Current Hypertension Reports (2018) 20: 65

https://doi.org/10.1007/s11906-018-0862-2

IMPLEMENTATION TO INCREASE BLOOD PRESSURE CONTROL: WHAT WORKS? (J BRETTLER AND K

REYNOLDS, SECTION EDITORS)

Nurse’s Contribution to Alleviate Non-adherence

to Hypertension Treatment
G. Georgiopoulos 1 & Z. Kollia 2 & V. Katsi 1 & D. Oikonomou 3 & C. Tsioufis 1 & D. Tousoulis 1

Published online: 15 June 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review Hypertension consists a major risk factor for cardiovascular events. Despite the proven effectiveness of
antihypertensive treatment, approximately half of hypertensive patients have inadequate blood pressure control. Non-adherence
to medication has been shown to be an important barrier to achieving adequate blood pressure control and nurse interventions can
substantially improve therapeutic compliance. We sought to evaluate the role of nurse interventions in alleviating non-adherence
to medication in patients with hypertension by performing a systematic review of the literature for all relevant articles.
Recent Findings Ten clinical studies were identified. The majority of studies reported beneficial effect of nursing intervention on
treatment adherence in hypertensive patients. Telephone contacts and home visits were found to be the most effective educational
approaches. Although comorbidities are considered to be an important barrier to adherence, there was not enough evidence to
elucidate this aspect. Identifying specific factors that affect behavioral change in the setting of a successful intervention was
difficult due to high heterogeneity among studies regarding materials and methods.
Summary Nursing interventions were shown to alleviate non-adherence to medication in patients with hypertension. Large well
designed clinical trials are needed to evaluate specific factors that are associated with effective interventions.

