Pharm World Sci (2008) 30:107–110
DOI 10.1007/s11096-007-9151-x
RESEARCH ARTICLE
Effect of pharmaceutical care programme on blood pressure and
quality of life in a nigerian pharmacy
Cletus N. Aguwa Æ Chinwe V. Ukwe Æ
Obinna I. Ekwunife
Received: 10 May 2007 / Accepted: 29 July 2007 / Published online: 17 August 2007

Springer Science+Business Media B.V. 2007
Abstract Objective The study aimed at evaluating the
effect of pharmaceutical care programme on blood pres-
sure and quality of life of patients who visit a Nigerian
community pharmacy. Method A non-randomised, single-
site, crossover design was used. Patients served as their
own control. They underwent 5 months of usual care and
another 5 months of pharmaceutical care. Main outcome
measure Blood pressure and quality of life measured
before implementation of pharmaceutical care and at the
end served as main outcome measures. Other end-points
assessed at baseline and at the end of investigation
included smoking cessation, adherence to therapy, exer-
cise, salt restriction, alcohol moderation and self blood
pressure measurement. Results Twenty four (24) patients
out of the 40 recruited completed the study. Mean
reductions were significant after pharmaceutical care
intervention for systolic BP (14.3  14.4 mmHg) and
diastolic BP (10.8  10.7 mmHg). There was a significant
mean increase in number of patients that adhered to salt
restriction ( 36%), aerobic exercise ( 46%), self BP
measurement ( 46%), alcohol moderation ( 33%) and
drug adherence ( 16.7%). There was a positive increase of
11.4 and 3.2 for physical health and social health
domain of quality of life evaluation respectively.
Conclusion Pharmaceutical care programme could pro-
duce a beneficial effect on hypertensive patients.
Keywords Pharmaceutical Care
Hypertension

