Chapter I

Introduction

Rationale

Hypertension is considered as the biggest single risk factor for deaths worldwide.
According to the World Health Organization (WHO), hypertension causes 7 million deaths every
year while 1.5 billion people suffer due to its complications.(Philippine Council for Health
Research and Development. n.d.).
.

In the Philippines, the Department of Health (DOH) reports that about eight out of ten
people who had their first stroke are diagnosed with hypertension. More than 276 Filipinos die
of heart disease daily and at least one Filipino suffers from stroke every nine minutes. The
Philippine Society of Hypertension (PSH) also reported that 21 percent of Filipinoadults are
hypertensive. (Philippine Council for Health Research and Development. n.d.).

Since hypertension is the major cause of heart disease and stroke, it is clear that one of
the biggest challenges facing public health authorities and medical practitioners is the control of
hypertension, both in individual patients and at the population level.

Compliance with treatment with appropriate medication is a key factor in the control of
hypertension and reduction in associated risk of complications.

The European Society of Cardiology reported in a study published in the European Heart
Journal in 2013 which involved 73,527 patients with hypertension found that patients who did
not adhere to their medication had a nearly four-fold increased risk of dying from stroke in the
second year after first being prescribed drugs to control their blood pressure, and a three-fold
increased risk in the tenth year, compared with adherent patients. (European Society of
Cardiology,2013).

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 By definition, compliance with treatment is defined and characterized when medical or
health advice coincides with the individual's behaviour with regard to the use of medication,
recommended changes in lifestyle, and attendance to medical appointments. (Osamor and
Owumi, 2011).

Quantitatively, although there is no consensus, adherence to medications is understood as

use of the prescribed medication at least 80% of the time, including hours, doses and length of
treatment. Patients with a use less than 80% present four times the risk for acute cardiovascular
risks. (Ben, Neumann and Mengue, 2012,Mahmoud, 2012)

Poor compliance with treatment can lead to uncontrolled blood pressure. A study
(Osamor and Owumi, 2011) reported that studies in the United States revealed that more than
50% of patients who were prescribed antihypertensive medications actually discontinued therapy
within 12 months. Reasons for stopping medication were related to adverse effects, patient's
knowledge about the disease, attitudes regarding treatment of an often asymptomatic condition,
and personal health beliefs, together with cost of medications and availability of healthcare.

The same study pointed out that many patients stopped taking the medicines if they feel
well. The socio-economic status of the patients was also considered a factor, since patients with
low economic status had to direct their limited resources available to meet the needs of other
family members such as children and parents instead of procuring their medicines. Other factors
included low level of education, unemployment, lack of effective social support networks,
unstable living conditions, long distance from treatment centers, high cost of transport, cultural
and lay beliefs about illness and treatment, and forgetfulness. (Osamor and Owumi, 2011).

There are several studies in many countries that have expounded on the factors that affect
compliance of medication treatment for hypertension. These will be pointed out in the review of
literature of this paper. However, in the Philippines, a search in the internet shows that there are
no published studies in the Philippines or in Cebu Province that study the factors that contribute
to the compliance of medication therapy among hypertensive patients.

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 An article in the Philippine Star, June 9, 2012, written by Ocampo, summarized a study
conducted in March 2012 in selected hospitals in National Capital Region by the Consumers
Action for Empowerment, a nongovernmental group involving health and social workers. The
article revealed that the study reported that out of 840 respondents, 99.8% underwent long-term
treatment including treatment for hypertension, or were required to take at least one weeks
dosage of medicines but actually didnt have the means to pay for their complete treatments.

Locally, an unpublished study (Grecia et.a., 2013) that identified factors that affect the
compliance of anti-hypertensive medications among 80 hypertensive patients who were admitted
in Vicente Sotto Memorial Medical Center, a government tertiary center in Cebu City in January
2013, reported that majority of the respondents did not comply with treatment due to insufficient
means to pay for their medications and reasons related with their behavioral practices and
beliefs. (Grecia, et al. 2013).

Insufficient means to pay for their medication must be seen in the light of efforts of the
Philippine government to bring down the cost of medicines, including medicines for
hypertension and cardiovascular diseases so they can be made affordable to the majority of the
Filipinos. Republic Act 9502 or the Universally Accessible Cheaper and Quality Medicines Act
of 2008 was enacted for this purpose which has resulted to the proliferation of cheap generic
anti-hypertensive medicines.

This study is therefore the first study that aims to investigate the level of compliance of
treatment for hypertension and the factors that contribute to it among hypertensive patients in
selected health centers in Cebu City. If compliance is a problem, recommendations can be made
to address the factors associated with it in order to ultimately bring down the morbidity and
mortality rates due to hypertension and its complications.

In this study, compliance of treatment shall be determined through the Morisky

Medication Adherence Scale (MMAS-8). Knowledge on hypertension shall be assessed in a
questionnaire used in the study by Barreto MS, Reiners AAO, Marcos SS (2014). Reasons for
non-adherence are assessed in questionnaire developed by Malik A, Yoshida Y, Erkin T, Slim D

3
and Hamajima N. (2014). The socio-demographic profile variables of age, sex, education
status, income, and marital status shall be related with the level of compliance and level of
knowledge. The level of knowledge shall also be related with the level of compliance.

Statement of the problem

The aim of this study is to assess the level of compliance to treatment and identify
factors which contribute to treatment compliance among hypertensives in selected health centers
in Cebu City.

Specific objectives

1. To determine the socio-demographic profile

a. age
b. sex
c. civil status
d. education status
e. work status
f. income
2. To determine the scores of the respondents in the Morisky Medication taking
Adherence Scale (MMAS -8)
3. To determine the percentage of respondents and their level of compliance or adherence
as to high, average and poor based on the MMAS-8.
4. To determine the level of knowledge on hypertension as satisfactory or dissatisfactory
based on a standardized 10-item questionnaire
5. To determine the reasons of non-compliance regarding psychology and knowledge
factors, social-economic factors, and therapy-related factors in an eight-item
questionnaire.
6. To relate the socio-demographic profile variables with the level of compliance.
7. To relate the socio-demographic profile variables with the level of knowledge on
hypertension

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8. To relate the level of knowledge with the level of compliance.

Significance of the study

It is an established fact that compliance of treatment is necessary in the control of

hypertension which leads to improved morbidity and mortality. However, many foreign studies
have reported that many hypertensive patients do not comply with the prescribed regimens or
drop out of treatment. When this happens, all previous efforts expended in detection, diagnostic
work-up, follow-up and treatment of the patients are wasted.

Previous foreign studies conducted have identified that compliance of medication among
hypertensive patients is a multi-factorial behavior. One factor is the lack of knowledge and
understanding among hypertensive patients of the need to maintain taking their medicines. If
this study supports this factor among patients in Cebu |City, local recommendations can be made
on how health professionals can better relate with their patients to enhance such knowledge and
understanding necessary for compliance of their medications.

Since non-compliance is also attributed to the lack of the means to buy the medications,
recommendations can be made on the need for massive information dissemination on the prices
of many anti-hypertensive medications that have become very cheap and affordable so that both
medical doctors and patients may know.

Ultimately, the study envisions that the implementation of effective strategies to address
the problem of non-compliance of anti-hypertensive and other cardiovascular medications will
lead to a reduction of the mortality rate due to cardiovascular diseases.

Definition of terms

1. Socio-demographic profile
a. Age age in years as of last birthday
b. Sex male or female

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 c. Civil status
i. single
ii. married (legally married or living with common-law partner)
iii widow
d. Education status
i. never went to school
ii. elementary graduate or undergraduate
iii. high school graduate or undergraduate
iv. college graduate or undergraduate
v. TESDA/vocational
vi, post graduate
e. Work status
i. currently working
ii. currently not working but not of retirable age
iii. retired

f. Income
i. no income
ii. lower lower than P 5,000 a month
iii.lower middle 5,000 to 10,000
iv.middle 10,000 to 20,000
v. upper middle 20,000 to 50,000
vi. upper more than 50,000

2.Morisky Medication Adherence Scale (MMAS-8)is the best known and most widely used
scale that identifies barriers to nonadherence. It is the shortest, easiest to score and very
adaptable for various groups of medication. MAQ identifies barriers to nonadherence but
not self-efficacy.It is developed by Morisky et al. (Oliveira-Filho AD, Barreto-Filho JA,
Neves SJF, de Lyra DP, 2012)).

3. Level of compliance or level of adherence based on the scores of theMorisky Medication

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 Adherence Scale (MMAS-8). (Oliveira-Filho AD, Barreto-Filho JA, Neves SJF, de Lyra
DP, 2012). The level of compliance is determined according to the score resulting from
the sum of all the correct answers: high adherence (eight points), average adherence (6 to <
8 points) and poor adherence (< 6 points).

