Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No.

2, 2020 |47 – 53

Effect of Adherence with Clinical Outcomes and

Quality of Life Primary Hypertension Patients in
Pharmacy
Dumartina Hutauruk, Khairunnisa, and Wiryanto
Department of Pharmacology, Faculty of Pharmacy, Universitas Sumatera Utara, Medan, Indonesia

Abstract. This study aimed to examine the effect of adherence to clinical outcomes and the
quality of life of primary hypertension patients in pharmacy. The studywas conducted cross
sectionally involved 60 patients at one of the pharmacies in Medan, Indonesia. Adherence
was obtained in the form of adherence levels measured using the MMAS-8 questionnaire,
clinical outcomes assessed by measuring a patient's blood pressure, and quality of life
assessed using the EQ-5D-3L questionnaire. Then the data were analyzed using the
Spearmen rho test. Patients who participated in the study consisted of 24 men and 36
women. Almost patient has low adherence with blood pressure mean of 156/ 90 mmHg.
The patient's quality of life was 77.7%. Adherence has a significant relationship to clinical
outcomes (p<0.05) with a strong correlation of r= -0.745. Adherence has a relationship to
quality of life (p<0.05) with moderate correlation r= 0.554. This study concluded that
adherence has a correlation with clinical outcomes and the quality of life of primary
hypertension patients.

Keyword: Adherence, Hypertension, Pharmacy, Quality of life.

Abstrak. Penelitian ini bertujuan untuk mengkaji pengaruh kepatuhan terhadap outcome
klinis dan kualitas hidup pasien hipertensi primer di Apotek. Penelitian dilakukan secara
cross sectional dengan melibatkan 60 pasien di salah satu apotek di kota Medan,
Indonesia. Data kepatuhan diperoleh dalam bentuk tingkat kepatuhan yang diukur
menggunakan kuesioner MMAS-8, outcome klinis dinilai dengan mengukur tekanan darah
pasien, dan data kualitas hidup dinilai menggunakan kuesioner EQ-5D-3L. Kemudian data
dianalisis menggunakan uji Spearmen rho. Pasien yang mengikuti penelitian terdiri dari 24
laki-laki dan 36 perempuan. Rata-rata pasien memiliki kepatuhan rendah dengan tekanan
darah rata-rata sebesar 156/ 90 mmHg. Kualitas hidup pasien rata-rata diperoleh sebesar
77,7%. Kepatuhan memiliki hubungan yang signifikan terhadap outcome klinis (p<0,05)
dengan korelasi kuat r= -0,745. Kepatuhan juga memiliki korelasi terhadap kualitas hidup
(p<0,05) dengan korelasi cukup r= 0.554). Penelitian ini menyimpulkan bahwa
kepatuhan pengobatan mempunyai korelasi dengan outcome klinis dan kualitas hidup
pasien hipertensi primer.

Kata Kunci: Adherence, Hypertension, Pharmacy, Quality of life.

Received 12 December 2020 | Revised 8 January 2021 | Accepted 10 January 2021

*Corresponding author at: Department of Pharmacology, Faculty of Pharmacy, Universitas Sumatera Utara,
Medan, Indonesia

E-mail address: khairunnisa7@usu.ac.id

Copyright © 2020 Published by Talenta Publisher, Print ISSN : 2615-6199, Online ISSN : 2620-3731
Journal Homepage: https://talenta.usu.ac.id/index.php/idjpcr
 Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No. 2, 2020 48

1. Introduction

Data from WHO in 2017 showed that there were 17.9 million people in the world who died
from cardiovascular disease or about 31% of the total deaths worldwide [1]. Hypertension is one
of the risk factors for cardiovascular disease. In 2015, an increase in blood pressure resulted in
9.4 million deaths and was a disease that increased Disability-Adjusted Life Years [2]. WHO
data for 2019 estimated that at least 1.13 billion people in the world suffer from hypertension.

The treatment of hypertension in Asian countries is very important because the prevalence of
hypertension continuesly to increase, including in Indonesia [3]. Indonesia Basic Health
Research in 2018 reported that the number of hypertension patients increased from 25.8% in
2013 to 34.1% in 2018 based on blood pressure measurements in the age group 18 and older [4].

