Gen. Health Med. Sci., Vol(3), No (1), June, 2015. pp.

1-5

TI Journals

ISSN:

General Health and Medical Sciences

2409-9856

www.tijournals.com

Copyright 2015. All rights reserved for TI Journals.

Factors Affecting Medication Compliance Behavior among

Hypertension Patients based on Theory of Planned Behavior
Yu Ching Ho *
Department of Health Administration, Tzu Chi University of Science and Technology, Hualien, Taiwan.

Chen-Pei Ho
Department of Pharmacy, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.
Institute of Medical Sciences, College of Medicine, Tzu Chi University, Hualien, Taiwan.

Jia-Hui Shih
Department of Healthcare Administration, Taipei Medical University, Taipei, Taiwan.
*Corresponding author: bessie@ems.tcust.edu.tw

Keywords

Abstract

Hypertension
Medication compliance behavior
Theory of planned behavior

This study is based on the Theory of Planned Behavior to explore the factors influencing medication compliance
behavior among patients with hypertension. Its a cross-sectional study among patients with hypertension in a
medical center in East of Taiwan. The research tool of this study is structured questionnaire based on the Theory of
Planned Behavior and 586 questionnaires were collected. Results of MMAS-8 shows that the score of medication
compliance behavior among patients with hypertension is averaged at 5.96 out of 8 which shows that the
compliance behavior still needs to be improved. In addition, the patients attitude towards medication and
subjective norms of medication both has strong positive association with behavioral intention of medication.
Behavioral intention of medication and perceived behavioral control of medication both have strong positive
association with medication compliance behavior. Therefore, improving attitude towards taking medication,
subjective norms of medication, behavioral intention of medication and perceived behavioral control of medication
will also medication compliance behavior and thus improve the health status of patients with hypertension.

1.

Introduction

In 2011, WHO reported that hypertension consisted 13% of the global mortality rate that ranked the highest among non-transmitted disease and
also a leading factor for cardiovascular and cerebrovascular disease. According to Taiwan Ministry of Health and Welfare, one of every four
persons those ages above 40 has been diagnosed with hypertension in Taiwan. Hypertension related diseases consists five of the top ten leading
cause of death in Taiwan, including cardiovascular diseases and cerebrovascular disease. Most of the chronically ill patients are older with lower
educational status and might have other comorbid diseases that are under long-term medication therapy. These unfortunately also comes with
rather poor medication compliance behavior, thus make it harder to control the disease. Previous studies have shown that 50% of patients do not
follow doctors drug order [17], this makes it unable to control the disease, worsen the health status and affects the quality of life [14]. Especially
when the patient does not follow doctors order and blood pressure cannot maintain under 140/90 mmHg, the incidence of comorbidity increases
[4].To prevent and control hypertension effectively is an important public health topic nowadays. It is very important for hypertension patients to
take drugs comply with medication in order to control blood pressure well. Therefore, recognizing influencing factors on drug compliance of
hypertension patients could improve their health status. Many studies on hypertensive drug compliance often measure attitude, social support,
health belief model and self-efficacy theory to predict compliance behavior [3,9,16,25]. In the past behavioral studies, the theory of planned
behavior was often used to effectively predict and explain personal behavioral intention, and had been supported by many studies. This study
therefore used theory of planned behavior to explore the influencing factors of compliance behavior of patient with hypertension from the
outpatient unit in a medical center located at East of Taiwan.

2.

Literature Review

2.1 Medication compliance behavior of hypertension patients

Daniels and Kochar (1979) defined compliance as a complex behavior that is created by the interaction of many factors or a health problem
influenced by many different factors [6]. Dracup and Meleis (1982) argue that compliance refers to how the patients health behavior follows the
doctors medical order [8]. Take above definitions into consideration, compliance can be defined when patient follows the medication regimen
prescribed by the physician in correct dosage and time. Unable to follow the medication regimen prescribed by the physician is the main reason
for uncontrolled hypertension [13,24]. When blood pressure is not well controlled, the high pressure may be worsen and cause other disease,
such as, stroke, renal disease and heart failure, etc. DiMatteo et al. (2002) presented that the patient with better compliance is able to control his
blood pressure better [7]. According to Ong et al. (2007), in 2003 to 2004, there was only 37% of the hypertensive population that have their
blood pressure in controlled [24]. Li (2004) also found out that the patients with higher compliance would have a lower systolic pressure [15].
2.2 Theory of Planned Behavior (TPB)
Theory of Planned Behavior is originated from psychology and proposed by Ajzen in 1985 [1]. Theory of Planned Behavior built on Theory of
Rational Behavior which was proposed in 1975. Theory of Rational Behavior believes that attitude and subjective norms can influence
behavioral intention and behavioral intention can also influence behavior. However, Theory of Planned Behavior has one extra component which
is perceived behavioral control. Theory of Planned Behavior argued that behavioral intention is influenced by attitude, subject norm and
perceived behavioral control. Moreover, behavior can be influenced by behavioral intention and perceived behavioral control. After its
introduction, Theory of Planned Behavior has been used effectively on varies topic of health behavior such as multiple behavior change, patterns
of health behavior changes, drug compliance, smoking cessation, self-monitoring compliance, substance abuse treatment completion
[2,5,18,20,21,26,27].