Keywords Nursing intervention . Treatment adherence . Hypertension

Introduction Although there is availability of various antihypertensive

Hypertension (HT) consists the most common chronic cardio-
vascular (CV) disease and is associated with increased risk of
CV events including stroke, myocardial infarction, sudden
death, heart failure, and peripheral artery disease, as well as
end-stage renal disease [1–3].
This article is part of the Topical Collection on Implementation to
Increase Blood Pressure Control: What Works?
* G. Georgiopoulos
georgiopoulosgeorgios@gmail.com
1
First Department of Cardiology, ‘Hippokration’ Hospital, University
of Athens, Medical School, Vasilissis Sofias 80, TK 115
27 Athens, Greece
2
Emergency Department, ‘Amalia Fleming’ General Hospital,
Athens, Greece
3
Department of Cardiology, ‘Evaggelismos’ General Hospital of
Athens, Athens, Greece
drugs with established effectiveness and safety, only 50% of
all patients with HT achieve adequate blood pressure control
[4]. According to world health organization (WHO), low ad-
herence to antihypertensive drugs is the most common cause
of inadequate blood pressure control, resulting in increased
CV events and repeated hospitalizations [5]. Adherence is de-
fined as the extent to which a person’s behavior corresponds
with agreed recommendations by a health care provider [5].
Non-adherence in this group of patients might be aggravated
by the increased number of required antihypertensive agents
[6], and complicated treatment schemes, especially in high-
risk subjects under combination therapy [7]. Evidence sug-
gests that 50 to 80% of patients who were prescribed pharma-
cological antihypertensive therapy have low adherence to
their treatment regimen [8, 9]. Therefore, compliance to med-
ical treatment has become a major issue for health care pro-
viders. Recent studies suggest that nurse-administered inter-
ventions within the frame of a healthcare team can improve
blood pressure control among hypertensive patients [10].
Towards this direction, a systematic review of randomized
65 Page 2 of 6
controlled trials (RCTs) concluded that motivational and com-
plex interventions delivered by nurses increased treatment ad-
herence in patients with HT [11].
Considering all the above, the aim of this paper was
to systematically review and highlight the importance of
nursing interventions to improve adherence in patients
with HT.
Methods
A systematic review of the literature was conducted for all
articles that evaluated nursing interventions to alleviate non-
adherence to antihypertension treatment. The current review
was designed to determine the effect of education implement-
ed by nurses on adherence in patients who receive
antihypertension treatment.
Two of the authors carried out independently a systematic
bibliographic search in February 2017. Literature search was
conducted using PubMed interface, Scopus, and CINAHL
database. A search period from 2000 to 2017 was set. Terms
that were used were “adherence,” “hypertension,” “treat-
ment,” “nurse,” and combinations of them. Only articles pub-
lished in the English language were taken into consideration.
Retrieved articles were originally selected for more detailed
evaluation. References lists of each study were also checked in
order to identify additional studies that answered the research
question.
For the selection of studies which were used in the system-
atic review, the study population was previously determined
and the inclusion/exclusion criteria were defined. Patients
with hypertension, adults (≥ 18 years old), regardless their
gender, who had received nursing intervention to promote
adherence constituted the study population. In order to evalu-
ate adherence, valid materials should had been used.
Articles that were excluded involved firstly studies that
assessed the views of physicians, nurses. or families of pa-
tients with hypertension regarding improving adherence, sec-
ondly studies in which intervention was carried out by any
health professional other than a nurse, and finally qualitative
studies in which level of adherence was not evaluated by
reliable methods. A flow chart is presented in Fig. 1.
Results
Ten original studies were identified according to the inclusion
criteria [12–21•]. Table 1 summarizes the main characteristics
of selected studies. Seven studies reported improvement in
medication adherence after the implementation of a nursing
intervention [12, 13, 16, 18–21•] (Table 1).
In total, we included eight randomized controlled trials
[13•–20], one single-group clinical trial [21•], and one
Curr Hypertens Rep (2018) 20: 65
observational study [12]. In all studies, follow-up duration
lasted between 2 and 36 months (Table 1).
Various methods to evaluate adherence to antihypertension
are available, including subjective and objective methods [22].
Self-reported questionnaires were used to validate adherence in
seven studies, which are easy to implement, cheap and widely
available [12, 15, 17–21•]. Four studies used scales based on
Morisky Adherence Questionnaire, which is the most commonly
used [12, 15, 17, 19], one study used Treatment Adherence
Questionnaire of Patients with Hypertension [20], and two stud-
ies used adherence assessment forms that were created for the
purpose of those studies [18, 21•]. However, five studies used
objective methods to assess adherence to medication in hyper-
tension patients [13•, 14, 16–18]. Blood pressure monitors, elec-
tronic medication monitors, pill counting, urine testing, and re-
view of electronical database records were applied by re-
