Abstract
This study aims to investigate the impact of a multicomponent support intervention on medication adherence and self-efficacy levels among patients with hypertension. This quasi-experimental controlled study was conducted in Turkey with 63 hypertensive patients assigned to intervention and control groups using a non-random allocation approach. Pre-test data were collected face-to-face. The intervention group received structured training on blood pressure self-monitoring using the “Hypertension Training Manual” and measured their blood pressure twice daily at home. Data were collected using the General Self-Efficacy Scale and the Medication Adherence Self-Efficacy Scale in Hypertensive Patients. The intervention consisted of a multicomponent support program including individualized education, a hypertension education booklet, home blood pressure monitoring, SMS reminders, and monthly follow-up calls. To support adherence, SMS reminders were sent three times per week for three months. Post-test data were collected online, and outcome assessments and statistical analyses were conducted by a researcher who was not involved in the intervention process. Post-test medication adherence self-efficacy scores were significantly higher in the intervention group than in the control group (45.97±5.86 vs. 39.75±5.57, p<0.001, Cohen’s d=0.87). General self-efficacy scores were also significantly higher in the intervention group compared with the control group (81.16±19.18 vs. 74.53±11.30, p=0.048, Cohen’s d=0.51). Statistically significant reductions in systolic and diastolic blood pressure and body mass index were observed over time in the intervention group (p < 0.001), whereas no significant differences were observed in the control group.A multicomponent educational and behavioral support intervention may contribute to improved medication adherence and self-efficacy among patients with hypertension.
Keywords: Nursing, Hypertension, Medication, Self-efficacy, Multicomponent support intervention, Adherence
Subject terms: Cardiology, Diseases, Health care, Medical research
Introduction
Hypertension (HT) is a serious health concern characterized by a systolic blood pressure of 140 mmHg and a diastolic blood pressure of 90 mmHg. It causes high morbidity and mortality and is a worldwide health problem1. Treatment for hypertension can include a variety of methods, including dietary changes, physical exercise, medical nutrition therapy, and non-pharmacological and pharmacological medication2. Maintaining healthy blood pressure, reducing the damage and complications caused by hypertension in the affected organs, minimizing side effects by ensuring medication adherence, ensuring patients’ adherence to treatment recommendations, and taking responsibility for their treatment are all essential aspects of hypertension management3.
In hypertension management, adherence involves following medication regimens, attending appointments, and adhering to dietary and lifestyle recommendations4. Despite the proven effectiveness of antihypertensive drugs, non-adherence remains a significant barrier to achieving target blood pressure levels. Studies indicate that nearly 50% of patients discontinue their medication within a few months, neglect follow-up visits, and fail to adhere to prescribed treatments3. In the literature, education regarding hypertension management can improve adherence to antihypertensive medication, allowing them to achieve the desired blood pressure level5.
Health professionals must educate patients and their relatives about the disease to increase adherence to antihypertensive medication.5. Involving the patient in the treatment plan is one of the most effective approaches to ensure treatment adherence. In the literature, nurses and other healthcare professionals play a significant role in implementing lifestyle modifications for patients, enhancing treatment adherence, and actively participating in their own health6. Self-efficacy plays a crucial role in hypertension management, as it does in all chronic diseases, by influencing patients’ efforts to manage their condition. As a key component of cognitive perception, self-efficacy reflects an individual’s belief in their ability to perform the behaviors needed to achieve desired outcomes. This study was conceptually informed by Bandura’s Self-Efficacy Theory, which emphasizes that repeated practice, reinforcement, self-monitoring, and supportive feedback may strengthen individuals’ confidence in engaging in effective self-management behaviors. This belief may strongly influence health-related behaviors and adherence7. The patient observes their actions, avoids negative behaviours that harm their health, and assesses how their activities affect their present health status during this process. By accepting responsibility for their condition, people can lower their blood pressure, improve their quality of life, and modify their lifestyle8,9. The primary goal of hypertension treatment is to keep blood pressure under control. Several international hypertension guidelines have emphasized the importance of self-measuring blood pressure (BP) at home in clinical practice10. Self-measurement of blood pressure at home encourages medication adherence, clinic visits, and active engagement in medical treatment. As a result, using blood pressure measurement at home to diagnose and treat hypertension can lower the costs in the long run11. Patients should develop self-efficacy in their health by regularly checking their blood pressure and taking their medications as prescribed. In this context, educational support, repeated self-monitoring, reminder messages, and follow-up communication may strengthen patients’ confidence in managing hypertension-related behaviors and maintaining medication adherence. In light of this information, this research aims to examine medication adherence and self-efficacy among patients with hypertension who self-monitor their blood pressure.
