International Journal of Nursing Studies 48 (2011) 235245

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Illness perceptions and adherence to therapeutic regimens among patients with hypertension: A structural modeling approach
Shiah-Lian Chen a, Jen-Chen Tsai b,*, Kuei-Ru Chou b
a b

Department of Nursing, Hungkuang University, Taichung, Taiwan School of Nursing, Taipei Medical University, 250 Wu-Xing Street, Taipei 110, Taiwan

A R T I C L E I N F O

A B S T R A C T

Article history: Received 25 January 2010 Received in revised form 2 July 2010 Accepted 5 July 2010 Keywords: Adherence Medication Self-management Hypertension Illness perception Structural equation model

Background: Patients lay views of illness are inuential on adherence to therapeutic regimes. However, factors associate with non-adherence are not examined simultaneously. Objectives: The purpose of the study was to test a hypothetical model of the relationships between illness perception and adherence to prescribed medication and self-management recommendations of hypertensive patients based on theoretical assumptions of the Common-Sense Model. Design: A cross-sectional, descriptive, correlational design. Settings: Cardiovascular clinics of three teaching hospitals in central Taiwan. Participants: Three hundred and fty-ve hypertensive patients. Methods: Data were collected through face-to-face interviews using structured questionnaires, including the Illness Perception Questionnaire-Revised, the Medication Adherence Inventory, and the Inventory of Adherence to Self-Management. Data were analyzed by structural equation modeling using LISREL. Results: The ndings suggested that the illness identity may directly affect patient adherence to prescribed medications or indirectly affect patient adherence via control of the disease and cause. Control of the disease exhibited direct effects on adherence to prescribed medications and self-management, while the cause of the illness only showed direct effects on adherence to prescribed medications. The relationships were independent of systolic blood pressure, age, the total number of antihypertensive medication, and comorbidity. Conclusions: The ndings of the study extend the utility of the Common-Sense Model, suggesting that adherence to therapeutic regimens may be enhanced by improving a sense of controllability. For patients who experience symptoms related to high blood pressure, barriers to adherence may be reduced by assessing and clarifying the meaning of illness identity and causal attributions. 2010 Elsevier Ltd. All rights reserved.

What is already known about the topic?  The theoretical framework of the Common-Sense Model is useful for examining patient adherence behavior.

 Patients lay views are associated with adherence to therapeutic regimens.

What this paper adds  The study provides evidence supporting the role of illness identity in adherence to therapeutic regimens of patients with hypertension.

* Corresponding author. Tel.: +886 2 27361661x6308; fax: +886 2 2377 2842. E-mail address: jenchent@tmu.edu.tw (J.-C. Tsai). 0020-7489/$ see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.07.005

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 Control of the disease exhibited direct effects on adherence to prescribed medications and self-management, while the cause of disease only showed direct effects on adherence to prescribed medications. The relationships were independent of systolic blood pressure, age, the total number of antihypertensive medication, and comorbidity. 1. Introduction Hypertension is one of the most important preventable causes of death worldwide (World Health Organization, 2003). It is estimated that about a quarter of adults in the world have hypertension (Kearney et al., 2005), and 59% of hypertensive patients have received treatment (Chobanian et al., 2003). Yet, adherence to treatment is around 5070% (World Health Organization, 2003). DiMatteo (2004) estimated that monetary waste related to non-adherence for patients with hypertension is around US$ 8.4 million per year. In Taiwan, over 60% of elderly hypertensive patients take medication for their blood pressure control, but the control rate is <29% (Chen, 2003). Improving adherence to treatment is one of the most cost-effective strategies for desirable therapeutic outcomes and preventing adverse cardiovascular events. Many studies have explored issues of non-adherence since the term became popular in the 1970s (Lutfey and Wishner, 1999). However, recent ndings of metaanalyses have reported that most interventions are expensive, complex, or labor-intensive, and the effects on improving patient adherence are limited (Haynes et al., 2002; McDonald et al., 2002). Tailoring interventions to address specic barriers to change from the patients perspective is imperative (Takiya et al., 2004). Nevertheless, in past decades, issues of patient adherence were mostly explored from the perspective of health professionals rather than patients lay view (Morris and Schulz, 1992; Vermeire et al., 2001). An individual constructs his/ her own views about disease and treatment which can greatly differ from those of health professionals (Steven et al., 2002; Larun and Malterud, 2007). Some studies found that patients may make their own decisions about medication adherence based on their own lay views (Chen et al., 2009; Meyer et al., 1985; Ross et al., 2004). Yet, most studies are descriptive, and a comprehensive understanding of patient adherence behavior is lacking. 1.1. Theoretical framework and review of previous research Hypertension is one of the most common chronic diseases for which long-term adherence to therapeutic recommendations are required for favorable outcomes. Factors that motivate patients to adhere to long-term therapeutic regimens are not clear. The assumptions of the Common-Sense Model (CSM) reveal that patients taking actions to reduce health risks are guided by their subjective or common-sense perceptions of the health threat (Leventhal et al., 2003). Individuals form this illness perception based on their reactions to external and internal stimuli through two parallel pathways: cognitive and emotional representations. The components of the