Quality of life
Community Pharmacy
Nigeria
C. N. Aguwa
C. V. Ukwe
O. I. Ekwunife (&)
Department of Clinical Pharmacy and Pharmacy Management,
University of Nigeria, P.O. Box 410001, Nsukka, Nigeria
e-mail: oekwunife@gmail.com
Impact of findings on practice
• Through the practise of pharmaceutical care, a phar-
macist could complement a GP in the management of
hypertension.
• Pharmaceutical care is an effective approach to
improving adherence to chronic therapies and modifi-
cation of life style.
• Pharmacists could effectively participate in health
education and promotion through the practise of
pharmaceutical care.
Introduction
Hypertension is still a major health problem in Nigeria.
Prevention and control of hypertension remains a crucial
challenge. Community pharmacists have the potential of
preventing hypertension especially when the new philoso-
phy of practice; pharmaceutical care (PC) is applied.
Hypertensive patients visit community pharmacies to refill
their medications and thus a pharmacist can institute a care
process. PC comprises the detection, prevention and solu-
tion of drug-related problems [1].
Pharmaceutical care practice in hospital and community
pharmacies in Nigeria is still nascent. In 2005, the Phar-
macist Council of Nigeria (PCN) set minimum standards
for the assurance of PC in Nigeria [2]. Few studies have
been conducted to establish PC’s comparative advantage as
well as difficulties towards pharmaceutical care imple-
mentation in Nigerian community pharmacies.
In this study, we aimed at determining the effect of a
community pharmacy-based PC programme on hyperten-
sive patients using clinical outcome (blood pressure) and
humanistic outcome (quality of life) for evaluation. Other
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outcome measures included smoking cessation, adherence
to therapy, exercise, salt restriction, alcohol moderation
and self blood pressure measurement.
Method
This single site study was carried out in Port Harcourt, the
capital of Rivers state and the largest oil producing state in
Nigeria. As at the time of study, two hundred and thirty
three pharmacies were registered in the state. The selection
of the pharmacy for the study was based on its suitability. It
was one of the biggest pharmacies in the city and had a
pharmacist’s consulting room.
The ten-month study comprised of five months of usual
care and another five months of PC, and was carried out
from March 2006 to December 2006. Two pharmacists, a
research pharmacist and the superintendent pharmacist of
the community pharmacy conducted the study. The super-
intendent pharmacist received a one day training on the PC
programme and the study protocol. A non-randomised,
crossover design was used. Patients served as their own
control. Forty hypertensive patients were registered for the
study after oral consent was obtained. Patient recruited had
blood pressure reading that was greater than 140/90 mmHg,
were on anti-hypertensive therapy and had been diagnosed
of high BP in a hospital. During the five months of usual
care period, recruited patients had contact with the phar-
macy either to refill their prescription or to measure their
BP. The fifth month of usual care was used as baseline.
Pharmaceutical care was instituted for another five
months after the usual care period and was evaluated at the
end. The nine steps of good PC practice were followed,
specifically, developing a pharmacist-patient relationship;
collecting, analysing, and interpreting relevant informa-
tion; listing and ranking drug-related problems;
establishing pharmacotherapeutic outcomes with the
patients; determining feasible pharmacotherapeutic alter-
natives; selecting the best pharmacotherapeutic solution;
designing a therapeutic monitoring plan; implementing the
individual regimen and monitoring plan; and follow-up [1].
Patients had face-to-face, goal-directed medication and
lifestyle counselling once every month and were provided
with an educational material. They were taught how to take
BP readings and encouraged to buy a BP measuring
apparatus. Patients who smoked were encouraged to quit
smoking. They were also advised on indulging in aerobic
exercise particularly to take walk or to skip in their houses
at least three times a week. Adherence to salt restriction
and to medication was also promoted. Medication adher-
ence was determined by using the number of times a
patient reported to have taken his medication in a month.
Alcohol moderation (i.e., 20 g/day for males and 10 g/day
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Pharm World Sci (2008) 30:107–110
for females) was recommended. Clinical and medication-
related data were sent to the patient’s physician as the need
arose. Blood pressure measured by the pharmacists, and
other patient reported outcome measures (smoking,
adherence to therapy, exercise, salt restriction, alcohol
moderation and self blood pressure measurement) were
used to access the intervention at end of pharmaceutical
care period. World health organisation quality of life bref
(WHOQOL-BREF) questionnaire, which was self-admin-
istered, was given to the patients at baseline and at the end
of 5 months of PC intervention.
Statistical analyses were carried out using SPSS for
Windows (version 11; SPSS, Chicago, IL). Data were
summarized as mean  SD, means  SEM, median [inter-
quartile range] or percentages. As the sample size was small,
two-sample comparisons were done using non-parametric
tests; Wilcoxon signed-rank tests. Comparisons of propor-
tions were by Mcnemar’s tests. A two-tailed significance
level of 0.05 was used. Administration and scoring of the
WHOQOL-BREF was carried out according to the manner
stipulated in the WHOQOL-BREF manual [3].
Results
Forty patients were recruited for the study. Twenty-four
patients (60%) completed the study. Seventy five percent
(75%) were males. They had a mean age of
51.6  11.7 years. Twenty nine percent (29%) of the
patients had diabetes concurrently with hypertension and
another 33.3% had a family history of cardiovascular
disease.
Changes in clinical outcome over 5 months are shown in
Table 1. There was a significant reduction in systolic and
diastolic blood pressure. The reduction in body mass index
was not significant. The percentage of patients that
indulged in aerobic exercise increased significantly at the
end of the intervention. Patients also adhered to salt
restriction, smoking cessation and alcohol moderation. Out
of the subjects that completed the study, 45.8% of them
learnt how to take their own blood pressure readings and
purchased a BP measuring apparatus. There was a signifi-
cant increase in medication adherence. In 12.5% of the
subjects, drug related problems were identified. The prob-
lems identified were dysphagia caused by insulin therapy
and frequent urination caused by thiazide diuretics. Patients
were educated on the drug related problems they presented.
Forty two percent (42%) of the subjects were referred back
to their physician in order to optimise their drug therapy, as
their BP was above 140/90 mmHg [4]. Details of these
outcome measures are presented in Table 1.
The changes after PC intervention for the four domain
scores of the WHOQOL-BREF are presented in Table 2.
Pharm World Sci (2008) 30:107–110 109

Table 1 Clinical and process outcome changes after PC implementation (n = 24)

