**8. Patients knowledge about cardiovascular diseases and medicines**

An individual must know at least 75% of the items used in the summary variables to qualify as having acquired adequate knowledge [45]. For those patients who can achieve adequate knowledge, this should be the target for having

**307**

*Exploring Cardiovascular Diseases Treatment in Africa DOI: http://dx.doi.org/10.5772/intechopen.95871*

nant of uncontrolled hypertension [46].

comprehensive knowledge. However, in cardiovascular diseases, this may be affected by age, agility, and cognitive skills particularly in elderly patients.

According to Mugomeri and colleagues, nearly 36% had inadequate knowledge about hypertension while 44% had inadequate knowledge about their medicines [46]. In this study, in total, 52.4% of the patients did not turn up for appointment dates while 64.6% failed to take their medications according to the prescription at least once. It was also stated that inadequate knowledge of antihypertensive medicines was significantly associated (P = .028) with having uncontrolled hypertension [46]. Inadequate knowledge of antihypertensive medicines is an important determi-

The study carried out on village health workers (VHW) in Lesotho, as health workers, determining adequate knowledge and translation of knowledge to offered services indicated that among household members aged 15 years and above, only a third was advised by the VHW to go for HIV testing [47]. Communities served by VHWs with adequate knowledge did not only demonstrate better knowledge compared to their counterparts served by VHWs with inadequate knowledge, in utilization VHWs' services were high [47]. The finding confirmed what was suggested by the literature of Hirsch-Moverman [48]. Community health workers (CHWs) form part of the primary health care system [47]. The community health workers who have adequate knowledge can play a very important role in their communities in terms of education, monitoring adherence and referrals [47]. It is therefore, recommended that training of CHW on cardiovascular diseases, treatment and preven-

Information is crucial to promote patients' knowledge which increases the sense of control, decrease emotional distress, support effective self-management, and eliminate disruptions of daily activities [49, 50]. Patients want to have control over their symptoms therefore, they need as much information as possible about their symptoms and strategies to manage these symptoms. The patient knowledge about cardiovascular diseases leads to good management of the diseases. Bandura [51] reiterates that a contributing factor to the difference in symptom self-management is a person's perceived self-efficacy. Perceived self-efficacy forms the basis of any decision to act on and is defined as the perception of one's own ability to implement behavior(s) to achieve designated types of outcomes such as symptom management. Bandura [52] further explains that perceived self-efficacy beliefs are considered to be central and influential factors in determining the course of action to be chosen, the degree of effort applied,

Intervention is required in order to improve the knowledge of patients regarding cardiovascular diseases, hypertension, and associated medications [53, 54]. This intervention comprises of the patient essential educational topics and method of delivery of patient education. Patient education topics should include pathophysiology and etiology, symptoms and signs, pharmacological treatment, risk factor modification, diet and exercise, sexual activity, immunization, sleep and breathing disorders, adherence, psychosocial aspects and prognosis associated with certain skills or self-management behaviors [54–56]. However, patient education alone is not enough, the delivery of patient education content should consider level literacy, age, and other cognitive measures. Medium of delivery of patient education must be individualized according to the needs of the patient. Some patients benefit from one-on-one sessions, while others benefit from group sessions, some still can benefit from both sessions. The guidelines recommend patient education and counseling targeting patient skills and behavior [57]. For patient education to be effective Meng and colleagues [53] recommend outcome and measurement strategies to enlighten on primary and secondary outcomes. The primary outcome entails self-management competencies which are measured through self-monitoring and insight, skill and technique acquisition,

tion of complication be taken as a priority in the African continent.

and the perseverance to continue in the face of problems and obstacles.

#### *Exploring Cardiovascular Diseases Treatment in Africa DOI: http://dx.doi.org/10.5772/intechopen.95871*

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

countries including in those in sub-Saharan Africa [38].

effects of public policies.

the results would be even more favorable.

This can improve on patients quality of life with cost savings.

**7. Cost effectiveness of cardiovascular disease prevention and treatment**

The highest age standardized death rate from non-communicable diseases (NCDs) (779 per 100, 000) occur mostly in the African Region [35]. In sub Saharan Africa, the probability of dying from NCDs between 30 and 70 years is very high. It is also indicated that behavioral risk factors are estimated to be responsible for about 80% of coronary heart disease and cerebrovascular disease and these include tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol. The cost of implementing reduction measures for tobacco control (smoke-free policies, raise tobacco taxes, package warnings, advertising bans), harmful alcohol consumption, and physical activity and diet modification is found to be low [36]. Usually these costs include media campaigns and overall program management. It is feasible to deliver cardiovascular risk reduction interventions in primary care, even in low-resource settings with non-physician health workers [37]. Currently, there are major gaps in access to these essential primary care interventions in developing