illness perception are illness identity (symptoms that an individual experiences in his/her illness), cause (causal attribution of the illness), timeline (individual perceptions about the duration of the illness), timeline-cyclical (changeability of the illness), personal control (beliefs about controllability of the illness by the patient), treatment control (beliefs about controllability or curability of the illness by treatment), consequences (impacts of the illness on the patient and his/her daily life), illness coherence (the coherence of usefulness of individual illness representations), and emotional representation (the emotional responses aroused by the illness (Leventhal et al., 2003; Moss-Morris et al., 2002)). Some studies focusing on patient perspectives reported that patients have their own views of illness, and they selfregulate their treatment behaviors accordingly. Meyer et al. (1985) found that newly diagnosed patients with hypertension were more likely to drop out of treatment if they perceived the disease to be acute or experienced symptoms upon their rst clinical visit. Even though some patients may agree that the nature of hypertension is asymptomatic, they will still predict their blood pressure by symptom presentations. Heurtin-Roberts and Reisin (1992) reported that those patients who dened their hypertension as high-pertension were less compliant with their treatment and had a lower blood pressure control rate. Enlund et al. (2001) found that patients with three or more problems (such as symptoms and interference with daily routines) were ve times more likely to have modied their dosage instructions than those without problems. Similar results were also reported by qualitative studies (Rose et al., 2000). Based on the theoretical framework of the CSM, Ross et al. (2004) and Patel and Taylor (2002) reported similar predictive effects of adherence behaviors in patients with hypertension. Patients with lower emotional representation, with less perceived personal control, and who were older were more likely to adhere to prescribed medications. Chen et al. (2009) found that signicant predictors of adherence to prescribed medications and self-management greatly differ. Variables associated with medication adherence are: treatment control, risk factors, and psychological attribution, while symptoms experienced after a hypertension diagnosis, symptoms for blood pressure prediction, personal control, balance and cultural causal attribution were signicantly associated with adherence to self-management. The ndings may suggest that patients lay views are more inuential within the domain of self-management. Cameron et al. (1993) found that patients use symptoms to create and update representations. Illness is identied by both an abstract label and concrete sensory symptoms. When given a diagnosis (label), a person will look for symptoms to match, and a person experiencing symptoms will seek to label the symptoms (Leventhal et al., 1998). Most patients are usually labeled as being hypertensive after blood pressure screening without experiencing any symptoms. Contrary to the asymptomatic nature of hypertension, in longitudinal (Sigurdsson and Bengtsson, 1983), cross-sectional (Erickson et al., 2004), and population-based studies (Kjellgren et al., 1998)

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as well as a randomized double-blind clinical trial (Hollenberg et al., 2000), some researchers found that many patients experience symptoms before (Kjellgren et al., 1998) and after (Kyngas and Lahdenpera, 1999; Mena-Martin et al., 2003) a hypertension diagnosis. Some patients may even predict their blood pressure based on their personal inference of somatic cues (Pennebaker and Watson, 1988), even though the inference may largely be inaccurate (Brondolo et al., 1999). Patients may use environmental cues to make sense of the ambiguous symptoms, and seek meaning for the symptoms (Baumann et al., 1989). Causal attributions of the illness are also at the core of health behaviors (Chang, 2000), and there is a universal need for individuals to conceptualize abstract labels in adapting to health risks (Baumann, 2003). In Taiwanese society, multiple healthcare delivery systems (Western medicine, traditional Chinese medicine, and folk medicine) coexist at the same time. Decisions for health care advice are based on individual symptom perceptions (Chang, 1998), and causal attributions of the illness (Chang, 2000). For example, if a patient perceives the symptom which is resulted from bacteria, he/she will seek help from Western medicine; an imbalance between inner and outer systems may lead one to try Chinese medicine, while bad luck might cause one to seek help from folk medicine. Causal attribution not only implies the possibility of gaining a certain degree of control over an illness, but also affects the experience of symptoms and the illness (Kirmayer et al., 1994). Attention to causal attribution of illness is essential to elicit cultural variations in illness experiences and health behaviors. Even though many studies explored factors associated with adherence to therapeutic regimens, most of them are descriptive and correlational ndings. A comprehensive understanding of relationships among the variables based on a theoretical model is needed (Hagger and Orbell, 2003). There are very few studies analyzing the relationship of illness perceptions with adherence to prescribed medications and self-management at the same time, particularly which describe the roles of illness identity and cause of adherence among patients with hypertension. Symptoms experienced by hypertensive patients may be subjective

