Antihypertensive drug adherence and its association with blood pressure control status

Journal Pre-proof Antihypertensive drugs adherence and its association with blood pressure control status Kimiya Seify, Medical student, Mehrbod Vakhshoori, Medical Doctor, Maryam Eghbali-Babadi, PhD, Maryam Heidarpour, Assistant Professor of Endocrinology, Alireza Khosravi, Professor, Awat Feizi, Professor, Nizal Sarrafzadegan, Professor, Davood Shafie, Assistant Professor of Cardiology PII:

S2352-0817(20)30035-0

DOI:

https://doi.org/10.1016/j.cmrp.2020.03.008

Reference:

CMRP 473

To appear in:

Current Medicine Research and Practice

Received Date: 16 October 2019 Revised Date:

11 March 2020

Accepted Date: 24 March 2020

Please cite this article as: Seify K, Vakhshoori M, Eghbali-Babadi M, Heidarpour M, Khosravi A, Feizi A, Sarrafzadegan N, Shafie D, Antihypertensive drugs adherence and its association with blood pressure control status, Current Medicine Research and Practice, https://doi.org/10.1016/j.cmrp.2020.03.008. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Sir Ganga Ram Hospital.

Antihypertensive drugs adherence and its association with blood pressure control status Kimiya Seify1*, Mehrbod Vakhshoori2*, Maryam Eghbali-Babadi3, Maryam Heidarpour4, Alireza Khosravi5, Awat Feizi6, Nizal Sarrafzadegan7, Davood Shafie8

1

Medical student, Hypertension Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, Email address:[email protected] 2

Medical Doctor, Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. Email address: [email protected]

3

PhD, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran, Email address: [email protected]

4

Assistant Professor of Endocrinology, Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, Email address: [email protected] 5

Professor, Interventional Cardiology Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran, Email address: [email protected]

6

Professor, Hypertension Research Center, Department of Biostatistics and Epidemiology, Isfahan University of Medical Sciences, Isfahan, Iran, Email address: [email protected] 7

Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran, Email address:

[email protected] 8

Assistant Professor of Cardiology/Fellowship in Heart Failure and Transplantation, Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran, Email address: [email protected] *: Kimia Seify and Mehrbod Vakhshoori contributed the same in this article and considered to be co-first authors. Correspondence to: Davood Shafie, MD Assistant Professor of Cardiology/Fellowship in Heart Failure and Transplantation, Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran, Phone: 0098-913-318-8054 Email address: [email protected]

Short title: hypertension and medication adherence Type of article: original article Total number of pages: 19 Total number of tables: 5 Total number of photographs: 0 Abstract word count: 237 Main text word count: 2547 Conflicts of interest: None of the authors had any personal or financial conflicts of interest.

Antihypertensive drugs adherence and its association with blood pressure control status Abstract: Background: The relation between antihypertensive drugs adherence and blood pressure (BP) control status has been less frequently investigated. Objectives: In this article we aimed to evaluate the relation between medication adherence and hypertension (HTN) status among Iranian hypertensive adults. Materials and Methods: This cross-sectional study was conducted from August 2015 to March 2016 in one city in Iran, Isfahan. Participants aged 18-84 years were eligible for enrollment in the project. After 5 minutes of rest in a quiet room, BP was measured three times from each participant’s right arm with calibrated tools and standard methods. Drug adherence scores were collected through specific questionnaire. Finally, 252 individuals diagnosed with HTN and being aware of their disorder formerly were selected for further analysis. Results: The mean age of male and female participants were 60.5 ± 11.5 and 60.6 ± 11.3 years, respectively (P= 0.94). Controlled and uncontrolled HTN were observed among 59.9 and 40.1% of study population, respectively. Employed subjects had poor adherence status (P= 0.04) and older age was associated with better drug adherence scores (P= 0.03). Our considerable finding revealed that increasing drug frequency was associated with higher medication usage compliance (P< 0.001). Conclusion: Our data suggested that in spite of decreasing drug adherence with being employees, younger age, new HTN occurrence or higher educational duration, increasing 1

number of drugs was associated with better medication adherence grades. Several comprehensive population based studies are necessary proving these relations. Keywords: blood pressure, hypertension, medication adherence

