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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 39-44

Quality of care: A strong predictor of treatment compliance in hypertensives

1 Department of Community Medicine, IIMSR, Integral University, Lucknow, Uttar Pradesh, India
2 Department of Community Medicine, JNMC, AMU, Aligarh, Uttar Pradesh, India

Date of Submission11-Apr-2019
Date of Acceptance30-May-2019
Date of Web Publication30-Jul-2019

Correspondence Address:
Dr. Mariyam Khwaja
202A/58, Jawahar Nagar, Opposite Hathi Park, Lucknow - 226 018, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijas.ijas_8_19

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Context: Many countries have reported <25% of patients treated for hypertension achieve optimum control despite the availability of effective treatments. Poor compliance to treatment forms the main reason of uncontrolled blood pressure. Strategies for improving accessibility and affordability of drugs have an important influence on compliance particularly in poor sections of the population.
Aims: This study aims (1) to determine the impact of health care and provider factors on compliance to hypertension treatment and (2) to suggest measures for the removal of the identified barriers.
Settings and Design: This was community-based cross-sectional study conducted in urban and rural areas in Aligarh.
Subjects and Methods: A total of 356 hypertensive patients were selected using simple random sampling. A pretested semi-structured questionnaire was used for the study. Compliance was measured by Morisky 8-item Medication Adherence Scale.
Statistical Analysis Used: Analysis was done using proportions and Chi square test in SPSS (Statistical Package for the Social Sciences) software version 20.0. It was developed initially in 1968. It was acquired by IBM in 2009. The current versions (2015) are named IBM SPSS Statistics.
Results: Easy accessibility and affordability of drugs were found to be significantly associated with treatment compliance. Long clinic waiting time and dissatisfaction with relation with physician were some other reported barriers to treatment compliance.
Conclusions: An uninterrupted supply of medicines; sustainable financing, affordable prices, and reliable supply systems can help the poor sections of the society and improve compliance. Universal access of health-care services is another area to be emphasized, especially in the outreach areas.

Keywords: Accessibility, affordability, compliance, hypertension, quality of care

How to cite this article:
Khwaja M, Ansari MA, Mehnaz S. Quality of care: A strong predictor of treatment compliance in hypertensives. Imam J Appl Sci 2019;4:39-44

How to cite this URL:
Khwaja M, Ansari MA, Mehnaz S. Quality of care: A strong predictor of treatment compliance in hypertensives. Imam J Appl Sci [serial online] 2019 [cited 2022 Jul 3];4:39-44. Available from:

  Introduction Top

Quality of health-care focuses on the concept that health care has three major cornerstones: quality, access, and care.[1] The WHO suggests that to improve quality and outcomes, the services should be effective, efficient, and equitable. The affordability, acceptability, and safety of services are also a matter of concern.[2] Noncommunicable diseases (39.1%) and injuries (11.8%) now constitute the bulk of the country's disease burden.[3] Despite the availability of effective treatments, studies have shown that in many countries <25% of patients treated for hypertension achieve optimum blood pressure.[4] Compliance is a primary determinant of the effectiveness of treatment[5] because poor compliance attenuates optimum clinical benefits.[6] Furthermore, the effectiveness of the pharmacological-based risk-reduction interventions is improved by a better compliance to treatment.[5],[7] Effective treatment of hypertension can reduce the risk of stroke,[8] myocardial infarction, and other costly consequences.[9] Poor compliance to treatment is the most important cause of uncontrolled blood pressure[10] and only 20%–80% of patients receiving treatment for hypertension are considered as “good compliers.”[11] The burden of noncompliance must be shared between the health-care provider, the patient, and the health-care system.[12] Strategies for improving accessibility and affordability of drugs have an important influence on compliance particularly in poor sections of the population. Hence, the need of the hour is remove the barriers to treatment compliance. Keeping in mind, the above-mentioned observations, the study was aimed to determine the impact of health care and provider factors on compliance to hypertension treatment and to suggest measures for the removal of the identified barriers.