and not sensitive or specic. Symptom is an important cue activating illness representations (Leventhal et al., 1998), is part of cognitive representation (Leventhal et al., 2003), may be used to appraise the efcacy of the therapeutic regimen (Leventhal et al., 1992), and illness representations may be modied in response to feedback from action behaviors (Meyer et al., 1985; Leventhal et al., 2003). Yet, very few studies validate the role of illness identity in the theoretical framework of CSM. The aim of this study was to test a hypothetical model of adherence to both prescribed medications and self-management behaviors in patients with hypertension in a Taiwanese (ethnic Chinese) social context using the technique of structural equation modeling (SEM). 1.2. Research model and hypotheses Based on the CSM and the above literature review, patients coping with a health threat is inuenced by the illness representation that is shaped by the internal and external stimuli the patient perceives. Illness identity is the symptom related to the illness the patient perceives which serves as an internal somatic stimulus during the coping process (Chang, 1998). Dependent on the acuity and distress prompt of symptom experiences, illness identity may affect patient adherence behavior directly or indirectly via renegotiated with other cognitive or emotional representations (Kirmayer and Sartorius, 2007; Leventhal et al., 2003). The conceptual framework of the hypothesized model is presented in Fig. 1. The framework identies direct relations among the three factors of illness representations and adherence behavior, while illness identity is an eliciting cue for adherence to prescribed medication and self-management recommendations directly or indirectly through cause, a negative illness representation (negative IR), and control. Four factors including age (Kjellgren et al., 1998; Ross et al., 2004), systolic blood pressure (Kjellgren et al., 1998; Pennebaker and Watson, 1988), the total number of antihypertensive medications (AHMs) (Iskedjian et al., 2002; Schroeder et al., 2004), and comorbidities (Chen et al., 2009; Hagger and Orbell, 2003) were selected as confounding factors. After controlling for confounding

Fig. 1. The hypothesized model of the study. Neg. IR = Negative illness representation; AHM = the total number of the antihypertensive medication.

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factors, the relationships of the hypothetical model remained signicant. 2. Methods 2.1. Design and setting A cross-sectional, descriptive, correlational design was used. The study was conducted at cardiovascular clinics of three teaching hospitals in central Taiwan. The study was carried out between 1 September 2006 and 12 December 2007. 2.2. Participants Data were obtained from a purposive sample of 355 hypertensive patients. Inclusion criteria for participation in the study were adult patients with a diagnosis of essential hypertension conrmed by a cardiovascular physician, and having been prescribed an antihypertensive for their high blood pressure for at least 1 month prior to the study. Patients were excluded if they were medically unstable, with any critical or acute episodes, with a diagnosis of secondary hypertension, or with any psychiatric problems. Sample sizes that exceed 200 subjects could be considered adequate for using the technique of structural equation modeling analysis (Kline, 2005). Ethical approval was obtained from the Institutional Review Board of Taichung Veterans General Hospital. Permission to access the study sites was granted from the participating hospitals. Patients who met the study criteria and agreed to participate were asked to sign a consent form before data collection. Data was collected through face-toface interviews by a trained research assistant and the rst author following a standardized procedure. Anonymity and condentiality were guaranteed to participants. 2.3. Instruments Illness Perception Questionnaire-Revised (IPQ-R): Illness perception was measured using the IPQ-R (Moss-Morris et al., 2002). We translated the IPQ-R into Chinese and validated its psychometric properties for use in a Taiwanese sample (Chen et al., 2008). The Chinese IPQ-R is comprised of three components: illness representations, causes, and identity. Mean scores of each of the three components can be computed individually. The illness representations component of the IPQ-R consists of 32 questions on seven subscales including timeline, timelinecyclical, consequences, treatment control, personal control, coherence, and emotional representation. The ndings of the conrmatory factor analysis (CFA) indicated that ve rst-order factors made major contributions to the twosecond-order factors: negative illness presentation and control of the disease (Chen et al., 2008). Negative illness representation comprises three rst-order factor structure, including consequence, timeline-cyclic and emotional representation, while, control of the illness consists of two rst-order factor structure, representing personal control and treatment control. The items are rated on a ve-point response scale ranging from strongly disagree

