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Journal of Evaluation in Clinical Practice ISSN 1365-2753

Effect of medication adherence on blood pressure control

and risk factors for antihypertensive medication adherence
Zhao Yue MS,1 Wang Bin PhD,2 Qi Weilin MD3 and Yang Aifang MS1
1
3

Master Student, 2Professor, Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
Professor, Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China

Keywords
Chinese, clinical outcome, hypertension,
medication adherence, risk factors, social
support
Correspondence
Professor Wang Bin
Department of Pharmacy
Huashan Hospital
Fudan University
12 Middle Wu Lu Mu Qi Road
200040 Shanghai
China
E-mail: fdzy1990@gmail.com
Professor Qi Weilin
Department of Cardiology
Huashan Hospital
Fudan University
12 Middle Wu Lu Mu Qi Road
200040 Shanghai
China
E-mail: qiweilin@medmail.com.cn

Abstract
Rationale, aims and objectives We aim to investigate a range of risk factors associated
with medication adherence among Chinese hypertensive patients. We also aim to investigate the association between medication adherence and blood pressure control.
Methods A cross-sectional study was conducted among Chinese hypertensive patients in
a comprehensive teaching hospital in Shanghai, China, using a validated scale, a selfdesigned questionnaire and patients medical records.
Results Of the 232 eligible participants, 61 (26.3%), 51 (22.0%) and 120 (51.7%) showed
low, medium and high adherence, respectively. Adjusted for socio-demographic, clinical
and patient-related factors, antihypertensive medication adherence was significantly associated with better systolic blood pressure control (P = 0.001), whereas the association with
diastolic blood pressure control was relatively weak (P = 0.334). In the multivariate analysis, patients with longer duration of drug use [P = 0.012, odds ratio (OR) = 0.46, 95%
confidence interval (CI) 0.250.84], combination of antiplatelet agents (0.002, 0.38, 0.20
0.71), less concerns of medical cost (0.001, 0.18, 0.020.51), more availability of professional guidance (0.002, 0.34, 0.170.66) and more availability of family support (0.036,
0.51, 0.270.96) were more likely to adhere to their drug regimens.
Conclusions The rate of suboptimal medication adherence among Chinese hypertensive
patients is quite high. Interventions could focus upon the risk factors to improve antihypertensive medication adherence in clinical practice.

Accepted for publication: 2 September 2014

doi:10.1111/jep.12268

Introduction
Hypertension (HTN) is one of the most common chronic diseases in China, and data from epidemiological investigations
show that one out of five Chinese adults suffers from HTN [1].
The systolic and diastolic levels of <140 and <90 mmHg are generally considered as clinically acceptable targets for blood pressure (BP) control in China. Despite the availability of effective
medications, the control of BP is still far from optimal in China,
with the control rate of less than 10%, and suboptimal BP
control is associated with increased cardiovascular mortality [2].
The low control rate of HTN may be largely attributed to
patients poor adherence to their drug regimens, which is a very
common phenomenon all over the world [3,4]. Some studies
have shown that over 50% of hypertensive patients do not adhere
to their drug regimens well, and patients poor medication adherence results in poor treatment outcomes and added health care
costs [57].
166

Patients non-adherence to drug regimens might be due to unintentional reasons, such as simply forgetfulness, and intentional
reasons, such as disagreement with the doctors [8]. To improve
patients antihypertensive medication adherence, we should have a
deep understanding of patients medication adherence and then
develop more effective strategies on that basis [9,10]. There have
been a number of studies on antihypertensive medication adherence among Chinese patients in Hong Kong and among Chinese
immigrates [1114]; however, there is scarcity of detailed studies
evaluating antihypertensive medication adherence among patients
in mainland China, where the culture and medical system are very
different.
Thus, we conducted a cross-sectional study of medication adherence among hypertensive patients in Shanghai, a city in mainland
China. We aim to investigate a range of socio-demographic, clinical
and patient-related factors for medication adherence among
Chinese hypertensive patients. We also aim to investigate the association between medication adherence and BP control. The study

Journal of Evaluation in Clinical Practice 21 (2015) 166172 2014 John Wiley & Sons, Ltd.

Z. Yue et al.

focused upon risk factors such as drug combinations, social support

and so on, which could provide more information to improve
antihypertensive medication adherence in clinical practice.

