Antihypertensive medication nonadherence and predictors among adult patients on

follow up, Ethiopia: Prospective study.

Bezie Kebede 1*: [email protected], mamo magaze2: [email protected]

1. Department of Pharmacy, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia

2. Department of Pharmacy, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia

Abstract

Introduction: The overall burden of hypertension-related diseases is rapidly rising in the developing world. A systematic
review of prevalence and associated factors in Ethiopia indicates the prevalence of hypertension in Ethiopia ranges from 0.8-
31.5%. Low antihypertensive medication adherence has been proposed as an important barrier to achieving hypertension
control. Demographic, treatment, clinical and behavioral factors have been shown to be associated with medication
nonadherence, and previous studies have indicated that psychosocial factors are important determinants of antihypertensive
medication nonadherence in older adults.
Objective: To assess the magnitude of nonadherence and predictors among adult hypertensive patients on follow up in
chronic follow-up, MTUTH.
Method: Institutional based prospective study was conducted to assess the prevalence and predictors of nonadherence of all
adult hypertensive patients that attend during study period from February 19 to April 5/2019. A structured interview
questionnaire of data collection format and 10-item drug attitude inventory adherence scale was used and the patient
medication chart was reviewed. Data was entered into epi-data version 3.1 and analyzed using STATA version 14.2. Mean or
median and the standard deviation was used for continuous variable and chi-square test for ordinal and nominal variables.
Independent predictors of outcome were identified and strength of association between dependent and independent variables
determined by using by regression analysis. Before computing binary logistic regression analysis, the presence of colinearity
between independent factor (having 1.5 variance inflation factor) and model fitness (with Hosmer Lemeshow p-value 0.16)
was checked. A P-value less than 0.25 in binary logistic regression was entered into the multivariate model and finally P -value
of <0.05 was considered to declare statistical significance.

Result: A total of 153 study participants were included in the study making the response rate of 98.7%. More than half of
respondents were male 54.2%. The mean age of respondents was 46.85 years with a standard deviation of 11.7. Seventy two
(47.06%, 95%CI: 4 5 -57) respondents were non adherent according to adherence scale of drug attitude
inventory(DAI-10)scale. Lack of previous counseling/education (p=0.021), educational status (p=0.032),
patient knowledge (p=0.035), family support (p=0.037), blood control status (P=0.028) and patients
cover their drug cost by themselves (p=0.048) were factors that significantly associated with
nonadherence.

Conclusion and recommendation: The rate of non-adherence to antihypertensive medication is high and different factors can
contribute to occur it. The government shall try to cover under the umbrella of health insurance to prevent medication
nonadherence because of drug acquisition costs. Health care providers especially pharmacist should consider counseling an
integral part of patient management and give ample information about the negative impact of nonadherence on blood control
status and post blood pressure complication.

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 Key-words: HTN, nonadherence, MTUTH, outpatient

1. Introduction

The overall burden of hypertension (HTN) and related diseases are rapidly rising in the developing world.
HTN is a prevalent and often asymptomatic chronic disease. A systematic review of prevalence and
associated factors in Ethiopia indicates the prevalence of HTN in Ethiopia ranges from 0.8- 31.5%. Low
antihypertensive medication adherence has been proposed as an important barrier to achieving blood
pressure (BP) control (1).

The World Health Organization defines adherence to long-term therapy as “the extent to which a person’s
behavior of taking medication, following a diet, and/or executing lifestyle changes corresponds with
agreed recommendations from a health care provider (2).

Patients' non-adherence to medications has been attributed to both intentional (conscious decision not to
take medications) and unintentional (failure to take medications due to poor understanding or
forgetfulness or other factors) reasons. Providers may be unaware of patients' medication-taking behavior
and patients' understanding of how to take their medications. Without this information, it is difficult for
providers to distinguish whether the problem is due to drug efficacy or adherence related issues. Effective
communication between the patient and health professionals is very important for providers’ assessment
of patients' adherence to medications (3).

Poor adherence to antihypertensive therapy is one of the biggest obstacles in therapeutic control of high
BP. It also compromises the efforts of the health care system, policymakers and health care professionals
in improving the health of populations. Failure to adhere causes medical and psychological complications
of the disease/ reduces patients’ quality of life, wastes health care resources and erodes public confidence
in health systems. Poor adherence to antihypertensive therapy is usually associated with the bad outcome
of the disease and wastage of limited health care resources (4). Globally, poor adherence has been
estimated to cost approximately $177 billion annually in total direct and indirect health care costs (5).

