Medication Adherence In Patients With Arterial Hypertension: The Relationship With Healthcare Systems’ Organizational Factors

Figures & data

Figure 1 PRISMA flow diagram.

Figure 2 Graphic representation of mean adherence to medication by country.

Note: Dashed line represents median adherence for all countries.

Table 1 Summary Of Data Collected From The Studies Included In This Review

Country	Author	Year	Adherence Level	Method Used To Assess Adherence	Adherence Criteria	Quality Assessment
Australia	Mc Namara et al^Citation16	2014	A: 85.0% NA: 15.0%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
Austria	Morrison et al^Citation17	2015	A: 66.3% NA: 33.7%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
Bangladesh	Khanam et al^Citation18	2014	A: 73.8% NA: 26.2%	Discontinuation of medication at any time since the beginning of therapy (Y or N)	A: No NA: Yes	Good
Belgium	Morrison et al^Citation17	2015	A: 61.1% NA: 38.9%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
Brazil	Barreto et al^Citation19	2015	A: 57.4% NA: 42.6%	QAM-Q (3 questions)	A: taking 80 to 120% of predicted doses	Good
	Ben et al^Citation20	2012	A: 38.8% NA: 61.2%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
	Bezerra et al^Citation21	2012	A: 87.0% NA: 13.0%	MMAS-7 (Y or N)	A: 0 or 1 Yes NA: > 1 Yes	Good
	Carvalho et al^Citation22	2012	A: 22.5% NA: 77.5%	Batalla Test (3 questions)	A: 3 correct answers NA: <3 correct answers	Good
	de Oliveira-Filho et al^Citation23	2014	A: 20.3% NA: 79.7%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Very Good
	de Santa-Helena et al^Citation24	2010	A: 46.9% NA: 53.1%	QAM-Q (3 questions)	A: taking 80 to 120% of predicted doses	Good
	Demoner et al^Citation25	2012	A: 36.0% NA: 64.0%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
	Magnabosco et al^Citation26	2015	A: 38.1% NA: 61.9%	QAM-Q (3 questions)	A: taking 80 to 120% of predicted doses	Good
	Oliveira-Filho et al^Citation27	2012	A: 19.7% NA: 80.3%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
	Ungari et al^Citation28	2010	A: 43.1% NA: 56.9%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
Canada	Evans et al^Citation29	2012	A: 38.1% NA: 61.9%	MPR (by questionnaire)	A: > 80% NA: ≤ 80%	Very Good
China	Ma et al^Citation30	2016	A: 21.3% NA: 78.7%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
	Strand et al^Citation31	2017	A: 60.0% NA: 40.0%	Questionnaire about medication taken, frequency and dose and subsequent comparison with standard frequency and dosage for each drug	A: Responses given by participants match the standard	Insufficient
	Yang et al^Citation32	2016	A: 43.5% NA: 56.5%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Sufficient
	Yue et al^Citation33	2015	A: 51.7% NA: 48.3%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
Ethiopia	Ambaw et al^Citation34	2012	A: 64.6% NA: 35.4%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: > 1 Yes	Good
	Berhe et al^Citation35	2017	AT: 21.0% NA: 79.0%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
	Mekonnen et al^Citation36	2017	A: 67.2% NA: 32.8%	MMAS-8 (7 Y or N + 1 Likert scale)	A: ≥6 points NA: <6 points	Good
Finland	Nabi et al^Citation37	2008	A: 60.0% NA: 40.0%	PDC (by clinical records)	A: coverage for 365 days NA: coverage for <365 days	Good
France	Hamdidouche et al^Citation38	2017	A: 85.0% NA: 15.0%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥1 Yes	Good
	Korb-Salvodelli et al^Citation39	2012	AT: 44.2% NA: 55.8%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Very Good
Germany	Morrison et al^Citation17	2015	A: 66.8% NA: 33.2%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥1 Yes	Good
	Ude et al^Citation40	2013	A: 58.2% NA: 41.8%	MMAS-5 (Y or N)	A: 0 points NA: ≥1 point; (1 positive answer = 1 point)	Good
			A: 71.9% NA: 28.1%	MMAS-6 (Y or N)
	Van de Steeg et al^Citation41	2009	A: 71.1% NA: 28.9%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Sufficient
Hong Kong (Special Administrative Region)	Kang et al^Citation42	2015	A: 55.2% NA: 44.8%	MMAS-8 (7 Y or N + 1 Likert scale)	A: >6 points NA: ≤6 points	Good
	Lee et al^Citation43	2013	A: 65.1% NA: 32.6%	MMAS-8 (7 Y or N + 1 Likert scale)	A: >6 points NA: ≤6 points	Good
Hungary	Doró et al^Citation44	2011	A: 75.2% NA: 24.8%	(Number of prescribed doses – Number of doses not taken)/Number of prescribed doses x 100 + MEMS^® track cap + MMAS-4 (Y or N)	A: ≥80% NA: <80% + A: ≥80% NA: <80% + A: 0 Yes NA: ≥1 Yes	Sufficient
	Morrison et al^Citation17	2015	A: 29.7% NA: 70.3%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥ 1 Yes	Good
