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 OJCD  Vol.11 No.2 , June 2021
Patient and Health System Related Factors Associated with Non-Adherence to Antihypertensive Medication among Patients at Chuka Referral Hospital, Kenya
Abstract: Background: Non-adherence to hypertensive medication continues to become a contributing factor to hypertensive complications like stroke, heart attacks, kidney disease heart failure. Associated factors to non-adherence are complex, are both internal and external to the patient and are difficult to extrapolate. Reports from Chuka referral hospital records showed that in 2016 there were 140 patients with hypertensive complications from 560 patients who attended the medical clinic that year. Objective: This study sought to explore the patient’s related factors that are associated with non-adherence to hypertension medication. Methods: This is a descriptive study design of (N = 575) people among them doctors, pharmacists, nurses, record officers and hypertension patients. Simple random sampling for patients (n = 81) and census sampling for health care workers was done and data collected using questionnaires and interview schedules between April 4th-May 30th 2019. Inferential and descriptive statistics were used for data analysis, aided by SPSS version 25. Results: 64% of the patients stated that they had missed medication. A significant negative correlation (rpb = -0.23, p < 0.05) between age and non-adherence, significant positive correlation with monthly income (rpb = 0.24, p < 0.04), non-significant relationship between non-adherence and marital status (rpb = -0.13, p = 0.25) and patients’ level of education (rpb = -0.06, p = 0.57). The overall model of health system related factors were found to be significant (p < 0.05) and this included; quality of health service, physician patient relationship, stock out, health education, and availability of medicine (p = 0.012). Conclusion: Lacks of funds, unavailability of drugs are the leading factors to regimen completion. This could be easily be addressed by the government.
Cite this paper: Gikunda, C. , Gitonga, L. and Kamweru, P. (2021) Patient and Health System Related Factors Associated with Non-Adherence to Antihypertensive Medication among Patients at Chuka Referral Hospital, Kenya. Open Journal of Clinical Diagnostics, 11, 19-46. doi: 10.4236/ojcd.2021.112002.
References

[1]   Lim, S.S., Vos, T., Flaxman, A.D., Danaei, G., Shibuya, K., Adair-Rohani, H., Aryee, M., et al. (2013) A Comparative Risk Assessment of Burden of Disease and Injury Attributable to 67 Risk Factors and Risk Factor Clusters in 21 Regions, 1990-2010: A Systematic Analysis for the Global Burden of Disease Study 2010. The Lancet, 380, 2224-2260.

[2]   Crim, M.T., Yoon, S.S. and Ortiz, E. (2012) National Surveillance Definitions for Hypertension Prevalence and Control among Adults. Cardiovascular Quality and Outcomes, 5, 343-351.
https://doi.org/10.1161/CIRCOUTCOMES.111.963439

[3]   Forouzanfar, M.H., Liu, P., Roth, G.A., Ng, M., Biryukov, S., Marczak, L. and Ali, R. (2017) Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 Mm Hg, 1990-2015. JAMA, 317, 165-182.
https://doi.org/10.1001/jama.2016.19043

[4]   Persell, D. (2011) Prevalence of Resistant Hypertension in the United States, 2008- 2012. Hypertension Journal, 57, 1076-1080.
https://doi.org/10.1161/HYPERTENSIONAHA.111.170308

[5]   World Health Organization (2019)
https://www.who.int/News-Room%20Factsheet/Detail/Hypertension

[6]   World Health Organization (2017) Global Health Observatory Data Raised Blood Pressure.
http://www.Who.Int/Gho/Ncd/Risk_Factors/Blood_Pressure_Prevalence_Text/En (Updated 2017)

[7]   World Health Organization (2012) Kenya Who Statistical Profile.
http://www.Who.Int/Gho/Countries/Ken.Pdf?Ua=1 (Updated 2012)

[8]   Mwenda, K., Kirigia, C., Kamweru, P.K. and Gitonga, L.K. (2020) Factors Affecting Health Seeking Behaviour in Hypertensive Patients of Imenti North Sub County, Kenya. International Journal of Community Medicine and Public Health, 8, 37-42.
https://doi.org/10.18203/2394-6040.ijcmph20205675