Patient demographic characteristics, treatment, clinical and behavioral factors have been shown to be
associated with medication nonadherence, and previous studies have indicated that psychosocial factors
are important determinants of antihypertensive medication adherence in older adults (2). In general,
factors determining the level of antihypertensive drug nonadherence can be classified as related to
treatment, the interaction of the patient with a health care provider and patient-related factors(6). Here in

2
Mizan-Teferi, there is no data conducted to evaluated patient adherence status. Therefore the aim of this
study is to evaluate patient medication adherence and contributing factors for nonadherence.

2. Methods and participants

This study was conducted in Mizan-Tepi University teaching hospital (MTUTH), Mizan-Teferi,
Ethiopia. MTUTH is located in Mizan-Aman town which is 561km far from Addis Ababa towards
southwest Ethiopia. It is one of the teaching University hospitals in Ethiopia since 2016. MTUTH is
offering diagnosis and treatment for approximately 6484 patients per month (7). There are more than
four outpatient clinics located within the hospital which serves over 420 visits/month (7). Among
these outpatient department visits, about 242 patients are hypertensive per month (8). This study was
conducted specifically at outpatient service which is a chronic care unit from March to May
/2019.

A Hospital-based prospective study was used to assess the prevalence and determinants of nonadherence
among adult antihypertensive patients attending a chronic care unit in MTUTH. After obtaining the
approval from the ethical committee and letter of cooperation from internal medicine the study was
initiated at the outpatient medicine department by selecting patients based on inclusion and exclusion
criteria. All adults with age 18 and above, patients with confirmed diagnosis of HTN and have been
receiving drugs for HTN for at least 3 months before data collection. Patients who have followed up at
the outpatient chronic care unit and having confirmed diagnosis for HTN were taken as the source
population. Patients having psychiatric co-morbidity/mental illness and a pregnant woman were excluded
from this study. Finally, all adult patients who satisfy the inclusion criteria were candidates as a subject
for the study.

Selection of study participants was as follows in figure 1

Total patients who came to hospital during data
collection period and invited to participate the

Number of patients who did

not fulfill inclusion criteria (n=
Total patients who fulfill
inclusion criteria=155

Number of patients who

refused to participate (n=2)

Total patients
included in the study

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Fig. 1 Hypertension patient selection flow chart at MTUTH from March to May, 2019

2.1 Data collection procedure and data analysis

Patient socio-demographic data was recorded (age, gender, level of education, occupational status).
Medical history (duration of illness, co-morbidity ), smoking status, knowledge, attitude towards their
medication and the disease itself, availability of drugs, number of drugs, distance from the health
institution, alcohol and khat consumption, adherence (assessed by drug attitude inventory scale) were
recorded using structured questionnaire (adapted from different previously published literatures (2, 9, 10,
11, 12, 13, 14, 15). The questionnaire was first developed in English and translated to the local language
and then retranslated to English to evaluate consistency. Adherence was dichotomized as adherent and
nonadherent after summing up of the patient score. The questionnaire contained 6 positives and four
negative questions. Positive question represents(+1) and negatives represent (-1) and finally total score of
the patients summed up. Patients who had a positive score were adherent and those having negative
scores were treated as nonadherent. A pre-test was administered on 8 patients at Tepi general Hospital,
southwest Ethiopia. Some amendment was made on the tool after the pre-test was done. Relevant data
were obtained by interviewing the patient and chart review when necessary. Data was collected by one
pharmacist and one nurse after 1-day training about how to extract information from the patient and from
the chart when necessary. Supplementary information and clarifications on some patient’s medical
information were obtained through discussion with respective nurses and physicians.

Data were entered into a computer using Epi data 3.1software and analyzed with STATA version 14.2.
All continuous variables were evaluated for normal distribution and found to be normally distributed
using descriptive statistics including skewness and kurtosis. Before computing multivariate binary
logistic regression analysis, the presence of colinearity between independent factor (having 1.5 variance
inflation factor) and model fitness (with Hosmer Lemeshow p-value 0.16) was checked. Chi-square
statistics were used to check the adequacy of cells for binary logistic regression. Independent predictors
of outcome and strength of association between dependent and independent variables were identified by
using binary logistic regression analysis and P-value < 0.25 entered to multiple regression. P-value < 0.05
was declared as significant predictors. Descriptive statistics were used to characterize adherence and
independent variables. The results of the study were organized in the form of frequencies and
percentages. The data was summarized and described using tables and figures.
4
3. Results

