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\def\RunningAuthor{Sivasakthi R et al.}
\firstPage{436}
\articleType{Original Article}
\receivedDate{20 Sep 2020}
\acceptedDate{20 Oct 2020}
\revisedDate{17 Oct 2020}
\journalVolume{2021, 12}
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\journalDoi{ijrps.v12i1.4077}
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\title{\textbf{Assessment of knowledge, attitude and practice among hypertension patients at tertiary care hospital on drugs}}
\author{Sivasakthi~R\textsuperscript{*}\textsuperscript{1},  
            Senthil~Kumar~C\textsuperscript{1},  
            Mohan~S\textsuperscript{1}, 
            Nithiyan~P\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Pharmacy Practice, Karpagam College of Pharmacy, Othakalmandapam, Coimbatore, Tamil Nadu, India}~\\{\textsuperscript{2}Interventional Cardiologist, KG Hospital and Postgraduate Research Institute, Coimbatore-641018, Tamil Nadu, India}}

\begin{abstract}
Drug therapy problems are significant for the pharmaceutical care practitioner. The evaluation of drug therapy problems is the target of the assessment and shows the major decisions made in that step of the patient care process. Although drug therapy problem evaluation is technically part of the assessment procedure, it performs the very particular input made by pharmaceutical care practitioners.\ensuremath{^{}} The prospective observational study was conducted at the Cardiology department with 450 hypertension patient based on Inclusion and exclusion criteria. The data collection form was administered after getting the Consent form. The data were analyzed by using SPSS software. A total of 450 HTN patients were included in the study \& only 402 patients of them enrolled in the study as per the inclusion \& Exclusion criteria stated in the protocol. In this study, 452 Interventions were performed \& documented for both drug therapy 35.84\% (n=162) \& health education 64.15\% (n=290). These interventions were equally distributed among the patients. Drug therapy-related intervention was solved amid adjustment of medication chart in HTN patients. The study sealed that pharmaceutical care Intervention is a basic device to enhance BP management in HTN patients. The role of Clinical pharmacist is essential to improve the knowledge of patient for better treatment outcome.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Cardiology,\newline Drug Therapy,\newline SPSS Software,\newline Hypertension
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sivasakthi~R~\\ Phone:\ 9894369182~\\  Email:\ sivasakthimpharm@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Hypertension is described by persistent elevation of arterial blood pressure \unskip~\citep{932714:20766019}. The Seventh Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) classifies adult BP as shown in Table~\ref{tw-95ef37b8c941}\unskip~\citep{932714:20766026}. Evaluation of drug-related problems (DRPs) is an essential topic in the pharmaceutical field, which would aid to resolve the consequences caused by negative drug therapy. The purpose of identifying drug-related problems is to help patients to reach their goals of therapy and achieve the best possible outcomes from drug therapy \unskip~\citep{932714:20766023}. Hypertensive patients are one of those who are suffering from undesirable events of drug therapy. Hypertension is one among the leading causes of cardiovascular diseases worldwide, and it is defined as the constant deviation of the blood pressure (BP) in the arteries, to add, hypertension is a chronic disease, which is diagnosed most commonly in persons aged 50 and older. According to World Health Organization (WHO): "The prevalence of raised blood pressure (SBP\ensuremath{\geq }140 or DBP\ensuremath{\geq }90), age standardized 18+, completed in percentage (\%), which was performed in 2015, the prevalence in Lithuania in male is 36.1\%, in female 23.1\% and Russia in male 32.6\% and female 22.3\%, respectively'' \unskip~\citep{932714:20766027} as well as WHO has assessed that about 62\% of cerebrovascular disease and 49\% of ischemic heart disease are a primary concern all over the world.


\bgroup
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\centering \makeatletter\IfFileExists{images/f81f0ce4-58e2-4af4-aa9b-fa1279e84d4e-upicture1.png}{\includegraphics{images/f81f0ce4-58e2-4af4-aa9b-fa1279e84d4e-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Gender Distribution.}}
\label{f-ca196ef7f196}
\end{figure}
\egroup
Elevated blood pressure has assessed to cause 7.1 million deaths each year, considering 13\% of all deaths globally \unskip~\citep{932714:20766022}. The Pharmacist intervention helps to reduce the economic burden of the patient by reducing the Prescription of irrational drugs \unskip~\citep{932714:20766021}.