to strongly agree. A higher score reects a stronger belief in a specic dimension. The cause component of the IPQ-R consists of 18 items on four subscales (psychology, risk factor, balance, and cultural attribution) that inquire about patients attributions about their illness. The score of each item is from 1 to 5, with 1 representing strongly disagree, and 5 representing strongly agree. A higher score reects a stronger belief of the causal attribution of the illness. Illness identity of the patients was measured using three sets of items: symptom score (symptoms that patients identied as being hypertension-related), symptom occasion (symptom experience before and after a hypertension diagnosis), and blood pressure prediction (symptoms used for blood pressure prediction) (Chen et al., 2008; Jessop and Rutter, 2003). Symptom scores were obtained by asking a patient to rate 30 symptoms with yes/no dichotomous responses. Only those symptoms identied by patients as being hypertension-related were counted in the symptom score. Symptom occasion was assessed by asking patients to indicate if they had experienced symptoms before and after the hypertension diagnosis. Blood pressure prediction was assessed by asking if patients could predict their blood pressure through symptom presentation on an ordinal response scale of yes, uncertain, or no. The total number of symptoms used for blood prediction was also counted. The Medication Adherence Inventory (MAI): The MAI contains 13 items that correspond to three subscales: the decreasing-type of dosage deviation, increasing-type of dosage deviation, and unintentional type. Scores on each item are rated on a ve-point Likert-type scale ranging from 1 (never) to 5 (always). Scores of negative statements were reversed, with a higher score indicating a greater adherence rate. Psychometric properties of the MAI were satisfactory. A three-factor solution was extracted by the factor analysis which explained 68.77% of the total variance of the MAI. Cronbachs alpha was 0.89 (Chen et al., 2009). The Inventory of Adherence to Self-Management (IASM): The 11 items IASM was developed based on a literature review. The tool assesses behavioral domains of selfmanagement activities across three subscales: an unhealthy diet, a healthy diet, and an exercise regimen. Each item of the IASM has a ve-point response format ranging from 1 (never) to 5 (always). A higher score indicates a greater adherence to self-management recommendations. The ndings of the factor analysis revealed that the IASM was a three-factor structure and accounted for 56.13% of the IASM variance. Cronbachs alpha was 0.70 (Chen et al., 2009). 2.4. Statistical analysis Data were analyzed using SPSS for Windows (vers. 13.0) to describe characteristics of the sample and measures. The SEM analyses were conducted with LISREL 8.54 software. The SEM analysis was conducted according to the two-step approach suggested by Anderson and Gerbing (1988). In the rst step, conrmatory factor analysis (CFA) was performed to test the measurement model for latent

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constructs. Second, the SEM was used to test the study hypotheses. Covariances between variables were computed with PRELIS (Brown, 2006). The hypothesized model against the observed data was obtained rst. Modication indices were used to relax the parameter constraints to improve the best t of the model. Model t was evaluated using x2, root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), comparative t index (CFI), Bentler and Bonetts nonnormed t index (NNFI), the Goodness of Fit Index (GFI), and critical N (CN). The results of the Wald test and Lagrange Multiplier test were examined to determine a parsimonious model (Kline, 2005). No outliers were evident in the analysis. With a normal distribution of the data (skewness < 2, Kurtosis < 5), an estimation of maximum likelihood (ML) was used. 3. Results 3.1. Characteristics of the sample The sample of respondents consisted of 214 men (60.3%) and 141 women (39.7%), with a mean age of 65.19 (SD = 12.82) years. The mean duration of hypertension history was 10.45 (SD = 8.74) years, with a mean systolic blood pressure of 138.56 (SD = 15.10) mmHg and a mean diastolic blood pressure of 79.35 (SD = 11.69) mmHg. The majority of the respondents were married (87.3%). About 12.7% of the respondents were uneducated, whereas 35.8% had received an elementary school education, and 51.5% had received an education at the junior high school level or above. About 75.2% of the respondents earned less than NT$30,000 monthly, while only 24.8% earned > NT$30,000 monthly (The average exchange rate in 2009 was US$1.00 = NT$32.23). Over half of the sample (53.5%) reported being aficted with at least one other disease. The mean total number of AHMs was 3.61 (SD = 1.80). 3.2. The preliminary analyses A measurement model was tested using a conrmatory factor analysis in the preliminary analyses. The factorial structures of the measures were evaluated respectively by a CFA series. For the scale of illness representations, the second-order analysis indicated that two factors (control and negative IR), respectively represented the latent constructs underlying the factors of personal control, treatment control, consequence, timeline-cyclic, and emotional representation. The component of the cause of illness was found to be an 18-item structure with four rst-order factors. The three-factor model of the MAI was collapsed into a two-factor structure model, reecting selfregulation and unintentional dimensions of the original instrument. The items of the decrease- and increase-types of dosage deviation were combined into a single factor named the self-regulating type. Finally, the ISAM was an 11-item scale with three rst-order factors. The psychometric properties of the instruments for the fteen latent constructs were then analyzed using a measurement model. The indicators were eliminated from the measurement model if the factor loadings were low.