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Introduction: One of the most common cardiovascular diseases (CVDs) risk factors with increasing prevalence is hypertension (HTN)(1). The prevalence of this second preventable cause of premature death was estimated to be 22% globally(2). This disease affects one billion people and it has been predicted that approximate 1.56 billion individuals will be affected by the year 2025 in which two thirds of them would be occurred in developing countries(3). In Iran, it has been reported that one-fifth of population suffered from HTN(4). Despite improvements in its management during three decades, HTN is one of the leading cause of morbidity and mortality worldwide(5). Vascular diseases resulted from this pathologic condition is a key step leading to cardiovascular events(6). HTN complications account for 9.4 million deaths out of 17 million ones each year(3). Furthermore, 45 and 51% of deaths due to cardiac diseases and strokes had been related to this disease, respectively(2, 3). Because of insidious nature of the disease and unknown therapy duration, medication adherence is becoming a great issue in a way that adherence to antihypertensive medication therapy is the main predictor of treatment success and an effective step in controlling blood pressure and preventing complications(1). However, this adherence is not optimal. For instance, in one study it had been shown that 40-60% of hypertensive patients did not follow their medication schedules(7). Moreover, another research showed that among individuals with HTN more than half of them had been classified as low adherent to their medications(8). HTN control rate was reported to be 46.2 and 44.9% in different nations(9, 10). In Iran, its prevalence was estimated to be ranged from 62 to 65% in different times(8).

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While it has been suggested that medication non-adherence is a potential risk factor of HTN control rate, in this study we aimed to evaluate adherence of antihypertensive drugs and its relation with blood pressure (BP) control among Iranian hypertensive adults. Materials and methods: Study population This cross-sectional study was performed on Iranian adults living in third greatest city of Iran, Isfahan. From August 2015 to March 2016 anyone aged 18-84 years living in this city were eligible for recruitment in the study. The exact methodology of data sampling was published elsewhere(11). After inviting individuals to health care clinic, demographic information was gathered through questionnaire after signing of informed consent form. Then, further questions were asked about medication history and drug adherence while the subject was seated. Thereafter, each individual was relaxed in a quiet room for extra five minutes and BP was measured three times from both arms with one-minute interval. Any limitations in BP assessing including arm casting or presence of shunts or fistula, being on any special diet in order to control body weight or fasting state, presence of mental illnesses or organic ones including Cushing syndrome, pheochromocytoma, any types of cancer or chronic kidney disease needing hemodialysis in addition to pregnancy was considered exclusion criteria. A total number of 2107 subjects had been selected and after BP measurements, 352 of them were demonstrated to suffer from HTN which 100 individuals were not aware of their disorder at all. Finally, after merging of all information, data of 252 persons were available for analysis. This study was approved by ethical committee affiliated to Isfahan University of Medical Sciences (IUMS). Assessment of variables: 4

Data on age, sex, marital status (married, single/widow), occupation status (employed, housewife, retired), education years (less than 6 years, 6-12 years, more than 12 years) and presence or absence of diabetes mellitus (DM), hyperlipidemia (HLP) or being smoker (yes/no) were assessed through questionnaire. HTN drug history information including usages of diuretics, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), beta-blockers, alpha-blockers and nitrates plus medication adherence were assessed subjectively and through Morisky Medication Adherence Scale(12). This 8-item scale questionnaire contained seven questions with two choices (yes/no) and one Likert-type answer selection (never, rarely, sometimes, usually and all the time). Each question had one score and participants were categorized based on sum of points to low (< 6), moderate (6-7) and high adherence (8) group(8). Standard methods were utilized measuring BP in a way that participants were seated on backed chairs with their soles of feet on the ground and were notified not to cross their legs. Their arms had been located at the heart level with their palms facing upward. After resting for five minutes in a silent room, BP was measured three times with one-minute interval from both arms. The means of 2nd and 3rd right arm BP being measured by digital arm BP tool (Microlife, Widnau, Switzerland) was considered as each participant’s BP status. In order to minimize the effect of white coat hypertension, all measurements were done by personnel clothing as general population. Digital BP measurement tool was calibrated with standard mercury sphygmomanometer several times on 1-3 individuals. Data on height and weight of subjects were collected by non-elastic measuring tape located on the wall and digital weight scale (Soehnle, Nassau, Germany), respectively. Calibration of aforementioned devices were performed using daily metal tape and 5 kilograms (Kg) weight for control, respectively. Body mass index (BMI) 5