\bgroup
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\makeatother 
\caption{\boldmath {Family history of HTN.}}
\label{f-e8db19ef07f6}
\end{figure}
\egroup
A clinical pharmacist is a person to provide medicated information and instruction to the Patients \unskip~\citep{932714:20766029}. Storage and retrieval of intervention can reduce the drug-related problems and improve the quality of life among the patients \unskip~\citep{932714:20766017}. Pharmacist Intervention can improve the management of hypertension through follow up and communications \unskip~\citep{932714:20766030}. Community-based health camp and counseling may increase the medicated knowledge on Drugs \unskip~\citep{932714:20766020}. The collaborative Intervention of Health care team may improve the quality of life of the patient \unskip~\citep{932714:20766018}. The Health care awareness camp improves the diabetic and blood pressure control among the patient with multiple diseases \unskip~\citep{932714:20766025}. Majority of the discharged patients were very well satisfied with the counseling of clinical pharmacist \unskip~\citep{932714:20766028}. 


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\centering \makeatletter\IfFileExists{images/a159d314-aea4-4466-bea8-15998be3f2be-upicture3.png}{\includegraphics{images/a159d314-aea4-4466-bea8-15998be3f2be-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Co-morbidity of study patients.}}
\label{f-6eb52a1abb80}
\end{figure}
\egroup
Hypertension is one of the leading causes of cardiovascular diseases worldwide. Various researches have indicated that more than half of the hypertensive patients on treatment are still suffering from increased blood pressure (over 140/90 mm Hg), despite the availability of efficient medical therapy.
\bgroup
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\makeatother 
\caption{\boldmath {Social history of the patients.}}
\label{f-f5f6f551a8f4}
\end{figure}
\egroup

    
\section{Results and Discussion}
A total of 450 HTN patients were included in the study \& only 402 patients of them enrolled in the study as per the inclusion \& Exclusion criteria stated in the protocol. The intervention was done \& in first follow up, 402 patients were assessed for baseline assessment. During the second follow up, 360 patients attended the patient education programme \& the rest of 42 patients were assessed by telephonically. There were 52.73\% (n=212) were male \& 47.31\% (n=190) were female Figure~\ref{f-ca196ef7f196}. The majority of the patients were within the age group of 51 {\textendash} 70 years in 59.69\% (n=240) \& the minimum was 21 {\textendash} 30 years in 2.98\% (n=12). 


\begin{table*}[!htbp]
\caption{\boldmath {Age distribution of study population.} }
\label{tw-95ef37b8c941}
\def\arraystretch{1.1}
\ignorespaces 
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\begin{tabulary}{\linewidth}{p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.3279\linewidth-2\tabcolsep}p{\dimexpr.34209999999999994\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Age in Years & \cAlignHack No. of Patients & \cAlignHack \% of Patients\\
\tblmidrule 
\cAlignHack 21 {\textendash} 30 &
  \cAlignHack 12 &
  \cAlignHack 2.98\\
\cAlignHack 31 {\textendash} 40 &
  \cAlignHack 48 &
  \cAlignHack 11.94\\
\cAlignHack 41 {\textendash} 50 &
  \cAlignHack 96 &
  \cAlignHack 23.88\\
\cAlignHack 51 {\textendash} 60 &
  \cAlignHack 214 &
  \cAlignHack 53.23\\
\cAlignHack 61 {\textendash} 70 &
  \cAlignHack 26 &
  \cAlignHack 6.46\\
\cAlignHack 71 {\textendash} 80 &
  \cAlignHack 06 &
  \cAlignHack 1.49\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Blood pressure values.} }
\label{tw-34d125fee07d}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3632\linewidth-2\tabcolsep}p{\dimexpr.29680000000000003\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Blood pressure (mmHg) & \cAlignHack Baseline (n=402) & \cAlignHack End of the study (n=360)\\
\tblmidrule 
\cAlignHack Mean systolic &
  \cAlignHack 144.5 &
  \cAlignHack 142.1\\
\cAlignHack Mean diastolic &
  \cAlignHack 93.4 &
  \cAlignHack 89.9\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
The age distribution was given in Table~\ref{tw-95ef37b8c941}.