4. Level of knowledge on hypertension. The knowledge about the disease shall be determined
using a questionnaire with 10 questions, with dichotomous answers (yes/no) used in the study
by Barreto MS, Reiners AAO, Marcos SS (2014). Through the instrument, people who
answers all the questions correctly receive a score 10 (100%) and those who answer them all
receive a zero. The knowledge isconsidered satisfactory for those with scores equal or above
seven (70%) and dissatisfactory for the others in this investigation.

5. Reasons for non-adherence. There are eight reasons for non-adherence in a questionnaire
used in the study by Malik A, Yoshida Y, Erkin T, Slim D and Hamajima N. (2014), which
are divided into three factors, namely, psychology and knowledge factors, social-economic
factors, and therapy-related factors.

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 Chapter II
Review of Related Literature

Hypertension is a major risk factor for stroke and coronary heart disease. Compliance to
treatment regimen is essential to achieve effective care and control of hypertension. In the
United States, it is estimated that noncompliance rates with prescribed therapeutic regimens
among patients diagnosed with hypertension range from 30% to 60%, and at least 50% of
patients for whom drugs are prescribed failed to receive full benefit through inadequate
compliance. With noncompliance, the patients health outcomes are sacrificed and lead to costly
treatment for the complications of untreated or inadequately treated hypertension.
Unfortunately, physicians are not routinely assessing patients compliance level and patients
rarely volunteer this information to their physicians. (Kim et al. 2000).

The first line of treatment for hypertension is preventive lifestyle changes and medication
and maintaining good compliance. Patient compliance is defined as the extent to which a
persons behaviour in terms of taking medication, following diet, or executing life-style changes
coincides with medical or health advice. Compliance can be viewed as a patients behaviour in
terms of timeliness in seeking care, attendance at follow-up appointments or observance of the
physicians advice. As compliance improves the outcome of hypertension, understanding its
pattern is an important step in evaluating the effect of a hypertension treatment regime. It is usual
to consider patients to be sufficiently compliant with their treatment when they take at least 80%
of their prescribed anti-hypertensive drugs. (Mahmoud, 2012).

Factors affecting compliance of treatment

Many studies have been conducted on the factors that affect compliance of medications
among hypertensive patients.

Al-Mehza et al. (2009) conducted a study among 132 hypertensive patients in Kuwait. It
reported that 17% of the 84 (64% of 132 subjects) who had uncontrolled hypertension were non-
compliant by pill count as compared to 2% of the controlled hypertensives. Lack of knowledge

8
was associated with non- compliance. There was no statistically significant difference in the
age, sex, civil status and nationality, duration of hypertension and presence of complication rates
between compliant and non -compliant hypertensives. Reasons for non-compliance included lack
of knowledge about hypertension, forgetfulness, drugs side effects, shortage of drugs, and the
asymptomatic nature of hypertension.

A study Hadi and Rostami-Gooran (2004) conducted among 532 hypertensivepatients in

Shiraz, Iran said that patients medication compliance is a multi-factorialbehavior. Having a
good understanding of hypertension, a positive attitude towardsantihypertensive drugs, shorter
intervals between visits of doctors, complications due tohypertension, using other drugs and
taking anti-hypertensive drugs for more than five yearswere factors associated with medication
compliance.

A study by Mahmoud (2012) among hypertensive patients attending primary health

centers in Saudi Arabia reported that factors that affectedpatients compliance were their sex, level of
education, workstatus, smoking habits, self-reported response to medications and theirperception of
hypertension. Most of the women showed poor compliance; 86% of these had received only
basic education, but 84.7% of those with higher education were also poorly compliant. Only
12.4% of those who had jobs and 13.5% of married participants showed good compliance. Only
9.7% of non-smokers had fair-to-goo compliance and 83.0% of people with co-morbid condition
had poor compliance.

A study by Kamran et al. (2014) in Iran found out that adherence to hypertension
medications was found to be higher in age groups 30-39 years and above 60 years when
compared to other age groups. Adherence was slightly high among female respondents than male
respondents. Similarly, the married respondents have more adherence to hypertensive medication
compared with unmarried, but these differences were not significant. Furthermore, adherence
was significantly higher among respondents taking only one medication 145 (90%), once daily
130 (80.7%) compared to individuals taking four types of medication, 35 (21.7%) and as
frequent as three or more times a day, 33 (20.4%). Thus, adherence increased with a decrease in
number and frequency of medication.

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 A study done by Gascon et. al. (2004) using focus group discussions among 44
hypertensive patients in Spain who were not compliant, gathered beliefs and attitudes toward
antihypertensive drugs, about hypertension, and their clinical encounters with their physicians.
The patients expressed fears and negative feelings about the long-term use of antihypertensive
medication which were perceived as having bad effects on the body. Some patients who did not
always take medication as prescribed, thought that it was perfectly safe not to, and because they
forgot it, and, basically, because they felt well. For some patients, taking the medicine for a long
time caused boredom and made them drop out. Others also resorted to herbal or natural
remedies. Some patients knew that having elevated blood pressure had well-recognized familiar
symptoms so that absence of the latter meant for them that their blood pressure was controlled
and there was no need to take medicines. On clinical encounters with their physicians, some
patients complained that most of the time of the consultation was just to have a prescription and
little time on education about their illness, so that some patients believed that their physicians
were always very busy. Other patients also complained that their physicians asked few questions,
spent time just taking down notes and spoke and wrote in language difficult to understand.

A study by Jokisalo et. al., (2002) among 1561 hypertensive patients in Finland studied
the associations of factors related with perceived health care system-related problems and
patient-related problems to non-compliance. The perceived health care system-related problems
included lack of follow-up by health center, perceived lack of information, perceived lack of
support by health care personnel, problems with practical aspects of hypertension care, problems
with scheduling blood pressure measurements, and lack of special reimbursement for
medication. Patient-related problems included difficulties to accept being hypertensive, careless
attitude towards hypertension, hopeless attitude towards hypertension, perceived tension related
to blood pressure measurement, perceived economic problems and frustration with treatment.

The majority of patients reported having one or more perceived health care system-
related problems (88%) and patient-related problems (92%). Those with high levels of perceived
health care system-related problems were almost four times more likely to be non-compliant.
Moreover, those with high levels of patient-related problems were over two times more likely to
be non-compliant. Patients who had experienced adverse drug effects were significantly more

10
likely to be non-compliant (17%) than those without adverse drug effects (11%). Furthermore,
among patients who used two anti-hypertensive drugs, non-compliance was more prevalent
among the less educated than among the more educated.

A study by Osamor (2011) in Southwest Nigeria showed that respondents who were non-
compliant to medication said that they had no symptoms and, therefore, had no need to continue
taking their medication. Other factors included forgetfulness, lack of funds to purchase drugs ,
side-effects of drugs and having a busy schedule but limited medication. Others said that they
were tired of taking drugs. When the respondents perceived forgetting to take medication and
side- effects of treatment as problematic, they were less likely to comply with treatment.

In the study by Kamran et. al (2014), adherence was significantly higher among
respondents taking only one medication, once daily compared to individuals taking four types of
medication and as frequent as three or more times a day. Thus, adherence increased with a
decrease in number and frequency of medication.

Bilal et al. (2015) conducted a study 113 hypertensive patients in Karachi, Pakistan in
2011. The study revealed that non-compliance was found to be more prevalent among females
more than males, unemployed persons and those in the low socioeconomic status. Regarding
medicine related factors, non-compliance was higher among those who were taking medicine for
less than five years than more than five years, and those taking mono therapy and di therapy than
three or more medicines.

Non-compliance is reported greatest among patients who paid themselves for their
medicines than those whose medicine paid by family or others. Around 50% were non-
compliant due to lack of counselling by physician not only for medication but also for life style.
The study did not find adverse drug effects as a primary reason for poor compliance to anti-
hypertensive medications. Finally, non-compliance was found to be high in patients who visited
the doctors after a prolong period of time.

A study by Krzesinski and Leeman (2011) found out that unsatisfactory compliance in
the treatment of high blood pressure is frequently due to sequential barriers, such as insufficient

11
patient education about the illness and low motivation to receive any treatment, existence of a
large gap between physicians' perceptions of the problem and clinical reality, complexity of the
treatment potentially generating adverse effects, and a health care environment with few public
education campaigns and incentives for better coordinated supportive care.

