Patient Education and Counseling 102 (2019) 1045–1056

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review Article

Health beliefs and medication adherence in patients with

hypertension: A systematic review of quantitative studies
Huda Al-Noumania,* , Jia-Rong Wub , Debra Barksdalec , Gwen Sherwoodb ,
Esra AlKhasawneha , George Knaflb
a
College of Nursing, Sultan Qaboos University, Muscat, Oman
b
School of Nursing, University of North Carolina at Chapel Hill, NC, USA
c
School of Nursing, Virginia Commonwealth University, VA, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objective: This review synthesizes findings of quantitative studies examining the relationship between
Received 2 July 2018 health beliefs and medication adherence in hypertension.
Received in revised form 20 February 2019 Methods: This review included published studies in PubMed, CINHAL, EMBASE, and PsycINFO databases.
Accepted 22 February 2019
Studies were included if they examined beliefs of patients with hypertension. Quality of the studies was
evaluated using the Quality Assessment Tool for Systematic Review of Observational Studies.
Keywords: Results: Of the 1558 articles searched, 30 articles were included in the analysis. Most beliefs examined by
Antihypertensive medication
studies of this review in relation to medication adherence were beliefs related to hypertension severity
Beliefs
Hypertension
and susceptibility to its consequences, medication effectiveness or necessity, and barriers to medication
Medication adherence adherence. Higher medication adherence was significantly related to fewer perceived barriers
Systematic review to adherence (e.g, side-effects) was fairly consistent across studies. Higher self-efficacy was related to
higher medication adherence. Patients' beliefs and their relationship to medication adherence appear to
vary unpredictably across and within countries.
Conclusion: Clinicians should assess beliefs for individual patients. When individual beliefs appear likely
to undermine adherence, it may be useful to undertake educational interventions to try to modify them.
Practical implications: Clinicians should explore individual patients' beliefs about hypertension and blood
pressure medications, discuss their implications for medication adherence, and try to modify
counterproductive beliefs.
© 2019 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
1.1. Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
2.1. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
2.2. Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
3.1. Selection of the studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
3.2. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047
3.3. Themes on relationship between beliefs and medication adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1048
3.3.1. Beliefs about hypertension and medication adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1048
3.3.2. Beliefs about medications and medication adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1048
3.3.3. Other beliefs and medication adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051
4. Discussion and conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051

* Corresponding author at: Sultan Qaboos University, College of Nursing, P.O.

Box 66, P.C. 123, Alkhoud, Muscat, Oman.
E-mail address: hudasn@squ.edu.om (H. Al-Noumani).

https://doi.org/10.1016/j.pec.2019.02.022
0738-3991/© 2019 Elsevier B.V. All rights reserved.
1046 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056

4.1. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051

4.2. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1053
4.3. Practice implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1054
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1054
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1054
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1054

