Base on the TASHP cutoff score, 134 patients (27.46%) had satisfactory adherence behaviors, while the remaining 354 (72.54%) patients were noncompliant. The univariate analysis of the socio-demographic and clinical factors for treatment adherence is provided in Table 3. Three factors were significantly associated with adherence: gender (P = .018), residence (P = .004), and duration of HBP (P = .048).
Table 4 summarizes the result of the binary logistic regression analysis. Gender (P = .034), residence (P = .029), and duration of HBP (P < .001) were identified as being independently associated with antihypertensive treatment adherence. Comparing to females, males were less compliant (P = .026, odds ratio [OR] = 2.184, 95% confidence interval [CI]: 1.097–4.350). Urban patients were more adherent to their treatment plan than those from rural areas (P = .047, OR = 0.145, 95% CI: 0.022–0.971). The longer the time since they were diagnosed with HBP resulted in greater adherence for the HBP patients in this study (P = .009, OR = 0.909, 95% CI: 0.846–0.976).
The results of the general linear model analysis are shown in Table 5. The score for each category is the sum of the scores of all items in the category. There were 4 factors for which the scores were significantly different in specific categories: gender, occupation, residence, and duration of antihypertensive drug use. For example, the scores obtained for gender were found to be significantly different in category 3 (daily life management). Female scores in category 3 were higher than those for males (P < .001). Since a higher score indicates greater adherence, females were more compliant in daily life management. In addition, category 3 was the main aspect of the compliance difference between genders. Category 3 was also the main aspect influenced by occupation. Retired patients earned the highest score, with employed patients having the lowest (P = .004), which indicates that the retired people were the most compliant individuals regarding daily life management. Patients in urban areas were more adherent than those in rural with the higher scores in category1 (adherence with taking medicines) (P = .024) and category2 (poor medication behavior) (P = .008). The longer of the time used antihypertensive drugs, the more adherent patients were in category 2 (P = .011) and category 3 (P = .034).
Due to an increasingly aging population, hypertension has become a common global public health problem. Nonadherence to antihypertensive treatment in patients with hypertension is associated with an increased risk of stroke and cardiovascular disease.[6,26] The purpose of this investigation was to study the treatment adherence of Chinese hypertensive patients and the associated risk factors. Since culture and economy are important factors that affect the treatment compliance of hypertensive patients, treatment compliance scales, and questionnaires produced in different cultural and economic backgrounds cannot be fully applied to other populations. In this study, we used the TASHP, which was demonstrated to be a validated and reliable instrument and suitable for the Chinese population.
This study revealed that only 134 patients (27.46%) adhered to their antihypertensive treatment, and most patients (72.54%) do not have satisfactory adherence behaviors. The adherence rate found in this study was much lower than that reported in some developed countries, developing countries, and other developed regions in China.[27–32] Cultural and economic characteristics are crucial factors that may explain different levels of adherence among different populations. This study was conducted in the northwestern region of China, which is an underdeveloped region. The treatment adherence of hypertensive patients in underdeveloped regions should be pained more attention and be provided additional health care resources by health care professionals and policymakers.
There are many factors that may be associated with the rates of nonadherence, including gender, age, location, cost of the medications, and socioeconomic status. In this study, there were 3 independent risk factors related to antihypertensive treatment adherence: gender, residence, and the duration of hypertension. By dividing the impact of each risk factor on treatment adherence into 4 different categories, we found that gender, residence, occupation, and duration of antihypertensive drugs used had significant effects on treatment compliance in certain categories.
The association between gender and antihypertensive treatment adherence remains a subject of debate. Both negative and positive relationships have been reported in the literature. In this study, gender was a predictor of antihypertensive treatment adherence with females reporting better adherence than males. This finding was consistent with some previous studies,[25,34] but opposite to several others.[35,36] Another study showed that medication adherence in females was 1.531 times higher than that of males, but the difference was not statistically significant. Our study revealed that the higher compliance of females is mainly in the category of daily life management (category 3). This finding is consistent with a previous study conducted on a Korean population, which showed that males were generally more associated with nonadherence to lifestyle recommendations, even if they were aware of their disease. The possible reason is that females perceive and report their health problems more obstinately than men and they would like to pay more attention to diet, weight reduction, physical exercise, BP monitor, and so on. In addition, males are usually busier than females and experience more heavy pressure from work, which may prohibit spending more time to make lifestyle modifications.
This study found that location of hypertension patients also affected treatment adherence. It was determined that patients lived in rural areas were less adherent than those living in an urban setting. This finding was not consistent with most of the previous studies, which showed no association between place of residence and nonadherence to treatment.[40,41] This study revealed that the lower compliance of rural people than urban people was mainly in the category of adherence with taking medicines (category 1) and poor medication behavior (category 2). There exist large differences in cultural levels, economic status, and medical conditions between rural and urban people in China. A recent paper showed that although the urban-rural gaps in health care utilization have gradually narrowed, the urban-rural disparities are still evident in health care resources.