Interventions to address compliance

Compliance with treatment to antihypertensive medication to achieve blood pressure

targets does not only consider the side of the patients. Physicians play a crucial role to ensure
that their patients comply with their treatment. Physicians must make appropriate treatment
choices and optimize doses of medicines for individual patients to ensure success of therapy.
Thus, health professionals need to work in partnership with their patients to achieve treatment
goals. (Ramli, 2012)

Krzesinski J, Leeman M ( 2011) study suggested three ways on how to improve drug
compliance where the doctor plays an essential role. Their first suggestion was to have a good
doctorpatient relationship with regular education of the patient about hypertension and its risks,
discussion about adverse drug effects, and the complexity and cost of treatment. Second, the
doctor should offer convenient appointments and tailor the treatment regimen to the patient's
lifestyle and needs, with written instructions. Third, the doctor should promote active patient
collaboration with treatment. The doctor can come up with an innovative combination of home
self-measurement of blood pressure, use of new technology options, (e.g. texting or
telemedicine), and creation of a multidisciplinary working team to handle the patient. The study
also suggested the establishment of personalized plans adapted to each patient.

Doctors should be aware of the problem of noncompliance and its consequences in their
hypertensive patients. Drug regimens should be kept as simple as possible and directions as clear
as we can make them. The fewer the medications, and the less often they need to be taken, are
important considerations. Human frailty being what it is, people will make errors anyway.
Patients, doctors and nurses are all prone to error in drug administration and, if a patient is not
responding to treatment, investigation of the possibility of noncompliance is mandatory, and

12
possible reasons for this unearthed. It seems reasonable that doctors and other health care staff
should talk to patients about drug treatment. It may be that, in some patients, long-term
antihypertensive therapy is unnecessary and this aspect merits serious investigation.
(Breckenridge, 1983)

Kabir (2004) encouraged doctors to consider the financial status of their patients in
prescribing antihypertensive drugs to enable affordability. The study pointed out that prescribing
an effective, inexpensive, single dose daily medication with minimal side effects will improve
patient compliance considerably.

Furthermore, the health care delivery system should be designed to provide minimal
waiting times for patients, appointment reminders, and rapid responses to missed appointments.
Use of treatment algorithms, guidelines, or both in the primary care setting can facilitate therapy.
Not only physicians but also other healthcare professionals including nurse clinicians, physician
assistants, dieticians, nutritionists, and pharmacists have an important role in the education and
monitoring of hypertensive patients. (Chobanian, 2009)

Hand in hand with physicians and other clinical staff, patients need to get involved in
decision making on their treatment to improve their compliance with medical advice, rather than
being mere passive recipients of medical advice. A study done by Ross, Walker and MacLeod
(2004) in the United Kingdom suggested that exploring the health beliefs of patients may be
important in achieving the involvement of patients in decision-making. These health beliefs are
a possible target for interventions to improve compliance and thereby blood pressure. It may
even be possible to make changes at a population level by changing the perceptions of illness and
medication in society. This could in turn improve population blood pressure control.

Going beyond the confines of the clinic and hospital, society should get involved in
addressing the problem of noncompliance.

Kabir (2004) in a study among hypertensive patients in a hospital in Nigeria found that
there is a need for launching a comprehensive approach involving health care providers, patients

13
and the general public to educating patients on the need to take their drugs regularly and in the
manner prescribed. They also suggested that prices of anti-hypertensive drugs should be
subsidized where possible.

Measuring medication adherence

In order to address adherence to the medical regimen in the management of patients with
essential hypertension, it is important for physicians and other health professionals to be able to
measure patient medication adherence to improve health outcomes.

Various methods have been utilized to evaluate low adherence, such as self-report, manual
and electronic counts of medication, retrieval of medication from pharmacies, laboratory tests for
pharmaceuticals or metabolites of pharmaceuticals, and questionnaires. (Ben, Neumann and
Mengue, 2012)

Despite low sensitivity and accuracy, self-report scales or questionnaires are more often
utilized due to low cost and ease of application in large populations to measure adherence to
medications.

An article by Culig and Leppee (2014) describes various self-report scales by which to
monitor medication adherence, their advantages and disadvantages, and discusses the
effectiveness of their application at different chronic diseases. However, there is no gold-
standard scale for measuring medication adherence but the nearest to gold-standard is the
Morisky Medication Adherence Scale (MMAS-8) by Morisky et.al.

Morisky Medication Adherence Scale (MMAS-8)

The Morisky Medication Adherence Scale (MMAS-8) (see annex D) by Morisky et al.
(Oliveira-Filho AD, Barreto-Filho JA, Neves SJF, de Lyra DP, 2012), is the best known and
most widely used scales for medication adherence. It identifies barriers to nonadherence, is the
shortest, easiest to score and very adaptable for various groups of medication. The questions
address barriers to medication-taking and information can be used to educate patients on the need

14
for medication adherence.

The MMAS-8 is an updated version of the four-item scale published in 1986with a

greater sensitivityto determine adherence. It contains eight questions with closed dichotomous
(yes / no answers, a yes is equivalent to one point and a no is equivalent to zero point). It is
designed to prevent the bias of positive responses from patients questions asked by health
professionals, by reversing the responses related to the interviewee's adherence behavior. Thus,
each item measured a specific adherence behavior. The first seven questions are answerable by
yes or no. Except for the fifth question, a yes answer to the first seven questions will mean
noncompliance of treatment. The eighth question is answerable by never/rarely (0 point), once
in a while (1 point), sometimes (2 points), usually (1 point), and all the time (4 points).

The degree of adherence was determinedin the study by Oliveira-Filho AD, Barreto-Filho
JA, Neves SJF, de Lyra DP (2012) according to the score resulting from the sum of all the
correct answers: high adherence (eight points), average adherence (6 to < 8 points) and poor
adherence (< 6 points). In this study, the level of compliance is determined according to the score
resulting from the sum of all the correct answers: high adherence (eight points), average
adherence (6 to < 8 points) and poor adherence (< 6 points).

Conceptual Framework

The Health Belief Model (HBM) is a psychological model that attempts to explain and
predict health behaviors by focusing on the attitudes and beliefs of individuals. The HBM was
first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working
in the U.S. Public Health Services. The model was developed in response to the failure of a free
tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a
variety of long- and short-term health behaviors, including sexual risk behaviors and the
transmission of HIV/AIDS. (University of Twente.n.d.)

The persons health behavior depends on his perception of four critical areas, namely, the
severity of a potential illness, the persons susceptibility to that illness, the benefits of taking a
preventive action, and the barriers to taking that action. (Nursing theories, 2012).

15
 HBM enables us to understand and predict how patients will behave in relation to their
health and how they will comply with health care therapies.The model was used in several
studies investigating the factors on compliance of treatment with hypertension and in coming up
with interventions to address non-compliance. (Kamran, Kamran A, et.al. 2014, Newell
M, Modeste N, Marshak HH, Wilson C. 2009, Onoruoiza SI, Mus A, Dangani B. Kunle YS.,
2015, and Barros AA et al. , Guedes MVC, Moura DM, 2014).

In this study on compliance on treatment for hypertension, the model can help the
researchers understand and explain the factors related with non-compliance of treatment.

16
 Chapter III
Methodology

Research design

The study is a cross-sectional study that investigates the compliance of treatment among
selected hypertensive residents who seek consultation in fiveselected health centers in Cebu City.
A total of 384 respondents shall be enrolled using the consecutive sampling method.

After obtaining informed consent, the subjects will be administered a questionnaire on

socio-demographic profile composed of age, sex, education status, income, and marital status,
level of knowledge on hypertension, the Morisky Medication Adherence Scale (MMAS), and
reasons for non-adherence.

The answers to the questionnaire shall be tabulated, collated and interpreted. The Chi-
square test will be used in assessing the significance of associations between the socio-
demographic variables and the level of compliance, between the variables and the level of
knowledge, and between the level of knowledge and level of compliance.

Research environment

The study shall be conducted in the following health centers in Cebu City, namely:
Mabolo, Pardo, Barrio Luz, Punta Princesa and Parian.

Research subjects/respondents

A total of 384 respondents shall be enrolled using the consecutive sampling method, that
is, as many hypertensive patients as possible shall be selected until the 384 quota is reached. The
384 respondents shall be equally divided among the five health centers, with 77 respondents per
center.

17
 The inclusion criteria include, adults with ages 30 years above, Filipino, male and female,
who seek consultation in the health centers during the study period, are diagnosed hypertension
for at least six months prior to the study by blood-pressure measurements by a health
professional, and taking medications for hypertension for at least the past six months. The only
exclusion criteria is refusal to participate.

