Antihypertensive Medication Adherence and Associated Factors

among Hypertensive Patients at Zewditu Memorial Hospital,

Addis Ababa, Ethiopia, 2023

By: Agizew Yitagesu

Advisor:

February 2023

Addis Ababa, Ethiopia

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Table of Contents

1. Introduction.........................................................................................................................2

1.1 Background.......................................................................................................................2

1.2 Statement of the Problem.................................................................................................4

1.3 Justification.......................................................................................................................5

1.4 Significance of the Study..................................................................................................6

2. Literature Review...............................................................................................................6

2.1 Prevalence of Anti-hypertensive Medication Adherence.................................................6

2.2 Factors Associated with Antihypertensive Medication Adherence..................................7

2.2.1 Socio-Demographic Factors......................................................................................7

2.2.2 Individual Factors......................................................................................................9

2.2.3 Clinical Factors........................................................................................................10

2.2.4 Healthcare System Related Factors.........................................................................11

2.3 Conceptual Framework..................................................................................................12

3. Objectives.........................................................................................................................13

3.1 General Objective...........................................................................................................13

3.2 Specific Objectives.........................................................................................................13

4. Methods............................................................................................................................14

4.1 Study Design, Area and Period......................................................................................14

4.2 Population.......................................................................................................................14

4.2.1 Source Population....................................................................................................14

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 4.2.2 Study Population......................................................................................................15

4.3 Inclusion and Exclusion Criteria....................................................................................15

4.3.1 Inclusion Criteria.....................................................................................................15

4.3.2 Exclusion Criteria....................................................................................................15

4.4 Study Variables..............................................................................................................15

4.4.1 Dependent Variable.................................................................................................15

4.4.2 Independent variables..............................................................................................15

4.5 Sample Size Determination and Sampling Method........................................................16

4.5.1 Sample Size Determination.....................................................................................16

4.5.2 Sampling Technique................................................................................................16

4.6 Data Collection Tools.....................................................................................................16

4.7 Data Quality Assurance..................................................................................................17

4.8 Data Processing and Analysis........................................................................................17

4.9 Ethical Considerations....................................................................................................17

4.10 Result Dissemination Plan............................................................................................18

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1. Introduction

1.1 Background

Hypertension (HTN) (elevated blood pressure (BP)) is defined as systolic BP equal to or

greater than 140 mm Hg and/or diastolic BP equal to or greater than 90 mm Hg. It is a serious

global public health problem, attributed to heart, brain and kidney disease and leading to

heart attacks and strokes. HTN is considered a major cardiovascular risk factor as well as a

major contributor to global deaths. In addition, it is also the leading cause of premature death

worldwide. According to the World Health Organization (WHO), more than 80% of deaths

from hypertension and associated cardiovascular disease (CVD) now occur in low- and

middle-income countries, and this is particularly common among people of low

socioeconomic status. Optimal BP control is paramount to prevent hypertension-related

complications and deaths. High adherence to anti-hypertensive medications can effectively

reduce hypertension-related complications and improve survival.

Medication adherence is defined as the degree to which the patient's medication behavior

conforms to agreed recommendations/prescriptions. Patients taking medication must

understand that medication is essential to achieving BP control. Many studies suggest that a

high level of adherence to anti-hypertensive medication is associated with better BP control

and reduced CVD risk. However, low adherence to anti-hypertensive medications is a major

clinical challenge in the management of hypertension in low- and middle-income countries.

Patients with poor adherence to anti-hypertensive medications are at higher risk of adverse

outcomes, including hospitalization, and have higher health care costs due to complications

compared with patients who had good adherence.

A number of factors contribute to antihypertensive treatment, including patients' beliefs about

health, illness, and treatment. In the treatment of hypertension, a fundamental understanding

is the patient's belief in medication adherence, since hypertension is silent and asymptomatic.

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Thus, patients may have misconceptions about hypertension, its severity, and the importance

of its treatment. Low socioeconomic status, low level of education, unemployment, lack of

effective family/social support, and forgetfulness are also associated with adherence. Patients'

disease manifestations also have a direct influence on adherence to antihypertensive

treatment.

