Patient Preference and Adherence

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A qualitative study on hypertensive care behavior

in primary health care settings in Malaysia

Razatul Shima, Mohd Hairi Farizah & Hazreen Abdul Majid

To cite this article: Razatul Shima, Mohd Hairi Farizah & Hazreen Abdul Majid (2014) A
qualitative study on hypertensive care behavior in primary health care settings in Malaysia,
Patient Preference and Adherence, , 1597-1609, DOI: 10.2147/PPA.S69680

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Patient Preference and Adherence Dovepress
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Open Access Full Text Article Original Research

A qualitative study on hypertensive care behavior

in primary health care settings in Malaysia
This article was published in the following Dove Press journal:
Patient Preference and Adherence
17 November 2014
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Razatul Shima 1,3 Purpose: The aim of this study was to explore patients’ experiences with their illnesses and
Mohd Hairi Farizah 1,2 the reasons which influenced them in not following hypertensive care recommendations (anti-
Hazreen Abdul Majid 1,2 hypertensive medication intake, physical activity, and diet changes) in primary health clinic
settings.
1
Department of Social and Preventive
Medicine; 2Centre for Population Patients and methods: A qualitative methodology was applied. The data were gathered
Health, Faculty of Medicine, University from in-depth interviews with 25 hypertensive patients attending follow-up in nine govern-
of Malaya, Kuala Lumpur, Malaysia;
ment primary health clinics in two districts (Hulu Langat and Klang) in the state of Selangor,
3
Ministry of Health Malaysia, Putrajaya,
Malaysia Malaysia. The transcribed data were analyzed using thematic analysis.
Results: There was evidence of lack of patient self-empowerment and community support in
Malaysian society. Most of the participants did not take their antihypertensive medication or
change their physical activity and diet after diagnosis. There was an agreement between the
patients and the health care professionals before starting the treatment recommendation, but
there lacked further counseling and monitoring. Most of the reasons given for not taking anti-
hypertensive medication, not doing physical activity and not following diet recommendations
were due to side effects or fear of the side effects of antihypertensive medication, patients’
attitudes, lack of information from health care professionals and insufficient social support
from their surrounding environment. We also observed the differences on these reasons for
nonadherence among the three ethnic groups.
Conclusion: Health care professionals should move toward supporting adherence in the
management of hypertensive patients by maintaining a dialogue. Patients need to be given time to
enable them to overcome their inhibition of asking questions and to accept the recommendations.
A self-management approach must be responsive to the needs of individuals, ethnicities, and
communities.
Keywords: adherence, hypertension, in-depth interview, qualitative research

Introduction
Globally, many patients diagnosed with hypertension do not follow medical or
lifestyle recommendations.1 There are many terminologies related to the definitions
and the measurements of why patients do not take their prescribed medication and
do not follow health recommendation, but the evidence converges on average at only
50%.1,2 The most widely used terms to describe patients’ behavior are compliance
and adherence. The main difference is that adherence requires patients’ agreement
Correspondence: Shima Razatul to the recommendations from the health care provider.2 Most of the studies did not
Department of Social and Preventive
Medicine, Faculty of Medicine, University state if the patients’ previous agreement to the recommendations was taken into
of Malaya, Kuala Lumpur 50603, Malaysia consideration. A study in Malaysia, which was done among hypertensive patients
Tel +60 3 7967 4756
Fax +60 3 7967 4975 in a community health clinic in the state of Selangor found that the participants per-
Email [email protected] ceive prescribed Western medicine from the health clinic as scientifically proven but

