PLOS ONE

RESEARCH ARTICLE

Predictors of non-adherence to
antihypertensive medications: A cross-
sectional study from a regional hospital in
Afghanistan
Muhammad Haroon Stanikzai1,2,3, Mohammad Hashim Wafa ID4, Essa Tawfiq5,
Massoma Jafari6, Cua Ngoc Le ID1,2, Abdul Wahed Wasiq7, Bilal Ahmad Rahimi ID8, Ahmad
Haroon Baray3, Temesgen Anjulo Ageru ID1,2, Charuai Suwanbamrung ID1,2*

1 Public Health Research Program, School of Public Health, Walailak University, Thai Buri, Thailand,
a1111111111
2 Excellent Center for Dengue and Community Public Health (EC for DACH), Walailak University, Thai Buri,
a1111111111 Thailand, 3 Faculty of Medicine, Department of Public Health, Kandahar University, Kandahar, Afghanistan,
a1111111111 4 Faculty of Medicine, Neuropsychiatric and Behavioral science Department, Kandahar University,
a1111111111 Kandahar, Afghanistan, 5 The Kirby Institute, UNSW Sydney, Sydney, Australia, 6 McMaster University,
a1111111111 Hamilton, Ontario, Canada, 7 Faculty of Medicine, Department of Internal Medicine, Kandahar University,
Kandahar, Afghanistan, 8 Department of Pediatrics, Faculty of Medicine, Kandahar University, Kandahar,
Afghanistan

* [email protected]

OPEN ACCESS

Citation: Stanikzai MH, Wafa MH, Tawfiq E, Jafari

M, Le CN, Wasiq AW, et al. (2023) Predictors of
Abstract
non-adherence to antihypertensive medications: A
cross-sectional study from a regional hospital in
Afghanistan. PLoS ONE 18(12): e0295246. https:// Background
doi.org/10.1371/journal.pone.0295246 Non-adherence to antihypertensive medications (AHMs) is a widespread problem. Cardio-
Editor: Kahsu Gebrekidan, UiA: Universitetet i vascular morbidity and mortality reduction is possible via better adherence rates among
Agder, AUSTRALIA hypertensive patients.
Received: September 13, 2023

Accepted: November 20, 2023

Objectives
This study aimed to assess the prevalence of non-adherence to AHMs and its predictors
Published: December 27, 2023
among hypertensive patients who attended Mirwais Regional Hospital in Kandahar,
Peer Review History: PLOS recognizes the
Afghanistan.
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author Methods
responses alongside final, published articles. The
A cross-sectional study using random sampling method was conducted among hyperten-
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0295246 sive patients, aged �18 years in Mirwais Regional Hospital at a 6-month follow-up between
October and December 2022. To assess non-adherence to AHMs, we employed the Hill-
Copyright: © 2023 Stanikzai et al. This is an open
access article distributed under the terms of the Bone Medication Adherence scale. A value below or equal to 80% of the total score was
Creative Commons Attribution License, which used to signify non-adherence. A multivariable binary logistic regression model was used to
permits unrestricted use, distribution, and identify predictors of non-adherence to AHMs.
reproduction in any medium, provided the original
author and source are credited.
Results
Data Availability Statement: The authors confirm
that all data underlying the findings are fully We used data from 669 patients and found that 47.9% (95%CI: 44.1–51.8%) of them were
available without restriction. All relevant data are non-adherent to AHMs. The majority (71.2%) of patients had poorly controlled blood

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

within the paper and its Supporting Information pressure (BP). The likelihood of non-adherence to AHMs was significantly higher among
files. patients from low monthly-income households [Adjusted odds ratio (AOR) 1.70 (95%CI:
Funding: This study was financially supported by 1.13–2.55)], those with daily intake of multiple AHMs [AOR 2.02 (1.29–3.16)], presence of
the Excellent Center for Dengue and Community comorbid medical conditions [AOR 1.68 (1.05–2.67), lack of awareness of hypertension-
Public Health, School of Public Health [WU-COE-
66-16], and the Walailak University. The funders
related complications [AOR 2.40 (1.59–3.63)], and presence of depressive symptoms [AOR
had no role in study design, data collection and 1.65 (1.14–2.38)].
analysis, decision to publish, or preparation of the
manuscript.
Conclusion
Competing interests: The authors have no conflict
of interest. Non-adherence to AHMs was high. Non-adherence to AHMs is a potential risk factor for
uncontrolled hypertension and subsequent cardiovascular complications. Policymakers and
clinicians should implement evidence-based interventions to address factors undermining
AHMs adherence in Afghanistan.