Methods
Subjects
The study was conducted in Shanghai, China. Participants were
enrolled from September 2013 to May 2014 in a comprehensive
teaching hospital. Outpatients who were diagnosed with primary
HTN and under antihypertensive drug treatment for a least 1
month were included in the study. Given the requirement of the
study, we excluded patients having difficulty in understanding or
communicating with the investigator and patients with severe
acute diseases, who may be too weak to join. Patients who agreed
to join and signed consent form were finally included in the study.
Sample size was calculated before data collection with = 0.05,
= 0.20 (power = 0.80) using NCSS-PASS software (NCSS LLC,
Kaysville, UT, USA).

Questionnaires and scales

Morisky medication adherence scale (MMAS-8)
The 8-item MMAS is a validated self-report scale that measures
patients antihypertensive medication adherence. Based upon previous studies, patients with a score of 8 were considered as high
adherence, a score of 6 to <8 as medium adherence and a score of
<6 as low adherence, and the MMAS has been demonstrated to be
significantly associated with drug pharmacy refill adherence using
the cut-off points [15]. The Chinese version of MMAS is widely
used and has been demonstrated to be valid and reliable [16].
Self-designed questionnaire
The self-designed questionnaire was used to collect data of risk
factors for patients non-adherence (Appendix S1). It was developed after a literature review by a panel of internal experts (epidemiologists, clinicians and pharmacists) and was assessed by a
group of external experts. The questionnaire contains 28 items,
which could be divided into three categories: socio-demographic
details of the participants; clinical characteristics related to disease
and treatment; and patient-related factors that might trigger or
restrain patients medication adherence.

Procedure
This is a pharmacist-led cross-sectional study. The pharmacist
recruited subjects according to inclusion and exclusion criteria. A
standard consent form approved by the Research Ethics Committee of Huashan Hospital was provided if they agreed to participate
in the study. After the consent form was signed, the pharmacist
collected data of risk factors using the self-designed questionnaire,
and some professional variables related to treatment regimens,
including number of co-morbidity, frequency of drugs, number of
drugs, categories of drugs, combination of other drugs (antiplatelet
agents, antilipemic agents, hypoglycaemic agents, noncardiovascular medicine, Chinese medicine), were collected

2014 John Wiley & Sons, Ltd.

Adherence, risk factors and blood pressure

according to patients medical records. Patients medication adherence was measured using the MMAS. The pharmacist administered all questionnaires and scales to participants via a face-to-face
interview at the hospital clinic. Patients BP were measured three
times at the hospital clinic, using standardized methodology by a
professional doctor. Based upon the Chinese guidelines for BP
measurement, the mercury sphygmomanometer used in the study
was calibrated over time to ensure reliability, and the patients were
checked to sit quietly for 10 minutes and not to drink tea or coffee
before the measurement. The average of three BP values was used
for analysis in the study.

Statistics
Statistical analysis was conducted with SPSS version 20 (SPSS
Inc., Chicago, IL, USA). The univariate analysis of risk factors for
medication adherence was conducted by chi-squared (categorical
variables) and Students t-test or MannWhitney U-test (continuous variables). The variables with P < 0.20 in the univariate analysis were further included in multivariate logistic regression
analysis. The analysis was two-tailed, and variables with P < 0.05
in multivariate analysis were considered as risk factors that independently affect patients antihypertensive medication adherence.
The association between BP and medication adherence was investigated with logistic regression, adjusted for all 28 sociodemographic, clinical and patient-related risk factors.

Results
From September 2013 to May 2014, a total of 1089 cardiovascular
patients visited the clinic, of which 256 Chinese hypertensive
patients were recruited. The participants mainly came from the
provinces of Shanghai, Jiangsu and Zhejiang, population of which
accounts for 12% of the Chinese population. Of the 256 participants, 232 completed all questionnaires and scales entirely, and the
other 24 who dropped out or refused to provide sensitive information, such as income and family members, were further excluded.
As calculated before the data collection, the sample size ensures
the statistical power of the study. On the basis of MMAS scores, 61
(26.3%) showed low adherence, 51 (22.0%) showed medium
adherence, and 120 (51.7%) showed high adherence. In the study,
patients with high adherence were considered as optimal adherer,
and patients with low/medium adherence were considered as suboptimal adherer. This is a little different from previous studies that
compared high/medium adherence with low adherence.
The analysis of association between medication adherence and
BP control showed that patients antihypertensive medication
adherence is significantly associated with systolic blood pressure
(SBP), whereas the association with diastolic blood pressure
(DBP) is relatively weak. The mean SBP was 135.2 mmHg in
optimal adherence group and 143.3 mmHg in suboptimal adherence group (P = 0.001, adjusted for all factors). The mean DBP
was 81.5 mmHg in optimal adherence group and 85.2 mmHg in
suboptimal adherence group (P = 0.334, adjusted for all factors).
Table 1 shows the univariate analysis of the socio-demographic
factors for medication adherence among Chinese hypertensive
patients. A significant association was found between patients age
and medication adherence (P = 0.037).
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Adherence, risk factors and blood pressure