was calculated by division of weight in kilograms over height in squares of meter (Kg/m2). In order to increase the measurements accuracy all assessments were done by fully trained personnel after several months of practical courses and obtaining official letters from Isfahan Cardiovascular Research Institute. Participants were also asked to wear light weighting clothes as possible with their shoes taken off in order to increase likelihood of precise weight measurement. Moreover, reading digital numbers was associated with less odds of committing errors comparing to traditional methods. Statistical analysis: Categorical and continuous variables were reported as frequencies (percentages) and mean ± standard deviation (SD), respectively. Chi-square, independent t test and analysis of variance (ANOVA) were used analyzing categorical and numerical variables as appropriate. Relation between medication adherence scales and demographic factors was evaluated by Pearson’s correlation coefficient. Moreover, aforementioned grades were reported based on age specified group (less than 50, 50-60, 60-70 and 70 or more than 70 years old). All analyses were done using Statistical Package for Social Sciences (SPSS Inc., version 19.0, Chicago, IL, USA) and Pvalues less than 0.05 were considered statistically significant. Results: The mean age and BMI of study population were 60.5 ± 11.4 years and 29.6 ± 4.2 kg/m2, respectively. Females contained the dominant group of participants(54.7%). The most prevalent anti-hypertensive consuming agents were ARBs plus beta-blockers and drug subtypes difference was not significant between participants with/without controlled HTN except in terms of CCBs showing borderline significance (P= 0.04) (data not shown). General characteristics of 6

individuals are provided in Table 1. Males had lower BMI and were mostly married, being employed or retired, more educated and smoked more frequently in addition to having lower abnormal lipid levels comparing to females. There was no significant relation in terms of DM or BP indices including systolic blood pressure (SBP) or diastolic blood pressure (DBP) between genders. Table 2 illustrated drug compliance scores based on different variables. According to job status, housewives had significantly higher mean scores than the other employment categories. Although women had higher scores than men, this relation was not statistically significant (P= 0.10). Furthermore, no considerable association had been found in terms of other variables including marital status, DM, HLP and smoking habits. In Table 3, general characteristics of study population has been depicted based on drug compliance and BP status. Our results showed that participants with good drug adherence were slightly older (P= 0.03) and had lower DBP means (P= 0.01) compared to low or medium adherence groups. No other variables except BP indices were different among patients with/without controlled HTN showing significant higher means of both SBP and DBP means among uncontrolled hypertensive individuals (P< 0.001). Information on distribution of drug compliance according to numbers of drug usages was shown in Table 4. The mean medication adherence score of patients using three drugs was 6.60±1.8 and was significantly higher than patients using one or two drugs (5.02±2.26 and 5.90±1.98, respectively, P< 0.001). Further analysis revealed that patients with good medication adherence consumed higher numbers of drugs compared to low adherence one. Moreover, data correlation of drug compliance revealed that although BMI had insignificant correlation with drug