High quality medicines are already widely prescribed for patients, but there are more than 50%
of non-adherence patients. In asimptomatic diseases such as hypertension, the non-adherence
can reach 80% [15]. Low levels of patient adherence to treatment of hypertension are the main
problems of complications, decreased effectiveness of treatment, and resulting in increased
mortality [6], [8]. Non-adherence lead to uncontrolled blood pressure. In United States, only
50% of patients had controlled their blood pressure. Non-adherence patients are more likely to
experience of cardiovascular complications indeed death compared with the adherence patients
[9]. Some factors affected non-adherence were reported by several studies, including age,
presence or absence of comorbid diseases, number of medicines taken, and patients knowledge
[10], [11], [12]. The patient quality of life is also influenced by factors related to physical,
emotional, social conditions as well as factors related to medication treatment [13].
Hypertension also related to quality of life. Patients with hypertension tend to have a poor
quality of life compared to patients with normal blood pressure [14], [15]. The poor quality of
life due to they have the risk of complications and adverse effects form medicines. The main
factor affected the quality of life of hypertensive patients are mental and emotional conditions
[14].

There are several studies related to adherence and the quality of life of hypertensive patients, but
very limited data is obtained from pharmacies. This study aimed to examine the effect of
adherence to clinical outcomes and the quality of life of primary hypertension patients in
pharmacy.

2. Material and Methods

2.1 Patients and study design

This was an observational study through cross sectional design in one of pharmacies in Medan,
North Sumatera, Indonesia on July-Augustus 2020. The study was conducted on hypertensive
 Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No. 2, 2020 49

patients who were redeemed the medical prescription at the pharmacy and meet the inclusion
criteria (patient diagnosed with primary hypertension more than 2 months, aged older than 18
years, and signed the inform consent. This study has been approved by the Ethical Committee
of the Health Research, Faculty of Nursing, Universitas Sumatera Utara No. 2175/VII/SP/2020.

2.2 Measurement of adherence by MMAS-8, clinical outcome, and quality of life

Adherence was measured by the 8-item Morisky Medication Adherence Scale (MMAS-8)
questionnaire. The study used MMAS-8 version of Indonesia contained 8 questions with closed
dichotomous (yes/no) answer. The questionnaire has been validated with high reliability and
validity well [16]. Respons of the questions were scored from 0 to 8 for adherence. Total score
were translated into 3 category, they were high adherence (score 8), medium adherence (score 6
to <8), and low adherence (score <6).

Clinical outcome was assed by blood pressure measure using digital blood pressure device. The
outcome was recorded as systol and diastol. The number was used to interpret clinical outcome
to adherence scale.

Quality of life was measured by EQ-5D-3L consist of 5 dimensions (mobility, self-care, usual
activities, pain/ discomfort, and anxiety/ depression), and has 3 levels (no problems, some
problems, and extreme problems) of each dimension. Health state was converted to utility score.
EQ-5D index score was measured using UK value set [17]. Utility range of EQ-5D from 0.0 (the
worst health) to 1.0 (the best health).

2.3 Data analysis

The correlated data were adherence versus clinical outcome and adherence versus quality of life.
The value of systolic and diastolic blood pressure were obtained by the mean of blood pressure
measurements. EQ-5D-3L assessment was performed by precentage of quality of life.
Furthermore, data analysis was displayed using SPSS version of 22 by Spearmen rho test.

3. Result and Discussion

Patients who participated in the study consisted of 24 men and 36 women. Characteristic of
patients are shown in Table 1.
 Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No. 2, 2020 50

Table 1. Patient Characteristics

Total
Characteristic n (60) Perscentage
(%)
Man 24 40
gender
Women 36 60
36-45 6 10
46-55 17 28
Age (years)
56-65 25 42
>65 12 20
junior high school 2 3
Level of education senior high school 28 47
bachelor 30 50
Unemployed 1 2
Entrepreneur 20 33
Occupation Housewife 15 25
Officer 14 23
Pensionary 10 17
By the age, 42% patients were 56-65 years old and half of respondents graduated from
universities. Overall women had higher admissions (60%) compare to those man (40%). By the
gender, the result in accordance with Peltzer and Pengpid (2018), 31.0% experienced by men
and 33.4% in women [18]. Otherwise, Everett and Zajacova (2015) found that women was less
likely affected of hypertensive (12%) compared those to men (27%) [19]. There are many
factors affected hypertension prevalence, as psychological, life styles, social support, economic
factor and others are also relevant to change the hyepertension state [20].

