LEVEL OF MEDICATION ADHERENCE AND ASSOCIATED FACTORS

AMONG ADULTS ON HYPERTENSION TREATMENT IN DEBRE

BIRHAN TOWN GOVERNMENTAL HEALTH INSTITUION, 2026

A RESEARCH PROPOSAL WILL BE SUBMITTED TO DEBREBIRHAN

UNIVERSITY ASRAT WOLDEYES HEALTH SCIENCE CAMPUS,
NURSING AND MIDWIFERY EDUCATION AND SERVICE
DIRECTORATE FOR PARTIAL FULFILLMENT OF DEGREE OF
BACHELOR SCIENCE IN COMPREHENSIVE NURSING

September, 2025

DEBRE BIRHAN, ETHIOPIA

1
 LEVEL OF MEDICATION ADHERENCE AND ASSOCIATED
FACTORS AMONG ADULTS ON HYPERTENSION TREATMENT IN DEBRE
BIRHAN TOWN GOVERNMENTAL HEALTH INSTITUION, 2026

BY: TAGELE SHITAYE

TILAHUN GEBREMARIAM

YEMISRACH AKALU

YESHAREG TIRSET

ADVISOR: Mrs ELDA M. (Bsc,Msc)

Mr. HAYLIYE M. (Bsc,Msc)

September 2025 DEBRE BIRHAN, ETHIOPIA

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Acknowledgment
First of all, Praise to God, who makes all things done in their appropriate time. We would like to
acknowledge Debre Birhan University Asrat Woldeyes health science Campus nursing and
midwifery education and service directorate for giving us this golden opportunity to prepare this
research proposal. We would like to extend our gratitude and thanks for our advisors Mrs Elda
Mekonnen and Mr Hayliye Mitikie (Bsc Msc) for thier critical comment and supervision.

At last but not list we want to thank our friends and all our supporter who valued for our hard
work.

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Summary
Background: Hypertension is defined as Systolic Blood Pressure ≥ 140 mmHg and/ or Diastolic
Blood Pressure ≥ 90 mmHg. It’s global public health challenge worldwide that contributes to the
burden of Hypertensive Heart Disease, stroke, renal failure, premature morbidity and mortality.
Adherence to pharmacological treatment is a key in guaranteeing success full therapy outcomes.

Objective: To assess Level of Medication Adherence and Associated Factors among Adults on
Hypertension Treatment in Debre Birhan Town Governmental Health Institution

Work plan budget: The work plan of this proposal will be complete from starting time of
September 2025 up to jaunary 2026 and the total cost of budget is 6940birr.

Key word: Hypertension, Adherence of treatment

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Table of content
Acknowledgment.........................................................................................................................................3
ABBREVIATIONS.....................................................................................................................................9
1. INTRODUCTION.................................................................................................................................10
1.1 Background.....................................................................................................................................10
1.2 Statement of the Problem.................................................................................................................11
1.3 Significance of the study.................................................................................................................14
2. LITERATURE REVIEW......................................................................................................................15
2.1 Adherence to antihypertensive treatment.........................................................................................15
2.2 Socio demographic factor................................................................................................................15
2.3 Drug related factor...........................................................................................................................16
2.4 Clinical related factor......................................................................................................................17
2.5 Patient related factors......................................................................................................................18
3. OBJECTIVES.......................................................................................................................................21
3.1 General objective.............................................................................................................................21
3.2 Specific objectives.....................................................................................................................21
4. METHODOLOGY................................................................................................................................22
4.1 Study area and period......................................................................................................................22
4.2 Study design....................................................................................................................................22
4.3 Population........................................................................................................................................22
4.3.1 Source population.....................................................................................................................22
4.3.2 Study population.......................................................................................................................23
4.4 Inclusion and exclusion criteria.......................................................................................................23
4.4.1 Inclusion criteria.......................................................................................................................23
4.4.2 Exclusion criteria.....................................................................................................................23
4.5 Sample size determination and Sampling procedure........................................................................23
4.5.1 Sample size determination........................................................................................................23
4.5.2 Sampling procedure..................................................................................................................24
4.6 Study variables................................................................................................................................24
4.6.1 Dependent Variable..................................................................................................................24
4.6.2 Independent Variable................................................................................................................24

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 4.7 Operational Definition.....................................................................................................................25
4.8 Data collection tools and Procedures...............................................................................................25
4.9 Data quality control.........................................................................................................................26
4.10 Data Processing and Analysis........................................................................................................26
4.11 Ethical consideration.....................................................................................................................26
4.12 Dissemination of the result............................................................................................................27
5. W0RK PLAN AND BUDGET..............................................................................................................28
5.1 WORK PLAN.................................................................................................................................28
5.2 BUDGET.........................................................................................................................................29
REFERENCE............................................................................................................................................30
ANNEXES................................................................................................................................................32