[9]   Dragomir, A., Cote, R., Roy, L., Blais, L., Lalonde, L., Bérard, A. and Perreault, S. (2010) Impact of Adherence to Antihypertensive Agents on Clinical Outcomes and Hospitalization Costs. Medical Care, 48, 418-425.
https://doi.org/10.1097/MLR.0b013e3181d567bd

[10]   Jaffe, M.G., Frieden, T.R., Campbell, N.R., Matsushita, K., Appel, L.J., Lackland, D.T. and Whelton, P.K. (2018) Recommended Treatment Protocols to Improve Management of Hypertension Globally: A Statement by Resolve to Save Lives and the World Hypertension League (WHL). The Journal of Clinical Hypertension, 20, 829-836.
https://doi.org/10.1111/jch.13280

[11]   Primatesta, P. and Poulter, N.R. (2006) Improvement in Hypertension Management in England: Results from the Health Survey for England. Journal of Hypertension, 24, 1187-1192.
https://doi.org/10.1097/01.hjh.0000226210.95936.bc

[12]   Hashmi, S.K., Afridi, M.B., Abbas, K., Sajwani, R.A., Saleheen, D., Frossard, P.M. and Ahmad, U. (2007) Factors Associated with Adherence to Anti-Hypertensive Treatment in Pakistan. PLoS ONE, 2, e280.
https://doi.org/10.1371/journal.pone.0000280

[13]   De Simoni, A., Hardeman, W. and Mant, J. (2013) Trials to Improve Blood Pressure through Adherence to Antihypertensive in Stroke/TIA: Systematic Review and Meta-Analysis. Journal of the American Heart Association, 2, 1-8.
https://doi.org/10.1161/JAHA.113.000251

[14]   Brinker, S., Pandey, A. and Ayers, C. (2014) Therapeutic Drug Monitoring Facilitates BP Control in Resistant Hypertension. Journal of the American College of Cardiology, 63, 834-835.
https://doi.org/10.1016/j.jacc.2013.10.067

[15]   Corrao, G., Parodi, A. and Nicotra, F. (2011) Better Compliance to Antihypertensive Medications Reduces Cardiovascular Risk. Journal of Hypertension, 29, 610-618.
https://doi.org/10.1097/HJH.0b013e328342ca97

[16]   Perreault, S., Yu, A.Y. and Côté, R. (2012) Adherence to Antihypertensive Agents after Ischemic Stroke and Risk of Cardiovascular Outcomes. Neurology Journal, 79, 2037-2043.
https://doi.org/10.1212/WNL.0b013e3182749e56

[17]   WHO (2013) Global Status Report on Non-Communicable Diseases 2013: Attaining the Nine Global Non-Communicable Diseases Targets; a Shared Responsibility.

[18]   Panjabi, S., Lacey, M., Bancroft, T. and Cao, F. (2012) Treatment Adherence, Clinical Outcome and Economic of Triple Drug Therapy in Hypertensive Patients. Journal of American Society of Hypertension, 7, 46-60.
https://doi.org/10.1016/j.jash.2012.11.001

[19]   Kronish, I.M. and Ye, S. (2013) Adherence to Cardiovascular Medications: Lessons Learned and Future Directions. Progress in Cardiovascular Diseases, 55, 590-600.
https://doi.org/10.1016/j.pcad.2013.02.001

[20]   Arshia, B., Mehwish, R., Noor-Ulain, S., Mariam, A., Sadaf, S. and Rasheed, S. (2010) Non-Compliance to Anti-Hypertensive Medication and Its Associated Factors among Hypertensives. Karachi Medical and Dental College, Karachi.

[21]   Mathenge, W., Foster, A. and Kuper, H. (2010) Urbanization, Ethnicity and Cardiovascular Risk in a Population in Transition in Nakuru, Kenya: A Population-Based Survey. BMC Public Health, 10, 569.
https://doi.org/10.1186/1471-2458-10-569

[22]   Atinga, R.A., Yarney, L. and Gavu, N.M. (2018) Factors Influencing Long-Term Medication Non-Adherence among Diabetes and Hypertensive Patients in Ghana: A Qualitative Investigation. PLoS ONE, 13, e0193995.
https://doi.org/10.1371/journal.pone.0193995

[23]   Buckley, L., Labonville, S. and Barr, J. (2016) A Systematic Review of Beliefs about Hypertension and Its Treatment among African Americans. Current Hypertension Reports, 18, 52.
https://doi.org/10.1007/s11906-016-0662-5