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having ­undesirable side effects. ­Therefore, complementary approach that is often used to understand the experiences of
and alternative medicine was used to counteract the harm- a particular group or community because it allows flexible
ful effects of the Western medicine. The types of adherence exploration of participants’ experiences.12 In addition, some
behavior found in the study include faithful follower, self- of the qualitative research has identified important issues
regulator, and intentional nonadherer.3 These behaviors pose such as the quality of the doctor–patient relationship and
a major concern in health care research, especially in the patients’ health beliefs in a behavioral context toward health
management of chronic conditions such as hypertension, recommendations.13
where drug treatment and lifestyle changes are the prin- Therefore, this study was initiated to explore hypertensive
cipal management in preventing cardiovascular mortality patients’ experiences with their illness and the reasons
and morbidity.2,4 Lack of conformance toward health care which influence them in not following hypertensive care
recommendations is associated with greater health care recommendations (antihypertensive medication intake,
utilization, via cardiovascular-related hospitalizations and physical activity, and diet changes) in those attending
emergency department visits, which contribute to increases government primary health clinics follow-up. Hence, this
in total health care costs.5 study will provide better understanding of the reasons
It has been proposed that primary health care centers why hypertensive patients do not follow treatment and
play a major role in providing care to hypertensive patients.6 lifestyle changes recommendations in different ethnici-
Globally, the medication adherence rate was found to be low ties in Malaysia. It also provides essential information to
among primary care hypertensive patients.2 In Malaysia, health care providers, public health specialists, and policy
78.4% of known hypertensive patients claimed to be on makers for developing interventions which will consider
oral antihypertensive medications, 82.7% were on specific all these barriers.
diet, and 75.2% had been advised to be more physically
active or to start exercising, whereby half of them received Materials and methods
treatment at the government primary health clinics (53%).7 A qualitative approach was adopted in this study, and the
Nevertheless, good medication adherence rate among methodological schema of description-reduction-interpretation
hypertensive patients treated at primary care facilities in was used.14 Initial data collection was via in-depth interviews
Malaysia was only 53.4%.8 (description) with hypertensive patients who underwent
A study carried out in the outpatient hypertension clinic follow-up at the chronic disease clinics of government pri-
in Penang General Hospital, Malaysia revealed that 51.3% mary health clinics in Hulu Langat and Klang districts, in the
of hypertensive patients had poor adherence to antihyper- state of Selangor, Malaysia. This was followed by finding
tensive medication, and a study conducted at the Family emerging themes (reduction) in the data and hermeneutic
Medicine Clinic, University of Science in Kelantan, Malaysia reflection (interpretation of results). The purpose of these
had identified that 55.8% of hypertensive patients were interviews was to explore the patients’ experiences with their
noncompliant to their antihypertensive medication.9,10 It is illnesses and to identify the reasons that influenced them in
important to recognize the reasons why hypertensive patients not following hypertensive care recommendations. In-depth
do not follow hypertensive care recommendations by their interview was chosen as the method, as this approach yields
health care provider before implementing any intervention more information regarding individuals’ complex beliefs than
programs for hypertensive patients undergoing follow-up focusing on group discussions.15,16
in primary health care facilities in Malaysia. Most studies Ethical approval was obtained from the Malaysian Min-
done in Malaysia focus on quantitative measurements of the istry of Health (National Medical Research Register number
determinants of nonadherence.8–10 There was no explora- 12-625-12500) and the University Malaya Medical Ethics
tion between ethnic differences in terms of the reasons for Committee (number 914.5).
nonadherence and factors which influence the three major
ethnic groups (Malay, Chinese and Indian) to adhere to Study participants
health care recommendations. The research gap in this field The participants were both men and women diagnosed
is the absence of the patients’ perspective and a dearth of with hypertension, who went for follow-up at the chronic
qualitative research, and there is lack of understanding of disease clinics in government primary health centers within
the way patients think and feel about their medications and the districts of Hulu Langat (Bangi, Semenyih, Beranang,
their behavior.3,11 Qualitative research is a methodological Kajang, Batu 9, Bandar Seri Putra, and Sungai Chua health

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Dovepress Antihypertensive medication adherence in Malaysia

clinics) and Klang (Bandar Botanik, Bukit Kuda, Meru, Also, the interview guides were pretested with eight hyperten-
Pandamaran, Port Klang, and Kapar health clinics) in the sive patients for their relevance, suitability, and ease to carry
state of Selangor, Malaysia. out in primary health care settings. The research questions were
Purposive sampling was adopted to select different age designed with open-ended questions. Probes, such as “Would
groups and different ethnic groups to represent the major you explain that further?”, “Would you give me an example?”,
ethnic groups in Malaysia: Malays, Chinese, and Indians. “Is there anything else?” were used throughout the interview to
Two doctors in each health clinic were involved in selecting encourage the interviewees to converse. Each interview began
the hypertensive patients who did not follow medication or with the same opening question: “How did you first discover
change their lifestyles, as perceived by the doctors. you have hypertension?” This gave the participants the chance
The inclusion criteria were patients diagnosed with to narrate their flow of thoughts on the topic.
essential hypertension for at least 6 months, Malaysian
nationality, aged above 18 years, able to read and understand Study procedures
English or Bahasa Malaysia, and without physical disabilities The participants were selected from government primary
which would limit them from undertaking physical activity health clinics, which serve the lower socioeconomic strata to
recommendations. Table 1 shows the characteristics of the affluent middle class strata. Between March 2013 and the end
25 participants involved in this study. of July 2013, the hypertensive patients who were selected by
their doctors were approached while waiting for their appoint-
Study instruments ments at the chronic disease clinics. They were approached
A rough interview guide was developed from the literature accompanied by the staff nurse in charge after their blood
review as a reminder of areas to be covered during the inter- pressure readings were taken at the screening counter. An
views (Table S1). The interview guide was developed in information sheet on the study and informed consent form
English and was translated into Malay. This interview guide were given. The in-depth interviews were all done face to
was discussed among the research team, and the contents were face in an isolated room in the health clinic after the patients
evaluated by experts (three family medicine specialists, one had seen their doctors and had taken their medicines in the
internal medicine specialist, and two public health specialists). pharmacy. The confidentiality of the interviews was ensured.
Only the interviewer and the interviewee were present to
Table 1 Characteristics of participants involved in the study ensure that the participants’ answers were exclusive. All
Characteristics In-depth interview
the interviews were conducted in both English and Bahasa
(n=25) Malaysia by the primary investigator, with each interview
Age lasting between 45 and 90 minutes.
Mean age in years (SD) 49±9.3 A demographic questionnaire was also administered
Sex
verbally at the beginning of the interview. All the interviews
Male 11
Female 14 were audio taped. First member checking was done as vali-
Ethnicity dation to confirm the information given by each participant.
Malay 8 The final sample size reflected continuous sampling until
Chinese 7
Indian 7
saturation with no new issues or ideas emerging from the
Others 3 participants. Participants’ case notes reviews were done in
Positive family history of hypertension order to verify the personal information and the blood pres-
Yes 23
sure reading. Five patients were not keen to be interviewed
No 2
Hypertension control because they claimed that they followed the treatment
Adequate control (less than 140/90 mmHg) 6 and lifestyle recommendations from their doctors. Thus,
Not adequate control (equal or more than 25 participants were interviewed.
140/90 mmHg) 19
Duration of hypertension
Mean in years (SD) 5.0±3.3 Data analysis
Occupation The data from the in-depth interviews were transcribed
Government sector 8
verbatim. Data were analyzed by the primary investigator
Private sector 14
Housewife 3 (SR) using thematic analysis. The transcriptions were stored
Abbreviation: SD, standard deviation. and managed accordingly to ensure confidentiality. Second