3.1 Background characteristics of participants

A total of 153 patients were included in this study and have a response rate of which 98.7%. More than
half of the respondents were male 54.25%. The mean age of respondents was 46.85 years with a standard
deviation of 11.7 and with the maximum number of patients being in the age group of 41-60 years
(52.3%). More than half of the respondents 80(52.29%) were living the urban. Ninety-six (62.7%)
respondents, on a single trip, it took more than thirty minutes to reach the hospital. Regarding
educational status, illiterates were account for 47(30.72%). One hundred thirty-three (86.9%) patients
used their medication once per day. The majority of patients have no family support when they take their
medication 54.9%. More than 90% of patients were followed regular follow up during their hospital visit.
Almost half of the patients were had good knowledge (Table:1).

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Table 1: Socio-demographic characteristics and behavior of participants, chronic care unit,
MTUTH, Ethiopia, 2019

Socio-demographics Category Frequency Percent

characteristics and
behavior of respondents
Gender Male 83 54.25
Female 70 45.75
Age group 19-40 50 32.7
41-60 80 52.3
>60 23 15.0
Co morbidity Yes 51 33.33
No 102 66.67
Educational status Illiterate 47 30.72
Primary school 38 24.84
Secondary school 24 15.69
12+ 44 28.76
Residence Urban 80 52.29
Rural 73 47.06 3.2 Disease
Do you drink alcohol? Yes 19 12.42 and
No 134 87.58
Medication
Knowledge Good 76 49.67
Poor 77 50.33
Attitude Positive 58 39.91
Negative 95 62.09
Smoking status Non smoker 127 83
Ex-smoker 25 16.35
Currently smoker 1 0.65
Do you chew khat? Yes 11 7.19
No 142 92.81
Do you take salt more Yes 51 33.33
than recommended? No 102 66.67
Do you adhere to your Yes 75 49.0
regular follow up? No 78 51.0
Do you have family Yes 69 45.1
support? No 84 54.9
How far you live from <30min 57 37.25
the hospital? ≥30min 96 62.75
Frequency of follow up < 2 months 139 90.8
≥ 2 month 14 9.2

characteristic of patients

Nearly half of the patients (47.7%) had stage I hypertension and 66(43.1%) having hypertension for more
than two years. More than 77% of the patients had uncontrolled hypertension. The majority of patients
had more than two drugs. Only 64 (42.0%) of patients received counseling from different health
6
professionals and others and pharmacists involved less frequently. With regard to treatment cost
coverage, only 10(6.5%) patients cost was covered by the government (Table: 2)

Table 2: Disease and Medication characteristic of respondents, MTUTH, Ethiopia, 2019

S.no Characteristic Variables Frequency Percentage

1. Stage of HTN Per HTN 44 30.7
Stage I 73 47.7
Stage II 33 21.6
2. Duration of illness <2 years 42 27.5
2-4 years 66 43.1
>5 years 45 29.4
3. BP control status Controlled 34 22.2
Uncontrolled 119 77.8
4. Number of drugs per patient <2 drug 18 11.8
2-4 drug 110 71.9
> 5 drug 25 16.3
5. Did you receive counseling Yes 89 58.0
No 64 42.0
6. From whom you got counseling? Pharmacist 21 13.7
Physicians 30 19.6
Nurse 29 19
Other* 9 5.9
7. Who covers your treatment cost Self 143 93.5
Government 10 6.5
9. Frequency of dosing? Once /day 133 87.5
Twice/day 18 11.84
Three times/day 1 0.66

3.3 Prevalence of nonadherence and reasons

Eighty-one (52.94%) patients were adherent and the rest 72(47.06%, 95%CI: 40-53) were nonadherent. A
number of factors can be considered as the reason for nonadherence the patients towards their
medication. Forgetfulness is the major reason for patient nonadherence, 31.13%, followed by drug
acquisition cost, 16.4% and fear of medication side effect shared less than 6% (fig.2).

7
 30.00%
20.00%
10.00%

% of patients
0.00%
s gs t n y l n
r ug ru en tio ac p ita tio
m a m s c
ed f d a t
ed
ic ar o ea
ta
k
sto f tre m ph h eh u gr
to Co o ly t r
ke Po om ed
got tion ta fr r s
r a to e e
Fo dur sy nc adv
u ta
ng B
Di
s us
Lo evio
Pr
Reasons for medication non adherence

Fig. 2 Reasons for nonadherence among participants, chronic care unit, MTUTH, Ethiopia, 2019

3.4 Predictors of nonadherence

Different factors were contributed to influence patient antihypertensive medication nonadherence.