Material and method
Research type
The study was designed as a controlled interventional study with a quasi-experimental allocation approach (Fig. 1).
Fig. 1.
Flow diagram of participant recruitment, allocation, follow-up, and analysis. This study was registered at ClinicalTrials.gov with the identifier NCT05341973, First Posted on 21/04/2022.
Population and sample
The study included 63 hypertensive patients aged 18 years or older attending the cardiology outpatient clinics at Turhal State Hospital. Based on power analysis, a minimum of 30 participants per group was required. Accounting for potential dropouts, 100 patients were initially recruited; however, 12 withdrew, and 25 did not complete the study. Participant loss during follow-up should be considered when interpreting the findings. Only participants who completed both pre-test and post-test assessments were included in the final analyses, and no imputation method was applied for missing data. The final sample consisted of 31 intervention and 32 control group patients, all of whom met the following criteria: a minimum six-month diagnosis of hypertension, stable medication use, no cognitive issues, and at least a primary education.
Data collection
Data were collected using the "Patient Information Form", "General Self-Efficacy Scale", and "Medication Adherence Self-Efficacy Scale in Hypertensive Patients."
Patient information form
The researchers developed this form based on the existing literature. It comprises 19 questions and includes patients’ socio-demographic characteristics and disease-related features.
General self-efficacy scale
The scale developed by Sherer et al.12 was adapted into Turkish by Gözüm and Aksayan in 198213. The scale measures individuals’ general self-efficacy perceptions, independent of specific domains. This scale was used to evaluate individuals’ overall self-efficacy perceptions in daily life situations rather than medication-specific behaviors. It includes 23 items on a 5-point Likert scale, with total scores ranging from 23 to 115. The original Cronbach’s Alpha coefficient was reported as 0.823, while in this study, it ranged from 0.603 to 0.892, indicating acceptable to high internal consistency.
Medication adherence self-efficacy scale in hypertensive patients
14Ogedegbe et al. established the scale in 200314, and Hachasanolu et al.15 translated it into Turkish. The scale, designed to assess medication adherence in hypertensive patients, consists of 13 items rated on a four-point Likert scale, with total scores ranging from 13 to 52. Unlike the general self-efficacy scale, this instrument specifically assesses confidence in adherence to antihypertensive medication regimens. Higher scores indicate greater adherence to antihypertensive medication. The original internal consistency reliability (Cronbach’s Alpha) was 0.94; in this study, it was 0.92, indicating high reliability.
Hypertension education booklet
The Hypertension Education Booklet was developed by the researchers following a comprehensive literature review. It includes information on the disease, treatment options, lifestyle modifications, the importance of adherence, and home blood pressure monitoring. Expert opinions were obtained from one internal medicine specialist, three nursing faculty members, and one specialist nurse. To ensure clarity, the booklet was also reviewed by three hypertensive patients, and revisions were made based on their feedback. Item and content validity analyses were conducted before finalizing the material.
Research implementation
Eligible patients who agreed to participate completed informed consent forms. Both groups were administered the "Patient Introductory Information Form," " General Self-Efficacy Scale," and "Medication Adherence Self-Efficacy Scale in Hypertensive Patients" through face-to-face interviews as a pre-test. Patients were assigned to intervention and control groups using a non-random allocation approach based on the order of admission to the outpatient clinic. To reduce potential selection bias, baseline sociodemographic and clinical characteristics of the groups were compared and found to be statistically similar. The intervention group received a 30-minute individualized training session on blood pressure monitoring using the “Hypertension Education Booklet” in the ECG room. Participants in the intervention group were provided with home monitors and were instructed to measure BP twice daily. They received reminder texts three times a week and monthly follow-up calls for three months. A three-month follow-up period was considered sufficient to evaluate short-term changes in medication adherence and self-efficacy following the intervention. The educational content focused on hypertension management, medication adherence, lifestyle modification, and regular self-monitoring of blood pressure. The intervention components were designed to support self-efficacy through repeated reinforcement, active self-monitoring, behavioral reinforcement through reminders, and increased patient engagement in hypertension management. All participants in the intervention group received the same educational booklet and follow-up schedule. Post-tests were collected online at the end using the same validated measurement tools administered during the pre-test phase. The control group received no intervention and completed the same validated post-test forms online. A preliminary test with two patients ensured the clarity of the forms; their data were excluded from analysis.