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member checking was done as each participant received a remember, the upper reading was 160. The doctor asked me
copy of the interview transcript for them to review to check to take medication but I don’t want to because I don’t think
for narrative accuracy. The NVivo 9 software from QSR I need this medication. I’ve tried controlling my stress, but
International (the Melbourne-based software developer spe- my blood pressure is still high. [in-depth interview (IDI)/43
cializing in qualitative research software) was used for the years-old/6 years diagnosed with hypertension]
analysis to assist and to facilitate the coding processes, and
further categorization was done to make sense of the essential I’ve got headaches, but I don’t know it was high blood
meanings of the phenomenon and to allow the emergence of pressure. I have to take care of my husband who is suf-
the common themes. The primary investigator and a public fering from stroke. I’ve overworked and can you imagine
health specialist who has experience in research generated how stressful I am? That’s why my blood pressure shot
different initial coding schemes, and the differences were up. I know if I don’t take my medication, I can be just
resolved via discussion. like my husband. [IDI/65 years-old/1 year diagnosed with
The finalized transcripts were then translated into English hypertension]
by another independent translator. The first author then read
the transcripts line by line, repeatedly and thematically, to I experienced dizziness on and off because I don’t have
analyze the contents. In order to draw in-depth views, the enough rest and sleep. I work and continue working without
participants were given the freedom to express additional sleeping. I have no time to rest and I feel so stressed. That’s
reviews and comments. The interviews mainly focused on why I’m suffering from high blood pressure. [IDI/50 years-
the experiences with antihypertensive medication and the old/8 years diagnosed with hypertension]
reasons for not following the hypertensive care recommen-
dations (antihypertensive medication, physical activity, and I have blood pressure set at home. My son bought it for
diet recommendations). me, but I don’t check my blood pressure regularly until
at one time I had a really bad headache and I noticed my
Results pressure shot up. [IDI/61 years-old/2 years diagnosed with
From the analysis of responses, this study was able to identify hypertension].
four themes: a) symptoms of hypertension at first diagnosis,
b) barriers and facilitators of hypertensive care nonadherence
with antihypertensive medication, c) barriers and facilitators
Barriers and facilitators of hypertensive
of hypertensive care nonadherence with physical activity care nonadherence to antihypertensive
and diet, and d) issues with health care professionals and medication
health care system. Eighteen participants admitted not taking their antihypertensive
medication as prescribed. Despite being unsuccessful, they
Symptoms of hypertension believed that they could control their blood pressure through
physical activity, diet, and stress management, hence, medi-
at first diagnosis
cation was not necessary. Twenty one participants stated
The participants in this study generally experienced symp-
that their doctor did ask for their agreement to start the anti-
toms at first diagnosis, such as dizziness and headaches. They
hypertensive medication. However, they sometimes did not
reported that they had difficulty in sleeping due to stress and
take the medication without informing their doctor. Three of
overwork prior to the diagnosis. Six participants expressed
them did not consider taking medication as a priority. Fifteen
that they had stress due to workload at home. Most of the
participants expressed their nonchalant attitude, even though
participants also seemed to regard stress and blood pressure
they were aware of the complications of hypertension, such
as synonymous.
as stroke and heart disease.
Only six of the 25 participants were first diagnosed during
Most of the reasons for nonadherence to antihypertensive
a routine medical screening, whereas others were diagnosed
medication were comprised of attitudes of the patients
when they sought medical attention for their symptoms.
themselves, namely, forgetfulness, perceived side effects
Several patient comments are shown below:
of the medications such as dehydration, loss of interest
I have to reason with my new boss. I could not sleep and in sex, tire easily, palpitations, feeling hot, and sweating.
started having headaches. When I went and checked, I still Sixteen participants were afraid of the side effects of

