Volume 7 No 2 2019 (3).indd
74 International Journal of Integrated Health Sciences. 2019;7(2)
Original Article
Adherence to Antihypertensive Medication in Patients with
Hypertension in Indonesia
Abstract Objective: Adherence to medication is crucial for hypertension patients in
order to control and prevent complications. This study aimed to describe the
adherence to antihypertensive drugs among patients with hypertension in
Bandung District, West Java, Indonesia.
Methods: This was a cross-sectional observational study on patients with
hypertension in the work area of Cileunyi Public Health Center (PHC),
Bandung District, West Java, Indonesia. The inclusion criteria used were
patients with hypertension who were prescribed an antihypertensive drug
by a physician, above 18 years old, and had been using an antihypertensive
medication for at least two months before the study. Data were obtained
through interviews during the month of July to August 2018 using a modified
MMAS-8 questionnaire of the Morisky Medication Adherence Scale (MMAS-
8), which includes Likert-type scale questions. Data collected were then
analyzed using the Rasch Model, and the mean logit person was used as a cut
off between adherence and non-adherence categories.
Results: A total of 75 patients with hypertension were recruited. The
prevalence of adherence to medication was 59%. Most patients who adhered
to the medication were > 55 years old (31%), female (59%), had been
diagnosed with hypertension for < 5 years (31%), and received support from
family/social environment (40%).
Conclusions: Many factors support the adherence to antihypertensive
medication, including age, gender, time of hypertension diagnosis, and
support from family or social environment. The adherence to antihypertensive
medication among patients with hypertension visited Cileunyi Primary
Health Care, Bandung District, West Java, Indonesia is good.
Keywords: Adherence, antihypertensive medication, hypertension,
Indonesia, primary health care
pISSN: 2302-1381; eISSN: 2338-4506; http://doi.org/10.15850/ijihs.v7n2.1588
IJIHS. 2019;7(2):74–80
Received:
January 9, 2019
Revised:
September 30, 2019
Accepted:
October 19, 2019
Correspondence:
Vycke Yunivita,
Department of Biomedical Science, Faculty of Medicine
Universitas Padjadjaran
e-mail: v.yunivita@unpad.ac.id
Tania,1 Vycke Yunivita,2 Afiatin3
1Faculty of Medicine Universitas Padjadjaran, Indonesia
2Department of Biomedical Science Faculty of Medicine Universitas Padjadjaran, Indonesia
3Department of Internal Medicine Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin Hospital
Bandung, Indonesia
Introduction
Primary hypertension is a global health
problem that affects most countries in the
world. Hypertension is defined as a condition
with increased systolic blood pressure
(SBP) above 130 mmHg and increased
diastolic blood pressure (DBP) of more than
80 mmHg.1 An increase of about 20 mm Hg in
SBP and 10 mm Hg in DBP increases the risk
of death from vascular disease, stroke, and
other vascular diseases. Higher SBP and DBP
were associated with increased risk of several
vascular diseases, such as cardiovascular
diseases (CVDs), in more than one million
adult patients aged >30 years worldwide.1
Results of the Indonesian Basic Health Survey
(IBHS) 2018 show that the prevalence of
hypertension in Indonesia for the population
above 18 years old is 8.4% based on the self-
reported answer from the respondents who
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International Journal of Integrated Health Sciences. 2019;7(2) 75
stated that they had been diagnosed to be
suffering from hypertension by a physician.
Meanwhile, the same survey also reported that
the prevalence of hypertension is 34.1% based
on blood pressure measurement performed
during the survey. A higher prevalence of
hypertension is seen among women when
compared to men.2
In West Java Province, the West Java
Provincial Health Office reported that, in 2016,
there were 790,382 hypertension cases in the
province with 118,751 of them were found
in Bandung District, which was the highest
compared to the number found in other
districts in the province.3 Cileunyi Sub-District
is a peri-urban area of Bandung District that
has been transforming from a rural area to
an urban area. Cileunyi Sub-District is an
area that has access to several other districts:
Tasikmalaya and Garut District in the south
and Sumedang and Cirebon District in the east.
It is also directly adjacent to Jatinangor Sub-
District of Sumedang District. The fact that this
subdistrict is highly accessible from many other
areas making it one of the main destinations of
migration, resulting in increased population
and land-use shift from agricultural land
into residential and commercial areas.4 This
rural-to-urban shift does not only affect the
land use and infrastructure development
but also affects the lifestyle and culture of
the community. Changes in the lifestyle
also include changes in the diet that tend
to move towards instant food or fast food
consumption. The higher tendency to use
motorized vehicles has also reduced walking
activities among people.5 These two changes
create risk factors for non-communicable
diseases. Consequently, this leads to an
increase in the incidence and mortality caused
by non-communicable diseases, including
hypertension, in Cileunyi District.6
Several factors affect a person’s adherence.
