Patient Education and Counseling 99 (2016) 18941900

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Patient Education and Counseling

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Determinants of antihypertensive adherence among patients in

Beijing: Application of the health belief model
Shuaishuai Yanga,1, Chao Heb,1, Xuxi Zhanga , Kaige Suna , Shiyan Wua , Xinying Suna,* ,
Yindong Lib,*
a
Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China
b
Department of Health Education, Shunyi Center for Disease Prevention and Control, Beijing, China

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: This study was aimed to determine the factors associated with antihypertensive adherence
Received 23 November 2015 based on the Health Belief Model (HBM).
Received in revised form 3 May 2016 Methods: A cross-sectional study was conducted in a rural area of China in 2014. The questionnaire
Accepted 16 June 2016
included information about demographics, a scale based on the HBM, and the four-item Morisky
Medication Adherence Scale.
Keywords: Results: 745 hypertensive patients participated in the study (345 men, 400 women). Patients mean age
Hypertension
was 56.4
10.8 years. The prevalence of adherence was 43.5%. Structural equation modeling showed that
Medication adherence
Structural model
men, older participants, and those with greater knowledge of hypertension showed better medication
adherence than did other participants. Based on the HBM, higher levels of self-efcacy and perceived
severity and a lower level of perceived barriers were associated with better antihypertensive adherence.
Self-efcacy was one of the most important mediating variables affecting antihypertensive adherence.
Conclusions: Antihypertensive adherence was not optimal among patients in Beijing. Given that many
factors are associated with medication adherence, individualized intervention strategies should be
carried out in Beijing, China, especially in community settings.
Practice implications: Medication adherence can be improved by enhancing patients self-efcacy because
it was the most important inuence and mediating variable.
2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
In 2011, the World Health Organization (WHO) released the
Global Status Report on Non-communicable Diseases, which was the
rst detailed description of the global burden of non-communica-
ble diseases (NCDs). It reported that 36 million (or 63%) of the 57
million global deaths in 2008 were due to NCDs [1]. Globally,
cardiovascular diseases (CVDs) account for approximately 17
million deaths a year, nearly one third of the total. Of these,
complications of hypertension account for 9.4 million deaths
globally every year [2]. Hypertension is both a type of CVD and one
of the most important risk factors of CVDs such as coronary heart
disease and stroke. Poor control of blood pressure increases the
morbidity and mortality rates of other CVDs. Clinical trials have
demonstrated that the treatment of mild-to-moderate hyperten-
sion could reduce the risk of stroke by 30% to 43% and that of
* Corresponding authors.
E-mail addresses: xysun@bjmu.edu.cn (X. Sun), liyindong@sohu.com (Y. Li).
1
These authors contributed equally to this manuscript.
myocardial infarction by 15% [3]. In 2008, nearly 40% of adults aged
25 and above were diagnosed with hypertension worldwide, and
the number of patients rose from 600 million in 1980 to 1 billion in
2008 [2]. However, the treatment and control rates of hypertension
remained low despite the prevalence of the disease. For example,
the 2010 Report on Chronic Disease Risk Factor Surveillance in China
showed that the treatment and control rates were 80.4% and 17.2%,
respectively.
Non-adherence to antihypertensive medication regimens is a
major cause of inadequate blood pressure control. As many as half
of failures in blood pressure control may be attributable to such
non-adherence [4]. Given the differences in study groups, duration
of follow-up, methods of assessment of adherence, and drug
regimens used in different studies, estimates of the extent to which
patients adhere to pharmacotherapy for hypertension have varied
between 50% and 70% [3,5,6]. The problem of non-adherence is
even worse in developing countries because of the lower economic
levels and a more uneven distribution of health resources.
To evaluate antihypertensive adherence and its associated
factors in the Chinese population, we implemented the Health