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Dovepress Antihypertensive medication adherence in Malaysia

antihypertensive medication. Four participants were also I sometimes miss my medication because I have to take it
afraid of becoming too dependent on medication and twice daily. I prefer daily dosage of medication. I always
believed that taking medication could damage their body. forget to take my medicine due to my busy schedule. I
Most of the reasons given were due to the side effects of haven’t discuss this matter with the doctor yet, but I will
the medication and not due to the availability issues. More- tell him during the next appointment. [IDI/48 years-old/7
over, two participants took alternative treatments, such as years diagnosed with hypertension].
traditional medicine.
Eleven participants were encouraged or influenced not to Barriers and facilitators of hypertensive
take the medications by others, especially family members. care nonadherence with physical
Ten participants, however, did get support and motivation activity and diet
to take their antihypertensive medication from their family Three participants were unaware of the importance of exercise
members, whereas four participants motivated themselves and diet in managing their blood pressure. Seventeen par-
and were encouraged by their families. It was noted that ticipants found it difficult to change their lifestyle after being
there were differences in reasons and facilitators which diagnosed. Only three participants said that they exercised
influence them for nonadherence among the ethnicities. regularly and changed their diet according to the doctor’s
Malay patients tend to find alternative treatments other than advice. Eight participants felt that it was unsafe for them to
medication recommended by their doctors. Indian patients exercise or to walk outside their houses. Thirteen participants
were more influenced by people surrounding them, especially were not involved in any health-promoting activities, such as
their families (spouse, mother-in-law) and peers (neighbors, the healthy lifestyle campaign in their community, as they were
friends), in their decision making toward medication adher- unaware of such activities in their community. Participants
ence. Whereas, Chinese patients preferred simple medication claimed that they were busy with their work and daily life
dosage because they tend to forget their medication due to commitments, whereas the others were aware of the activities,
their busy schedule. These concepts are described in the but they claimed that they were too busy to get involved. Two
following patient comments: participants had exercise facilities at home, but the patients
neither had time nor self-motivation to use them.
I did not take my medication yesterday and today because
Most participants had difficulty in controlling their diet
I’m on leave. I left my medication at workplace. Taking
due to the widespread availability of food in Malaysia.
medication is not a priority in my daily routine. [IDI/49
While at work, eight participants expressed their preference
years-old/12 years diagnosed with hypertension]
to eat out rather than bring their own healthy meals. Salty
I feel dry when I take blood pressure medication. I find it and oily foods were still prepared at home and were served
so difficult because I always have to remember to take it to the whole family, even though the family members were
every day. I feel like I have lost sexual desire after taking aware of the participant’s high blood pressure. A common
the medication. All my children have advised me to seek reason given for not following a low salt and low fat diet was
alternative medicine first because they don’t want me to the lack of support from family and peers to enable them to
be too dependent on medication. [IDI/58 years-old/3 years resist eating tasty foods high in salt and fats rather than less
diagnosed with hypertension] tasty low salt and low fat options. Some patient comments
regarding these barriers were as follows:
The doctor did asked my agreement before starting medi-
cation. But I didn’t take my medication because I took I’ve got no time to exercise although I have a treadmill
alternative medication. My sexual life changed after I took at home. I just eat whatever I want to eat. I eat salted fish
the antihypertensive medication. I got tired easily and had every day and if taken a lot, I notice my blood pressure will
no mood. I also experienced heatiness, palpitations, and hike. My wife still cooks food high in salt and fats although
sweating with the medication. I’m afraid that my husband she knows I have hypertension. [IDI/63 years-old/4 years
and my mother in law know I’m taking antihypertensive diagnosed with hypertension]
medication. They said that I’m still young and need not any
medication yet. My neighbor also told me that medication I don’t care and there’s no point in controlling because
can cause damages to our body. [IDI/31 years-old/5 years I have already got the disease. [IDI/31 years-old/5 years
diagnosed with hypertension] diagnosed with hypertension]

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I go for exercise once a month but I find it so difficult to cooking demonstration. Some patient comments regarding
control my food because delicious food in Malaysia is the health care system are,
everywhere and I want to eat everything. I just bought food
I do not quite understand what the doctor says every time I
outside although I know that food from outside is unhealthy.
go for my follow-up. The doctor just says that I have high
[IDI/49 years-old/12 years diagnosed with hypertension]
blood pressure. I have to take the medication and control
my diet. He does not explain that high blood pressure is
I am unaware of any activities going on in my neighbor-
dangerous and what would happen in the future if I do not
hood. Nowadays is not like before because nobody talks to
take my medication. My children are still small. So, if the
their neighbors. I just go to church and watch television at
doctor doesn’t care about me, why must I care about myself?
home. I’m afraid to go for a jog alone. [IDI/62 years-old/1
[IDI/31 years-old/5 years diagnosed with hypertension]
year diagnosed with hypertension]

