European Journal of Cardiovascular Medicine

Hypertension, a leading non-communicable disease globally, is responsible for significant cardiovascular morbidity and mortality. Despite the availability of effective treatment modalities, poor patient awareness and low adherence to therapeutic guidelines continue to pose major barriers to optimal control. According to the World Health Organization, more than 1.28 billion adults aged 30–79 years have hypertension, yet nearly 46% are unaware of their condition, and only about 21% have their blood pressure effectively controlled [1].

Public health strategies aimed at improving hypertension control require a nuanced understanding of patient behaviors, system-level challenges, and sociocultural dynamics. Pang et al., in a study from Southwest China, emphasized the role of indigenous healthcare models and community-based services such as the Basic Public Health Services (BPHS), which significantly contributed to improved hypertension monitoring and follow-up [2]. These models incorporate culturally aligned interventions that enhance patient engagement and compliance.

Similarly, a cross-sectional study by Assefa et al. in Ethiopia revealed that despite regular follow-up, self-care practices among hypertensive patients remained inadequate. Factors such as low health literacy, lack of social support, and limited access to lifestyle counseling were significant contributors [3]. This aligns with global evidence indicating that poor awareness correlates with poor disease control.

Pharmacologic resistance in hypertension is increasingly observed, especially when lifestyle interventions are insufficient. Volpe and Gallo have described resistant hypertension as a multifactorial challenge requiring both lifestyle modification and therapeutic optimization, with a subset of patients requiring more aggressive or invasive approaches such as renal denervation [4].

Disparities in hypertension management are evident across various regions. Elnaem et al., in a systematic review, identified multiple barriers to hypertension control including healthcare accessibility, economic constraints, and patient-level misconceptions about disease and treatment [5]. These issues are compounded by inconsistent implementation of treatment protocols and inadequate provider-patient communication.

Medication adherence is a key determinant of therapeutic success. Hamrahian et al. reviewed critical barriers such as side effects, complex drug regimens, forgetfulness, and lack of perceived benefit, all of which contribute to non-adherence [6]. Moreover, behavioral interventions tailored to address these barriers—such as education, digital reminders, and pharmacist-led counseling—were found to significantly improve adherence rates.

The importance of understanding patient perspectives is highlighted in mixed-method studies like the one conducted by Bandiera et al. in Switzerland. They emphasized the necessity of aligning adherence programs with patient motivations and perceptions to enhance participation, particularly in individuals with comorbidities like diabetic kidney disease [7].

Patient empowerment through education is another crucial pillar. In Poland, Pluta et al. demonstrated that structured self-care programs significantly enhanced readiness and competence among diabetic patients managing hypertension, further supporting the integration of self-care into chronic disease management frameworks [8].

In South Korea, Kim reported that national-level chronic disease management policies positively influenced self-management behaviors, with improved clinical outcomes in hypertensive and diabetic cohorts [9]. This exemplifies the role of government-led interventions in augmenting patient responsibility and adherence.

Finally, interdisciplinary care models and allied health support also play essential roles. Faletra et al., through a national survey of physical therapy practitioners, underscored the potential of incorporating cardiovascular assessments into routine non-physician clinical workflows to identify at-risk individuals and reinforce lifestyle adherence [10].

Study Design and Setting

This was a cross-sectional, questionnaire-based survey conducted over a period of three months among hypertensive patients attending outpatient clinics at tertiary and secondary healthcare centers. The study aimed to evaluate patient awareness regarding hypertension and adherence to antihypertensive management protocols.

Study Population

The study included adult patients (≥18 years) previously diagnosed with essential hypertension for at least 6 months and currently on pharmacological treatment. Patients with secondary hypertension, cognitive impairment, or those unwilling to consent were excluded.

Sample Size and Sampling Technique

Based on prior prevalence estimates and assuming a 95% confidence level with a 5% margin of error, the minimum calculated sample size was 384. To account for potential non-responses, a total of 420 patients were approached using a convenience sampling method.