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List of table
Table 1: work plan preparation for the proposal.......................................................................................25
Table 2: Budget plan..................................................................................................................................26

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List of figure
Figure 1: Schematic presentation of Conceptual frame work....................................................................18

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ABBREVIATIONS
AOR – Adjusted Odd Ratio

BP- Blood Pressure

DBP – Diastolic Blood Pressure

HGH – Hakim Gzaw Hospital

DBT- Debre Birhan Town

DBU – Debre Birhan University

DM – Diabetes Mellitus

HHD- Hypertensive Heart Disease

HTN – Hypertension

Km – kilometer

MMAS – Morisky 8-Item Medication Adherence Scale

RVI – Retro Viral Infection

SBP – Systolic Blood Pressure

SPSS – Statistical Product and Service Solutions

WHO – World Health Organization

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1. INTRODUCTION

1.1 Background
Hypertension is a condition in which the blood vessels have persistently raised pressure. It can
also be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure
(DBP) ≥ 90 mmHg. HTN rarely causes symptoms in the early stages and many people go
undiagnosed. Those who are diagnosed may not have access to treatment and may not be able to
successfully control their illness over the long term. If left uncontrolled, hypertension can lead to
a heart attack, an enlargement of the heart and eventually heart failure (1).

Although the overall HTN prevalence is between 10%- 15% globally, the prevalence rates is
as high as 30% to 32% in middle-income countries. High-income countries have a lower
prevalence of hypertension (35%) than other groups (40%). The prevalence of hypertension is
35% in Highincome countries, like America. However prevalence of hypertension is increasing
in more rapid in African Region. Generally the overall prevalence of hypertension is expected to
be 46% in lowland middle-income countries. Prevalence of hypertension is increasing
dramatically in African due to uncontrolled population growth, weak health system for early
detection and treatment and poor health seeking behavior (2).

In our local set up there was no available data which shows the prevalence of HTN. Even if
there is shortage of extensive data around 10.5% of the Ethiopian population has been estimated
to have HTN. Approximately 30% of adults in Addis Ababa have HTN or reported use of anti-
hypertensive medication (3).

The term adherence is often used synonymously with compliance in accessing how patients
follow their medial instructions (regimes) from their respective medical practitioners. However,
some researchers prefer to use the term adherence. The researchers express their concerns that
compliance signifies a judgmental point of view (4).

According to Word Health Organization report antihypertensive medications adherence

ranges from 52% to 74% when adherence is defined as possession of a medication at least 80%
of the time. It also identified non adherence to medical treatment as a major public health

10
concern, especially in patients with chronic disease like hypertension. Adherence to therapies is a
primary determinant of treatment success. Poor adherence to treatment weakens optimum
clinical 2 benefits and therefore reduces the overall effectiveness of health systems. Medication
adherence has been defined in terms of an agreement between the patient's behavior of taking
medications and the clinical prescription. Faulty adherence or non-adherence with medications
may include errors of purpose, timing or dosage as well as total or partial omission, or use of
inadvertent combinations. Non-adherence with medications is one of the major factors in the
failure of therapeutic programs in patients having a chronic disease (1, 4).

Hypertension has no cure. Therefore, patients are expected to take medications for life. Drug
treatment of hypertension demands that patients adhere with their medication as prescribed
strictly. They should respect their appointments for follow up visits with their doctors and adopt
health actions that are recommended to lower their blood pressure. Adherence to drug treatment
and adjustment to required life style changes has been found to be very efficient in hypertension
management and has the following benefits for the individual, the health care systems and
society at large, it improves the quality of life and prevents complications and premature deaths.
It is also a cost saving measure since it decreases the incidence of compilation (12).

In our local setting there was no study done on adherence, but the prevalence of adherence to
AHT in Ethiopia ranges from 32% to 69% taken from different study done in different region of
the country. From those study factors like socio-demography, Medication payment, BP control
level, side effect of drug, presence of comorbidity, knowledge about HTN and its treatment were
identified as a reason for non- adherence (6 ,7).