Z. Yue et al.

Table 1 Univariate analysis of the socio-demographic factors for medication adherence among Chinese hypertensive patients

Age (mean SD, years)*

Gender
Male
Female
Education
None/Primary
Secondary
Tertiary
Marital status*
Single
Married
Divorced
Widowed
Family member*
Alone
With others
Distance to hospital (minutes)
<15
1560
>60
Health insurance*
Yes
No
Income (rmb month1)
1500
15003000
>3000
Medical cost (rmb month1)
100
100300
300

People with optimal adherence

People with suboptimal adherence

(n = 120)

(n = 112)

P-value

62.6 11.9

0.037
0.978

65.6 9.8
57
63

48%
52%

53
59

47%
53%

11
66
43

9%
55%
36%

13
70
29

12%
62%
26%

0
109
0
11

0%
91%
0%
9%

2
99
3
8

2%
88%
3%
7%

7
113

6%
94%

13
99

12%
88%

29
61
30

24%
51%
25%

27
54
31

24%
48%
28%

110
10

92%
8%

96
16

86%
14%

6
60
54

5%
50%
45%

10
58
44

9%
52%
39%

31
64
25

26%
53%
21%

40
48
24

36%
43%
21%

0.255

0.128

0.117

0.888

0.151

0.411

0.204

*Variables included in the multivariate analysis.

Optimal adherence refers to high adherence [Morisky medication adherence scale (MMAS) score of 8]; suboptimal adherence refers to medium
(MMAS score of 67) and low (MMAS score of <6) adherence. The categorization is a little different from previous studies that compare high/medium
adherence group with low adherence group. The results represented the difference between high and medium/low adherence groups.

Table 2 shows the univariate analysis of the clinical factors for

medication adherence among Chinese hypertensive patients. A
total of four clinical factors had P-value of less than 0.05, including duration of HTN (P = 0.003), duration of drug use (P = 0.001),
combination of antiplatelet agents (P < 0.001) and combination of
non-cardiovascular medications (P = 0.045).
Table 3 shows the univariate analysis of the patient-related
factors for medication adherence among Chinese hypertensive
patients. A total of seven factors were significantly associated with
medication adherence, including family history of HTN
(P = 0.005), experience of side effect (P = 0.013), concerns of
medical cost (P < 0.001), worries about long-term effects
(P = 0.030), availability of professional guidance (P < 0.001),
availability of family support (P = 0.001) and access to HTN
knowledge (P < 0.001).
Table 4 shows the results of multivariate logistic regression
analysis. A total of 16 factors with P < 0.20 were included in the
analysis, of which 5 were identified to be independently associated
with antihypertensive medication adherence. Patients with longer
168

duration of drug use [P = 0.012, odds ratio (OR) = 0.46, 95%

confidence interval (CI) 0.250.84], combination of antiplatelet
agents (P = 0.002, OR = 0.38, 95% CI 0.200.71), less concern of
medical cost (P < 0.001, OR = 0.18, 95% CI 0.020.51), more
availability of professional guidance (P = 0.002, OR = 0.34, 95%
CI 0.170.66) and more availability of family support (P = 0.036,
OR = 0.51, 95% CI 0.270.96) were more likely to adhere to their
drug regimens.

Discussion
Antihypertensive medication adherence and
BP control
The rate of patients that adhere to drug regimens in the real world
ranges from 20% to 80% [17]. The variation of medication adherence rate is related to some factors, such as difference in methods
to measure adherence and study population [18,19]. In the study,
we investigated the rate of medication adherence among Chinese

2014 John Wiley & Sons, Ltd.

Z. Yue et al.

Adherence, risk factors and blood pressure

Table 2 Univariate analysis of the clinical factors for medication adherence among Chinese hypertensive patients

Duration of HTN (years)*

10
>10
Duration of drug use (years)*
10
>10
Number of co-morbidity*
1
2
3
Frequency of drugs
1
2
3
Number of drugs
2
34
5
Category of drugs
1
2
3
Combination of antiplatelet agents*
No
Yes
Combination of antilipemic agents
No
Yes
Combination of hypoglycaemic agents
No
Yes
Combination of non-cardiovascular medicine*
No
Yes
Combination of Chinese medicine
No
Yes

People with optimal adherence

People with suboptimal adherence

(n = 120)

(n = 112)