As much as possible, the researchers themselves will enroll the subjects personally in the
health center when they visit the center for check-up. However, if it will be known that there are
only very few hypertensive patients seeking consultation in the health center and considering the
time constraints of the researchers to go to the health centers as well as the limited time for the
data gathering, the researchers will ask the health center personnel to select the respondents
either in the health center or locate the hypertensive patients in their homes and administer the
questionnaire.

Research instrument

The subjects will be administered a questionnaire composed of four sections, namely, (1)
socio-demographic profile composed of age, sex, education status, civil status, work status, and
income, (2) knowledge on hypertension, (3) Morisky Medication Adherence Scale (MMAS-8),
and (4) reasons for non-adherence.

Research procedure

1. Letter to the Cebu City Health Officer. A letter shall be personally given to the Cebu
City Health Officer of the Cebu City Health Department in order to inform him of the research
and to ask him for his approval to conduct the study in Cebu City and support by endorsing the
researchers to the barangay captains and barangay health center physician or public health nurse
so that they can have their midwives and barangay health workers assist the researchers in the
survey.

18
 2. Letter to the barangay captain of the selected barangays. A letter shall be personally
given to the barangay captain of the selected barangays to inform him of the research and to ask
his approval to conduct the study in his barangay and his support by endorsing the researchers to
the respective health center personnel.

3. Selection of respondents. A visit to the barangay health center shall be conducted to

orient the health personnel about the study and to ask them to help in the data gathering. As
much as possible, the researchers themselves will enroll the subjects personally in the health
center when they visit the center for check-up. However, if it will be difficult to have
hypertensive patients in the health center during their visits, the researchers will ask the health
center personnel to select hypertensive patients in the researchers absence in other days or locate
the hypertensive patients in their homes and administer the questionnaire. In this case, the
researchers shall give instructions on the administration of the questionnaire to the health center
personnel and leave the questionnaires there with them and agree when to collect them back.
The content of the questionnaire shall be thoroughly explained to the health center personnel and
ethical considerations shall also be ensured.

4. Getting the informed consent. Once a candidate respondent who fulfills the inclusion
criteria, he will be given the informed consent form, the content of which will be thoroughly
explained to him. Once he agrees to participate in the study, he will be asked to sign the
informed consent.

5. Administering the questionnaire. During the answering of the questionnaire, the

researchers or the health center personnel will assist the respondents for clarifications. The
confidentiality of the data will be assured.

Data processing and analysis

All data from the questionnaires will be input on a Micosoft Excel file and analyzed.A p-
value of 0.05 or less will be considered statistically significant.Spearmans correlation will be
used to obtain the p-value.

19
 Simple percentages and the mean and standard deviation of the questions on socio-
demographic profile, MMAS, knowledge on hypertension and reasons for non-adherence shall
be computed and statements shall be made when appropriate. Scoring of the MMAS shall be
done to arrive at the level of compliance. The level of compliance is determined according to the
score resulting from the sum of all the correct answers: high adherence (eight points), average
adherence (6 to < 8 points) and poor adherence (< 6 points).

The level of knowledge about hypertension shall be determined by adding the correct answers.
Those who answer all the questions correctly receive a score 10 (100%) and those who answer
them all incorrectly receive a zero. The knowledge is considered satisfactory for those with
scores equal or above seven (70%) and dissatisfactory for the others. All questions are correctly
answered with yes, except for question number two which is correctly answered with no, since
hypertension is most often a silent disease.

The Chi-square test will be used in assessing the significance of associations between the
socio-demographic variables and the level of compliance, between the socio-demographic
variables with the level of knowledge, and between the level of knowledge and level of
compliance.

Ethical considerations

This study will be conducted in accordance with the Declaration of Helsinki for biomedical
research involving human subjects. Approval of the study shall be obtained from the Institutional
Review Board of the University of the Visayas. Permission will be obtained from the Cebu City
Health Officer and the respective barangay captains to conduct the study in their areas.

An informed consent based on the template by the World Health Organization will be
obtained from the respondents prior to administering the questionnaires. No respondent will be
coerced to be a part of the study and confidentiality and privacy will be observed all throughout
the conduct of the study. A respondent will be allowed to terminate participation anytime for any
reason. In circumstances wherein respondents will have a misunderstanding of any part of the

20
questionnaire, they will be advised appropriately by the researchers.Each participant of the study
will be assigned with a respondent number in the data form.

All results obtained in this study will be handled with confidentiality. The questionnaires
will be secured by one of the authors in a locked cabinet. Data will be encoded in a room where
no other individuals aside from the researchers can visualize the laptop monitor or the
questionnaires. The laptop will be secured with a password and all electronic documents will be
secured with a password that only the researchers can access.

Flow chart of the study

Permission from the Permission from the

Cebu City Health barangay captain and health Selection of respondents
Officer center personnel

Writing the research Collation and Administration of the

paper interpretation of data questionnaire

21
 References

Websites

Al-Mehza AM, Al-Muhailije FA, Khalfan MM, and Al-Yahya A (2009). Drug Compliance
among Hypertensive Patients; an Area Based Study. Eur J Gen Med 6(1): 6 -
10.http://www.bioline.org.br/pdf?gm09002

Barros AA, Guedes MV, Moura DJM, Menezes LC, Aguiar L, Xavier GA, 2014. Health
behaviors of people with hypertension: health belief model.
www.revistarene.ufc.br/revista/index.php/revista/article/download/1719/pdf_

Barreto MS, Reiners AAO, Marcos SS (2014) Knowledge about hypertension and factors
associated with the non-adherence to drug therapy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292628

Ben AJ, Neumann CR, Mengue SS. (2012). The Brief Medication Questionnaire and Morisky-
Green Test to evaluate medication adherence. http://www.scielo.br/scielo.php?pid=S0034-
89102012000200010&script=sci_arttext&tlng=en

Bilal A, Riaz M, Shafiq NU, Ahmed M, Sheikh S, Rasheed S. (2015).Non-compliance to anti-

hypertensive medication and its associated factors among hypertensives.
http://jamc.ayubmed.edu.pk/index.php/jamc/article/view/1128

Breckenridge A. (1983) Compliance of Hypertensive Patients with PharmacologicalTreatment.

http://hyper.ahajournals.org/content/hypertensionaha/5/5_Pt_2/III85.full.pdf

Chobanian AV. (2009) Impact of Nonadherence to Antihypertensive Therapy.

http://circ.ahajournals.org/content/120/16/1558

Culig J and Leppee M. From Moriksky to Hill-Bone; Self-Reports Scales for Measuring
Adherence to Medication. Coll. Antropol. 38 (2014) 1: 55-
62.http://www.hrcak.srce.hr/file/178674

Gascn JJ, Snchez-Ortuo M, Llor B, Skidmore D and Saturno PJ. (2004). Why hypertensive
patients do not comply with the treatment.
http://fampra.oxfordjournals.org/content/21/2/125.long

Hadi N, Rostami-Gooran N. (2004). Determinant Factors of Medication Compliance in

Hypertensive Patients of Shiraz, Iran. Archives of Iranian Medicine, Volume 7, Number 4, 292
296. http://razi.ams.ac.ir/AIM/0474/0013.pdf

Jokisalo E, Kumpusalo E, Enlund H, Halonen P and Takala J. (2002).

Factors related to non-compliance with antihypertensive drug therapy.
http://www.nature.com/jhh/journal/v16/n8/full/1001448a.html

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Kabir M, Iliyasu Z, Abubakara IS, and Jibrilb M. (2004). Compliance to medication among
hypertensive patients in Murtala Mohammed Specialist Hospital, Kano, Nigeria.
http://www.ajol.info/index.php/jcmphc/article/viewFile/32401/6069

Kamran A, et.al. (2014) Determinants of Patient's Adherence to Hypertension Medications:

Application of Health Belief Model Among Rural Patients.
http://www.ajol.info/index.php/amhsr/article/view/112436/102191

Krzesinski J, Leeman M.(2011). Practical issues in medication compliance in hypertensive

patients.https://www.dovepress.com/practical-issues-in-medication-compliance-in-hypertensive-
patients-peer-reviewed-article-RRCC

Mahmoud M. (2012). Compliance with treatment of patients with hypertension in Almadinah

Almunawwarah: A community-based study.
http://www.sciencedirect.com/science/article/pii/S1658361212000297

Malik A, Yoshida Y, Erkin T, Salim D, Hamajima N. (2014). Hypertension-related knowledge,

practice and drug adherence among inpatients of a hospital in Samarkand, Uzbekistan.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345680/

Newell M, Modeste N, Marshak HH, Wilson C. (2009). Health beliefs and the prevention of
hypertension in a black population living in London. https://www.researchgate.net/.../24252754

Nursing theories (2012). The Health Belief Model.