1.2 Statement of the Problem

Hypertension is a global public health issue that contributes to the burden of heart disease,
stroke and renal failure with premature mortality and disability. It is an overwhelming global
challenge with high morbidity and mortality rate. Analysis of the global burden of hypertension
revealed that over 25% of the world adult population had hypertension in 2000, and the
proportion is expected to increase to 29% by 2025. Early detection and treatment of hyper-
tension and other risk factors, as well as public health policies that reduce exposure to behavioral

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risk factors, have contributed to the gradual decline in mortality due to hypertensive heart disease
and stroke in high-income countries over the last three decades (1, 4, &5)

Adherence to pharmacological treatment for hypertension is considered as a key factor in

guaranteeing successful treatment out -comes. Non-adherence to anti-hypertensive therapy can
be determined by demographic, drug related, disease related and setting related factors.
However, little is known about which factors determine low adherence in actual practice. WHO
describes poor adherence as the most important cause of uncontrolled blood pressure and
estimates that 50-70% of people do not take their antihypertensive medication as prescribed (3,
4).

In line with the global realities Hypertension sufferers are non-adherent to their
pharmacological regimen and frequent lifestyle changes that result in uncontrolled hypertension
again that leads to different life threatening organ complications such as cardiovascular, renal
and Cerebrovascular diseases (8). It is now evident from WHO data that coronary heart disease
and cerebrovascular disease are increasing rapidly that they will rank the 1st and 5th respectively
as causes of global burden by the year 2020. Hypertension was considered as the major risk
factor for stroke and cardiovascular disease. It is well known that high blood pressure increases
the risk of ischemic heart disease by three to four times and of overall cardiovascular risk
increase by two to three folds. The incidence of stroke increases approximately three times in
patients with borderline hypertension and approximately increases eight times in those with
definite hypertension. It has been estimated that 40% of cases of acute myocardial infarction and
stroke were attributable to hypertension (1, 5 & 8).

In general non-adherence is the most common problems especially in developing countries

because existences of different factors than developed countries such as religion, educational
status, cost of medication, and type of dosage form such as capsule, solution, suspension and
tablet forms, route of administration, test of medication and safety of medication can has effect
on adherence (13).

In order to mitigate the effects of the disease on the populations, it is essential to improve
adherence among sufferers of the disease by identifying underlying factors for non-adherence in

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order to overcome against non-adherent behavior and developing effective interventions to solve
identified factors (9).

Factors affecting adherence behavior are unique to individual patient and specific for
geographic area. Therefore, there is a great need of organized research that is closely linked to
the patient compliance towards their treatment to improve the adherence to antihypertensive
treatment. Concerning Client adherence towards antihypertensive treatment there were no
specific studies done in our local setting. So, taking this in to consideration this study assessed
the overall prevalence of adherence and identified the reasons for non-adherence to treatment
among hypertensive patients visiting HGH.

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1.3 Significance of the study

The adherence studies about the hypertension were frequently focused on only the
pharmacological interventions. However, the management of hypertension is composed of many
lifestyle interventions. This study focused on adherence and associated factors of adherence to
medication, diet, substance and exercise.

Therefore, the result of this study is of valuable to:

1. Health care providers, the general public, Nurses, the ministry of health or Ethiopian
Health service and administrators on Patients’ adherence to anti- hypertensive
Medications and lifestyle recommendations, such information would assist health care
Professionals to manage hypertension appropriately.

2. Identifying the information gap regarding to adherence to antihypertensive medication

And lifestyle changes recommendations for patients who are attending follow up care at Debre
Birhan town health institution.

3. Beside to this the result of this study could be used as a base line data to other activities or
researches.

4. It would also assist policy makers in developing context specific and relevant policies capable
of improving the management of hypertension.

5. Patients’ adherence to anti- hypertensive medications will be therefore improved

Significantly and this will prevent treatment failures encountered in therapy due to non-
adherence. As a result there will be much savings on the medicines budget both from
The patient as an individual and the government as a whole since hospital admissions
And cost of treatment will be reduced.

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2. LITERATURE REVIEW

2.1 Adherence to antihypertensive treatment

Globally, WHO estimates that the optimal adherence levels of high blood pressure
medications among hypertensive patients ranges from 50% to 70% (1).

In Africa a study done in Ghana by Haruna [Link] al showed that 49.3% of the study participant
were adherent to their antihypertensive treatment. Other study done in Nairobi by Antony
showed that 70.5% of the study participants were adherent to their antihypertensive treatment (5,
12).

In our country Ethiopia the prevalence of adherence to antihypertensive treatment varies from
study to study as well as from region to region. According to study done at mekele general
hospital and ayider referral hospital out of 121 study subjects, 64 (52.9%) were adherent, 25
(20.7%) were moderately adherent while 32 (26.4%) were non-adherent to their anti-
hypertensive medication (4).