India	Choudhary et al^Citation45	2016	A: 54.6% NA: 45.4%	Questionnaire (non-specified)	No information	Insufficient
	Dennis et al^Citation46	2011	A: 50.3% NA: 49.7%	BMQ (5 questions)	A: 0 points NA: ≥1 point	Good
Indonesia	Sulistiyowatiningsih et al^Citation47	2017	A: 11.8% NA: 88.2%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
Iran	Behnood-Rod et al^Citation48	2016	A: 16.4% NA: 83.5%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
	Moharamzad et al^Citation49	2015	A: 15.0% NA: 85.0%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Very Good
Jordan	Al-daken et al^Citation50	2017	A: 84.9% NA: 15.1%	HBC (14 items assessed by Likert scale)	A: >80% NA: ≤80%	Good
Nepal	Bhandari et al^Citation51	2015	A: 56.5% NA: 43.5%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
The Netherlands	Morrison et al^Citation17	2015	A: 75.9% NA: 24.1%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥1 Yes	Good
	Van Onzenoort et al^Citation52	2010	A: 91.6% NA: 8.4%	Monitoring the medication box’s opening every 24 hrs, by MEMS^® track cap	A: medication box opened in >90% of the days	Good
Nigeria	Adeyemo et al^Citation53	2013	A: 77.0% NA:33.0%	Pill counting (pills taken/pills prescribed) + Urine detection	A: Miss less than 2 doses or drug detected in urine	Good
	Iloh et al^Citation54	2013	A: 42.9% NA: 57.1%	5 items questionnaire (0 to 4 points)	A: 4 points NA: <4 points	Sufficient
	Okwuonu et al^Citation55	2014	A: 7.5% NA: 92.5%	MMAS-8 (7 Y or N + 1 Likert scale)	No information	Sufficient
	Okwuonu et al^Citation56	2015	A: 31.8% NA: 68.2%	MMAS-8 (7 Y or N + 1 Likert scale)	A: >4 points NA: <4 points	Good
Pakistan	Arshad et al^Citation57	2015	A: 70.7% NA: 29.3%	MMAS-4 (Y or N)	A: 0 Yes NA: ≥1 Yes	Good
	Hashmi et al^Citation58	2007	A: 77.0% NA: 23.0%	Pills taken in a period of time/Pills prescribed in the same period of time	A: ≥80% NA: <80%	Good
	Saleem et al^Citation59	2012	A: 0.0% NA: 100.0%	DAI-10 (10 Y or N, scoring between 10 and −10)	A: ≥6 points NA: <6 points	Good
Peru	Rodríguez-Abt et al^Citation60	2017	A: 46.7% NA: 53.3%	MBG (12 questions with a 5 option Likert scale, scoring between 0 and 48)	A: 38 to 48 points NA: 0 to 37 points	Good
Poland	Jankowska-Polan et al^Citation61	2016	A: 36.4% NA: 63.6%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Very Good
	Morrison et al^Citation17	2015	A: 42.4% NA: 57.6%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
	Wilinski et al^Citation62	2013	A: 26.0% NA: 74.0%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Sufficient
Portugal	da Costa et al^Citation63	2015	A: 54.6% NA: 45.4%	MMAS-7 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Sufficient
Spain	Baena-Díez et al^Citation64	2011	A: 48.7% NA: 51.3%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
	Calderón-Larrañaga et al^Citation65	2016	A: 79.8% NA: 20.2%	MPR (by questionnaire)	A: >80% NA: ≤80%	Good
Sudan	Omar et al^Citation66	2018	A: 70.5% NA: 29.5%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 0 to 2 Yes NA: ≥3 Yes	Good
Sweden	Qvarnström et al^Citation67	2013	A: 65.0% NA: 35.0%	Follow-up of medicines purchased in the pharmacy	A: ≤30 days without purchasing prescribed medicines	Good
Turkey	Karaeren et al^Citation68	2009	A: 72.0% NA: 28.0%	Questionnaire	No information	Sufficient
	Karakurt et al^Citation69	2012	A: 42.1% NA: 57.9%	Questionnaire	No information	Sufficient
United Arab Emirates	Bader et al^Citation70	2015	A: 54.4% NA: 45.6%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
	Fahey et al^Citation71	2006	A: 52.0% NA: 48.0%	MMAS-7 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
United Kingdom	Horne et al^Citation72	2010	A: 45.0% NA: 55.0%	MARS-6 (6 items with Likert scale, scoring between 6 and 30)	No information	Sufficient
	Morrison et al^Citation17	2015	A: 58.5% NA: 41.5%	MMAS-4 (Y or N)	A: 0 or 1 Yes NA: >1 Yes	Good
United States Of America	Fortuna et al^Citation73	2018	AT: 29.7% NA: 70.3%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Sufficient
	Grigoryan et al^Citation74	2012	A: 65.4% NA: 34.6%	Monitoring of taken dose in 30 days, by MEMS^® track cap	A: ≥80% NA: <80%	Sufficient
	Haley et al^Citation75	2016	A: 38.8% NA: 61.2%	MMAS-8 (7 Y or N + 1 Likert scale)	A: 8 points NA: <8 points	Good
	Pittman et al^Citation76	2010	A: 74.6% NA: 25.4%	MPR (by questionnaire)	A: ≥80% NA: <80%	Sufficient
	Roberts et al^Citation77	2014	A: 52.0% NA: 48.0%	PDC (by clinical records)	A: ≥80% NA: <80%	Good
	Roberts et al^Citation77	2014	A: 52.0% NA: 48.0%	PDC (by clinical records)	A: ≥80% NA: <80%	Good
	Whittle et al^Citation78	2016	A: 71.2% NA: 28.8%	In an interview, participants report the medication taken so far	A: ≥80% NA: <80%	Sufficient