P-value
0.003

44
76

37%
63%

63
49

56%
44%

47
73

39%
61%

69
43

62%
38%

69
29
22

58%
24%
18%

71
30
11

63%
27%
10%

84
27
9

70%
22%
8%

78
25
9

70%
22%
8%

93
23
4

78%
19%
3%

90
15
7

81%
13%
6%

54
36
30

45%
30%
25%

51
38
23

45%
34%
21%

54
66

45%
55%

76
36

68%
32%

62
58

52%
48%

67
45

60%
40%

97
23

81%
19%

89
23

79%
21%

66
54

55%
45%

76
36

68%
32%

70
50

58%
42%

74
38

66%
34%

0.001

0.179

0.988

0.320

0.674

<0.001

0.212

0.794

0.045

0.225

*Variables included in the multivariate analysis.

HTN, hypertension.

hypertensive patients using MMAS-8. We found that about half of

the participants did not adhere to their drug regimens perfectly, as
26.3% and 22.0% of the patients showed low and medium medication adherence, respectively. In addition, a number of studies
have found that suboptimal medication adherence is an important
cause for suboptimal BP control [20,21]. Our study further confirms that adjusted for socio-demographic, clinical and patientrelated factors, optimal medication adherence is significantly
associated with better SBP control, whereas the association with
DBP control is relatively weak. Meanwhile, the value of 140/90
(SBP/DBP) mmHg is generally considered as the cut-off point for
BP control in China [21,22]. Using the criteria, the mean BP of
optimal adherent group (135.2/81.5 mmHg) is within target,
whereas the mean BP of suboptimal adherent group (143.3/
85.2 mmHg) is not within target. The results suggest that antihy-

2014 John Wiley & Sons, Ltd.

pertensive medication adherence is an important factor for optimal

BP control, which could consequently reduce cardiovascular morbidity and mortality.

Duration of drug use and antihypertensive

medication adherence
The longer patients take antihypertensive drug, the more likely
they are to adhere to their drug regimens. Those who take drugs for
a longer time may get more used to their drug regimens: they may
have more experience in managing their drug schedules and have
less concerns or problems caused by the drug. The finding suggests
that interventions to improve hypertensive patients adherence
would better pay more attention to the patients who just started to
take antihypertensive drugs and help them adapt to their drug
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Z. Yue et al.

Table 3 Univariate analysis of the patient-related factors for medication adherence among Chinese hypertensive patients

Family history of HTN*

No
Yes
Experience of HTN symptoms
None/A little
A lot
Experience of side effects*
None/A little
A lot
Concerns of medical cost*
None/A little
A lot
Worries about long-term effects*
None/A little
A lot
Availability of professional guidance*
None/A little
A lot
Availability of family support*
None/A little
A lot
Access to HTN knowledge*
None/A little
A lot

People with optimal adherence

People with suboptimal adherence

(n = 120)

(n = 112)

P-value
0.005

26
94

22%
78%

43
69

38%
62%

54
66

45%
55%

59
53

53%
47%

110
10

92%
8%

90
22

80%
20%

118
2

98%
2%

96
16

86%
14%

80
40

67%
33%

59
53

53%
47%

21
99

18%
82%

56
56

50%
50%

44
76

37%
63%

65
47

58%
42%

29
91

24%
76%

52
60

46%
54%

0.723

0.013

<0.001

0.030

<0.001

0.001

<0.001

*Variables included in the multivariate analysis.

HTN, hypertension.

Table 4 Multivariate analysis of the risk factors for medication adherence among Chinese hypertensive patients
People with optimal
adherence
Duration of drug use (years)
10
>10
Combination of antiplatelet agents
No
Yes
Concerns of medical cost
None/A little
A lot
Availability of professional guidance
None/A little
A lot
Availability of family support
None/A little
A lot

People with suboptimal

adherence

P-value

Adjusted OR*
(95% CI)

47
73

69
43

0.012

0.46 (0.250.84)

54
66

76
36

0.002

0.38 (0.200.71)

118
2

96
16

<0.001

5.61 (1.9549.95)

21
99

56
56

0.002

0.34 (0.170.66)

44
76

65
47

0.036

0.51 (0.270.96)

*Adjusted OR = adjusted odds ratio. A total of 16 factors with P < 0.20 were included in the multivariate analysis, of which 11 were insignificant after
adjustment, including age, marital status, family member, health insurance, duration of hypertension (HTN), number of co-morbidity, combination of
non-cardiovascular medicine, family history of HTN, experience of side effect, worries of long-term effects and access to HTN knowledge.
CI, confidence interval.