searchers. As different measurement tools were used in each
study, it was difficult to aggregate data.
Studies were based on nurse-administered interventions in
order to enhance adherence to antihypertensive treatment.
Educational programs contained information regarding pa-
tient compliance to medication and lifestyle changes, hyper-
tension knowledge, and blood pressure control. Various
methods were used including written educational materials,
intervention software, and audiotapes, as well as support ses-
sions and verbal consultation.
Differences were observed among reviewed studies regard-
ing the timing of the education process. Education was deliv-
ered during visits in cardiovascular outpatient departments,
primary care units, or nurse-led clinics for hypertensive pa-
tients. Moreover, researchers implemented educational pro-
gram during home visits or by using telephone follow-up con-
sultation. According to the results, telephone contacts and
home visits seem to be more effective compared to education-
al sessions (Table 1).
Comorbidities adversely affect adherence to treatment. One
of the reviewed studies excluded patients with diabetes [17].
Another study stratified patients according to comorbidities
[12], while Maciejewski et al. [13•] stratified patients accord-
ing to diabetic status.
Among the reviewed studies, implementation of education-
al programs was found to be effective in improving adherence
in hypertensive patients in seven studies [12, 13•, 15, 16, 18,
20, 21•]. No statistically significant differences were found in
the remaining three studies [14, 17, 19] (Table 1).
Discussion
Our systematic review highlighted the important role of nurses
in alleviating non-adherence in patients receiving antihyper-
tensive treatment. [12–21•]. According to the results of most
studies, improvement was noticed in terms of treatment
Curr Hypertens Rep (2018) 20: 65
Fig. 1 Flow chart Relevant arcles retrieved from databases
(n=227)
Studies retrieved for more detailed
evaluaon (n=191)
Final studies included in the review (n=10)
adherence in subjects who participated in nursing intervention
programs. Education programs concerning lifestyle modifica-
tion and disease understanding presented the more favorable
results towards optimized blood pressure control and better
treatment adherence. In fewer studies though, a significant
benefit from relevant interventions was not established [14,
17, 19].
Interventions that were used to promote appropriate behav-
iors included various combinations such as telephone contacts
and home visits [12, 16, 18, 19, 21•], educational sessions
with verbal details and consultation [14, 15, 17, 20], and home
blood pressure measurements with tele-monitoring [13•].
Telephone contacts and home visits were found to be more
effective compared with educational sessions which have not
been successful in improving adherence in all relevant studies.
Nursing interventions for enhancing medication adherence in
hypertension included multiple aspects, such as hypertension
pathophysiology, symptoms of deterioration, and the impor-
tance of adherence, self-monitoring of blood pressure, combi-
nation pills, and practical support.
Inability to identify which specific factors are responsible
for the effectiveness of nursing interventions is possibly due to
differences in the design of reviewed studies, demographic
and clinical characteristics of patients with hypertension
among studies, time tracking, tools used to evaluate outcomes,
and educational approaches. A meta-analysis of randomized
and non-randomized trials that targeted antihypertensive med-
ication adherence improvement found that interventions had
Page 3 of 6 65
Arcles excluded because they were
reviews (n=36)
Studies excluded by tle (n=89)
Studies excluded following review of the
abstract (n=63)
Studies excluded following review of the
full text (n=29)
different effect on adherence and reported that the most effec-
tive interventions employed multiple components and were
delivered over many days [23••]. These studies were designed
with significant heterogeneity regarding population character-
istics, interventions, and measures used to assess adherence.
As a result, it is difficult to ascertain which factors affect
behavior change, even if an intervention is successful [24].
Level of adherence was estimated with different methods in
each study. Some researchers used subjective methods to eval-
uate adherence such as self-reported questionnaires (Morisky
Adherence Questionnaire, Morisky Medication Adherence
Scale) while others used objective methods such as review
of pharmacy database records, pill counting, and electronic
monitoring devices. In most studies, combined methods were
used. A Cochrane’s review underlined the need to use objec-
tive measures of non-adherence in future research [25].
However, we observed that both methods were effective in
evaluating adherence.
The majority of studies had a 6-month follow-up period. It
seems that the effect of intervention remained present through
short follow-up periods. Three out of ten reviewed studies had
longer follow-up period, 18 to 36 months, and in two of them
benefit was observed until the end of the study period. Park
and Kim [21•] reported improvement on adherence in a large
sample of hypertensive patients. However, they evaluated
them during a short period of 2 to 4 months. In evaluating
adherence to treatment, long-term beneficial effects are of vi-
tal importance.
Table 1 Clinical studies that evaluated the effect of nursing intervention on treatment adherence of hypertensive patients