Data evaluation
The data were analyzed using SPSS 20. Frequencies and percentages were used to assess their distribution across the groups. The intervention and control groups were compared using the chi-square test. An “independent sample t-test" was employed to compare two independent groups. A "Paired t-test" was performed to compare two dependent groups. Descriptive statistics (mean and standard deviation) were used. The statistical significance cut-off value was set at 0.05. Because multiple comparisons were conducted, findings should be interpreted cautiously due to the potential risk of type I error inflation.
Ethical principles of the research
This study was approved by the Ethics Committee of Erzurum Atatürk University Faculty of Medicine on 05/11/2020 (Approval No: B.30.2.ATA.0.01.00/…). The study was conducted in accordance with the principles of the Declaration of Helsinki and followed the national ethical standards of the Republic of Turkey. All participants provided written informed consent before participation.
Results
In the intervention group, 54.8% were aged 51–60, 35.5% were first-degree obese, 64.5% were women, 87.1% were married, 64.5% had primary education, 80% were unemployed, and 61.3% had average income. Sociodemographic characteristics were similar between groups. Medically, 53.1% used one antihypertensive drug, 46.9% had used it for ≥10 years, and 90.6% took it regularly. Additionally, 87.5% had a family history of hypertension, 90.6% perceived improvement in blood pressure control, 56.3% did not follow a diet, 65.6% were physically active, and 81.3% were non-smokers. Medical characteristics were also similar between groups (Table 1).
Table 1.
Distribution and comparison of sociodemographic characteristics of intervention and control groups (n=63).
| Intervention group (n=31) | Control group (n=32) | Test value | |||||
|---|---|---|---|---|---|---|---|
| Sociodemographic Characteristics | n | % | n | % | X2 | p* | |
| Age | 40–50 age | 7 | 22.6 | 6 | 18.8 | 4.257 | 0.119 |
| 51–60 age | 17 | 54.8 | 11 | 34.4 | |||
| 61 age and above | 7 | 22.6 | 15 | 46.8 | |||
|
BMI (Body Mass Index) |
Normal | 5 | 16.1 | 1 | 3.1 | 4.519 | 0.211 |
| Overweight | 7 | 22.6 | 13 | 40.6 | |||
| 1st degree obese | 11 | 35.5 | 11 | 34.4 | |||
| 2nd degree obese | 8 | 25.8 | 7 | 21.9 | |||
| Sex | Female | 20 | 64.5 | 21 | 65.6 | 0.009 | 0.926 |
| Male | 11 | 35.5 | 11 | 34.4 | |||
| Marital status | Married | 27 | 87.1 | 27 | 84.4 | 0.095 | 0.758 |
| Single | 4 | 12.9 | 5 | 15.6 | |||
| Educational status | Primary school | 20 | 64.5 | 23 | 71.9 | 1.285 | 0.526 |
| Middle school | 5 | 16.1 | 6 | 18.7 | |||
| High school and above | 6 | 19.4 | 3 | 9.4 | |||
| Working status | Yes | 8 | 20 | 8 | 25 | 1.575 | 0.455 |
| No | 23 | 80 | 24 | 75 | |||
| Economic status | Income less than expenses | 12 | 38.7 | 5 | 15.6 | 0.093 | 0.759 |
| Income equals expense | 19 | 61.3 | 27 | 84.4 | |||
| Number of antihypertensive drugs used | 1 | 21 | 67.7 | 17 | 53.1 | 2.828 | 0.419 |
| 2 | 8 | 25.8 | 10 | 31.3 | |||
| 3 and above | 2 | 6.5 | 5 | 15.6 | |||
| Duration of antihypertensive medication use | 0.5–1 year | 4 | 12.9 | 1 | 3.1 | 16.688 | 0.338 |
| 2–5 year | 11 | 35.5 | 14 | 43.8 | |||
| 6–9 year | 4 | 12.9 | 2 | 6.2 | |||
| 10 year and above | 12 | 38.7 | 15 | 46.9 | |||
| Regular use of drugs | Yes | 28 | 90.3 | 29 | 90.6 | 0.002 | 0.967 |
| No | 3 | 9.7 | 3 | 9.4 | |||
| Family history of hypertension | Yes | 25 | 80.6 | 28 | 87.5 | 0.554 | 0.457 |
| No | 6 | 19.4 | 4 | 12.5 | |||
| BP change | Yes | 30 | 96.8 | 29 | 90.6 | 1.001 | 0.317 |
| No | 1 | 3.2 | 3 | 9.4 | |||
| Special diet for hypertension | Salt-free-fat-free | 20 | 64.6 | 14 | 43.7 | 5.284 | 0.071 |
| No | 11 | 35.4 | 18 | 56.3 | |||
| Daily activity | Yes | 20 | 64.5 | 21 | 65.6 | 0.009 | 0.926 |
| No | 11 | 35.5 | 11 | 34.4 | |||
| Smoking status | Yes | 5 | 16.1 | 6 | 18.7 | 0.075 | 0.784 |
| No | 26 | 83.9 | 26 | 81.3 | |||
* chi-square test
Baseline pre-test scores did not differ significantly between groups (p > 0.05), indicating comparability. In post-test comparisons, the intervention group demonstrated significantly higher medication adherence self-efficacy (p < 0.001, Cohen’s d = 0.87) and general self-efficacy scores (p = 0.048, Cohen’s d = 0.51) than the control group. Within-group analyses showed significant improvements in both scales in the intervention group, whereas no significant changes were observed in the control group (Table 2).