First, the socioeconomic factors that include
low education level and limited motivation.
The second is the health service factors that
include the uneven distribution of health
facilities, inadequate number of health
workers, limited consultation time, lack of
communication with patients, and lack of
health worker’s knowledge in treating chronic
diseases. The third factor is the condition-
related factors, for example, the severity of
disease, complications, and prognosis. The
fourth factor is therapy-related factors, such
as complex therapy, duration of treatment,
history of previous therapy errors mistake,
and drug side effects. The last factor is the
patient-related factors that include the level
of knowledge and confidence, motivation in
treatment, absence of symptoms, frustration
caused by the disease, anxiety towards drug
side-effects, and confidence to recover. The
five factors above may reduce adherence to
medication in almost every country, including
Indonesia.7 Adherence to medication can be
interpreted as a patient’s behavior in abiding
to doctor’s recommendations in accordance
with medical demands. The low adherence is
the main cause of treatment failure, especially
in the treatment of chronic diseases such as
hypertension treatment.8
This study aimed to determine the level
of adherence to antihypertensive drugs
among hypertension patients visiting a public
health center in Bandung District, West Java,
Indonesia.
Methods
This is a cross-sectional quantitative
descriptive study on adherence to medication
for hypertensive patients. Data were obtained
by interview using the Morisky Medication
Adherence Scale-8 (MMAS-8) questionnaire,
a structured self-report indicator of drug-
taking behavior, which is commonly used
and has been validated for antihypertensive
drugs in different cultures.9 The study was
performed from July to August 2018 in the
working area of Cileunyi Primary Health Care
(PHC), Bandung District, West Java and has
been approved by the Health Research Ethics
Committee, Faculty of Medicine, Universitas
Padjadjaran no 847/UN6.KEP/EC/2018.
The subjects in this study were patients
with hypertension treated at the Cileunyi PHC
(n=75). The inclusion criteria were outpatients
aged more than 18, had received hypertension
diagnosis from a doctor, consumed
antihypertensive agents prescribed by a
doctor, duration of treatment minimum of two
months, and had given consent to participate
in the study. The exclusion criteria were the
subjects who bought their own medicine
without a doctor’s prescription, patients who
came to the PHC for the first time, and patients
who could not communicate well.
Data collection was carried out by
conducting interviews on patient’s
characteristics and adherence using the
MMAS-8 questionnaire that had been tested
for validity and reliability.10,11 The MMAS
questionnaire used in this study contained
eight questions with seven dichotomy scale
questions and one Likert scale question.
Tania, Vycke Yunivita, et al.
:74–80
76 International Journal of Integrated Health Sciences. 2019;7(2)
Data were then analyzed using the Rasch
Model on Winstep software 3.73 (Winsteps,
USA). Results were represented as a logit
person for each person to describe treatment
adherence. The adherence level were classified
into two categories. The first was the adherence
category represented by a logit person value
above the mean score and the second category
was the non-adherence category, which was
represented by a logit person value under the
mean score. Respondents characteristics in
terms of adherence were processed using the
SPSS version 22 (spss.license.unpad.ac.id).
Results
Seventy-five respondents who suffered from
hypertension and visiting the Cileunyi PHC
participated in this study. The Wright
distribution pattern of respondents and
questionnaire items were represented in a
Wright’s Map (Fig.). The average logit person
value based on analysis using the Rasch
model was -0.88. The Wright’s Map was then
used to determine the adherence level. Forty-
four respondents (59%) were included into
the adherence category (59%) and 31 were
classified into the non-adherence category
(41%).