  Subjects And Methods Top

Study design and sampling

A prospective cross-sectional study was conducted in the urban and rural field practice areas of Department of Community Medicine, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India. Patients aged 30 years and above who had been diagnosed with hypertension and were on antihypertensive for the past 6 months were included in this study. Pregnancy-induced hypertension patients were excluded from the study. Furthermore, excluded were hypertensive patients in an inpatient setting. Based on a previous study,[13] the prevalence for sample size calculation was taken as 15.3%. At 95% confidence with a marginal error of 5% sample size and 10% nonresponse sample size was calculated as 356. Of these six participants were excluded. A list of hypertensive patients in the study areas was prepared by door-to-door survey. After calculating the respective sample sizes to be drawn from each of the area by probability proportion to size, simple random sampling was done to draw the desired sample from each area.

Study instrument

Treatment compliance was measured by Morisky 8-item Medication Adherence Scale (MMAS-8) with a high reliability and validity,[14] which has been particularly useful in chronic conditions such as hypertension. Each of the 8 items was scored 0 or 1. A total score of “>2” suggested low adherence. Scores of “1–2” were reported as medium while “0” as high adherence. The sociodemographic and clinical characteristics evaluated were residence, sex, age, education, and socioeconomic class. To analyze the quality of health care, the implementation of key interventions was assessed individually: type of medical facility, conveyance, distance from the health facility, patient–physician relationship, and treatment outcome.

Study duration

The study was conducted for 1 year (June 2015–July 2016). The rights of the patients during interview were well respected.

Ethical approval

The study protocol was approved by the Institutional Research Ethics Committee, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India. Furthermore, written consent was obtained from the respondents before participation in the study.

  Results Top

A total of 350 participants were included in the study. The mean age of the participants was 58.95 ± 10.24 with a range of 33–89 years. Almost half of the respondents (47.1%) were in the age group of >61 years. Females (69.7%) were almost twice the number of males (30.3%). There was almost a uniform distribution of participants among Hindus (52.3%) and Muslims (49.7%). More than half of the respondents were illiterate (59.7%). Majority (32.9%) belonged to social Class IV. Most of the respondents were homemakers (64.6%).

The prevalence of treatment compliance was assessed using MMAS-8. As high level of compliance was not found in any of the participant, low compliance was taken as noncompliance while medium as compliance.[15],[16] With the above considerations, it was found that 76.3% of participants were not compliant while 23.7% of participants were compliant to antihypertensive medications.

Participants of <50 years were 55% less compliant than their counterparts. Females were twice more compliant than males (odds ratio [OR] = 1.915). Treatment compliance was reported to be 47% and 43% less than in those without any formal education (P = 0.012) and those in lower social class (P = 0.028), respectively [Table 1]. Area, marital status, religion, and duration of hypertension were not associated significantly.
Table 1: Association of sociodemographic profile and treatment compliance

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Compliance was associated with health facility distance of <5 km (OR = 2.266) and using transport (OR = 2.310) as a means of conveyance. Affordability of drugs was four times more likely to be associated with treatment compliance (OR = 3.869). Nonavailability of free medications decreased the compliance level by approximately 60% (OR = 0.473). However, the type of medical facility did not have a significant association [Table 2].
Table 2: Association of provider factors and treatment compliance

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Noncompliance was noted in 98.1% of patients receiving more than two medicine per day (OR = 25.036). Compliance to treatment was present in those patients taking medicine once a day (OR = 3.367). Reasonable clinic wait time (OR = 1.836), a satisfied relation with physician (OR = 2.956), and a strong family support (OR = 1.776) were associated with better levels of compliance. 98.7% of those experiencing side effect of the drugs were not compliant [Table 3].
Table 3: Association of health-care system factors and treatment compliance

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  Discussion Top

The identification of factors affecting compliance to appropriate medical therapy for hypertension can result in controlled blood pressure and reduction in adverse outcomes. In this study, compliance was found to be higher among people aged 50 years and above, and higher among females. In a similar study in Uttar Pradesh with a mean age of 50.46 ± 11.13 years found better compliance to be twice more likely in ≥50 years as compared to <50 years.[15] Similarly, age was found to be significantly associated with treatment compliance in some other studies.[17],[18],[19] However, the age was not found to be significantly associated in many other studies.[20],[21],[22],[23] The possible reason might be that older people have more concern about their health than younger patients.[24]