Rural residents tend to have less education, lower income, and more barriers to accessing healthcare than urban residents. The main reasons for the unsatisfactory treatment adherence of rural patents were probably attributed to lack of adequate knowledge and the economic factors also being a contributing factor. Both drug adherence and BP control rate were significantly associated with hypertension knowledge.
Lack of health knowledge is common among the elderly in the areas of rural China. Low levels of economic development lead to minimal health knowledge transmission among the population in rural areas. As better awareness of hypertension is a significant factor in improving treatment adherence, more appropriate health education strategies may be needed for rural hypertensive patients. Health education about hypertension is usually organized by healthcare professionals in hospitals or communities in the urban setting. Therefore, it is necessary for medical professionals to go to rural areas to convey hypertension knowledge. Furthermore, the society, government, and medical institutions should collaborate to help patients improve their hypertension awareness in rural China.
Since hypertensive patients requires lifelong continuous medical treatment, each hypertensive patient needs to allocate a specific budget every month to purchase medications. Furthermore, there is a wide range of rural people without any medical insurance coverage, even those who have medical insurance may not have all medications covered, and the patients may have to pay out-of-pocket. The government should invest more in medicine, thereby expanding the scope and reimbursement ratio of rural medical insurance.
In this study, the duration of hypertension was found to affect treatment adherence. The longer of the duration since they were diagnosed with hypertension, the more adherent the patients were; this founding was consistent with previous studies.[32,45] One possible reason for this was that it is convenient for elderly hypertensive patients to become knowledgeable about hypertension and its risks, so they have better medication-taking behaviors and tend to implement preventive measures such as decreasing salt intake, performing more regular exercise, controlling body weight, regularly monitoring BP, and managing stress. A study conducted on Canadian patients reported that few patients had lifestyle changes within 2 years after their diagnosis of hypertension.
We also found that the longer the duration they were using antihypertensive drugs, the more adherent were the patients in the categories of poor medication behavior (category 2) and daily life management (category 3). A possible reason for this is that with the extension of treatment time, patients gradually accept the fact that they are supposed to take their medication every day, and some patients who have negative attitudes eventually change their medicine taking and lifestyle habits.
As for occupations, farmers and employed patients tended to have poorer medication adherence when compared to unemployed or retired patients in daily life management; this is consistent with the findings of a previous study. A lack of awareness and busy work are the main reasons for this finding.
Our study findings highlight the importance of lifestyle modifications for better hypertensive treatment adherence. In the study, differences in compliance with hypertension caused by different genders, occupations, and duration of antihypertensive drugs used were mainly reflected in daily life management (category 3). Although effective antihypertensive medications are available for many people, especially urban dwellers, the hypertensive treatment adherence and control rate are still unsatisfactory. According to previous reports, lifestyle modifications that mainly include dietary adjustment, exercise, weight management, and stress release was a promising tool for promoting the prevention and control rate of hypertension.[49,50] However, some hypertensive patients principally rely on medication and do not comply with lifestyle recommendations. Therefore, it is necessary for hypertensive patients to understand that lifestyle modifications are also essential for BP control. Health education on lifestyle changes of patients in self-managing their hypertension should be strengthened.
Our study has some policy implications. It was found that gender, residence, and duration of HBP were significantly associated with treatment adherence. Hence, evidence-based interventions, such as educational programs, could be used to target hypertensive patients who are male, live in rural areas, and/or have a short duration of HBP, to improve their treatment adherence. Meanwhile, differences in hypertension treatment compliance caused by different genders, occupations, and duration of antihypertensive drug use were mainly reflected in daily life management, which suggests that changing patient perceptions towards the role of life modifications could be a primary focus of patient education initiatives.
There are some limitations to this study. First, samples in this investigation were selected from a limited area in Western China with a relatively homogeneous population; therefore, the result may not be generalizable. Second, the measurement of treatment adherence was based on self-reported questionnaires, which may introduce recall bias. Third, the sample size was small, larger-scale investigations should be carried out in the future.
In conclusion, we used the TASHP criteria to evaluate the risk factors associated with hypertension treatment adherence in Chinese hypertensive patients. A total of 72.54% of the study patients were nonadherent to antihypertensive treatment. Gender, residence, and the duration of hypertension were found to be the main factors affecting treatment adherence. We also found that gender, residence, occupation, and duration of antihypertensive drug use had significant effects on treatment adherence in certain categories. The education and awareness regarding hypertension knowledge need to be strengthened. Furthermore, the importance of lifestyle modifications in compliance with hypertension treatment needs to be emphasized.
