Journal of Epidemiology and

Global Health
ISSN (Online): 2210-6014 ISSN (Print): 2210-6006
Journal Home Page: https://www.atlantis-press.com/journals/jegh

Adherence to medications and associated factors: A cross-sectional

study among Palestinian hypertensive patients
Rowa’ Al-Ramahi

To cite this article: Rowa’ Al-Ramahi (2015) Adherence to medications and associated
factors: A cross-sectional study among Palestinian hypertensive patients, Journal of
Epidemiology and Global Health 5:2, 125–132, DOI:
https://doi.org/10.1016/j.jegh.2014.05.005

To link to this article: https://doi.org/10.1016/j.jegh.2014.05.005

Published online: 23 April 2019

Journal of Epidemiology and Global Health (2015) 5, 125– 132

http:// www.elsevier.com/locate/jegh

Adherence to medications and associated

factors: A cross-sectional study among
Palestinian hypertensive patients
RowaÕ Al-Ramahi *

Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University,
P.O. Box: 7, Nablus, Palestine

Received 2 August 2013; received in revised form 8 May 2014; accepted 14 May 2014
Available online 21 June 2014

KEYWORDS Abstract Objective: To assess adherence of Palestinian hypertensive patients to

Adherence; therapy and to investigate the effect of a range of demographic and psychosocial
Hypertension;
variables on medication adherence.
Forgetfulness;
Methods: A questionnaire-based, cross-sectional descriptive study was under-
Palestine
taken at a group of outpatient clinics of the Ministry of Health, in addition to a group
of private clinics and pharmacies in the West Bank. Social and demographic variables
and self-reported drug adherence (Morisky scale) were determined for each patient.
Results: Low adherence with medications was present in 244 (54.2%) of the
patients. The multivariate logistic regression showed that younger age (<45 years),
living in a village compared with a city, evaluating health status as very good, good
or poor compared with excellent, forgetfulness, fear of getting used to medication,
adverse effect, and dissatisfaction with treatment had a statistically significant
association with lower levels of medication adherence (P < 0.05).
Conclusions: Poor adherence to medications was very common. The findings of
this study may be used to identify the subset of population at risk of poor adherence
who should be targeted for interventions to achieve better blood pressure control
and hence prevent complications. This study should encourage the health policy
makers in Palestine to implement strategies to reduce non-compliance, and thus
contribute toward reducing national health care expenditures. Better patient
education and communication with healthcare professionals could improve some
factors that decrease adherence such as forgetfulness and dissatisfaction with
treatment.
ª 2014 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

* Tel.: +972 9 2345113.

E-mail address: rawa_ramahi@najah.edu

http://dx.doi.org/10.1016/j.jegh.2014.05.005
2210-6006/ª 2014 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
126 R. Al-Ramahi

