ORIGINAL ARTICLE

JIACM 2009; 10(1 & 2): 32-5

Do all Non-responders to Anti-hypertensive Medication

Need a Change in Medication Regimen?
Aditi Chaturvedi*, Yogendra Singh**, Juhi Kalra*, Vikram Bhandari***, DC Dhashmana****,
Sohaib Ahmad*****, Harish Chaturvedi******

Abstract
Aim: Hypertension requires long-term and often life-long treatment; however, it is quite often uncontrolled. Is a modification of
the medication needed if the patient is not responding to antihypertensive treatment, or should his adherence to the regimen be
ascertained before considering any change? We undertook this study to assess the level of adherence in non-responders to
antihypertensive medication in our hospital.
Material and methods: A four-question preformed questionnaire, the Morisky instrument was used to assess the level of adherence
to the prescribed anti-hypertensive of the selected study group. Included in the study were 600 patients with hypertension presenting
in the Medicine and Cardiology OPDs, and the results were analysed using standard statistical methods.
Results: Only 15% of the patients were considered adherent to the prescribed antihypertensives. There was a significant association
between the non-adherent participants and those with low economic status and lack of awareness of the consequences of missing
a drug (p < 0.05). Two-third of the non-adherent patients were reluctant to share their non-adherence with their treating physicians
while three-fifth of the patients wished to receive medication free of cost (p < 0.05).
Conclusion: Drug and dose modification in managing chronic diseases like hypertension should be preceded by an assessment of
adherence to medication. Adherence to medications may be increased by proper patient education regarding the complications of
the disease and reduction of cost of medication.
Keywords: Adherence, antihypertensive treatment, Morisky instrument.

Introduction
Drugs dont work if people dont take them1. Hippocrates
once said keep watch also on the fault of the patient
which often makes them lie about the taking of the
things prescribed 2. Our health-care system has been
designed in such a way that acute diseases are taken
care of in a better way than chronic diseases. The
increasing prevalence of chronic diseases has proved the
inadequacy of health-care systems to address the health
needs of the population3.

the antihypertensive regimen? In developed countries,

adherence among patients suffering from chronic
diseases averages only 50%3, 4. Studies have reported
that in case of insufficient control of a chronic disease
like hypertension instead of adapted treatment, nonadherence should be considered first in most patients.
Such strategies will prevent a folie deux, i.e., double
madness where the physicians perception of treatment
failure results in the physician increasing the dose or
number of drugs, and the patients adherence
temporarily improving, resulting in drug toxicity5.

Adherence is defined as the extent to which the patient

behaviour corresponds with the agreed
recommendations from the health-care giver3.
Hypertension often causes no symptoms; therefore, it is
difficult to motivate the patient to continue taking antihypertensive medications, mostly life-long. Do physicians
always need to modify the medication regimen if a
patient has uncontrolled BP? Should adherence
assessment be done for such patients before changing

Is there any short questionnaire that can help the

physicians to measure adherence to antihypertensive
treatment quickly in their increasingly overcrowded
clinics? Adherence studies are being carried-out
extensively in developed countries6,7. The prevalence rate
of hypertension among urban population in India has
gone up from 6.64% in 1988 to 36.4% in 2003 indicating
a rising trend in hypertension in India8. However, the
scenario of adherence in most chronic diseases in the

* Assistant Professor in Pharmacology, ** Associate Professor in Cardiology, *** Resident in Pharmacology,

**** Professor in Pharmacology, ***** Assistant Professor in Medicine, ****** Assistant Professor in Anatomy,
Himalayan Institute of Medical Sciences, Jolly Grant, P.O. Doiwala, Dehra Dun - 248 140, Uttarakhand.

Indian sub-continent is still unknown. Such queries

motivated us to assess the level of adherence to
antihypertensive medications amongst the
hypertensives coming to our hospital, and identify the
factors contributing to non-adherence, if any.

Material and methods

The study group was selected over a period of six-months
(July to December, 2007) from the medicine and
cardiology out-patient departments of the Himalayan
Institute of Medical Sciences, HIHT University, Dehra Dun.
A total of 600 patients of 18 years and above with office
blood pressure (BP) over 140/90 mmHg despite being
prescribed antihypertensive medication for over a month
were included in the study. The selected patients were
interviewed regarding their socio-demographic
characteristics, income, frequency of drug intake, and
reasons for non-adherence, using a preformed
questionnaire. Adherence was assessed through the
specific four-question patient questionnaire, the Morisky
instrument, that has high reliability and validity and the
patient was deemed to be adherent if he answered in the
negative to all the four questions7, 9.
Simple percentages were used to describe different
variables. The chi-square test was used to assess the
significance of association between the groups. A p-value
of 0.05 or less was considered statistically significant.

Results
Table I shows the socio-economic and demographic
parameters among the study group. Only 15% of the
patients answered no to every question and were
considered adherent according to the Morisky instrument
(Table II), while two-third of the non-adherent patients
were reluctant to share their non-adherence with their
treating physicians. The various reasons for non-adherence
that were assessed are tabulated in Table III.
A statistically significant association was observed
between participants who missed their drugs very often
and the monthly income Rs. 10,000 (p < 0.05). Nonadherence was highly significantly (p < 0.001) associated
with multiple drugs or multiple dosing. Nearly half of the
patients wanted a decrease in the number and/or the

Journal, Indian Academy of Clinical Medicine

frequency of medications. One-third of the patients were

not aware of the consequences of missing the drugs and
non-adherence was significantly noted in such patients
(p < 0.05).
Table I: Socio-demographic outcome variables in nonresponders to antihypertensive medication.
Variable

Category

Frequency
(N=600)

Percentage
(%)

Age(years)

31-40
41-50
51-60
61-70
71-80
81-90

45
120
165
180
75
15

7.5
20
27.5
30
12.5
2.5

Gender

Women
Men

105
495

17.5
82.5

Business
Govt.service
Retired
Housewife
Manualworker

165
150
180
60
15

27.5
25
30
15
2.5

>Rs.10,000
Rs.10,000

285
315

47.5
52.5

Occupation

Income

Table II: Morisky instrument: Assessment of adherence

among non-responders to antihypertensive
medication.
Four-questionpatient
questionnaire
(Moriskyinstrument)

No.ofpatients
whosaidNo
(N= 600)

Percentage
(%)

Q1. Didyoueverforgettotake
yourmedication?

