International Journal of Public Health Science (IJPHS)

Vol. 8, No. 1, March 2019, pp. 14~19

ISSN: 2252-8806, DOI: 10.11591/ijphs.v8i1.15240  14

Adherence and quality of life among diabetic patients with

hypertension

Akrom Akrom1, Wima Anggitasari2

1Ahmad Dahlan Drug Informatian and Crisis Center (ADDICC), Indonesia
1,2Pharmacy Faculty, Universitas Ahmad Dahlan, Indonesia

Article Info ABSTRACT

Article history: The level of treatment adherence and quality of life are not known in diabetic
patients with hypertension. The study aim was to evaluate the level of
Received Aug 27, 2018 adherence and quality of life of diabetic patients with hypertension in Bantul
Revised Nov 12, 2018 Public Hospital (BPH), Bantul, Indonesia. This study used a Cross-sectional
Accepted Dec 04, 2018 method by conducting a survey through a direct interview with the patient.
Participants of this study were 143 diabetic patients with hypertension in the
internal disease clinic of BPH. Modified Morisky Medication Adherence
Keywords: Scale was used to measure the level of treatment adherence and SF36
questionnaires were used to measure the quality of life. Descriptive and
Adherence analytical statistical was performed on data from the adherence assessment,
Cross sectional study quality of life, demographic characteristic and the clinical condition of the
Diabetic patients research participant. Bivariate analysis with Chi-square was performed to
Hypertension assess the relationship between demographic and clinical factors to the high
Quality of life level of adherence. The majority of respondents had moderate and low levels
of adherence. There were 34 patients (23.78%) with a high level of
adherence, 56 patients (39.16%) with moderate level of adherence, and 53
patients (37.06%) with low level of adherence. Respondents also had low
quality of life, in which the average score of quality of life was 61.96±12.48.
Male and college-educated patients have higher adherence (OR>1, p<0.05)
compared to other groups. Medication adherence and quality of life of
diabetic patients with hypertension in BPH were relatively low. Male and
high college-educated patients were associated with high levels of adherence.
Copyright © 2019 Institute of Advanced Engineering and Science.
All rights reserved.

Corresponding Author:
Akrom Akrom,
Department of Pharmacology and Clinical Pharmacy,
Pharmacy Faculty, Universitas Ahmad Dahlan,
Jl. Prof. Dr. Soepomo SH, Janturan, Yogyakarta 55164.
Email: akrom@pharm.uad.ac.id

1. INTRODUCTION
Diabetes Mellitus (DM) and hypertension is a public health problem in Indonesia. Hypertension and
diabetes mellitus is a chronic disease that requires ongoing medical therapy, in which the incidence is
continuously increasing and the success rate of therapy is not satisfying [1-2]. By 2030, the estimated
prevalence of DM in Indonesia reaches 21.3 million [3]. DM with hypertension is associated with decreased
quality of life [4]. DM with hypertension also increases the risk of heart disease, peripheral vascular disease,
and stroke. The prevalence of albuminuria and renal injury is higher in diabetic patients with hypertension
compared to diabetic patients without hypertension [5]. DM increases the relative risk of stroke by 6-fold and
hypertension increases it up to 4-fold [6]. DM will display a wide range of DM complications when it is not
treated properly, such as: neuropathy, nephropathy, retinopathy, hyperlipid, ulcers on the feet, and infection.
These complications affect the quality of life of patients with diabetes mellitus. Micro and macrovascular
damage due to hyperglycemia and increased levels of HbA1c, lipid metabolism abnormality, accumulation of