1. Introduction The same search strategy was used with other databases as well,
with Mesh and text-words appropriately modified to fit each
Hypertension (HTN) is a prevalent health concern around the database. The search was restricted to English, peer-reviewed, and
globe that affects about 40% of the world’s population aged 25 full text research articles. There were no limitations on geographical
years and older [1]. Effective HTN management, using antihyper- location, year of publication, or type of patients’ beliefs because this
tensive medications, is vital and leads to substantial improvements review aimed to identify all possible beliefs and to include all
in patients’ health outcomes (e.g., blood pressure (BP) control, possible studies matching the purpose of this review. All authors
complications risk reduction) and in cost reduction [2–4]. Despite reviewed the search strategy.
the guidelines regulating HTN management, control of BP remains
a challenge. Proper adherence to antihypertensive medications is 2.1. Eligibility criteria
only 50% or less, which contributes to poor control of BP [5].
Medication adherence is linked to several factors [6,7] that Studies were included in the review if they (a) were
require understanding before implementation of strategies to quantitative; (b) included participants with HTN taking at least
improve adherence to antihypertensive medications [8–10]. one antihypertensive medication who were 18 years (because a
Patients’ beliefs about health, illness, and treatment are significant majority of literature on HTN and medication adherence included
predictors of medication adherence in patients with various participants with a minimum age of 18 years); (c) addressed
chronic illnesses including HTN [11–16]. In treating HTN, patients’ beliefs; and (d) measured antihypertensive medication
understanding patient’s beliefs in relation to medication adher- adherence as an outcome variable. Studies were excluded if they
ence is fundamental because HTN is silent and asymptomatic in (a) were qualitative, as a review of qualitative studies was already
nature. Thus, patients might have misperceptions about HTN, its conducted [18]; (b) focused only on providers’ beliefs; or
severity, and the significance of its management [5,17,18] that (c) included subjects with concomitant morbidities in addition
could influence their adherence to medication. to HTN or had medications other than antihypertensive medi-
After a thorough search of related literature, we found two reviews cations because having concomitant morbidities will influence
focused on barriers to antihypertensive medication adherence, but patients’ perceived burdens and the severity of a disease and its
they included very limited studies concerning beliefs as possible management [28] and the focus of this review was to identify
barriers [19,20]. Another review focused on examining patients’ HTN-related beliefs in specific.
beliefs on HTN and medication adherence [18]; however, this was a
review of qualitative studies and excluded findings from quantitative 2.2. Review process
studies. Over the past decades, several quantitative studies have found
that various beliefs held by patients influence medication adherence All retrieved articles were organized and screened using a
[21–26]; nevertheless, we identified no reviews summarizing and Microsoft Excel spread sheet and Refworks reference management
synthesizing these studies’ findings. software. After removing duplicates, articles’ titles and abstracts
were assessed for eligibility. Then, the full-text articles were
1.1. Aim screened and data of the eligible articles were extracted into a
table. Extraction of the data was based on the following categories:
This systematic review of quantitative studies aimed to identify authors, theory, sample size and population, mean age and gender,
different HTN-related health beliefs and to examine their types of beliefs, adherence measure, and findings. Quality of the
relationship to medication adherence. The examination of the studies was evaluated using the Quality Assessment Tool for
relationship between different patients’ beliefs and adherence to Systematic Review of Observational Studies (QATSO) checklist
antihypertensive medications among patients with HTN will guide [29], which was slightly modified to fit the review (Table 1). The
the development of effective and customized strategies to enhance QATSO consists of items to assess external validity, bias and
medication adherence by incorporating patients’ specific beliefs confounding, and measures’ validity/reliability. Total quality score
into patient-centered treatment plans. is the total score divided by total number of items multiplied by 100.
We referred to studies as bad (0–33%), Satisfactory (34–66%), and
2. Methods good (67–100%) quality (Appendix 1). Relevant articles were not
excluded based on quality evaluation because the purpose of the
The Preferred Reporting Items for Systematic Reviews and review was to identify as many beliefs as possible. Articles screening,
Meta-Analyses (PRISMA) guidelines was used to guide the review review, and quality evaluation was done by the first author (HA) and
[27]. The search, in collaboration with a librarian, included articles verified by the second author (JRW).
published from 1980 to end of November 2018, retrieved from PubMed,
CINHAL, EMBASE, and PsycINFO databases. To retrieve appropriate 3. Results
articles, the following Medical Subject Headings (Mesh) and text-
words were used in PubMed: adherence [tw] OR compliance [tw]) AND 3.1. Selection of the studies
(attitude*[tw] OR belief*[tw] OR perception*[tw] OR perceiv*[tw] OR
psychosocial [tw]) AND ("Antihypertensive Agents"[Mesh] OR "Antihyper- The electronic search yielded 1558 articles (Fig. 1). After
tensive Agents" [Pharmacological Action] OR antihypertensive agent*[tw] removing duplicates (n = 383), 1175 articles remained. Of these,
OR medication*[tw]) AND (hypertension [tw] OR hypertensive [tw]. 924 articles were excluded after title and abstract screened
 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056 1047

Table 1
Quality Assessment of the studies included in the review.

Authors / Pub Year Sampling Response Rate Adherence Measure Adherence Measure Control of Total Quality
Method mentioned validity and Reliability (Objective, self-report,) Confounding Percentage* Score**
factors
Adidja, et al. [35] Probability No Yes self-report Yes 50% Satisfactory
Al-Noumani, et al. [46] Non- No Yes self-report Yes 33% Bad
probability
Alison,et al. [78] Non- No Yes Objective Yes 60 % Satisfactory
probability
Bane et al., [49] Non- No Yes Objective Yes 60 % Satisfactory
probability
Brown & Segal [36] Probability Yes Yes self-report Yes 80 % Good
Chen et al [50] Non- No Yes Objective Yes 60 % Satisfactory
probability
Daniell & Veiga [58] Non- No No self-report NA 0% Bad
probability
Dennis et al [37] Probability No Yes self-report Yes 60 % Satisfactory
Dijkstra et al [54] Non- No No self-report Yes 20 % Bad
probability
Fernandez-Arias et al [57] Non- No Yes self-report Yes 40 % Satisfactory
probability
Gilbert et al [61] Non- Yes Yes Objective NA 75 % Good
probability
Hall et al [52] Non- No Yes self-report Yes 40 % Satisfactory
probability
Hassan et al, Non- Yes Yes self-report Yes 60 % Satisfactory
[44] probability
Haynes et al, [33] Probability Yes Yes Objective No 80 % Good
Hershey et al, [38] Probability Yes No self-report Yes 60 % Satisfactory
Hong et al [39] Probability No Yes self-report Yes 60 % Satisfactory
Hsu et at [51] Non- No Yes self-report NA 25 % Bad
probability
Kamran et al, [40] Probability No Yes self-report Yes 60 % Satisfactory
Khan et al., [59] Non- No Yes self-report NA 25 % Bad
probability
Larki et al., [47] Non- No Yes self-report Yes 33% Bad
probability
Morisky et al, [62] Probability Yes Yes self-report Yes 80 % Good
Olowookere et al, [41] Probability No Yes Objective NA 75 % Good
Patel & Taylor [64] Non- Yes Yes self-report No 40 % Satisfactory
probability
Peltzer [60] Non- No Yes self-report No 20 % Bad
probability
Richardson et al, [55] Non- No Yes self-report Yes 40 % Satisfactory
probability
Schoenthale et al., [34] Probability Yes Yes self-report Yes 67% Good
Trevino et al, [63] Non- No Yes self-report Yes 40 % Satisfactory
probability
Ungari & Fabbro [42] Probability No Yes self-report No 40 % Satisfactory
Wong et al, [56] Non- Yes No self-report Yes 40 % Satisfactory
probability
Yang et al., [48] Probability No Yes self-report Yes 50% Satisfactory