I don’t share my problem regarding taking medication

I was invited a few times by the staff nurse in charge to
with the doctor. They usually say a few words “Okay, just
join aerobic class handled by the community but I’ve got
take your medication and you can go now.” It’s not even
no time. I know some of my friends with hypertension
five minutes compared to the long time spent for waiting.
have joined the aerobic class twice a week. They also have
The nurses usually spend their time talking to the patients.
it once a week during the weekend outside the mosque in
I always talk to the nurse who usually takes my blood
my neighborhood. [IDI/59 years-old/12 years diagnosed
pressure outside the consultation room. She advises me a
with hypertension].
lot. She told me the correct way of taking meals. [IDI/43
years-old/6 years diagnosed with hypertension]

Issues with health care professionals

The doctor told me that I might experience some side effects
and the health care system with this antihypertensive medication, such as headaches,
Fifteen participants expressed their feelings that the doc-
stomach upsets, and others. But he didn’t tell me how to
tor’s consultation time with them was too short after hours
handle the side effects. [IDI/49 years-old/7 years diagnosed
of waiting in the queue. Nineteen felt that the doctor should
with hypertension]
spend more time to explain the side effects of the medica-
tion and how to exercise and control their diet. Only five
Pharmacist in this health clinic will explain regarding the
participants said that their doctor informed them that they
dosage and frequency of the medication. Sometimes they
might experience some side effects at the time of the initial
also explain the side effects of the medication if I ask them.
diagnosis. With regard to information on dietary measures,
But I need more information from the doctor regarding the
thirteen participants claimed that they were referred once
side effects and how to deal with it. If I have the time, I
to a dietitian for diet counseling after being diagnosed with
will surf the internet. [IDI/56 years-old/10 years diagnosed
hypertension, but no follow-up or further management was
with hypertension]
done. In terms of health care service delivery, they preferred
the same doctors and nurses to routinely manage their hyper-
I’m not sure about the resource center. I’ve been referred to
tensive clinic follow-up. The participants also found that
a dietitian once after the doctor discovered I have hyperten-
the nurses were friendlier and were able to spend more time
sion, but there’s no follow-up. [IDI/39 years-old/9 years
with the patients than other members of the health care staff.
diagnosed with hypertension].
Three participants were uncomfortable talking about the
health care service and refused to give their comments.
Finally, six participants were unsure if the resource center Discussion
was available for chronic diseases in their respective health This study showed that there was evidence of an agreement
clinics. Every health clinic has a resource center, which between the participants interviewed and their doctors before
provides counseling and educational materials for patients starting the health care recommendations. However, it later
with chronic diseases attending follow-up. The counseling resulted in partial adherence due to poor monitoring and
methods involve educational class discussion within a small counseling from their health care professionals. Most of
group of patients, individual counseling, and healthy food the participants admitted not taking their antihypertensive

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Dovepress Antihypertensive medication adherence in Malaysia