Yu Ching Ho *, Chen-Pei Ho, Jia-Hui Shih

General Health and Medical Sciences Vol(3), No (1), June, 2015.

3.

Methodology

A cross-sectional study was conducted and the research subjects were hypertension patients at a Medical center in Hualien located at East of
Taiwan. A structured questionnaire based on TPB was developed and the research model is shown in Figure 1.

Figure 1. Research model

3.1 Research Tool

The structured questionnaire consisted of three parts. The first part aims to measures the hypertensive patients compliance behavior, which uses
Modified Motor Assessment Scale (MMAS). Studies had proved that MMAS-8 is easy to understand with good reliability [12,19]. Furthermore,
MMAS-8 has been translated to different language and proven that the reliability is good [11,23]. Therefore this study uses the Chinese version
of the MMAS-8 with 8 questions. The total scores will be sum up with each question and the full mark is 8. The second part includes 15
questions with Likert 5 scales and the questions ask on subjective attitude towards medication (AT), subjective norms (SN), perceived
behavioral control (PBC) and behavioral intention (BI). The third part collects socio-demographic data of survey respondents includes
occupation, economic status, marital status, living style, educational level, age and gender. Occupation is divided into full-time job, part-time job
and unemployed; economic status is divided to monthly income more than needed, monthly income equals needed and monthly income less than
needed; marital status is divided to unmarried, married, divorced and widowed. Living style is divided into live alone, live with family, live with
friends, live in a care center and other; educational level includes illiterate, elementary school, junior high school, senior high school, university
or graduate school and above; gender includes male and female. Factor analysis is performed to test the construct validity. The KMO value is
0.850, which is closed to 1, and Bartletts Sphericity Test is significant (p<0.05). After using unweighted-least-squres method and factor
analysis, 4 factors are identified which are perceived behavioral control, subjective norms, behavioral intention and attitude towards medication
respectively. These four factors can explain 66.03% of variance that represent effectiveness on all the items. To improve the consistency of each
construct, this study uses Cronbachs Alpha to test construct reliability. Nunnally (1978) proposes that when the Cronbachs Alpha scale is
above 0.7, it means highly reliable. Vice versa, when the scale is below 0.35, it is lowly reliable [22]. In this study, the Cronbachs Alpha of
research variables are between 0.772 to 0.971 which are all above 0.7, hence that the questionnaire is highly internal consistency and reliable.

4.

Results

4.1 Data collection

This study sent out 600 questionnaires and received 600 questionnaires; the overall response rate was 100%. After excluding 14 invalid
questionnaires due to 1 or more unanswered question, there were 586 valid questionnaires; the overall valid response rate was 97.67%.
4.2 Socio-demographic Descriptive Statistics of the Data
The descriptive statistics of demographic are summarized in Table 1. The survey respondents were mostly unemployed, 67.2% (n=394).
Economic status were mostly monthly income more than needed, 49.1% (n=288). Participants were mostly married 78.8% (n=462) and were
mostly living with family 90.3% (n=529). Their educational level were mostly elementary level 32.4% (n=190). Participants were mostly female
51% (n=299) and aged between 51-70 years old, 57.2% (n=335).
4.3 Descriptive Statistics of the Quantitative Variables
The quantitative variables include attitude towards medication (AT), subjective norms (SN), perceived behavioral control (PBC), behavioral
intention (BI) and medication compliance behavior (MCB). Descriptive statistics for each of the quantitative variables are shown in Table 2.
4.4 Difference Analysis
Independent T-test and ANOVA are performed to do difference analysis. If t-value or F-value is significant then LSD is used to verify the posthoc test. The significant difference results are summarized in Table 3.
4.5 Regression Analysis
Two regression models were set up to verify the causal relationship based on TPB. Model I took behavioral intention (BI) as dependent variable
and three independent variables were attitude towards medication (AT), subjective norms (SN) and perceived behavioral control (PBC)
respectively. Model II took medication compliance behavior (MCB) as dependent variable and two independent variables were perceived
behavioral control (PBC) and behavioral intention (BI). The regression results were shown in Table 4 and Table 5.