Note: NA = Not Applicable.

*Scoring: Total score (0/1) divided by total number of items multiplied by 100.
**Bad = 0–33%; Satisfactory = 34–66%; Good =. 67–100%

applying inclusion and exclusion criteria. The remaining 251 full
text articles were further screened for eligibility. Of these, 221
articles were excluded because these articles: (a) included subjects
who had other comorbidities in addition to HTN (n = 92); (b) did
not address patients’ beliefs (n = 27); (c) did not measure
medication adherence or measured adherence to other therapeutic
behaviors (e.g., diet and exercises) (n = 53); (d) measured adher-
ence of medications other than antihypertensive (n = 8); (e) did not
measure adherence as an outcome variable (n = 8); or (f) were
qualitative studies (n = 7). The remaining 30 studies were included
in the systematic review.
Methodological quality evaluation of the studies revealed that
77% (n = 23) of the reviewed studies scored from satisfactory to good
(Table 1). Although 87% (n = 26) of the studies reported validity and
reliability of the adherence measures, majority of them used only
self-reporting measures (n = 24), and the remaining used either
objective measure only, or both. However, self-report measures, such
as Morisky Medication Adherence Scale (MMAS), have been
correlated with other objective measures such as pharmacy refills
and the Medical Events Monitoring System (MEMS) [30–32].
Moreover, majority of studies used non-probability sampling
(n = 18), which could limit the studies’ external validity.
3.2. Study characteristics
The 30 studies reviewed appeared from 1980 2018 (Table 2).
The studies’ sample sizes ranged from 45 to 1367 participants with a
total of 8414 participants. The samples represented people from the
following countries: Canada (n = 1), Brazil (n = 2), South Africa (n = 1),
Northern Ireland (n = 1), Malaysia (n = 1), the Netherlands (n = 1),
Taiwan (n = 1), India (n = 1), Peru (n = 1), Iran (n = 2), the United
Kingdom (n = 1), Australia (n = 1), Nigeria (n = 1), Oman (n = 1), China
(n = 1), Cameroon (n = 1) and the United States (n = 12). Studies from
the United States included the following ethnicities: White
1048 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056
Fig. 1. Flow diagram of selection process for study inclusion.
American, Black/African American, Native American, Hispanic,
Chinese American, and Caucasian. The mean age of participants
included in the studies ranged from 42 75 years old.
Twenty-eight studies, (93%), had cross-sectional designs, and only
two studies had a longitudinal design [33,34]. Of the 30 included
studies,11 included a randomized sample [31,33–42]. The majority of
the studies used one measure to assess medication adherence, one
study used three measures (i.e., medication event monitoring system,
Morisky medication adherence scale (MMAS), and the medication
adherence report scale) [43], and another study used four measures of
medications adherence (i.e., pill counts, serum uric acid, urinary
chlorthalidone, and self-reports) [33]. Self-report measures were
used by 28 studies; of these, the MMAS was used in 13 studies. Forty
percent of studies (n = 12) used a theoretical model: the health beliefs
model (n = 7) [36,40,44–48], self-efficacy and the theory of planned
behavior (n = 1) [49], self-regulation model (n = 1) [50], medication
adherence model (n = 1) [51], commonsense self-regulation model
(n = 1) [43], and ecological system theory (n = 1) [52].
3.3. Themes on relationship between beliefs and medication adherence
Findings of this review were categorized based on belief types:
(a) beliefs about hypertension; (b) beliefs about antihypertensive
medications; and (c) other patient-related beliefs (Table 3) and
how these beliefs related to antihypertensive medication
adherence (Table 4).
3.3.1. Beliefs about hypertension and medication adherence
Twelve studies (40%) examined beliefs about the severity of
HTN and susceptibility to HTN complications in relation to
antihypertensive medication adherence. Beliefs about severity of
HTN, which are patients’ perceptions about the seriousness of HTN
were reported in ten studies; five studies found that stronger
beliefs about HTN severity was significantly related to higher
medication adherence [33,40,47,48,53] whereas five studies
reported no relationship [36,38,44–46].
Patients’ beliefs regarding their susceptibility to HTN compli-
cations were reported in eight studies and revealed mixed findings.
Two studies reported that as patient believe that they are at higher
risk of complications, they significantly demonstrated higher
medication adherence [40,54]. One study found that as that as
patient believe that they are at higher risk of complications, they
significantly demonstrated lower medication adherence [50], and
five studies reported no relationship [36,38,44,45,47].
3.3.2. Beliefs about medications and medication adherence
Twenty studies (67%) reported perceived barriers to taking
antihypertensive medications and beliefs about medications
Table 2
Characteristics of the studies.