The results exhibited that the majority
of the respondents were over 55 years old,
female, graduated from elementary school,
and unemployed. All respondents were
married and consumed only one type of
Figure Wright Distribution Pattern of Respondents and Questionnaire Items
Adherence to Antihypertensive Medication in Patients with Hypertension in Indonesia
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International Journal of Integrated Health Sciences. 2019;7(2) 77
Table Respondent Characteristics by Adherence
Characteristics Adherence n (%)
Non-adherence
n (%)
Total (%)
n=75
Age
≤ 55 years 21 (60%) 14 (40%) 35 (47%)
> 55 years 23 (57%) 17 (43%) 40 (53%)
Gender
Male 7 (47%) 8 (53%) 15 (20%)
Female 37 (62%) 23 (38%) 60 (80%)
Education
No school 2 (100%) 0 (0%) 2 (3%)
Elementary school 29 (63%) 17 (37%) 46 (61%)
Junior high school 6 (46%) 7 (54%) 13 (17%)
Senior high school 5 (42%) 7 (58%) 12 (16%)
College 2 (100%) 0 (0%) 2 (3%)
Occupation
Employment 8 (67%) 4 (33%) 12 (16%)
Unemployment 36 (57%) 27 (43%) 63 (84%)
Marital status
Single 0 (0%) 0 (0%) 0 (0%)
Married 44 (59%) 31 (41%) 75 (100%)
Duration of being aware of hypertension status
≤ 5 years 23 (59%) 16 (41%) 39 (52%)
>5 years 21 (58%) 15 (42%) 36 (48%)
Number of drug type
1 44 (59%) 31 (41%) 75 (100%)
>1 0 (0%) 0 (0%) 0 (0%)
Drug type
ACE Inhibitor 23 (70%) 10 (30%) 33 (44%)
Calcium channel blocker 21 (50%) 21 (50%) 42 (56%)
Other 0 (0%) 0 (0%) 0 (0%)
Income (Indonesian Rupiah/IDR)
<1,500,000 41 (57%) 31 (43%) 72 (96%)
1,500,000–2.500.000 2 (100%) 0 (0%) 2 (3%)
2,500,000–3,500,000 1 (100%) 0 (0%) 1 (1%)
3,500,000 0 (0%) 0 (0%) 0 (0%)
Cost coverage
Out-of-Pocket 17 (81%) 4 (19%) 21 (28%)
Borne by other parties (insurance, family, etc.) 27 (50%) 27 (50%) 54 (72%)
Support from family/social environment
Yes 30 (64%) 17 (36%) 47 (63%)
No 14 (50%) 14 (50%) 28 (37%)
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78 International Journal of Integrated Health Sciences. 2019;7(2)
drug. Most respondents had known that they
had hypertension for less than 5 years, took
Calcium Channel Blocker drugs, had a monthly
income of less than Indonesian Rupiahs (IDR)
1,500,000,00, had the treatment costs borne by
other parties, and received good support and
motivation from family or social environment.
The number of respondents in the age group
>55 years who were in the non-adherence
category was higher (Table 2). Women showed
a higher percentage of adherence than men
and most of the non-adherence respondents
were graduated from elementary school.
Respondents who were employed were most
likely to be in the adherence group than those
who were unemployed. Married respondents
tended to be adherent. When adherence was
assessed from the perspective on how long the
patients had known about their hypertension
status, adherence was found to be more
prevalent in the group who was were aware
that they were hypertensive for less than 5
years. All respondents took one type of drug
and mostly adhered to the treatment. In terms
of the type of drug consumed, respondents
in the non-adherence group were more
likely to take Calcium Channel Blocker. Most
respondents, who had an income less than
IDR 1,500,000, were adherent. Respondents
who use their own money tended to adhere
to the treatment. Family and social support
also influenced the adherence with a higher
percentage of respondents with good family
and social supports adhered to the treatment.
Discussion
Patients with hypertension visited the
Cileunyi PHC were analyzed based on several
characteristics. When the age was cross-
examined with adherence, it was revealed that
more patients who were >55 years old were
in the non-adherence group compared to the
younger counterpart (≤55 years old). This is in
accordance with the results of the IBHR 2018
stating that the most common disease in the
elderly is hypertension (57.6%).2 It is expected
that when a person is getting older, his or her
incidence of having a high blood pressure
increases. This is because the blood vessel
structure and function change with aging,
which in turns affect body hemodynamics
or blood pressure regulation. These changes
include the, including loss of connective tissue
elasticity, decreased relaxation of vascular
smooth muscle, and atherosclerosis.12 As
people get older, the organ system also
experiences declined function, including the
limbic system which controls memories.13 As
a result, patients who are >55 years may have
a lower level of adherence than patients who
are ≤55 years due to lower memory capacity.