medication as prescribed by their doctor although they agreed between health professionals and their patients, and efforts
with the treatment recommendations earlier. The participants to build trust in the therapeutic relationship.27 Participants
also had poor self-management and low self-efficacy in needed more information regarding side effects and long-
adherence to their hypertensive care. Consistent with pre- term effects of medications that they were taking. This study
vious studies conducted in other developing countries17,18 revealed that the pharmacist have an important role in giving
and developed countries,19,20 this was partly attributed to information related to missed doses, adverse effects, and
lack of awareness of self-care and the importance of health patient understanding of medication regimen.
screening. Most participants only had their blood pressure However, there was evidence that lack of communication
assessed during visits to their doctors or to the pharmacy. still exists between patients and health care providers with
Only two participants had a blood pressure set at home, yet regard to medications, especially on their use and side effects.
even they did not use it to regularly monitor their blood Participants need to understand the importance of maintaining
pressure. A qualitative study done in Malaysia found that blood pressure and to take their drugs routinely. Furthermore,
patients who self-monitored were eager to be more involved they need to learn how to deal with missed doses, how to
in discussions about their blood pressure control.21 Similar identify adverse events, and what to do when that occur. Par-
findings were also reported in a qualitative study looking ticipants also preferred simple daily dosing. A study showed
at primary care patients’ experiences of home blood pres- that reducing the number of daily doses appeared to be effec-
sure measurement in the United Kingdom and Japan.22,23 tive in increasing adherence to antihypertensive medication
Therefore, wherever feasible, patients should be taught to intake and should be tried as a first-line strategy.28
measure and monitor their own blood pressure and to assess Among the many reasons given for not adhering to
their own adherence. medication and other hypertensive care, most were due to
The participants’ lifestyles also remained the same after patients’ attitudes and not due to health service availability
being diagnosed with hypertension. However, they claimed issues. Although the participants’ health visit duration had
to have tried to lower their blood pressure by changing their been long, and they had to wait more than 3 hours outside
lifestyle. However, their attempts have clearly failed. The the consultation room to see the doctor, this did not affect
participants in this study wanted to know more about how their satisfaction with the overall services at the clinic. The
to control their diet and how to exercise correctly. However, participants also did not have problems with the accessibility
accurate information was not given at screening and dur- and affordability with their antihypertensive medication. This
ing follow-up. Seven participants stated that they were not finding is consistent with another study done in Malaysia.29
referred to other health care providers, such as dietitian or There were 1,025 government health clinics in Malaysia as of
staff nurse in charge in the resource center for counseling December 31, 2012,30,31 and these clinics are highly subsidized
regarding their lifestyle changes. There is a need for dietitian by the Malaysian government, including the medications and
referral because if the participants knew what food to eat, treatments.31 However, this may not be applied to other patient
they might succeed in controlling their diet. Most of the populations; hence, other studies found that patients who were
participants were unaware of the existence of the resource without insurance coverage or who had low income were more
center in the health clinics, where they can get information likely to be nonadherent to their treatment.32
regarding hypertension from counseling, flyers, healthy Patients must be given the opportunity to relate their
cooking demonstration. As a result, the participants were experiences with hypertension during the follow-up. This
uncertain what they should do. A study in Malaysia reported may allow the health professionals to understand the crucial
that three quarters of the subjects had unsatisfactory hyper- elements of patients’ adherence, such as their beliefs, atti-
tensive control and it was related to food intake and eating tudes, subjective norms, cultural context, social supports, and
habits, including high salt diet.24 emotional problems. For example, most of the participants
Moreover, a study showed that knowledge by itself may interviewed experienced stress before they were diagnosed
not impact adherence.25 However, knowledge has been shown as hypertensive. Therefore, it is important to recognize that
to enhance behavior changes, but to a limited extent.26 Health such patients need to have early referrals for counseling and
care providers should give patients enough education about aid from psychologists to reduce the stress before it becomes
the treatment and disease. Health visits should include real- worse. A study by Crowley et al found that high stress was
istic assessment of patients’ knowledge and understanding of associated with medication nonadherence among hyperten-
their medication regimen, clear and effective communication sive patients from primary health clinics.33

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There was a wide variety of reasons why patients did By conducting these qualitative interviews, items for the
not adhere to their antihypertensive medications, diet, and reasons of nonadherence or noncompliance can be generated
exercise. These study findings suggest that adhering to each for development within a clinically meaningful scale. This
of these behaviors posed different challenges for the partici- scale may have the greatest importance in developing coun-
pants. Family members played an important role and may tries, such as Malaysia, because the information derived from
also pose barriers in motivating participants to take their the self-administered health questionnaires is comprehensive,
medications compared to friends, neighbors, and others. practical, and inexpensive.
This study found that family members discouraged some A further study among hypertensive patients from
patients from taking antihypertensive medication or resisted private clinics could be included for comparison to bet-
dietary changes, such as cooking the same high salt foods. ter reflect the needs and preferences of hypertensive
Studies showed family support was associated with better patients to improve clinical management and public health
adherence.34–37 intervention.
This study identified aspects of patients’ beliefs and behav- Different tools have been used to evaluate and to
iors regarding antihypertensive medications and their lifestyle assess patient adherence to medication, but there is no
change after being diagnosed as hypertensive. Most patients single measurement of patient adherence to medications
demonstrated that they accepted responsibility for the manage- that can be referred to as the “gold standard.” The most
ment of their hypertension, but some were unwilling to make commonly and widely used self-reporting measures of
decisions for themselves. The responsibility for adherence must medication adherence for hypertension are the Morisky
be shared between the patient, health care provider, and com- Medication Adherence Scale and the Hill-Bone Compli-
munity. Mutual collaboration between the patients and their ance to Medication Scale.41,42 The Morisky Medication
health care providers fosters greater patient satisfaction, reduces Adherence Scale classified nonadherence as intentional
the risks of nonadherence, and improves patients’ health care and unintentional factors related to forgetfulness, care-
outcomes.38 Community mobilization is needed in terms of lessness, and stopping medications when feeling better
advocacy to empower patients to adhere to their hypertensive or worse. The Hill-Bone Compliance to Medication Scale
care and to create positive advocating environments. addressed barriers and self-efficacy of patients’ in tak-
Community resources to empower this group of patients ing their medications. However, in addition to these two
should be established in community settings, such as in scales, the literature has reported other important reasons
mosques and churches, as a starting point for patients to why individuals are nonadherent to their antihypertensive
develop self-care and create peer support groups. Social sup- medications. To this date, the measure of nonadherence
port received by patients from other members of their com- is yet to be comprehensive. Furthermore, a study showed
munity has been consistently reported as an important factor that the use of both scales cannot be recommended because
that affected health outcomes and improved adherence.39 their ability to identify medication adherence was essen-
Social support groups are needed to promote the exchange tially by chance, with inconsistency for nearly every third
of experiences in dealing with hypertension, its care, and to hypertensive patient.43
promote patients’ responsibility for their own care. There is
evidence that peer support groups among patients were able Limitations
to improve adherence to therapy, while reducing the amount All the interviews were done in government primary health
of time devoted by health care professionals for chronic care clinics, and this may affect the participants’ responses.
disease management.40 Further exploration by interviewing family members
and health care providers would be useful for a better
Implications for further research understanding of the problem.
and clinical practice
This study discovered that there were differences between Conclusion
ethnicities in reasons and facilitators for nonadherence In conclusion, understanding patients’ need and lack of
which influenced the participants. Future qualitative study shared decision making seem to be the major adherence bar-
should be done to further explore the reasons and facilitators riers faced by hypertensive patients in this study. Therefore,
which influence the hypertensive patients in each ethnicity the responsibility for nonadherence has to be shared by
in Malaysia. the patients, health professionals, the health care system,