Factors Affecting Medication Compliance Behavior among Hypertension Patients based on Theory of Planned Behavior
General Health and Medical Sciences Vol(3), No (1), June, 2015.

Table 1. Demographic descriptive statistics of the sample

Demographic Variables
Description
Number
Gender
Male
287
Female
299
Living style
Live alone
53
Live with family
529
Live with friends
2
Live in a care center
2
Other
0
Occupation
Full-time job
135
Part-time job
57
Unemployed
394
Economy status
Monthly income more than needed
175
Monthly income equals needed
288
Monthly income less than needed
123
Marital status
unmarried
34
married
462
widow or widower
62
divorce
28
Education
Illiterate
43
Elementary school
190
Junior high school
85
Senior high school
156
University
101
Graduate and above
11
Age

less than 50 years old

51~70 years old
71~90 years old
<91 years old

84
335
164
3

Table 2. Descriptive statistics of quantitative variables (n=586)

Variables
Mean
Attitude towards medication (AT)
4.73
Subjective norms (SN)
4.14
Perceived behavioral control (PBC)
4.63
Behavioral intention (BI)
4.82
Medication compliance behavior (MCB)
5.96

Independent
Gender

Living style

Occupation

Economy status

Marital status

Education

Age

Table 3. Significance statistic results of difference analysis

Dependent
T/F-value
post-hoc test
Attitude towards medication (AT)
t= -2.284*
1<2
Subjective norms (SN)
t= -1.525
Perceived behavioral control (PBC)
t= -0.468
Behavioral intention (BI)
t= -1.997*
1<2
Medication compliance behavior (MCB)
t= -0.740
Attitude towards medication (AT)
t= -1.245
Subjective norms (SN)
t= -2.438*
1<2
Perceived behavioral control (PBC)
t= -1.501
Behavioral intention (BI)
t= -1.171
Medication compliance behavior (MCB)
t= -0.769
1<32<3
Attitude towards medication (AT)
F=16.121***
Subjective norms (SN)
F=5.423**
1<3
1<32<3
Perceived behavioral control (PBC)
F=17.299***
Behavioral intention (BI)
1<32<3
F=22.374***
Medication compliance behavior (MCB)
1<32<3
F=31.116***
Attitude towards medication (AT)
F=4.643*
3<2
Subjective norms (SN)
F=2.777
Perceived behavioral control (PBC)
F=3.903*
3<2
Behavioral intention (BI)
F=3.053*
Medication compliance behavior (MCB)
F=16.005***
3<1<2
Attitude towards medication (AT)
F=6.029***
1<2, 1<3, 1<4
Subjective norms (SN)
F=4.222**
1<2, 1<3
Perceived behavioral control (PBC)
F=5.040**
1<2
Behavioral intention (BI)
F=4.729**
1<2, 1<3
Medication compliance behavior (MCB)
F=2.585
Attitude towards medication (AT)
F=5.934***
5<2, 6<2, 5<3, 6<3
Subjective norms (SN)
F=3.268***
4<2
Perceived behavioral control (PBC)
F=4.799***
6<1, 6<2, 6<3, 6<4
Behavioral intention (BI)
F=4.6.188**
5<1, 5<2, 5<3, 5<4
Medication compliance behavior (MCB)
F=5.765***
5<1, 5<2, 5<3
Attitude towards medication (AT)
Subjective norms (SN)
Perceived behavioral control (PBC)
Behavioral intention (BI)
Medication compliance behavior (MCB)

*p<.05 **p<.01 ***p<.001

F=7.900***
F=3.546*
F=13.412***
F=20.167***
F=23.652***

Percentage
49.0
51.0
9
90.3
0.3
0.3
0.0
23.0
9.7
67.2
29.9
49.1
21.0
5.8
78.8
10.6
4.8
7.3
32.4
14.5
26.6
17.2
1.9

1<2, 1<3
1<3
1<2, 1<3
1<2<3, 1<4
1<2, 1<3, 1<4

14.3
57.2
28
0.5

SD
0.47888
0.98629
0.58873
0.54081
2.25137

Denote
1=male
2=female

1=living alone
2=living with family

1=full time job

2=part time job
3=unemployed

1=monthly income more than needed

2=monthly income equals needed
3=monthly income less than needed

1=unmarried
2=married
3=widow or widower
4=divorce
1=Illiterate
2=Elementary school
3=Junior high school
4=Senior high school
5=University
6=graduate and above
1=less than 50 years old
2=51~70 years old
3=71~90 years old
4=91~100 years old

Yu Ching Ho *, Chen-Pei Ho, Jia-Hui Shih

General Health and Medical Sciences Vol(3), No (1), June, 2015.