Model modication was also guided by the Lagrange Multiplier test and Wald test. The statistic ts of the original measurement model were x2 = 3388.55 (df = 1974), x2/df = 1.72, AIC = 3862.55, NNFI = 0.93, CFI = 0.94, GFI = 0.78, RMSEA = 0.045. After deletion of eight indicators sequentially (four items of the MAI, and four items of healthy diet), the statistic ts of the measurement were improved (x2 = 2501.81, df = 1665, x2/df = 1.50, AIC = 2953.81, N/FI = 0.95, CFI = 0.96, GFI = 0.81, RMSEA = 0.038). In the CFA analysis of the second-order factor, the fourdimension cause model and the three-dimension model of adherence to self-management were not supported because of poor loadings. Two factors including culture and healthy diet were excluded in the subsequent analysis. Three dimensions of the cause model were used as indicators of the cause, while the unhealthy diet and exercise were used as the indicator of adherence to selfmanagement. The nal statistic ts of the measurement model was x2 = 2145.89 (df = 1407), x2/df = 1.53, AIC = 2523.89, NNFI = 0.95, CFI = 0.96, GFI = 0.82, RMSEA = 0.039. The factor loadings (l) of the measures were 0.510.59 for identity, 0.490.80 for psychological factor, 0.460.67 for balance, 0.650.82 for culture, 0.420.88 for risk factor, 0.570.80 for consequence, 0.660.83 for time-cyclical, 0.780.87 for emotional representation, 0.500.80 for personal control, 0.480.66 for treatment control, 0.64 0.92 for self-regulation, 0.560.88 for unintentional, 0.51 0.74 for unhealthy diet, and 0.910.98 for exercise. All factor loadings for the measurement model were statistically signicant (t = 7.7022.28, p < 0.01), and observed indicators were loaded on predetermined factors, respectively. Convergent validity was acceptable. Table 1 shows the mean, standardized deviation, reliabilities and correlations of the 15 observed variables. The strongest factor correlations were found among timeline-cyclical, consequence, and emotional representation (r = 0.540.74). The average variance-extracted estimates were greater than the estimated squared correlations of factors for all measures, indicating discriminant validity. Internal consistency of the measures was supported by adequate Cronbachs alpha values (a = 0.700.89) and composite reliability (CR) coefcients (CR = 0.650.95). Overall, the ndings of the CFA provided acceptable support for the internal consistency, convergent validity, discriminant validity, and factorial validity of the proposed constructs in the measures. 3.3. Structural equation model (SEM) To test the additional construct relationships absent in the CSM, we conduct a hierarchical model comparison to test if adding the proposed paths to the CSM makes a signicant improvement in model t indices. The model specied as preliminary hypothesized model in Fig. 1 was examined as base model. The t statistics of the model were satisfactory (x2 = 136.14, df = 76, NNFI = 0.94, NFI = 0.91, GFI = 0.95, CFI = 0.95, RMSEA = 0.047). We used four confounding factors in the analysis. After adding the confounding factors to each of the endogenous latent factors, the t statistics did not show good t in the sample (x2 = 336.51, df = 118, NNFI = 0.82, NFI = 0.83, GFI = 0.91,

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Table 1 Mean, standard deviation (SD), correlations and reliabilities of the observed variables.

The square roots of averaged variance-extracted estimates are on the diagonal and correlation coefcients are on the off-diagonal. CR, composite reliability. * p < 0.05. ** p < 0.01. *** p < 0.001.

Mean

1. Occasion 2. BP prediction 3. Symptom score 4. Psychological 5. Balance 6. Risk factor 7. Consequence 8. Time-cyclical 9. Emotional representation 10. Personal control 11. Treatment control 12. Self-regulation 13. Non-intentional 14. Unhealthy diet 15. Exercise

4.03 2.88 3.12 22.16 14.85 9.16 12.67 10.16 10.09 17.27 14.75 18.96 22.09 11.51 19.95

