Journal of Taibah University Medical Sciences (2012) 7(2), 92–98

Taibah University

Journal of Taibah University Medical Sciences

www.jtaibahumedsc.net
www.sciencedirect.com

Clinical Study

Compliance with treatment of patients with hypertension

in Almadinah Almunawwarah: A community-based study
Manal Ibrahim Hanafi Mahmoud, PhD

Department of Family and Community Medicine, College of Medicine, Taibah University, Almadinah Almunawwarah, Kingdom of
Saudi Arabia
Community Medicine Department, Faculty of Medicine, Alexandria University, Egypt

Received 11 March 2012; revised 7 September 2012; accepted 3 November 2012

KEYWORDS Abstract Objective: The success of long-term maintenance therapy for hypertension depends lar-
Compliance; gely on the patient’s compliance with a therapeutic plan. The objective of this study was to deter-
Diet; mine the compliance with treatment of hypertensive patients attending primary health care centres
Exercise; in Almadinah Almunawwarah, Kingdom of Saudi Arabia.
Medication; Methods: A community-based cross-sectional study was adopted, with cluster random sampling.
Hypertension Sociodemographic data and subjective information were collected at interviews and clinical data by
reviewing patients’ medical records.
Results: The total mean percentage score for compliance was 35.1%. The best compliance was
with electrocardiography and Doppler scanning, followed by laboratory investigations; the worst
compliance was with exercise. In general, patients showed poor compliance with exercise and die-
tary regimes. The factors that affected patients’ compliance were their sex, level of education, work
status, smoking habits, self-reported response to medications and their perception of hypertension.
A satisfactory patient–physician relationship was reported by only 14.4% of patients with fair-to-
good compliance; 83.0% of patients with associated co-morbidity had poor compliance.
Conclusion: A healthy lifestyle, patient education, family counselling and social support net-
works should be strengthened in health promotion programmes in order to enhance compliance
of hypertensive patients with the therapeutic regimen and to improve their quality of life.
ª 2012 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.

Introduction
Corresponding author: Department of Family and Community
Medicine, College of Medicine, Taibah University, Almadinah Hypertension is a common chronic problem worldwide. It is
Almunawwarah, Kingdom of Saudi Arabia. Tel.: +966 4 8460008; defined as systolic blood pressure P140 mm Hg and/or dia-
fax: +966 4 8461407. stolic blood pressure P90 mm Hg and/or receiving antihyper-
E-mail address: [email protected] (M.I.H. Mahmoud). tensive medication. Its prevalence differs from one country to
Peer review under responsibility of Taibah University. another. In 2000, nearly 1 billion people or 26% of the adult
population worldwide had hypertension, and it was common
in both developed (333 million) and underdeveloped (639 mil-
lion) countries.1 Over 90–95% of adult hypertension is of the
Production and hosting by Elsevier
essential type.2
1658-3612 ª 2012 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jtumed.2012.11.004
 M.I.H. Mahmoud 93

In western countries, hypertension affects 28–44% of the Materials and Methods

population.3 Epidemiological studies in Arab countries show
prevalences ranging from 20.1% in Egypt, 26.3% in Kuwait, A community-based cross-sectional study was performed, with
32.1% in Qatar and 33% in Oman.4–7 A recent study in the random sampling of 30 clusters in the Medina City administra-
Kingdom of Saudi Arabia found that 26% of adults were tive divisions and random selection of one primary health care
hypertensive.8 centre from each cluster. At each primary health care centre,
Hypertension is a major risk factor for stroke and coro- 30 hypertensive patients aged P20 years with a diagnosis of
nary heart disease.9,10 A large percentage of the population, hypertension who were being investigated or treated were se-
however, are unaware that they have hypertension, and those lected during a 5-month period starting in October 2011. All
known to be hypertensive are often not adequately con- 900 hypertensive patients gave verbal consent for inclusion in
trolled.11–13 The first line of treatment for hypertension is pre- the study. Data were collected by interview with a question-
ventive lifestyle changes and medication,14,15 and poor control naire designed to elicit sociodemographic data (basic educa-
is attributed to poor compliance with the treatment tion including primary and preparatory level, higher
regime.16–18 Sackett and Haynes19 defined patient compliance education including secondary level and university degree or
as ‘‘the extent to which a person’s behaviour in terms of tak- more), clinical data including concurrent diseases such as dia-
ing medication, following diet, or executing life-style changes betes, heart disease and rheumatic disorders, views on health
coincides with medical or health advice.’’ Compliance can be care services, the patient’s beliefs and perceptions concerning
viewed as a patient’s behaviour in terms of timeliness in seek- hypertension, compliance with the treatment regime and barri-
ing care, attendance at follow-up appointments or observance ers to good compliance.
of the physician’s advice. As compliance improves the out- Patient compliance was assessed from their attendance,
come of hypertension, understanding its pattern is an impor- according to the WHO guidelines.16 Fair-to-good compliance
tant step in evaluating the effect of a hypertension treatment was recorded when the patient attended the clinic for periodic
regime. medical check-ups and blood pressure measurement on more
The objective of this study was to determine the compliance than two occasions during 6 months and annual check-ups
of patients with hypertension with their treatment regime. for eye and renal screening. Poor compliance was recorded

Table 1: Socio-demographic and disease characteristics of hypertensive patients by compliance level.