Table 4. Regression results of model I

Dependent
Independent
AT
SN
PBC

BI
Beta
P-value
0.349***
.000
0.018
.579
0.425***
.000
F=177.647*** R2 =0.478

VIF
1.515
1.113
1.496

*p<.05 **p<.01 ***p<.001

Table 5. Regression results of model II

Dependent
Independent
PBC
BI

DCB
Beta
P-value
0.426***
.000
0.285***
.000
F=207.142*** R2 =0.415

VIF
1.648
1.648

*p<.05 **p<.01 ***p<.001

5.

Conclusion

According to the descriptive statistic results of TPB constructs, the score of behavioral intention is the highest (4.82), second highest is the
attitude towards medication (4.73), perceived behavioral control (4.63) and the lowest score is subjective norms (4.14). These show that patients
with hypertensions are willing to comply with physicians prescriptions and their attitude towards medication is good. They are also pretty
confident about their medication status, but they are less concern with their relatives opinions. The MMAS get a mean score of 5.96 out of 8,
which shows that the hypertensive patients medication compliance behavior still needs to be improving so as to maintain their health status.
The difference results of ANOVA and T-test show that socio-demographic characteristics are partially significantly different to attitude towards
medication, subjective norms, behavioral intention, perceived behavioral control and medication compliance behavior. The multiple regression
analysis shows that attitude towards medication and subjective norms have positive impaction to behavioral intention. Behavioral intention and
perceived behavioral control both have positive impact on medication compliance behavior.
There are some interest findings. First, female have better attitude towards medication and behavioral intention than male. Therefore, we should
pay more attention on male population to promote their attitude towards medication and behavioral intention in order to improve male
populations medication compliance behavior. Second, although patients living with family tend to have stronger subjective norms, but the
regression result shows that subjective norms dont impact behavioral intention. So even the patients do care about how the familys opinions,
but they will not improve their medication compliance behavior under their family willing. Third, respondents with full-time job and part-time
job have poor attitude towards medication, subjective norms, perceived behavioral control, behavioral intention and medication compliance
behavior. The reason might be people with job forget to take drug on time due to busy work. We argue that hypertensive patient with full-time
job and part-time job can purchase medication box that is suitable for him to prevent loss of medication. Patients can also set alarm on the phone
to remind him to take medication on time, so give them a reminder method might improve their medication compliance behavior. Fourth, elderly
and poor-educated respondents tend to have better medication compliance behavior. Hence, we need to advocate the younger and well-educated
people about the importance of medication compliance behavior with hypertension control.
The findings of this study show that TPB can explain medication compliance behavior well. Meanwhile, hypertension patients can control their
blood pressure much better if they can enhance attitude towards medication, perceived behavioral control, and behavioral intention. Doctors and
nurses can also put their efforts in these ways to help patients to maintain health.

Acknowledgements
We gratefully acknowledge the financial support by a grant (TCCT-1011A02) from Tzu Chi University of Science and Technology, Hualien
City, Taiwan, R.O.C.

References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]

[12]
[13]

Ajzen, I., Kuhl, J. & Beckman, J. (1985). From Intentions to Actions: A Theory of Planned Behavior. Action Control: From Cognition to Behavior.
Ashing-Giwa, K. (1999). Health behavior change models and their socio-cultural relevance for breast cancer screening in African American women. Women
& Health, 28(4), 53-71.
Bane, C., Hughe, C.M. & McElnay, J.C. (2006). Determinants of medication adherence in hypertensive patients: an application of self-efficacy and the
Theory of Planned Behaviour. International Journal of Pharmacy Practice, 14, 197204.
Bosworth, H.B., Olsen, M.K., Neary, A., Orr, M., Grubber, J., Svetkey, L., Adams, M. & Oddone, E.Z. (2008). Take control of your blood pressure study: a
multifactorial tailored behavioral and educational intervention for achieving blood pressure control. Patient Education and Counseling, 70, 338-347.
Conner, M., Black, K. & Stratton, P. (1998). Understand drug compliance in a psychiatric population: An application of the theory of planned behavior.
Psychology, Health & Medicine, 3(3), 337-344.
Daniels, L.M. and Kochar, M.S. (1979). What influences adherence to hypertension therapy. Nursing Forum, 18 (3), 231-245.
DiMatteo, M.R., Giordani, P.J., Lepper, H.S., and Croghan, T.W. (2002). Patient adherence and medical treatment outcomes: a meta-analysis. Medical Care,
40, 794-811.
Dracup, K., & Meleis, A.I. (1982). Compliance: an interactionist approach. Nursing Research, 31, 31-36.
Figueiras, M., Marcelino, D.S., Claudino, A., Cortes, M. A., Maroco, J., Weinman, J. (2010). Patients' illness schemata of hypertension: the role of beliefs for
the choice of treatment. Psychology & Health, 25(4), 507-517.
Fishbein, M. and Ajzen, I. (1975). Beliefs, attitude, intention, and behavior: An introduction to theory and research, Reading. Ma: AddisonWesley.
Korb-Savoldelli, Virginie Gillaizeau, Florence Pouchot, Jacques Lenain, Emilie Postel-Vinay, Nicolas Plouin, Pierre-Franois Durieux, Pierre
Sabatier.& Brigitte. (2012). Validation of a French Version of the 8-Item Morisky Medication Adherence Scale in Hypertensive Adults. The Journal of
Clinical Hypertension, 14, 429-434.
Krousel-Wood, M., Islam, T., Webber, L. S., Richard, N., Morisky, D. E. & Muntner, P. (2009). New Medication Adherence Scale Versus Pharmacy Fill Rates
in Seniors With Hypertension. The American Journal of Managed Care, 15(1), 59-66.
Krousel-Wood, M.A., Muntner, P., He, J., Whelton, P.K. (2004). Primary prevention of essential hypertension. Medical Clinics of North America, 88, 223238.