CFI = 0.88, RMSEA = 0.072). Based on modication indices, the error term between negative IR and cause was freed. The change results in improvements in the t of the model (x2 = 261.04, df = 117, NNFI = 0.88, NFI = 0.87, GFI = 0.93, CFI = 0.92, RMSEA = 0.059). The positive association between a negative IR and cause reects the more negative impact of illness representation an individual experiences, the more cause etiology the one attributes to. The base model was presented in Fig. 2. We used this model as base model and added additional paths from illness identity to cause, control, negative IR, and adherence to the prescribed medication and selfmanagement, respectively. The model comparison ndings suggested that adding the proposed factors into the basic model makes a substantially improvement in the t statistics. The Chi-square differences between the model 2 and the basic competing models are signicant, indicating that the proposed model is better than the basic models (Table 2). The structural relationships with standardized path coefcients among the variables of the nal model are presented in Fig. 3. The paths from control (t = 4.06, b = 0.41), cause (t = 2.49, b = 0.25) and illness identity (t = 2.09, b = 0.23) to adherence to the prescribed medication were statistically signicant. The effect from control to adherence to self-management was also statistically signicant (t = 2.88, b = 0.52). Illness identity had a signicant positive effect on cause (t = 4.08, b = 0.37) and a negative IR (t = 4.86, b = 0.48), but a signicant negative effect on control (t = 2.63, b = 0.27). There were no effects of a negative IR on either adherence to the prescribed medications or self-management. The signicant paths that affect patients adherence to therapeutic regimens are similar in all the models. The nal model respectively accounted for 27.0% and 71.5% of the variance in adherence to the prescribed medications and selfmanagement recommendations. The indirect effects from illness identity to medication and self-management adherence were 0.20 (t = 2.75, p < 0.01) and 0.30 (t = 2.53, p < 0.05). Because of the presence of inconsistent mediation, the total effects were not signicant (t = 0.29, p > 0.05). For the confounding factors, age was negatively related to illness identity and cause of illness, but was positively associated with adherence to prescribed medications and self-management. Systolic blood pressure was positively related to a negative IR, and was negatively associated with adherence to medications. The total number of AHMs was positively associated with cause and a negative IR, and comorbidity was positively related to illness identity and cause (Table 3). 4. Discussion The study examines the proposed relationship specied in the CSM, and evaluates the role of illness identity in patient adherence to therapeutic regimens in patients with hypertension. The results of the study found that adding illness identity into the CSM model as an antecedent makes signicant improvement in the model t indices, indicating the feasibility of using the proposed model as an

15

14

13

12

11

10

Variable

1.26 1.61 3.93 5.06 3.50 2.67 3.45 3.02 6.30 2.96 1.92 2.29 3.37 3.96 2.92

SD

0.82 0.73 0.78 0.80 0.83 0.87 0.79 0.65 0.87 0.85 0.74 0.95

CR

0.84 0.81 0.72 0.74 0.80 0.81 0.87 0.78 0.79 0.81 0.89 0.70 0.73

1.00 0.35*** 0.32*** 0.11 0.06 0.08 0.14* 0.16* 0.15** 0.08 0.01 0.03 0.01 0.08 0.12**

1.00 0.29*** 0.32*** 0.16** 0.08 0.24*** 0.17*** 0.17** 0.21*** 0.16* 0.10 0.04** 0.18** 0.07

1.00 0.27*** 0.13* 0.07 0.34*** 0.32*** 0.27*** 0.06 0.03 0.04 0.05 0.04 0.08

0.64 0.58*** 0.28*** 0.48*** 0.43*** 0.44*** 0.08 0.18* 0.19*** 0.19** 0.10 0.17**

0.60 0.36*** 0.36*** 0.44*** 0.31*** 0.10 0.02 0.04 0.05 0.04 0.01

0.75 0.15* 0.12* 0.07 0.00 0.01 0.01 0.10 0.13* 0.02

0.67 0.54*** 0.74*** 0.16** 0.22** 0.13* 0.03 0.20** 0.16**

0.74 0.57*** 0.11 0.15* 0.19*** 0.16** 0.16* 0.07

0.80 0.05 0.13 0.11 0.05 0.12 0.09

0.66 0.44*** 0.22*** 0.19** 0.17** 0.18**

0.57 0.31*** 0.32*** 0.16* 0.09

0.74 0.78*** 0.27*** 0.15**

0.80 0.25*** 0.15**

0.61 0.19**

0.95

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Fig. 2. The basic structural model for adherence to therapeutic regimens after controlling for the effects of age, the total number of the antihypertensive medications, systolic blood pressure, and comorbidities on each of the latent variables. Chi-squared = 261.04, df = 117, p < 0.001, RMSEA = 0.059; SHTN, symptom score; SOC, symptom occasion; BPP, blood pressure prediction; ER, emotional representation; Cyc, timeline-cyclical; Con, consequences. The large ovals represent latent factors and the rectangles indicators of latent factors. The solid lines indicate p < 0.05, the dotted lines indicate p > 0.05.