There are other strategies that can be employed to prevent cardiovascular diseases. This becomes attractive to providers and can lead to policy change. According to recent surveys there is high prevalence of salt consumption [39] in South Africa. The burden of cardiovascular disease (CVD) in the same country is rising, and to address this, the government recently developed policies to reduce salt consumption in the population [39]. Population-based salt reduction strategies have been found to be a cost-effective approach to lowering the prevalence of hypertension and preventing cardiovascular disease (CVD). The cost saving for both household and providers was significantly different. The extended cost-effectiveness analysis (ECEA), which models the health gains, financial risk protection and distributional

Mathers [40] states that cardiovascular diseases are responsible for about 30% of all deaths worldwide, and total deaths occurring in developing countries amount to about 80% [41]. Several authors have suggested that the combination of several preventive treatments could cut more than half the occurrence of cardiovascular disease [41–43]. The analyses have shown that two multidrug regimens of four highly effective drugs could lead to cost-effective prevention and treatment for patients with cardiovascular disease in all developing regions [44]. Wald and Law [41] specifically proposed a polypill, consisting of a statin, aspirin, a β blocker, an angiotensin-converting-enzyme inhibitor (ACEI), a thiazide, and folic acid. Suggested primary preventive therapy consists of aspirin, ACEI, calcium-channel blocker, and statin. While secondary preventive therapy consists of aspirin, ACEI, β blocker, and statin [41]. If two polypills, consisting of the same drug combinations as the primary and secondary prevention strategies, would also improve adherence,

In conclusion, these lifestyle modification strategies such as tobacco use control, reduction in harmful effects of alcohol, diet and physical activity and salt intake reduction are perceived to be cost-effective. Primary and secondary preventive treatments are also found to be cost-effective in preventing cardiovascular disease.

**8. Patients knowledge about cardiovascular diseases and medicines**

An individual must know at least 75% of the items used in the summary variables to qualify as having acquired adequate knowledge [45]. For those

patients who can achieve adequate knowledge, this should be the target for having

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comprehensive knowledge. However, in cardiovascular diseases, this may be affected by age, agility, and cognitive skills particularly in elderly patients.

According to Mugomeri and colleagues, nearly 36% had inadequate knowledge about hypertension while 44% had inadequate knowledge about their medicines [46]. In this study, in total, 52.4% of the patients did not turn up for appointment dates while 64.6% failed to take their medications according to the prescription at least once. It was also stated that inadequate knowledge of antihypertensive medicines was significantly associated (P = .028) with having uncontrolled hypertension [46]. Inadequate knowledge of antihypertensive medicines is an important determinant of uncontrolled hypertension [46].

The study carried out on village health workers (VHW) in Lesotho, as health workers, determining adequate knowledge and translation of knowledge to offered services indicated that among household members aged 15 years and above, only a third was advised by the VHW to go for HIV testing [47]. Communities served by VHWs with adequate knowledge did not only demonstrate better knowledge compared to their counterparts served by VHWs with inadequate knowledge, in utilization VHWs' services were high [47]. The finding confirmed what was suggested by the literature of Hirsch-Moverman [48]. Community health workers (CHWs) form part of the primary health care system [47]. The community health workers who have adequate knowledge can play a very important role in their communities in terms of education, monitoring adherence and referrals [47]. It is therefore, recommended that training of CHW on cardiovascular diseases, treatment and prevention of complication be taken as a priority in the African continent.

Information is crucial to promote patients' knowledge which increases the sense of control, decrease emotional distress, support effective self-management, and eliminate disruptions of daily activities [49, 50]. Patients want to have control over their symptoms therefore, they need as much information as possible about their symptoms and strategies to manage these symptoms. The patient knowledge about cardiovascular diseases leads to good management of the diseases. Bandura [51] reiterates that a contributing factor to the difference in symptom self-management is a person's perceived self-efficacy. Perceived self-efficacy forms the basis of any decision to act on and is defined as the perception of one's own ability to implement behavior(s) to achieve designated types of outcomes such as symptom management. Bandura [52] further explains that perceived self-efficacy beliefs are considered to be central and influential factors in determining the course of action to be chosen, the degree of effort applied, and the perseverance to continue in the face of problems and obstacles.

Intervention is required in order to improve the knowledge of patients regarding cardiovascular diseases, hypertension, and associated medications [53, 54]. This intervention comprises of the patient essential educational topics and method of delivery of patient education. Patient education topics should include pathophysiology and etiology, symptoms and signs, pharmacological treatment, risk factor modification, diet and exercise, sexual activity, immunization, sleep and breathing disorders, adherence, psychosocial aspects and prognosis associated with certain skills or self-management behaviors [54–56]. However, patient education alone is not enough, the delivery of patient education content should consider level literacy, age, and other cognitive measures. Medium of delivery of patient education must be individualized according to the needs of the patient. Some patients benefit from one-on-one sessions, while others benefit from group sessions, some still can benefit from both sessions.

