• Users Online: 542
  • Print this page
  • Email this page

Table of Contents
Year : 2022  |  Volume : 19  |  Issue : 4  |  Page : 569-574

Medication adherence in hypertensive diabetic patients

1 Department of Community and Family Medicine, College of Medicine of Hamorabi, University of Babylon, Hilla, Iraq
2 Department of Community and Family Medicine, College of Medicine, University of Babylon, Hilla, Iraq

Date of Submission22-Jul-2022
Date of Acceptance12-Aug-2022
Date of Web Publication09-Jan-2023

Correspondence Address:
Mustafa Bahaa Makai
Department of Community and Family Medicine, College of Medicine, University of Babylon, Hilla
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_129_22

Rights and Permissions

Background: Diabetes-related hypertension increases mortality risk by 7.2 times in the underdeveloped countries such as Iraq, with a greater risk of death. In developing countries, patients’ adherence to chronic illness treatments such as hypertension and diabetes is low. Nonadherence is linked to higher rates of hospitalization and poor health outcomes. Objectives: The aim of this study to determine the prevalence of medication adherence among the hypertensive diabetic patients and to identify factors that associated with poor or nonadherence to medications. Materials and Methods: This is a hospital-based descriptive cross-sectional study. The study included a sample of 385 hypertensive diabetic patients of both gender, their ages above 18 years. The study was carried out from February 2022 to the end of May 2022 at the consultation clinics at Imam Al-Sadiq and Marjan Teaching Hospitals, Babylon, Iraq. Following verbal consent, the participants were interviewed using a prepared structured validated and reliable questionnaire will be use that includes demographic characteristics using the Morisky 8 Item Medication Adherence Scale (MMAS-8) was used to assess medication adherence. Results: This study showed that more than half of the patients (51.2%) had low adherence, whereas 22.9% had medium adherence. Those with high adherence constituted 26.0%. There were statistically significant associations between good adherence and high level of education, younger age, and nonsmoking. Patients with good adherence to medications have better blood pressure and blood sugar control. Conclusion: The level of medication adherence among diabetic hypertensive patients in Babylon province is low.

Keywords: Adherence, blood pressure, glycemic control, hypertensive diabetic

How to cite this article:
Baiee HA, Makai MB. Medication adherence in hypertensive diabetic patients. Med J Babylon 2022;19:569-74

How to cite this URL:
Baiee HA, Makai MB. Medication adherence in hypertensive diabetic patients. Med J Babylon [serial online] 2022 [cited 2023 Feb 6];19:569-74. Available from: https://www.medjbabylon.org/text.asp?2022/19/4/569/367324

  Introduction Top

Patients with type 2 diabetes mellitus commonly display a cluster of metabolic abnormalities called the cardiometabolic or cardiorenal metabolic syndrome.[1]

The coexistence of hypertension and diabetes significantly increases the risk of cardiovascular disease, cerebrovascular accident, retinopathy, and nephropathy.[2] The prevalence of diabetes co-occurring with hypertension is rising globally.[3]

The rise in the number of diabetic, hypertensive patients causes burden, particularly in the Middle East.[4] Controlling hypertension in diabetics can have a significant impact on cardiovascular disease outcomes.[3]

Diabetes-related hypertension raises the probability of death by 7.2 times, with a greater chance in the underdeveloped countries including Iraq.[5],[6] Furthermore, in this developing nation, patients’ adherence to chronic illness treatments such as hypertension and diabetes is low.[7]

Pharmacotherapy, in conjunction with lifestyle changes, remains the cornerstone in the treatment of hypertension and diabetes mellitus. Adherence to medication is critical for achieving the desired clinical outcomes. It is vital to assess medication adherence and the factors that influence it so that required steps may be adopted within primary care settings to enhance patients’ medication adherence, minimize long-term negative consequences of nonadherence, and lessen the load on the secondary care.[8]

The World Health Organization defines medication adherence as “the degree to which a person’s conduct conforms with the agreed-upon instructions from a health care practitioner.” This most frequently relates to medication or drug compliance.[9]

Patients with chronic diseases, particularly those that are asymptomatic, such as hypertension and diabetes mellitus, are more likely to be noncompliant.