http://currentnursing.com/nursing_theory/health_belief_model.html

Oliveira-Filho AD, Barreto-Filho JA, Neves SJF, de Lyra DP, (2012). Association between the
8-item Morisky Medication Adherence Scale (MMAS-8) and blood pressure control.
http://www.scielo.br/scielo.php?pid=S0066-782X2012001000011&script=sci_arttext&tlng=en

Onoruoiza SI, Mus A, Dangani B. Kunle YS. (2015). Using Health Beliefs Model as an
Intervention to Non Compliance with Hypertension Information among Hypertensive Patient.
www.iosrjournals.org/iosr-jhss/papers/Vol20-issue9/Version-5/B020951116.pdf

Osamor P. (2011) Factors Associated with Treatment Compliance in Hypertension in Southwest

Nigeria. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259725/

Philippine Council for Health Research and Development. n.d.).Prevalence of hypertension

among Filipinos increasing PSH. http://www.pchrd.dost.gov.ph/index.php/news/2806-
prevalence-of-hypertension-among-filipinos-increasing-psh

23
Philippine Council for Health Research and Development.(n.d.). More than 1B people expected
to have hypertension by 2025. http://www.pchrd.dost.gov.ph/index.php/news/library-health-
news/4941-more-than-1b-people-expected-to-have-hypertension-by-2025

Ramli A. (2012). Medication adherence among hypertensive patients of primary health clinics in
Malaysia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437910/

Ross S, Walker A, and MacLeod MJ (2004). Patient compliance in hypertension: Role of Illness
Perceptions and Treatment Beliefs. Journal of Human Hypertension 18, 607613.
https://www.researchgate.net/publication/8672530_Patient_compliance_in_hypertension_Role_o
f_illness_perceptions_and_treatment_beliefs

University of Twente. n.d. Health_Belief_Model.

https://www.utwente.nl/cw/theorieenoverzicht/Theory%20Clusters/Health%20Communication/

Unpublished studies

Grecia IB, (2013).Cosep CO, Cuadra PMA, Gidayawan KRV, Hadjula MN, Mercado HY,
Pacharasetethasakul KP. Supnet EM. Factors affecting the compliance of anti-hypertensive
medications among hypertensive patients admitted in Vicente Sotto Memorial Medical Center.
Paper available in Gullasd College of Medicine library.

Newspaper articles.

Ocampo, S. (2012). Survey on Accessibility, Affordability and Availability of Medicines.

Philippine Star, June 9, 2012.

24
 Annex A
Letter to the Cebu City Health Officer

Gullas College of Medicine

UNIVERSITY OF THE VISAYAS
Banilad, Mandaue City
Tel No. 346-4224 Telefax 345-2159

Cebu City Health Officer

Cebu City

Dear Sir/Madam:

Greetings!

The second year medical students of the Gullas College of Medicine of the University of
the Visayas are currently conducting five researches in compliance with their course
requirements in the subject Preventive and Social Medicine. The researches shall have Cebu City
as the research setting. They include the following, namely:

1. Hypertension-related knowledge and drug compliance among hypertensive patients in

selected health centers in Cebu City
2. Compliance of treatment among patients with tuberculosis in selected health centers in
Cebu City
3. Knowledge, attitudes practices regarding dengue fever in selected barangays in
Cebu City
4. Knowledge, attitudes and practices regarding family planning among married
women in Cebu City
5. Enhancing the role of barangay health workers in the prevention of dengue in hotspot
areas in Cebu City.

We have chosen these topics because they are of relevant public health concerns. We
shall furnish copies of the completed researches to your office in the hope that they can be of use
in your programs. The researches have all been approved by the Institutional Review Board of
the University of the Visayas.

There are five groups of students, each group which is composed of five to six members,
shall conduct one research. They shall conduct the researches in the following barangays,
namely: Mabolo, Barrio Luz, Punta Princesa, Parian, and Pardo this coming February 2017.

25
 May we ask your support in this undertaking of the students by endorsing them to the
health center personnel in the above barangays so that they can help them in conducting the
studies and looking for research respondents to answer the study questionnaires.

Thank you very much for your kind support.

Respectfully yours,

Erlinda Y. Posadas, M.D.

Research adviser
Noted by:

Ray C. Perez, M.D.

Dean, Gullas College of Medicine

26
 Annex B
Letter to the Barangay Captains

Gullas College of Medicine

UNIVERSITY OF THE VISAYAS
Banilad, Mandaue City
Tel No. 346-4224 Telefax 345-2159

Hon. ________
Barangay captain, Barangay
Cebu City

Dear Sir/Madam:

Greetings!

The second year medical students of the Gullas College of Medicine of the University of
the Visayas are currently conducting five researches in compliance with their course
requirements in the subject Preventive and Social Medicine. The researches shall have Cebu City
as the research setting. They include the following, namely:

1. Hypertension-related knowledge and drug compliance among hypertensive patients in

selected health centers in Cebu City
2. Compliance of treatment among patients with tuberculosis in selected health centers in
Cebu City
3. Knowledge, attitudespractices regarding dengue fever in selected barangays in
Cebu City
4. Knowledge, attitudes and practices regarding family planning among married
women in Cebu City
5. Enhancing the role of barangay health workers in the prevention of dengue in hotspot
areas in Cebu City.

We have chosen these topics because they are of relevant public health concerns. We
shall furnish copies of the completed researches to your office in the hope that they can be of use
in your programs. The researches have all been approved by the Institutional Review Board of
the University of the Visayas.

There are five groups of students, each group which is composed of five to six members,
shall conduct one research. They shall conduct the researches in the following barangays,
namely: Mabolo, Barrio Luz, Punta Princesa, Parian, and Pardo this coming February 2017.

27
 May we ask your support in this undertaking of the students. One of the five groups will
go to your office. Please endorse them to the health center personnel in your barangay or to your
office personnel to help them look for research subjects to participate in the study and answer the
questionnaires that they shall administer.

Thank you very much for your kind support.

Respectfully yours,

Erlinda Y. Posadas, M.D.

Research adviser
Noted by:

Ray C. Perez, M.D.

Dean, Gullas College of Medicine

28
 Annex C

Gullas College of Medicine

UNIVERSITY OF THE VISAYAS
Banilad, Mandaue City
Tel No. 346-4224 Telefax 345-2159

Informed Consent Form for community members in Barangay ___

who we are inviting to participate in the research,
Hypertension-related knowledge and drug compliance among
hypertensive patients in selected health centers in Cebu City

Researchers: (list the names of the students)

Gullas College of Medicine

Part I: Information Sheet

Introduction

We are medical students of the Gullas College of Medicine who are currently conducting a research
on Hypertension-related knowledge and drug compliance among hypertensive patients in selected health
centers in Cebu City. This is a research which is a requirement in our course. /

I am going to give you information and invite you to be part of this research. We will go through the
information and the consent form. If there is anything that you do not understand, please ask me to
explain. If you agree to be a part of the research, please sign this consent form.

Purpose of the research

Hypertension is a very common problem in our country today. To control hypertension, we know that we
have to take medicine everyday. However, we also know that there are many hypertensive patients who
do not take their medicines everyday, especially when they do not have symptoms like headache, nape
pain, dizziness, chest pains, blurring of vision, or because they cannot afford to buy the medicines. Our
doctors have told us that this is not good since control of hypertension can only be achieved by taking the
medicines daily, and that poor compliance will lead to complications later on such as stroke, heart attack,
kidney problems or even death.

We are conducting this study in order to find out if hypertensive patients have good or poor compliance of
their treatment and to find out the factors associated with it. We will ask personal information including
their age, sex, marital status, education status, work status and income. We will also ask about knowledge
on hypertension. Then we will ask questions about compliance of medications for your hypertension.

29
We will also ask reasons for non-compliance if applicable. Then, we will see if there is a relationship of
personal information with level of knowledge and level of compliance, and relationship of level of
knowledge and level of compliance.

These data will be used only for our research purpose.

Type of Research Intervention

We invite you to be a part of this study. We will give you a questionnaire to answer, which will take you
about 30 minutes to answer. We will explain to you the questions as you go along in answering.

Participant Selection

We need 384 participants for this research. You are being invited to take part in this research because we
have been told by the health center that you have been diagnosed to have hypertension. Your answers to
the questionnaire will contribute much to our understanding of the reasons why hypertensive people,
including you, fully take or do not fully take their medicines.

Voluntary Participation

Your participation in this research is entirely voluntary. It is your choice whether to participate or not. If
you choose not to participate all the services you receive at this health center will continue and nothing
will change. You may change your mind later and stop participating even if you agreed earlier.)