A study done in Gondar hospital shows that out of 384 study participant only 64.6% of them
were adherent for their anti-hypertensive treatment. Other similar study done on prevalence of
adherence was at Adama referral hospital, Black lion hospital, Dese referral Hospital and Jima
Hospital with an outcome of 59.5%, 69.5%, 31.8%, and 55.7% respectively (2, 3, 7, 9 &10)

2.2 Socio demographic factor

A study done in Ghana by Haruna A. indicates that patients below 50 years and between 60 to
69 years had significantly better adherences than those from 50 –59 years and 70 years and
above. Generally, at 70 years and above patients tend to forget their medication taking regimen
and this adversely affects adherence (5).

In Ethiopia, A study done in Jima by Fiseha G. showed that participants whose age group
ranges from 41 to 60 and above 60 years has better adherence than those whose age group
between 18 to 40 years. Married respondents were two times more likely to adhere to
antihypertensive treatment compared to divorced respondent. Respondents who had private

15
business were 72% less likely to adhere to medication compared to governmental employed.
Respondents who attended most of the time in private clinic to receive health care were six times
more likely to adhere to medication than who attend government health care facility (2, 5, &7).

A Study done at Muhimbili University by Angelina A. showed that female had higher
proportion of treatment adherence (63.2%) than males (45.8%).Proportion of treatment
adherence decreases as the level of education increases, that is participants with primary school
education and no formal education were higher treatment adherence compared to those with
secondary school educational though it was not statistically significant. Participants who were
employed had high proportion of treatment compliance compared to those who were not
employed (6).

In Ethiopia study done in Jima shows participant who complete their secondary education were 6
times more likely to antihypertensive than illiterate (6, 7, 10).

A study done in Saudi Arebiaby Fatmal A. showed that economic status was associated with
medication adherence that linked to the ability of the patient to afford the medication. Similarly
low income status was associated with poor medication adherence (8).

A study done in Adama referral hospital by Habtamu A. showed that Muslim religion
followers were three times adherent to their antihypertensive than Orthodox. Absence of family
support decrease adherence, while living in city increase adherence to antihypertensive treatment
(3, 4).

A study done in Dese referral hospital shows association between religion and non-adherence
were from the data only 4.4% of respondents from all religion stop their medication due to
fasting one of the rules of Orthodox and Muslim religion did not affect the adherence of the
patient (9).

2.3 Drug related factor

A study done in Addis Ababa black lion hospital by Habtamu A. showed that there are drug
related barrier that affect adherence like duration of treatment, number of drug prescribed, fear of
side effect of the drug as well as cost of the medication. Respondents with the duration of

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diagnosis of five or more years were 89% less likely to adhere to treatment when compared to
with diagnosis of hypertension less than two years. Those with treatment duration between two
to four years were 4 times more likely to adhere to treatment compared to less than 2 years.
Participant who take less than or equal to 3 drug has higher adherence than those who take more
than 4 drug regimen (2, 7).

Research done at Adama referral hospital, show that duration of treatment was one of the
barriers to adhere to their anti-hypertensive treatment for around 54.2% of study participant. On
the other 8 hand cost of the drug was not considered as a barrier for around 55.3% study
participant. Similarly fear of side effect has no impact on their adherence for around 75.3% of
respondent (3).

A study conducted in University of Gondar hospital indicates that21.8% of the respondents’

adherence was affected due to side effects of the drug (10). A study done in dese referral hospital
symptom of high BP and adverse effect of the drug had an effect on adherence for around58.24%
of respondents. The odd of adherence to antihypertensive treatment was higher in hypertensive
patient who took only one, two, and three drug regimen in relation to those who took four and
above drug combination (7, 9, &10).

According to research conducted in Pakistan showed that there is increased non adherence
among patients who paid themselves for their medicines (p=0.06) than those whose medicine
paid by family or others. Similarly Side effects of drugs also contribute to some extent in causing
nonadherence in 9% of study participant. Common side effects which were reported by patients
were dizziness (17%), polyuria (12%), and sedation (9%) (11).

2.4 Clinical related factor

There are different clinical factor those affect patient adherence to antihypertensive like blood
pressure level, family history of hypertension, presence of comorbidity and complication. A
study done in Adama Referral Hospital by Habtamu A. showed that Presence of comorbidity
among study participant decrease adherence to Antihypertensive treatment by half while,
absence of comorbidity improve adherence to Antihypertensive treatment by 50%. The odd of
adherence among study participants with no or one comorbidity where 2.5 and 2.6 times

17
respectively higher than the odd of adherence among those who had two or more than two
comorbidity. Comorbidities can worsen the condition of the patient and make them unable to
adhere to their antihypertensive treatment (3).

