**2.12 Discussion**

The aim of the study was to evaluate the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district. The study found a significant percentage (93.4%) of non-adherence to hypertension guidelines among consulting nurses at selected PHC facilities. Based on the results of this study, some professional nurses could not interpret the danger related to an elevated eGFR or cholesterol. Where the BMI was measured, it was not interpreted so that interventions could be implemented. In the follow-up visit, there was total misunderstanding of lifestyle modification and how it must be implemented in the management of hypertension. It was clear that PHC facilities require greater assistance and support from the employer, the NDoH of South Africa, to enable PHC nurses in the Tshwane district to adopt more follow-up care of hypertensive patients. Furthermore, in order to assist, guide and motivate the nurses to become active partners in their care, in-service trainings, resources and equipment are needed. There should be a remediation programme for professional nurses who have been trained but are found to be non-adherent to the guidelines. In a study conducted in Kinshasa, Congo, in which knowledge of consulting nurse's was assessed, 84% of the nurses reported to have received training [19]. The results suggest that training alone may not be enough, but continuous support and remedial actions may be necessary [19].

In addition, nurses of PHC facilities need to be supported by policy and organisational change. The results of the study [19] also supported the earlier observation made by the researcher in the research problem that chronic services are regarded as fast track and sometimes very incompetent nurses are allocated to these services since they are regarded as predominantly treatment collection with no specialised skills required. In accordance with other similar studies, most of the files of hypertensive patients that were audited for this study were found to be demonstrating positive and negative strengths regarding the follow-up care received by patients with hypertension.

A study conducted in Brazil by [16] on the association between follow-up care in health services and adherence to antihypertensive medication indicated that the level of therapeutic adherence in different populations of hypertensive patients is frequently investigated, given the severity of the problem. The adherence identified in the population was high (63%), possibly influenced by the characteristics of the participants, who had cardiovascular disease associated with arterial hypertension and, consequently, needed and sought health care more frequently. The findings indicate that higher consultation attendance has a statistically significant relationship with better medication adherence. This reinforces the notion that accessibility and frequent use of health services significantly affects the health conditions of hypertensive patients with associated cardiovascular disease [16].

Furthermore, the significance of follow-up care in clinics was analysed in relation to the level of therapeutic adherence and the prevalence of acute events [20, 21]. Patients who did not seek emergency services in the last two years had better adherence rates (p = 0.04). Since acute episodes usually lead to the introduction of new drugs in the treatment protocol of hypertensive patients, the lower adherence of the group that sought emergency services may be related to the problem in adapting to combination therapy, which demands post-discharge follow-up [20, 21].

In the study conducted in Brazil [16], the authors sought to advance knowledge concerning the correlation between health services and medication adherence when investigating attendance of hypertensive patients' at nursing consultations, since these are mainly focused on health education [16]. Regardless of the fact

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*Assessment of Follow-Up Care Received by Patients with Hypertension at Primary Health Care…*

that the respondents had a greater number of medical appointments than nursing consultations, drug adherence was better among those who attended nursing consultations more frequently (p = 0.022). In addition, the study indicated the number of consultations necessary to improve the therapeutic adherence of

Repeated nursing follow-up does not necessarily result in increased therapeutic adherence, and can increase health care costs [22]. The practice revealed by the present chapter of 4 to 6 nursing consultations per annum is the preferred level of nursing follow-ups, to attain better levels of antihypertensive treatment adherence. It was also observed that hypertensive patients who attended medical and nursing consultations or who had received health orientations in the last 6 months presented greater therapeutic adherence, with a statistically significant correlation (p = 0.013). PHC professionals have a high capability and meaningful opportunity to impact the improvement of patients' treatment adherence, through the support of guidelines and care during visits, home visits, health talk actions and tracking of

Regarding the view of impact of follow-ups in PHC services on therapeutic adherence of hypertensive patients, directed public policies are necessary to enhance this level of attention, and bring it closer to the population. Also meriting consideration is the social capital of the Brazilian population, which assists people overcome obstacles regarding the accessibility and utilisation of clinics by giving information and treatment support. For hypertensive patients, involvement into social health networks encourages them to look for specialised health care, although the decision to take part in treatment follow-up must be from the patients themselves [24]. However, treatment adherence will definitely be influenced by participation in social health networks and presence of follow-up

The results of this chapter are valid in the specific context of the Tshwane district and cannot be generalised to the entire Gauteng province or to the whole country.