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Int. J. Public Health Sci. ISSN: 2252-8806  15

reactive radical, impaired platelet function and blood clotting factors are the responsible factors for the
decline in quality of life and the risk of cardiovascular disease in diabetic patients with hypertension [7-8].
Non-adherence in undergoing medication therapy in diabetic patients with hypertension is the key
factor that hinders the achievement of therapeutic targets, blood sugar control and blood pressure control.
The level of adherence to therapy on diabetic patients with hypertension is estimated to range between
30-50% [9]. The causes of this non-adherence is very complex, including the complexity of the drug
regimen, drug charges, age, gender, lack of social support, education level, type of personality and cognitive
problems of the patient [10]. Medication adherence can be measured by using various methods [11-12].
The success in the management of diabetes mellitus is influenced by medication therapy, physical
exercise therapy, diet, and other lifestyle changes [13-14]. A more comprehensive approach is required to
achieve an intensive control of blood sugar level and optimal blood pressure in diabetic patients with
hypertension. It is necessary to avoid complications and decreased the quality of life. Based on that
condition, this study aimed to evaluate the quality of life, adherence to medication therapy, and other related
factors in diabetic patients with hypertension in Bantul public hospital.

2. RESEARCH METHOD
2.1. Design
This research was a cross-sectional study among 143 DM with hypertension patients. Data were
collected from survey through interviews by using Modified-Adherence Questionnaire (MAQ). M-AQ
consisted of eight questions with the response that ranges from 0 to 8. Item 1-7 were yes or no questions.
Score value 1 was for the “no” response, and 0 was for the “yes” response, except for item number 5 in
which the score value was reversed (0=no and 1=yes). Responses for item 8 were a rating with 5 Likert scale,
which values: never=1, occasionally=0.75, sometimes=0.5, and usually=0.25, always=0. Adherence to
therapy level was categorized into three levels: high adherence ( score 8), moderate adherence ( score 6-8)
and poor adherence ( score >6).
It is necessary to check the correlation between the score (value) of each item with the total score of
the questionnaire. Meanwhile, validity was tested to determine the extent to which the measurement results
could be trusted or relied upon. Reliability showed the degree of consistency from the instrument when it was
applied several times on different occasions. The measurement results could be trusted if the instrument was
implemented for several times on the same group of subjects and relatively similar results were obtained.
This questionnaire has been through pilot testing, validation testing, reliability testing and has been declared
as valid and reliable.

2.2. Participant overview

The population of this study is diabetic patients with hypertension in internal disease clinic of
Panembahan Senopati Bantul Hospital, Yogyakarta during April 2014-May 2015. There are 143 DM with
hypertension patients. All participants meet the inclusion and exclusion criteria. The inclusion criteria were:
(1) adult patients, both men and women aged 18-60 years old and geriatric patients who could be counseled,
(2) diabetic patients with hypertension in the internal disease clinic of Bantul public hospital during the
period of the study, (3) patient was diagnosed with level I or level II of diabetes mellitus with hypertension,
(4) patients has received medication for diabetes and hypertension, (5) willing to be a participant in the study
by completing an informed consent. Meanwhile, the exclusion criteria for this study were: (1) deaf, (2)
illiteracy, and (3) pregnant women.

2.3. Data collection

This study had been approved by the ethics committee of the University of Muhammadiyah
Yogyakarta. The procedures of this research were as follows: (1) patients’ data with a clinical diagnosis of
diabetes and hypertension were collected from the doctor in the internal disease clinic of Bantul hospital,
Yogyakarta, (2) prospective participants were given an explanation about the purpose and the benefit of the
research as well as risks that may be received by the participant before the interviewer requested approval as
a participant of the research, (3) after obtaining patient’ consent to participate in the study, patients were
asked to complete and sign the informed consent sheet, (4) patients then asked to fill out a record and
assessment of the patient's health (demographic data, habits, history of diseases, and treatments), (5) quality
of life and adherence data were obtained through interviews based on the questionnaire. M-AQ was used to
assess patient’s adherence and the SF-36 questionnaire was used to assess patient’s quality of life. Interviews
were conducted by personnel that has been specially trained to conduct interviews, (6) data of the patient’s
clinical condition (results of laboratory examinations, blood pressure examinations, GDS,

Adherence and quality of life among diabetic patients with hypertension (Akrom Akrom)
16  ISSN: 2252-8806

the antihypertensive drug therapy and anti-diabetic therapy) were collected from the medical record and
treatment records or prescriptions written on the notes of patient’s form.