Authors/Year
Adidja et al., [35]
Al-Noumani et al., [46]
Alison Phillips, et al. [78]
Theory Used Design Sample size (n) Population Mean Age Beliefs Type Measure of Beliefs Medication Adherence Measure
Gender
(Female)
None Cross-sectional n = 183 Cameroon M=60 65% (F) Efficacy of medication 1-item self-report question Morisky Medication Adherence
Scale *
HBM Cross-sectional n = 45 Oman M=52 64% (F) Severity of disease Beliefs about Medicine Morisky Medication Adherence
Effectiveness of medication Questionnaire Scale *
Concerns of medication Brief Illness Perception
Medication adherence self- Questionnaire
efficacy Revised Medication
Adherence Self-Efficacy Scale
Commonsense self- Cross-sectional n = 71 White, Africa-American, M=68 63% (F) Necessity of medications Illness perception Medication Event Monitoring
regulation model Asian, Native American, Hispanic questionnaire System*
Beliefs about Medicine Morisky Medication Adherence

H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056

Questionnaire Scale *
Medication Adherence Report
Scale *
Bane et al, [49] Self-efficacy Theory of Cross-sectional n = 139 Northern Ireland M= 52 Perception of self-efficacy 1. Self-efficacy scale 1. Self-report
planned behavior 50% (F), Perception of subjective 2. Theory of Planned 2. Patient medication report*
norms Behavior questionnaire
Brown & Segal [36] HBM Cross- sectional n = 300 African-American/White M= 60 Perception of susceptibility 1. Health belief model 1. Self-report*
Americans 56% (F) Perception of severity questionnaire
Benefits of medication
Cost of medication
Side-effects of medication
Chen et al, [50] Self-Regulation Cross- sectional n = 277 M=66 Illness perception Illness perception The Medication Adherence
model Taiwanese 40% (F) Self-efficacy (Treatment questionnaire Inventory*
and personal control)
Daniell & Veiga, [58] None Cross-sectional n = 69 Brazilian M=64 67% (F) Side effects of medication Self-report about Instrument to Evaluate Attitudes
Cost of medication environmental and personal Regarding Taking Medications
Doctor-patient factors
communication
Dennis et al, [37] None Cross sectional n = 608 Urban Indian M=58 49% (F) Medication barriers Brief Medication Brief Medication Questionnaire *
Cost Questionnaire
Dijkstra et al, [54] None Cross-sectional n = 176 Netherlands M= 62 52% (F) HTN severity 1-item self-report question 1. Self-report (1-item)
Fernandez-Arias et al, [57] None Cross-sectional n = 115 Peru M=62 67% (F) Medication harm 1. Beliefs about Medicine 1. Morisky Medication Adherence
Medication Concern Questionnaire Scale (8-items)*
Medication Necessity
Gilbert et al, [61] None Cross-sectional n = 110 Australian M= 59 55% (F) Self-efficacy 5-point scale self-report Prescription re-fill*
Self-report of consumption
Hall et al, [52] Ecological System Cross-sectional n = 45 Hispanic 28-60 56% (F) Perceived stress 1. Perceived Stress scale 1. Morisky Medication Adherence
Theory Scale (8-items)*
Hassan et al, [44] HBM Cross-sectional n = 240 Malaysian M= 55 50% (F) Severity of HTN 1. 35-items self-report 1. Self-report*
Susceptibility to HTN questionnaire
consequences
Barriers (complex regimen,
cost)
Haynes et al, [33] None Longitudinal/ 6 n = 134 Canadian M= 42 100% Medication safety Self-report measure Pill count*
months follow-up (M) Medication benefits Serum Uric acid and potassium
HTN seriousness determination*
Urinary chlorthalidone and
hydrochlorothiazide*
Self-report
Hershey et al, [38] None Cross-sectional n = 132 92% Black and white M= 52 61% (F) Susceptibility Self-report measure Self-report
Americans Severity of HTN
Benefits of medications

