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Introduction
============

Hypertension (HTN) is one of the major attributable risk for the cardiovascular morbidity and mortality and hence it makes up more than half of the global disease burden causing numerous premature deaths per annum \[[@REF1]-[@REF2]\]. Research studies indicate that blood pressure (BP) management helps to reduce the disease intensity and risk of other comorbidities like stroke, renal disease, heart failure, and death \[[@REF3]-[@REF4]\]. Moreover, the disease risk and associated death ratio are more commonly observed in low to middle-income countries, with increased prevalence among individuals having lower socioeconomic statuses \[[@REF5]-[@REF6]\]. According to the estimates provided by the World Health Organization (WHO), each year about 17.3 million lives are carried away by cardiovascular diseases and by 2030 it is predicted that the rate might increase to 23 million \[[@REF7]\]. Also, one-quarter of the adult population is affected by this chronic non-communicable disease worldwide. Pakistan being on top of the list contributing 50% of the affectees to this global burden, being a developing state with compromised healthcare facilities the diagnosis and treatment of such health risks are infrequent \[[@REF7]\]. 

Among numerous influencers those are associated with HTN, advancing age is one of the most significant non-modifiable risk factor \[[@REF8]\]. However, gender is another lead with greater susceptibility in men at an early age while in women, developing HTN is more after the age of 60 years \[[@REF9]\]. Followed by race as the other influencer to increase the risk of HTN with reported higher prevalence among the black population when compared to white with mechanism still unknown. Other than that, there can be an influence of family disposition, decreased physical activity, increased weight, smoking, alcohol consumption as well as the precipitating influence of dietary factors such as high sodium, low potassium, and decreased Vitamin D consumption. Among the serious complexities' cholesterol, diabetes, sleep apnea, and kidney diseases might play the role of triggering factors.

Even though the field of medication has advanced and flourished rapidly, still HTN is poorly controlled among the diagnosed patients \[[@REF10]\]. It may be due to poor medication adherence, non-compliance with follow-up visits, and lifestyle modifications \[[@REF10]\]. Medication non-adherence is the prime difficulty that must be identified and addressed in each case. Around 50% of the patients suffering from chronic illnesses are adherent to antihypertensive medications prescribed by the healthcare provider \[[@REF11]\]. It is recommended that moderating the salt and fat intake, regular exercising, reducing stress as well as quitting the habits of alcohol consumption and smoking can keep BP quite under optimal range \[[@REF12]-[@REF13]\]. Furthermore, it also reduces the risk of having a stroke, myocardial infarction, or heart failure \[[@REF14]\]. For treatment adherence and long-term effectiveness, self-management is necessary along with the self-information of the patient about their clinical condition that should be well understood by the patient and assessed regularly \[[@REF15]\]. Though due to long-term morbidity, the patient can develop coping skills to combat the disease more appropriately with active involvement in disease handling, which is a progressive approach \[[@REF16]\].

Therefore, lifestyle modification and treatment adherence are the two prime factors that must be keenly planned for the effective management of HTN \[[@REF10]\]. The primary aim of the study was to evaluate medication adherence and the contributing factors of HTN along with the assessment of common perceptions and practices related to its management.

Materials and methods
=====================

This cross-sectional, single center study was conducted at the cardiology clinic of tertiary care hospital, National Institute of Cardiovascular Diseases Karachi, Pakistan. The study continued for a period of three months from 4 July 2019 to 3 September 2019. A total of 200 patients with a primary diagnosis of HTN were recruited for the study. Patients on antihypertensive medications for at least three months were enrolled irrespective of the gender using consecutive sampling technique. While patients under hypertensive emergency with BP \> 180/110 mmHg or those with acute coronary syndrome, acute stroke, hypertensive encephalopathy, aortic dissection, or acute kidney injury, uncontrolled psychiatric disorder (schizophrenia or major depression), stage V chronic kidney disease (CKD) or end-stage renal disease (glomerular filtration rate \< 15 ml/min/1.73 m^2^) were excluded. Moreover, patients with a history of active substance abuse, patients who refused to take medications, and pregnant female patients were excluded from the study sample.