1. Introduction investigate the rate of medication adherence and

its associated factors in hypertensive patients from
The World Health Organization defines adherence the West Bank. The objectives of this study are to
as ‘‘the extent to which a personÕs behavior-taking measure the rate of medication adherence, to
medication, following a diet, and/or executing investigate the factors associated with this adher-
lifestyle changes corresponds with agreed recom- ence and the reasons for poor adherence. This
mendations from a health-care provider’’ [1]. study could be helpful to health policy makers in
Generally, adherence to a medical regimen is most Palestine to implement health education strategies
likely to be a problem in chronic diseases such as to reduce poor adherence and thus to reduce com-
diabetes, hypertension, coronary artery disease, plications of the disease and national health costs.
osteoporosis, and asthma, and is responsible for
suboptimal clinical outcomes, decreased quality 2. Methods
of life, and increased expense to the health-care
system [1–3]. Poor adherence to treatment of 2.1. Patient selection
chronic diseases is a worldwide problem of striking
magnitude. According to the World Health Organi- The study was a questionnaire-based cross-sec-
zation adherence to long-term therapy for chronic tional descriptive study. It was conducted between
illnesses in developed countries averages 50%. In September and December 2011. It included a sim-
developing countries, the rates are even lower [1]. ple random sample from patients visiting outpa-
Hypertension is a significant public health prob- tient clinics of governmental primary healthcare
lem in many countries. It remains an important centers in addition to a group of private clinics
public health challenge and one of the most and pharmacies in the West Bank. Approval to per-
important risk factors for coronary heart disease, form the study was obtained from the Palestinian
stroke, heart failure and end stage renal disease Ministry of Health (MOH) and the Institutional
[4,5]. Lowering blood pressure by antihypertensive Review Board (IRB) committee at An-Najah
drugs reduces the risks of cardiovascular events, National University. The study complied with the
stroke, and total mortality [6,7]. Lack of compli- Declaration of Helsinki and did not endanger
ance with blood pressure-lowering medication is a the well-being of the patients. Patients who met
major reason for poor control of hypertension. the following criteria were invited to participate
Patients with high blood pressure may fail to take in this study: (1) Patients P 18 years; (2) Those
their medication because of the chronic nature of who had been diagnosed with hypertension; and
the disease and the absence of overt symptoms (3) Those who were on prescribed antihypertensive
[8]. In Palestine, hypertension is among the leading medications for at least one month. Patients who
causes of death; it is the eighth cause of death and agreed to participate were explained the nature
is a risk factor for cardiovascular and cerebrovas- and the objectives of the study, and informed
cular diseases which represent the first and second consent was formally obtained.
causes of death [9]. Since there was no available literature showing
Factors that affect medication adherence are the prevalence of adherence among the Palestinian
complex; low adherence was reported among community in general, a 50% expected prevalence
younger individuals, men, and black persons. Other was used; minimum sample size was calculated to
factors that were reported to negatively impact be 384, so 500 patients were asked to participate
adherence to prescribed therapies include beliefs in the study.
about illness and treatment, forgetfulness, side
effects of medications, complexity of treatment 2.2. Data collection
regimens, lack of knowledge regarding hyperten-
sion and its treatment, financial difficulties, psy- The data collection tool was a questionnaire,
chological factors, social support, quality of the designed-based on an extensive literature review
relationship between patient and physician and of similar studies [2,5,17]. The questionnaire
poor quality of life [5,10–16]. included information regarding patient demo-
Studies related to medication adherence are graphics and clinical characteristics such as: sex,
very limited in Palestine. Compared with other age, education, insurance, income, medical his-
variables being considered in therapeutics, adher- tory, and co-morbidities. Patients were asked
ence to medications has long been given minor about their prescribed medication regimen, includ-
attention although it affects every aspect of med- ing the number of their antihypertensive drugs and
ical care. This study appears to be the first to other medications – if present – frequency per
Adherence to medications and associated factors 127

day, side effects of medications and reasons for was generated. The translated questionnaire was
not taking their medications. Adherence was distributed to 20 patients who completed the ques-
assessed through the 8-item self-report Morisky tionnaire and commented on the questions. These
Medication Adherence Scale (MMAS) [5]. Each item individuals were not included in the study.
measures a specific medication-taking behavior.
Approval was obtained from professor Morisky to 2.3. Data analysis
use his scale. This scale is a questionnaire with a
high reliability and validity, which has been partic- Statistical analyses were performed using SPSS ver-
ularly useful in chronic conditions such as hyper- sion 16 (SPSS, Chicago, IL, USA). Means ± standard
tension [5,12]. Highly adherent patients were deviation was computed for continuous data.
identified with the score of 8 on the scale, medium Frequencies and percentages were calculated for
adherers with a score of 6 to <8, and low adherers categorical variables. In univariate analyses, cate-
with a score of <6. For studying factors affecting gorical variables were compared using Chi-square
adherence, patients were divided into two groups: test. Multivariate logistic regression analysis was
poor adherent (score < 6) versus adherent (score conducted to evaluate the odds ratios of factors
6–8), because in the Morisky et al. study, correct that showed a statistically significant association
classification with blood pressure control was with medication adherence in the univariate analy-
based on a dichotomous low versus high/medium sis. A P-value < 0.05 was considered statistically
level of adherence, which had a rate of 80.3%. significant.
When they used a cut-off point of <6, the sensitiv-
ity of the measure to identify patients with poor 3. Results
blood pressure control was estimated to be 93% [5].
Forward translation of the original scale was 3.1. ParticipantsÕ characteristics
undertaken by translation from English to the Arabic
language to produce a version that was semantically From 500 people approached, 450 (90.0%) agreed
and conceptually as close as possible to the original to participate in the study. Females accounted
questionnaire. Then reverse translation of this ver- for 253 (56.2%) of the total sample. The average
sion from Arabic to English was carried out by age was 59.1 (±12.2) years (from 27 to 90 years).
another translator. After discussion between the Around one half of the participants (241, 53.6%)
translators and the researchers, inconsistencies had another chronic disease and more than two-
were resolved and a final version, ready for testing, thirds of them (317 70.4%) had a governmental