Introduction
Chronic illnesses have constantly presented substantial health issues on a worldwide scale.
Among these conditions, hypertension stands out as a particularly concerning disease. World
Health Organization (WHO) estimated that ~1.28 billion adults aged 30–79 years had hyper-
tension in 2019, and it may rise to 1.56 billion by 2025 [1–3]. According to the report, the
majority (two-thirds) of hypertensive patients live in low- and middle-income countries
(LMICs) [3]. Hypertension is a crucial contributor to cardiovascular complications and health
loss—for instance, only in 2019, it claimed ~7.5 million deaths (12.8% of global deaths) [1–3].
The occurrence of geopolitical instability and economic downturns in certain places, such as
Afghanistan, has had a dual impact on healthcare services, as well as the exacerbation of stress-
related diseases, notably hypertension [4]. In 2020, 5.3 million hypertensive patients and 7,995
hypertension-linked deaths were reported in Afghanistan [4].
Worldwide, only 21% of hypertensive patients have their blood pressure under control
[3,5,6]. The rate of blood pressure (BP) control differs between countries. In resource-poor
countries such as India, Ethiopia, and Uganda, the level of controlled BP among treated
patients was 17.5% [7], 47.9% [8], and 18% [9], respectively. In Afghanistan (with its healthcare
system still recovering from years of conflict), the national prevalence of uncontrolled hyper-
tension is ~80%, warranting immediate attention [4,10].
The benefits of lifestyle changes and pharmacotherapy in controlling blood pressure levels
are well established [1,5]. However, low or no adherence to AHMs is a widespread problem.
Aside from the obvious health consequences, poor adherence to AHMs has socioeconomic
implications in developing countries, such as higher medical costs, missed workdays, and
demand for healthcare systems [6]. Globally, AHMs adherence has recently become a central
concern to clinicians, policymakers, and researchers. In Afghanistan, where access to health-
care services and medications is quite limited, AHMs-adherence acquires additional impor-
tance [4].
Adherence to AHMs varies globally, influenced by sociodemographic factors and lifestyle
choices [11–18], leading to marked regional disparities in adherence levels. Moreover, adher-
ence to AHMs is suboptimal, particularly in the developing world [9,11–15]. For instance, a
recent study involving 27 million populations found that the global prevalence of no-adher-
ence to AHMs was high, ranging from 27% to 40% [11]. A study from 22 Asian countries

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

reported that approximately 48% of hypertensive patients had poor adherence to their AHMs
[12]. The proportion of hypertensive patients with low compliance to AHMs was 37.7% in Paki-
stan [13], 49.6% in Iran [14], 39.5%% in Nigeria [15], 34.5% in Ethiopia [16], 67.7% in Cameron
[17], 37.4% in Nepal [18], and 4%-81% in India [19]. In 2023, Baray et al. showed that Afghani-
stan’s current proportion of hypertensive patients with low adherence to hypertension treat-
ment is 42.1% [10]. In Afghanistan, the high prevalence of uncontrolled hypertension
compounded with non-adherence to AHMs constitutes a significant public health problem.
A fair amount of data in the developing world indicate that diverse factors such as age
[11,20], sex [11,21,22], marital status [11,23], employment status [11,24], area of residence
[11,20], education [11,25], health facility distance [21], household income [11,22], Body Mass
Index (BMI) [23,24], physical activity [11,20], alcohol consumption [22], smoking [11],
comorbidity [11,20–22], salt intake [11,20], family history of hypertension [11], hypertension
duration [11], number of AHMs [11,20–22], stage of the disease [11], knowledge about hyper-
tension and its treatment [21,24,25], history of depressive symptoms [11,23,24,26], hyperten-
sion-linked cost [11,22,24,25], social support [23,26], and client satisfaction [25] are associated
with adherence to AHMs.
Although non-adherence to AHMs is a global health concern, in developing countries such
as Afghanistan, where literacy, economy, and healthcare systems, to name a few, are highly
devastated, it is even more worrisome. Non-adherence to AHMs is associated with poor blood
pressure control, which, in turn, potentially contributes to the development of uncontrolled
hypertension. A study conducted in Afghanistan indicates that 77.3% of hypertensive patients
had poor BP control [10]. The literature gap, however, does exist on the prevalence of non-
adherence to AHMs and its predictors in Afghanistan. Considering the gap in knowledge, we
aimed to assess the prevalence of non-adherence to AHMs and related predictors among
hypertensive patients who attended Mirwais Regional Hospital in Afghanistan to aid and
direct future interventions.