http://dx.doi.org/10.1016/j.pec.2016.06.014
0738-3991/ 2016 Elsevier Ireland Ltd. All rights reserved.
 S. Yang et al. / Patient Education and Counseling 99 (2016) 18941900
Belief Model (HBM). The components of this model, which
emphasize the importance of human perception, include perceived
severity, susceptibility, benets, barriers, and cues to action. The
HBM is one of the mostly commonly used models in health-related
research attempting to explain and predict health behavior. Since
then, the HBM has been adapted to explore a variety of health
behaviors.
The study aimed to determine the factors associated with
antihypertensive adherence based on the HBM using structural
equation modeling (SEM), which integrates measurement model
and structural model and takes measurement errors into account.
It is believed that the results of this paper will provide directions
and motivation for future research and policymaking with regard
to improving medication adherence.
2. Methods
2.1. Ethics statement
The study was approved by Peking University Institutional
Review Board, and all participants signed informed consent forms
before they were enrolled into the study.
2.2. Study setting and sample
A cross-sectional study was conducted based on the HBM in
Shunyi District, Beijing, between June and August 2014.
Shunyi District covers 1021 square kilometers and has a
population of 983,000. Its economic development has maintained
a rapid growth as the Beijing Capital International Airport is
located here. Accordingly, residents living conditions have been
improving, and life expectancy reached 78.6 years in 2013.
However, Beijing, especially Shunyi District, has a high prevalence
of chronic diseases in recent years. The prevalence of hypertension
was 42.9% and 55.6% in Beijings urban and rural areas respectively
[7] and both are higher than the average rate in China (33.5%) [8].
Sample size was calculated using the following formula:
Z 21a P1  P
N 2
1
d2
Wherein the a was 0.01, permissible error (d) was 0.05, and the
estimated prevalence of antihypertensive adherence was 0.551 [9].
The rate of losses to follow-up was anticipated to be 10%.
Ultimately, the estimated sample size was 725.
The probability-proportional-to-size sampling method was
applied to recruit hypertension patients in all 26 health care
community centers of the Shunyi District. In each community
center, a quota of hypertension patients was assigned according to
the proportion of residents in Shunyi. All conrmed hypertension
patients aged 18 years or older who were taking at least one kind of
antihypertensive drug were included in our study.
2.3. Questionnaire
Interviews using a questionnaire based on HBM designed for
this study were performed. We referred to some questionnaires
used to research Chinese hypertensive patients and consulted
several specialists in this eld. A pre-survey was implemented
before the study and it proved to be an accepted instrument. The
questionnaire consisted of demographic information (e.g. age,
gender, degree of education and income), history of diseases, items
on hypertension knowledge, self-efcacy, perceived barriers,
perceived severity, cues to action and the four-item Morisky
Medication Adherence Scale (MMAS-4) [1014]. In this study, the
perceived benet of antihypertensives was considered reective of
1895
hypertension knowledge. The questionnaire survey was conducted
by well-trained community health workers.
Patients adherence to medication was assessed by the MMAS-
4, which is commonly used in various populations. The MMAS-4
has good validity and reliability [15]. The Chinese version has good
internal consistency, with a Cronbach's alpha of 0.75 [16]. The
MMAS-4 included the following items: (a) Do you ever forget to
take your medicine, (b) Are you careless about taking your
medication at times, (c) When you feel better sometimes, do you
stop taking your medication, and (d) Sometimes if you feel worse
while taking medication, do you stop taking it? Antihypertensive
non-adherence was indicated for any respondent who had a
history of hypertension for more than 6 months and answered
Yes for any one of the four items of the MMAS-4. A score of 4
reects good adherence [17,18].
Self-efcacy was measured with four items while perceived
barriers, perceived severity of non-adherence, and cues to action
were each measure with three items. All items were evaluated on a
5-point Likert scale from 1 (totally agree) to 5 (totally disagree).
Thus, the self-efcacy score ranged from 0 to 20, and the other
belief scores ranged from 0 to 15. High scores reected greater self-
efcacy and perceived severity and more cues to action; in
contrast, higher scores for perceived barriers indicated fewer
barriers.
2.4. Analysis
Data were analyzed with SPSS version 18.0. The demographic
characteristics of the participants were reported using descriptive
statistics (frequencies, proportions, means, and standard devia-
tions). The construct validity was evaluated using factor analysis,
and the internal consistency using Cronbach's alpha. The chi-
square test was used to determine whether noncompliant patients
differed signicantly from compliant patients. The t test and
Kruskal-Wallis test was used to determine whether different
characteristics showed signicantly different factor scores on the
HBM scale. SEM was applied to illustrate correlations between
health belief and medication adherence and potential indirect
effect. Maximum Likelihood Estimator (MLR) was used to
construct and t the model according to skewed distribution
metric data. Listwise deletion was used to address missing data.
P < 0.05 was considered statistically signicant. The probability for
stepwise entry was a < 0.05 and that for removal was a > 0.10.
3. Results
3.1. Demographic characteristics and adherence status
Table 1 shows the demographic characteristics of study
participants. A total of 745 residents diagnosed with essential
hypertension reported taking at least one kind of antihypertensive
medication at the time of study. Patients mean age was
56.4
10.8 years, 53.7% were female, 97.7% possessed at least
one kind of health insurance.
Among all participants, 43.5% were regarded as having good
adherence (i.e., a score of 4 on the MMAS-4); all other participants
had a score below 4, which was considered to indicate poor
adherence. Good adherence was signicantly more common
among older participants, those with health insurance, and those
with a higher level of hypertension knowledge.
3.2. Validity of the HBM scale and factor scores
Table 2 shows that the reliability of both scales was acceptable.
The Cronbach's alpha for the MMAS-4 was 0.712. Using factor
analysis, four factors were extracted from the scale based on the
1896 S. Yang et al. / Patient Education and Counseling 99 (2016) 18941900