Study Type Duration Comparison Instrument Outcomes Results

65 Page 4 of 6

Sample

Bosworth et al. RCT 24 months 588 Telephone-based medication and Morisky Self-reported Treatment adherence No significant difference in adherence
2005 [19] behavioral management VS Medication-Taking Scale among groups (at 6 months):
usual care 0.007; 95% CI − 0.062 to 0.076
Schroeder et al. RCT 6 months 245 Educational session VS usual care Electronic medication monitors Adherence defined as No benefit VS usual care: 87.2 VS 90.2%,
2005 [14] timing compliance p = 0.63
Bosworth et al. RCT 24 months 636 Telephone-based behavioral Morisky Self-reported Treatment adherence Increase in adherence form baseline VS
2008 [15] management VS usual care Medication-Taking Scale usual care (at 6 months):
7 VS 1%
Chiu and Wong RCT 2 months 63 Clinic-based management VS Home BP monitoring BP control BP reduction in both groups; significantly
2010 [18] clinic-based management plus Adherence assessment form Treatment adherence higher reduction in 2nd group
telephone follow-up SBP − 7.97, p = 0.034 VS – 19.03, p = 0.0001
DBP: − 3.72, p = 0.057 VS – 11.68,
p = 0.0001
No significant difference in adherence
among groups
Adeyemo et al. RCT 6 months 698 Clinic-based management VS Pill count Treatment adherence High adherence compared to baseline in both
2013 [16] clinic-based management Urine testing groups (~ 77%), with no significant
plus home visits difference among groups
Beune et al. RCT 6 months 146 Education sessions VS usual care Automated BP monitor SBP reduction No significant difference in BP conrtol:
2014 [17] Morisky Self-reported (≥ 10 mmHg) OR 0.42; 95% CI 0.11–1.54, p = 0.19
Medication-Taking Scale Treatment adherence No significant difference in adherence:
mean change − 0.09; 95% CI
20.65–0.46, p = 0.74
Ma et al. 2014 [20] RCT 6 months 120 Motivational education session Clinic BP monitoring BP control Higher BP reduction VS usual care:
VS usual care Treatment Adherence Treatment adherence Difference: SBP – 4.92; DBP – 2.58,
Questionnaire p < 0.05
Increased treatment adherence:
Difference in score 2.72, p < 0.05
Maciejewski ML RTC 36 months 591 Telephone-based medication Telemedicine and home BP BP control (proportion Increase in BP control VS usual care:
et al. 2014 [13•] management VS telephone-based monitoring of patients) Medication: 20.2%; 95% CI 9.7–30.6%
behavioral management VS Behavioral: 17.1%; 95% CI6.9–27.4%
telephone-based combined Combined: 20.4%; 95% CI 10–30.8%,
management VS usual care p < 0.05 for all
Raymundo et al. Retrospective 17 months 283 Adherence before VS after Morisky-Green test Treatment adherence Increase in adherence after intervention
2014 [12] management program with From 25.1 to 85.5%, p < 0.05
telephone contacts and
home visits
Park and Kim Single group 2–4 months 13,452 Adherence before VS after Self-report assessment score Treatment adherence Increase in adherence after intervention
2016 [21•] management program with Change in score: from 4.08 to 4.66,
home visits p < 0.001