1604 submit your manuscript | www.dovepress.com Patient Preference and Adherence 2014:8
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Dovepress Antihypertensive medication adherence in Malaysia

and the community. Also, community resources should be 6. Al-Mustafa BA, Abulrahi HA. The role of primary health care centers
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to the needs of individuals, communities, and populations, 7. Ministry of Health. National Health and Morbidity Survey IV. Vol II.
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recognizing that the provision of information or resources
8. Ramli A, Ahmad NS, Paraidathathu T. Medication adherence among
alone does not mean that people can or will access and use hypertensive patients of primary health clinics in Malaysia. Patient
them. Within the limitations, our findings can help doctors Prefer Adherence. 2012;6:613–622.
9. Turki AK, Sulaiman SAS. Adherence to antihypertensive therapy
who seek to understand their patients’ thinking regarding among patients in Penang General Hospital using structural equation
their antihypertensive medication at the start or review of modelling (SEM). Int J Pharm Pharm Sci. 2010;2(1):24–32.
10. Hassan NB, Hasanah CI, Foong K, et al. Identification of psychosocial
the course of drugs. They can contribute to discussions on
factors of noncompliance in hypertensive patients. J Hum Hypertens.
the advantages of drugs in a way that is relevant for patients 2006;20(1):23–29.
personally, in support of decisions that are concordant 11. Khuan L, Siew CY, Rahman HA, Yee LY. From compliance to adher-
ence and concordance, what quantitative and qualitative studies have
between patients and doctors. synthesized? J Health Management. 2008;4(1):36–61.
The widespread preference of people to seek alterna- 12. Berg BL. Qualitative Research Methods for the Social Sciences. 4th
ed. Boston: Allyn and Bacon; 2001.
tive and complementary medicines must be acknowledged,
13. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adher-
and patients need to be encouraged to adopt approaches ence to treatment: three decades of research. A comprehensive review.
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14. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded
evidence. Community resources should be established Sourcebook. Thousand Oaks, CA: Sage; 1994.
to act as peer support groups to improve patients’ self- 15. Ulin PR, Robinson ET, Tolley EE. Qualitative Methods in Public
Health: A Field Guide for Applied Research. San Francisco, CA:
efficacy in order to empower them to adhere to their
Jossey-Bass; 2004.
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to reading and appraising qualitative research. BMJ: British Medical
Journal. 2008:404–407.
Acknowledgments 17. Saleem F, Hassali M, Shafie A, Atif M. Drug attitude and adherence:
We would like to thank the Malaysian Director General of a qualitative insight of patients with hypertension. J Young Pharm.
2012;4(2):101–107.
Health for granting us the permission to publish this study. 18. Dennis T, Meera NK, Binny K, Sekhar MS, Kishore G, Sasidharan S.
We would like to extend our gratitude to the doctors, to the Medication adherence and associated barriers in hypertension manage-
patients who participated in the in-depth interviews, and the ment in India. CVD Prev Control. 2011;6(1):9–13.
19. Lau E, Kaczorowski J, Karwalajtys T, Dolovich L, Levine M, Chambers L.
staff members involved at the chronic disease clinics in the Blood pressure awareness and self-monitoring practices among primary
primary health clinics during data collection. This study is care elderly patients. Can Pharm J. 2006;139(6):34–41.
20. Knight EL, Bohn RL, Wang PS, Glynn RJ, Mogun H, Avorn J.
supported by the research grant from the Ministry of Educa- Predictors of uncontrolled hypertension in ambulatory patients.
tion and University of Malaya, grant number FL 009/2011. Hypertension. 2001;38(4):809–814.
21. Abdullah A, Othman S. The influence of self-owned home blood pres-
sure monitoring (HBPM) on primary care patients with hypertension:
Disclosure a qualitative study. BMC Fam Pract. 2011;12:143.
Researcher time was paid by the Ministry of Health fel- 22. Rickerby J, Woodward J. Patients’ experiences and opinions of
home blood pressure measurement. J Hum Hypertens. 2003;17(7):
lowship. The authors report no conflicts of interest in this 495–503.
work. 23. Saito I, Nomura M, Hirose H, Kawabe H. Use of home blood pressure
monitoring and exercise, diet and medication compliance in Japan. Clin
Exp Hypertens. 2010;32(4):210–213.
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Supplementary material