The guidelines recommend patient education and counseling targeting patient skills and behavior [57]. For patient education to be effective Meng and colleagues [53] recommend outcome and measurement strategies to enlighten on primary and secondary outcomes. The primary outcome entails self-management competencies which are measured through self-monitoring and insight, skill and technique acquisition,

and self-efficacy. While secondary outcomes are measured through self-management health behavior (symptom control, physical activity, medication adherence), healthrelated quality of life, and treatment satisfaction. Meng and colleagues [53] concluded that a patient-centered self-management might be more effective regarding certain self-management outcomes than a lecture-based usual care education.

Hinderlang [58] suggests that the material for patient education should be developed bearing in mind patients' cultural and language barriers. Patients' preferences should also be considered before embarking on patient education that may not be effective [59]. The content of patient education material should be broken down into concise, manageable sessions that do not overwhelm with vast amounts of facts and details and be free of medical jargon. The learning environment should be free of stress, environmental distractions, cultural conflicts, and value judgments all should be eliminated if possible. Timing should be based on the available time, attention span, and readiness for learning without rushing or taking too much time. The patients have to be actively involved in the process of learning and understand the value of the information and procedures being taught for improving the quality of his or her life [58]. Patients increasingly demand access to medical information, this has improved the patient-physician relationship and consequently improved patient care.

The disease management education plan should also include practical skills for patients and caregivers to participate in their own care. These may include:


In summary self-efficacy and self-management of cardiovascular diseases will encourage patients to be in control of their diseases, and their treatment. This will

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**10. Barriers of adherence to medication**

There are barriers of adherence to medication that affect patients with cardiovascular diseases, diabetes mellitus and hypertension thus, leading to

*Exploring Cardiovascular Diseases Treatment in Africa DOI: http://dx.doi.org/10.5772/intechopen.95871*

**9. Adherence to medications**

improve their treatment outcome. The community health workers can provide

Non-communicable diseases (NCDs) are chronic diseases where adherence to medication is essential to controlling these diseases. Patients with NCDs such as cardiovascular diseases, diabetes mellitus and hypertension are put on long-term therapy to manage their conditions. The health outcomes of these patients depend mainly on how they adhere to medication as well as on lifestyle modification. The World Health Organization (WHO) defined adherence as the extent to which the behavior of a person, such as taking medication, following a diet or lifestyle modification, corresponds

Although adherence is important to patients with NCDs who are on medication, non-adherence to medications is a concern in Africa. In a study conducted among patients with NCDs in Puducherry, South India, the prevalence of low adherence to medication was 32.7% [61]. In contrast, prevalence of poor adherence to diabetes mellitus medication in rural Kerala, South India was 74% [62]. A study conducted in a health facility in a peri-urban district in the Ashanti region of Ghana found that the overall prevalence of medication noncompliance among patients with chronic diseases was 55.5% [63]. Inadequate medication possession ratios and thereby treatment adherence was observed in hypertensive patients at two private outpatient health clinics in Sierra Leone, with more than 80% of patients assessed not having medication for more than 40% of the time period studied [64]. In a specialist clinic and general outpatient clinic in Nigeria, the overall self-reported high medication adherence was low among Nigerian hypertensive subjects [65]. Adherence level of hypertensive patients at Jimma University specialized hospital, Ethiopia, to antihypertensive medications was found to be sub-optimal due to daily alcohol intake, comorbidity, number of antihypertensive medications and availability of medications without fee [66]. A study conducted in Kampala (Uganda) among hypertensive stroke patients found that 17% of the patients were adherent to antihypertensive medications, and the main cause of non-adherence was lack of knowledge [67]. Non-adherence is when patients do not take their medications at all, are taking reduced amounts, or are taking doses at the prescribed frequencies but not taking into consideration medication to food requirements [68]. Non-adherence can either be intentional or unintentional. Intentional non-adherence is when a patient makes a rational decision not to use treatment or follow treatment recommendations [69–72]. Intentional adherence includes patient-related, therapy-related, and conditionrelated factors [69–72]. Unintentional non-adherence is unplanned patient behavior and is less strongly associated with beliefs and the level of cognition as compared to intentional non-adherence [69–72]. Unintentional non-adherence may be caused by forgetfulness and not knowing when and how to take medicines [69–72]. Factors affecting adherence of patients to their medicines such as therapy-related and condition-related factors are associated with unintentional non-adherence [69–72]. Barriers of adherence to medication are discussed in the subsequent subsection and mainly include categories of factors affecting patients' adherence to their medicines.

education, support and referral roles particularly in rural settings.

with the agreed recommendations from a health care provider [60].

improve their treatment outcome. The community health workers can provide education, support and referral roles particularly in rural settings.
