Hypertension (HTN) is a widespread and key public health problem.[1] It attributes to a significant health alarm in India, contributing for over 50% of stroke related mortalities and nearly 25% of the deaths from coronary heart disease (CHD). [2]

World Health Organization (WHO) describes medication adherence as "the degree to which the person's behaviour corresponds with agreed recommendations from a health care provider".[3] It is an essential element of treatment accomplishment. For individuals with hypertension to satisfactorily regulate their blood pressure, the compliance to antihypertensive medication is crucial. The existing literature recognized a substantial gap in both awareness as well as control of blood pressure among hypertensive patients.[4] Adherence to a drug treatment necessitates a chain of actions, like procuring the prescribed drug, consuming it on time with the recommended dose and route of administration, and sustaining the treatment for as long as it is indicated. [5, 6]

Several studies reported that the pooled prevalence of noncompliance to antihypertensive drugs was around 46%.[6] The efficient treatment of hypertension is vital for reducing associated complications and also for curtailing healthcare expenditures related to treatment failure.[6,7] The latent and lifelong nature of the disease considerably leads to deprived adherence.[7,8] Other known determinants of inadequate adherence comprise socio-demographic aspects like age, literacy status, the socioeconomic conditions, knowledge and attitudes of patient towards hypertension, the accessibility to treatment and different life style elements.[9] Ascertaining the factors which influence adherence is indispensable for improving compliance and formulating targeted approaches to facilitate blood pressure control.[9,10] The need of additional research on treatment adherence is being underscored. A methodical assessment of non-adherence is essential for deciding its effect on clinical outcomes. However, research in India has studied medication adherence among hypertensive patients, mainly were implemented in hospital-based settings or in rural population groups.

Sparse evidence exists from urban community locations, particularly in western India. The emerging research data facilitates the development of effective, community-oriented strategies to promote medication compliance. The present study was carried out to determine the prevalence of antihypertensive medication non-compliance in hypertensive patients in urban Mumbai as well as to ascertain factors linked with non-compliance.

It was a cross-sectional study which was executed among diagnosed hypertensive patients inhabiting in the urban field practice region of the institute. The current study was approved by Brij Niramaya Memorial Hospital and Research Centre in Maharashtra, India (approval number: BMC/EC/513/2024). The written informed consent was taken from the study participants. Respondents involved adults aged 28 years and more diagnosed with essential hypertension who were on antihypertensive medication for minimum 12 months. The exclusion criteria included patients with secondary hypertension, pregnant females and patients with partial hypertension treatment details. All 315 eligible patients who had been registered during January to June 2025 were included as study respondents through complete enumeration sampling method. The data collection was performed through a pre-validated semi structured modified questionnaire. It comprises information regarding socio-demographic features of respondents, addictions, treatment details of hypertension, reasons for irregular treatment if any and questions about knowledge of hypertension including risk factors, diagnosis and management. Blood pressure (BP) recordings were done as per WHO guidelines for blood pressure measurement.[11] Study respondents were inquired regarding their most recent mealtime, and data collection was performed one hour post meal. The standard blood pressure levels and grades of hypertension were determined according to WHO recommendations. [11] Medication adherence was evaluated through 8- item Morisky Medication Adherence Scale (MMAS) [12] which includes eight questions with dichotomous responses and the final item was assessed with 5-point Likert scale varying from “Never” to “Always.” The adherence rate was assessed by the summative score acquired from the responses. High, average and poor adherence was considered with scores of 8, 6-8 and below 6 respectively. The cut off figure of 8 was considered to define “adherent” and “nonadherent”. The statistical analysis was performed using IBM SPSS Statistics version 30. The data was entered into Microsoft Excel Sheet for statistical analysis. Categorical variables were computed using numbers and percentages and continuous variables were summarized as means and standard deviations. Chi-square test or Fisher’s exact test were utilized to examine association between categorical variables. P value <0.05 was considered as statistically significant.

A total of 315 study respondents were involved in the present study. However, the data analysis was done only for 285 respondents as remaining did not participate in questionnaire completion process. The mean age of the respondents was 59.42 years, with a standard deviation of 11.20 years. Male respondents were 72 (25.26%), and females were 213 (74.73%). Maximum respondents belonged to Hindu religion (61%) followed by other religions. Of 285 respondents, 69 (24.21%) were unemployed, 110 were skilled workers and rest were semiskilled workers. Ninety-nine (34.73%) were illiterates, 63 (22.10%) were educated up to primary and secondary schooling and remaining (43.15%) were graduates.

Table 1: Grades of Antihypertensive Medication Adherence (n=285)

The grading was done using Morisky Medication Adherence Scale (MMAS)

 Table 1 depicts that the majority of respondents were highly adherent to medication (95% CI: 84.4– 93.1). The percentage of non-adherence respondents was observed to be less in the present study (Table 1). In this study, noncompliance to antihypertensive treatment was greatest with respondents of 28–45 years of age (22.5%), followed by 46–60 years (11.9%) and above 60 years (6.8%), indicating a statistically significant decrease with increasing age. Female respondents reported high non-adherence rate compared to male respondents. Greater non-adherence was also detected among separated/widowed respondents, illiterates and unskilled workers, respondents with socioeconomic class III and IV and members belonging to nuclear families. Nevertheless, these correlations were not statistically significant (p>0.05).