Bivariate regression analysis showed that illiterate respondents were more nonadherent than as
compared to patients who attend post-secondary school(P=0.02). Patients who have no previous
counseling were nonadherence than those who received counseling from health care providers
(P=0.043). Previous adverse drug reaction (ADR) is one of the predictors for nonadherence in which
patients who were experienced ADR is more prone to nonadherence (P=0.024) but is not independent
predictors after confounding factors were controlled in multiple regression model. Regarding co-
morbidity, patients having co-morbidity is more likely nonadherent as compared to patients having
HTN only (P=0.049) but it was not statistically significant after confounding variables were adjusted.
Patients who pay for their medication by themselves were more likely nonadherent than those
sponsored by the government (Table:3).

Table :3 Bivariate analysis for predictors of nonadherence among hypertensive patients, chronic care
unit, MTUTH, Ethiopia, 2019
Variables NonAdherence (%) Bivariate analysis
Yes No COR(CI) P-value
Gender Male 32(43.8) 51(63.75) 0.3(0.1-0.72) 0.32

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 Female 40(56.2) 30(36.25) 1.00 1.00
Age 19-39 26(36.1) 24(29.62) 0.72(0.21-0.81) 0.92
40-60 39(54.16) 41(50.6) 0.55(0.21-1.45) 0.47
>60 7(9.74) 16(19.78) 1.00 1.00
Educational Illiterate 24(33.33.) 23(28.39) 1.89(1.02-2.54) 0.02
status Primary school 17(23.61) 21(25.92) 0.18(0.063-0.49) 0.1
Secondary school 10(13.88) 14(17.3) 1.13(0.54-6.1) 0.54
12+ 21(29.18) 23(28.39) 1.00 1.00
Family No 45(62.5) 39(48.14) 0.5(0.1-3.76) 0.17
support Yes 27(37.5) 42(51.86) 1.000 1.00
Regular No 29(40.27) 42(48.15) 1.9(0.43-8.87) 0.81
follow up? Yes 42(59.73) 39(52.5) 1.00 1.00
Attitude Negative 42(58.33) 53(65.43) 1.47(1.35-3.46) 0.04
Positive 30(41.67) 28(34.57) 1.00 1.00
Previous No 30(41.67) 34(41.97) 3.7(3.62-15.3) 0.043
counseling Yes 42(58.33) 47(58.03) 1.00 1.00
Knowledge Poor 47(65.27) 30(37.0) 2.65(1.303-7.21) .23
Good 25(34.73) 51(63.0) 1.00 1.00
Frequency of < very 2 months 66(91.67) 73(90.12) 1.4(0.23-2.82) 0.43
follow up ≥ every 2 months 6(8.33) 8(9.88) 1.00 1.00
Previous ADR Yes 12(16.67) 8(9.87) 3.2(1.8-13.4) 0.024
No 60(83.33) 73(90.13) 1.00 1.00
Co-morbidity Yes 29(40.27) 22(27.16) 2.8(1.7-8.432) 0.049
No 43(59.73) 59(72.84) 1.00 1.00
HTN control Uncontrolled 65(90.27) 54(66.67) 3.21(3.132-11.98) 0.087
status Controlled 7(9.73) 27(33.33) 1.00 1.00
Who covers Self 69(95.83) 74(91.35) 2.1(1.82-7.5) 0.045
drug costs? Government 3(4.17) 7(8.65) 1.00 1.00
ADR: Adverse Drug Reaction, HTN: hypertension, COR: crude odds ratio

9
After the multivariate analysis was computed, significant determinants for nonadherence were identified.
Illiterate patients were more likely nonadherent than those who attend post-secondary school
(AOR=1.89, 95%CI: 1.02-2.54, P=0.032). Family support is one of the statistically significant predictors
for medication nonadherence. Patients who have no family support were more prone to nonadherent as
compared to those having family support (AOR2.01,95CI: 1.01-8.76, P=0.037). In addition, previous
exposure for health-related counseling, patient attitude, cost of medication coverage and HTN control
status were statistically significant determinant factors for the antihypertensive medication (Table: 4).