2.4. Data analysis

Data were analyzed by using SPSS 16.0. Data on demographic and clinical characteristics, quality
of life scores and level of compliance were presented descriptively. Chi Square was conducted to determine
assosciation between age, gender, education, payment or clinical condition with the high level of adherence.

3. RESULTS AND ANALYSIS

3.1. Characteristics of patients
Demographic characteristics of the patients are shown in Table 1. According to Table 1, total
participants of this study were 143 patients. There were 87 female patients (60.84%) and there were 56 male
patients (39.16%). Ninety-one patients were aged less than 60 years (63.64%), meanwhile, 52 patients were
geriatric patients (36.36%). The majority of patients’ level of education was high school
(53 patients/37.06%), and the majority of patients were using health insurance as their payment method
(115 patients/80.42%). Most patients were diagnosed with diabetes mellitus and hypertension, but several
patients also diagnosed by dyslipidemia (15 patients/10.49%), uric acid (13 patients/9.09%) and the
combination of both dyslipidemia and uric acid (2 patients/1.40%).

Table 1. Demographic and clinical characteristics respondent

Variable Category N (%)
≤ 60 91(63.64)
Age
> 60 52(36.36)
Male 56(39.16)
Gender
Female 87(60.84)
Not educated 3(2.10)
Elementary or Junior High School 43(30.07)
Level of education
Senior High School 53(37.06)
University/College 44(30.77)
Type of Health Health insurance 115(80.42)
insurance Non-health insurance 28(19.58)
Smoking 19(13.30)
Smoking habit
Not smoking 124(86.70)
DM+HT 113(79.02
DM+HT+Dyslipidemia 15(10.49)
Clinical Diagnosis
DM+HT+Uric Acid disorder 13(9.09)
DM+HT+Dyslipidemia+Uric Acid 2(1.40)
Type of anti- OAD 77(53.80%)
diabetes medicine Insulin 31(21.70%)
therapy OAD + Insulin 35(24.50%)
ACEI 43(30.10)
AIRA 37(25.90)
Type of anti-
Amlodipine 62(43.40)
hypertension
Diltiazem 3(2.10)
medicine therapy
Nifedipine 3(2.10)
Diuretika 13(9.10)
Beta blocker 2(1.40)
2 40(28.00)
3 69(48.20)
Number of
4 25(17.50)
medicine
5 7(4.90)
6 2(1.40)
note: DM=diabetes mellitus; HT=hypertension;
ACEI=angiotensin converting enzime inhibitor;
AIRA=angiotensin I receptor antagonis; OAD=oral antidiabetes

There were 109 patients (76.2%) who received 2-3 medicines, while there were only 34 patients
(23.8%) who received 4 or more medicines. There were 77 patients (53.8%) who received oral anti-diabetes
(OAD) medication therapy, 35 patients (24.5%) received OAD combined with insulin therapy and 31 patients
(21.7%) received insulin therapy. The widely used antihypertensive medications were the calcium
antagonists (such as amlodipine, diltiazem, and nifedipine), which was used for 68 patients.

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Int. J. Public Health Sci. ISSN: 2252-8806  17

Meanwhile, other commonly prescribed antihypertensive medication were ACEI in 43 patients (30.1%),
AIRA in 37 patients (25.9%) and diuretics in 13 patients (9.1%).

3.2. Clinical characteristic, patients’ quality of life and adherence level

The clinical condition, quality of life and medicine adherence of patient are presented in Table 2.
Table 2 shows that the adherence level of the patient was low (scores=6.27±1.71). In line with this low
adherence scores, the average score of the total quality of life was also not satisfying (72.75±13.40).
It indicates that patients had a poor quality of life. The average blood sugar levels of patients were higher
than normal (200.56±91.97 mg/dl), which showed that the goals of anti-diabetes medicine therapy were not
achieved. Physical function and emotional domains of quality of life obtained high scores (>80), but the
score of pain, disability and general quality of life domains were low (score=60). These results are in
accordance with results of the previous studies [15-17].