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compliance, age and HTN were correlated weakly positive and education years and BP indices including SBP and DBP were associated weakly negative with medication adherence. Distribution of HTN status according to medication adherence classifications, as depicted in Table 5 failed to prove any significant relation between aforementioned variables. Discussion: The main aim of this study was evaluating the relation between antihypertensive medication adherence and HTN control status among Iranian individuals suffering from HTN. The dominant percentage of patients had controlled HTN (59.9% vs. 40.1%). While this rate was higher than previous study reports in Iran (44.9%, 46.2%) (9, 10) and China(12), it was lower than Miedema et al.’s research reported a control rate of 72.7% (13). Since medication non-adherence is a risk factor of uncontrolled hypertension, it is important to evaluate antihypertensive drug adherence and its associated risk factors. Our findings revealed that patients’ employment status, age, number of prescribed medication, HTN and education duration had been associated with medication adherence. This study showed that being a housewife and retired were associated with good adherence despite several studies reported controversial results(14, 15). Moreover, there are multiple studies evaluating the relationship between age and medication adherence(16). Our outcomes suggested that older patients had better adherence which was consistent with other studies. This may be due to the fact that several other comorbidities could result in taking their sicknesses more seriously and consequently having a better adherence. On the other hand, other studies reported an association between increasing age and poor adherence which might be due to other factors like lower cognitive function level(17). 8

Our results was inconsistent with other studies in terms of drug frequency. A cross-sectional study was conducted in Southwest Ethiopia in order to find the relation between medication adherence and drug frequency. They enrolled 311 individuals aged at least 18 years and completed questionnaire through interview. Morisky Medication Adherence questionnaire was used to assess drug adherence and scores of at least six categorized participants to adherent group. After data analysis they reported there was a reverse association between drug adherence and number of prescribed medications(1). Another study recruited 346 participants of older than 18 years. Their BP data were gathered through three measurements previously assessed in each subject’s medical form and the mean of them was considered as patient’s BP. They defined controlled HTN with BP of lower than 150/90 and 140/90 mmHg in individuals higher and lower than sixty years, respectively. Medication adherence was assessed by 4-item Morisky-GreenLevine scale. Their findings revealed that a larger number of oral prescribed medications results in a lower level of adherence(3). Moreover, Ramli et al. performed a multi-centered study on 653 individuals of more than 30 years. They obtained the last BP measurement in each participant’s medical profile and further categorized them to controlled or uncontrolled HTN status based on Malaysian BP classification. Participants’ drug adherence was collected through a combination of Hill-Bone Adherence to Blood pressure therapy and 8-item Morisky Medication Adherence Scale. They found that patients consuming less drug had better treatment adherence(18). Another research in Sweden on 384 participants was done by Henex and colleagues and they defined a BP level of lower than 130/80 mmHg and 140/90 mmHg for diabetic and healthy individuals as controlled level, respectively. Their findings showed that there is a reverse association between patients’ adherence and number of prescribed medications (19). Research location of aforementioned 9

studies which were hospitals plus assessment of BP just according to medical records might affect their outcomes. Although a lower number of drugs could be easier to be used, a possible explanation would be that patients with a higher number of prescribed medications would probably consider themselves sicker and they subsequently tend to adhere better. Another factor that showed an association with medication adherence was duration of hypertension. This study suggested that patients who were hypertensive for a longer period had better adherence scores. This finding was consistent with Caro et al.’s study(20), while some other studies reported that there was not any association between duration of hypertension and medication adherence(18). A probable hypothesis for this finding might be that the longer a patient lives with an illness, the more he/she would aware of the nature of the disease. With regards to education years, this study showed that longer duration of studying resulted in lower adherence grades. This was in disagreement with previous studies and it might be due to the fact that years of education were generally defined fewer in our study compared with others(21, 22). Accurate BP measurement with standard methods and via calibrated tools were some parts of our strengths. Also, we used digital BP equipment in order to minimize the human error occurring during BP assessment, especially via traditional methods. This current study was not free from limitations. The main one was the design of the project preventing us from determining causality relation. All BPs were measured by a digital device; therefore, generalization of our data to studies using other methods for BP assessment must be taken with cautious. Furthermore, data of some effective variables including psychological status were not gathered in this study. In conclusion, our data suggested that drug adherence scores may not necessarily become lower by increasing the number of medications. Also employees, younger patients, new hypertensive patients and patients having a higher level of education tend to have poor medication adherence. 10

Health care policies should prioritized strategies in order to enhance adherence in these groups of patients.