The educational status of the study population found that 47.76\%(n=192) were graduate \& only 2.23\%(n=09) were illiterate. The family history of the patient shows that 66.66\%(n= 280) have no family history of HTN, followed by 18.40\%(n=74) were under the family history of HTN, which was given in Figure~\ref{f-e8db19ef07f6}. The Co-morbidity of study patients was assessed \& found that, 26.87\%(n=108) were having the co-morbidity \& 73.13\%(n=294) patients amid no comorbidity. It was given in Figure~\ref{f-6eb52a1abb80}. The Social history of the patients was assessed \& results that, most of the patients have the habit of chewing tobacco 30.09\% (n=121) followed by alcohol intake 13.93\% (n=56). It was represented in Figure~\ref{f-f5f6f551a8f4}. At the beginning of the study, the mean SBP \& DBP of the study patient was found to be 144.5 mmHg \& 93.4 mmHg.

At the end of the study, BP was controlled. Where the SBP was reduced by 2.4 mmHg \& DBP was reduced by 3.5 mmHg. It was given in Table~\ref{tw-34d125fee07d}. The pharmacist intervention on patient treatment \& counseling of HTN patients was assessed in 402 patients who were studied for knowledge, concordance, attitude, lifestyle modification before \& after the study \& its result found that there was a significant increase in their knowledge, concordance, attitude \& lifestyle modification \& it was statistically significant. The P-Value was found to be \textless\ 0.001. There was a significant increase in the knowledge of the patient after pharmacist intervention towards disease, drugs, symptoms \& good improvement in the aspects of complications of HTN \& improvement in QOL, which was given in Table~\ref{tw-16779e4e3d11}.

HRQOL questionnaire consists of approaches of exercise, reduction of salt, having a DASH diet, reduce alcohol consumption \& avoid tobacco chewing habits \& smoking cessations. In all the above aspects, there has been an improvement. Among the patients who were treated amid monotherapy CCB (43.1\%) were mostly prescribed. In combination therapy of HTN drugs, CCB+BB \& ARB+ Thiazide were mostly prescribed. 40.29\% (n=162) DRP were found in that study. Mainly the higher occurrence of problems in the safety category 64\%(n=103).  Analgesics caused these DRP in 46.6\% (n=48), diuretics in 23.3\% (n=24) \& ACE inhibitors in 17.4\% (n=18) amid the symptoms of Orthostatic HTN, gastritis, dizziness \& muscle cramps.

In this study, 452 Interventions were performed \& documented for both drug therapy 35.84\%(n=162) \& health education 64.15\% (n=290). These interventions were equally distributed among the patients. Drug therapy related intervention was solved amid adjustment of medication chart in HTN patients. Other interventions required physician decision \& Co operative working between the research pharmacist, prescriber \& patient. This intervention was a key factor in solving \& preventing DRP inpatient care. Previous studies also proofed the same result of interventions leading to the solution \& prevention of DRP, improve economic therapy \& increase patient satisfaction on pharmaceutical care. Previous studies indicate that the core of the intervention lies in its potential to empower the patients to disclose their concerns \& questions about treatment. In this study interventions of HTN management were effective in reducing HTN. The role of pharmacist can help the patient to reduce their weight \& manage the BP in control. After the intervention, the patient showed a reduction of 27\% in weight. Previous studies showed that, no statistically significant difference (P \textless\  0.001) of BMI after pharmacist Interventions.