Table 2. Score of quality of life (SF36) and adherence (M-AQ) among respondents
Characteristics Mean ±SD (Minimum-Maximum)
Clinical Characteristic: Blood Sugar Level (mg/dl) 200.56±91.97 (57.00-603.00)
Systolic Blood Pressure (mmHg) 135.70±17.90 (90.00-180.00)
Diastolic Blood Pressure (mmHg) 83.18±9.99 (60.00-110.00)
Quality of Life: Score of General Quality of Life 61.96±12.48 (29.17-91.67)
Score of Physical Functioning 81.75±18.82 (10.00-100.00)
Score of Physical Limitation 61.89±39.57 (0.00-100.00)
Score of Emotion Limitation 77.86±32.61 (0.00-100.00)
Score of Social Functioning 78.25±22.62 (22.50-100.00)
Score of Pain 68.36±28.76 (0.00-100.00)
Score of Spirit 70.82±14.96 (15.00-100.00)
Score of Emotions 81.15±12.37 (32.00-100.00)
Total Score of Quality Of Life 72.75±13.40 (28.71-98.96)
Score of Adherence 6.27±1.71 (1.50-8.00)

Adherence levels in anti-diabetes and anti-hypertension medication therapy are presented in Table 3.
Table 3 shows that the majority of participants had low until moderate levels of adherence (76.22%).
Meanwhile, there were only 34 patients (23.78%) with high level of adherence.

Table 3. Adherence level of diabetic patient with hypertension

Score of M-AQ Category N (%) p
<6 Low 53(37.10) P=0.05
6-<8 Moderate 56(39.16)
8 High 34(23.78)
Total 143(100.00)

3.3. Correlation between age, gender, education, payment method and clinical conditions of patients
with medication adherence
Factors associated with adherence level in anti-diabetes and anti-hypertension medication therapy
are presented in Table 4. Table 4 shows that female gender and level of education factors were related to the
low level of adherence. Female and low educated (below university) diabetic patient with hypertension have
a higher risk (OR>1) to have a low level of adherence (>0.05) 2.13-fold or 2.2-fold compared to male and
college-educated diabetic patient with hypertension. Diabetic patient with hypertension who used health
insurance have others clinical diagnosis besides diabetes and hypertension, and who received more than 4
medication therapy have a higher potential of low adherence level (OR>1), although it was not statistically
significant (p>0.05). Patients with insulin therapy have a higher potential to have a low level of adherence
(OR=0.77), although it was not statistically significant (p>0.05).

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Table 4. Factors related to the level of adherence (Height) of DM patients with hypertension outpatient
Variable Category OR (CI, 95%) of high adherence P
<=60 0.96(0.47 - 1.93)
Age 0.900
>60
Male
Gender 0.47(0.23 - 0.98) 0.030*
Female
Level of Lower than University 2.2(1.01 - 4.87)
0.046*
Education University
Health Health Insurance (Askes) 1.68(CI:0.71 - 3.96)
0.300
Insurance Non-Health Insurance
Clinical DM+HT+others 1.97(CI:0.90 - 4.46)
0.080
Diagnosis DM+HT
Number of >4
1.39(CI:0.36 - 5.41) 0.640
medication 4 or less
Insulin Yes
0.77(0.38 - 1.52) 0.450
Usage No
*significant difference (p<0.05)
Note: DM=diabetes mellitus; HT=hypertension;