The lack of knowledge about the importance of adherence is a factor that contributes significantly to medication nonadherence.[10] In Iraq, the adherence to antihypertensive medication is about 28.36%[11] and to antidiabetic agents is about 45%.[12] This means that adherence to treatment is low.


The objective was to determine the prevalence of medication levels of medication adherence among the hypertensive diabetic patients and to identify factors that associated with poor or nonadherence to medications.

  Materials and Methods Top

This is a hospital-based descriptive cross-sectional study. The study was conducted at the consultation clinics in Imam Al-Sadiq and Marjan Teaching Hospitals, during the period from the beginning of February through the end of May 2022. The study includes 385 hypertensive, diabetic individuals over the age of 18 who attended internal medicine consultation clinics. A prepared structured questionnaire was used that includes questions about demographic characteristics and the medication compliance (adherence); the scale of adherence was based on the Morisky 8 items. The Morisky 8 Item Medication Adherence Scale (MMAS-8) was created to assess the patient’s compliance with their prescribed course of therapy. There are eight questions on it. The response options for questions 1 through 7 are “yes” or “no.” For the first seven items, the score was “yes” = 0 and “no” = 1, with the exception of item number five, when the values of “yes” and “no” were switched.[13]

Responses to the eighth questions are given on a five-point scale, with never, almost never, occasionally, frequently, and always being the correct choice. There are a total of 0–8 points on this scale. Patients are classified based on their ratings as follows: less than 6 (poor adherence), 6 or 7 (moderate adherence), and 8 (adherent or high adherence).

Through a direct interview, a questionnaire form was filled up for each patient after obtaining his or her verbal consent. The investigator measures the blood pressure in a standard way. HbA1c results of all diabetic patients were studied or asked to be done.

The Statistical Package for the Social Sciences was used to analyze the data (SPSS IBM, version 26). The chi-square test was used to test the association between categorical variables. P value < 0.05 was considered statistically significant.

Ethical approval

The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. Official approval of the research work was approved by the scientific committee of the Department of Family and Community Medicine in College of Medicine, Babylon University; ethical approval was obtained from the ethical research committee of Babylon Medical College; official approval was obtained from Imam Al-Sadiq and Marjan Teaching Hospitals according to the document number 646 (including the number and the date in 11/5/2022), and verbal consents from the participants were obtained after explaining to them the purposes of the study.

Current smoker

Current smokers are those who smoke cigarettes at the time of interview or those who used to smoke within the last 6 months. Nonsmokers are those who never smoked.


Ex-smokers are previous smokers who had quit smoking for at least 6 months from the time of the study.[14]

Poor control of blood sugar (poor glycemic control)

When a patient’s HbA1c was greater than 7.0%, a patient was regarded to have poor glycemic control.[15]

Uncontrolled hypertension

Uncontrolled hypertension is defined as systolic blood pressure >130 and diastolic blood pressure >80 (the target of blood pressure in diabetic patients is <130/80).[16]

  Results Top

This study included a total of 385 patients who were diagnosed as hypertensive and type 2 diabetic for duration of 6 months or longer. Gender distribution was almost equal between males and females. The vast majority of them are above 40 years of age (92.5%). Most of them have a secondary level of education and above [Table 1].
Table 1: Demographic characteristics of study patients (n = 385)

Click here to view

More than half of the patients (197 patients, forming 51.2%) had low adherence, whereas 88 patients (22.9%) had medium adherence. Those with high adherence were 100 patients, forming 26.0% of the total study sample [Figure 1].
Figure 1: Levels of adherence of study patients (n = 385)

Click here to view

There was a highly significant association between age group (<40 years) and level of medication adherence (P < 0.001). Younger patients had a higher level of adherence [Table 2].
Table 2: Levels of adherence by demographic characteristics

Click here to view

Females showed a highly significant level of adherence compared with males (P < 0.001). Other demographic variables that were found to have significant relationship with the level of adherence are educational level, occupation, and monthly income level (P < 0.001 for each). Higher education level was associated with higher adherence, so as the employment.