Although the importance of medication adherence has been recognized by previous studies in

Ethiopia, previous studies were conducted on small numbers of patients often from a single

hospital and focused mostly only on sociodemographic factors. Important independent factors

that could influence patient adherence to treatment, such as illness perception and health

belief, have hardly been studied in Ethiopia.

1.2 Statement of the Problem

Globally, 45.3% of hypertensive patients do not adhere to their anti-hypertensive treatment,

with non-adherence rates reported as high as 62.5% in African hypertensive patients. A

comprehensive meta-analysis showed that nearly half (45.2%) of hypertensive patients were

non-adherent to their anti-hypertensive medication and 83.7% of patients had uncontrolled

BP. In developing countries, the prevalence of medication non-adherence among

hypertensive patients ranged from 23% to 67.6% with a mean of 47.34%.

In 12 sub-Saharan African countries, only 35.6% of hypertensive patients are adherent, but

64.4% of hypertensive patients have low adherence to anti-hypertensive medications, with

different distributions of adherence levels between countries, ranging from 15% in Senegal to

55.2% in Democratic Republic of Congo. Various studies in different regions of Ethiopia

show that the prevalence of adherence to anti-hypertensive medication ranges from 32% to

69%. In Ethiopia, studies conducted in Adama and Gonder showed that the level of

adherence to anti-hypertensive treatment was 59.9 and 64.6%, respectively.

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There are various factors that influence the level of adherence of hypertensive patients to

anti-hypertensive medications. Knowledge about HTN and its treatment, demographics,

treatment beliefs, patient-provider relationship, and support provided by health services are

factors that influence treatment adherence among hypertensive patients. Various studies have

also reported that socio-demographics; drug reimbursement, level of BP control, drug side

effect, presence of comorbidity; knowledge about HTN and its treatment was identified as a

reason for non-adherence to hypertension medication.

Poor adherence to anti-hypertensive medications can lead to sub-optimal blood pressure

control and lead to additional health and psycho-social complications, reduced quality of life

and waste of healthcare resources, posing a potential burden on the healthcare system. In

addition, poor adherence to anti-hypertensive drugs can lead to long duration of treatment,

unnecessary over-prescription of drugs, substantial worsening of diseases, unnecessary

increase in the number of hospitalizations, longer hospital stays, leading to a significant

health burden, especially in low-income countries. For example, studies conducted in various

hospitals in Ethiopia including Tikur Anbessa Specialist Hospital in Addis Ababa, Dessie

Referral Hospital and Yirgalem Hospital revealed that 69.2%, 68.13% and 40% of patients

were non-adherent to prescribed anti-hypertensive medication. According to these reports,

hopelessness, social drug use, economic problems, forgetfulness and lack of money were the

main factors associated with non-adherence.

Identifying the factors that hinder the adherence status of patients with HTN to their

medications was an essential step for future improvements that tailor specific interventions to

improve medication adherence. Factors affecting adherence to anti-hypertensive medication

are unique to the individual patient and specific to the geographic area. Therefore, there is a

great need for research closely related to patient adherence to improve adherence to anti-

hypertensive therapy in each specific geographic area. However, there is a paucity and

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inconsistency of results regarding anti-hypertensive medication adherence and related factors

in Ethiopia, and no study has previously been conducted in this study area.

1.3 Justification

Although hypertension is a preventable disease, the availability of effective antihypertensive

medication alone has not produced the intended result. Globally, most hypertensive patients

have poor medication adherence and are less aware of associated factors, especially in

developing countries including Ethiopia. Poor adherence to their medication has a negative

impact on the quality of life of hypertensive patients and is an unavoidable challenge for

healthcare providers. Although various studies have attempted to determine the associated

factors of adherence to antihypertensive medication, the factors are not yet clearly defined

and only a few studies have been conducted to our knowledge. However, there is a paucity of

data and inconsistent results regarding adherence to antihypertensive medication and related

factors, such as the study conducted in Ethiopia earlier, and no study has been conducted in

this study area. To fill this research gap, this study aimed to assess the magnitude of

antihypertensive medication adherence and associated factors among hypertensive patients at

Zewditu Hospital, Addis Ababa, Ethiopia, 2023.