[24]   Lewis, L. (2012) Factors Associated with Medication Adherence in Hypertensive Blacks: A Review of the Literature. Journal of Cardiovascular Nursing, 27, 208-219.
https://doi.org/10.1097/JCN.0b013e318215bb8f

[25]   Bruce, S., Acheampong, F. and Kretchy, I. (2015) Adherence to Oral Anti-Diabetic Drugs among Patients Attending a Ghanaian Teaching Hospital. Pharmacy Practice, 13, 533.
https://doi.org/10.18549/PharmPract.2015.01.533

[26]   Wu, J.R., Lennie, T.A., Chung, M.L., Frazier, S.K., Dekker, R.L., Biddle, M.J. and Moser, D.K. (2012) Medication Adherence Mediate the Relationship between Marital Status and Cardiac Event-Free Survival in Patients with Heart Failure. Heart and Lung—The Journal of Acute And Critical Care, 41, 107-114.
https://doi.org/10.1016/j.hrtlng.2011.09.009

[27]   Zyoud, S.H., Al-Jabi, S.W., Sweileh, W.M. and Morisky, D.E. (2013) Relationship of Treatment Satisfaction to Medication Adherence: Findings from a Cross-Sectional Survey among Hypertensive Patients in Palestine. Health and Quality of Life Outcomes, 11, 191-197.
https://doi.org/10.1186/1477-7525-11-191

[28]   Mcmullen, C., Safford, M., Bosworth, H., Phansalkar, S., Leong, A. and Fagan, M.B. (2015) Patient-Centered Priorities for Improving Medication Management and Adherence. Patient Education and Counseling, 98, 102-110.
https://doi.org/10.1016/j.pec.2014.09.015

[29]   WHO (2012) Clinical Guidelines for the Management of Hypertension. World Health Organization, Cairo.

[30]   Kioko, J. (2017) Government Unveils Strategies to Control Hypertension, the Silent Killer. Ministry of Health, Nairobi.

[31]   Ministry of Health Kenya (2018) Kenya National Guidelines for Cardiovascular Diseases Management.

[32]   Al-Khaldi, Y.M. and Al-Sharif, A.I. (2005) Health Education Resources Availability for Diabetes and Hypertension at Primary Care Settings, Aseer Region, Saudi Arabia. Journal of Family and Community Medicine, 12, 75.

[33]   Baune, B. and Aljeesh, Y. (2006) The Association of Psychological Stress and Health Related Quality of Life among Patients with Stroke and Hypertension in Gaza Strip. Annals of General Psychiatry, 5, 6.

[34]   Zolnierek, K.B.H. and Dimatteo, M.R. (2009) Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care, 47, 826-834.
https://doi.org/10.1097/MLR.0b013e31819a5acc

[35]   Schoenthaler, A., Chaplin, W.F., Allegrante, J.P., Fernandez, S., Diaz-Gloster, M., Tobin, J.N. and Ogedegbe, G. (2012) Effects of Patients Provider Communication on Medication Adherence in Hypertensive Black Patients: Does Race Concordance Matter?
https://doi.org/10.1007/s12160-011-9342-5

[36]   Cane. J., O’Connor, D. and Michie, S. (2012) Validation of the Theoretical Domains Framework for Use in Behavior Change and Implementation Research. Implementation Science, 24, 37.
https://doi.org/10.1186/1748-5908-7-37

[37]   Craig, H.M. (1985) Accuracy of Indirect Measures of Medication Compliance in Hypertension. Research in Nursing and Health, 8, 61-66.
https://doi.org/10.1002/nur.4770080112

[38]   Haynes, R.B., Ackloo, E., Sahota, N., Mcdonald, H.P. and Yao, X. (2008) Intervention for Enhancing Medication Adherence. Cochrane Database of Systematic Reviews, 2, CD00011.
https://doi.org/10.1002/14651858.CD000011.pub3

[39]   Ley, P. (1988) Communicating with Patients: Improving Communication, Satsfaction and Compliance. Croom Helm, New York.