1049
Concerns about health
 1050
Table 2 (Continued)
Authors/Year Theory Used Design Sample size (n) Population Mean Age Beliefs Type Measure of Beliefs Medication Adherence Measure
Gender
(Female)
Control over HTN
Dependence on the
provider
Barriers
Hong et al, [39] None Cross-sectional n = 588 White/African American M= 63 2% (F) Barriers (side-effects, Nine-items Measure 1. Self-report (Morisky 4-items)*
complex regimen, Health locus of control Scale
forgetting)
Internal locus of control
Hsu et al, [51] Medication Cross-sectional n = 94 Chinese American M = 75 Necessity and effectiveness The Adherence factor Hill-Bone Compliance*
Adherence Model 63% (F) of medication questionnaire The Adherence Factor
Side-effects medication Questionnaire*
Safety

H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056

Kamran et al., [40] HBM Cross-sectional n = 671 Iran >30 75% (F) Severity of HTN Health belief model 1. Morisky Medication Adherence
Susceptibility to HTN questionnaire Scale (4-items)*
consequences
Benefits of medications
Barriers
Self-efficacy
Khan et al., [59] None Cross-sectional n = 200 UK >18 62% (F) Side-effects 1. 1-item question 1. Morisky Medication Adherence
Scale (4-items)*
Larki, et al., [47] HBM Cross-sectional N = 152Iran M= 57 72% (F) Severity of HTN 39-items questionnaire Hypertension self-care activity
Susceptibility to HTN level effects (H-Scale)*
consequences
Benefits of medications
Barriers
Self-efficacy
Morisky et al., [62] None Cross-sectional n = 1367 American M= 62 59% (F) Health status Attitude toward Self-report (Morisky 4-items, & 8-
Social support Hypertension items)*
Stress Social support scale Blood pressure
4-items stress scale
Olowookere et al, [41] None Cross-sectional n = 420 Nigerian M= 61 51% (F) Family Support Perceived social support 1. Bill count*
family scale
Patel & Taylor, [64] None Cross-sectional n = 102 80% white M = 59 60% (F) Control over HTN 4-items scale 1. Self-report (Morisky 4-items)*
Peltzer, [60] HBM Cross-sectional n = 100 South African M=61 Benefits of medication Health belief model scale 1. Self-report on adherence*
67% (F) Side effects & cost of
medication
Severity of HTN
Susceptibility to HTN
consequences
Richardson et al, [55] None Cross-sectional n = 197 American M= 54 68% (F) Barriers Net barriers score Self-report*
Provider interview
Schoenthaler et al., [34] None Longitudinal N = 593 Black/African American M=58 63% (F) Self-efficacy Behavior specific scale Morisky Medication Adherence
study Scale *
Trevino et al., [63] None Cross-sectional n = 109 American M= 50 58% (F) Marital adjustment and 32-item dyadic adjustment 1. Self- report
function scale
Ungari & Fabbro, [42] None Cross-sectional n = 109 Brazilian > 20 yrs 84% Trust in doctors Self-report questions Morisky Medication Adherence
(F) Scale (4-items)*
Wong et al., [56] None Cross-sectional n = 323 Hmong American M=58. 60% (F) HTN preventable Self-report questions self-report
Side-effects
Yang et al., [48] HBM Cross-sectional n = 745Chinese M=56. 54% (F) Self-efficacy Self-report questionnaire Morisky Medication Adherence
Severity of hypertension Scale *
Barriers to medications

Note: HBM = Health Belief Model; M = Mean age; F = Female.

* Reliability and validity reported.
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Table 3
Beliefs Definitions.

Belief Definition
Susceptibility Perception about susceptibility to HTN complications
Severity Perception about seriousness of HTN
Illness control Perception about effectiveness of antihypertensive medications to control BP
Illness burden Individual believes on illness-related discomfort
Necessity Individual believes on importance of medication to manage illness
Benefits Individual believes on benefits of taking medication or action
Side effects Individual believes on undesirable/harmful effects of medication
Treatment control Individual believes on curability of illness by medication
Self-efficacy Individual believes on his/her ability to successfully manage illness
Spirituality Individual believes spiritual practice guide medication taking and relief illness and side-effects
Subjective norms Individual believes on the importance to take medication because significant others believe on its importance.