References 1. Asgedom SW, Atey TM, Desse TA. Antihypertensive medication adherence and associated factors among adult hypertensive patients at Jimma University Specialized Hospital, southwest Ethiopia. BMC research notes. 2018;11(1):27. 2. Animut Y, Assefa AT, Lemma DG. Blood pressure control status and associated factors among adult hypertensive patients on outpatient follow-up at University of Gondar Referral Hospital, northwest Ethiopia: a retrospective follow-up study. Integrated blood pressure control. 2018;11:37-46. 3. Teshome DF, Bekele KB, Habitu YA, Gelagay AA. Medication adherence and its associated factors among hypertensive patients attending the Debre Tabor General Hospital, northwest Ethiopia. Integrated blood pressure control. 2017;10:1-7. 4. Najafipour H, Nasri HR, Afshari M, Moazenzadeh M, Shokoohi M, Foroud A, et al. Hypertension: diagnosis, control status and its predictors in general population aged between 15 and 75 years: a community-based study in southeastern Iran. International journal of public health. 2014;59(6):9991009. 5. Volpe M, Tocci G, de la Sierra A, Kreutz R, Laurent S, Manolis AJ, et al. Personalised Single-Pill Combination Therapy in Hypertensive Patients: An Update of a Practical Treatment Platform. High blood pressure & cardiovascular prevention : the official journal of the Italian Society of Hypertension. 2017;24(4):463-72. 6. Chen X, Huang B, Liu M, Li X. Effects of different types of antihypertensive agents on arterial stiffness: a systematic review and meta-analysis of randomized controlled trials. Journal of thoracic disease. 2015;7(12):2339. 7. Jankowska-Polanska B, Chudiak A, Uchmanowicz I, Dudek K, Mazur G. Selected factors affecting adherence in the pharmacological treatment of arterial hypertension. Patient preference and adherence. 2017;11:363-71. 8. Moharamzad Y, Saadat H, Shahraki BN, Rai A, Saadat Z, Aerab-Sheibani H, et al. Validation of the Persian version of the 8-item Morisky Medication Adherence Scale (MMAS-8) in Iranian hypertensive patients. Global journal of health science. 2015;7(4):173. 9. Ghaffari S, Pourafkari L, Tajlil A, Sahebihagh MH, Mohammadpoorasl A, Tabrizi JS, et al. The prevalence, awareness and control rate of hypertension among elderly in northwest of Iran. Journal of cardiovascular and thoracic research. 2016;8(4):176-82. 10. Jahangiry L, Ghanbari J, Abbasalizad Farhangi M, Sarbakhsh P, Ponnet K. Predictors of poor blood pressure control among Iranian hypertensive patients. BMC research notes. 2017;10(1):668. 11. Eghbali-Babadi M, Khosravi A, Feizi A, Sarrafzadegan N. Design and implementation of a combined observational and interventional study: Trends of prevalence, awareness, treatment and control hypertension and the effect of expanded chronic care model on control, treatment and self-care. ARYA atherosclerosis. 2017;13(5):211. 12. Kang CD, Tsang PP, Li WT, Wang HH, Liu KQ, Griffiths SM, et al. Determinants of medication adherence and blood pressure control among hypertensive patients in Hong Kong: a cross-sectional study. International journal of cardiology. 2015;182:250-7. 11