Table 1
Demographics of study participants and relation to adherence.

Characteristic Group N (%) Non-adherence Adherence x2

Gender Male 345 (46.3) 182 (52.8) 163 (47.2) 3.689
Female 400 (53.7) 239 (59.8) 161 (40.3)

Age (years) 1829 12 (1.6) 11 (91.7) 1 (8.3) 27.029b

3039 26 (3.5) 22 (84.6) 5 (15.4)
4049 159 (21.3) 101 (63.5) 58 (36.5)
5059 275 (36.9) 157 (57.1) 118 (42.9)
6069 174 (23.4) 86 (49.4) 88 (50.6)
7080 99 (13.3) 44 (44.4) 55 (55.6)

Education level Primary or lower 172 (23.1) 93 (54.1) 79 (45.9) 3.361

Junior high school 416 (55.8) 232 (55.8) 184 (44.2)
Senior high school 129 (17.3) 82 (63.6) 47 (36.4)
Bachelor's degree 27 (3.6) 14 (51.9) 13 (48.1)

Family monthly income(yuan) Less than 2000 156 (20.9) 84 (53.8) 72 (46.2) 9.147
20002999 120 (16.1) 62 (51.7) 58 (48.3)
30003999 104 (14.0) 62 (59.6) 42 (40.4)
40004999 133 (17.9) 79 (59.4) 54 (40.6)
50009999 175 (23.5) 95 (54.3) 80 (45.7)
10,00015,000 39 (5.2) 23 (59.0) 16 (41.0)
15,000 or more 16 (2.1) 14 (87.5) 2 (12.5)

Having health insurance Yes 728 (97.7) 406 (55.8) 322 (44.2) 7.125a
No 17 (2.3) 15 (88.2) 2 (11.8)
Hypertension knowledge
k1. Good adherence benets blood pressure control Yes 700 (94.0) 384 (54.9) 316 (45.1) 12.883a
No 45 (6.0) 37 (82.2) 8 (17.8)
k2. Hypertension needs lifelong medical treatment Yes 647 (86.8) 342 (52.9) 305 (47.1) 28.844b
No 95 (12.8) 78 (82.1) 17 (17.9)

Note: aP < 0.05; bP < 0.01.

Table 2
Reliability and total variance explained of the HBM scale.