Sixty women (80%) with hypertension
participated as the respondents, which is
far greater than men (n=15, 20%). This is
consistent with the results of the IBHR 2018
that demonstrated a higher prevalence of
hypertension among women in Indonesia
when compared to men.2 Women experience
menopause, which involves hormonal changes
resulting in a decreased ratio of estrogen to
androgen hormones that leads to higher renin
release which then triggers an increase in
blood pressure.14 Nevertheless, women have
a higher level of adherence than men, which
is similar to the finding of a previous study
that reported female respondents to be more
concerned about their health due to the higher
availability of time and opportunities to visit
the PHC than men.15
The respondents of this study were
predominantly graduated from elementary
school (n= 46, (61%) with varied adherence
level. Thus, education seems to not affecting
patient’s adherence. A person with a higher
education level does not necessarily have
better adherence and vice versa. This is
because respondents’ knowledge is not only
obtained through formal education but also
from experience or other information media,
such as television, newspaper, radio, and
the internet. The knowledge of treatment
adherence could also be gained from the
communication between patients and their
healthcare provider.16
Based on the occupational group, most
respondents were unemployed. The reason
for the high rates of hypertension among
unemployed patients is that the physical
activities of unemployed patients are less
than those who work. Physical activities can
facilitate blood flow while the lack of physical
activities can increase the risk of obesity
and hypertension.17 Respondents who work
have higher adherence than those who do
not work. On the contrary, a previous study
stated that higher adherence is found among
unemployed patients. Their argument is that
these patients have more time at home so
they have more opportunities to take their
medication regularly.18 All hypertensive
patients in the Cileunyi PHC were married.
No previous report has explained the relation
between marital status and hypertension,
but an assumption can be made that because
hypertension is more common in old age and
Adherence to Antihypertensive Medication in Patients with Hypertension in Indonesia
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International Journal of Integrated Health Sciences. 2019;7(2) 79
one tends to get married at the age of 20 years
old or older, more married patients experience
hypertension. Patients who are married
have more family support for taking the
medicine by reminding to take the medicine as
prescribed. Hence, they have more controlled
hypertension.19
Most respondents of this study have known
about their hypertension status for less than
5 years and all of the respondents only took
one type of drug. A previous study stated that
patients with one drug regimen have a higher
adherence level than patients with multiple
drug regimens.8 This may be because patients
who consume multiple drugs tend to forget to
take their medicine and finally get tired of it,
resulting in a lower adherence.
Based on the type of drug consumed, two
classes of antihypertensive drugs were used
by the respndents, namely ACE inhibitors
(Captopril) and calcium channel blockers
(Amlodipine). The number of respondents
who took Captopril was less than those who
took Amlodipine, albeit with a higher level
of adherence. This is in contrast with the
adherence level is a previous study showing
that patients who take Amlodipine are more
adherent that those who take Captopril. The
researchers assumed that it may be due to
the most common side effect of Captopril,
which is coughing, that is less tolerable and
may interfere with patients’ daily activities.
This is also because patients only need to take
Amlodipine once a day.20
Out of seventy-five respondents in the
Cileunyi PHC, the majority had a monthly
income below IDR 1,500,000. There were
two respondents whose income was between
IDR 1,500,000 and IDR 2,500,000 and one
respondent had an income of between IDR
2,500,000 and IDR 3,500,000. No statistically
significant difference is found regarding
income.18 However, this study cannot conclude
the relationship due to limited sample size and
possible bias.
Respondents who bear their own costs
have higher adherence than respondents
whose cost was borne by other parties.
Most of the respondents have their medical
expenses covered by other parties such as by
the National Health Insurance. This situation is
the opposite of the findings of a previous study
that shows a lower adherence level among
those who pay for their own cost. Other study
reported that with the availability of health
insurance, patients can obtain drugs regularly
and, thus, more adherent than those who are
not covered by insurance.18
This study shows that patients that do
not have family/social support have a lower
adherence level. The form of support can
be a reminder to take the antihypertensive
drug from the child or spouse. Moral support
from others can also increase patient’s self-
motivation and lead to a high adherence level.
Adherence to drugs is the most important
aspect of a patient’s treatment. Good support
from the patient’s family or social environment
is a social factor that can predict adherence.21
To summarize, the adherence to treatment
is crucial for every patient. It is necessary
to control hypertension and prevent
complications. The Primary Health Care plays a
role in improving patient adherence. Education
about the benefit of taking antihypertensive
drugs regularly should be provided to patients
so they are more aware of their disease and the
importance of taking medicine, thus leading
to a high adherence level. Education to the
patient’s family members is also important.
It can be concluded that the majority
of the respondents are over 55 years old,
female, graduated from elementary school,
and unemployed. All respondents are
married and take one drug regimen. Most of
the respondents have known that they have
hypertension for less than 5 years, take Calcium
Channel Blocker, have monthly income less
than IDR 1,500,000,00, havve the costs borne
by other parties, and get good motivational
support from family or social environment.
Most patients with hypertension in Cileunyi
Primary Health Care have good adherence to
antihypertensive drugs.
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