Females were found to be almost twice more compliant to treatment than males in the present study. Studies conducted in Karnataka and Andhra Pradesh reported females having significantly higher compliance than males.[13],[20] However, some studies have reported no association with gender.[15],[18],[22],[25]

The study reports that the absence of any formal education resulted in significantly higher numbers of noncompliers. Studies in Andhra Pradesh found that illiterates had a higher odds of low adherence score as compared literates.[13],[26] In contrast to this education was not found to have a significant association with treatment compliance in few studies.[19],[20]

The present study found participants of upper social class to be significantly better compliant to treatment. Similarly, studies in Uttar Pradesh and Kolkata also found upper middle socioeconomic status to be significantly associated with good adherence.[15],[21] However, no significant association was reported in studies.[13],[18],[20],[27] One explanation may be that in many of these studies, only a negligible number belong to the high socioeconomic class, making it difficult to access nonadherence in the high socioeconomic class. On the other hand, the lack of association between income and nonadherence may reflect an interplay of other factors that contribute to medication adherence.[27]

In the present study, no significant difference was noticed among those taking treatment from public sector or private sector. However, in a study in rural Tamil Nadu authors found participants taking treatment from private facility were less adherent than those who were public facility.[22] The most probable reason might be a different study setting than the present study which included both urban and rural areas.

Participants living near the health facility were better compliant to treatment. Likewise, many studies suggest that decreasing distance from health-care facility improved compliance.[15],[22],[28] Yet the researchers in a study in Mangalore did not find the distance from health facility to be significant correlate.[16] In this study, the use of transport as a means of conveyance was reported to significantly increase compliance rates. Similar results were reported in the study by Ahmad.[15] In another study in Karnataka, means of conveyance were not found to be statistically significant.[25]

Similar to the present study, availability of free drugs was found to improve levels of compliance.[15],[16],[21] This study found the affordability of drugs to be one of the major barriers to treatment compliance. Several studies[19],[25],[29] have also reported the same.

Number of pills and daily dose frequencies were found to have an inverse relation with treatment compliance. Several studies from India[13],[15],[16],[30] have also discussed the association of number of pills with treatment compliance. In contrast to this Hashmi et al.[19] in their study in Pakistan hypothesized compliance to improve with increase in number of pills. In contrast to this, no significant association was discovered between percentage adherence and number of antihypertensive drugs in another study.[31]

A daily dose of more than once per day decreased the level of compliance. Similar results were reported in other studies.[13],[15],[23] Clinic wait time and patient–physician relationship were other provider factors that influenced treatment compliance. Flynn et al.[32] and Mahmoud[33] also reported a low level of compliance in patients who had to wait long in the clinics. In this study, the patient satisfaction was assessed and found that only 27% of patients with a satisfactory patient–physician relationship were compliant. Likewise, a significant association was reported between patient–physician relationship and treatment compliance in few studies.

A strong family support was found to have higher odds of treatment compliance. Of those, who lacked family support, a low level of compliance was found in 82.4% of the participants (P = 0.033). Similar findings were reported in a study by Hashmi et al.[19]

  Conclusions and Recommendations Top

To conclude, monotherapy and unpleasant side effects were the strongest of all the factors affecting adherence to antihypertensive medication. Easy accessibility to health facility and affordability of drugs were other contributory barriers along with the patient–physician relationship [Figure 1]. Future studies are recommended to confirm our findings, as compliance to medication predicts better outcomes and indicators of poor compliance to a medication regimen are a useful resource for policy makers to help identify barriers to improve compliance. Universal access of health-care services is another area to be emphasized, especially in the outreach areas.
Figure 1: Facilitators and barriers to treatment compliance

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The limitation of our study would be that the Morisky adherence questionnaire used in this study has not been validated in the Indian population. Furthermore, the sample size of our study is small to generalize the findings to a large extent. However, there is a paucity of literature on adherence to antihypertensive medications in the Indian subcontinent. In addition, there was a potential recall bias in the study.


The authors want to express their heartfelt gratitude to Dr. Ali Jafar Abedi for his constant. We are indebted to all those patients who participated in the study as participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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