Factors Affecting Medication Compliance Behavior among Hypertension Patients based on Theory of Planned Behavior
General Health and Medical Sciences Vol(3), No (1), June, 2015.

[14] Krousel-Wood, M, Thomas, Muntner, S. Morisky P.D. (2004). Medication adherence: a key factor in achieving blood pressure control and good clinical
outcomes in hypertensive patients. Current Opinion in Cardiology. 19(4), 357-362.
[15] Li, M. Z. (2004). Factors Associated with Medication Adherence in Patients with Hypertension. Masters degree of institute of Medical Sciences, Tzu Chi
University, Hualien City, Taiwan, R.O.C., unpublished. [Text in Chinese]
[16] Lennon, C., Hughes, C., Johnston, D. & McElnay, J. (2001). Identification of psychosocial factors which influence patient adherence with antihypertensive
medication. The International Journal of Pharmacy Practice, 9, 113-113.
[17] Littenberg, B., MacLean, C., & Hurowitz, L. (2006). The use of adherence aids by adults with diabetes: A cross-sectional survey. BMC Family Practice. 7(1),
Retrieved from http://www.biomedCentral.com/1471-2296/7/1.
[18] McGuckin, C., Prentice, G.R., McLaughlin, C. G., & Harkin, E. (2012). Prediction of self-monitoring compliance: Application of the theory of planned
behavior to chronic illness sufferers. Psychology, Health & Medicine, 17(4), 478-487.
[19] Morisky, D. E., Ang, A., Krousel-Wood, M. & Ward, H. J. (2008). Predictive validity of a medication adherence measure in an Outpatient setting. The
Journal of Clinical Hypertension, 10(5), 348-354.
[20] Noar, S.M., Chabot, M. & Zimmerman, R.S. (2008). Applying health behavior theory to multiple behavior change: Considerations and approaches.
Preventive Medicine, 46(3), 275-280.
[21] Norman, P., Conner, M. & Bell, R. (1999). The theory of planned behavior and smoking cessation. Health Psychology, 18(1), 89-94.
[22] Nunnally, J.C., (1978), Psychometric Theory, New York: McGraw-Hill.
[23] Oliveira-Filho, A.D., Barreto-Filho, J.A., Neves, Sj. & Lyra Junior, D.P. (2012). Association between the 8-item Morisky Medication Adherence Scale
(MMAS-8) and blood pressure control. Arq Bras Cardiol, 99(1), 649-658.
[24] Ong, K.L., Cheung, B.M., Man ,Y.B., Lau, C.P., and Lam, K.S. (2007). Prevalence, awareness, treatment, and control of hypertension among United States
adults 1999-2004. Hypertension, 49(1), 69-75.
[25] Patel, R.P., & Taylor, S.D. (2002). Factors affecting medication adherence in hypertensive patients. The Annals of Pharmacotherapy, 36(1), 40-45.
[26] Sheeran, P., Conner, M. & Norman, P. (2001). Can the theory of planned behavior explain patterns of health behavior change? Health Psychology, 20(1), 1219.
[27] Zemore, S.E. & Ajzen, L. (2014). Predicing substance abuse treatment completion using a new scale based on the theory of planned behavior. Journal of
substance Abuse Treatment, 46(2), 174-182.