Table: 4 Multivariate analysis for predictors of nonadherence among hypertensive patients, chronic care
unit, MTUTH, Ethiopia, 2019
Variables NonAdherence (%) Multivariate analysis
Yes No AOR(CI) P-value
Educational Illiterate 24(33.33.) 23(28.39) 2.11(1.06-4.080) 0.032
status Primary school 17(23.61) 21(25.92) 1.87(0.89-12.09) 0.16
Secondary school 10(13.88) 14(17.3) 0.544(0.78-1.87) 0.98
12+ 21(29.18) 23(28.39) 1.00 1.00
Family No 45(62.5) 39(48.14) 2.010(1.01-8.76) 0.037
support Yes 27(37.5) 42(51.86) 1.000 1.00
Attitude Negative 42(58.33) 53(65.43) 1.47(1.22-3.46) 0.045
Positive 30(41.67) 28(34.57) 1.00 1.00
Who covers Self 69(95.83) 74(91.35) 3.9(3.12-12.87) 0.048
drug costs? Government 3(4.17) 7(8.65) 1.00 1.00
Previous No 30(41.67) 34(41.97) 2.09(1.89-14.3) .021
counseling Yes 42(58.33) 47(58.03) 1.00 1.00
Knowledge Poor 47(65.27) 30(37.0) 0.73(0.303-1.34) 0.35
Good 25(34.73) 51(63.0) 1.00 1.00
Previous Yes 12(16.67) 8(9.87) 3.42(1.74-11.12) 0.054
ADR No 60(83.33) 73(90.13) 1.00 1.00
Co-morbidity Yes 29(40.27) 22(27.16) 2.8(0.7-6.32) 0.081
No 43(59.73) 59(72.84) 1.00 1.00
HTN control Uncontrolled 65(90.27) 54(66.67) 4.101(2.13-13.98) 0.028
status Controlled 7(9.73) 27(33.33) 1.00 1.00
AOR: adjusted odds ratio, HTN: hypertension

4. Discussion

Medication nonadherence profiles of hypertensive patients prescribed with anti-hypertensive drugs and
the determinants of medication nonadherence were investigated in this study. With the adoption of

10
representative sampling, the prevalence of medication nonadherence was estimated and found to be
47.06%. Thus, it is significantly lower than the expected index of 80% medication adherence. The
prevalence of medication nonadherence in this study relatively higher compared to the study done in
Gondar (9). This discrepancy could be because of in our study area there is no sufficient number of
clinical pharmacist and a large proportion of patients had no previous exposure of education concerning
medication adherence as compared to Gondar university hospital where a sufficient number of clinical
pharmacists and more senior staffs were available. The current study implies that health care provider
especially pharmacists should continuously evaluate patient adherence to the provided regimen. And
the proportion of illiterate patients is high in our study compared with the previous study done which
can contribute to nonadherence unknowingly.

The major reported reasons to miss/discontinue antihypertensive medication were forgotten to take
their medication 30.13%, followed by the costs of drugs 16.4%. A long duration of treatment is one of
the reasons to skip their medication which accounts for 15.06%. Patients workload and being loaded
with many drugs are anther reason for nonadherence 12.3% each. In this study, other minor reasons
were considered for nonadherent, because of previous ADR. The same reasons were reported in
previous studies (3, 4, 10, 14,16).

It is difficult for health care providers to switch or stop any medications without identifying the major
reasons for nonadherence. Therefore it is essential for health care providers to create a strong bond with
their patients and identify the reasons for nonadherence so as to improve medication adherence and
optimize treatment outcomes.

Identifying significant predictors for nonadherence is by far beneficial for the patient to optimize
adherence and treatment outcome/PB control. Our findings showed that different predictors are
significantly associated with medication adherence. Educational status is one of the major significant
predictors for nonadherence. Respondents who are illiterate were more likely nonadherent compared to
patients attending postsecondary school. Our study contradicts the study done in Congo which showed
that educational status is not significant predictors(17). This discrepancy could be because of in our
study, the proportion of illiterate patients was higher as compared to the finding in Congo.

This result implies that since there are substantial numbers of illiterate patients, health care providers
should continuously evaluate the patient on the compliance of their medication. Health education
especially for those who have a low understanding of what they provided by health professionals during
physician contact or pharmacist counseling about medication adherence.

11
 Our study also found that a strong association between previous education about the disease/their
medication and adherence. Patients who have no previous educational exposure about the importance
of medication adherence by health care providers were more than two times more likely nonadherent
than those who have exposure. This result is supported by the study done in Adama in which
respondents who have not at all previously exposed to the information provided about their medication
are 88% less likely to be adherent as compared to those who exposed the information very well (18).
As the previous study done in Hong Kong showed that non-adherence is the major factor for poor blood
control status(19), the patient should be convinced about their medication adherence. The pharmacist
should play the major role of counseling of patients at every hospital visit.