Table 1 Responses to Morisky scale questions.

Number Question Yes No
Frequency (%) Frequency (%)
1 Do you sometimes forget to take your 262 (58.2) 188 (41.8)
high blood pressure pills?
2 Over the past 2 weeks, were there any days 162 (36.0) 288 (64.0)
when you did not take your high blood pressure medicine?
3 Have you ever cut back or stopped taking your 124 (27.6) 326 (72.4)
medication without telling your doctor
because you felt worse when you took it?
4 When you travel or leave home, do you 181 (40.2) 269 (59.8)
sometimes forget to bring along your medications?
5 Did you take your high blood pressure medicine yesterday? 378 (84.0) 72 (16.0)
6 When you feel like your blood pressure is under 128 (28.4) 322 (71.6)
control, do you sometimes stop taking your medicine?
7 Do you ever feel hassled about sticking to your blood 216 (48.0) 234 (52.0)
pressure treatment plan?
8 How often do you have difficulty remembering to take
all your blood pressure medication?
Never 172 (38.2%)
Once in a while 148 (32.9%)
Sometimes 81 (18.0%)
Usually 28 (6.2%)
All the time 21(4.7%)
128 R. Al-Ramahi

Table 2 Univariate analysis of the association of potential demographic and clinical variables with self-reported
adherence.
Characteristic Total sample MMAS category (score range) P value
N = 450 Low (<6) Medium/High
(6–8)
N = 244 N = 206
N (%) N (%)
Age 0.006
18–44 41 32 (78.0) 9 (22.0)
45–64 259 134 (51.7) 125 (48.3)
P65 150 78 (52.0) 72 (48.0)
Gender 0.972
Male 197 107 (54.3) 90(45.7)
Female 253 137 (54.2) 116 (45.8)
Education 0.590
College/ university or higher 129 66 (51.2) 63 (48.8)
High school 118 68 (57.6) 50 (42.4)
Primary/ middle school 112 64 (57.1) 48 (42.9)
Illiterate 91 46 (50.5) 45(49.5)
Area of residence 0.001
City 233 106 (45.5) 127 (54.5)
Village 175 111 (63.4) 64 (36.6)
Camp 42 27 (64.3) 15 (35.7)
Household monthly income 0.035
<400 JD 247 145 (58.7) 102 (41.3)
P400 JD 203 99 (48.8) 104 (51.2)
Marital status 0.088
Single 26 16 (61.5) 10 (38.5)
Married 341 178 (52.2) 163 (47.8)
Divorced 17 14 (82.4) 3 (17.6)
Widowed 66 36 (54.5) 30 (45.5)
Health insurance 0.505
Governmental 317 169 (53.3) 148 (46.7)
Private 42 21 (50.0) 21 (50.0)
No insurance 91 54 (59.3) 37 (40.7)
Current health status 0.012
Excellent 24 7 (29.2) 17 (70.8)
Very good 123 75 (61.0) 48 (39.0)
Good 178 102 (57.3) 76 (42.7)
Poor 125 60 (48.0) 65 (52.0)
Another chronic disease 0.009
Yes 241 117 (48.5) 124 (51.5)
No 209 127 (60.8) 82 (39.2)
Number of tablets per day 0.001
1 140 59 (42.1) 81 (57.9)
2 150 85 (56.7) 65 (43.3)
P3 160 100 (62.5) 60 (37.5)
Number of medications per day 0.496
1 221 114 (51.6) 107 (48.4)
2 163 94 (57.7) 69 (42.3)
P3 66 36 (54.5) 30 (45.5)
Frequency of dosing <0.0001
1 192 80 (41.7) 112 (58.3)
>1 258 164 (63.6) 94 (36.4)