Smoking was also found to exhibit a statistically significant relationship with medication adherence (P = 0.030). More than 62% of active smokers had low adherence compared with 43.9% among nonsmokers [Table 3].
Table 3: Levels of adherence by smoking habit

Click here to view

Regarding the control of blood pressure and glycated hemoglobin (HbA1c), both are significant and highly associated with the level of adherence (P < 0.001 for each). Sixty percent of patients with high adherence have controlled blood pressure, whereas only 17.3% of those with low adherence have controlled blood pressure [Table 4].
Table 4: Control of blood pressure by the level of adherence

Click here to view

Similarly, a proportion of patients (63%) with high adherence have controlled blood sugar (HbA1c ≤ 7%) compared with only 15.7% among those with low adherence [Table 5].
Table 5: Control of glycated hemoglobin by the level of adherence

Click here to view

  Discussion Top

The findings of this study revealed that only 26% of patients in this study had good adherence to their antihypertensive and antidiabetic medications, whereas 51.2% of patients had poor adherence.

This low rate of antihypertensive medication adherence is lower than that reported by other studies[11],[12],[17],[18]; these differences may be related to different factors such as sample sizes, health-care services levels, health insurances, availability of drugs in low prices, and other socio-economic status such as the level of public and health-care awareness about the importance of medication adherences for chronic diseases.

The rate of adherence in the current study is higher than that reported by other researchers.[19],[20],[21],[22]

In our study, the age range (<40 years) was significantly associated with medication adherent, whereas other researchers[12],[20],[23] reported the opposite finding. Young age group in this study has a high level of education; they are knowledgeable about the importance of regular use of treatment to avoid complications of diabetes mellitus and hypertension.

Females in our study appeared to have better medication adherence than males, this agrees with the findings of other reporters.[17],[24]

Generally, females are more mindful than males in following physician’s instructions, particularly in relation to taking medications.

Our study found no significant relationship between marital status and medication adherence, which goes in line with other local study[25] and a study performed in Iran,[26] but disagrees with another study.[27]

This study confirms the findings of other local studies by finding no connection between study participants’ residences and their level of medication adherence.[28] This may be related to the high proportion of the participants are living in urban areas which reflects the no difference of this independent variable, or may be due to the absence of clear-cut between rural and urban areas during the last years related to the economic cultural and social situation of the participants.

In the current study, high levels of education were significantly linked to patients’ adherence; this finding is consistent with those of other Iraqi study conducted[20] and the finding reported by an international study conducted by many researchers.[29] However, it disagrees with studies that show that patients with a low level of education have a higher rate of adherence.[25],[26] This could be explained that well-educated patients may have more knowledge about hypertension and diabetes mellitus, as well as the benefits of using drugs regularly to control these chronic diseases to avoid future complications.

The relationship between occupational status and drug adherence is well established; the rate of nonadherence is higher among unemployed and housewives compared with the employed participants. This finding is comparable to that reported by study conducted in Iraq[25] and other study conducted in the United States,[30] but disagrees with other study.[31]

This could be due to financial constraints, which make the employed person more concerned about his or her health, as well as their ability to afford the cost of antihypertensive and antidiabetic medications.

More than 62% of active smokers have low medication adherence compared with nonsmokers, who are highly adherent; this finding agrees with other local study[11] and with findings of an international study.[32]

In this study, 60% of patients with high medication compliance had normal blood pressure, whereas 82.7 % of the patients with low medication adherence had a poor control of blood pressure; this difference is highly and significantly statistical association. This outcome was rationally sound and supported by research done in Iraq[11],[20] and other international studies.[23],[25]

In this study, 63% of patients with high medication adherence had a good glycemic control (HbA1C < 7%), whereas those with low adherence, 84.2% of them, have a poor glycemic control (HbA1C > 7%); this result agrees with findings explained by different studies.[33],[34]

Glycemic control is hence the ultimate objective of any diabetes mellitus therapy. A good glycemic control among type 2 diabetes mellitus patients involves an interplay of self-management measures including physical activity and diet in addition to medication adherence.[35] This can explain the discrepancy between the better medication adherence scores and poorer glycemic control outcome in this study group.

  Conclusion Top

This study concludes that the level of medication adherence among diabetic hypertensive patients in Babylon province is low; female patients are more adherent than males; patients with higher education level are more adherent than those with low educational levels; and high level of medication adherence led to blood pressure and type 2 diabetes mellitus control. We recommend urgent education campaigns to increase the level of public awareness about the crucial importance of medication adherence as well as the awareness of health-care providers; further large scale studies are strongly recommended.


