Introduction

Hypertension (HTN), another name for high blood pressure, is a frequent illness marked by elevated arterial pressure. According to the American Heart Association, HTN is diagnosed when a person’s blood pressure is continuously 130/80 mmHg or above [1] (Table 1). Studies show chronic HTN’s continuous strain on the artery walls causes atherosclerotic plaques, resulting in endothelial dysfunction and arterial hardness [2]. This pathological alteration decreases the blood flow and increases the risk of cardiovascular events like stroke and heart attacks together with microvascular (neuropathy, retinopathy, nephropathy) problems, which result in arterial damage and end-organ dysfunction [1].

Ensuring patients’ adherence to treatment regimens is essential for achieving optimum health outcomes and lowering healthcare expenses associated with preventable complications because some disorders cannot be fully cured and require long-term maintenance [3]. Different factors and elements may influence the prevalence rates of hypertensive disorders in Pakistan, which may be gender, age, or social and economic status, which covers the public from 25 to 30% of the whole population of Pakistan, which is an alarming number. These numbers require significant and substantial steps and initiatives in modifications of health policies to deal with this deadly disease, which affects both men and women [4]. For patients in which HTN is not controlled, medications in combination are used at a high rate or who are at greater risk of heart disorders [5] as illustrated in Table 1.

Patients are educated by physicians, pharmacists, and other experts on the importance of dietary changes, adherence activities, and medication regulation. Face-to-face encounters focus on maximizing health outcomes [6]. Adherence activities are crucial for managing HTN, including following medical advice for regulating HTN [7, 8]. The General Medication Adherence Scale (GMAS) questionnaire helps assess if patients stick to their medication plans, ensuring they stay on track. The GMAS, developed by Naqvi et al. [9], evaluates various aspects of medication adherence, with each part receiving a score contributing to an overall score. Emphasizing these points was intended to aid in good awareness of adherence to drugs and patient behavior in the country’s capital for maximizing adherence percentages and good results in areas. So, it aimed to comprehensively evaluate medication adherence among patients using the GMAS questionnaire among hypertensive patients of Islamabad and Rawalpindi, Pakistan, and identify factors influencing medication adherence.

Materials and methods

Results

The sociodemographic and clinical features of 246 participants with an average age of 57.1 years are presented in Table 2. The gender distribution was nearly equal, with 47.6% males and 52.4% females. A significant proportion of participants were married (82.1%), a lower proportion (9.3%) was widowed, 7.3% were divorced, and only 1.2% were single. Most participants (93.9%) live with their families, and 63% of participants were from Islamabad, while the remaining were from Rawalpindi. 6.9% of participants were illiterate, while 65.4% held a university degree, 78.9% of the participants were actively employed, and regarding monthly income, 53.3% of participants earned between 30,001 and 40,000 PKR each month. Regarding smoking status, 12.6% were previous smokers, 21.1% were current smokers, and 66.3% didn’t smoke. 61.4% of participants take medicines with a doctor’s prescription, 9.3% without a doctor’s prescription, and 29.3% take both. Regarding HTN treatment, 41.9% of participants began medication 2 to less than five years ago, while 58.1% had been on it for five years or more. Overall, patients in our cohort took 7.5 (2.5) medications daily, including anti-hypertensive and other medicines that may interfere with adherence to antihypertensives.

Table 3 shows adherence levels across different domains. Patient behavior-related non-adherence had an adherence score of 11.2 ± 1.3, indicating high adherence. Similarly, additional disease and pill burden (ADPB) had a score of 12.2 ± 1.5, showing high adherence. However, cost-related non-adherence (CRNA) scored 3.25 ± 1.0, showing partial adherence. The total score of GMAS-11 was 26.5 ± 2.1, indicating partial to good adherence.

Based on the value of the adherence count summed of every response, the outcome is given to each response, either “Adherent” or “Non-Adherent”. Figure 1 shows the percentage of patients who are adherent or non-adherent to their hypertensive drug treatment. 72.4% of respondents were 80% adherent, and 27.6% of patients/respondents were not 80% adherent/non-adherent.

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Figure 1. 

Outcome distribution of hypertensive drug treatment

An independent sample t-test was used to investigate the study respondents’ significant statistical variations in drug adherence (Table 4). The test revealed significant differences in medication adherence among females (30.51 ± 3.29) along males (29.24 ± 2.41) (t = 1.629, P = 0.03). Moreover, the results showed no significant statistical differences in adherence to medications between patients living with family or those living alone in Islamabad or Rawalpindi.

A one-way ANOVA was conducted to determine the influence of independent variables (social status, monthly income, educational level, using medications with or without prescription, smoking status, year of starting hypertensive, who was providing medications, and cost). The study found substantial variations in medication adherence based on characteristics such as monthly income and educational level (P < 0.05). There were additionally significant statistical variations in prescription adherence, referring to the availability (P = 0.04) along with the price (P = 0.001) of medication. However, the results showed no significant statistical differences in medication adherence, referring to variables such as social status (P = 0.141), smoking (P = 0.12), and using medications with or without prescriptions (P = 0.54) as explained in Table 5.

Discussion

Non-adherence is one of the most considerable challenges that clinicians confront when managing HTN. Unfortunately, due to time restrictions, clinicians do not discuss medication adherence with their patients [10]. HTN is a chronic condition that is a risk factor for several complications, such as chronic kidney disease, stroke, and ischemic heart disease. Hence, the aim was to evaluate the medication adherence and the factors impacting the medication adherence of HTN patients in Islamabad and Rawalpindi.

Prior research indicates that measuring adherence and patient compliance is complex and primarily relies on patients [3, 11]. We found that 72.4% of participants adhered to antihypertensive medications, while the rest did not. These findings are fewer compared to the results of earlier studies that used various adherence to medication methods for assessment [12]. Gender showed a statistically significant link (P = 0.03), however, the results of other research studies often contradict each other on the impact of gender on the rate of drug adherence. According to some researchers, female patients exhibit a higher level of adherence [13]. At the same time, other studies failed to find a relationship between gender and medication adherence [14].

In the study group, the income level was significantly correlated (P = 0.001), however, inconsistent results were observed and, thus, were mostly uncertain [14, 15]. The socioeconomic status of research respondents and their household members, as well as the extent of their insurance coverage, might impact the cost of medical services and compliance with medications. This conclusion can result from the fact that even at government hospitals, patients must pay for their prescription drugs. This was further supported by a noteworthy link (P = 0.001) found in this study between the level of adherence and medication cost consideration.

Education level may favor drug adherence by assisting patients in comprehending the nature of their illness and the significance of treatment. This aligns with prior research demonstrating a favorable relationship between educational status and degree of adherence [11, 13].

Family support is beneficial in treatment and medication adherence [16]. Patients in this study were asked if they took their prescriptions independently or with help from family members. The findings indicate a strong relationship (P = 0.04) between the degree of adherence and family help in giving medicine. Comparable results were also observed in other investigations [12, 17]. Large-scale prospective studies, including additional cities and rural areas, would provide a more comprehensive view of medication adherence across different regions and populations and determine the causal association between medication adherence among HTN patients and social support.