The objectives of the study were to describe the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district and to determine nurses' adherence or non-adherence to the guidelines regarding hypertension follow-up care. The conclusion drawn is that follow-up care obtained by hypertensive patients in PHC facilities in the Tshwane district was found to be insufficient, and demonstrated by a trend of non-adherence to the guidelines. This showed a considerable lack of knowledge and practice in the treatment of hypertension in

• It is recommended that unskilled professional nurses should not be allocated to hypertension follow-up care or to a chronic section. Even if guidelines are available, they will yield better results if they are used by professional nurses

*DOI: http://dx.doi.org/10.5772/intechopen.99623*

hypertension patients [16].

non-adherent behaviours [23].

visits in the clinics.

**2.13 Limitations**

**3. Conclusions**

PHC clinics.

**4. Recommendation**

**4.1 Nursing practice**

*Assessment of Follow-Up Care Received by Patients with Hypertension at Primary Health Care… DOI: http://dx.doi.org/10.5772/intechopen.99623*

that the respondents had a greater number of medical appointments than nursing consultations, drug adherence was better among those who attended nursing consultations more frequently (p = 0.022). In addition, the study indicated the number of consultations necessary to improve the therapeutic adherence of hypertension patients [16].

Repeated nursing follow-up does not necessarily result in increased therapeutic adherence, and can increase health care costs [22]. The practice revealed by the present chapter of 4 to 6 nursing consultations per annum is the preferred level of nursing follow-ups, to attain better levels of antihypertensive treatment adherence. It was also observed that hypertensive patients who attended medical and nursing consultations or who had received health orientations in the last 6 months presented greater therapeutic adherence, with a statistically significant correlation (p = 0.013). PHC professionals have a high capability and meaningful opportunity to impact the improvement of patients' treatment adherence, through the support of guidelines and care during visits, home visits, health talk actions and tracking of non-adherent behaviours [23].

Regarding the view of impact of follow-ups in PHC services on therapeutic adherence of hypertensive patients, directed public policies are necessary to enhance this level of attention, and bring it closer to the population. Also meriting consideration is the social capital of the Brazilian population, which assists people overcome obstacles regarding the accessibility and utilisation of clinics by giving information and treatment support. For hypertensive patients, involvement into social health networks encourages them to look for specialised health care, although the decision to take part in treatment follow-up must be from the patients themselves [24]. However, treatment adherence will definitely be influenced by participation in social health networks and presence of follow-up visits in the clinics.

#### **2.13 Limitations**

The results of this chapter are valid in the specific context of the Tshwane district and cannot be generalised to the entire Gauteng province or to the whole country.

## **3. Conclusions**

The objectives of the study were to describe the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district and to determine nurses' adherence or non-adherence to the guidelines regarding hypertension follow-up care. The conclusion drawn is that follow-up care obtained by hypertensive patients in PHC facilities in the Tshwane district was found to be insufficient, and demonstrated by a trend of non-adherence to the guidelines. This showed a considerable lack of knowledge and practice in the treatment of hypertension in PHC clinics.

#### **4. Recommendation**

#### **4.1 Nursing practice**

• It is recommended that unskilled professional nurses should not be allocated to hypertension follow-up care or to a chronic section. Even if guidelines are available, they will yield better results if they are used by professional nurses who understand consultation skills such as history taking, physical examination and interpretation of investigations.