[40]   Michie, S., Van Stralen, M.M. and West, R. (2011) The Behaviour Change Wheel: A New Method for Characterising and Designing Behaviour Change Interventions. Implement Science, 6, 42.
https://doi.org/10.1186/1748-5908-6-42

[41]   Clinical Effectiveness Research Agenda Group (CERAG) (2008) An Implementation Research Agenda: A Report Prepared for the High Level Group on Clinical Effectiveness. CERAG, London.

[42]   Newman, M., Papadopoulous, L. and Sigsworth, J. (1998) Barriers to Evidence-Based Practice. Clinical Effectiveness in Nursing, 2, 11-18.
https://doi.org/10.1016/S1361-9004(98)80080-0

[43]   Grol, R. and Grimshaw, J. (2003) From Evidence to Best Practice: Effective Implementation of Change in Patients’ Care. The Lancet, 362, 1225-1230.
https://doi.org/10.1016/S0140-6736(03)14546-1

[44]   Abraham, C., Kelly, M.P., West, R. and Michie, S. (2009) The UK National Institute for Health and Clinical Excellence Public Health Guidance on Behavior Change: A Brief Introduction. Psychology, Health and Medicine, 14, 1-8.
https://doi.org/10.1080/13548500802537903

[45]   Noar, S.M. and Zimmerman, R.S. (2009) Health Behavior Theory and Cumulative Knowledge Regarding Health Behaviors: Are We Moving in the Right Direction. Health Education Research: Theory and Practice, 20, 275-290.
https://doi.org/10.1093/her/cyg113

[46]   Salaria, N. (2012) Meaning of the Term Descriptive Survey Research Method. International Journal of Transmission in Business Management, 16, 1-7.

[47]   Nassiuma, D.K. (2000) Survey Sampling: Theory and Methods. Nairobi University Press, Nairobi.

[48]   Chuka Referral Hospital (2016) Chuka Referral Hospital Morbidity Report for Year 2016.

[49]   Nagelkerke, N.J.D. (I991) A Note on General Definitions of the Coefficient of Determination. Biometrika, 78, 691-692.
https://doi.org/10.1093/biomet/78.3.691

[50]   Courtenay, W.H. (2000) Constructions of Masculinity and Their Influence on Men’s Well-Being: A Theory of Gender and Health. Social Science and Medicine Journal, 50, 1385-1401.
https://doi.org/10.1016/S0277-9536(99)00390-1

[51]   Silva, S., Oliveira, S. and Pierin, A.M.G. (2016) The Control of Hypertension in Men and Women: A Comparative Analysis. Revista Da Escola De Enfermagem Da USP, 50, 50-58.
https://doi.org/10.1590/S0080-623420160000100007

[52]   Thompson, A.E., Anisimowicz, Y., Miedema, B., Hogg, W., Wodchis, W.P. and Aubrey-Bassler, K. (2016) The Influence of Gender and Other Patient Characteristics on Health Care-Seeking Behaviour. BMC Family Practice, 17, 38.
https://doi.org/10.1186/s12875-016-0440-0

[53]   Li, W.W., Wallhagen, M.I. and Froelicher, E.S. (2008) Hypertension Control, Predictors for Medication Adherence and Gender Differences in Older Chinese Immigrants. Journal of Advanced Nursing, 61, 326-335.
https://doi.org/10.1111/j.1365-2648.2007.04537.x

[54]   Demonceau, J., Ruppar, T., Kristanto, P., et al. (2013) Identification and Assessment of Adherence-Enhancing Interventions in Studies Assessing Medication Adherence through Electronically Compiled Drug Dosing Histories: A Systematic Literature Review and Meta-Analysis. Drugs, 73, 545-562.
https://doi.org/10.1007/s40265-013-0041-3

[55]   Trivedi, R.B., Ayotte, B., Edelman, D. and Bosworth, H.B. (2008) The Association of Emotional Well-Being and Marital Status with Treatment Adherence among Patients with Hypertension. Journal of Behavioral Medicine, 31, 489-497.
https://doi.org/10.1007/s10865-008-9173-4

[56]   Chung, M., Lennie, T., Riegel, B., Wu, J., Dekker, R. and Moser, D. (2009) Marital Status as an Independent Predictor of Event-Free Survival of Patients with Heart Failure. American Journal of Critical Care, 18, 562-570.
https://doi.org/10.4037/ajcc2009388

[57]   Vincent, B., Adebowale, A., Francis, A., Aina, O. and Ezenwafor, O. (2015) Factors Associated with Medication Non-Adherence among Hypertensive in Ghana and Nigeria. International Journal of Hypertension, 2015, Article ID: 205716.