\begin{table*}[!htbp]
\caption{\boldmath {Distribution of study population by knowledge, attitude, concordance \& practice.} }
\label{tw-16779e4e3d11}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.06459999999999998\linewidth-2\tabcolsep}p{\dimexpr.4036999999999999\linewidth-2\tabcolsep}p{\dimexpr.1265\linewidth-2\tabcolsep}p{\dimexpr.13519999999999998\linewidth-2\tabcolsep}p{\dimexpr.12819999999999999\linewidth-2\tabcolsep}p{\dimexpr.1418\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}{\multirow{2}{*}{S No}} & {\multirow{2}{*}{Interventions}} & \multicolumn{4}{p{\dimexpr(.53169999999999995\linewidth-2\tabcolsep)}}{\cAlignHack Total = 402 Patients}\\
\rowcolor{kwdboxcolor} &  & \cAlignHack Before & \cAlignHack After & \cAlignHack P-Value & \cAlignHack Significance\\
\tblmidrule 
\multicolumn{6}{p{\dimexpr(.9999999999999997\linewidth-2\tabcolsep)}}{\textbf{Knowledge}}\\
1 &
  Do you know your BP? &
  \cAlignHack 180 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
2 &
  Do you know HTN lifelong \& \mbox{}\protect\newline required medication? &
  \cAlignHack 130 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
3 &
  Do you know your BP is high? &
  \cAlignHack 105 &
  \cAlignHack 400 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
4 &
  High BP is a series of disease? &
  \cAlignHack 95 &
  \cAlignHack 398 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
5 &
  Excess intake of salt causes high BP? &
  \cAlignHack 108 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
6 &
  Stress in life causes BP?  &
  \cAlignHack 110 &
  \cAlignHack 399 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
7 &
  Yoga, meditation controls BP? &
  \cAlignHack 200 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
8 &
  Regular, mild exercise control, BP? &
  \cAlignHack 210 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
9 &
  Do you know the consequences of HTN? &
  \cAlignHack 105 &
  \cAlignHack 400 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
10 &
  Do you know the precautions for HTN? &
  \cAlignHack 100 &
  \cAlignHack 401 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
11 &
  Do you Know HTN cause stroke? &
  \cAlignHack 110 &
  \cAlignHack 398 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
12 &
  Regular drug therapy is essential? &
  \cAlignHack 105 &
  \cAlignHack 399 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
13 &
  HTN leads to CKD? &
  \cAlignHack 100 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
14 &
  HTN leads to Paralysis? &
  \cAlignHack 110 &
  \cAlignHack 400 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
15 &
  HTN pts. Can involve daily activities? &
  \cAlignHack 105 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
16 &
  Do you know the drugs cause ADR? &
  \cAlignHack 110 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
17 &
  Is regular check-up important for BP? &
  \cAlignHack 120 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
 &
   &
   &
   &
   &
  \\
\multicolumn{6}{p{\dimexpr(.9999999999999997\linewidth-2\tabcolsep)}}{\textbf{Concordance}}\\
18 &
  Have you prescribed drugs to reduce \mbox{}\protect\newline BP? &
  \cAlignHack 210 &
  \cAlignHack 398 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
19 &
  Do you take all your Drugs? &
  \cAlignHack 110 &
  \cAlignHack 399 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
20 &
  How many different drugs do you take? &
  \cAlignHack 108 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
21 &
  If you don't take a drug, why don't you take them as directed? &
  \cAlignHack 205 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
 &
   &
   &
   &
   &
  \\
\multicolumn{6}{p{\dimexpr(.9999999999999997\linewidth-2\tabcolsep)}}{\textbf{Attitude}}\\
22 &
  Intention to exercise for controlling BP? &
  \cAlignHack 210 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
23 &
  Intension to stop exercise once HTN \mbox{}\protect\newline controlled? &
  \cAlignHack 110 &
  \cAlignHack 400 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
24 &
  Intension to reduce salt? &
  \cAlignHack 205 &
  \cAlignHack 398 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
25 &
  Intention to undergo regular check-up? &
  \cAlignHack 210 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
 &
   &
   &
   &
   &
  \\