The data were collected through a questionnaire based on components of the nine-item modified Morisky Adherence Predictor Scale (MMAPS), to assess medication adherence, patients' practices, and perception about HTN and BP outcomes \[[@REF17]\]. HTN status was marked as controlled and uncontrolled BP. Systolic blood pressure (SBP)\>140 or diastolic blood pressure (DBP)\> 90 was considered as uncontrolled BP, else it was considered as controlled. The patient demographic details were collected along with smoking status, history of comorbidities such as obesity, diabetes, and high cholesterol and history of past complications like stroke, kidney failure, visual problem, and heart attack or failure.

Before administering the study questionnaire, informed consent was obtained from each patient (both in Urdu and English). All conducts were performed ethically in accordance with the International Conference on Harmonization - Good Clinical Practice (ICH-GCP) guidelines and the ethical approval was received from the Ethical Review Committee of National Institute of Cardiovascular Diseases (Ref. No. ERC-39/2019) prior to the study.

The collected data were analyzed using International Business Machines Statistical Package for the Social Sciences (IBM SPSS), Version 21.0, qualitative data were summarized as frequency and percentage while mean ± standard deviation was used for quantitative data. The association of gender, smoking status, education, comorbidities, and past complications with the HTN status was evaluated through the Chi-square test. Mann-Whitney U-test was used to assess the relationship between patient's practices, perception, and HTN status where p value \<0.05 was considered significant.

Results
=======

A total of 200 patients fulfilling the eligibility criteria and provided consent. Out of which 124 were males and 76 were females. The mean age of the study participants was 56.45±12.36 years with a mean duration of HTN 5.80 ± 6.43 years (Table [1](#TAB1){ref-type="table"}). The clinical and personal history was also recorded, i.e., 85 out of the total were smokers, 143 had a sedentary lifestyle, and 76 were overweight. The information regarding comorbidities was also taken and it was found that 122 patients were diabetic, 154 with high cholesterol, 140 reported visual problems, and 169 had the previous history of heart attack/failure. Based on the criteria mentioned in the above methodology, 73 out of 200 patients were observed with controlled BP while 127 had uncontrolled BP (Table [1](#TAB1){ref-type="table"}).

###### Demographics and clinical characteristics of the study population

\*BP: Blood Pressure; HTN: Hypertension; SBP: Systolic Blood Pressure; DBP: Diastolic Blood; BMI: Body Mass Index

\*Quantitative data were presented with mean ± standard deviation; Qualitative data were presented with frequency and percentage.

  ------------------------- ---------------- -------------
  Variables                 Sub-categories   (n=200)
  Age (Years)                                56.45±12.36
  Duration of HTN (Years)                    5.80±6.43
  SBP (mmHg)                                 150±27.99
  DBP (mmHg)                                 85.70±12.74
  Gender                    Male             124(62.0)
  Female                    76(38.0)         
  Education                 No Education     87(43.5)
  Primary                   38(19.0)         
  Secondary (Metric)        40(20.0)         
  Intermediate              13(6.5)          
  Bachelors                 17(8.5)          
  Masters                   5(2.5)           
  Smoker                    Yes              85(42.5)
  No                        115(57.5)        
  HTN Status                Controlled BP    73(36.5)
  Uncontrolled BP           127(63.5)        
  Lifestyle                 Active           57(28.5)
  Sedentary                 143(71.5)        
  BMI Index                 Underweight      5(2.5)
  Normal                    119(59.5)        
  Over weight               76(38)           
  Other chronic illnesses   Diabetes         122(61.0)
  High Cholesterol          154(77.0)        
  Stroke                    17 (8.5)         
  Kidney failure            26 (13.0)        
  Visual problem            140 (70.0)       
  Heart attack/failure      169 (84.5)       
  ------------------------- ---------------- -------------