A study done in Gondar hospital revealed that the number of comorbidities among
hypertensive patient had significant association on adherence behavior. Patient with more
number of co morbidities could suffer from serious complication and complex treatment regimen
which were favorable condition not to adhere to their medication (10).

A study done in Mekele General Hospital and Ayider Referral Hospital by Mediha A. showed
that People who developed HHD were 21 times more non-adherent to their AHT than the other
population. Controlled blood pressure level was associated with good adherence behavior (4
&10).

2.5 Patient related factors

There are other patient related factors that affect adherence to antihypertensive treatment like
distance of health service from house of patient, frequency of follow up visit, use of social drug
forget fullness of drug , knowledge about hypertension and medication.

Study done in Dese Referral hospital showed that out of 69 study participants around 78.8%
are social drug users. Out of them 8.79% were non-adherent and 16.48% of them had memory
problem. They forgot to take their medication of prescribed by the prescribers. In this study
social drug use had significant association to non-adherence of the patient (9).

A study done in University of Gondar Hospital showed that long distance from health facility
was a big barrier for adherence to treatment especially when it was accompanied by lack
transportation and poverty. So distance from hospital was another variable found to be
significantly and independently associated with adherence status of the respondent. Those patient
from distant area were less likely to be adherent as compared to study subject from closer area.
Knowledge about HTN and its treatment was found to be positively associated with adherence
behavior. Patient with better awareness were more likely to adhere to their treatment (10).

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 A study done in Jima University Specialized hospital by Fiseha G. showed that the odd of
adherence to antihypertensive medication was higher among hypertensive patient who highly
perceived their disease severity and benefit of adherence to antihypertensive treatment than those
who have lower perception which was 3 and 10 times respectively. According to research done
in Dese Referral Hospitalthere is significant association between social drug use (cigarette,
alcohol) and adherent of the patient. Most drinkers missed their medication during drinking time
(day) (11%), Post drinking day (7%) and at non drinking day 4.1% (7 & 9).

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 Conceptual frame work

Patient related factor, like:

Socio-demographic
 Family history of
Factor, like:
hypertension
 Age,  Use of social drug
 Sex,  Forget fullness
 Occupation  Knowledge about
 Educational, hypertension and
 Religion, medication
 Residence,
 Income,
 Marital Status,
 Family support
Adherence
status

Clinical factor like: Drug related factor, like:

 Presence of comorbidity  Duration of therapy,
and complication,  number drugs
 Blood pressure control  side effect of drugs
level  Cost of the drug

Figure 1: Schematic presentation of Conceptual frame work

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3. OBJECTIVES

3.1 General objective

 To Asses Level of Medication Adherence and Associated Factors among Adults on

Hypertension Treatment in Debre Birhan Town Governmental Health Institution, 2026.

3.2 Specific objectives

 To assess Level of Medication Adherence among adults on Hypertension Treatment in

Debre Birhan Town Governmental Health Institution, 2026.
 To identify factor affecting medication adherence among Adults on Hypertension
Treatment in Debre Birhan Town Governmental Health Institution, 2026.

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4. METHODOLOGY

4.1 Study area and period

The study will be conducted in Governmental Health Institution. which is found at Debre
Birhan town from August to january, 2026. Debre Berhan is the capital city of North Shoa, one
of the 13 zones of Amhara regional state which is located 130 Km to north of Addis Ababa,
Ethiopia.

In the city there are two governmental health institutions those are Hakim Gizaw hospital and
Debre Birhan Referal hospital .Those institution are serving care for around 150,000 people
annually and it can also give inpatient care for around 7700 patient annually. Debre Birhan
Referal hospital was established in 1929 (E.C). Currently the hospital has a total of 310 health
professionals as reported from DBRH human power resource management. Totally the hospital
has around 200 beds. In the hospital there are inpatient and outpatient treatment. The outpatient
treatment takes place at the adult, pediatrics, maternal and emergency OPD. There are six adult
OPD from those there is one chronic OPD. This study was done at chronic OPD and hakim
Gizaw hospital was established in ----- (E.C). Currently the hospital has a total of --------health
professionals as reported from HGH human power resource management. Totally the hospital
has around ---------- beds. In the hospital there are inpatient and outpatient treatment. The
outpatient treatment takes place at the adult, pediatrics, maternal and emergency OPD. There are
-----adult OPD from those there is ----- chronic OPD. This study was done at chronic OPD

4.2 Study design

Institution based cross sectional study design will be conducted in Debre Birhan town
governmental health institution among hypertensive patients from August to jaunary, 2026.