health insurance plan. The mean number of antihy- adherence, 130 (28.9%) had medium adherence
pertensive medications was 2.35 (±1.49). Based on and 244 (54.2%) had poor adherence. Table 1 shows
the MMAS, only 76 (16.9%) participants had high the responses to the Morisky scale questions.
Adherence to medications and associated factors 129

In univariate analysis, factors that were associ- Table 4 Odds ratios of determinants of poor medication
ated with poor medication adherence were youn- adherence.
ger age, living in a village or a camp, having
Odd 95% confidence
lower income, receiving a higher number of antihy-
ratio (OR) interval (CI)
pertensive tablets daily or a higher dosing fre-
quency, evaluating health status as very good, Age
good or poor, and having no other chronic disease, 18–44 1
45–64 0.40 0.157–0.99
(p < 0.05). The main socio-demographic and clini-
P65 0.32 0.12–0.87
cal baseline characteristics of the responders and Area of residence
their association with poor adherence are shown City 1
in Table 2. Village 1.79 1.10–2.92
PatientsÕ reasons for low-adherence to medica- Current health status
tions were recorded as forgetfulness 275 (61.1%), Excellent 1
cost 72 (16.0%), lack of access to medication 66 Very good 5.58 1.83–17.04
(14.7%), traveling 53 (11.8%), dissatisfaction with Good 5.40 1.78–16.32
treatment 45 (10.0%), adverse effect 45 (10.0%), Poor 4.55 1.44–14.41
fear of getting used to medication 33 (7.3%), and Forgetfulness 5.12 3.12–8.41
other reasons such as the unavailability of these Dissatisfaction with 2.93 1.22–7.02
treatment
medications at the Ministry of Health healthcare
Side effects 4.58 1.87–11.25
centers 40 (8.9%). Among these reasons, forgetful- Fear of getting used 8.00 2.44–26.19
ness, fear of getting used to medication, adverse to medication
effect, and dissatisfaction with treatment had a
statistically significant association with poor adher-
ence (Table 3).
The multivariate logistic regression showed that 4. Discussion
younger age (<45 years), living in a village com-
pared to a city, evaluating health status as very Medication adherence is a key component of treat-
good, good or poor compared with excellent, for- ment for patients with hypertension. This study
getfulness, fear of getting used to medication, found a very high percentage of low adherence
adverse effect, and dissatisfaction with treatment (54.2% of patients). This means that for many
had a statistically significant association with lower hypertensive patients, medication adherence
levels of medication adherence (P < 0.05) as shown needs to be improved. This result is close to what
in Table 4. has been reported from Taiwan (47.5%) [18], Saudi
The Chi-square test showed a significant rela- Arabia (47.0%) [19], and Pakistan (64.7%) [11]. It is
tionship between MMAS categories and reported higher than studies from the United States (9.0%)
control of blood pressure. Among the patients, [12], Egypt (25.9%) [20] and Ethiopia (35.4%) [21].
113 (25.1%) reported that their blood pressure However, the lack of standard measurements pre-
measurements were within the goal all the time, vents comparisons being made between studies
284 (63.1) said they were within the goal some- and across populations.
times, and 53 (11.8%) reported that their measure- In this study, younger age (<45 years), living in a
ments were above the goal all the time (Fig. 1). village compared with a city, evaluating health

Table 3 PatientsÕ reasons for non-adherence to medications.