Table 2: Association Of Addictions, Drug Treatment and Family History with Compliance Level Among Study Respondents (n=285)

*p value was statistically significant

High level of noncompliance to antihypertensive treatment was documented among respondents without pre-existing illnesses or family history of hypertension. (Table 2) Similarly, respondents on treatment for less than 12 months and with addictions showed greater non-adherences rates towards hypertension treatment. (Table 2) 

Table 3: Perceived Reasons for Irregularities of Medication (n=31)

*One study respondent can provide multiple responses

Table 3 indicates that, among the 31 respondents who were irregular with hypertension treatment, the most common perceived reason for noncompliance was “feeling better after taking drug and did not feel the need to continue it” followed by “busy life schedule” and “forgot to take medicine”.

In context of knowledge of respondents about hypertension, less than 50% of respondents were aware about required controllable blood pressure levels and addictions including smoking and alcohol. Additionally, understanding about multiorgan failure due to uncontrolled hypertension was also inadequate. Conversely, most respondents identified “junk food/ fatty food” as a potential risk factor and “salt restriction” as an effective measure to control blood pressure and associated complications. (Table 4)   

The present study also revealed that respondents who were unaware of hypertension associated complications were 4.1 times more likely to be non-compliant comparing to respondents with awareness for the same (OR: 4.012; 95% CI).

Table 4: Knowledge of Respondents about Unmanageable Hypertension

Among respondents receiving antihypertensive medication for less than twelve months, none of the variables showed a statistically significant relationship with non-compliance. Among respondents on drug treatment for more than 12 months, tobacco was significantly correlated with non-compliance (OR: 3.245; 95% CI). However, no significant relationship was detected with age group, knowledge about complications of uncontrolled hypertension and frequency of medication consumption.

In present study, 10.17% of respondents were noncompliant to drug treatment. In a parallel study conducted by Bandi H [13], the drug non-compliance rate in hypertensive individuals was 8.6%. Tabassum N et al.[14] reported the non-adherence rate of 38.3%. The low non-adherence rate detected in the existing study compared to other study might be due to multiple contextual variations. The other study was done in slums highlighted by substandard socioeconomic surroundings, restricted health literacy, unbalanced employment rates and significant challenges to healthcare access, all of which can negatively impact drug compliance. Conversely, the current study population had comparatively improved accessibility to urban healthcare services and antihypertensive medicines through government services. A study implemented by Ramli A et al. [15] among reported non-adherence rate of around 47%. Variations in education levels, sampling features, sensitization about hypertension might be the reasons for such differences. The considerably high nonadherence documented rate of 64% in another study done by Nielson J et al. [16] might illustrate heterogeneity in health systems, medicine affordability, religious and cultural views, and compliance assessment approaches across nations. In this study, respondents without pre-existing health problems were observed to have greater rates of non-adherence. It may be due to several medications might make them perceive as sick and subsequently adhere better to treatment.[17] In the current study, the maximum nonadherent respondents were smokers or tobacco chewers, which was similar to the results of Bandi H et al.[13] However, Nair et al.[18] showed that lesser adherence (16%) in those participants using both alcohol and tobacco. In present study, respondents with deficient knowledge about complications were 4.1 times more non-compliant compared to another group. It may indicate that scarce knowledge of uncontrolled disease complications can significantly diminish perceived need for long-term treatment compliance. This outcome highpoints the necessity for structured health education programs emphasizing on cerebrovascular accidents, cardiac diseases, renal problems, and longstanding infirmity related with unregulated hypertension. Likewise, tobacco users were more likely to be non-complaint, signifying that harmful health behavioral practices can coincide with deprived treatment-seeking behaviors. Implementing tobacco/smoking cessation counselling sessions into NCD clinics and community oriented NCD programs may consequently promote both compliance as well as cardiovascular risk reduction. One of the strengths of this study was that, it was a community- based research and was carried out in hypertensives belonged to urban population. The majority of preceding studies were done in hospital settings. The utilized questionnaire comprised not only medical aspects but also socio-demographic, psychosocial and knowledge-based components. The study had some limitations. Due to cross-sectional study design, causal associations between addressed determinants and drug non-compliance could not be investigated. Since it was implemented in an urban region, the outcomes cannot precisely reflect the rural inhabitants and patients in healthcare settings. Furthermore, the usage of self-reported adherence procedures like MMAS-8 scale might have presented social desirability bias, with respondents possibly overreporting compliance behaviours. Though a significant percentage of respondents showed adherence to antihypertensive medicines, the inferences must be interpreted carefully as adherence evaluation was based merely on self-reported answers, which might overemphasize factual compliance behavior due to likely social desirability bias in self-reporting.

There is need for sustained health education to patients regarding hypertension complications, positive behavioral change and healthy lifestyle practices to enhance treatment compliance among hypertensive patients. Health-care professionals must highlight constant motivation, strengthening of knowledge, and smoking cessation drives as vital approaches to warrant better prolonged blood pressure regulation and subsequent prevention of complications. Targeted educational strategies and incorporation of tobacco/smoking cessation services into hypertension control programs can increase medication compliance and enduring blood pressure control.

Source of Funding – NIL

Conflict of interest – None

Acknowledgements: Authors are thankful to community volunteers and health educators for their valuable help in data gathering process.

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