4.3 Population

4.3.1 Source population

All people who are diagnosed with hypertension and on follow up in Debre Birhan town
governmental health institution.

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 4.3.2 Study population

All sampled / selected hypertensive patients who are on follow up at Debre Birhan town
governmental health institution as out-patient during study period.

4.4 Inclusion and exclusion criteria

4.4.1 Inclusion criteria

 Hypertensive patients who are on follow up as outpatients.

 Patient whose age of 18 or greater than it.

4.4.2 Exclusion criteria

 Patient who are critically and mentally ill.

 Pregnancy related hypertensive patients.
 Participant who have hearing and speaking difficulty.

4.5 Sample size determination and Sampling procedure

4.5.1 Sample size determination

The number of participants that will be included in the study will determined by using a
formula for estimating a single population proportion by assuming a confidence interval of 95%,
the key proportion of medication adherence by hypertensive patients in Debre Birhan town
governmental health institution taken as 32% (from the same research conducted at Dese
Referral Hospital) and degree of accuracy of deviation from the true proportion in population
taken as 5%.

n = (Z α/2) 2 p (1-p)
d2

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 Where:

n=the minimum sample size required

Z= the standardized normal distribution curve value for the 95% confidence interval (1.96)

P= Estimated proportion of medication adherence by hypertensive patients=0.32

q= Estimated proportion of medication non-adherence amongst hypertensive patients=0.68

d= Acceptable degree of accuracy required taken as 0.05

n= (1.96)2 × (0.32) × (0.68)/ (0.05)2 =334.4

NB; After we get total source population and if its less than 10,000 we will use correction
formula.

4.5.2 Sampling procedure

All hypertensive patients who has follow up visit during study period and who fulfill the
inclusion criteria will include in the study. Systematic random sampling method will be used to
recruit a specific number of study participants each day depending on patient turn out.

Participants will be informed on the need to participate only once in the study to avoid
multiple enrollments. Sampled participants who fulfill the inclusion criteria will be interview
after being reviewed by the clinicians.

4.6 Study variables

4.6.1 Dependent Variable

 Adherence towards antihypertensive treatment

4.6.2 Independent Variable

 Socio demographic characteristics:

such as Age, Sex, Occupational status, Educational status, Religion, Ethnicity, Income,
Marital Status, financial support, social life, residence.

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  Clinical factors: like blood pressure control level, presence of comorbidity and
complication.
 Drug related variables: like duration of therapy, number of drugs, side effect and cost
of drug.
 Patient related factors: like family history of hypertension, use of social drug, forget
fullness, knowledge about hypertension and medication.

4.7 Operational Definition

Adherence: is the extent to which the patient behaves as clinician recommendation on dose,
frequency, appointment, and timing and MMAS score ≥ 8

Non-adherence: any form of deviation from adherence like losing one appointment, missing
doses, etc. and 8 item MMAS score less than 8.

Hypertension: is defined as the persistent systolic blood pressure equal to and greater than 140
mmHg and/or persistent diastolic blood pressure equal to and greater than 90 mmHg.

Comorbidity: Is when the patient has two or more disease at the same time.

Hypertensive patients: a patient who was diagnosed as having hypertension.

4.8 Data collection tools and Procedures

A structured interviewer will administer questionnaire which contains five parts will applied to
assess the socio-demography of patient, adherence status, clinical related factors, drug related
factor, health care system related factors, and patient related factors. Before starting the data
collection the questionnaire will be prepare in English language and translate to Amharic as
needed. Pre-tested will be held on 5% of the sample. The data will be collect by principal
investigators by using a pre-tested structured interviewer administered questionnaire.

25
 4.9 Data quality control
Before data collection the data collectors will be discussed on the questionnaires to have
common understanding and pre-test will be held on 5% of the sample. Possible correction will be
done after a pre-test and all interviewed questionnaire will be re-evaluated for completeness and
consistency on daily basis with close supervision.

4.10 Data Processing and Analysis

After data collection the data will be enter and clear using EPI info version 3.6.1 and will be
analyze by using SPSS version 20 software. Then descriptive statistics like frequency
distributions, percentage, mean and standard deviations will be used to summarize findings. The
level of medication adherence on hypertensive treatemnet will be computed as the proportion of
participants who have a score of eight and above in MMAS score. Antihypertensive treatment
adherence will be categorize in to treatment adherence (MMAS) score ≥ 8 (Adherence) and score
< 8 (Non-adherence). Binary logistic regression will perform to determine the factors
independently associated with antihypertensive treatment adherence. Crude odds ratios with,
95% confidence interval will be calculated for all variables included in the bivariate model. A
multivariate analysis will be perform for variable that has p-value less than 0.2 to determine the
independent effects of the explanatory variables. P-value less than 0.05 will be taken as
statistically significant for all analysis. Finally, the result of the study will be summarize by
frequency distribution and present by using tables and graphs.