Factor Items Loading Cronbach's a % of variance

Self-efcacy b1. Im sure of complying with the prescription. 0.791 0.748 26.2
b2. Ill never forget to take my antihypertensive on time. 0.803
b3. I wont stop taking my antihypertensive even if my blood pressure is normal for a period. 0.755
b4. I think my blood pressure is controlled very well. 0.512

Perceived severity d1. Poor blood pressure will cause many complications. 0.778 0.664 13.4
d2. Poor blood pressure makes me feel uncomfortable. 0.709
d3. Poor blood pressure will cause heavy nancial burden. 0.684

Perceived barriers a1. I cant follow the prescription, as the antihypertensives are too expensive. 0.790 0.527 9.2
a2. Im afraid of the side effects of antihypertensives. 0.632
a3. The medication regimen is too complex to remember. 0.668

Cues to action c1. My family always reminds me to take my medicines. 0.825 0.499 8.1
c2. People around me controlled their blood pressure well. 0.606
c3. Advertisements are common on TV about medication adherence. 0.559

Note: The data in this table are based on a rotated component matrix.

HBM; these factors together contributed to 57.0% of the sum of the
squared loadings. The Cronbach's alphas for the four factors were
as follows: self-efcacy (0.748), perceived severity (0.664),
perceived barriers (0.527), and cues to action (0.499).
Original health belief scores did not obey normal distribution,
so median and quartile was used to describe them (Table 3). Older
patients presented higher self-efcacy and lower barriers, while
women perceived higher severity of hypertension.
3.3. Structural equation modeling (SEM)
SEM was used to illustrate the internal correlations of
adherence and other variables. Fig. 1 showed the measurement
model and Fig. 2 and Table 4 showed the structural model. Patients
age, gender, insurance status, hypertension knowledge item,
MMAS-4 scores, and HBM questionnaire item scores, were entered
into the SEM Model as observed variables. The latent variables
were adherence, perceived benets, self-efcacy, cues to action,
perceived barriers, perceived severity and hypertension knowl-
edge. Men (P = 0.012), older participants (P < 0.001), and partic-
ipants with more hypertension knowledge (P = 0.001) were more
likely to comply with medication regimens, which coincided with
the univariate analysis. Higher levels of self-efcacy (P < 0.001)
and perceived severity (P = 0.001) and a lower level of perceived
barriers (P < 0.001) were signicantly associated with better
antihypertensive medication adherence.
The standardized indirect effects from the variables to
medication adherence were as follows: age (0.220, 69.8% of total
effects, P < 0.001); perceived barriers (0.269, 56.2% of total effects,
P < 0.001); hypertension knowledge (0.316, 98.1% of total effects,
 S. Yang et al. / Patient Education and Counseling 99 (2016) 18941900 1897

Table 3
Compare of original health belief scores.

Characteristic Group Self-efcacy Perceived severity Perceived barriers Cues to action

Median (Lower quartile, Upper quartile)

Gender Male 18 (16, 18) 15 (12, 15) 11 (9, 11) 13 (11, 13)
Female 19 (16, 19) 15 (14, 15) 11 (9, 11) 14 (11, 14)
t 0.791 2.137a 1.463 0.462

Age 1829 11.5 (9.8, 11.5) 15 (13.5, 15) 9 (7, 9) 11 (9.8, 11)
3039 16 (12, 16) 15 (12, 15) 11 (8, 11) 12 (9, 12)
4049 18 (14.3, 18) 15 (14, 15) 11 (8, 11) 14 (11, 14)
5059 19 (16, 19) 15 (13, 15) 11 (8.8, 11) 13 (11, 13)
6069 19 (16, 19) 15 (13, 15) 12 (10, 12) 14 (11, 14)
7080 20 (18, 20) 15 (12.3, 15) 12 (10, 12) 13 (11, 13)
Hc 55.883b 7.614 36.965b 7.966
a
P < 0.05.
b
P < 0.01.
c
Kruskal Wallis Test.