Adherence is a major component in achieving goals of medicine therapy [10]. There are several
ways to assess the adherence to medication therapy on diabetic patient with hypertension. One of them is by
using the Modified-Morisky Adherence Score (M-MMAS) [11]. Factors associated with adherence in the
diabetic patient with hypertension are age, education, patients’ knowledge about the medication, patients'
knowledge about the diseases, therapies, patient interactions, social environment and economic
status [16-18]. Schoberberger et al [19] and Ramli et al [2] showed that the level of adherence is lower in
male hypertensive patients. However, a systematic review of several studies on the effect of age, gender,
knowledge, and attitudes towards medication adherence gave inconsistent results [20].
Lack of adherence to anti-DM and anti-hypertension medication is associated with decreased quality
of life. Uncontrolled blood sugar and blood pressure might bring serious consequences, including the
emergence of various complications to diabetes and hypertension, elevated cardiovascular
mortality,increased the prevalence of albuminuria, 5-fold higher renal injury risks and increased risk
of stroke [21-22]. High level of blood sugar in this study appeared to be related to the decreased quality of
life and this result is in line with the previous studies [23]. The efforts of researchers to reduce the occurrence
of bias include recruitment of subjects based on criteria; data collection was carried out by trained staff and
validated questionnaires used.

4. CONCLUSION
It can be concluded that the level of adherence and quality of life in diabetic patient with
hypertension were low. Factors associated with low levels of adherence were female gender and low level of
education. We suggest to give intervention for improving patient’s adherence is necessary so the therapeutic
targets can be achieved and patient’s quality of life can be improved with the DM and hypertension therapy.

ACKNOWLEDGEMENTS
The authors would like to say gratitude and reward for all patients and officers of Panembahan
Senopati, Bantul District Hospital, Indonesia, for their cooperation during the research.

REFERENCES
[1] Vijan, S., Sussman, J.B., Yudkin, J.S., Rodney A. Hayward, R.A., Effect of Patients’ Risks and Preferences on
Health Gains With Plasma Glucose Level Lowering in Type 2 Diabetes Mellitus, JAMA.Intern.Med. 174(8):1227-
1234, 2014
[2] Ramli, Azuana., Ahmad, Nur Sufiza., Paraidathathu., 2012, Medication Adherence Among Hypertensive Patients
of Primary Health Clinics In Malaysia, dovepress, Patient Preference and Adherence, 6 613-622., 2012
[3] Depkes, Pharmaceutical Care Untuk Penyakit Hipertensi, Direktorat Bina Farmasi dan Komunitas dan Klinik,
Depkes RI, Jakarta, 2007
[4] Redmon B, Caccamo D, Flavin P, Michels R, O’Connor P, Roberts J, Smith S, Sperl-Hillen J. Institute for Clinical
Systems Improvement. Diagnosis and Management of Type 2 Diabetes Mellitus in Adults. Updated July 2014