Table 2 Model comparison results. Model Measurement model Basic modela Model 1b Model 2c (nal model)
a b

x2 (df)
2113.94/1383 (1.53) 261.04/117 (2.23) 212.55/116 (1.83) 209.27/114 (1.84)

Dx2 (Ddf)
1884.85*** (1290) 48.49*** (1) 51.77*** (3)/3.28(2)

NFI 0.89 0.88 0.89 0.89

NNFI 0.95 0.87 0.91 0.91

CFI 0.96 0.92 0.94 0.94

GFI 0.83 0.93 0.94 0.94

RMSEA 0.038 0.059 0.049 0.046

AIC 2520.40 407.04 360.55 361.26

Basic model including four confounding variables and an error correlation between a negative illness representation and cause. Illness identity as an exogenous variable (indirect effects). c Including direct and indirect effects from illness identity to adherence to therapeutic regimens. *** p < 0.001.

Table 3 Path coefcients (g) of the confounding factors. Variable Illness identity Cause Negative illness representation Control Medication adherence Self-management Mean SD Systolic BP 0.06 0.08 0.15** 0.02 0.12* 0.14 139.53 14.94 Age 0.22** 0.07* 0.01 0.09 0.23*** 0.56*** 65.96 12.31 AHM 0.06 0.17** 0.16** 0.10 0.09 0.13 3.61 1.80 Comorbidity 0.23** 0.15*** 0.01 0.07 0.05 0.03

Values are standardized path coefcients. Comorbidity: none = 0, yes = 1. AHM, the total number of antihypertensive medications. * p < 0.05. ** p < 0.01. *** p < 0.001.

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Fig. 3. The nal structural model for adherence to therapeutic regimens after controlling for the effects of age, the total number of the antihypertensive medications, systolic blood pressure, and comorbidities on each of the latent variables. Chi-squared = 209.27, df = 114, p < 0.001, RMSEA = 0.049; SHTN, symptom score; SOC, symptom occasion; BPE, blood pressure prediction; ER, emotional representation; Cyc, timeline-cyclical; Con, consequences, Exe, exercise. The large ovals represent latent factors and the rectangles indicators of latent factors. The solid lines indicate p < 0.05, the dotted lines indicate p > 0.05.

alternative in understanding patient adherence to therapeutic regimen. Illness identity directly and indirectly affected adherence to therapeutic regimens via cause and control of illness. Since multiple mediators were included in this model, inconsistent mediations were very likely occurred. Although the total effects are not signicant, the indirect effects remain valid (MacKinnon, 2008). Even after controlling for confounding factors, most of the relationships remained signicant. The ndings may reect the non-static and changeable regulating process of illness perception when coping with health threats. The mean duration of hypertension history of the sample is 10.45 (SD = 8.74) years. From a biomedical perspective, hypertension is asymptomatic, but our ndings indicated that patients reported experienced symptom after hypertension diagnosis. Symptom experience may imply ineffectiveness of therapeutic regimens, and lead to nonadherence (Leventhal et al., 1998). In this study, illness identity refers to experience with symptoms. We formed the scale items of illness identity (symptom score, symptom experience before and after a hypertension diagnosis, and blood pressure prediction) based on a literature review, and the psychometric properties of the scale were validated by the ndings of the CFAs. Physical symptoms are usually ambiguous, and interpretation of symptoms is also affected by psychological and social inuences (Petrie and Weinman, 2003).

Yet, in our study only symptoms recognized as being illness-related was counted in the symptom scores. This study provides new evidence of the component and the role of illness identity in the adherence behavior of patients with hypertension. Consistent with previous ndings (Frostholm et al., 2005; Hagger and Orbell, 2003), individuals who reported more symptoms tended to seek more causal attributions, perceived the illness to be more negative (such as cyclic variations, serious consequences, and more-emotional reactions to the illness) and less controllable. Previous studies produced inconsistent results for the relationship between cause and adherence (Meyer et al., 1985; Ross et al., 2004). In this study, we modied the cause scale items to include the categories of balance and cultural attribution to reect the attributes and research concerns of patients in an ethnic Chinese social context. Consistent with the results of previous ndings (Chen et al., 2009; Meyer et al., 1985; Orbell et al., 2008), we found that cause was associated with low adherence rates to prescribed medications. These ndings indicate that individuals who experience more symptoms will seek more causal attribution, and negative feelings toward illness representations are also intensied. Ethnic Chinese patients usually hold different causal explanations simultaneously and selfdiagnosis symptom/illness attributions before seeking help (Chang, 1998, 2000). Causal attributions not only