According to the results in Table [2](#TAB2){ref-type="table"}, 62.90% (78/124) of males and 64.47% (49/76) of females were having uncontrolled BP, out of 127 patients from the uncontrolled BP group 40.15% were smokers while 46.67% of the 73 patients in controlled BP group were smokers. A significant association was observed between obesity and HTN status (p\<0.05), and 65.79% (50/76) overweight patients were having controlled BP. Similarly, diabetes and visual problems also had a significant association with HTN status. Moreover, increased comorbidities were observed among the patients having uncontrolled BP.

###### Association of hypertension status with sociodemographic characteristics of the study population

\*BP: Blood pressure; BMI: Body Mass Index

\*SBP \> 130 or DBP \> 80 was considered as uncontrolled BP;

\*Chi-square was applied; p value\<0.05 was considered significant. 

  ------------------------- ---------------------- ------------ ----------- -------
  Variables                 Sub-category           HTN status   P-value     
  Controlled (n=73)         Uncontrolled (n=127)                            
  Gender                    Male                   46(63.01)    78(61.4)    0.823
  Female                    27(36.9)               49(38.58)                
  Smoking Status            Smoker                 34(46.57)    51(40.15)   0.377
  Non-smoker                39(53.42)              76(59.84)                
  BMI Index                 Underweight            5(6.84)      0(0)        0.023
  Normal                    42(57.53)              77(60.62)                
  Over weight               26(35.61)              50(39.37)                
  Other Chronic Illnesses   Diabetes               37(50.68)    85(66.92)   0.023
  High cholesterol          58(79.45)              96(75.59)    0.532       
  Stroke                    6(8.21)                10(7.87)     0.894       
  Kidney failure             10(13.69)             16(12.59)    0.824       
  Visual problem            41(56.16)              99(77.95)    0.001       
  Heart attack/failure      60(82.19)              109(85.82)   0.874       
  Life style                Sedentary              51(69.86)    92(72.44)   0.697
  Active                    22(30.13)              35(27.55)                
  ------------------------- ---------------------- ------------ ----------- -------

Participants\' perceptions and practices regarding their hypertensive illness showed that 125/200 were taking medication daily while 13/200 were those who never took prescribed medication. Follow-up frequency was also monitored, 70/200 preferred follow-up visit once per month while 71/200 never went for a follow-up visit. BP monitoring frequency was also recorded 20/200 monitored BP daily while 71/200 never monitored their BP. 100/200 believed that BP is mostly controlled and 40 disagreed to the point moreover, 64/200 agreed that BP medication is necessary while 25/200 disagreed (Table [3](#TAB3){ref-type="table"}).

###### Perceptions and practices of hypertensive patients regarding blood pressure management

\*BP: Blood pressure

  ---------------------------- --------------------------- ------------
  Variables                    Sub-categories              n(%)
  Medication Intake            Everyday                    125 (62.5)
  Most of the days             31 (15.5)                   
  Some of the days             31 (15.5)                   
  Never                        13 (6.5)                    
  Follow-up Visits             Multiple times in a month   11 (5.5)
  Once in a month              70 (35.0)                   
  Once every 6 months          21 (10.5)                   
  Once a year                  27 (13.5)                   
  Never                        71 (35.5)                   
  BP Monitoring Frequency      Everyday                    20 (10.0)
  Every 2-3 days               40 (20.0)                   
  Once a week                  22 (11.0)                   
  Once a month                 47 (23.5)                   
  Never                        71 (35.5)                   
  BP is mostly controlled      Strongly agree              4 (2.0)
  Agree                        100 (50.0)                  
  Uncertain                    41 (20.5)                   
  Disagree                     40 (20.0)                   
  Strongly disagree            15 (7.5)                    
  BP medication is necessary   Strongly agree              55 (27.5)
  Agree                        64 (32.0)                   
  Uncertain                    43 (21.5)                   
  Disagree                     25 (12.5)                   
  Strongly disagree            13 (6.5)                    
  ---------------------------- --------------------------- ------------

There was a significant association observed between medication intake frequency and HTN status (p\<0.05). Moreover, it was also significantly associated with perceptions of hypertensive patients related to the illness. Perceptions like BP is mostly controlled and BP medication necessity was also positively associated (p\<0.05) (Table [4](#TAB4){ref-type="table"}).