Procedures

We will ask you to fill out a survey which will be provided by me and collected by me. You may answer
the questionnaire yourself, or it can be read to you and you can say out loud the answer you want me to
write down.

If you do not wish to answer any of the questions included in the survey, you may skip them and move on
to the next question. The information recorded is confidential, your name is not being included on the
forms, only a number will identify you, and no one else except me and my research group members with
access to the information will have access to your survey.

Duration

The questionnaire can be answered in less than 30 minutes. Afterwards, your participation is
finished.

Risks

You do not have to answer any question if you don't wish to do so, and that is also fine. You do not have
to give us any reason for not responding to any question.

There are questions that need answers which are personal or confidential information by chance, or that
you may feel uncomfortable talking about some of the topics. However, we do not wish for this to
happen. You do not have to answer any question if you feel the question(s) are too personal or if talking
about them makes you uncomfortable.

30
Benefits

There will be no direct benefit to you, but your participation is likely to help us find out if hypertensive
patients are taking their medicines daily or not and the reasons of doing so. It will also help you know
how much you understand about hypertension and your level of compliance with drug intake.

Reimbursements

You will not be provided any incentive to take part in the research.

Confidentiality

We will not be sharing information about you to anyone outside of the research team. The information
that we collect from this research project will be kept private. Any information about you will have a
number on it instead of your name. Only the researchers will know what your number is and we will lock
that information up with a lock and key. It will not be shared with or given to anyone except the research
team.

Who to Contact

If you have any questions, you can ask them now or later. If you wish to ask questions later, you may
contact any of the following: : (name of principal investigator/group leader)

This proposal has been reviewed and approved by the University of the Visayas Institutional Review
Board which is a committee whose task it is to make sure that research participants are protected from
harm.

31
Part II: Certificate of Consent

I have been invited to participate in research about compliance of treatment among hypertensive patients
in selected health centers in Cebu City.

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions I have been asked have been answered to my satisfaction. I consent
voluntarily to be a participant in this study

Print Name of Participant__________________

Signature of Participant ___________________
Date ___________________________
Day/month/year

Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant, and to the best of
my ability made sure that the participant understands that he will answer a questionnaire.

I confirm that the participant was given an opportunity to ask questions about the study, and all
the questions asked by the participant have been answered correctly and to the best of my ability.
I confirm that the individual has not been coerced into giving consent, and the consent has been
given freely and voluntarily.

A copy of this ICF has been provided to the participant.

Print Name of Researcher/person taking the consent________________________

Signature of Researcher /person taking the consent__________________________
Date ___________________________
Day/month/year

32
 Annex D
Informed consent in Cebuano

Part I: Pahibalo

Kami mga estudyante gikan sa Gullas College of Medicine usa sa mga naghimo ug Researcg
bahin sa Hypertension-Related knowledge and drugcompliance among hypertensive patients in
selected health centers in Cebu City
Karon mohatag mi ug mga pahibalo ug imbetasyon nimo nga mahimong usa sa kabahin sa
among research. Kini among gipahinungod ug usa ka impormasyon nga sulat. Kung aduna kay
dili masabtan, palihug pagpangutana lang naku para akong ma esplikar. Kung ikaw mosugot nga
usa kabahin sa among research, palihug ko pag perma ani.

Tuyo ug Tumong sa Research

Ang Altapresyon usa sa mga kumon natung problema sa atong nasud karong panahona. Para
atong ma kontrol ang Altapresyon, kahibaw ta nga kinahanglan ta nga moinom sa mga medisina
adlaw-adlaw, hilabina na gayud kung wala pay mga sintomas sama sa sakit sa ulo, sakit sa
tangkugo, lipong2x, sakit sa dughan, hanap ug panan-aw, o tungod ba kay dili makaya pagpalit
sa mga tambal. Atong mga Doktor nagtambag kanato nga kining mga butanga dili makaayu nga
maoy makapugong sa Altapresyon ug kini pod ato lang makab-ot pinaagi lang sa pagtumar ug
tambal adlaw-adlaw, ug kon kana dili nimo matuman pagbuhat, kini makahatag ug dakong
problema sama sa Stroke, attaki sa kasing kasing, kidney, o kamatayon. Kami nagahimo ani nga
research ug pagtulun-an para mapangitaan ug pamaagi kung ang Altapresyon nga pasyente naa
bay maayu o walay pagtuman sa ilang pagtambal ug para mahibaw-an kung unsay mga rason
nga makahatag ug complikasyon niini.
Kami nagaimbetar kanimo nga moapil sa kini nga pagtulun-an. Mohatag kami nimo ug mga
pangutana para pagtubag niini, kini modagan sulod lamang sa 15 ka minutos sa pagtubag. Kami
magaesplikar nimo sa mga pangutana samtang ikaw nagatubag sa mga pangutana.

Katungod sa Partisipante

Nagaimbitar kami nimo sa pag apil niining maong research kay kami gipahibalo sa atong health
center nga ikaw usa sa mga na kompirma nga naay Altapresyon. Ang imong mga tubag sa mga
pangutana makahatag ug dakong kontribusyon para sa atong pag-sabot kung unsay rason ngano
ang mga tawo nga adunay altapresyon magkinahanglan o dili magkinahanglan mo tumar sa ilang
mga tambal.

Boluntaryo nga Partisipasyon

Ang imong pag apil sa mao nga Research usa ka boluntaryo sa imong kaugalingon. Naa ra nimo
kung moapil ka o dili. Kung imong pilion ang dili sa pag apil sa maong pagtulon-an, Ang tanang
serbisyo sa health center imo gihapong madawat ug walay magbag-o niini. Pwede nimo usbon
imong desisyon unya kung moundang ka sa pag partisipar bisan pa ug misugot ka ganina.

33
Mga Buluhaton

Pangutan-on ka namo para tubagon ang among pagpaniid na ihatag nimo ug gikan nimo. Imo
kining pagatubagon ang mga pangutana sa imong kaugalingon, o basahon usa namo ug pwede
nimo esulti ang imong mga tubag nga imong ihatag ug ako ang mo sulat niini.
Kon dili nimo gusto mo tubag sa mga pangutana kabahin sa pag studyo, pwede nimo lat-angan
ug mopadayun sa sunod nga pangutana. Ang mga impormasyon usa kini ka secreto lamang,
imong pangalan dili apil sa maong papel, mga numero lamang kini ang mahibaluan, walay lain
kondi kami lamang uban sa among grupo ang naay katungod mo kuha ug impormasyon kabahin
sa imong mga parti sa pagstudyu.

Katas-on

Ang mga pangutana pwede lamang tubagon sa kinsi (15) ka minutos lamang. Sunod ana, imong
pag partisipar mahuman.

Risky

Dili na kinahanglan mo tubag sa mga pangutana kung dili nimo gusto, ug kini okay lamang. Dili
na kinahanglan mohatag paka ug rason kon dili ka motubag sa mga pagutana.
Adunay mga pagutana nga kinahanglan pagatubagon personal o ato-ato lamang nga
impormasyon kon adunay higayon, o kon dili ka komportabli makigsulti kabahin sa maong
hisgutanan. Tood man, wala mi manganduy nga kini mahitabo. Dili na kinahanglan moyubag sa
mga pangutana kung imong gibati sa mga pangutana grabi lang kini ka kinaugalingon o
naghisgot kini nga makahatag nimo ug dili komportabli.

Benepisyo

Wala kini diriktang benepisyo diha nimo, pero ang imong pag apil makatabang namo pagpangita
kon ang Altapresyon nga pasyente nagainom ba sa ilang midisina adla-adlaw o wala ba ug ang
tuyo sa pagbuhat niini.

Reimbursement

Dili ka makadawat ug insintibo isip usa sa mga partisipante niining research.

Kompedensiyal

Dili kami mohatag ug impormasyon kabahin nimo ngadto sa uban o sa bisan kinsa nga dili apil
sa among grupo. Ang mga impormasyn nga among matigum sa kining among proyekto usa
lamang ka pribado. Bisan unsang impormasyon kabahin nimo dili pangalan ang ibutang kundi
numero lamang. Ang mga grupo sa research lamang ang makahibalo unsa ang imong numero ug
makasigurado kami nga pribado lang gyud kini.

34
Kinsa ang Tawagon

Kung aduna moy mga pangutana, pwede mo mangtana unya. Kung gusto nimo mangutana unya,
pwede nimo tawagun bisan kinsa ani:
Kining proposiyon, adunay nagsubay ug na aprobahan sa University of The Visayas Institutional
Review Board kon diin usa ka grupo nga maoy gitahasan paghatag ug kasiguraduhan nga kining
maong research nga giapilan usa ka protectado sa kadautan.