[58]   Ibrahim, S.A. (2003) Hypertension and Medication Adherence among African Americans: A Potential Factor in Cardiovascular Disparities. Journal of the National Medical Association, 95, 28-29.

[59]   Shaw, R. and Bosworth, H.B. (2012) Baseline Medication Adherence and Blood Pressure in a 24 Month Longitudinal Hypertension Study. Journal of Clinical Nursing, 21, 1401-1406.
https://doi.org/10.1111/j.1365-2702.2011.03859.x

[60]   Després, F., Perreault, S., Lalonde, L., Forget, A., Kettani, F.-Z. and Blais, L. (2014) Impact of Drug Plans on Adherence to and the Cost of Antihypertensive Medications among Patients Covered by a Universal Drug Insurance Program. The Canadian Journal of Cardiology, 30, 560-567.
https://doi.org/10.1016/j.cjca.2013.11.032

[61]   Goldman, D.P., Joyce, G.F. and Zheng, Y. (2007) Prescription Drug Cost Sharing: Associations with Medication and Medical Utilization and Spending and Health. The Journal of the American Medical Association, 298, 61-69.
https://doi.org/10.1001/jama.298.1.61

[62]   Bagonza, J., Rutebemberwa, E. and Bazeyo, W. (2015) Adherence to Anti Diabetic Medication among Patients with Diabetes in Eastern Uganda; a Cross Sectional Study. BMC Health Services Research, 15, 168.
https://doi.org/10.1186/s12913-015-0820-5

[63]   Park, Y.H., Kim, H., Jang, S.-N. and Koh, C.K. (2013) Predictors of Adherence to Medication in Older Korean Patients with Hypertension. European Journal of Cardiovascular Nursing, 12, 17-24.
https://doi.org/10.1016/j.ejcnurse.2011.05.006

[64]   Jambedu, H.A. (2006) Adherence to Antihypertensive Medication among Patients Attending the G.P.H.A Hospital in Tokoradi Ghana.

[65]   Grueninger US (1995) Arterial Hypertensionlesson from Patients Education. Patient Education and Counseling, 26, 37-55.
https://doi.org/10.1016/0738-3991(95)00750-T

[66]   Bailer-Goering, M.M. and Royk, H.D.H. (2019) Relationship between Adherence to Antihypertensives Medication Regimen and out of Pocket Cost among People Aged 35-64 with Employer Sponsored Health Insurance. Preventing Chronic Disease, 16, 180-381.
https://doi.org/10.5888/pcd16.180381

[67]   Olowookere, A.J., Olowookere, S.A., Talabi, A.O., Entonyeaku, A.C., Adeleke, O.E. and Aikuboboje, O.O. (2015) Perceived Family Support and Factors Influencing Medication Adherence among Hypertensive Patients Attending a Nigerian Tertiary Hospital. Annals of Tropical Medicine and Public Health, 8, 241-245.
https://doi.org/10.4103/1755-6783.162668

[68]   Kearney, P.M., Whelton, M., Whelton, P.K., Reynolds, K., Muntner, P. and He, J. (2005) Global Burden of Hypertension: Analysis of Worldwide Data. The Lancet, 365, 217-223.
https://doi.org/10.1016/S0140-6736(05)17741-1

[69]   Clark, C.E., Smith, L.F. and Taylor, J.L. (2010) Nurses Led Intervention to Improve Control of Blood Pressure in People with Hypertension. BMJ, 341, c3995.

[70]   Robertson, J., Mace, C., Forte, G., Dejoncheere, K. and Beran, D. (2015) Medicines Availability for Non-Communicable Diseases: The Case of Standardized Monitoring. Globalization and Health, 11, 35.
https://doi.org/10.1186/s12992-015-0120-1

[71]   Rajesh, V., Nelly, T., Clare, K., Evans, B., Jemima, K., Violet, N., Sylvester, T., Carol, H. and Valentin, F. (2016) Barriers and Facilitators to Nurse Management of Hypertension: A Qualitative Analysis from Western Kenya. Ethnicity & Disease, 26, 315-322.
https://doi.org/10.18865/ed.26.3.315