We would like to thank all patients for their cooperation and patience during conducting this work; without their help, this work cannot be done.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2020.  Back to cited text no. 1
Naha S, Gardner MJ, Khangura D, Kurukulasuriya LR, Sowers JR Hypertension in diabetes. In: Feingold KR, Anawalt B, Boyce A, et al, editors. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2021.  Back to cited text no. 2
Omar M, Nouh F, Younis M, Younis M, Nabil N, Saad M, et al. Vitamin D status and contributing factors in patients attending three polyclinics in Benghazi, Libya. J Adv Med Med Res 2017;24:1-13.  Back to cited text no. 3
El-Saharty S, Kaneda T Curbing the noncommunicable disease epidemic in the Middle East and North Africa: Prevention among young people is key. In: Handbook of Healthcare in the Arab World. Washington, DC: Population Reference Bureau; 2017. p. 1-35.  Back to cited text no. 4
Hernando Vargas-Uricoechea, Manuel Felipe Cáceres-Acosta. Blood pressure control and impact on cardiovascular events in patients with type 2 diabetes mellitus: A critical analysis of the literature. Clínica e Investigación en Arteriosclerosis (English Edition) 2019;31:31-7.  Back to cited text no. 5
International Diabetes Federation. IDF Diabetes Atlas 8th edition. Available from: https://diabetesatlas.org/atlas/eighth-edition/; 2017.  Back to cited text no. 6
Lam WY, Fresco P Medication adherence measures: An overview. Biomed Res Int 2015;2015:217047.  Back to cited text no. 7
Khayyat SM, Khayyat SM, Hyat Alhazmi RS, Mohamed MM, Abdul Hadi M Predictors of medication adherence and blood pressure control among Saudi hypertensive patients attending primary care clinics: A cross-sectional study. PLOS One 2017;12:e0171255.  Back to cited text no. 8
Lin CS, Khan H, Chang RY, Liao WC, Chen YH, Siao SY, et al. A study on the impact of poor medication adherence on health status and medical expense for diabetes mellitus patients in Taiwan: A longitudinal panel data analysis. Medicine (Baltimore) 2020;99:e20800.  Back to cited text no. 9
Alsaqabi YS, Rabbani U Medication adherence and its association with quality of life among hypertensive patients attending primary health care centers in Saudi Arabia. Cureus 2020;12:e11853.  Back to cited text no. 10
Alnasrawi Z, al Jobori S, Nassrallah A Compliance of hypertensive patients to medication in AL-Imam AL-Hussein medical City-Kerbala. Karbala J Med 2018;11:4048-58.  Back to cited text no. 11
Al-Khfajy W, Anees A, Salim Al-Khfajy W, Aboddy AA, Sameh Arif I Diabetic patients’ adherence to medications and related factors in a sample of the Iraqi population. Proceedings of 177th TheIIER International Conference, Istanbul, Turkey, July 20–21, 2018.  Back to cited text no. 12
Exarchos KP, Rovina N, Krommidas G, Latsios D, Gogali A, Kostikas K Adherence and quality of life assessment in patients with asthma treatment with budesonide/formoterol via the Elpenhaler device: The complete study. BMC Pulm Med 2022;22:254.  Back to cited text no. 13
Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G, et al. Tobacco product use and cessation indicators among adults—United States, 2018. Morb Mortal Wkly Rep 2019;68:1013-9.  Back to cited text no. 14
Alice YY The Canadian Diabetes Association 2013 clinical practice guidelines—Raising the bar and setting higher standards! Can J Diabetes 2013;37:137-8.  Back to cited text no. 15
Mahdi HA, Al-Humairi AK Assessment of knowledge about hypertension among hypertensive patients in Babylon Province. Med J Babylon 2022;19:31-6.  Back to cited text no. 16
Osamor PE, Owumi BE Factors associated with treatment compliance in hypertension in Southwest Nigeria. J Health Popul Nutr 2011;29:619-28.  Back to cited text no. 17
Fadheel QJ, Mohammed AJ Adherence to therapy among Iraqi patients with type 2 diabetes mellitus. J Health Med Nurs 2016;32:75-82.  Back to cited text no. 18
