Relationship of Health Belief Model with Medication Adherence and Risk Factor Prevention in Hypertension Patients in Cimahi City, Indonesia

Document Type : Original Quantitative and Qualitative Research Paper

Authors

1 Public Health Faculty, Diponegoro University, Semarang, Indonesia

2 Epidemiology Department, Faculty of Public Health, Diponegoro University, Semarang, Indonesia

3 Faculty of Medicine, Diponegoro University, Semarang, Indonesia

4 Public Health Faculty, Airlangga University, Surabaya, Indonesia

Abstract

Background: Medical adherence is critical to hypertension treatment. Medication non-adherence is one of the problems affecting hypertensive patients. Belief in health treatment is very important to support adherence behavior, especially in hypertension.  Aim: The present research aimed to determine the relationship of the health belief model with medical adherence and risk factor prevention in hypertension patients. Method: This cross-sectional study was conducted on patients referring to health centers in Cimahi City, Indonesia, in 2020. A total of 180 patients were selected via the purposive sampling method. The instrument used to measure medical treatment adherence and risk factor prevention was the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The data were analyzed in SPSS Software using the Chi-square test and Logistic regression test. Results: The majority of participants were female (88.9%), unemployed (76.7%), within the age range of 40-59 years (60.0%), and had low education (75.0%). Moreover, most cases had health insurance (91.7%), with a maximum duration of hypertension less than 5 years (70.6%), and a body mass index (BMI) between 18.5-25.0 (45%). The health belief model was related to adherence to hypertension treatment (P<0.05); nonetheless, in the multivariate model, the perceived benefit had no significant relationship when entering into the regression model. Implications for Practice: To improve medication adherence and risk factor prevention in hypertensive patients, it is necessary to strengthen the health belief model with continuous and ongoing education about hypertension. 

Keywords


Introduction

Hypertension is estimated to claim 7.5 million lives, about 12.8% of total deaths across the globe. This accounts for 57 million disability-adjusted life years (1). World Health Organization (WHO) reported that approximately 40% of people over the age of 25 years suffer from hypertension (2). Surveys conducted in the last 10 years indicated that the prevalence of hypertension in Southeast Asia is estimated to be approximately one-third of the number of adults suffering from hypertension with 9.4% of deaths due to hypertension (2). Hypertension often causes no symptoms, while persistent high blood pressure can cause serious complications in the long term. Therefore, the early detection of hypertension is necessary with regular blood pressure checks (3).

The prevalence of hypertension in Indonesia in the population aged 18 years has increased from 25.8% in 2007 to 31.7% in 2013 and 34.1% in 2018 (4). On a national level, the results of Indonesian Basic Health Research in 2018 demonstrated that the prevalence of high blood pressure was 34.11%. The prevalence of high blood pressure in women (36.85%) was higher than that in men (31.34%). The prevalence was higher in urban areas (34.43%), compared to that in rural areas (33.72%); moreover, the prevalence was reported to increase with age (5).  Medication non-adherence among hypertensive patients can be caused by different reasons, such as feeling healthy, not controlling, forgetting, and not being able to buy hypertension medicines. The Institute for Health Metrics and Evaluation (IHME) in 2019 stated that 23.8% of the 1.7 million deaths in Indonesia were caused by hypertension (6).

West Java province ranks second in Indonesia in the prevalence of hypertension (7). Based on the health profile of Cimahi City in 2019, the number of people with hypertension continued to increase from 2016 to 2019. This increase in the number of cases was accompanied by an increase in non-compliance with routine treatment and control once a month (8). The success of hypertension treatment is generally influenced by the patient's adherence to taking high blood pressure medication and making lifestyle modifications (9). Failure to achieve treatment targets leads to complications and poor quality of life.

Compliance with pharmacological treatment is still low among hypertensive patients, ranging from %50-70% in patients whose blood pressure is not controlled, and 50% of them have compliance problems (10). Non-compliance with hypertension treatment is often caused by behavioral and treatment factors (11). Changes in patient's compliance depends on the symptoms of illness. That is to say, if blood pressure elevation is accompanied by symptoms of illness, the patient takes the medication, while in the absence of symptoms, the patient feels no need to do so. This poses a serious obstacle to medication adherence among hypertensive patients and hinders the success of hypertension treatment in the community (12).

Public awareness in handling hypertension is reported to be higher in Western countries, such as the UK (66%), as well as Canada and America (80%), when compared to Asia, which is more varied, ranging from 37%-64%. The highest awareness was in Korea, while Indonesia reported the lowest level (37%). This unawareness is related to the lack of hypertension monitoring; therefore, it is necessary to educate the public about the effects and complications of hypertension if it is not handled properly (13).

The results of previous studies pointed out that public confidence in the treatment of hypertension needed to be explored. Public awareness of the importance of health is still lacking, and people only realized the importance of health after suffering from a serious illness. Some of the interventions had been carried out only in the short term since they do not involve the health belief model. Therefore, it is necessary to conduct research on the relationship between the health belief model and medication adherence among hypertension sufferers. In light of the aforementioned issues, the present study aimed to determine the relationship of the health belief model with medical adherence and risk factors prevention in hypertension patients in Cimahi city.