Baseline After PC Change over 5 months P value

BMI (kg/m2) 26.8  4.2 26.3  4.2 0.5 0.18

No of smokers (%) 7 0 7 0.50
Systolic BP (mmHg) 158.1  14.4 143.8  10.7 14.3 \0.001
Diastolic BP (mmHg) 100.6  11.5 89.8  9.7 10.8 \0.001
Exercise (%) 46 92 46 0.001
Salt restriction (%) 63 100 37 0.004
Alcohol moderation (%) 67 100 33 0.008
Self measurement (%) 0 46 46 0.001
Drug adherence/month (%) 66.3  26.5 83.5  13.3 16.7 0.001
Drug related problems observed (%) – 13 – –
Referral to GP (%) – 42 – –
Data are mean(s)  SD or SEM or percentages. Changes over 5 months are mean difference or percentages. BMI, body mass index

The scores are scaled in a positive direction, with a score
range of 0–100, and with higher scores denoting higher
quality of life [3]. A significant increase was achieved in
physical health and social relationship of the subjects after
PC implementation (47.9–59.3 and 47.8–51.0 respec-
tively). However, in the psychological health domain, there
was no difference noticed after 5 months of PC interven-
tion. There was a significant decrease from 46.3 to 40.1 in
the environmental component of the WHOQOL-BREF
after implementation of PC.
Discussion
Our study had limitations and the results obtained were
interpreted in this light. The sample size was small and
non-randomised, therefore may not represent the real
population of hypertensive patients in Nigeria. Many of the
subjects were educated and are of the middle class. Many
patients dropped out from the study and those that com-
pleted the study did so voluntarily which may reflect
stronger interest in self-management. Some of the outcome
measures were based on patient’s report, which might not
have been factual. Lastly, the sustainability of beneficial
outcomes beyond 5 months was not assessed.
However, the study revealed that PC programme for
hypertensive patients from a community pharmacy in
Nigeria could produce beneficial reduction in blood pres-
sure and improve their health related quality of life. Positive
results were obtained in the various outcome measures.
After PC implementation, more of the patients exercised
frequently. Many of the patients became aware of salt
restriction and they complied well. Evidence from clinical
trials have shown that systolic BP reductions of 2–8 mmHg
can be achieved with restricting sodium intake to 2.4 g
daily [5]. The subjects also complied to alcohol moderation.
Moderate alcohol consumption of two or fewer drinks daily
in men and one or fewer drinks daily in women or lighter
weight persons have been shown to decrease systolic BP
approximately by to 2–4 mmHg [4]. Prior to the PC inter-
vention, none of the patients knew how to take their BP
readings. Forty-six percent (46%) of the subject learnt to
take their BP readings and acquired a BP measuring appa-
ratus. Home BP devices have been reported to be very
useful in involving patients in their own care [6]. It is also
recognised as a simple and economic tool for obtaining
blood pressure profile [7]. Medication adherence by the
patients also improved. There was a significant increase
from 66.3% per month to 83.5% per month after PC inter-
vention. Increase in drug compliance obtained could be
attributed to the drug education given to them. Lack of
knowledge has been recognised as a barrier to adherence
[7]. Again, during the PC period, some patients complained
of some drug related problems which included frequent

Table 2 Changes in quality of life of the subjects after PC implementation (n = 24)

Baseline After PC Change over 5 months P value

Physical health 47.9  9.9 59.3  7.9 11.4 \0.001

Psychological health 52.2  5.4 52.2  5.6 0 1.00
Social relationship 47.8  7.0 51.0  10.8 3.2 0.002
Environment 46.3  10.9 40.1  10.8 6.2 \0.001
Data are mean  SD. Changes over 5 months are mean difference