Int. J. Public Health Sci. Vol. 8, No. 1, March 2019: 14 – 19

Int. J. Public Health Sci. ISSN: 2252-8806  19

[5] Yang, CW., Park, JT., Kim, YL., Lee, YS., Oh, YS., Kang, SW.,2011, Prevalence of Diabetic Nephropaty in
Primary Care Type 2 Diabetic Patien with Hypertension: Data From the Korean Epidemiology Study on
Hypertension III (KEY III Study), Nephrol Dial Transplant, 26: 3249-3255.
[6] Jozwiak, BP., Bogousslavsky, J., Antihypertensive and Lipid Lowering Treatment in Stroke Prevention: Current
State and Future, Acta neurol. Belg., 105: 57-61, 2005
[7] Moran, A.E., Odden, M.C., Thanataveerat, A., Tzong, K.Y., Rasmussen, P.W., Guzman, D. Cost-Effectiveness of
Hypertension Therapy According to 2014 Guidelines, NEJM, 372: 447-55, 2015
[8] Epstein, M., Sowers, JR., Diabetes Mellitus and Hypertension, American Heart Association, 19: 403-418, 1992
[9] Wabe, N.T., Angamo MT, Hussein S. Medication adherence in diabetes mellitus and self management practices
among type-2 diabetics in Ethiopia, North.Am.J.Med Sci.: 3: 418-423, 2011
[10] Sabate E. Adherence to Long-term Therapies: Evidence for Action. Geneva, Switzerland: World Health
Organization; 2003.
[11] Morisky, D.E., Ang A, Krousel-Wood, M.A., Ward H, Predictive Validity of A Medication Adherence Measure in
an Outpatient Setting, J. Health-Syst. Pharm, 10:348-54.
[12] McHorney CA1, Zhang NJ, Stump T, Zhao X.2012. Structural equation modelling of the proximal-distal
continuum of adherence drivers. Patient Prefer Adherence. 2012;6:789-804. doi: 10.2147/PPA.S36535. Epub 2012
Nov 9.
[13] Palaian, S., Acharya, LD., Rao, PGM., Shanker, PR., Nair, NM., Nair, PN.,2006, Knowledge, Attitude, and
Practice Outcome: Evaluating the Impact of Counseling in Hospitalized Diabetic Patient in India, P&T, Vol. 31 No.
7., 2008
[14] AHRQ. Screening for Type 2 Diabetes Mellitus: Systematic Review to Update the 2008 U.S. Preventive Services
Task Force Recommendation, AHRQ Publication No. 13-05190-EF-1 October 2014
[15] Obreli-Neto, P.R. Marusic, S. Guidoni, C.M., de Oliveira Baldoni, A., Renovato, R..D., Pilger, D. Cuman, R.K.N.,
Pereira, L.R.L., Economic Evaluation of a Pharmaceutical Care Program for Elderly Diabetic and Hypertensive
Patients in Primary Health Care: A 36-Month Randomized Controlled Clinical Trial, JMCP, Vol. 21, No. 1, 2015
[16] Al-Qasem, A.1., Smith F, Clifford, S. 2011. Adherence to medication among chronic patients in Middle Eastern
countries: review of studies. East Mediterr Health J. 2011 Apr;17(4):356-63.
[17] Lemay, J., Waheedi, M., Al-Sharqawi, S., Bayoud, T. 2018. Medication adherence in chronic illness: do beliefs
about medications play a role? Patient Prefer Adherence. 2018 Sep 5;12:1687-1698. doi: 10.2147/PPA.S169236.
eCollection 2018.
[18] Gomes-Villas Boas, L.C., Pedroso de Lima, M.L.S.A., Pace, A.E. Adherence to treatment for diabetes mellitus:
validation of instruments for oral antidiabetics and insulin, Rev. Latino-Am. Enfermagem.;22(1):11-8, 2014 Jan.-
Feb
[19] Schoberberger R, Janda M, Pescosta W, Sonneek G.,2002, The Compliance Praxis Survey (COMPASS): a
multidimensional instrument to monitor compliance for patient on antihypertensive medication. J Hum Hypertens.
2002; 16(11): 779-787
[20] Balkrishnan R., 1998, Predictors of Medication Adherence in the Elderly, Clin Ther, 1998; 20(4):764-771.
[21] Clark, M., Adherence to treatment in patients with type 2 diabetes, Journal of Diabetes Nursing Vol 8 No 10, 2004
[22] Palmer, MJ; Barnard, S; Perel, P; Free, C; (2018) Mobile phone-based interventions for improving adherence to
medication prescribed for the primary prevention of cardiovascular disease in adults. The Cochrane database of
systematic reviews, 6. CD012675. ISSN 1469-493X DOI: https://doi.org/10.1002/14651858.CD012675.pub2
[23] Bidonde J., Fagerlund B.C., Frønsdal KB Lund UH, Robberstad B. FreeStyle, Libre flash glucose self‐monitoring
system: a single‐technology assessment, Norwegian Institute of Public Health (NIPH), Oslo, NIPH, 2017

Adherence and quality of life among diabetic patients with hypertension (Akrom Akrom)