 

Methods

The present study was conducted based on a quantitative-based cross-sectional design The independent variables of the study were the perceptions of seriousness, vulnerability, benefits, and barriers, while the dependent variable was medication adherence and prevention of hypertension risk factors (14). The population of this study were all hypertensive patients in Cimahi City in 2019 (they numbered 13,460 people based on data from the Cimahi City Health Office). The sample is part of the population and is representative of the population. Participants of this study were hypertensive patients in Cimahi City selected via the purposive sampling method and based on certain criteria. A number of 60 participants were selected from each of three public health centers, namely Cipageran, Cibereum, and Padasuka, yielding a total of 180 subjects. The inclusion criteria were as follows: age range of above 18 years, receiving antihypertensive medication from the public health center, and willingness to take part in this research. On the other hand, the exclusion criteria entailed a history of chronic diseases that could be dangerous (heart disease, asthma, diabetes mellitus, tuberculosis, and stroke), illiteracy, and sickness during the study period.

The Hill-Bone Compliance to High Blood Pressure Therapy Scale was used to assess compliance with hypertensive treatment. Moreover, the instrument to measure the health belief model used several questions that have been tested for validity and reliability, consisting of 6 items on perceived seriousness, 6 items on perceived susceptibility, 7 items on perceived benefits, and 9 items on perceived barriers. All items were valid and reliable. To test the validity and reliability of this research instrument, it was conducted on 30 people with hypertension from the Luewigajah Health Center, which was different from the research location. The results of instrument validity were all R>0.3, and Cronbach’s alpha coefficients of 0.930, 0.970, 0.879, and 0.782 were obtained for the subscales of perceived seriousness, perceived susceptibility, perceived benefits, and perceived barriers, respectively. Bivariate analysis by Chi-square test was used to determine the related variables and was included in the binary logistic regression model. The final obtained model is a model of the relationship between the health belief model and compliance with hypertension treatment. For ethical consideration, this research has a Certificate of Ethical Approval from the Health Research Ethics Commission Diponegoro University Semarang.

 

Results

The characteristics of the research participants (n=180) are presented in Table 1. The majority of them were female(88.9%), unemployed (76.7%), within the age range of 40-59 years (60.0%), and had low education (75.0%). Moreover, most cases had health insurance (91.7%), with a maximum duration of hypertension less than 5 years (70.6%), and a body mass index (BMI) between 18.5-25.0 (45%).

The results of the Bivariate analysis by the Chi-square test are displayed in Table 2. Most of the participants with a good perception of seriousness (70.0%) adhered to treatment, while the majority of

Table 1. Characteristics of hypertensive patients

Variable

Category

f

%

Gender

Male

20

11.1

 

Female

160

88.9

 

 

 

 

Age (Years)

20-39

12

6.7

40-59

108

60.0

≥ 60

60

33.3

 

 

 

 

Education

Low

135

75.0

Medium

41

22.8

High

4

2.2

 

 

 

 

Occupation

No

138

76.7

 

Yes

42

23.3

 

 

 

 

Health Insurance Ownership

No

15

8.3

Yes

165

91.7

 

 

 

 

Length of time suffering from hypertension (years)

<  5

127

70.6

6 - 10

23

12.8

> 10

30

16.7

 

 

 

 

Body Mass Index (BMI)

≤ 18,5

3

1,7

18.5-25.0

81

45.0

25.1-27.0

31

17.2

>27.0

65

36.1

Total

180

100.0

 

participants with a low perception of seriousness (64.0%) did not. Respondents with the perception of susceptibility were mostly compliant (68.4%) and those who were not vulnerable were mostly non-compliant (63.4%). Participants with a good perception of benefits were more compliant (68.8%), and respondents who felt there was no benefit were more likely to be non-adherent in taking medication (62.1%). Respondents with high perceptions of obstacles were mostly compliant, and those who felt that there were no obstacles were mostly non-adherent (72.0%). The P-value was <0.001 in all vraibles-that is to say, all variables can be included in the binary logistic regression model.

Binary logistic regression models are explained in Table 3. Based on the bivariate analysis in Table 2, all independent variables were associated with medication adherence (P<0.001). However, after being included in the binary logistic regression model, perceived benefits were not significantly related to hypertension medication adherence (P=0.15). After the removal of perceived benefits from the model, the final model was obtained, Perceived seriousness [P<0.001), CI: 0.090-0.432, Exp(B):0.206], perceived susceptibility [P<0.001), CI: 0.141 -0.602, Exp(B):0.292] and perceived barriers [P<0.001), CI: 0.066-0.295, Exp(B):0.139] remained statistically significant.

 

Table 2. Relationship between health belief model and patients’ adherence

Variables

Adherence

p value*

 

Obey

Not obey

OR (CI 95%)

f

%

f

%

 

Perceived of seriousness

 

 

 

 

 

 

Good

66

70.2

28

29.8

<0.001

2.15 (1.51-3.04)

Bad

31

36.0

55

64.0

 

 

Perceived of susceptibility

 

 

 

 

 

 

Not vulnerable

30

36.6

52

63.4

<0.001

2.01 (1.43-2.80)

Vulnerable

67

68.4

31

31.6