Part II: Sertipikate sa Pagtugot

Ako giimbitar sa pagparticipar sa research kabahin sa pagtuman ug pagtambal sa maong

Altapresyon nga pasyente sa gipili nga Health Center diri sa Cebu City.
Akong nabasa ang gipadayong impormasyon, o ako gyud kining nabasa. Ako naay oportunidad
sa pagpangutana kabahin niini ug bisan unsang pangutana nga ilang gipangutana diri naku ug
ako kining gitubag sa akong comportabli nga pagtubag. Akong gitugutan sa pag boluntaryu isip
usa ka partisipante kabahin ani nga pagtulun-an.

Kompleto nga Pangalan __________________________

Asignatura sa Partisipante_________________________
Adlaw karun__________________________
Adlaw/buwan/tuig karun
Statement by the Researcher/person taking consent
Akong nabasa ang mga impormasyon nga papel kutob sa kapasidad sa partisipante, ug kutob sa
akong dakong kapasidad akong esaad nga ang partisipante nakasabot ug motubag sa mga
pangutana.
Akong gikumpirma nga ang partisipante sa aning oportunidad sa pagpangutana ani nga pagtulun-
an, ug ang tanang pangutana gikan sa partisipante natubag ug tarung ug sa akong dakong
kapasidad. Ako kining gekompirma nga ang matag-usa nila wala naku gipugos pag hatag ug
pagtugot nga boluntaryo .
Ang matag usa ka partisipanti nahatagan ug kopya sa ICF.
Ngalan sa Researcher/tawo nga nagkuha sa pagtugot_________________________________
Pirma sa Researcher/ Tawo nga nagkuha sa pagtugot_________________________________
Petsa (adlaw/bulan/tuig)______________________________________

35
 Annex E
Questionnaire
Hypertension-related knowledge and drug compliance among
hypertensive patients in selected health centers in Cebu City

Researchers: Names of the students

Patient Study ID __ __ __ __

Socio-demographic profile

1. Age: _______

2. Sex: Male ____ Female _____

3. Civil status
_____ Single
_____ Married (legally or has a common-law partner)
_____ Widow

4. Education status
____ Never went to school
_____Elementary graduate or undergraduate
_____High school graduate or undergraduate
_____College graduate or undergraduate
_____ TESDA/vocational
_____Post graduate

5. Work status
____ Currently working
____ Currently not working but not of retirable age
____ Retired

6. Income
_____ No income
_____ Lower: lower than P 5,000 a month
_____ Lower middle P 5,000 to 10,000
_____ Middle P 10,000 to 20,000
_____ Upper middle P 20,000 to 50,000
_____ Upper more than 50,000

36
Knowledge on hypertension.
The following are ten questions on hypertension. Please answer with a Yes or a No.
Yes No
1. Is high blood pressure a lifelong disease? ___ ___
2. Most times, do people with high blood pressure feel anything different? ___ ___
3. Is the pressure high when it is more than 140/90? ___ ___
4. Can high blood pressure cause heart, brain and kidney problems? ___ ___
5. Is the treatment for high blood pressure a lifelong one? ___ ___
6. Can high blood pressure be treated without the use of medication? ___ ___
7. Do regular physical exercises help control high blood pressure? ___ ___
8. Does losing weight help control high blood pressure in obese people? ___ ___
9. Does reducing salt intake help control high blood pressure? ___ ___
10. Does reducing stress help control high blood pressure? ___ ___

Morisky Medication Adherence Scale 8

You indicated that you are taking medication for your hypertension. Individuals have identified
several issues regarding their medication-taking behavior and we are interested in your
experiences. There is no right or wrong answer. Please answer each question based on your
personal experience with your medications. Please encircle your answer.

1. Do you sometimes forget to take your medicine?

Yes No

2. People sometimes miss taking their medicines for reasons other than forgetting.
Thinking over the past 2 weeks, were there any days when you did not take your
medicine?
Yes No

3. Have you ever cut back or stopped taking your medicine without telling your doctor
because you felt worse when you took it?
Yes No

4. When you travel or leave home, do you sometimes forget to bring along your medicine?
Yes No

5. Did you take your medicine yesterday?

Yes No

6. When you feel like your hypertension is under control, do you sometimes stop taking your medicine?
Yes No

7. Taking medication everyday is a real inconvenience for some people. Do you ever feel hassled about
sticking to your blood pressure plan?

37
 Yes No

8. How often do you have difficulty remembering to take all your medications? Please circle the correct
answer
Never/rarely 0
Once in a while1
Sometimes2
Usually.3
All the time. 4

Points: Yes 1 No 0

If you had answered the questions 1, 2, 3, 4, 6, and 7 with a Yes, please answer the following
questions with Yes or No.
Yes No
1. Takes medicines when feels rise in blood pressure ____ ____
2. Prefers traditional medicine ____ ____
3. Is afraid of being addicted to drugs ____ ____
4. Doesnt like side effects of drugs ____ ____
5. Forgets to take medicine on time ____ ____
6. Doesnt afford the cost of drugs prescribed ____ ____
7. Medication is not easily available ____ ____
8. Doesnt like to take medication regularly, for a long time ____ ____

Thank you very much for your time and participation in this research.

38
 Annex F
Questionnaire in Cebuano
Hypertension-related knowledge and drug compliance among
hypertensive patients in selected health centers in Cebu City

The names of the students

Patient Study ID __ __ __ __

Socio-demographic profile

1. Edad: _______

2. Kinaiyahon sa matang sa tawo: Lalake ____ Babae _____

3. Sibil katuyuan

_____ Single
_____ Minyo (minyo sa simbahan/ adunay live-in partner)
_____ biyuda o biyudo

4. Nakab-ot nga edukasyon

____ wala ko kaiskwela

_____Nakagraduwar sa elementary o wala nahuman sa elementary
_____Nakagraduwar sa high school o wala mahuman sa high school
_____Nakagraduwar sa college o wala mahuman sa college
_____TESDA/vocational
_____ Uban: ________________

5. Trabaho
____ Nagtrabaho karon panahona
____ Walay trabaho pero dili pa retired
____ Retired na

6. Kita /suweldo matag bulan

_____ walay kita/suweldo
_____ Ubos sa P 5,000 kada bulan
_____ P 5,000 --P10,000 kada bulan
_____ P 10,000 P 20,000 kada bulan
_____ P 20,000 -- P 50,000 kada bulan

39
 _____ Sobra sa P50,000 kada bulan

Kahibalo bahin saaltapresyun (taas nga dugo).

Mga napulo kapangutana mahitungud sa altapresyun (taas nga dugo). Palihug sa pagtubag ug Oo
o Dili.
Oo Dili
1. Ang altapresyon ba usa ka walay kaayuhan nga sakit ? ___ ___
2. Kasagaran ba nga panahon, ang tawo nga nadunay altapresyon
makasinati ug bati nga pamation? ___ ___
3. Taas ba ang presyur sa dugo kung moabot kini ug 140/90? ___ ___
4. Ang altapresyon ba makadaot sa kasingkasing, utok, ug sa kidney? ___ ___
5. Ang pagtambal sa altapresyon wala bay kaayuhan? ___ ___
6. Ang altapresyon maayo bisan walay tambal-tambal? ___ ___
7. Ang pagkanunayung ehersisyu sa lawas ba
makatabang sa pag pugong sa altapresyon? ___ ___
8. Ang pag-ubos ug timbang ba makatabang ug pugong
sa altapresyon? ___ ___
9. Ang pag-menos sa pagkaon nga adunay asin usa sa
makatabang sa pagpugong sa altapresyon? ___ ___
10. Ang pag-menos sa kakapoy sa lawas
makatabang sa pag pugong sa altapresyon? ___ ___

Morisky Medication Adherence Scale 8

Niingon ka nga nagtumar ka og tambal para sa imong altapresyon. Naay mga tawo nga adunay
mga hisgutanan kabahin sa ilang mga pamaagi kung unsa sila ka matinumanon sa pagtumar sa
ilang tambal. Ug mao na, interesado kami sa imong mga kasinatian kabahin niini. Walay sakto o
sayop nga tubag. Kami namalihug nga ibase imong mga tubag sa imong kasinatian sa pagtumar
nimo sa tambal. Palihog ko butangi ug lingin sa inyung mga tubag.

