject we return to below)21 or would be free of significant side effects. Fourth, as subjects were not asked about the type of treatment and how many times they should take the medicine prescribed, irregular treatment could have been as a result of either their own decisions or inadequate or incorrect advice from the doctor or other health professional. Fifth, the low variability in irregular treatment explained by the final model in our exploratory analysis suggests that other factors which were not recorded in the survey are also important predictors. We were unable to ascertain directly from the questionnaire the reasons why those prescribed medication did not take it daily; other factors could include prescription patterns, drug availability and financial factors. Although we did not find an association with the individual's economic situation, patients must pay out of pocket charges for medication throughout the former Soviet Union, now often at substantially inflated costs due to large mark-ups along the supply chain.22 23 The introduction of co-payments for outpatient medication in the USA, which is analogous to the situation in the former Soviet Union where patients must pay for their drugs, has reduced adherence to treatment among those with chronic disorders.24 Russian physicians identify financial problems as the major problem facing patients (implying that regular drug use would be unaffordable) even though patients place the highest priority on the risk of complications from hypertension.25 26 Finally, we were unable to ascertain whether those with hypertension were self-treating, although we do know that a range of ineffective herbal remedies are used widely for treatment of hypertension in this region.

The study does, however, have some important strengths in the range of countries included and the ability to study nationally representative samples. All previous research on hypertension in this region has studied only one or a few settings in a single country.

What do the findings mean? The observation that men are less likely to take regular treatment adds to a literature on the role of gender on treatment adherence that is inconsistent and context dependent.27 28 However, it is consistent with other research from Russia25 and it is noteworthy that the male disadvantage reduces considerably when account is taken of their greater probability of drinking and smoking. When viewed alongside the independent effect of these two behaviours on adherence, it seems at least plausible that money being spent on alcohol and cigarettes is indeed displacing resources for the purchase of drugs, and is consistent with other research showing that tobacco accounts for a disproportionate share of household expenditures among the poor in this region.29

Regular treatment is less likely among those in rural areas and, importantly, this is not explained by the measureable characteristics of those living there, suggesting a real problem of geographical access to essential medication. This is consistent with our earlier work with people with diabetes in some of the countries studied here, whereby pharmacies in rural areas often had irregular and limited supplies.30 31

The associations with low levels of fitness and poor health accord with findings from Russia which have shown that individuals with hypertension who have other serious illnesses are more likely to take their hypertensive medication,25 26 perhaps due to a greater awareness, among physicians and patients, of the potential consequences of non-adherence to treatment among those who are already ill. It is also consistent with research in this region suggesting that the asymptomatic nature of all but the most severe hypertension creates the impression among patients of a ‘safe’ illness where the regular use of medication is not required.25

It is important to situate our findings in the context of what is already known about treatment of hypertension in this region. During the Soviet period, long-term drug treatment for hypertension was much less common than in the West. Instead, individuals found to have high blood pressure were often given a range of unconventional and ineffective treatments. They included a range of physical therapies (typically exposure to magnetic fields, either directed at the renal area or of auto-transfused blood,32 exposure to coloured light,33 lasers,34 or baths in chemical solutions)35 as well as intermittent injections of preparations such as spasmolytics (eg, magnesium sulphate).36 These were sometimes administered in sanatoria and balneological centres, paid for by non-cash benefits from employers, so were popular with employees who could take a break from work to obtain treatment. Those who were prescribed oral medication were often advised by their physicians to take it only when they felt unwell, even though unless very severe, hypertension is asymptomatic and daily treatment is necessary.37

Although there have been many improvements since independence, including better knowledge of effective treatment by physicians,38 and the supply of medication has improved following liberalisation of the private pharmaceutical sector, problems remain. Surveys reveal a low level of awareness of the need for regular treatment and high levels of uncontrolled hypertension,39–42 with one recent study in Russia finding that, although 40–42% of the population aged 15 and above had hypertension, only 6–17% of cases were receiving effective treatment.43

Although this study has provided important new insights into adherence to medication regimes in this region, more research is needed to determine what might be done to address the problems observed. In particular, there is a need for more detailed understanding, using qualitative methods, of the reasons why people do not adhere to the treatment they have been recommended. Our findings identify probable roles for access to reliable supplies, but the other research that we have reviewed also identifies clinical decision-making and, potentially, persistence of obsolete and unproven treatments. We are now undertaking qualitative studies in each of these countries to understand better the health beliefs and behaviours of physicians and patients with long-term disorders in the hope of resolving these uncertainties. There are now some signs of acceptance of evidence-based medicine appearing in these countries,44 45 and policy makers have expressed commitments to modern primary care,46 so there is some reason to hope that this research may make a difference. However, in the long term, it is unlikely that real change will come about without a substantial increase in funding for healthcare.

What is already known on this subject

  • Cerebrovascular disease is a major cause of premature mortality in countries of the former Soviet Union.

  • Effective treatment of hypertension can substantially reduce the onset of its complications, especially stroke.

  • However, globally there remains a low level of awareness of the need for regular treatment and there are still high levels of uncontrolled hypertension.

What this study adds

  • This study provides data from nationally representative samples in eight countries of the former Soviet Union on factors associated with those suffering from high blood pressure not taking hypertensive medication regularly.

  • The study quantifies the scale of irregular treatment for hypertension in the former Soviet Union, and explores factors associated with irregular treatment.

  • Findings suggest that irregular hypertension treatment may contribute to the high burden of disease in this region.

  • Further research, accompanied by evidence-based policies, is required to better address and understand the reasons for irregular treatment of hypertension in this region.

Acknowledgments

We are grateful to all members of the Living Conditions, Lifestyles and Health Project (LLH) study teams who participated in the coordination and organisation of data collection for this study.

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Footnotes

  • Funding The LLH Project was funded by the European Community under the FP5 horizontal programme ‘Confirming the International Role of Community Research’ (INCO2-Copernicus; contract no: ICA2-2000–10031, project no: ICA2-1999–10074). However, the European Commission cannot accept any responsibility for any information provided or views expressed.

  • Competing interests None declared.

  • Ethics approval This study was conducted with the approval of the London School of Hygiene and Tropical Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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