Data curation: Jingjing Pan, Tao Lei, Bin Hu, Xiaorong Xue.
Investigation: Jingjing Pan.
Project administration: Lian Wu.
Software: Qiongge Li.
Supervision: Huichuan Wang.
Validation: Qiongge Li.
Writing – original draft: Jingjing Pan.
Writing – review and editing: Lian Wu.
. Wolf M, Ewen S, Mahfoud F, et al. Hypertension
: history and development of established and novel treatments. Clin Res Cardiol 2018;107(Suppl 2):16–29.
. Uchmanowicz I, Jankowska-Polanska B, Chudiak A, et al. Psychometric evaluation of the polish adaptation of the hill-bone compliance to high blood pressure therapy scale. BMC Cardiovasc Disord 2016;16:87.
. Lim SS, Vos T, Flaxman AD, et al. 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. Lancet (London, England) 2012;380:2224–60.
. Gleason-Comstock J, Streater A, Goodman A, et al. Willingness to pay and willingness to accept in a patient-centered blood pressure control study. BMC Health Serv Res 2017;17:538.
. Wang J, Zhang L, Wang F, et al. Prevalence, awareness, treatment, and control of hypertension
: results from a national survey. Am J Hypertens 2014;27:1355–61.
. Yang Q, Chang A, Ritchey MD, et al. Antihypertensive medication adherence and risk of cardiovascular disease among older adults: a population-based cohort study. J Am Heart Assoc 2017;6:e006056.
. Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol 2012;73:691–705.
. Shehab A, Elnour AA, Swaidi SA, et al. Evaluation and implementation of behavioral and educational tools that improves the patients’ intentional and unintentional non-adherence to cardiovascular medications in family medicine clinics. Saudi Pharm J 2016;24:182–8.
. Akhu-Zaheya LM, Shiyab WY. The effect of short message system (SMS) reminder on adherence to a healthy diet, medication, and cessation of smoking among adult patients with cardiovascular diseases. Int J Med Inform 2017;98:65–75.
. Christensen A, Osterberg LG, Hansen EH. Electronic monitoring of patient adherence to oral antihypertensive medical treatment: a systematic review. J Hypertens 2009;27:1540–51.
. Hou MY, Hurwitz S, Kavanagh E, et al. Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial. Obstet Gynecol 2010;116:633–40.
. Gupta P, Patel P, Horne R, et al. How to screen for non-adherence to antihypertensive therapy. Curr Hypertens Rep 2016;18:89.
. Piette JD, Datwani H, Gaudioso S, et al. Hypertension
management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Telemed J E Health 2012;18:613–20.
. He W, Bonner A, Anderson D. Patient reported adherence to hypertension
treatment: a revalidation study. Eur J Cardiovasc Nurs 2016;15:150–6.
. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67–74.
. Morisky DE, Ang A, Krousel-Wood M, et al. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich, Conn) 2008;10:348–54.
. Lahdenpera TS, Wright CC, Kyngas HA. Development of a scale to assess the compliance of hypertensive patients. Int J Nurs Stud 2003;40:677–84.
. Kim MT, Hill MN, Bone LR, et al. Development and testing of the hill-bone compliance to high blood pressure therapy scale. Prog Cardiovasc Nurs 2000;15:90–6.
. Cate H, Bhattacharya D, Clark A, et al. A comparison of measures used to describe adherence to glaucoma medication in a randomised controlled trial. Clin Trials (London, England) 2015;12:608–17.
. AlGhurair SA, Hughes CA, Simpson SH, et al. A systematic review of patient self-reported barriers of adherence to antihypertensive medications using the world health organization multidimensional adherence model. J Clin Hypertens (Greenwich Conn) 2012;14:877–86.
. Jank S, Bertsche T, Schellberg D, et al. The A14-scale: development and evaluation of a questionnaire for assessment of adherence and individual barriers. Pharm World Sci 2009;31:426–31.
. Lee GK, Wang HH, Liu KQ, et al. Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky Medication Adherence Scale. PloS One 2013;8:e62775.
. Tang H, Zhu J, He H, et al. Development and evaluation of a new therapeutic adherence scale for hypertensive patients. J Third Military Med Univ (in Chinese) 2011;33:1400–3.
. Akoko BM, Fon PN, Ngu RC, et al. Knowledge of hypertension
and compliance with therapy among hypertensive patients in the Bamenda health district of Cameroon: a cross-sectional study. Cardiol Ther 2017;6:53–67.
. Pan J, Lei T, Hu B, et al. Post-discharge evaluation of medication adherence and knowledge of hypertension
among hypertensive stroke patients in northwestern China
. Patient Prefer Adherence 2017;11:1915–22.