Characteristic Level of compliance Total P value
Poor Fair to good
N = 760 % N = 140 % N = 900
Age in years: mean (SD) 47.4 (12.51) 46.9 (12.18) 47.3 (12.46) NS
Sex
Male 370 80.3 91 19.7 461 100.0 < 0.05a
Female 390 88.8 49 11.2 439 100.0
Education
No formal education 24 72.7 9 27.3 33 100.0 < 0.05a
Basic 117 86.0 19 14.0 136 100.0
High 619 84.7 112 15.3 731 100.0
Work status
Not working 239 78.4 66 21.6 305 100.0 < 0.05a
Working 521 87.6 74 12.4 595 100.0
Marital status
Single 168 85.3 29 14.7 197 100.0 NS
Married 314 86.5 49 13.5 363 100.0
Widow 157 84.0 30 16.0 187 100.0
Divorced 121 79.1 32 20.9 153 100.0
Smoking
Non-smoker 121 90.3 13 9.7 134 100.0 < 0.05a
Active smoker 382 88.2 51 11.8 433 100.0
Passive smoker 257 77.2 76 22.8 333 100.0
Self-reported response to medication
Not responding 214 79.0 57 21.0 271 100.0 <0.05a
Responding 546 86.8 83 13.2 629 100.0
Co-morbid conditions
Absent 267 87.3 39 12.7 306 100.0 NS
Present 493 83.0 101 17.0 594 100.0
Duration of hypertension (years): mean (SD) 4.6 (3.14) 4.4 (2.69) 4.6 (3.07) NS
a
Pearson’s chi-square test, p < 0.05; P value of Student’s t test.
94 Compliance with treatment of patients with hypertension in Almadinah Almunawwarah: A community-based study

when the patient had not attended the clinic during the previ- but 84.7% of those with higher education were also poorly
ous 6 months. compliant (p = 0.000) (Table 1). Only 12.4% of the working
To assess outcome of care, the patients’ medical records population and 13.5% of married participants showed good
were reviewed during their interview to obtain the most recent compliance (both p = 0.000). Only 9.7% of non-smokers
blood pressure measurements and any complications. Body had fair-to-good compliance, and 83.0% of people with co-
mass index, pulse and blood pressure were estimated. morbid conditions had poor compliance (Table 1).
A compliance score was calculated for each patient and The total mean percentage score for compliance was 35.1
converted to a total percentage score, categorized as poor (14.48), with a significant difference between poor and fair-
(<62.5%), fair (62.5–80.0%) or good (>80.0%). The mean to-good compliance (p = 0.000) (Table 2) The best compliance
score was estimated for each item, and the total mean percent- was with periodic electrocardiography and Doppler, followed
age score was calculated for each category. In order to study by periodic laboratory investigations. The worst compliance
the relations between degree of compliance and the study vari- was with exercise (Table 2).
ables, two levels were used: poor compliance (<62.5%) and More than two fifths (85.2%) of those who stated that they
good and fair compliance (>62.5%). could not access the prescribed medications and 80.5% of those
who found that that the delay before obtaining an appointment
Statistical analysis was too long also had poor compliance (p = 0.001). Poor com-
pliance was also seen for 80.0% of patients who complained
SPSS version 13 was used. Frequencies, percentages and arith- that their examination was too short (p = 0.000). Fair-to-good
metic mean were calculated. Chi-square test and Student’s t compliance was found for 14.4% of people who had a satisfac-
test were used appropriately. A P value <0.05 was considered tory patient–physician relationship (p = 0.015). Most patients
significant. who received supplementary health education materials
(87.8%) had poor compliance (p = 0.009) (Table 3).
Results The outcomes of care (systolic and diastolic blood pressure,
pulse rate per minute and complications) were significantly
poorer for patients with fair-to-good compliance than those
The mean age of the studied population was 47.3 (12.46) years. with poor compliance (Table 3). Yes this is result, but not
The mean duration of hypertension was 4.6 (3.07) years. every point expressed in the result section discussed in discus-
Most of the women (88.8%) showed poor compliance sion but the reverse is true.
(p = 0.000); 86.0% of these had received only basic education,

Table 2: Compliance of hypertensive patients with treatment regimen.