Materials and methods

Study setting and design
We conducted this cross-sectional study at Mirwais Regional Hospital (MRH) in Kandahar
City between October and December 2022. MRH is the largest public hospital allocated to
healthcare provision in the southwest region of Afghanistan. MRH provides services primarily
to the residents of 6 provinces (Kandahar, Helmand, Zabul, Oruzgan, Nimroze, and Farah),
that is, more than 5000,000 population in its catchment area. MRH is a public hospital and
provides secondary and tertiary health services free of charge to patients, including hyperten-
sive patients. Thus, the data generated from this hospital may be somewhat considered a fair
representation of the whole hypertensive mass of the country.

Study population
Our target population consisted of any hypertensive patient, aged � 18 years, who consented
to participate in this study and was receiving antihypertensive follow-up treatment at MRH for
at least six months at the time of data collection. We excluded pregnant women, unconscious
and critically ill individuals, and currently hospitalized patients.

Sample size and sampling procedure

The sample size for this study was estimated using the single population proportion formula,
which accounts for the expected prevalence, desired confidence level, and allowable error. We

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

Fig 1. Flowchart of participants’ recruitment.

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employed a 42.1% prevalence rate of non-adherence to AHMs for calculating our sample size
[10]. Considering 95% CI, 5% margin of error, 1.5 design effect, and a 15% non-response, we
reached out to 718 hypertensive patients. Out of those contacted, 669 agreed to join the study
while others declined or were unavailable. The sampling procedure involved a random selec-
tion of hypertensive patients who received antihypertensive treatment at the outpatient depart-
ment (OPD) of the hospital six months prior to data collection. We accessed the total list of
our hypertensive subjects from the patients’ registration book of the respective hospital in Sep-
tember 2022, consisting of 1869 hypertensive patients. The data pertaining to patients with
hypertension was recorded in Microsoft Excel spreadsheets. We employed a random sampling
procedure to select the 718 respondents for our follow-up study (Fig 1).

Study variables
Dependent variable. The outcome variable was the proportion of patients with non-
adherence levels to AHMs on the Hill-Bone Medication Adherence Scale. The Hill-Bone Med-
ication Adherence Scale, designed by Johns Hopkins University (1999), contains nine items
[27]. Each item is a four-point scale ranging from 1 (all the time) to 4 (none of the time), yield-
ing a total score from 9 to 36. A value below or equal to 80% of the total score was used to