4.11 Ethical consideration

Ethical clearance and formal letter will be obtained from Debre Birhan University and Chief of
Executive office of Debre Birhan town governmental health institution. Verbal Informed consent
will be obtain from the study participants after explain the purpose of the study before their
participation. Participants will be assure that their participation will be totally voluntary, their
name will not be stated, data will be kept confidential and anonymous and it will be used only
for research purpose. Finally study participant will be assure as there is no compensation offer.

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4.12 Dissemination of the result
The result of the study will be submit to DBU Asrat Woldeyes health science Campus nursing
and midwifery education and service directorate as partial fulfillment for Degree of Bachelor
Science in comprehensive nursing. The result will be presented on symposium of research
proposal defense. Every possible effort will be taken to publish the study result.

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 5. W0RK PLAN AND BUDGET

5.1 WORK PLAN

Table 1: work plan preparation for the proposal

S.N Activity AUG SEP OCT NOV DEC JAU

1. Topic selection

2 Research proposal
writing

3 Research Proposal
Submission

4 Questionnaire
preparation

5 Questionnaire pre-test

6 Data collection

7 Data Analysis

8 Research report writing

(final draft)

09 Research submission

10 Research defense

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5.2 BUDGET
Table 2: Budget plan

No Budget item Cost in Unit Duration Multiplicatio Total cost

birr n factor -cost
*unit
*duration
01 Pen 25 4 - 25*4 100
02 Paper 3 400 - 400*3 1200
03 Printing and 10 birr per 40 - 40*10 400
binding paper
04 Pencil 10 4 - 10*4 40
05 Lunch 200 per 4 5 days 200*5*4 4000
day
06 Water 30 birr one 4 5 days 30*5*4 600
person
07 Flash 600 1 - 600*1 600
Total 6940 birr

29
 REFERENCE
1. World Health Organization. The global brief of hypertension: WHO report on HTN.
2013: 10-22
2. Habtamu A. Mesfin A. Adherence to hypertension medication and associated factors
among hypertensive patient attending TikurAmbessa Specialized hospital renal unit.
International Journal of Nursing science, 2013, 3 (1): 3-6

3. Habtamu A. Dr. Molla G. Bekel S. Assessment of prevalence and associated factors of

adherence to anti-hypertensive agent among adult. International Journal of current
microbiology and applied science, 2014, 3(1): 764-768.

4. Madiha A. Mebratu L. GebrehiwotT. Antihypertensive medication Non adherence and

its determinants among patient on follow up in public Hospital. International journal of
clinical trials, 2014, 1(3): 95-104.

5. Claxton AJ, Cramer J, Pierce C. Systematic review of theassociation between dose

regimens and medication compliance. Clinical Therapeutics. 2001; 23: 1296 – 1310

6. Fiseha G. Solomon E. Altaye M. and Fessehaye A. Compliance with antihypertensive

treatment and associated factors among hypertensive patient on follow up in Jima
University specialized hospital. Journal of HTN open access, 2014, 3: 174.

7. Angelina A. Factors affecting treatment compliance among hypertension patients in three

district hospitals. Muhuhinbili University of health allied science. 2012, 1, 36-40.

8. Fatmah A., Xiang and H. Ignacio C. Factors Affecting Antihypertensive Treatment

Adherence A Saudi Arabian perspectives. Clinical medicine and diagnosis, 2012, 2(4):
27-32.

9. Belayneh K. Yitayih K. Gizaw D. and Esayas T. Assessment of Adherence of Patient

with antihypertensive medication and factors for non-adherence in Amhara region DRH.
International Journal of Chemical and Natural science, 2013, 2(1):51-57.

10. Abere G. Getahun A. Solomon M. and Zelalem B. Adherence to antihypertensive

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treatment and associated factors among patient on follow up at University of Gondar
hospital. 2012, view article at PubMed Google scholar
11. Arshia B. Mehwish R. Mariam A. et. Non-compliance to antihypertensive medication
and its associated factors among hypertensive patients. J Ayub med Coll Abbottabad
2015; 27(1) ; 158-63

12. Antony T. Factors influencing adherence to hypertension medication. University of

Nairobi, 2013, 47-60.