Table S1 Interview guide

Interview guide for in-depth interview

Code number/Kod nombor:

Date/Tarikh: _________________
Name of participant/Nama peserta: _________________________________
Place of interview/Tempat temuduga: _________________________
Phone number/Nombor telefon: _________________________
Start/Bermula: _____________
End/Berakhir: ______________

Personal information
1. What is your age?/Berapakah umur anda? ____________________ years old/tahun

2. What is your gender?/Apakah jantina anda

Male/Lelaki
Female/Perempuan

3. What is your ethnicity?/Apakah bangsa anda? Malay/Melayu

Chinese/Cina
Indian/India
Others/Lain-lain

4. Family history of hypertension/Sejarah keluarga untuk darah tinggi

Yes
No

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5. Blood pressure reading taken today/Bacaan tekanan darah tinggi yang diambil pada hari ini

6. Duration of hypertension/Tempoh menghidap darah tinggi _________________________________

7. Occupation/Pekerjaan_________________________________

Questions
1. How did you first discover you have hypertension? Please describe.
   Bagaimanakah anda mula-mula mendapat tahu yang anda menghidap darah tinggi? Huraikan.

2. Please describe your feelings regarding the antihypertensive medication you are taking.
   Ceritakan perasaan anda mengenai pengambilan ubat darah tinggi anda.

3. Describe problems and reasons for not taking your antihypertensive medication.
Huraikan masalah-masalah dan sebab-sebab tertentu mengapa anda tidak mengambil ubat darah tinggi anda.

4. Have you ever tried alternative medicine to control your blood pressure? Please describe.
   Adakah anda pernah mencuba ubat-ubatan alternatif untuk mengawal tekanan darah tinggi anda? Huraikan.

5. What causes you fear in taking hypertensive medication? Please describe.

   Apakah ketakutan yang menyebabkan anda tidak mengambil ubat darah tinggi? Huraikan.

6. Is there any changes in your lifestyle in terms of physical activity and your diet after being diagnosed as a hypertensive
patient? Describe the reasons.
   Adakah terdapat perubahan cara hidup anda dari segi aktiviti fizikal dan pemakanan selepas bergelar sebagai pesakit
darah tinggi? Huraikan sebab-sebabnya.

7. Do you think it is important to take care of your own health and your own blood pressure?
   Adakah anda rasa penting untuk menjaga kesihatan anda dan tekanan darah anda sendiri?

8. Describe any activities conducted in your community which you have been involved in such as exercise group (­aerobic,
brisk walking), talks regarding healthy lifestyle, membership of a club or joining any support group in the mosque,
church, or temple?
   Huraikan mana-mana aktiviti yang dijalankan dalam komuniti yang anda pernah terlibat seperti kumpulan senaman
(aerobik, berjalan pantas), ceramah mengenai gaya hidup sihat, keahlian kelab atau menyertai mana-mana kumpulan
sokongan di masjid, gereja atau kuil?

9. Who motivates you to take the antihypertensive medication and to follow the health recommendation? Please
describe.
   Siapakah yang memberi motivasi kepada anda untuk mengambil ubat dan untuk mengikut rawatan kesihatan yang
disyorkan? Huraikan.

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Dovepress Antihypertensive medication adherence in Malaysia

10. What is your opinion regarding the service in this health clinic? Please describe.
   Apakah pendapat anda mengenai perkhidmatan yang diberikan di klinik kesihatan ini. Huraikan.

11. Does your doctor ask for your agreement before starting the treatment or health recommendation?
   Adakah doktor anda meminta persetujuan anda sebelum memulakan rawatan atau cadangan kesihatan yang akan
diberikan kepada anda?

12. Describe what you think regarding information given about your illness and your antihypertensive medication from
your doctor, nurses, pharmacist, and dietitian.
   Huraikan apakah pendapat anda dengan maklumat yang mengenai penyakit anda dan ubat darah tinggi anda oleh
doktor, jururawat, pegawai farmasi dan pegawai dietitik.

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