RCT randomized control trials, BP blood pressure, DBP diastolic blood pressure, SBP systolic blood pressure, OR odds ratio
Curr Hypertens Rep (2018) 20: 65
Curr Hypertens Rep (2018) 20: 65
In our review, nurses contribution to alleviate antihyperten-
sive treatment adherence was studied, as studies included par-
ticipation of other health care professionals were rejected.
Nursing interventions were reported to influence behaviors
positively; also, multidisciplinary approaches applied in vari-
ous studies showed positive results in adherence too. Fortuna
et al. [26] examined the implementation of a multidisciplinary
intervention involving registered nurses, pharmacists, and
physicians and they found substantial improvements in blood
pressure control. Moreover, a meta-analysis that evaluated
strategies implemented by team-based care reported a positive
effect on blood pressure control [27].
Demographic characteristics of the recruited patients in the
reviewed studies played an important role in the effectiveness
of nursing interventions. Park and Kim [21•] enrolled patients
aged over 65 years old. The majority of studies included patients
younger than 65 years old and only Schroeder K et al. [14]
evaluated adherence in a population with mean age over than
65 years old. However, elderly patients appear to be at high risk
of misunderstanding prescription instructions [28], and this sub-
group of patients should have been included in more clinical
studies.
In some studies, comorbidities were not assessed during
research process, although patients with concurrent chronic
disease who receive complex medications are less likely to
be adherent to medication. This is supported by studies which
reported that adherence to antihypertensive treatment de-
creases in patients with comorbidities [29–31].
In addition, depression has also been reported to af-
fect adherence to antihypertensive treatment [32] and
control of blood pressure [33]. Evidence suggests that
depression is associated with poor adherence to medica-
tion across a range of chronic diseases, and researchers
supported the importance of assessing depression in
clinical studies that evaluate adherence [34]. However,
none of the reviewed articles have assessed the impact
of depression or depressive symptoms on treatment
adherence.
Conclusion
Our systematic review demonstrated a strong positive effect of
nursing interventions on antihypertensive treatment adher-
ence. Patients showed a great improvement on medication
adherence after their participation in educational programs
regarding disease management. Nurses can support signifi-
cantly patients with hypertension to control their blood pres-
sure, receive their medication properly, and make lifestyle
modifications in order to manage their disease effectively.
Well-designed clinical trials are needed to identify which spe-
cific factors contribute to the effectiveness of nursing
interventions.
Page 5 of 6 65
Compliance with Ethical Standards
Conflict of Interest The authors declare no conflicts of interest relevant
to this manuscript.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
What’s New?
•Nursing interventions improve adherence to treatment
•Home visits and telephone calls are effective methods
•The role of comorbidities has not been fully elucidated
•Elderly patients should be included in more clinical studies
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-
specific relevance of usual blood pressure to vascular mortality: a
meta-analysis of individual data for one million adults in 61 pro-
spective studies. Lancet. 2002;360(9349):1903–13.
2. Britton KA, Gaziano JM, Djoussé L. Normal systolic blood pres-
sure and risk of heart failure in US male physicians. Eur J Heart
Fail. 2009;11(12):1129–34. https://doi.org/10.1093/eurjhf/hfp141.
3. Kalaitzidis RG, Bakris GL. Prehypertension: is it relevant for ne-
phrologists? Kidney Int. 2010;77(3):194–200. https://doi.org/10.
1038/ki.2009.439.
4. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness,
treatment, and control of hypertension, 1988-2008. JAMA.
2010;303(20):2043–50. https://doi.org/10.1001/jama.2010.650.
5. Burkhart PV, Sabate E. Adherence to long-term therapies: evidence
for action. J Nurs Scholarsh. 2003;35(3):207.
6. Cushman WC, Ford CE, Cutler JA, Margolis KL, Davis BR,
Grimm RH, et al. Success and predictors of blood pressure control
in diverse North American settings: the antihypertensive and lipid-
lowering treatment to prevent heart attack trial (ALLHAT). J Clin
Hypertens (Greenwich). 2002;4(6):393–404.
7. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm
M, et al. 2013 ESH/ESC guidelines for the management of arterial
hypertension: the Task Force for the Management of Arterial
Hypertension of the European Society of Hypertension (ESH) and
of the European Society of Cardiology (ESC). Eur Heart J.
2013;34(28):2159–219. https://doi.org/10.1093/eurheartj/eht151.
8. Souza ARAD, Costa A, Nakamura D, Mocheti LN, Stevanato Filho
PR, Ovando LA. Um estudo sobre hipertensão arterial sistêmica na
cidade de Campo Grande, MS. Arq Bras Cardiol. 2007;88:441–6.
9. Ebrahim S. Detection, adherence and control of hypertension for
the prevention of stroke: a systematic review. Health Technol
Assess. 1998;2(11):i-iv):1–78.
10. Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM,
Powers BJ, et al. Two self-management interventions to improve
hypertension control: a randomized trial. Ann Intern Med.
2009;151(10):687–95. https://doi.org/10.7326/0003-4819-151-10-
200911170-00148.
65 Page 6 of 6
11. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence
to blood pressure-lowering medication in ambulatory care?
Systematic review of randomized controlled trials. Arch Intern