1.4 Significance of the Study

Knowledge of the prevalence of adherence to antihypertensive medication and related factors

in hypertensive patients allows health professionals and planners to establish appropriate

measures to prevent complications of hypertension, to increase the final clinical outcome and

survival status of hypertensive patients. The findings of this study will provide hypertensive

patients with information about their adherence and related factors to help prevent problems

and seek medical care early. The results of this study will also inform the Addis Ababa

Health Authority and policy makers to review or strengthen their plan for adherence to

antihypertensive medications and related factors. It would also assist policy makers in

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creating context-specific and relevant policies capable of improving hypertension

management. In addition, it will serve as an input for future researchers on related topics.

2. Literature Review

2.1 Prevalence of Antihypertensive Medication Adherence

Based on findings from different studies at different times and regions, the prevalence of

adherence to anti-hypertensive medication varies. According to the WHO report, adherence

to anti-hypertensive medication ranges from 52% to 74%, if adherence is defined as taking

the medication at least 80% of the time. It also identified non-adherence to medical care as a

major public health problem, particularly among patients with chronic conditions such as

hypertension. However, a study in 12 SSA countries revealed that there are different levels of

adherence to anti-hypertensive drugs in different countries. From the study, 30.8%, 33.6%,

35.6% of the participants were low, medium and high adherence to anti-hypertensive

medication. The distribution of adherence levels varied between countries, with the

proportion of low medication adherence ranging from 15.0% in Senegal to 55.2% in the

Democratic Republic of Congo.

Based on the results of the don study in Sirilanka, the majority of patients (84.5%) had poor

adherence to anti-hypertensive medication. In contrast, the adherence levels of hypertensive

patients from hospitals in Ghana and Nigeria and Kenya were 33.3% and 31.8%,

respectively. Various studies conducted in different regions of Ethiopia revealed that the

prevalence of adherence to anti-hypertensive treatment ranges from 32% to 69% of

participants. Studies conducted in Addis Ababa in 12 selected hospitals revealed that only

66.8% were compliant with regimens while the remaining 33.2% were non-compliant with

prescribed anti-hypertensive drugs. Similarly, studies conducted at Debire Birhan Referral

Hospital and Jima Referral Hospital revealed that adherence to anti-hypertensive medication

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was 63% and 55.5%, respectively, while 37% and 44.3% of participants were non-adherent.

In contrast to this study, a study conducted in western Ethiopia revealed that only 31.4% of

participants were adherent to anti-hypertensive medication and 68.6% were non-adherent. In

addition, studies conducted at University of Gondar Referral Hospital, Black Lion Hospital,

Northern Ethiopia and Adama Referral Hospital and Debire tabor General Hospital show that

adherence rates to anti-hypertensive medications were 64.6%, 69.2%, 52.9%, 59.5%, 75.1%,

respectively, which was lower than the expected level of compliance with WHO standards

(80%).

2.2 Factors Associated with Antihypertensive Medication Adherence

2.2.1 Socio-Demographic Factors

Numerous studies have investigated the association between demographic factors of patients

with hypertension and their adherence to treatment regimens. However, different studies in

different settings have revealed both different and complementary associations of

demographic factors with treatment adherence in hypertensive patients. For example, a study

conducted in SSA countries showed that low adherence was not significantly associated with

age and gender. However, a study conducted in Debire Birhan, North Shoa, Ethiopia shows

that age, religion, presence of family support, employment status, and presence of memory

problems were independently associated with adherence to anti-hypertensive treatment.

Similarly, a study conducted in primary health care clinics in Al-Has in the Arab region

shows that participants who were male were 20% less likely to adhere to anti-hypertensive

treatment.