effectiveness/benefits, safety, and necessity. Perceived barriers to
taking medications were reported by 16 studies; of these, 12
studies found that stronger beliefs in barriers to taking medi-
cations such as medications’ side effects, high cost, bad taste, and
harmful effects, were significantly associated with lower medica-
tion adherence [36,38–40,44,48,55–60]. However, four studies
reported no relationship between beliefs concerning side effects of
medication and medication adherence [46,47,51] or between
medication cost and medication adherence [37].
Additionally, of 11 studies examining beliefs about effective-
ness, necessity, and safety of medications, seven examined the
relationship between medications’ effectiveness/benefits and
medication adherence; of these, two studies reported that stronger
beliefs about the effectiveness of antihypertensive medications
were associated with higher medication adherence [40,60] and
five studies found no relationship [33,35,36,38,47]. Of the five
studies examining beliefs about medications’ necessity and safety,
only two showed that higher adherence is related to higher
perceived medication necessity [46] and safety [33].
3.3.3. Other beliefs and medication adherence
Fifteen studies examined other beliefs in relation to antihyper-
tensive medication adherence. These studies reported that higher
adherence was related to (a) higher self-efficacy, patients’ beliefs
about their own capabilities to perform a certain behavior (n = 7)
[34,40,46,48–50,61]; (b) higher internal locus of control, (i.e., the
degree to which people believe that their health status is
influenced by their own behavior (n = 1) [39], (c) higher subjective
norms (i.e., beliefs that taking medications is important because
significant others believe it is important (n = 1) [49]; (d) perceived
good general health (n = 1) [62]; (e) perceived good relationship
with health care providers (n = 2) [38,42]; (f) perceived good
relationship with spouses (i.e., marital function) (n = 1) [63];
(g) perceived good control over HTN (n = 1) [38]; and (h) perceived
strong family support (n = 1) [41]. However, medication adherence
was lower with more perceived stress (n = 1) [62] and in another
study, with control over HTN (n = 1) [64]. Other studies reported no
relationship between adherence and perceived stress (n = 1) [52],
perceived general concerns about health (n = 1) [38], and Self-
efficacy (n = 1) [47].
4. Discussion and conclusion
4.1. Discussion
This review identified 30 quantitative studies examining the
relationships between different patients’ beliefs and medication
adherence among patients with HTN. The review identified that
beliefs about medications, beliefs about HTN, and self-efficacy are
the commonly reported and studied beliefs in relation to
antihypertensive medication adherence. This review also showed
that Health Belief Model is the most commonly used theoretical
framework to guide studies' design, questions, measures, and
discussion.
Majority of the studies examining beliefs about medications
(12 out of 16) found a negative association between barriers to
taking medications and medication adherence; these findings are
similar to those of other reviews conducted among patients with
HTN and other chronic diseases [16,18,19,65]. Additionally, our
findings are consistent with those of studies included in the meta-
analysis by Horne and colleagues [14], who found that medication
adherence was significantly higher in patients with fewer concerns
regarding medications’ side effects and safety. Findings from this
review and others underline the importance of assessing patients’
perceived barriers to medication adherence (e.g., side effects) to
identify the best strategies for educating patients regarding
medications and enhancing medication adherence. Of these 12,
only one study have considered type of antihypertensive
medications used by patients [55]; however this study reported
no association between type of medication and adherence. Type of
medication in relation to adherence could be considered by future
researchers examining barriers and concerns related to antihyper-
tensive medication because barriers to adherence could vary
across medication type.
Majority of studies (73%) in our review reported no relationship
between beliefs about medication necessity, effectiveness, and
safety and medication adherence; this finding is inconsistent with
Horne and colleagues’ [14] who reported that medication
adherence was higher among those who believe that medications
are effective, necessary, and safe. The inconsistency in findings
could be explained by: (a) variation in measures of beliefs about
medications as studies of this review include different types of
beliefs measures such as (BMQ, Health beliefs model question-
naire, Brief Medication questionnaire, the adherence factor
questionnaire, other self-report questionnaires) (Table 2), while
Horne’s review included studies that only used the Beliefs About
Medicine Questionnaire (BMQ); (b) differences in symptoms
experienced by patients, as their review included more than 22
different chronic conditions (e.g., cancer, diabetes, HIV, asthma,
and depression) that have more evident and severe symptoms than
HTN, which could influence patients’ beliefs about disease and
medication adherence differently; and (c) difference in total
sample size included because Horne’s review included a total
sample size of 25,072 compared to 8414 in the current review;
therefore, Horne’s review could had more power to detect a
relationship between some beliefs and medication adherence.
Seven studies in this review reported that stronger beliefs about
severity of HTN and their susceptibility to its complications is
related to higher medication adherence, which is consistent with
the findings of other reviews examining barriers to medication
adherence among patients with HTN [19], patients with chronic
conditions [16], and elderly patients [6]. Moreover, six other
1052 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056

Table 4
Findings of studies in the review.