###### Patients' practices and perception in relation to hypertension status

\*HTN: Hypertension; BP: Blood pressure

\*Mann--Whitney U-test was applied keeping P-value \<0.05 as statistically significant cutoff

  ----------------------------- ---------------------- --------- -------
  Variables                     HTN Status Mean Rank   P-value   
  Controlled                    Uncontrolled                     
  Medication Intake Frequency   137.19                 79.41     0.000
  Follow up visit Frequency     99.58                  101.03    0.857
  BP monitoring Frequency       109.84                 95.13     0.073
  BP is mostly controlled       113.18                 93.21     0.011
  BP medication is necessary    137.84                 79.04     0.000
  ----------------------------- ---------------------- --------- -------

No association was observed between medication adherence and the educational level of the patient. The association of medication adherence status with educational level of the patient is presented in Table [5](#TAB5){ref-type="table"}.

###### Association of medication adherence status with the educational level of patient

Non-adherent = "some of the days" or "never"

Adherent = "every day" or "most of the days"

\*Chi-square was applied; P-value\<0.05 was considered significant 

  --------------------------- ------------ --------------------------- ----------- -------
  Educational Level           Base \[N\]   Medication Adherence Rate   P-value     
  Non-adherent                Adherent                                             
  Illiterate                  87           18(20.69)                   69(79.31)   0.958
  Primary                     38           8(21.05)                    30(78.95)   
  Secondary to intermediate   53           13(24.53)                   40(75.47)   
  Bachelors or higher         22           5(22.73)                    17(77.27)   
  --------------------------- ------------ --------------------------- ----------- -------

Discussion
==========

The current study provides several important insights into the perceptions and practices of the patients towards HTN management. The major recognizable features associated with uncontrolled HTN were gender, smoking, marital status, diabetes, medication adherence, etc. It is a known fact that lack of treatment adherence leads to increased hypertensive severity and boosts the mortality rate \[[@REF18]\]. An optimal medication intake frequency was observed in the study sample, 62.5% of patients were taking medication daily while 15.5% showed intermittent adherence and 6.5% never took the prescribed medication (Table [3](#TAB3){ref-type="table"}). It is evident that following the prescribed treatment regime and attending the follow-up visits results in improved health outcomes and decreases the overall healthcare costs \[[@REF19]-[@REF20]\]. According to the previous literature more than half of the hypertensive patients discontinue medication roughly a year after initiation \[[@REF21]\]. The most highlighted factor found in association with the treatment non-adherence are the side-effects of the medication \[[@REF12]\].

Though it has been revealed that low literacy rate is one of the leading aspects behind poor treatment adherence \[[@REF22]\]. But according to our findings, most of the HTN patients enrolled in the study were adherent to medication (Table [3](#TAB3){ref-type="table"}), which in comparison to their educational status was contradictory as many of them had below-average literacy rate (Table [5](#TAB5){ref-type="table"}). Around 43.5% were illiterate while only 20% had passed the secondary education (Table [1](#TAB1){ref-type="table"}). Several unintentional reasons such as forgetfulness, decreased health literacy, lack of symptoms and carelessness are also associated with medication non-adherence \[[@REF23]\]. Hence, it is the prime responsibility of the healthcare providers to prevent non-adherence either through reflective listening or by considering the patient's psychosocial and medical requirements keeping personal opinions aside.