Participants who were illiterate and participants whose education was primary were

significantly associated with non-adherence. A study conducted at Debire Tabor General

Hospital revealed that patients over the age of 60 were 67% less likely to adhere to their anti-

hypertensive medication compared to younger patients. A study from China shows that

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gender and residence were independently associated with adherence to anti-hypertensive

treatment. Compared to women, men were less compliant. Urban patients adhered to their

treatment plan more than patients from rural areas. Despite this, various studies have

identified the inability to afford medication costs as an important barrier to treatment

adherence, but have not shown an association of treatment adherence with income level. In

contrast to these studies, a study conducted at the Nedjo General Hospital demonstrated the

presence of an association between income level and non-adherence, with 18.51 times higher

probability of non-adherence in patients with low income than higher income. In addition, a

study conducted in SSA countries revealed that low adherence was significantly associated

with patient wealth index; patients with a lower wealth index were more likely to be less

adherent to their anti-hypertensive medications.

Various studies show that residence as one of the demographic factors affecting the level of

adherence of hypertensive patients to their treatment. A study conducted at Debire Tabor

General Hospital revealed that patients who lived in urban areas were twice as likely to

adhere to anti-hypertensive drug therapy compared to those who lived in rural areas. The

distance between the patient's residence and the medical facility that treats and monitors the

patient determines the adherence rate of hypertensive patients. A study conducted at Gondar

University revealed that as the distance of hypertensive patients' residence from the hospital

decreased, adherence to hypertension treatment improved.

2.2.2 Individual Factors

Lifestyle and Behavioral factors

A study conducted in the city of Ardabil, Iran, found that there was a significant association

of alcohol consumption and smoking with a negative effect on anti-hypertensive medication

adherence. A study conducted in Nigeria showed that exercise was significantly associated

with anti-hypertensive medication adherence. Another study conducted at Nedjo General

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Hospital revealed that hypertensive patients who have low physical activity were

significantly associated with non-adherence to anti-hypertensive medication. A study

conducted at Jimma Specialist Hospital revealed that patients who drink alcohol are 90 times

more likely to be non-adherent compared to non-drinkers.

Knowledge and Attitude towards Hypertension and its Medications

Patient knowledge about hypertension and treatment is related to treatment adherence.

Hypertensive patients who had good knowledge about HTN and its management were

approximately nine times more likely to adhere to their anti-hypertensive medication

compared with those who had poor knowledge. A study done at the University of Gondar

Hospital also revealed that the odds of adherence to anti-hypertensive treatment among

informed clients were 6 times higher than the odds of adherence among HTN patients who

had no knowledge. Similarly, a study by done in Poland revealed that hypertensive patients

with poor knowledge were less adherent than patients with good knowledge about

medications. Specifically, among patients with a low level of knowledge, there were

significantly more patients with low adherence than patients with a high level of knowledge.

A study conducted in Western Ethiopia revealed that participants who had a favorable

attitude toward anti-hypertensive treatment were ten times more likely to adhere to anti-

hypertensive medication than those who had a negative attitude.

2.2.3 Clinical Factors

Duration of Treatment

Duration of treatment is one of the clinical factors that influence the level of adherence to

antihypertensive treatment, and different literatures conducted in different settings have

revealed different findings regarding the association between adherence and duration of

treatment or diagnosis. For example, a study conducted in China revealed that the longer time

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since being diagnosed with hypertension resulted in greater adherence in hypertensive

patients. Similarly, a study conducted in north-western Ethiopia revealed that respondents

who had been taking antihypertensive drugs for three years or more were twice as likely to be

adherent to antihypertensive drugs compared to those who had been taking antihypertensive

drugs for less than three years. However, findings from a study conducted at the Black Lion

Hospital revealed that patients treated for hypertension for five years or more were 5.41 times

more likely to be non-adherent than those with less than two years of treatment.