1. Beliefs about hypertension

Severity Haynes [33] * Positive association Higher perceived seriousness of HTN is related to higher
Kamran [40] *** medication adherence.
Larki [47]*
Wong [56] ***
Yang [48] **
Al-Noumani [46] No association Perceived seriousness of HTN is not related to
Brown [36] medication adherence.
Hassan [44]
Hershey [38]
Peltzer [60]
Susceptibility Dijkstra [54]* Positive association Higher perceived susceptibility to HTN/ complications is
Kamran [40]** related to higher medication adherence.
Brown [36] No association Perceived susceptibility to HTN/ complications is not
Hassan [44] related to medication adherence.
Hershey [38]
Larki [47]
Peltzer [60]
Chen [50]* Negative association Higher perceived susceptibility to HTN/ complications is
related to lower medication adherence.
2. Beliefs about Anti-hypertensive Medications
Barriers: Brown [36]* Negative association More perceived barriers to taking medications are
Side-effects Daniell [58]# related to lower medication adherence.
Taste Fernandez-Arias [57]**
Cost Hassan [44]**
Harm Hershey [38]*
Hong [39]***
Kamran [40]***
Khan [59]#
Richardson [55]*
Peltzer [60]***
Wong [56]*
Yang [48] ***
Al-Noumani [46] No association Perceived barriers to taking medications are not related
Dennis [37] to medication adherence.
Hsu [51]
Larki [47]
Benefits/Effectiveness Kamran [40]** Positive association Higher perceived effectiveness of antihypertensive
Peltzer [60]** medications is related to higher medication adherence.
Adidja [35] No association Perceived medication effectiveness is not related to
Brown [36] medication adherence.
Haynes [33]
Hershey [38]
Larki [47]
Necessity Alison [78] No association Perceived medication Necessity is not related to
Fernandez-Arias [57] medication adherence.
Hsu [51]
Al-Noumani [46]* Positive association Higher perceived necessity of antihypertensive
medications is related to higher medication adherence.
Safety Haynes [33]* Positive association Higher perceived safety of medication is related to
higher medication adherence.
Hsu [51] No association Perceived medication safety is not related to medication
adherence.
3. Other Beliefs
Self-efficacy Al-Noumani [46]* Positive association Higher self-efficacy is related to higher medication
Bane [49]*** adherence.
Chen [50]**
Gilbert [61]#
Kamran [40]***
Schoenthaler [34]***
Yang [48]***
Larki [47] No association Perceived self-efficacy is not related to medication
adherence.
Internal locus of control Hong [39]* Positive association Higher Internal locus of control is related to higher
medication adherence.
Patient- provider communication Hershey [38]* Positive association Higher self-efficacy is related to higher medication
Ungari [42]* adherence.
Control over HTN Hershey [38]* Positive association Higher perceived control over HTN is related to higher
medication adherence.
Patel [64]** Negative association Higher perceived control over HTN is related to Lower
medication adherence.
Stress Morisky [62]* Negative association Higher perceived stress is related to lower medication
adherence.
Hall [52] No association Perceived stress is not related to medication adherence.
Marital Adjustment Trevino [63]** Positive association Perception of good marital relationship is related to
higher medication adherence.
Family support Olowookere [41]*** Positive Association Stronger perception of family support is related to
higher medication adherence
 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056
Subjective Norms Bane [49]**
General health status Morisky [62]*
Concern about health Hershey [38]
Note: * p-value  .05 ** p-value  .01 *** p-value  .001 # used only descriptive statistics.
studies of our review reported no association and one found a
negative relationship. These mixed findings could be related to the
influence of culture on how people view illness causality, severity,
and susceptibility to complications, especially because HTN is
silent in nature. In our review, studies that examined these beliefs
represented people from different countries with different cultural
backgrounds (e.g., Canada, Brazil, South Africa, Northern Ireland,
Malaysia, the Netherlands, Taiwan, India, Peru, Iran, the United
Kingdom, Australia, Nigeria, Oman, Cameroon, China, and the
United States) that might perceive HTN differently. For instance,
adherence to antihypertensive medications was lower among
Hmong Americans who attributed HTN to bad deeds [56] and
Chinese who attributed HTN to cultural causality (e.g., imbalance
between internal and external environment [50]. Accordingly,
researchers need to explore and examine how patients' culture
could influence their beliefs regarding HTN causality and severity,
which as a result influence their adherence behavior. Exploring
these beliefs will support healthcare providers to understand
individual beliefs and design proper educational program related
to HTN and its management to improve medication adherence.
Another reason for the mixed findings could be attributed to
variation in measures of beliefs used; although studies measuring
these beliefs used self-report measures, these measures vary in-
term of items, validity, and reliability.
In this review, higher self-efficacy was significantly related to
higher medication adherence, as reported in seven studies from
Northern Ireland, Australia, Taiwan, Oman, China, the United States
and Iran [34,40,46,48–50,61]. Our review is consistent with
findings from current literature among patients with hypertension
in addition to other chronic illness (e.g., diabetes, arthritis, and
cancer) [16,65,66]. Within the context of HTN, higher self-efficacy