4. Discussion and conclusion

4.1. Discussion

Several studies have investigated the prevalence of antihyper-

Fig. 1. Measurement Model of Determinants of Antihypertensive Adherence. Note
a1- m4: items of scale, barriers: perceived barriers, efcacy: self-efcacy, cues: cues
to action, knowledge: hypertension knowledge, severity: perceived severity; model
information: Chi-Square Value = 363.278, Degrees of Freedom = 136, Comparative
Fit Index = 0.897, Tucker- Lewis Index = 0.870, Root Mean Square Error of
Approximation = 0.047; Standardized Root Mean Square Residual = 0.046.
P < 0.001); perceived severity (0.116, P = 0.001); and cues to action
(0.210, P = 0.001). The indirect effects of insurance and gender on
medication adherence were not statistically signicant. Self-
efcacy was the most important mediating variable.
tensive adherence and its determinants [11,12,1922]. However,
few have focused on mainland Chinese residents, though other
Chinese populations have been studied [11,20,23,24]. Accordingly,
this paper aimed to investigate adherence and its associated
factors among residents in rural area of Beijing, the capital of China.
The rate of high antihypertensive adherence was 43.5% in
Shunyi District of Beijing, which was similar to the nding of a
previous study (43.7%) [25], but lower than that of recent studies in
another developed city of eastern China [26] and some Asian
countries [27,28], and the average level of the world [3]. The
control rate of hypertension among Chinese residents was poor at
the same time, which suggests that China should enhance the
management of hypertension and address the noncompliance of
medication therapy as it concerns approximate 300 million
Chinese patients wellbeing.
The widely used Health Belief Model was applied, because it
focuses on the importance of perception and has better
interpretation of understanding and predicting health behavior
like medication adherence than other theoretical models (e.g
social cognitive theory, motivational interviewing or planned
behavior model). When it comes to interventional researches,
other alternative models like social cognitive theory and motiva-
tional interviewing may be better and more effective than HBM.
Decades of research have helped to rene the model, yet variable
ordering of HBM constructs remains uncertain [18,29,30]. In this
study, male, older age, higher self-efcacy and perceived severity,
and lower perceived barriers were signicantly related to better
adherence, which coincides with a recently published literature on
hypertensive medication adherence among Chinese patients [31].
The differences were the correlations we found between gender,
hypertension knowledge, and medication adherence.
Many participants in this study perceived various barriers such
as not remembering, side effects and costs, which coincides with a
study reporting that not remembering was the most common
reason for having difculty in taking medication (32.4%), followed
by cost (22.6%), and having no insurance (22.4%) [19]. Given this
situation, some effective methods, for example, electronic
medication devices integrated into the care delivery system [32]
could be used to improved patients adherence. Further more,
health department should build a sound social health insurance
system. As different residents had different affordability to
medication therapy, universal health care was urgent to relieve
1898 S. Yang et al. / Patient Education and Counseling 99 (2016) 18941900

0.095

Perceived
Age
0.227 Barriers 0.209

0.438

Knowledge
0.174

0.514
0.615
Self-efficacy Adherence

0.341

Cues to
Action

-0.165

0.153 Perceived 0.189

Gender
Severity

-0.076

Chi-Square Value=559.356, Degrees of Freedom=182, Comparative Fit Index=0.844, Tucker-

Lewis Index=0.804, Root Mean Square Error of Approximation=0.053; Standardized Root Mean
Square Residual=0.068; only structural model and significant paths were showed in this figure.
Fig. 2. Structural Model of Determinants of Antihypertensive Adherence. Chi-Square Value = 559.356, Degrees of Freedom = 182, Comparative Fit Index = 0.844, Tucker- Lewis
Index = 0.804, Root Mean Square Error of Approximation = 0.053; Standardized Root Mean Square Residual = 0.068; only structural model and signicant paths were showed
in this gure.

Table 4
Parameter estimators of latent constructs of SEM.