Item Level of compliance Mean score
Poor Fair to good
N = 760 % N = 140 %
Periodic medical check-up
Not compliant 554 72.9 37 26.4 0.34 (0.48)
Compliant 206 27.1 103 73.6
Periodic electrocardiography and Doppler scan
Not compliant 18 2.4 6 4.3 1.0 (0.16)
Compliant 742 97.6 134 95.7
Periodic laboratory investigations
Not compliant 371 48.8 22 15.7 0.56 (0.49)
Compliant 389 51.2 118 84.3
Self-measurement of blood pressure
Not compliant 732 96.3 118 84.3 0.15 (0.22)
Compliant 28 3.7 22 15.7
Medications
Not compliant 642 84.5 57 40.7 0.22 (0.42)
Compliant 118 15.5 83 59.3
Dietary regimen
Not compliant 665 87.5 72 51.4 0.18 (0.39)
Compliant 95 12.5 68 48.6
Exercise
Not compliant 719 94.6 77 55.0 0.12 (0.32)
Compliant 41 5.4 63 45.0
Total mean score (SD) 30.4 (10.11) 60.3 (6.19) 35.1 (14.48)
P value <0.05a
a
P value of Student’s t test significant at <0.05.
 M.I.H. Mahmoud 95

Table 3: Patients’ satisfaction with quality of care and compliance level.

Level of compliance Total P value
Poor Fair to good
N = 760 % N = 140 % N = 900
Medications
Not available 306 85.2 53 14.8 359 100.0 NS
Available 454 83.9 87 16.1 541 100.0
Waiting time
Long 350 80.5 85 19.5 435 100.0 <0.05a
Reasonable 410 88.2 55 11.8 465 100.0
Examination time
Insufficient 360 80.0 90 20.0 450 100.0 <0.05a
Sufficient 400 88.9 50 11.1 450 100.0
Patient–physician relationship
Unsatisfactory 241 82.0 53 18.0 294 100.0 <0.05a
Satisfactory 519 85.6 87 14.4 606 100.0
Health education about: Type of treatment
No 441 82.7 92 17.3 533 100.0 NS
Yes 319 86.9 48 13.1 367 100.0
Proper use of medications
No 449 82.8 93 17.2 542 100.0
Yes 311 86.9 47 13.1 358 100.0 <0.05a
Complications of hypertension
No 457 84.0 87 16.0 544 100.0 NS
Yes 303 85.1 53 14.9 356 100.0
Follow-up schedule
No 351 80.3 86 19.7 437 100.0 <0.05a
Yes 409 88.3 54 11.7 463 100.0
Supplementary health education material
No 387 81.5 88 18.5 475 100.0 <0.05a
Yes 373 87.8 52 12.2 425 100.0
Outcome of care 120.1 (10.59) 115.4 (9.67) 116.2 (8.73) <0.05a
Systolic blood pressure
Mean (SD)
Diastolic blood pressure 81.5 (12.34) 80.1 (10.81) 80.5 (9.64) <0.05a
Mean (SD)
Pulse rate/minute 78.5 (5.8) 75.9 (7.61) 77.3 (5.21) <0.05a
Mean (SD)
Complications
Absent 301 74.9 101 25.1 402 100.0 <0.05a
Present 459 92.2 39 7.8 498 100.0
a
Pearson’s chi-square test, p < 0.05; P value of Student’s t test.

All 20.9%
All 28.3%

Frequent micturation 15.0%

No dietary knowledge 19.2%
No motivation 21.2%
Dificulty in preparing specific food 28.3%
Feel better 16.7%

Financial 13.4%
Forgetting 13.1%

Financial 13.1% Difficulty in changing habit 10.8%

Figure 1: Causes of poor compliance with medication. Figure 2: Causes of poor compliance with dietary regimen.
96 Compliance with treatment of patients with hypertension in Almadinah Almunawwarah: A community-based study

knowledge was the chief cause of non-compliance with the

All 27.7%
exercise regime (Fig. 3).
The mean percentage score for patient perceptions concern-
Lack of knowledge 20.0%
ing hypertension was 65.4 (10.52) (p = 0.002), with the highest
Disabling illness 10.4%
values for benefits of compliance (81.6%) and the role of fam-
ily support (70.0%) (Table 4).
Strenuous work 15.1% Compliance with a treatment regimen was positively corre-
lated with duration of hypertension (r = 0.066, p = 0.043)
No time 14.2% (Fig. 4).