\multicolumn{6}{p{\dimexpr(.9999999999999997\linewidth-2\tabcolsep)}}{\textbf{Practice}}\\
26 &
  Regular exercise &
  \cAlignHack 200 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
27 &
  Reduced salt intake &
  \cAlignHack 110 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
28 &
  Take medicine regularly as prescribed. &
  \cAlignHack 220 &
  \cAlignHack 398 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
29 &
  Under regular check-up &
  \cAlignHack 105 &
  \cAlignHack 401 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
30 &
  Don't omit the drug any time &
  \cAlignHack 220 &
  \cAlignHack 402 &
  \cAlignHack \textless\ 0.001 &
  \cAlignHack HS\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{HS = Highly significance.}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Body mass index (BMI) of study populations.} }
\label{tw-7816279d31cc}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2116\linewidth-2\tabcolsep}p{\dimexpr.1884\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20330000000000002\linewidth-2\tabcolsep}p{\dimexpr.19669999999999998\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}{\multirow{2}{*}{BMI}} & \multicolumn{2}{p{\dimexpr(.3884\linewidth-2\tabcolsep)}}{\cAlignHack Baseline} & \multicolumn{2}{p{\dimexpr(.40\linewidth-2\tabcolsep)}}{\cAlignHack End of study}\\
\rowcolor{kwdboxcolor} & \cAlignHack (Number) & \cAlignHack (percentage) & \cAlignHack (Number) & \cAlignHack (percentage)\\
\tblmidrule 
Underweight &
  \cAlignHack 04 &
  \cAlignHack 0.99 &
  \cAlignHack 03 &
  \cAlignHack 0.07\\
Normal Weight &
  \cAlignHack 98 &
  \cAlignHack 24.37 &
  \cAlignHack 150 &
  \cAlignHack 37.31\\
Overweight &
  \cAlignHack 282 &
  \cAlignHack 70.14 &
  \cAlignHack 205 &
  \cAlignHack 50.99\\
Obese &
  \cAlignHack 18 &
  \cAlignHack 4.47 &
  \cAlignHack 15 &
  \cAlignHack 3.73\\
\textbf{Total} &
  \cAlignHack \textbf{402} &
  \cAlignHack \textbf{100\%} &
  \cAlignHack \textbf{373} &
  \cAlignHack \textbf{92.78\%}\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Peoples, especially geriatrics, have difficulty in reducing \& manage their weight. Hence, there was a need for intervention to encourage the patients to reduce \& manage their weight, which was given in Table~\ref{tw-7816279d31cc}. At the starting stage, only 15 patients have BP control (BP\textless\  120/80 mmHg) \& after the pharmaceutical intervention, 50.99\% (n=205) patients attained a target BP of 120/80 mmHg. At the second follow up, it was found that another 44.27\% (n=178) patients achieved improvement in BP control \& only 6.2\% (n= 25) patients were worsened control of BP. These study results are proofed more significant result in pharmacist Intervention than other studies \unskip~\citep{932714:20766026}. This study also consistent amid three other studies that obtained the same reduction in BP values. 

Furthermore, it is noted to highlight that 19.04 \% (n= 80) HTN patients had diabetes \& JNC-VII (2003) guidelines was recommended pressure of \textless\  130/85 mmHg for these patients\textbf{. }The study exhibits that, enhancing the patient's well-being related QOL about HTN can expand the patient concordance \& enhances the medication-related outcomes. The study discovered significant diminishment of SBP \& DBP, which is coincided amid the study conducted by \unskip~\citep{932714:20766024}. The study confirms that pharmacist gave patient education is successful in enhancing the patient learning towards HTN control \& furthermore demonstrates the move of a pharmacist in QOL of the patients through medication-related outcomes. Toward the finish of the study, BP was controlled \& compliance was expanded in the patients after the Interventions.
    
\section{Conclusions}
The outcome infers that the intervention did not watch the hugeness of great distinction in BMI. The management of BP was accomplished in 95.27\% of the study population. The study sealed that pharmaceutical care Intervention is a basic device to enhance BP management in HTN patients. Thus, the study recommends the consideration on the disease \& enhanced drug specialist, patient \& doctor association may encourage drug treatment adjustments to accomplish the objective circulatory strain \& drug-related results.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.
    

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