75

12.5

Q.2. Wereyoucarelessattimesabout
takingyourmedication?

435

72.5

Q.3. Whenyoufeltbetter,didyou
sometimesstoptakingyour
medication?

465

77.5

Q4. Sometimes,ifyoufeltworse
whenyoutookyourmedicine,
didyoustoptakingit?

570

95

Theno.ofpatientswhosaidnotoall
fourquestions(i.e.,no.ofpatients
whowereadherentto
antihypertensivetreatment)

90

15

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33

Table III: Reasons for non-adherence to

antihypertensive medication in non-responders
Factors

No. of patients
who said Yes
(N = 600)

If the drug was provided free

of cost, would have taken it
more regularly
Too many drugs

360 (60)

345 (57.5)

Not aware of the consequences

of missing the doses

300 (50)

Multiple dosing

335 (47.5)

Missed the drug very often

165 (27.5)

Self-discontinuation

135 (22.5)

Shifted to alternative treatment

105 (17.5)

Side-effects of medication

30(5)

Figures in parenthesis indicate percentage.

Discussion
Burnier and colleagues studied adherence among
patients with refractory hypertension using microelectronic monitors. During monitoring, blood pressure
was normalised (systolic < 140 mmHg or diastolic < 90
mmHg) in one-third of the patients and insufficient
compliance was unmasked in another 20%1. Our results
vary from the results of the above-mentioned study due
to the difference in the selection criteria and monitoring
devices.
The American Association of Retired Persons (AARP)
survey of ambulatory elderly observed lack of significant
symptoms as the reason of premature discontinuation
of the prescribed anti-hypertensive medication in 33%10
similar to 22.5% in our study. The difference may be
because only the elderly were studied in the survey;
however, the reason is universally observed among all
age groups.
We noted a significant association between patients with
low income and non-adherence to drugs. This was
supported by other studies of non-adherence and lack of
funds for the purchase of drugs11,12. India is home to onethird of the worlds poor people and according to the latest
World Banks estimates on poverty, India has 41.6% of its
population living below the new international poverty line

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of $1.25 per day13. Also, we did not find a significant

association between the level of income and patients who
were desirous of receiving free medication.
The total number of medicines and frequency of drug
intake by non-responders in our study supported the fact
that patients wanted less number of longer acting drugs
for the treatment. Minimising the number of daily doses
had been found to be important in promoting
adherence11. However, a few recent studies report on the
contrary14,15.
Unless the physician maintains a cordial and friendly
relationship with the patients, they will not open up with
their problems regarding drug intake as observed in 65%
of our study group. Lack of awareness can contribute to
non-adherence. Studies have reported that adherence
can be improved by patient education, motivational
strategies, improving doctor-patient relationship,
considering the cost of anti-hypertensive medication
and simplifying dosage regimen16, 17. Moore reported
that optimal control of blood pressure was impeded by
poor patient-physician communication and cost of antihypertensive medication18.

Conclusions
An increase in the number of patients of chronic diseases
with their debilitating consequences are imposing a
huge burden on the already scanty and ineffective health
services in a developing country like ours. An adherence
level of only 15% observed in the present study for an
extremely common disease like hypertension can
provide a better understanding of the situation with
reference to all the chronic diseases. The Morisky
instrument was adopted as a method of measuring
adherence because of its simplicity, economic feasibility,
and as one of the most useful methods in clinical
settings19. Such, short time saving Morisky instrument
questionnaire allows the physician to assess the level of
adherence in areas where doctor to patient ratio is very
low and physicians cannot devote much time to the
patient. The introduction of information of nonadherence to the physicians has the potential to improve
both adherence and clinical outcomes.
Health-care providers need to adopt a more

Journal, Indian Academy of Clinical Medicine

Vol. 10, No. 1 & 2

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comprehensive approach in chronic diseases like

hypertension, which includes patient education, patient
motivation, tailoring of medication to reduce
inconvenience and forgetfulness, construction of
compliance clinics, telephonic reminders, pill-counts,
MEMS (Medication Event Monitoring System) and above
all, the patients may be considered as active participants
in their own treatment regimen1, 2. Not all nonresponders to the anti-hypertension regimen need
increase in dose or number of the ongoing medication
unless we measure adherence. Awareness to adherence
is required not only for the patients but also for the
physicians. All the effort, time, and expense taken to
diagnose the disease and prescribe medications are
wasted if the patient does not adhere to the medication.
Without an evolved health system that addresses the
importance of adherence, advances in biomedical
technology will fail to realise their potential to reduce the
burden of chronic diseases like hypertension. The disease
burden has slowly shifted from acute to chronic diseases
over the past five decades4. Increasing the effectiveness
of adherence interventions may have a far greater impact
on the health of the population than any improvement in
specific medical treatment4.

Limitations
Our study has many limitations, the sample size was small
and studies with larger sample size are required to support
these findings. This study does not indicate the adherence
levels in the general population as it included patients
from a teaching hospital. Self-reporting had the
disadvantage of recall bias and admitting to only socially
acceptable responses; therefore it may under-estimate or
over-estimate adherence.

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World Health Organisation. Chapter XIII. Hypertension in

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