Table 2.
Intragroup and intergroup evaluation of general self-efficacy and medication adherence self-efficacy scores in the intervention and control groups.
| Groups | Test value and significance between groupsx | Effect size (Cohen’s d) | |||
|---|---|---|---|---|---|
| Intervention group (n=31) | Control group (n=32) | ||||
| X±SD | X±SD | ||||
| Medication adherence self-efficacy scale | Pre-test | 39.65±4.27 | 39.84±7.51 |
t=-0.126 p=0.900 |
|
| Post-test | 45.97±5.86 | 39.75±5.57 |
t=4.321 p<0.001 |
0.87 | |
| Intra-group test value and significancey |
t=5.838 p<0.001 |
t=0.088 p=0.931 |
|||
| General self-efficacy scale | Pre-test | 73.81±13.83 | 73.94±12.22 |
t=-0.040 p=0.968 |
|
| Post-test | 81.16±19.18 | 74.53±11.30 |
t=1.678 p=0.048 |
0.51 | |
| Intra-group test value and significancey |
t=2.503 p=0.018 |
t=0.259 p=0.798 |
|||
Bold values indicate statistically significant differences (p 0.05).
x= Independent sample t-test, y= Paired t-test
Cohen’s d values of 0.20, 0.50, and 0.80 indicate small, medium, and large effect sizes, respectively.
Significant differences were observed between pre- and post-test SBP, DBP, and BMI values in the intervention group (p < 0.01). No statistically significant differences were observed in the control group (p>0.05) (Table 3).
Table 3.
Comparison of Pretest-Posttest Blood Pressure and BMI Results of Intervention and Control Groups (n=63).
| Characteristics | Pre-test | Post-test | Test Value | Effect Size (Cohen’s d) | ||
|---|---|---|---|---|---|---|
| X±SD | X±SD | t | p* | |||
| Intervention Group | SBP | 137.84±14.68 | 125.74±15.01 | 5.614 | p<0.001 | 1.01 |
| DBP | 85.38±6.23 | 80.29±6.96 | 4.574 | p<0.001 | 0.82 | |
| BMI | 31.16± 5.17 | 30.68± 5.11 | 3.981 | p<0.001 | 0.71 | |
| Control Group | SBP | 134.22±14.35 | 137.06±15.07 | -1.970 | 0.058 | |
| DBP | 85.18±9.78 | 85.81±7.92 | -.812 | 0.414 | ||
| BMI | 31.12± 3.90 | 30.97± 3.80 | 1.222 | 0.236 | ||
Bold values indicate statistically significant differences (p 0.05).
* Paired t-test
Cohen’s d values of 0.20, 0.50, and 0.80 indicate small, medium, and large effect sizes, respectively.
Discussion
Improving hypertension management is a national priority that has the potential to lower morbidity and mortality. Self-measured blood pressure is recommended in evidence-based hypertension management guidelines.16 The findings were interpreted in relation to the existing literature to examine the medication adherence and self-efficacy levels of patients with hypertension in relation to a multicomponent support intervention.