Survey Instrument

A structured, pre-validated questionnaire was developed in English and translated into local languages (Hindi/Marathi) using standard forward–backward translation methods. The tool comprised three sections:

1.       Demographics – Age, gender, education, occupation, income, and duration of hypertension.

2.       Awareness Section – Knowledge of blood pressure targets, risk factors, complications, and lifestyle measures.

3.       Adherence Section – Medication-taking behavior assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8), with scores categorized as high (8), medium (6–7), or low (<6) adherence.

Data Collection Procedure

Trained investigators administered the questionnaire via face-to-face interviews after obtaining written informed consent. Interviews were conducted in a private setting to ensure participant confidentiality and comfort. Patients were encouraged to answer all questions truthfully and assured that non-participation would not affect their clinical care.

Ethical Considerations

The study was approved by the Institutional Ethics Committee of [Insert Institution Name]. Written informed consent was obtained from all participants prior to enrollment. Confidentiality of patient information was strictly maintained.

Data Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used for demographic variables. Chi-square test and Student’s t-test were employed to assess associations between awareness/adherence and sociodemographic variables. A p-value <0.05 was considered statistically significant.

Table 1: Sociodemographic Characteristics

The study population comprised 400 hypertensive patients. The majority of participants were in the age group of 46–60 years (41%), followed by those above 60 years (25%). Males constituted 55% of the sample. Educational attainment varied, with 39.5% having completed secondary education and 30% holding graduate or higher degrees. Employment status revealed that 33% were employed, while 22.5% were retired or unemployed. These demographic patterns highlight a predominantly middle-aged population with moderate educational and occupational diversity.

Table 2: Awareness of Hypertension and Its Management

The overall awareness among patients was moderately high. About 69% of participants correctly identified the normal blood pressure threshold. A substantial 78% acknowledged that hypertension is a lifelong disease requiring continuous care. Awareness regarding complications such as stroke and heart disease was noted in 73.5% of respondents. Importantly, 85% believed in the role of lifestyle modifications, and 78.5% recognized the importance of medication adherence. Additionally, 72% were aware of dietary salt restriction, indicating a reasonable level of health education among the participants.

Table 3: Medication Adherence Based on MMAS-8

Medication adherence levels were stratified using the Morisky Medication Adherence Scale (MMAS-8). High adherence was observed in only 24% of patients, while 46% showed medium adherence. Alarmingly, 30% of participants demonstrated low adherence. This pattern emphasizes a critical gap between awareness and actual compliance with treatment, suggesting behavioral or systemic barriers.

Table 4: Association between Adherence and Demographic Variables

A statistically significant association was observed between high adherence and older age (>60 years, p=0.002), as well as higher education (p=0.001). Awareness level also strongly correlated with better adherence (p<0.001). However, no significant difference was found based on gender (p=0.78). These findings indicate that while demographic factors such as age and education can enhance adherence, targeted awareness interventions are pivotal in improving patient behavior across subgroups.

Table 1: Sociodemographic Characteristics of the Study Population (n = 400)

Table 2: Patient Awareness of Hypertension and Its Management (n = 400)

Table 3: Medication Adherence Level Based on MMAS-8 Score (n = 400)

Table 4: Association between Adherence and Demographic Variables

        Note: p-values calculated using Chi-square test. p<0.05 considered statistically significant.

The present study highlights crucial insights into the awareness and adherence patterns among hypertensive patients attending outpatient care facilities. Despite considerable public health efforts, the findings reaffirm a well-documented gap between knowledge and behavior in chronic disease management. While a significant proportion of patients demonstrated moderate to good awareness regarding hypertension and its complications, actual adherence to prescribed therapeutic regimens remains suboptimal.

Globally, hypertension awareness and treatment adherence vary significantly across regions and healthcare settings. In a scoping review of hypertension care cascades in low- and middle-income countries (LMICs), Peters et al. emphasized the need to expand care strategies beyond diagnosis and prescription to include long-term patient support mechanisms and behavioral counseling [11]. Our study aligns with these findings, as only 24% of patients reported high adherence, despite 78% acknowledging that hypertension is a lifelong condition.