170

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Z. Yue et al.

regimens. However, some other studies showed that diabetes

patients with longer history of insulin use are more likely to forget
their insulin injection [23]. This may be due to the difference in the
type of disease, study population and, more importantly, tolerance
to drug formulation. Thus, strategies to improve medication adherence should be suitable for different diseases, populations and
drug formulations.

Drug combinations and antihypertensive

medication adherence
Patients who take antihypertensive drugs combined with
antiplatelet agents are more likely to adhere to their drug regimens.
Combination of antiplatelet agents might improve patients intentional non-adherence. Stroke is the most common cause of death
and is the primary health concern in Chinese population [24],
whereas antiplatelet agents, such as aspirin, are well known as
effective drugs to prevent stroke. The perception of the benefit of
antiplatelet agents for reducing stroke risk may be a positive factor
for medication adherence [25,26]. Thus, patients may be more
concerned about the risk of stroke and are more aware of the
necessity of medicines when their antihypertensive drugs are combined with antiplatelet agents, which consequently improves their
adherence to drug regimens. The result is a little different from the
previous ones that complex drug regimens have a negative effect
on medication adherence [27,28]. It suggests that properly organized complexity of drug regimens may improve patients intentional non-adherence and offset its negative effect on unintentional
non-adherence caused by simply forgetfulness. The finding provides a new and completely different strategy to improve medication adherence among Chinese hypertensive patients: health care
providers could prescribe patients with properly complex and
organized drug regimens, for example, antihypertensive drugs
combined with antiplatelet agents, and emphasize more on the
benefit of their drug regimens for reducing stroke risk.

Concerns of medical cost and antihypertensive

medication adherence
Patients with more concerns of the medical cost are less likely to
adhere to their drug regimens. Patients concerns of medical cost
might be a factor for intentional non-adherence. With limited
resource available, the patients may have more difficulties in
affording the price of their drug treatment as they have to choose
among competing priorities, such as food, basic supplies and the
need of other family members. Thus, the patients may be more
adversely influenced by economic factors that lead them to not
following drug regimens [29,30]. Given the impact of patients
concerns of medical cost, strategies to improve Chinese
patients adherence to antihypertensive drugs would better take
patients economic capability into consideration, and a more
affordable drug prize or financial support may have a positive
effect on patients medication adherence. A study conducted in
England and Wales has shown that offering modest financial
incentives to patients is an effective method to improve medication
adherence [31]. According to the result of our study, the method
might also be suitable for Chinese hypertensive patients.

2014 John Wiley & Sons, Ltd.

Adherence, risk factors and blood pressure

Social supports and antihypertensive

medication adherence
Patients with more availability of professional guidance or family
support are more likely to adhere to their drug regimens. The
beneficial effects of social support on medication adherence have
been documented in many studies, and social support could be
provided by family members, friends, heath care professionals,
etc. [3234]. To overcome barriers to medication adherence,
hypertensive patients often need long-term reminders and emotional support from their intimate ties, such as family members and
friends [35]. However, these types of social support may have
some limitations, particularly lack of professional information.
Thus, professional guidance from health care providers is equally
important to improve patients medication adherence. However,
professional support from health care providers is rarely available
to all patients over long periods of time [36]. Thus, either family
support or professional guidance has its own strengths and weaknesses. In the study, we found that availability of family support
and professional guidance are both associated with medication
adherence among Chinese hypertensive patients. The results suggested that interventions to improve medication adherence among
Chinese hypertensive patients may attempt to promote availability
of both family support and professional guidance by linking
patients with their family members and medical professionals
closely. A combination of family support and professional guidance could provide long-term, intimate and professional social
support to mostly improve antihypertensive medication adherence.

Limitations
The study has some limitations. Firstly, as the questionnaires and
scales were administered to participants via a face-to-face interview, there may be social desirability bias. Due to self-presentation
concerns, patients may understate socially undesirable activities
(non-adherence) and overstate socially desirable ones (adherence),
which may result in health care providers overestimation of
patients medication adherence [37]. Secondly, this is a singlecentre study with modest number of individuals. Considering the
large Chinese population and high prevalence of HTN in China,
the study may not be representative of all hypertensive patients in
China, which may limit the generalization of the findings to wider
contexts. Thirdly, for the restriction of survey methods and
research ethics, we excluded patients having difficulty in understanding or communicating with the investigator and patients with
severe acute diseases, who may represent a substantial amount of
hypertensive patients. Thus, more studies should be conducted to
investigate risk factors for medication adherence among such
patients. In addition, as some variables, such as sociodemographic variables, were collected by patients self-report,
there may be recall bias.

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