The intervention group demonstrated significantly higher medication adherence self-efficacy scores in the post-test period, suggesting improved adherence levels. These findings are consistent with previous studies reporting improved medication adherence following educational and behavioral interventions. Similar results may be explained by the fact that repeated education, self-monitoring practices, and continuous follow-up can increase patients’ awareness of hypertension management and strengthen treatment-related self-efficacy. Unlike previous studies that focused solely on educational support or motivational interviewing, the present study combined individualized education, home blood pressure monitoring, reminder messages, and follow-up communication within a multicomponent intervention framework17–19. In other research, however, motivational interviewing was observed to improve medication adherence in the intervention group9,20. Improved medication adherence may contribute to better hypertension management and quality of life. In this study, as in others, education and self-monitoring enhanced adherence, likely due to increased patient responsibility and improved understanding of blood pressure management.
The increase in medication adherence self-efficacy suggests that the intervention may have supported patients’ confidence in managing their treatment. Considering the scale’s range, post-intervention scores indicate a relatively high level of adherence. According to previous studies examining general self-efficacy perceptions, education may contribute to beneficial changes in patients’ self-efficacy perceptions8,20. High self-efficacy enhances motivation and persistence, while low self-efficacy can amplify perceived challenges. Supporting self-efficacy in hypertension management promotes lasting behavioral change, improves adherence, and reduces complications. The post-intervention increase suggests the training encouraged more active patient involvement. Regular reminders, self-monitoring practices, and continuous follow-up may have reinforced patients’ confidence in managing their condition and maintaining treatment-related behaviors. This finding supports Bandura’s theoretical perspective that repeated reinforcement and successful self-management experiences may strengthen individuals’ confidence in managing chronic conditions.
Significant differences were observed in the pre- and post-test SBP, DBP, and BMI values between the intervention and control groups. Previous studies have suggested that educational interventions may contribute to lower blood pressure in patients with hypertension5,9,19. The observed decrease in blood pressure may be linked to the twice-daily self-monitoring included in the multicomponent support intervention. Additionally, the observed changes in BMI in the intervention group may reflect increased awareness of lifestyle behaviors during the intervention; however, these findings should be interpreted cautiously because dietary intake and physical activity were not assessed using objective measurement methods. Furthermore, previous studies21,22 have shown that significant improvements in BMI were reported after the intervention. Obesity, especially with a high BMI, is a key risk factor for hypertension. Education and self-management interventions may support weight loss and maintenance by increasing awareness and encouraging healthier lifestyle choices. Despite these limitations, this study contributes to the literature by evaluating a multicomponent support intervention that integrates education, self-monitoring, reminder systems, and follow-up communication in hypertensive patients in a real-world clinical setting.
Limitations
This study has several limitations. First, participants were allocated using a non-random allocation approach based on admission order rather than computer-generated randomization, which may have introduced selection bias. Second, allocation concealment was not implemented. Third, the post-test data were collected online, whereas the pre-test data were collected face-to-face, which may have introduced measurement mode differences and response bias. In addition, the attrition rate during follow-up may limit the generalisability of the findings. In addition, the relatively small sample size and single-center design may limit the external validity and generalisability of the findings to broader hypertensive populations. Additionally, intervention fidelity was not formally evaluated, and the multicomponent nature of the intervention limits the ability to determine which specific component contributed most to the observed outcomes. Confidence intervals were not reported for all analyses, which may limit the interpretation of the findings’ precision.
Conclusion
Improvements were observed in medication adherence and self-efficacy scores among patients in the intervention group. A multicomponent educational and behavioral support intervention may improve medication adherence, blood pressure regulation, and lifestyle-related behaviors among hypertensive patients. In collaboration with primary care providers, studies to assess multicomponent support interventions and medication adherence among hypertensive patients can be planned.
Acknowledgement
The Research Atatürk University Scientific Research Projects funded the research Project number: TSA-2021-8985 We thank the patient for taking part in the study.
Author contributions
Study design: B.Ç., E.N.N, Data collection: E.N.N , Data analysis: E.N.N, Study supervision: B.Ç., Manuscript writing: B.Ç., E.N.N, Critical revisions for important intellectual content: B.Ç., E.N.N, All listed authors meet the authorship criteria and that all authors are in the agreement with the content of the manuscript.
Funding
The Research, Atatürk University Scientific Research Projects, funded the research Project number TSA-2021-8985
Data Availability
The datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions and patient confidentiality, but are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Ethics
This study received approval on 05/11/2020, dated (B.30.2.ATA.. 0.01.00/), from the Erzurum Atatürk University Faculty of Medicine Ethical Board. We thank the patient for taking part in the study.
Footnotes
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions and patient confidentiality, but are available from the corresponding author on reasonable request.