. Lee HJ, Jang SI, Park EC. Effect of adherence to antihypertensive medication on stroke incidence in patients with hypertension
: a population-based retrospective cohort study. BMJ Open 2017;7:e014486.
. Schulz M, Krueger K, Schuessel K, et al. Medication adherence and persistence according to different antihypertensive drug classes: a retrospective cohort study of 255,500 patients. Int J Cardiol 2016;220:668–76.
. Gupta P, Patel P, Strauch B, et al. Risk factors for non-adherence to antihypertensive treatment. Hypertension
. Lauffenburger JC, Landon JE, Fischer MA. Effect of combination therapy on adherence among US patients initiating therapy for hypertension
: a cohort study. J Gen Intern Med 2017;32:619–25.
. Fontil V, Bibbins-Domingo K, Kazi DS, et al. Simulating strategies for improving control of hypertension
among patients with usual source of care in the United States: the blood pressure control model. J Gen Intern Med 2015;30:1147–55.
. Alhaddad IA, Hamoui O, Hammoudeh A, et al. Treatment adherence
and quality of life in patients on antihypertensive medications in a Middle Eastern population: adherence. Vasc Health Risk Manag 2016;12:407–13.
. Yue Z, Bin W, Weilin Q, et al. Effect of medication adherence on blood pressure control and risk factors for antihypertensive medication adherence. J Eval Clin Pract 2015;21:166–72.
. Arbuckle C, Tomaszewski D, Aronson BD, et al. Evaluating factors impacting medication adherence among rural, urban, and suburban populations. J Rural Health 2018;34:339–46.
. Yassine M, Al-Hajje A, Awada S, et al. Evaluation of medication adherence in Lebanese hypertensive patients. J Epidemiol Glob Health 2016;6:157–67.
. Zhang X, Zhu M, Dib HH, et al. Knowledge, awareness, behavior (KAB) and control of hypertension
among urban elderly in western China
. Int J Cardiol 2009;137:9–15.
. Abegaz TM, Shehab A, Gebreyohannes EA, et al. Nonadherence to antihypertensive drugs: a systematic review and meta-analysis. Medicine 2017;96:e5641.
. Nguyen TP, Schuiling-Veninga CC, Nguyen TB, et al. Adherence to hypertension
medication: quantitative and qualitative investigations in a rural Northern Vietnamese community. PloS One 2017;12:e0171203.
. Kim Y, Kong KA. Do hypertensive individuals who are aware of their disease follow lifestyle recommendations better than those who are not aware? PloS One 2015;10:e0136858.
. Santa Helena ETNM, Eluf-Neto J. Evaluation of care provided for people with arterial hypertension
in family health strategy services. Saúde Soc 2010;19:614–26.
. Murphy GK, McAlister FA, Weir DL, et al. Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis. BMC Public Health 2014;14:544.
. Magnabosco P, Teraoka EC, de Oliveira EM, et al. Comparative analysis of non-adherence to medication treatment for systemic arterial hypertension
in urban and rural populations. Rev Lat Am Enfermagem 2015;23:20–7.
. Li J, Shi L, Liang H, et al. Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011. BMC Health Serv Res 2018;18:102.
. Malik A, Yoshida Y, Erkin T, et al. Hypertension
-related knowledge, practice and drug adherence among inpatients of a hospital in Samarkand, Uzbekistan. Nagoya J Med Sci 2014;76:255–63.
. He Z, Cheng Z, Shao T, et al. Factors influencing health knowledge and behaviors among the elderly in rural China
. Int J Environ Res Public Health 2016;13:975.
. Hultgren F, Jonasson G, Billhult A. From resistance to rescue–patients’ shifting attitudes to antihypertensives: a qualitative study. Scand J Prim Health Care 2014;32:163–9.
. Neutel CI, Campbell N. Changes in lifestyle after hypertension
diagnosis in Canada. Can J Cardiol 2008;24:199–204.
. Kang CD, Tsang PP, Li WT, et al. Determinants of medication adherence and blood pressure control among hypertensive patients in Hong Kong: a cross-sectional study. Int J Cardiol 2015;182:250–7.
. Chung N, Baek S, Chen MF, et al. Expert recommendations on the challenges of hypertension
in Asia. Int J Clin Pract 2008;62:1306–12.
. Su TT, Majid HA, Nahar AM, et al. The effectiveness of a life style modification and peer support home blood pressure monitoring in control of hypertension
: protocol for a cluster randomized controlled trial. BMC Public Health 2014;14(Suppl 3):S4.
. Scisney-Matlock M, Bosworth HB, Giger JN, et al. Strategies for implementing and sustaining therapeutic lifestyle changes as part of hypertension
management in African Americans. Postgrad Med 2009;121:147–59.
China; hypertension; TASHP; treatment adherence
Supplemental Digital Content
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.