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give meanings to symptoms for illness identity, but also indicate the possibility of losing certain degree of control over the situation (Kirmayer et al., 1994). A higher score for the cause may thus lead to a lower adherent rate to the prescribed medication. Non-adherence may merely reect individuals efforts to maintain their ordinary identity (Hansson and Lowhagen, 2004). In addition, our ndings are consistent with reports in the literature (Chen et al., 2009; Horne and Weinman, 2002; Jessop and Rutter, 2003; Orbell et al., 2008) and indicate that control of illness is the most signicant predictor of a favorable outcome. Individuals who experience more symptoms may perceive less ability to control he/her illness, this may lead to lower adherence rates to both prescribed medications and self-management. The goal of individuals action behavior for health threats is danger control and fear control (Leventhal et al., 2003). Perception of a lower ability to control a health threat may imply an ineffectiveness of ones behavioral actions, or cognitive and emotional changes in illness representations because of somatic experiences. Higher control is associated with lower anxiety, lower avoidance/denial of coping strategies, and positive reappraisal (Hagger and Orbell, 2003; Orbell et al., 2008). Increased patient personal control and treatment control of an illness may be an effective way to improve adherence to therapeutic regimens. However, some studies reported a negative association between the perception of personal control and medication adherence (Patel and Taylor, 2002; Ross et al., 2004). This discrepancy may have resulted from different characteristics of the samples, such as household income, educational level, or locus of control. Further studies should explore which specic populations can benet from an increasing sense of personal control and treatment control. In contrast to previous ndings (Enlund et al., 2001; Horne and Weinman, 2002), this study found no relationship between a negative IR and patient adherence. This result may be related to the characteristics of the study sample and the stability of the disease status. In this study, the sample has long history of hypertension, so patients may have been more knowledgeable and aware of the consequences and time-cyclic nature of the illness. Also, since patients were attended by cardiovascular physicians with their blood pressure controlled to within normal ranges, they might not have interpreted somatic changes (symptoms) as an imminent danger because their coping actions are reinforced by the positive feedback of the action (Leventhal et al., 2003). Similar to previous ndings (Jessop and Rutter, 2003; Ross et al., 2004), the study found that age and systolic blood pressure inuenced adherence to therapeutic regimes. The total number of AHMs and comorbidities may moderate the effects through cause, negative IR, or illness identity. The results show those who were younger and had high systolic blood pressure were at greater risk for non-adherence. Kjellgren et al. (1998) found that younger patients tended to be more aware of hypertension and reported more symptoms. Health professionals should pay more attention to these subpopulations that are at risk in clinical encounters.

4.1. Limitations Several limitations related to the methodological issues of this study were found. The study was a cross-sectional design. The results were not able to determine the dynamic process of self-regulation. Although we used the SEM technique to test the hypothesized model, the relationships between the variables were tentative and require further validation. A longitudinal study design following the causaleffect variables over time would be helpful in validating the role of illness identity in patient adherence to therapeutic regimens. The ndings provide evidences supporting indirect effects from illness identity to medication and self-management adherence. Because of the presence of inconsistent mediation, the total effects were non-signicant. Further studies need to evaluate the presence of suppressor variables and their effects on patient adherence. Generalization of the ndings is also limited because of the technique of purposive sampling. Finally, adherence to therapeutic regimens was assessed with a self-reported measure. The result may be subject to social desirability and may have overestimated patient adherence. However, to obtain more-reliable data, the data were collected by trained research assistants with a standard protocol, and condentiality of the data was ensured to maximize the accuracy. 5. Conclusions The ndings of this study extend the function of the CSM by identied the role of illness identity in predicting adherence to therapeutic regimens in hypertensive patients. The study identied the disease-specic content of illness identity and culturally specic content of cause, and found that patients illness representations may have been inuenced by internal stimuli of somatic cues such as symptom experience and likely affected patient adherence accordingly. Variables of illness identity, cause and control were found to have great inuences on adherence to prescribed medications and self-management in the nal model, indicating the utility of the CSM in studying patient adherence. Based on the signicant ndings of this study, patients lay views of their illness should be a target variable for intervention to enhance adherence to therapeutic regimens. Even though patients views of illness identity and causal attribution of hypertension are primarily subjective, these beliefs do directly or indirectly affect adherence to therapeutic regimens. Adherence to treatment is more likely to be achieved if the self-regulative process (stimuli, representation, and coping) within an individuals selfsystem is coherent. Overemphasizing the asymptomatic nature of hypertension may create more barriers to adherence. Health professionals need to recognize the effects of the lay view on adherence, and accordingly provide proper information. The ndings of the study also suggest that to improve patient adherence, health professionals need to stress personal control and treatment control over the illness rather than negative effects of the illness, especially for those patients with high systolic blood pressure and who are younger.

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Conict of interests: The authors declare that they have no conict of interests. Funding: None. Ethical approval: The Institutional Review Board of Taichung Veterans General Hospital, 950216/C06036. References
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