[72]   Beune, E.J., Charante, E.P., Beem, L., Mohrs, J., Agyemang, C.O., Ogedegbe, G. and Haafkens, J.A. (2014) Culturally Adapted Hypertension Education (CAHE) to Improve Blood Pressure Control and Treatment Adherence in Patients of African Origin with Uncontrolled Hypertension: Cluster-Randomized Trial. PLoS ONE, 9, e90103.
https://doi.org/10.1371/journal.pone.0090103

[73]   Krousel-Wood, M., Thomas, S., Muntenes, P. and Morisky, D. (2004) Medication Adherence a Key Factor in Achieving BP Control and a Good Clinical Outcome in Hypertension Patient. Current Opinion in Cardiology, 19, 357-362.
https://doi.org/10.1097/01.hco.0000126978.03828.9e

[74]   Cokkinos, D.V., Mountokalakis, Td., et al. (2005) Adherence to Antihypertensive Treatment: A Critical Factor for Blood Pressure Control. European Journal of Cardiovascular Prevention & Rehabilitation, 12, 243-249.
https://doi.org/10.1097/01.hjr.0000160601.41762.44

[75]   Isezuo, A.S. and Opera, T.C. (2000) Hypertension Awareness among Nigerians in a Nigeria Tertiary Health Institution. Sahel Medical Journal, 3, 93-9622.

[76]   Kaboru, B. (2013) Patients-Related Predictors of Poor Adherence to Antihypertensive Treatment in Congo-Brazzaville: A Cross-Sectional Study. Global Journal of Medicine and Global Health, 2, 1-9.

[77]   Marie, I., Jerniffer, B., Supana, D. and Catherine, D. (2016) Medication Adherence Truth and Consequences. The American Journal of the Medical Sciences, 351, 387-399.
https://doi.org/10.1016/j.amjms.2016.01.010

[78]   Paling, J. (2003) Strategies to Help Patient Understand Risks. BMJ, 327, 745-748.
https://doi.org/10.1136/bmj.327.7417.745

[79]   Lapane, K.L., Dube, C.E., Schreider, K.L. and Quilliam, B.J. (2007) Mis-Perception of Patients vs Providers Regarding Medication Related Communication Issues. The American Journal of Managed Care, 13, 613-618.

[80]   Palterson Sm Cadogai, C.A., Kersee, N., Cardwell, C.R., Bradaey, M.C., Ryan, C. and Huges (2014) Intervention to Improve the Appropriate Use of Poly Pharmacy for Older People. The British Medical Journal, 326, 450-459.

[81]   Inkster, M.E., Donnan, P.T., Macdonald, T.M., Sullivan, F.M. and Fahey, T. (2006) Adherence to Antihypertensive Medication and Association with Patient and Practice Factors. Journal of Human Hypertension, 20, 295-297.
https://doi.org/10.1038/sj.jhh.1001981

[82]   Osterberg, L. and Blaschke, T. (2005) Adherence to Medication. The New England Journal of Medicine, 353, 487-497.
https://doi.org/10.1056/NEJMra050100

[83]   Shea, O., Griffin, T. and Fitzigibbon, M. (2016) The Role of Biochemistry in Diagnosis and Management. Clinica Chimica Acta, 465, 131-143.

[84]   Anglada Martinez, H., Riuviladoms, G., Martin Conds, M., Roviraillamola, M., Sotoca-Mombiana, J.M. and Codin, J.C. (2015) Does Health Increase Adherence to Medication. Results of a Systematic Review. International Journal of Clinical Practice, 69, 9-32.
https://doi.org/10.1111/ijcp.12582

[85]   Ambaw, A.D., Alemie, G.A. and Mengesha, Z.B. (2012) Adherence to Antihypertensive Treatment and Associated Factors among Patients on Follow up at University of Gondar Hospital, Northwest Ethiopia. BMC Public Health, 12, 282.
https://doi.org/10.1186/1471-2458-12-282

[86]   Schafheutle, E.I., Hassell, K., Noyce, P.R. and Weiss, M.C. (2002) Access to Medicines: Cost as an Influence on the Views and Behaviour of Patients. Health and Social Care in the Community, 10, 187-195.
https://doi.org/10.1046/j.1365-2524.2002.00356.x

 
 
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