Factor Total no. MMAS category (score range) P value
Low (<6) Medium/High (6–8)
No. (%) No. (%)
Forgetfulness 275 179 (65.1) 96 (34.9) <0.0001
Cost of medication 72 40 (55.6) 32(44.4) 0.804
Lack of access to medication 66 41 (62.1) 25 (37.9) 0.163
Traveling 53 34 (64.2) 19 (35.8) 0.122
Dissatisfaction with treatment 45 36 (80.0) 9 (20.0) <0.0001
Side effects 45 35 (77.8) 10(22.2) 0.001
Others 40 19 (47.5) 21 (52.5) 0.371
Fear of getting used to medication 33 29 (87.9) 4 (12.1) <0.0001
130 R. Al-Ramahi

250
36

200
BP is not controlled all the
me
150
166 12 BP is controlled somemes

100 BP is controlled all the me

82 5
36
50
42 36 35
0

8)
6)

8)
-<
(<

(=
(6
ce

ce
ce
en

en
en
er

er
er
h

h
Ad

Ad
h
Ad
w

gh
Lo

Hi
iu
ed
M

Fig. 1 Relationship between adherence scale and blood pressure control.

status as very good, good or poor compared with studies [13,17]; efforts of greater emphasis on this
excellent, forgetfulness, fear of getting used to point are recommended. Adverse effects are well-
medication, adverse effect, and dissatisfaction known reasons for poor adherence to medications
with treatment had a statistically significant asso- [19,20]. The patients who were fearful of getting
ciation with lower levels of medication adherence used to medication and who were dissatisfied with
(P < 0.05) in multivariate logistic regression. Effect treatment were significantly associated with poor
of age is consistent with some other studies; for adherence. Better communication with prescribers
example, in a study from the United Kingdom, and pharmacists might solve these problems. It can
patients over the age of 50 were found to be more be noticed that a low level of adherence was not
adherent than those in the younger age groups influenced by sex or by the level of education. This
[22], and in Pakistan, subjects who were less than might reflect an important cultural behavior that
40 years old were less adherent than those older could influence the proposed strategies to improve
than 70. The highest mean adherence rate was adherence. They should cover both males and
observed in the age group 70–80 years [17]. It females from different educational levels.
seems that the people care more when they get Better communication with health-care provid-
older and/or start to have disease complications. ers and better education about the medications
This should be considered during patient counsel- and the nature of the disease can be of a great
ing; complications of hypertension in addition to value in improving patientsÕ adherence to their
risks of poor adherence to medications should be medications. Identifying patients at high risk for
explained well to patients in the younger age poor adherence can help in interventions to
groups. Living in a village compared with a city improve adherence. These interventions can be
was a reason for poor adherence also; this may educational interventions. Education may take
be related to lower levels of education or income the form of individual instruction or group classes.
in addition to difficulties in reaching doctors and Effective interventions can be behavioral
health-care facilities. Evaluating health status as approaches that use techniques such as reminders,
very good, good or poor compared with excellent memory aids, and synchronizing therapeutic activ-
was significantly associated with poor adherence. ities with routine life events (e.g., taking pills
In some studies, lower medication adherence was before you shower or after your prayers) [23].
associated with poor health-related quality of life Effective interventions seek to enhance adherence
[11]. Poor health may cause the patient to be by providing emotional support and encourage-
depressed and less satisfied with his medications. ment. It should be remembered that the applica-
Forgetting to take medication was the main reason tion of multiple interventions of different types is
for low-adherence in this study similar to other more effective than any single intervention [16].
Adherence to medications and associated factors 131

It is of utmost importance to discuss the impedi- Morisky who gave the permission for use of the
ments faced by each patient and to work together ªMMAS-8 in this study.
as partners to overcome them. It is only then that
the full benefits of adherence and the effective References
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