A significant association was observed between medication adherence and HTN status (Table [4](#TAB4){ref-type="table"}), as other parallel studies also specified a direct relationship between treatment adherence and outcomes of HTN \[[@REF24]\]. Research indicates that the patient's perception and behaviors are dependent upon their belief regarding disease susceptibility, disease severity and the benefits they are willing to attain \[[@REF25]\]. Our results showed that more than half of the population agreed that BP medication is necessary (Table [2](#TAB2){ref-type="table"}). Likewise, another study reported that 90% patients believed antihypertensive medications were necessary to keep their BP under normal range, while there were a few who believed that it is a benign illness and no therapeutic help is required for recovery \[[@REF19]\]. Despite being diagnosed with high BP, more than 70% of the Asian hypertensive patients have uncontrolled BP \[[@REF26]\]. Reluctance and negative perceptions have taken over the disease management rate. Around 50% of the study patients believed that their BP is mostly controlled and this negative perception holds a significant impact on HTN status (p\<0.05) (Tables [3](#TAB3){ref-type="table"} and 4).

It was observed that 5.5% patients visited the healthcare provider for follow-up multiple times in a year, 13.5% preferred follow-up visit once in a year while 35.5% patients never went for the follow-up visits (Table [3](#TAB3){ref-type="table"}). Follow-up visits have the utmost importance in the life of hypertensive patients, the risk of multimorbidity and mortality increases due to the untracked visit-to-visit variability (VVV) of BP \[[@REF27]\]. Secondary to the follow-up frequency, BP monitoring frequency was also observed, 35.5% of patients never monitored their BP while only 10% were consistently monitoring their BP (Table [3](#TAB3){ref-type="table"}). Moreover, no significant association was observed between the monitoring frequency and HTN status (p=0.073) (Table [4](#TAB4){ref-type="table"}). Similarly, Ramón and his colleagues concluded in their study that the mean BP values are linked with the duration of measurement as compared to the frequency of measurement \[[@REF28]\].

According to the National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center, increased weight leads to numerous health problems mainly associated with heart \[[@REF29]\]. BMI holds significant association with the HTN status either controlled or uncontrolled, 39.37% overweight patients had uncontrolled BP (Table [2](#TAB2){ref-type="table"}). Centers for Disease Control and Prevention (CDC) report states regarding obesity and BP states that increased weight intensifies the risk of high BP disposing an individual to several other co-morbidities.

Our study explored medication adherence, perceptions, and practices among hypertensive patients. There are few limitations associated with it, first and the most significant is self-reporting of medication adherence, although MMAPS was used to assess compliance, other is the high prevalence of diabetes and coronary artery disease which may be overestimated as most of these patients have multiple comorbid conditions. Moreover, it was a uni-center study, the sample was limited to a single tertiary healthcare center only. There could be a more pronounced display of patient's perception and practices regarding the illness. Therefore, further research is required to explore other associated factors with HTN to fill gaps in the existing literature.

Conclusions
===========

This study explored the association of negative perception regarding controlled BP and HTN status. Majority of the patients believed that antihypertensive medication is necessary for effective BP control. It is suggested that treatment adherence education and counseling for hypertensive patients are necessary in order to ensure improved BP control and therapeutic outcomes.

The authors have declared that no competing interests exist.

Consent was obtained by all participants in this study. National Institute of Cardiovascular Diseases Karachi issued approval ERC-39/2019. Ethical approval was received from the Ethical Review Committee of National Institute of Cardiovascular Diseases (Ref. No. ERC-39/2019) prior to the study

**Animal subjects:** All authors have confirmed that this study did not involve animal subjects or tissue.

Authors are thankful to Ali Moazzam and Sonia Bashir, heart failure and study coordinators. The authors wish to acknowledge the support of Medical Affairs department of Getz Pharma for providing technical support in terms of manuscript editing and formatting.