Dosse C, Cesarino CB, Martin JF, Castedo MC Factors associated to patients’ noncompliance with hypertension treatment. Rev Lat Am Enfermagem 2009;17:201-6.  Back to cited text no. 19
Alsallami SHA, Abutiheen AAK Hypertensive patients compliance with medications in Marjan Teaching Hospital/Babylon. Med J Babylon 2015;12:592-602.  Back to cited text no. 20
Shlash A, Rabeea IS Evaluation of diabetic-medications adherence among diabetic type 2 patients. Indian J Forensic Med Toxicol 2021;15:1920-7.  Back to cited text no. 21
Saied Q, Abbas H, Al-Tukmagi F, AL-Auqbi Tawfeeq F Assessment of Morisky Medication Adherence Scale in a sample of Iraqi type 2 diabetic patients. Iraqi J Com Med 2015;28:212-5.  Back to cited text no. 22
Alhaddad IA, Hamoui O, Hammoudeh A, Mallat S Treatment adherence and quality of life in patients on antihypertensive medications in a middle eastern population: Adherence. Vasc Health Risk Manag 2016;12:407-13.  Back to cited text no. 23
Kwan MW, Wong MC, Wang HH, Liu KQ, Lee CL, Yan BP, et al. Compliance with the dietary approaches to stop hypertension (Dash) diet: A systematic review. PLoS One 2013;8:e78412.  Back to cited text no. 24
Hawrami OH, Abdulla MH Noncompliance with antihypertensive drugs among patients with essential hypertension in Sulaimani city. Iraqi Academic Scientific Journal 2016;15:140-7.  Back to cited text no. 25
Esmaeili R, Matlabi M, Khajavi A, Aliasghari E, Sajjadi M Factors affecting adherence to antihypertensive medication: Results from a rural population study in east of Iran. Glob J Health Sci 2016;9:286.  Back to cited text no. 26
Aus BS, Kumar SN Medication adherence and health belief model among hypertensive patients attending rural health centers of a tertiary care hospital in South India. Int J Community Med Public Health 2017;4:1159.  Back to cited text no. 27
Aladhab R, Alabbood M Adherence of patients with diabetes to a lifestyle advice and management plan in Basra, Southern Iraq. Dubai Diabetes and Endocrinol J 2019;25:100-5.  Back to cited text no. 28
Alsolami F, Correa-Velez I, Hou XY Factors affecting antihypertensive medications adherence among hypertensive patients in Saudi Arabia. Am J Med Med Sci 2015;5:181-9.  Back to cited text no. 29
Kearney SM, Aldridge AP, Castle NG, Peterson J, Pringle JL The association of job strain with medication adherence: Is your job affecting your compliance with a prescribed medication regimen? J Occup Environ Med 2016;58:707-11.  Back to cited text no. 30
Lötsch F, Auer-Hackenberg L, Groger M, Rehman K, Morrison V, Holmes E, et al. Adherence of patients to long-term medication: A cross-sectional study of antihypertensive regimens in Austria. Wien Klin Wochenschr 2015;127:379-84.  Back to cited text no. 31
Sherman BW, Lynch WD The association of smoking with medical treatment adherence in the workforce of a large employer. Patient Prefer Adherence 2014;8:477-86.  Back to cited text no. 32
Olagbemide OJ, Omosanya OE, Ayodapo AO, Agboola SM, Adeagbo AO, Olukokun TA Family support and medication adherence among adult type 2 diabetes: Any meeting point? Ann Afr Med 2021;20:282-7.  Back to cited text no. 33
Hussain SA, Al-Tukmagi HF, Abdulrahman ZS, Sadeq MM, Hashim DN, Kahdhim RS, et al. Evaluation of the adherence to antidiabetic medications among Iraqi patients with T2DM using the Iraqi antidiabetic medication adherence scale (IADMAS). İstanbul J Pharm 2021;51:307-12.  Back to cited text no. 34
Pokhrel S, Shrestha S, Timilsina A, Sapkota M, Bhatt MP, Pardhe BD Self-care adherence and barriers to good glycaemic control in Nepalese type 2 diabetes mellitus patients: A hospital-based cross-sectional study. J Multidiscip Healthc 2019; 12:817-26.  Back to cited text no. 35


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded35    
    Comments [Add]    

Recommend this journal