With regard to adherence, almost patients had a low adherence (52.6%) with blood pressure
mean of 156/90 mmHg. Only 22.8% of patients were highly adherence. Table 2 displyed the
correlation of adherence with clinical outcomes.

Table 2. Correlation of Adherence with Clinical Outcomes

Correlations
Adherence Outcome
score
Correlation
1.000 -.745**
Coefficient
Adherence score
Sig. (2-tailed) . .000
N 60 60
Spearman's rho
Correlation
-.745** 1.000
Coefficient
Outcome
Sig. (2-tailed) .000 .
N 60 60
**. Correlation is significant at the 0.01 level (2-tailed).
Based on statistical analysis, adherence has a significant relationship to clinical outcomes
(p<0.05) with a strong correlation of r= -0.745. The correlation coefficient was negative referred
to adherence and clinical outcomes has an inverse correlation, in case adherence decreases,
blood pressure become increase that indicated the decrease in clinical outcomes. There are many
factors affected the adherence of patients to take medication. According to Mekonnen et al.
(2017) study, patients who had experienced three or more years on taking antihypertensive
 Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No. 2, 2020 51

medication had two times more likely adhere compared to those patients with less than three
years. In developing countries, patients with high adherence were the most important challenge
to maintan their adherence understanding [21]. Mouraet al. (2016) reported that personal
reasons become the highest factors (70.3%) contributed to non-adherence, while non-
pharmacological dan pharmacological treatment contributed at 15.9% nd 21%, respectively
[22]. The global burden of hypertension described systolic blood pressure ≥140 mmHg and
diastolic blood pressure ≥90 mmHg or antihypertensive treatment was estimated to increase
from 918 million in year 2000 to 1.56 billion in 2025 [23]. Based on Table 3, patient's quality of
life was 77.7%.

Table 3. Correlation of Adherence with Quality of Life

Correlations
Adherence Utilit
score y
index
Correlation
1.000 .554**
Coefficient
Adherence score
Sig. (2-tailed) . .000
N 60 60
Spearman's rho
Correlation
.554** 1.000
Coefficient
Utility index
Sig. (2-tailed) .000 .
N 60 60
**. Correlation is significant at the 0.01 level (2-tailed).
Only 1.8%of the anxiety or depression was the extremely problems for quality of life
dimension. Adherence has a relationship to quality of life (p<0.05) with moderate correlation
r= 0.554. Correlation coefficien was positive, showed that the higher of adherence, the better of
quality of life. The result also supported by previous study, a positive correlation was detected
in adherence and quality of life, however the study has a strong correlation [24]. This was
probably due to the differences of hypertension stage observed. The study at Cumhuriyet
University Hospital revealed the positive correlation of adherence and quality of life on physical
and mental health which mental health score was higher than the physical score [24].
Otherwise, Souza et al (2016) in a systematic review of hypertensive patients revealed the
physical score health was higher than mental score [25]. A cross-sectional study in Alwatani
Hospital-Palestine revealed the high adherence (evaluated by MMAS) showed the higher
quality of life score (evaluated by the EQ-5D) [26]. The poor quality of life was associated with
low adherence for numerous reasons including psychosocial well-being and the attitude of
hypertensive patients toward taking medications [27]. Overall, adherence as a promoting factor
for quality of life in pharmacological treatment provided the awareness of hypertensive patients
to chase the health behaviour [25].

For further research, needed to emphasize the patients adherence for improving clinical
outcomes and quality of life.
 Indonesian Journal of Pharmaceutical and Clinical Research (IDJPCR) Vol. 03, No. 2, 2020 52

4. Conclusion
This study concluded that adherence has a correlation with clinical outcomes and the quality of
life of primary hypertension patients.

Acknowledgement

The authors are grateful thank to Faculty of Pharmacy, Universitas Sumatera Utara for the
facilities support.

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