Abbreviations: A, Adherence; NA, Non-Adherence; Y/N, Yes or No; MMAS, Morisky Medication Adherence Scale; QAM-Q, Questionário de Não-Adesão a Medicamentos da Equipa Qualiaids; MPR, Medication Possession Ratio; MEMS, medication events monitoring systems; PDC, proportion of days covered; BMQ, brief medication questionnaire; HBC, Hill-Bone Compliance Scale; DAI-10, the drug inventory; MBG, Martin-Bayarre-Grau Questionnaire; MARS-6, medication adherence report scale.

Table 2 Correlation Between The Determinants Of Organization Of Healthcare Systems And Adherence To Therapy In Patients With Arterial Hypertension

	All Countries		European Countries
	All Methods	MMAS	All Methods	MMAS
Mean Consultation Time (Minutes)	0.140	0.170	−0.011	−0.018
	(0.401)	(0.409)	(0.972)	(0.960)
Hospital Beds (per 10,000 Inhabitants)	0.248	0.188	0.198	0.200
	(0.185)	(0.402)	(0.517)	(0.580)
Number Of Doctors (Per 1000 Inhabitants)	0.587	0.460	0.581	0.358
	(0.001)	(0.031)	(0.037)	(0.310)
Number Of Nurses (Per 1000 Inhabitants)	0.394	0.387	0.467	0.733
	(0.031)	(0.075)	(0.108)	(0.016)
Number Of Pharmacists (Per 1000 Inhabitants)	0.339	0.144	−0.324	−0.418
	(0.067)	(0.523)	(0.280)	(0.229)
Health Expenditure (% GDP)	0.289	0.279	0.742	0.879
	(0.115)	(0.198)	(0.004)	(0.001)
Health Expenditure (Per Capita)	0.334	0.316	0.819	0.939
	(0.071)	(0.152)	(0.001)	(0.000)
Out-Of-Pocket Expenditure (Per Capita)	0.233	0.141	0.368	0.200
	(0.215)	(0.533)	(0.219)	(0.580)
General Government Expenditure (%)	0.247	0.197	0.670	0.855
	(0.189)	(0.379)	(0.012)	(0.002)

Notes: Calculated spearman correlations (ρ). The value in brackets corresponds to the significance (P), considering a bilateral distribution.

Abbreviations: MMAS, Morisky Medication Adherence Scale; GDP, Gross Domestic Product.

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