Presence of Comorbidity

Hypertensive patients with other comorbid diseases are required to take a different type and

number of drugs for each disease, which can affect adherence. Various studies have revealed

that the presence of an association between the presence of comorbidity and adherence to

antihypertensive drugs. For example, a study conducted in Ethiopia at Jima Hospital revealed

that patients with comorbidities were 12 times more likely to be nonadherent compared to

patients without comorbidities. Consistently, a study conducted in Debire Birhan, Ethiopia

revealed that those with comorbid conditions such as heart disease were 95.4% less likely to

adhere to their antihypertensive medication. Additionally, a study conducted in western

Ethiopia shows that those participants who had no comorbidity were four times more likely to

adhere to antihypertensive medication. A study conducted in primary health care clinics in

Al-Has, an Arab region, revealed that participants who had two or more comorbidities were

30% less likely to adhere to antihypertensive treatment. A study conducted at the University

of Gondar Hospital revealed that the odds of adherence among study participants with no or

one comorbidity were 2.5 and 2.68 times higher than the odds of adherence among those with

two or more than two comorbidities.

Blood Pressure Status

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The finding of some studies indicates the presence of an association between the level of

blood pressure and the level of adherence of hypertensive patients. A study conducted at the

University of Gondar revealed that the presence of an association between the blood pressure

status of hypertensive clients and adherence to treatment and those with HTN under control

had a significantly higher chance of adherence. While uncontrolled BP and non-prescribed

medication use were independently associated with anti-hypertensive medication non-

adherence in the study.

2.2.4 Healthcare System Related Factors

Availability and Cost of Medications

A cross-sectional study in the Democratic Republic of Congo revealed that unavailability of

anti-hypertensive drugs in health facilities, insufficient education of patients with

hypertension in health facilities were associated with non-adherence to anti-hypertensive

medication. Similarly, a study conducted in Ethiopia at Jimma Specialist Hospital revealed

that those who paid for their anti-hypertensive medication were 50 times more likely to be

non-adherent. In addition, the odds of adherence to anti-hypertensive medications were 2

times higher among respondents who received free or low-cost medications compared to

those who received high-cost medications due to unavailability.

Provider-Patient Relationship

The quality of the therapeutic relationship between patients and health care providers defined

in terms of the degree of satisfaction and the degree of patient autonomy in dealing with

health care providers. Patient satisfaction with the health care provided is a sign of a good

relationship between the patient and the doctor. Researchers have found that the level of

patient satisfaction and the process of interpersonal communication in the patient-physician

relationship has a positive effect on their adherence to taking necessary medications;

however, the level of satisfaction is difficult to measure. In addition, the odds of good

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adherence to anti-hypertensive medication were 4 times higher for respondents with a good

patient-provider relationship compared with a poor patient-provider relationship. A cross-

sectional study conducted in northwestern Ethiopia shows that individuals who had a good

patient-provider relationship were four times more likely to adhere to anti-hypertensive

treatment than their counterpart.

Counseling on Medication Adherence

The health care system and health care providers such as doctors, pharmacists and nurses

play a huge role in improving patient adherence in their daily practice. A cross-sectional

study conducted in Saudi Arabia shows that individuals who were counseled by health care

providers were more adherent to their medication than patients who were not counseled by

physicians. In Kenya, individuals who were counseled by their physicians about medication

adherence were more likely to be adherent than those who abstained.

2.3 Conceptual Framework

A conceptual framework is developed after reviewing a variety of literature to demonstrate

the relationship between independent variables and antihypertensive medication adherence.

Error: Reference source not found provides a visual representation of the variables that

influence antihypertensive medication adherence.

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3. Objectives

3.1 General Objective

The general objective of this study is to assess the magnitude of antihypertensive medication

adherence and associated factors among hypertensive patients at Zewditu Hospital, Addis

Ababa, Ethiopia.

3.2 Specific Objectives

 To determine the magnitude of antihypertensive medication adherence among

hypertensive patients at Zewditu Hospital, Addis Ababa, Ethiopia.

 To identify factors associated with antihypertensive medication adherence among

hypertensive patients at Zewditu Hospital, Addis Ababa, Ethiopia.

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4. Methods

4.1 Study Design, Area and Period

An institution-based cross-sectional study will be conducted at Zewditu Memorial Hospital

from April to May 2023.

4.2 Population

4.2.1 Source Population

The source population will included all hypertensive patients on antihypertensive treatment

follow up at Zewditu memorial Hospital in Addis Ababa.

4.2.2 Study Population

All hypertensive patients on antihypertensive treatment follow up at Zewditu memorial

Hospital in Addis Ababa during the specified study period will be the study population.