Difficulty in changing habits 17.6% Discussion

Figure 3: Causes of poor compliance with exercise regimen. This study shows that the worst compliance is with exercise
and dietary regimens and the best with laboratory investiga-
tions, even when hypertension was severe enough to justify
Lack of motivation was the most frequent cause of poor immediate medication. This result concurs with those of simi-
compliance (21.2%) (Fig. 1). Difficulty in preparing a specific lar studies17,18, even though the achievement and maintenance
diet (28.3%) was the most frequent cause of poor compliance of a more optimal standardized weight with a healthful dietary
to the dietary regimen (Fig. 2), and 20.0% stated that lack of plan, recommended levels of regular physical activity and

Table 4: Patients’ perceptions of hypertension and compliance level.

Level of compliance Total P value
Poor Fair to good
N = 760 % N = 140 % N = 900 %
Severity of hypertension
No 595 78.3/83.6 117 83.6/16.4 712 79.1/100.0 <0.05a
Yes 165 21.7/87.8 23 16.4/12.2 188 20.9/100.0
Susceptibility to complications
No 343 45.1/87.7 48 34.3/12.3 391 43.4/100.0 <0.05a
Yes 417 54.9/81.9 92 65.7/18.1 509 56.6/100.0
Impact on social life
No 448 58.9/83.0 92 65.7/17.0 540 60.0/100.0 NS
Yes 312 41.1/86.7 48 34.3/13.3 360 40.0/100.0
Benefits of compliance
No 156 20.5/94.0 10 7.1/6.0 166 18.4/100.0 <0.05a
Yes 604 79.5/82.3 130 92.9/17.7 734 81.6/100.0
Barriers to treatment
No 312 41.1/80.8 74 52.9/19.2 386 42.9/100.0 <0.05a
Yes 448 58.9/87.2 66 47.1/12.8 514 57.1/100.0
Barriers to diet
No 302 39.7/84.4 56 40.0/15.6 358 39.8/100.0 NS
Yes 458 60.3/84.5 84 60.0/15.5 542 60.2/100.0
Barriers to exercise
No 322 42.4/85.4 55 39.3/14.6 377 41.9/100.0 <0.05a
Yes 438 57.6/83.7 85 60.7/ 16.3 523 58.1/100.0
Internal cues to compliance: control of severe hypertension
No 242 31.8/79.9 61 43.6/20.1 303 33.7/100.0 <0.05a
Yes 518 68.2/86.8 79 56.4/13.2 597 66.3/100.0
External cues to compliance: family support
No 249 32.8/92.2 21 15.0/7.8 270 30.0/100.0 <0.05a
Yes 511 67.2/81.1 119 85.0/18.9 630 70.0/100.0
Educational support
No 387 50.9/81.5 88 62.9/18.5 475 52.8/100.0 <0.05a
Yes 373 49.1/87.8 52 37.1/12.2 425 47.2/100.0
Score: mean (SD) 50.4 (14.18) 75.9 (15.23) 65.4 (10.52) <0.05a
a
Pearson’s chi-square test, p < 0.05; P value of Student’s t test.
 M.I.H. Mahmoud 97

r= -.066*, sig.=.043 that 83.0% of patients with co-morbid conditions had poor
80.00
compliance. Such conditions may determine the target blood
pressure, with lower targets for patients with end-organ dam-
age or proteinurea.12,19–22 The results of this study lead us to
Compliance2

60.00 suggest that the most appropriate therapeutic attitude in treat-

ing patients with hypertension should be to avoid therapeutic
40.00
withdrawal and lack of medical control. In the United States,
only about one third of all people with hypertension are con-
trolled, and programmes to improve hypertension control
20.00 R Sq Linear = 0.004 rates and prevent hypertension are urgently needed.23

0.00 5.00 10.00 15.00 20.00 Conclusion

Duration_of_hypertension
Patients with hypertension were poorly compliant with exer-
Figure 4: Relation between duration of hypertension and cise and dietary regimens. Sex, educational level, work status,
compliance. smoking habits and self-reported response to medications af-
fected compliance, as did patients’ perceptions of hyperten-
other behavioural approaches are associated with a significant sion. A minority of patients with fair-to-good compliance
reduction in blood pressure. had a satisfactory patient–physician relationship. Most pa-
One limitation of this study is that we did not exclude pa- tients with co-morbid conditions were poorly compliant.
tients with psychiatric problems or those with severe complica- Health promotion programmes should emphasize a healthy
tions with perminant disabling sequlae, such as stroke. This lifestyle, patient education, family counselling and social sup-
should be avoided in future studies. port networks in order to enhance compliance with therapeutic
The level of compliance varies from patient to patient. We regimens for hypertension and to improve patients’ quality of
found that that sex, educational level, work status, smoking life.
habits and self-reported response to medications affected com-
pliance, as did patients’ perceptions of hypertension. Other References
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