Latent Independent Estimates Standard errors Signicance levels Residual variance

constructs
Adherence Perceived barriers 0.209 0.080 0.009 0.442
Self-efcacy 0.615 0.128 <0.001
Cues to action 0.165 0.072 0.022
Knowledge 0.006 0.124 0.963
Age group 0.095 0.036 0.009
Gender 0.076 0.035 0.027

Self-efcacy Perceived barriers 0.438 0.054 <0.001 0.325

Cues to action 0.341 0.062 <0.001
Perceived severity 0.189 0.061 0.002
Knowledge 0.514 0.099 <0.001
Age group 0.097 0.062 0.115
Gender 0.030 0.046 0.509

Perceived barriers Gender 0.081 0.042 0.057 0.944

Age group 0.227 0.046 <0.001

Perceived severity Gender 0.153 0.044 0.001 0.975

Age group 0.061 0.053 0.244

Cues to action Gender 0.046 0.052 0.382 0.991

Age group 0.069 0.053 0.190

Knowledge Gender 0.034 0.066 0.606 0.967

Age group 0.174 0.071 0.015
 S. Yang et al. / Patient Education and Counseling 99 (2016) 18941900
low-income populations medical nancial burden. It is possible
that experiencing more pain than comfort led some to stop taking
their medication. Thus, the type and dose of antihypertensive
agents must be adjusted to the individuals.
Older participants tended to comply with the antihypertensive
regimens more than young participants did, which is consistent
with previous ndings [12,15,19,22,3336]. However, most hyper-
tension patients here were older participants, and thus we should
seek to improve adherence in both older and younger hypertensive
patients.
SEM was applied to illustrate the indirect effects of different
constructs on adherence in this study. Indirect effects were quite
obvious in the model. More than half effect of perceived barriers on
adherence was through self-efcacy. Knowledge and perceived
severity inuenced self-efcacy directly instead of adherence. The
most interesting construct was cues to action, because its direct
and indirect effects on adherence were opposite. The possible
reason was that people may not rate the importance of cue to
change accurately and monotonous cues might even cause
patients negative attitude, but on the other hand, it raised
patients self-efcacy and then promoted their medication
adherence indirectly. The further health education should pay
attention to its form to make it more acceptable.
Self-efcacy was the most important determinant and media-
tor, as has been found in many previous studies [30,37]. Making
good adherence a persistent habit requires high self-efcacy,
which affects all other aspects of hypertension management (e.g.,
physical activity and diet therapy). The mediating effect implied
hypertensive patients self-efcacy could be raised by improving
other constructs of HBM.
This study has some limitations. First, this was a cross-
sectional study, which limited our ability to explain the causal
correlations between variables and adherence. Second, all
participants came from one district, and thus, the ndings
may not represent all of Beijing. Third, Social desirability maybe
exist among the interviewer, because most of them are primary
health service workers. They possibly regard this survey as a kind
of examination and trend to avoid negative response. To prevent
this situation, the investigators were systematically trained
before the survey. Fourth, the scale based on HBM has not yet
been validated and its predictive ability for medication adherence
was limited, which would be the point of future studies. Finally,
using only the MMAS-4 meant that we could not investigate the
true prevalence of medication adherence. Use of the 8-item
MMAS and some objective methods (e.g., pharmacy dispensing
records) would offer better reliability and validity in measuring
medication adherence. Thus, these should be used in future
research.
4.2. Conclusion
Control of hypertension is a key public health issue. Improving
patient adherence rates should be one major goal of hypertension
management [19]. However, the condition of antihypertensive
adherence is not optimistic in Beijing. Given that there are
many factors associated with medication adherence, individual-
ized intervention strategies should be carried out in China,
especially in community settings. This has inspired us to
conduct concrete work to improve compliance with medication,
such as by equalizing basic public health services and extending
coverage of primary health insurance. Health care providers
should follow up the patients in time to give them individualized
guidance. A multidisciplinary approach is needed to make
progress in this area; this will require coordinated action from
health professionals, researchers, health planners, and policy-
makers [3].
1899
4.3. Practice implications
This study revealed that medication adherence were not
optimal among patients with hypertension in China. Self-efcacy
was the most important determinants and mediating variable
among those factors related to medication adherence. Further
studies and policy-making should noticed this and improving
patient management by raised their self-efcacy.
Acknowledgments
This study was funded by the Beijing Natural Science
Foundation (Project No. 7162105). We appreciate the efforts of
the community health workers and the neighborhood committees
in the Shunyi District. They contributed considerable energy and
time during the whole questionnaire survey, without whom we
could not nish this meaningful job.
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