is also associated with higher adherence to other self-care
behaviors related to diet, exercise, weight, and smoking [67–69].
Several studies showed improved medication adherence and self-
care activities when self-efficacy was incorporated as a key
element in interventions such as mobile text message, health
education, counseling, and motivational interviewing [70–73]. This
indicates that self-efficacy is a critical element in behavioral
changes and plays a significant role in medication adherence
irrespective of different diseases or populations, signifying the
necessity to empower self-efficacy across different populations to
enhance adherence to antihypertensive medications [74–76].
Overall, studies included in this review showed that findings vary
in addressing the relationship between different beliefs and
medication adherence. While some studies found a positive or a
negative relationship, others reported no relationship. This variation
in findings could be explained by heterogeneity in (a) cultural
backgrounds of populations from 17 countries that might hold
different beliefs related to disease causality and treatment; (b)
sample size, which ranged from 45 to 1367 participants; (c) age,
which represented a mean age ranging from 42 75 years old; and
(d) defining and measuring medication adherence because adher-
ence was defined differently as numbers of pills taken per month
using a patient report [60], as a total score  75% on a self-report
questionnaire [44], or as a total score of 4 using MMAS-4 [40].
Therefore, variations in findings suggest that beliefs might vary
across age groups, populations, and cultures indicating the need to
understand different beliefs and how these beliefs could influence
1053
Positive association Subjective norms are related to higher medication
adherence.
Positive association Perception of good general health status is related to
higher medication adherence.
No association Perceived concern about health is not related to
medication adherence.
medication adherence differently. Therefore researchers and clini-
cians need to consider these variations in beliefs to design successful
interventions sensitive to age and culture to improve adherence.
Although this review excluded qualitative studies, however, our
findings were consistent with a another systematic review of
qualitative study by Marshall (2012), which recommended that
clinicians and researchers need to understand patients individual
perspective on HTN and its management to improve medication
adherence [18]. Therefore, it is worth noting that despite
inconsistencies in findings across cultures, patients' knowledge
about HTN and medications and their perspectives on importance
of HTN management should be evaluated by clinicians for any
individual patient; this will allow clinicians to link patients'
specific beliefs with their perspectives and to plan more accurate
educational intervention to improve medication adherence.
These findings should take into consideration the following
limitations of the studies reviewed. First, the majority of the
studies used cross-sectional design with non-probability sampling,
which limits causal relationships and generalizability of the
findings to populations with HTN. Additionally, a majority of
studies used self-report measures of medication adherence, which
could introduce recall bias and overestimation of medication
adherence. These studies also used different cut-off points for
medication adherence versus non-adherence. Therefore, future
studies should focus on measuring adherence using more objective
measures and a longitudinal design to assess long-term adherence
behaviors and changes over time. This review is subject to several
limitations inherent in systematic review. This review is at risk for
selection and reporting bias due to the possibility of missing some
relevant studies, as this review was limited to English full-text
studies retrieved from four electronic databases. Therefore, non-
English studies, books, dissertations, and studies obtained
manually or through reference lists were not included. Addition-
ally, Qualitative studies have not been included, which could reveal
additional findings related to beliefs and medication adherence.
Furthermore, this review was limited to patients with HTN who did
not have any concomitant comorbidity or complications from HTN,
which should be considered when dealing with patients having
other comorbidities in addition to HTN. However, findings of this
review emphasize that even with uncomplicated HTN, patients’
beliefs play a role in medication adherence. Compared to those
with significant findings, some studies with no association might
not been published in the peer-reviewed journals included in the
databases’ searches, leading to a publication bias. Finally, studies of
poor quality were included in reporting this review’s findings.
4.2. Conclusion
This review sought to systematically synthesize findings of
quantitative studies examining the relationship between individ-
ual health beliefs held by patients with HTN and antihypertensive
medication adherence. The findings of this review emphasize the
importance of assessing individual beliefs, particularly perceived
barriers and self-efficacy, to incorporate them while designing
strategies to improve medication adherence. Our recommenda-
tions support the conclusion of Atreja who reviewed the proven
strategies to improve adherence " SIMPLE", which categorized
strategies into six categories, of which, improving knowledge,
1054 H. Al-Noumani et al. / Patient Education and Counseling 102 (2019) 1045–1056

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