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urination after taking thiazide diuretic and polyphagia
caused by insulin therapy. Explanations were given and the
patients stated that they felt more comfortable with their
medications after knowing the reason for the drug effects
they experienced. Subjects who were not at BP goal were
referred to their physicians for optimisation of therapy.
Although the effects of these process outcomes cannot be
related to the clinical outcome, they helped patients to
achieve the best possible outcome from their medication.
Adoption of healthy lifestyle by all persons is critical for the
prevention of high BP and is an indispensable part of the
management of those with hypertension [8].
The WHOQOL bref was used as a humanistic outcome
to measure the effect of the 5 months PC intervention on
the physical, emotional and social well being of the
patients. In the physical health domain which is composed
of facets like pain and discomfort; dependence on medical
treatment; energy and fatigue; mobility; sleep and rest;
activities of daily living and work capacity, there was a
significant increase. In the Psychological health field which
deals with aspects such as positive affect; spirituality;
thinking, learning, memory and concentration; body image
and appearance; self-esteem; and negative affect, there was
no change after 5 months of PC implementation. There was
an appreciable change in the social relationship domain.
Items in the social relationship domain included personal
relationships, sexual activity and social support. However
there was a decrease in the environment domain after PC
implementation. Environment domain dealt with aspects
such as physical safety and security; physical environment;
financial resources; home environment; health and social
care etc. Since the PC program did not address the issues in
the environment facets, it might explain the negative
change obtained in the environment domain. In summary,
PC intervention had a positive effect on the physical and
social well being of the patients and no effect on their
emotional health. Some other pharmaceutical care inter-
ventions have shown that pharmaceutical care improves the
quality of life of hypertensive patients. For example, a
study carried out in the United States reported an
improvement in several quality of life scores in hyperten-
sive subjects after pharmaceutical care implementation [9].
Any qualified Nigerian pharmacist could implement this
PC program. Although not evaluated, pharmaceutical care
practice gives a better job satisfaction. For PC to be a
reality in Nigeria, a set of interventions seems necessary.
Many Nigerian faculties of pharmacy need to include
clinical courses and practise in their curricula. This will
produce patient oriented pharmacists; those that take pro-
active step and systematically try to identify, solve and
prevent all possible drug related problems. They also need
to offer pharmaceutical care practice experiences in phar-
macies that are designed to prepare students for PC
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Pharm World Sci (2008) 30:107–110
practice. These sites would provide students with the
opportunity to observe the integration of pharmaceutical
care activities into community practice [10]. Many Com-
munity pharmacies in Nigeria would need upgrade in order
to offer PC. Patients’ consultation area is absent in many
pharmacies. This detail in community pharmacy organi-
zational layout is important for the provision of PC as
patients do not like discussing sensitive issues over the
counter. Introduction of professional fee for the extra ser-
vices offered might be explored so as to motivate
pharmacists to practise pharmaceutical care.
Conclusion
Pharmaceutical care programmes for hypertensive patients
from a community pharmacy in Nigeria could produce
beneficial reduction in blood pressure and improve their
health related quality of life.
Acknowledgements We thank B.O. Ebugosi, the managing director
of Ebus Pharmacy, Port Harcourt for partly funding and providing the
necessary facilities for this study and Asor A.C. for his help and
support during the study.
References
1. Hepler C, Strand L. Opportunities and responsibilities in phar-
maceutical care. Am J Hosp Pharm 1990;47:533–43.
2. Pharmacists Council of Nigeria. Four-part compendium of min-
imum standards of pharmaceutical care in Nigeria. Abuja: 2005.
3. World Health Organization. Introduction, administration, scoring,
and generic version of the assessment. [Online] 2002. [Cited 2006
Jan]. Available from: URL: http://www.who.int/mental_health/
media/en/76.pdf.
4. Chobanian AV, Bakris JL, Black HR, Cushman WC, Green LA,
Izzo JL, et al. Seventh report of the Joint National committee on
prevention, detection, evaluation, and treatment of high blood
pressure: the JNC 7 report. JAMA 2003;289:2560.
5. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-
Morton DG, et al. Effects of diet and sodium intake on blood
pressure: subgroup analysis of the DASH – sodium trial. Ann
Intern Med 2001;135:1019.
6. Ebrahim S. Detection, adherence and control of hypertension for
the prevention of stroke: a systematic review. Health Technol
Assess 1998;2:22–3.
7. Whelton PK, He J, Appel LJ. Primary prevention of hyperten-
sion: Clinical and public health advisory from The National high
blood pressure education program. JAMA 2002;288:1882–8.
8. Cutler JA, McMahon SW, Furberg CD. Controlled clinical trials
of drug treatment for hypertension: a review. Hypertension. 1989;
13:136–4.
9. Cater BL, Barnette DG, Chriscilles E, Mazzotti GJ, Asali ZJ.
Evaluation of hypertensive patients after care provided by com-
munity pharmacists in a rural setting. Pharmacother 1997;17(6):
1274–85.
10. Dungan BD. Enhancing community pharmacy through advanced
pharmacy practice experiences. Am J Pharma Educ 2006;70(1):
1–3.