Med. 2004;164(7):722–32. https://doi.org/10.1001/archinte.164.7.
722.
12. Raymundo AC, Pierin AM. Adherence to anti-hypertensive treat-
ment within a chronic disease management program: a longitudinal,
retrospective study. Rev Esc Enferm USP. 2014;48(5):811–9.
13.• Maciejewski ML, Bosworth HB, Olsen MK, Smith VA, Edelman
D, Powers BJ, et al. Do the benefits of participation in a hyperten-
sion self-management trial persist after patients resume usual care?
Circ Cardiovasc Qual Outcomes. 2014;7(2):269–75. https://doi.
org/10.1161/circoutcomes.113.000309. Study with long follow-
up period (36 months)
14. Schroeder K, Fahey T, Hollinghurst S, Peters TJ. Nurse-led adher-
ence support in hypertension: a randomized controlled trial. Fam
Pract. 2005;22(2):144–51. https://doi.org/10.1093/fampra/cmh717.
15. Bosworth HB, Olsen MK, Neary A, Orr M, Grubber J, Svetkey L,
et al. Take Control of Your Blood Pressure (TCYB) study: a mul-
tifactorial tailored behavioral and educational intervention for
achieving blood pressure control. Patient Educ Couns.
2008;70(3):338–47. https://doi.org/10.1016/j.pec.2007.11.014.
16. Adeyemo A, Tayo BO, Luke A, Ogedegbe O, Durazo-Arvizu R,
Cooper RS. The Nigerian antihypertensive adherence trial: a
community-based randomized trial. J Hypertens. 2013;31(1):201–
7. https://doi.org/10.1097/HJH.0b013e32835b0842.
17. Beune EJ, Moll van Charante EP, Beem L, Mohrs J, Agyemang
CO, Ogedegbe G, et al. Culturally adapted hypertension education
(CAHE) to improve blood pressure control and treatment adherence
in patients of African origin with uncontrolled hypertension:
cluster-randomized trial. PLoS One. 2014;9(3):e90103. https://doi.
org/10.1371/journal.pone.0090103.
18. Chiu CW, Wong FK. Effects of 8 weeks sustained follow-up after a
nurse consultation on hypertension: a randomised trial. Int J Nurs
Stud. 2010;47(11):1374–82. https://doi.org/10.1016/j.ijnurstu.
2010.03.018.
19. Bosworth HB, Olsen MK, Gentry P, Orr M, Dudley T, McCant F, et
al. Nurse administered telephone intervention for blood pressure
control: a patient-tailored multifactorial intervention. Patient Educ
Couns. 2005;57(1):5–14. https://doi.org/10.1016/j.pec.2004.03.
011.
20. Ma C, Zhou Y, Zhou W, Huang C. Evaluation of the effect of
motivational interviewing counselling on hypertension care.
Patient Educ Couns. 2014;95(2):231–7. https://doi.org/10.1016/j.
pec.2014.01.011.
21.• Park E, Kim J. The impact of a nurse-led home visitation program
on hypertension self-management among older community-
dwelling Koreans. Public Health Nurs. 2016;33(1):42–52. https://
doi.org/10.1111/phn.12220. Included elderly patients that
consist a patient group with high risk of non-adherence
22. Gupta P, Patel P, Horne R, Buchanan H, Williams B, Tomaszewski
M. How to screen for non-adherence to antihypertensive therapy.
Curr Hypertens Rep (2018) 20: 65
Curr Hypertens Rep. 2016;18(12):89. https://doi.org/10.1007/
s11906-016-0697-7.
23.•• Conn VS, Ruppar TM, Chase JA, Enriquez M, Cooper PS.
Interventions to improve medication adherence in hypertensive pa-
tients: systematic review and meta-analysis. Curr Hypertens Rep.
2015;17(12):94. https://doi.org/10.1007/s11906-015-0606-5.
Recent meta-analysis investigating efficiency of various
interventions to attenuate non-adherence
24. Morrissey EC, Durand H, Nieuwlaat R, Navarro T, Haynes RB,
Walsh JC, et al. Effectiveness and content analysis of interventions
to enhance medication adherence in hypertension: a systematic re-
view and meta-analysis protocol. Syst Rev. 2016;5:96. https://doi.
org/10.1186/s13643-016-0278-5.
25. Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R,
Keepanasseril A, et al. Interventions for enhancing medication ad-
herence. Cochrane Database Syst Rev. 2014;(11):Cd000011.
https://doi.org/10.1002/14651858.CD000011.pub4.
26. Fortuna RJ, Nagel AK, Rose E, McCann R, Teeters JC, Quigley
DD, et al. Effectiveness of a multidisciplinary intervention to im-
prove hypertension control in an urban underserved practice. J Am
Soc Hypertens. 2015;9(12):966–74. https://doi.org/10.1016/j.jash.
2015.10.004.
27. Carter BL, Bosworth HB, Green BB. The hypertension team: the
role of the pharmacist, nurse, and teamwork in hypertension thera-
py. J Clin Hypertens (Greenwich). 2012;14(1):51–65. https://doi.
org/10.1111/j.1751-7176.2011.00542.x.
28. Choudhry NK, Shrank WH, Levin RL, Lee JL, Jan SA, Brookhart
MA, et al. Measuring concurrent adherence to multiple related med-
ications. Am J Manag Care. 2009;15(7):457–64.
29. Ghembaza MA, Senoussaoui Y, Tani MK, Meguenni K. Impact of
patient knowledge of hypertension complications on adherence to
antihypertensive therapy. Curr Hypertens Rev. 2014;10(1):41–8.
30. An J, Nichol MB. Multiple medication adherence and its effect on
clinical outcomes among patients with comorbid type 2 diabetes
and hypertension. Med Care. 2013;51(10):879–87. https://doi.org/
10.1097/MLR.0b013e31829fa8ed.
31. Saadat Z, Nikdoust F, Aerab-Sheibani H, Bahremand M, Shobeiri
E, Saadat H, et al. Adherence to Antihypertensives in patients with
comorbid condition. Nephrourol Mon. 2015;7(4):e29863. https://
doi.org/10.5812/numonthly.29863.
32. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med.
2005;353(5):487–97. https://doi.org/10.1056/NEJMra050100.
33. Hiligsmann M, Rabenda V, Gathon HJ, Ethgen O, Reginster JY.
Potential clinical and economic impact of nonadherence with oste-
oporosis medications. Calcif Tissue Int. 2010;86(3):202–10. https://
doi.org/10.1007/s00223-009-9329-4.
34. Grenard JL, Munjas BA, Adams JL, Suttorp M, Maglione M,
McGlynn EA, et al. Depression and medication adherence in the
treatment of chronic diseases in the United States: a meta-analysis. J
Gen Intern Med. 2011;26(10):1175–82. https://doi.org/10.1007/
s11606-011-1704-y.