13. Miedema MD, Lopez FL, Blaha MJ, Virani SS, Coresh J, Ballantyne CM, et al. Implications of the Eighth Joint National Committee guidelines for the management of high blood pressure for aging adults: Atherosclerosis Risk in Communities Study. Hypertension. 2015:HYPERTENSIONAHA. 115.05560. 14. Li YT, Wang HH, Liu KQ, Lee GK, Chan WM, Griffiths SM, et al. Medication adherence and blood pressure control among hypertensive patients with coexisting long-term conditions in primary care settings: A cross-sectional analysis. Medicine. 2016;95(20). 15. Zyczynski TM, Coyne KS. Hypertension and current issues in compliance and patient outcomes. Current hypertension reports. 2000;2(6):510-4. 16. Yang Q, Chang A, Ritchey MD, Loustalot F. Antihypertensive Medication Adherence and Risk of Cardiovascular Disease Among Older Adults: A Population-Based Cohort Study. Journal of the American Heart Association. 2017;6(6). 17. Hansell MW, Mann EM, Kirk JK. Hypertension treatment strategies for older adults. The Journal of family practice. 2017;66(9):546-54. 18. Ramli A, Ahmad NS, Paraidathathu T. Medication adherence among hypertensive patients of primary health clinics in Malaysia. Patient preference and adherence. 2012;6:613-22. 19. Hedna K, Hakkarainen KM, Gyllensten H, Jonsson AK, Andersson Sundell K, Petzold M, et al. Adherence to Antihypertensive Therapy and Elevated Blood Pressure: Should We Consider the Use of Multiple Medications? PloS one. 2015;10(9):e0137451. 20. Caro JJ, Salas M, Speckman JL, Raggio G, Jackson JD. Persistence with treatment for hypertension in actual practice. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 1999;160(1):31-7. 21. Mahmoudian A, Zamani A, Tavakoli N, Farajzadegan Z, Fathollahi-Dehkordi F. Medication adherence in patients with hypertension: Does satisfaction with doctor-patient relationship work? Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences. 2017;22:48. 22. Tilea I, Petra D, Voidazan S, Ardeleanu E, Varga A. Treatment adherence among adult hypertensive patients: a cross-sectional retrospective study in primary care in Romania. Patient preference and adherence. 2018;12:625-35.

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Table 1, general characteristics of study participants (n= 252).

Age (years) BMI (Kg/m2) BMI (%)

<25 25-30 30-35 ≥35 Marital status Married (%) Single/widow Employment Employed status (%) House wife Retired Years of 0 to 5 education (%) 6 to 12 More than 12 Diabetes Yes mellitus (%) No Hyperlipidemia Yes (%) No Smoking status Yes (%) No Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) BMI: body mass index

Male 60.50±11.55 28.6±3.6 15 (13.2) 68 (59.6) 26 (22.8) 5 (4.4) 107 (93.9) 7 (6.1) 45 (39.5) 0 (0) 69 (60.5) 69 (60.5) 37 (32.5) 25 (21.9) 35 (30.7) 79 (69.3) 50 (43.9) 64 (56.1) 22(19.3) 92(80.7) 136.71±16.26

Female 60.60±11.35 30.4±4.5 16 (11.6) 43 (31.2) 58 (42.0) 21 (15.2) 97 (70.3) 41 (29.7) 4 (2.9) 128 (92.8) 6 (4.3) 6 (4.3) 37 (26.8) 7 (5.1) 51 (37.0) 87 (63.0) 78 (56.5) 60 (43.5) 3(2.2) 135(97.8) 134.38±19.78

Total 60.56±11.42 29.61±4.2 31 (12.3) 111 (44.0) 84 (33.3) 26 (10.3) 204 (81.0) 48 (19.0) 49 (19.4) 128 (50.8) 75 (29.8) 146 (57.9) 74 (29.4) 32 (12.7) 86 (34.1) 166 (65.9) 128 (50.8) 124 (49.2) 25(9.9) 227(90.1) 135.43±18.27

P-value 0.94 0.001 <0.001

81.47±10.74

77.88±11.92

79.50±11.52

0.01

13

<0.001 <0.001

<0.001

0.29 <0.001 <0.001 0.31

Table 2, drug compliance scores across different categories of variables.

Sex

Female (N=138) Male (N=114) Marital status Married (N=204) Single/widow (N=48) Employment Employee status (N=49) Housewife (N=128) Retired (N=75) Diabetes Yes (N=86) mellitus No (N=166) Hyperlipidemia Yes (N=128) No (N=124) Smoking status Yes (N=25) No (N=227)

Drug compliance score 5.34±2.40

P-value 0.10

4.82±2.58 5.05±2.47

0.48

5.34±2.62 4.36±2.55

0.04

5.39±2.42 5.09±2.52 5.27±2.48 5.01±2.50 5.33±2.39 4.86±2.59 4.44±2.61 5.18±2.47

14

0.43 0.14 0.16

Table 3, general characteristics of study participants according drug compliance and blood pressure status.