It is by far good to prepare patients for separate blood pressure camps especially, non-adherent patients.
Patient education can be organized for noncompliant patients. These patients should be given adequate
opportunity to express their expectations/perceptions of both the disease and its treatment. Furthermore,
an extensive study should be conducted on how to optimize patient medication adherence.

Our study also found that family support is one of the significant factors for nonadherence of
antihypertensive medication. Those patients who have no family support are two times more likely
nonadherent as compared to those who have no family support. The patient should be identified and
prepare especial strategies to help patients how to remind to take their medication without disruption of
the frequency of dosing.

The occurrence of non-adherence to antihypertensive medications was more likely among patients with
negative attitudes in comparing with respondents having positive attitude based on our attitude
classification (patients respond above mean score is considered as a positive attitude and below mean
score is negative attitude). This result is consistent with the study done in Debre Markos Referral
Hospital, Felege Hiwot Referral Hospital, and Gondar university referral Hospital (20).

Since less than half of patients attended secondary and post-secondary school, the majority of patients
may encounter difficulty to understand what health providers told them and their perception about the
medication and the disease itself may be suboptimum. Thus, the present study suggested that health care
provider especially clinical pharmacist should involve patient education to boost patient good perception
concerning the consequence of being nonadherent.

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More importantly, BP control status is one of the significant determinants of nonadherence. Patients with
uncontrolled PB were four times nonadherent as compared to patients having controlled BP. There were
similar findings in previous studies done in Malaysia, Eastern Nigeria and study have done in Jimma
University Specialized Hospital(21, 22, 23). Therefore, health care providers should motivate patients to
adhere to their medication and intern to prevent post hypertension complications. Costs issue is another
significant predictor in our study and a similar study was reported by Mekonnen et al. (20) and study
done in Jimma University Specialized Hospital (23)in which patients who have been receiving their
drug-free of charge were more likely adhere than patients who pay out of pocket. However, co-
morbidity, sex, age, previous ADR and knowledge were associated with nonadherence in Bivariate
analysis but did not reach significant predictors after adjusted co-varieties. Therefore, evidence-based
interventions, such as medication adherence educational programs, could be targeted to hypertensive
patients who were poor self-perceived health status to improve their medication adherence; and at those
who were living alone and with multi-morbidity to improve their medication adherence and BP control.

4.1 Limitation: This study conducted in a single-center and with a small sample size; difficult to
generalize. Adherence was assessed by self-reported way and recall and personal desirability bias may
be an issue.

5. Conclusion and recommendation

The rate of non-adherence to antihypertensive medication is high (ie below the expected index of
medication adherence). Lack of previous education about medication, educational status, an attitude of
patients about the disease and the medication, family support, and BP control status have been
identified to have affected the nonadherence rate. However, age, sex, co-morbidity, knowledge, and
previous adverse ADR were not significantly determining patient adherence. More importantly, BP
control status was significantly correlated with nonadherence. Pharmacist involvement is low towards
patient counseling practice during their hospital visit. Measurement of the degree of non-adherence in
each individual patient becomes increasingly important in early interventional practice. Health care
providers especially pharmacist should consider patient counseling is an integral part of patient
management and give ample information about the negative impact of nonadherence on BP control.
The government tried to identify and cover patients under the umbrella of health insurance to prevent
nonadherence patients because of drug acquisition cost.

Abbreviations

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ADR: Adverse Drug Reaction; AOR: Adjusted Odds Ratio; BP: Blood Pressure; COR: Crude Odds Ratio;
MTUTH: Mizan-Tepi University Teaching Hospital;

Ethical considerations: A letter of ethical clearance was secured. A letter for cooperation from the
department of internal medicine was obtained. Verbal consent from respective physicians, nurses, and
patients were secured to extract data from patents' medical charts. Participants were also informed that
participation was depending on a voluntary basis and that they have the right to withdraw at any time if
they are not comfortable with the study. In order to keep confidentiality, all data were kept anonymously
in the observational checklist and interview questionnaire. Privacy and confidentiality were ensured
during patient interview and review of patient charts.

Consent for publication: not applicable

Availability of data and materials: all data analyzed during this study was available for publication.

Competing interest: The authors declare that they have no competing interests.

Funding: Not applicable

Authors contribution: Not applicable

Acknowledgment: I am very grateful to the nursing staff for their cooperation in giving sufficient patient
information. I would like to say thank you, my data collectors. I would like to give special thank you for
my study participants and data collectors for their cooperation to participate in this study.

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