13. Williams [Link]. The science and practice of pharmacy. In Remington

(17thed).2001: 2: 1966-1970.

14. Morisky DE, Ang A, Krousel-Wood H: Predictive validity of a medication adherence

measure for hypertension control. Journal of Clinical Hypertension 2008; 10(5):348-354

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ANNEXES

Annexes I Questioner English Version

Information sheet
Mr./Mrs,
We are student at DBU School of health science department of Nursing. We are
Conducting an academic research on adherence to and factors affecting antihypertensive
Treatment among hypertensive on follow at Debre Birhan town governmental . You have been
identified as a suitable person to provide information for this study.
I am kindly requesting you to answer this enclosed questionnaire as accurately and honestly as
Possible. The information you give will not in any way affect your treatment as well as will not
hart you. The information given will be treated with ultimate confidentiality. Participation in this
study is voluntary and you are free to withdraw at any stage.
Thank you.

32
 Part I Socio-demographic characteristics
NO Variables Response Skip
1 Age? -------
2 Sex? Male
Female
3 Marital status? Single
Married
Divorced
Widowed
4 Where do you currently live? Rural
Urban
5 What is your religion? Orthodox
Muslim
Protestant
Other specify -------
6 What is your ethnicity? Amara
Oromo
Tigre
Other specify----------
7 What is your occupation? Government employed,
Private business
House wife
Unemployed,
Pensioner,
Farmer
Daily laborer
Student
8 What is your average monthly income in birr? ……………………
I don’t know
9 What is the highest level of education that you Can’t read and write
Can read and write
attained?
Primary level,
Secondary level,
Diploma level
Degree level
Masters level
10 Do you have family support? Yes
No
Questionnaire
Questionnaire ID No --------------------------- Name of interviewer----------

33
 Part II. Participants clinical related factors
11 When were you diagnosed with blood pressure? ----------------
12 Do you suffer from any comorbidity? Yes
No
13 If yes which one(s)? ----------------
14 Do you have complications from hypertension? Yes
No
15 If yes, what was the complication? ---------------
16 What was your blood pressure control level? Good
Fair
Poor
I don’t know
Part III. Participant’s drug related factors
17 For how long you have been on treatment for ---------------
hypertension?
18 How many antihypertensive drugs are you on? Single drug,
Two drug,
Three drug,
Four and above drug
19 Have you ever noted any adverse effects of the Yes
drugs you are taking? No
20 If yes which ones? --------------
21 Who cover your medication cost? Government
Self
Family
Part IV. Assessment Patient related factors
22 Is there hypertensive patient in your family? Yes
No
23 Do you currently smoke cigarettes? Yes
No
24 If yes, how many sticks in a day? -----------
25 Do you currently take alcohol? Yes
No
26 If yes, how many unit in a week? ---------
27 Have you ever use traditional drug for Yes
hypertension? No
28 If yes, specify it ----------

34
29 Do you have difficulty of remembering to take of Yes
your medication? No
30 What does the term hypertension mean? Raised BP
Raised blood sugar level
Increase stress,
I don’t know
31 How dangerous is hypertension to your health? Extremely severe
Somehow
Not at all
32 Do you know normal Blood Pressure levels? Yes
No
33 If yes, what is the normal level of BP? -------------
34 Which number is more important? Top
Bottom
Both
I don’t know
35 Would lowering HBP improve your health? Yes
No
Somehow
I don’t know
Part V. Assessment of health care system related factors

36 Are you comfortable by with this hospital Yes

environmental set up? No
37 Does the health care provider give information Yes
about your disease condition and prescribed No
medication?
38 How far the hospital from your home in Km? ------------
39 For how long do you wait to get treatment? ------------
Part VI. Assessment of respondent’s adherence status

1 Do you sometimes forget to take your High Blood 1. No,

Pressure pills? 0. Yes
2 Over the past two weeks was there any days when 1. No,
you did not take your HBP medication? 0. Yes
3 Have you ever cut back or stopped taking your 1. No,
medication without telling your doctor, because 0. Yes
you felt worse when you took it?
4 When you travel or leave home, do you sometimes 1. No,
forget to bring along your HBP medication? 0. Yes

35
5 Did you take your HBP medication yesterday? 0. No,
1. Yes
6 When you feel like your HBP is under control, do 1. No,
you sometimes stop taking your medication? 0. Yes
7 Do you ever feel hassled about sticking to your 1. No,
HBP treatment plan? 0. Yes
8 How often do you have difficulty remembering to 0. All the time,
1. Usually,
take your medication?
2. Sometimes,
3. Once in a while,
4. Never/rarely,

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