Weak Age (years) Sex (%)

Drug compliance Medium Good

58.7±11.5

61.4±11.3

63.5±10.5

57 (41.6)

54 (39.4)

26 (19.0)

61 (53.5) 29.2±3.8 25 (53.2) 35 (52.2)

31 (27.2) 30.4±4.4 18 (38.3) 18 (26.9)

22 (19.3) 29.1±4.6 4 (8.5) 14 (20.9)

34 (50.0)

21 (30.9)

13 (19.1)

24 (34.8) Years of 0-5 62 (42.5) education 6-12 34 (46.6) (%) >12 22 (68.8) Diabetes Yes 37 (43) mellitus (%) No 81 (49.1) Hyperlipide Yes 53 (41.4) mia(%) No 65 (52.8) Duration of diseases 69±68.2 (months) Systolic blood 137.5±17. pressure (mmHg) 8 Diastolic blood 81.5±10.5 pressure (mmHg) BMI: body mass index

28 (40.6) 56 (38.4) 24 (32.9) 5 (15.6) 30 (34.9) 55 (33.3) 50 (39.1) 35 (28.5)

17 (24.6) 28 (19.2) 15 (20.5) 5 (15.6) 19 (22.1) 29 (17.6) 25 (19.5) 23 (18.7)

84±77.6

91.2±70

133.3±18. 6 78.6±11.9

Fema le Male

BMI (Kg/m2) <50 Age category (%) 50-60 6070 ≥70

P-value

0.03

Blood pressure Not controlled controlled 61.4±11.3 59.9±11.4

Pvalue 0.29

52 (37.7)

86 (62.3)

49 (43.0) 29.5±4 15 (31.9) 28 (41.2)

65 (57.0) 29.6±4.3 32 (68.1) 40 (58.8)

25 (36.8)

43 (63.2)

33 (47.8) 57 (39) 31 (41.9) 13 (40.6) 41 (47.7) 60 (36.1) 44 (34.4) 57 (46)

36 (52.2) 89 (61) 43 (58.1) 19 (59.4) 45 (52.3) 106 (63.9) 84 (65.6) 67 (54)

0.14

79.9±78.6

77.2±67.9

0.77

134.1±18.4

0.22

152.7±12. 6

123.8±10.7

<0.001

75.8±12

0.01

88.3±9.6

73.6±8.5

<0.001

15

0.09 0.09

0.15

0.08 0.58 0.14

0.39 0.93

0.33

0.91 0.07 0.60

Table 4, distribution of drug compliance status based on frequency of drug usages and its correlation with participants’ characteristics. Drugs

One

Average drug compliance score 5.02±2.26

P-value

<0.001

Two 5.90±1.98 Three 6.60±1.80 Variables Age (years) BMI (kg/m2) Years of education Hypertension duration (months) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) BMI: body mass index

Drug compliance status Medium Good Total

P-value

Weak

66 (68.8)

43 (50.6)

18 (38.3)

0.001

25 (26.0) 5 (5.2)

33 (38.8) 9 (10.6)

18 (38.3) 11 (23.4) R 0.207 0.078 -0.133 0.144 -0.124 -0.211

16

(55.7) 127 76 (33.3) 25 (11.0)

0.001 0.21 0.03 0.02 0.04 0.00

Table 5, distribution of hypertension status based on drug compliance status.

Drug compliance status Good Medium Weak

Hypertension status Not-controlled controlled

Total hypertensive patients

P-value

16 (16.0) 30 (30.0) 54 (54.0)

48 (19.1) 85 (33.9) 118 (47.0)

0.19

32 (22.1) 55 (36.4) 64 (42.4)

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