Adherence is a complex, multifactorial behavior. Rehman et al. reported that even in tertiary settings, many hypertensive patients are noncompliant with lifestyle modifications such as exercise, low-sodium diets, and stress management [12]. In our cohort, although 85% recognized the role of lifestyle changes, this did not translate into higher adherence scores, suggesting that awareness alone may be insufficient without reinforcement through counseling or support systems.

One possible explanation for the discrepancy between knowledge and practice is the psychological and systemic burden associated with chronic disease management. As Mullen and Anderson noted in their review, the lack of long-term blood pressure control after acute cerebrovascular events often stems from a combination of patient fatigue, polypharmacy, and inadequate follow-up [13]. These barriers are likely to apply to broader hypertensive populations as well, especially in busy outpatient clinics lacking dedicated lifestyle coaches or nurse-led interventions.

Another key determinant of adherence is demographic variation. Older adults in our study (>60 years) showed significantly better adherence than younger patients, a finding consistent with Muiruri et al.'s observations in Northwestern Tanzania, where elderly populations exhibited greater concern about cardiovascular risks and thus better compliance [14]. However, education was a more consistent predictor of high adherence than age, reinforcing the findings of Stokes et al., who concluded that digital and technology-based interventions need to be adapted to patients’ literacy levels for effective behavior change [15].

In terms of system-wide solutions, European hypertension guidelines recommend home blood pressure monitoring and telemedicine as scalable methods to reinforce adherence, especially post-COVID-19 [16]. Our study participants, particularly those from urban backgrounds, might benefit from such digital interventions if tailored to local language and literacy barriers. However, in LMICs, the feasibility of widespread telehealth use remains uncertain due to infrastructure limitations.

The role of healthcare providers also cannot be overstated. In the study by Zhang et al., a doctor-nurse-patient integration model led to significant improvements in blood pressure control among younger and middle-aged patients by focusing on heart rate management and communication strategies [17]. Such integrated care pathways, when adapted for rural and semi-urban Indian settings, could bridge the gap between diagnosis and sustainable adherence.

Furthermore, as Courtet et al. demonstrated in their web-based survey, patients with both cardiovascular and mental health conditions often feel disengaged from their care plans when their opinions are not considered during clinical decision-making [18]. This highlights the importance of personalized, patient-centered care, where therapeutic decisions are co-created with patients, improving both trust and compliance.

A region-specific study in Morocco by El Kardoudi et al. reported that poor blood pressure control was significantly associated with forgetfulness, economic stress, and a lack of understanding of long-term complications [19]. These findings parallel the results of our study where 30% of participants scored poorly on the MMAS-8, indicating that these universal barriers must be addressed through targeted interventions, especially in resource-constrained environments.

Finally, the study by Alshahrani et al. in Saudi Arabia revealed that patient satisfaction with healthcare providers was directly correlated with adherence to antihypertensive therapy [20]. This finding has implications for our own healthcare systems, where improving provider–patient interactions through better communication training and more consistent follow-up could substantially enhance adherence outcomes.

This study underscores a critical disparity between awareness and adherence among hypertensive patients in urban and semi-urban settings. While a majority of patients demonstrated adequate knowledge about hypertension, including its complications and the role of lifestyle modifications, only a minority achieved high adherence to treatment protocols. Factors such as age, education level, and awareness scores were significantly associated with adherence, highlighting the need for targeted educational and behavioral interventions. Bridging the knowledge-action gap requires not only improving patient health literacy but also integrating support systems such as counseling, regular follow-up, and personalized care. Adoption of digital tools and community-based strategies, when tailored to demographic contexts, may further enhance adherence and outcomes. Strengthening patient-provider communication and involving patients in shared decision-making are also essential. Future public health strategies should focus on sustainable, patient-centric models to address these multifactorial barriers and improve long-term hypertension control.

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