1. Aduna bay panahon nga makalimot ka ug tumar sa imong tambal?

Oo Wala

2. Naay mga rason ngano ang ubang tawo dili makatumar sa ilang tambal dili lang tungod kay
nakalimot sila. Sa mga niaging duha ka semana, naa bay higayon nga wala ka katumar sa imong
tambal?
Oo Wala

3. Nakasulay ba ka nga imong giundangan ug inom imong tambal maskin wala kay pananghid sa
imong doctor kay tungod maglain imong pamati inig human nimo ug tumar sa tambal?
Oo Wala

4. Kun magbiyahe o molakaw ka sa inyong balay, naa bay higayon nga malimtan nimo ug dala
imong tambal?
Oo Wala

5. Nitumar ba ka sa imong tambal kagahapon?

40
 Oo Wala

6. Kung pamati nimo normal na imong blood pressure, imong undangon ug inom ang tambal?
Oo Wala

7. Naay mga tawo nga dili makatumar sa ilang tambal kada adlaw. Nakapamati na ba ka nga hasul na
kaayo ang mga buhaton ( sama sa pagtumar sa tambal) para lang dili musaka ang imong BP?
Oo Wala

8. Mga kapila na ka kasuway nga maglisud ka ug timaan mo tumar sa imong tanang tambal? Palihug ko
pagbutang ug lignin sa imong tubag
Wala pa 0
Panagsa.1
Usahay..2
Permaminti...3
Halos kada adlaw 4

Kung gitubag nimo ang mga pangutana 1, 2, 3, 4, 6, ug 7 sa Oo, palihug pagtubag sa mga
pangutana sa ubos ug Oo o Dili.
Oo Wala
1. Moinom ug tambal lang kung gibati nimo nitaas imong presyur ____ ____
2. Mas mouyon ka moinom ug tradisyunal nga tambal (herbal) ____ ____
3. Nahadlok ka nga maadik sa tambal ____ ____
4. Dili ka ganahan sa side effects sa tambal ____ ____
5. Makalimot ka moinom sa tambal sa saktong oras ____ ____
6. Dili nimo kaya ang presyo sa tambal nga gi reseta ____ ____
7. Dili mapalit ang tambal diha-diha dayun ____ ____
8. Dili ka ganahan mo inom sa tambal kada adlaw,
sa dugay nga panahon ____ ____

Daghang salamat sa imong oras ug partisipasyon sa mga pangutana.

41
 Annex G
Dummy tables

I. Socio-demographic profile

Table 1. Age of respondents

Age Frequency Relative frequency
30 35
36 40
41 45
46 50
51 55
56 60
61 65
66 70
70 above
Total

Table 2 Sex of respondents

Sex Frequency Relative frequency
Male
Female
Total

Table 3. Education status of respondents

Education status Frequency Relative frequency
Never went to school
Elementary graduate or undergraduate
High school graduate or undergraduate
College graduate or undergraduate
Post graduate
Total

Table 4 Civil status of respondents

Civil status Frequency Relative frequency
Single
Married
Widow
Total

42
Table 5. Work status of respondents
Work status Frequency Relative frequency
Currently working
Currently not working
Retired
Total

Table 6.Income of respondents

Income Frequency Relative frequency
No income
lower: lower than P 5,000 a month
lower middle P 5,000 to 10,000
Middle P 10,000 to 20,000
Upper middle P 20,000 to 50,000
Upper more than 50,000
Total

Table 7. Knowledge on hypertension of respondents

Question Yes No
Frequency Relative Frequency Relative
frequency frequency
Is high blood pressure a lifelong
disease?
Most times, do people with high
blood pressure feel anything
different?
Is the pressure high when it is more
than 140/90?
Can high blood pressure cause heart,
brain and kidney problems?
Is the treatment for high blood
pressure a lifelong one?
Can high blood pressure be treated
without the use of medication?
Do regular physical exercises help
control high blood pressure?
Does losing weight help control high
blood pressure in obese people?
Does reducing salt intake help
control high blood pressure?
Does reducing stress help control
high blood pressure?

43
Table 8. Level of knowledge on hypertension of respondents
Level of knowledge Yes No
Frequency Relative Frequency Relative
frequency frequency
Satisfactory
Dissatisfactory
Total

Table 9. Sometimes forget to take medicine

Sometimes forget to take medicine Frequency Relative frequency
Yes
No
Total

Table 10 Missed taking medicineover the past 2 weeksfor reasons

other than forgetting.
Missed taking medicine Frequency Relative frequency
Yes
No
Total

Table 11. Stopped taking medicine without telling doctorbecause

of feeling worse when taken.
Stopped taking medicine Frequency Relative frequency
Yes
No
Total

Table 12. Sometimes forget to bring along medicine when traveling or leaving home
Sometimes forget to bring along medicine Frequency Relative frequency
Yes
No
Total

Table 13. Took medicine yesterday

Took medicine yesterday Frequency Relative frequency
Yes
No

44
Total

Table 14.Sometimes stop taking medicine when feeling like hypertension is under control
Sometimes stop taking medicine when feeling Frequency Relative frequency
like hypertension is under control

Yes
No
Total

Table 15. Feel hassled aboutsticking to blood pressure plan

Feel hassled aboutsticking to blood pressure plan Frequency Relative frequency
Yes
No
Total

Table 16. Have difficulty remembering to take all medications

Have difficulty remembering to take all medications Frequency Relative frequency

Never/rarely
Once in a while
Sometimes
Usually
All the time
Total

Table 17. Cross-tabulation of knowledge and level of compliance.

Level of High compliance Average compliance Poor compliance
knowledge Frequency Relative Frequency Relative Frequency Relative
frequency frequency frequency
Satisfactory
Dissatisfactory
Total

45
Table 18. Cross-tabulation of socio-demographic variables and level of knowledge .
Socio-demographic Satisfactory knowledge Dissatisfactory knowledge
variables Frequency Relative Frequency Relative
frequency frequency
Age
30- 35
36 40
41 45
46 50
51 55
56 60
61 - 65
65 70
71 above
Sex
Male
Female
Civil status
Single
Married
Widow
Education status
Never went to school
Elementary graduate
or undergraduate
High school graduate
or undergraduate
College graduate or
undergraduate
Post graduate
Work status
Working
Not working
Retired
Income
Lower
Lower middle
Middle middle
Upper middle
Upper
Total

46
Table 19. Cross-tabulation of socio-demographic variables and level of compliance
Socio- High compliance Average compliance Poor compliance
demographic Frequency Relative Frequency Relative Frequency Relative
variables frequency frequency frequency
Age
30- 35
36 40
41 45
46 50
51 55
56 60
61 - 65
65 70
71 above
Sex
Male
Female
Civil status
Single
Married
Widow
Education
status
Never went to
school
Elementary
graduate or
undergraduate
High school
graduate or
undergraduate
College graduate
or undergraduate
Post graduate
Work status
Working
Not working
Retired
Income
Lower
Lower middle
Middle middle
Upper middle

47
 Upper
Total
Table 20. Reasons for non-adherence.
Yes No
Frequency Relative Frequency Relative
frequency frequency
Takes medicines when feels rise
in blood pressure
Prefers traditional medicine
Is afraid of being addicted to
drugs
Doesnt like side effects of drugs.
Forgets to take medicine on time
Doesnt afford the cost of drugs
prescribed
Medication is not easily available
Doesnt like to take medication
regularly, for a long time
Total

48
 Annex H
Gantt chart
Activity October
2016
1 2 3 4
Finalization of
research protocol
Submission to
the UV
Institutional
Review Board
and Approval
Data gathering
Data collation
Writing of
research paper
Submission of
research paper

Activity October 2016 November 2016 December 2016 January 2016 February 2016 March 2016

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Finalization of research
protocol

Submission to the UV
Institutional Review Board
and Approval
Data gathering

Data collation

Writing of research paper

Submission of research
paper

49
 Annex I
Budget

Printing of questionnaires
Bond paper: P 220/ ream x 10 reams .. P 2,200
Transportation to the barangay captains and health centers
P 100/person x 30 persons .. 3,000
Printing and binding of the final manuscript
P 200/ copy x 3 copies .. 600
Total cost P5,800

50
51
 Annex I

Curriculum Vitae

RETCHIE JACOB G. MADRONA

Sto. Rosario Macrohon, Southern Leyte
jacs_25@yahoo.com
09182950233

Personal Information

Date of Birth: October 25, 1989

Place of birth: Maasin City, Southern Leyte
Civil Status: Single
Citizenship: Filipino

Educational Background

Elementary: Macrohon Central Elementary School, Macrohon Southern Leyte

Secondary: Macrohon Institute MACI Inc., Macrohon Southern Leyte

Tertiary: University of the Visaya College of Nursing, Cebu City

Bachelor of Science in Nursing

Work experience
Nephrology Nurse at Diocese of Maasin Dialysis Center, Maasin City, Southern Leyte

Research papers done (if any)

52
53