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4.3 Inclusion and Exclusion Criteria

4.3.1 Inclusion Criteria

All hypertensive patients on antihypertensive treatment follow up at Zewditu memorial

Hospital in Addis Ababa will be included.

4.3.2 Exclusion Criteria

Hypertensive patients who are critically ill and unable to communicate at the time of data

collection will be excluded from the study.

4.4 Study Variables

4.4.1 Dependent Variable

Adherence of antihypertensive treatment (adhered, not adhered)

4.4.2 Independent Variables

Socio demographic characteristics: age, sex, occupational status, educational status,

religion, ethnicity, income, marital status, financial support, social life, residence.

Individual factors: substance use, physical exercise, knowledge about hypertension and

medication.

Clinical factors: duration of treatment, blood pressure control level, the presence of

comorbidity and complications.

Health system factors: availability of drugs, quality of service, cost of the medication,

provider patient relationship and counselling on medication.

4.5 Sample Size Determination and Sampling Method

4.5.1 Sample Size Determination

The sample size is determined by using a single population proportion formula (n = Z 2 P (1-

P)/d2 ) by taking 47.5 % magnitude of antihypertensive medication adherence of a study

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conducted in Addis Ababa, Ethiopia with the following assumptions: 95% CI and 5% margin

of error and by adding 10% none response rate. Where: n= sample size, Z= Z-vale at 95%

confidence level (standard of 1.96), and d = margin of error 5% or (0.05). So based on the

formula, n = 1.96 2*0.475*(1-0.475)/ (0.05)2= 383. After adding 10% to account for non-

respondents, the final sample size is 421.

4.5.2 Sampling Technique

Systematic random sampling technique will be used to recruit 422 study subjects. List of

patients with hypertension in Zewditu hospital will be taken as a sampling frame and the

respondents will be selected in every Kth interval. K = N/n; where K= sampling interval, N=

the average monthly patients with hypertension who had visited Zewditu Hospital, and n=

sample size. Then, the first patient will be selected randomly and every k th patients will be

selected. Finally, the selected patients will be interviewed.

4.6 Data Collection Tools

Data will be collected using interview-administered questionnaire and document review.

First, the questionnaire is written in English and translated into the local language (Amharic).

It is then translated into English by language experts to ensure consistency. The questionnaire

had five sections: participants' demographic characteristics, individual factors, clinical

factors, health system-related factors and antihypertensive medication adherence.

4.7 Data Quality Assurance

To assure the quality of data, a pre-test will be done on 5% of the sample in a similar setting

prior to the actual study. Two days of training on data collection tools and methods will be

given to the data collectors and supervisors. Data will be checked daily for completeness and

accuracy.

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4.8 Data Processing and Analysis

After data collection, the questionnaire will be reviewed for completeness and consistency.

Data will be entered in Epi-Info version 7 and exported to SPSS software version 26 for

analysis. Descriptive statistics will be used to calculate mean, standard deviation and

frequency. Tables and graphs will be used to present the findings. Binary logistic regression

analysis will be performed to identify variables that are significantly associated with

antihypertensive medication adherence. Then, all independent variables with P-values less

than 0.2 in bivariate analysis will be entered into multivariate logistic regression to control

confounding effects. Finally, variables with P-value less than 0.05 will be considered

significantly associated factors.

4.9 Ethical Considerations

Ethical clearance will be obtained from the Ethics Review Board of the University. An

official letter will be obtained from the University and will be communicated with Zewditu

Memorial Hospital. Participants will be asked to voluntarily participate in the study and will

be informed that they had the right to withdraw from the study at any time without notice.

Data will be collected only after briefly explaining the purpose of the study and obtaining

informed consent from each patient. Participants will be assured of confidentiality and their

identifying information will not be shared with anyone not directly involved.

4.10 Result Dissemination Plan

The results of this study will be submitted to the University. This will be communicated to

selected Zewditu Memorial Hospital. In addition, the results will be presented in seminars

and workshops, and further efforts will be made to publish the findings in national or

international peer-reviewed journals.

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