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

signify medication non-adherence [28–30]. The Hill-Bone Medication Adherence Scale is a

globally credible instrument with good psychometric properties for assessing medication
adherence across various chronic diseases and conditions [30,31]. The Cronbach’s alpha value
for the Pashtu version was 0.89. This scale has been used previously in Afghanistan and has
demonstrated excellent psychometric properties [10].
Independent variables. Socio-demographic factors included age, marital status, sex, resi-
dence, education, employment, household monthly income, household size, and Body Mass
Index (BMI).
Behavioral factors included smoking history, level of physical activity, vegetable and fruit
consumption, and added table salt intake.
Disease-related factors included family history of high BP, duration of hypertension, pres-
ence of comorbid medical conditions, hospitalization history in the last six months, nonsteroi-
dal anti-inflammatory drugs (NSAIDs) use, BP monitoring at home (measurement of BP at
home), number of AHMs, and source of AHMs (public vs. private pharmacies).
In this study, we measured BP using a new manual sphygmomanometer, following the
guidelines set by the American Heart Association [32]. The device was tested on several
patients, and its readings of systolic BP and diastolic BP were compared with several other new
sphygmomanometers. We found no major differences between the readings of BP between the
sphygmomanometer we used and others. All patients had their BP measured twice, each sepa-
rated 10 minutes apart. The average of two BP values was used in the analysis. BP was defined
as controlled if systolic BP was <140 mmHg and diastolic BP was <90 mmHg or uncontrolled
if either one or both were elevated [33].
We employed the 9-item self-administrated Patient Health Questionnaire (PHQ-9) scale to
assess depressive symptoms in our patients over the last two weeks [34]. All nine items of
PHQ-9 were scored on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day), yielding
a total score from 0 to 27. The total scores were grouped into different categories of depression
symptoms based on the following ranges: normal = 1–4, mild = 5–9, moderate = 10–14,
severe = 15–19, and extremely severe = 20–27 [34,35]. The PHQ-9 demonstrated an excellent
internal reliability with a Cronbach’s α of 0.92. The PHQ-9 has been used previously in
Afghanistan [10].
Additionally, we employed the International Physical Activity Questionnaire short form
(IPAQ-SF) to assess physical activity levels in our population [36]. We considered walking 3
days/week for at least 20 min/day to be low level of physical activity or < 3 metabolic equiva-
lents (METs). Moderate physical activity 3-5days/week for at least 30 min/day represented
medium level of physical activity or 3 to 7.9 METs. Vigorous physical activity 3–7 days/week
signified high level of physical activity or >8.0 METs [36,37]. The Cronbach’s α value for our
sample was 0.876.

Data collection
The questionnaire, which consisted of sections on socio-demographic information, behavioral
factors, disease-related information, IPAQ-SF, PHQ-9, and the Hill-Bone Medication Adher-
ence Scale, was initially drafted in English and later translated into the local language (Pashtu)
for the ease of administration. Before the commencement of the study, we pretested the ques-
tionnaire in another setting (Kandahar Teaching Hospital) with 59 participants to check and
revise (if required) its verbal consistency.
Two male and two female doctors with an MD degree in curative medicine and a minimum
of three years of clinical experience composed our interview team. Although some interviewers
had participated in other clinical studies, all interviewers received one-day training for this

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

study. To ensure cultural sensitivity and patient comfort, particularly given the diverse demo-
graphic of hypertensive patients, we strategically included two male and two female doctors in
the team. The investigators screened all records of hypertensive patients registered in the OPD
of MRH from April 2021 to March 2022. We employed a random selection process and made
a telephone call to 718 patients. If the patients would like to participate, they could willfully
provide verbal consent and schedule the interview at their convenience. Female doctors inter-
viewed female patients. This gender division facilitated smoother interactions, especially in
scenarios where female patients preferred being interviewed by a female doctor. Each inter-
view took approximately 20 minutes to complete. We called consented patients from October
to December 2022, and the principal investigators supervised the data collection process. Par-
ticipants were compensated for their travel expenses and time. We checked the questionnaires
within 24 hours for completion.

Statistical analysis
We transferred the data from Microsoft Excel 2019 to IBM SPSS Statistics version 21.00 for
cleaning and analyses [38]. We employed descriptive statistics for most variables, such as fre-
quency and percentage. Next, we conducted univariate and multivariable analyses to identify
predictors of non-adherence. We adjusted the model for potential confounders such as age
and sex. We set the significance level at a P value of <0.05.

Ethical approval
The permission to conduct the study was obtained from the Public Health Directorate of Kan-
dahar Province and the Research and Ethics Committee (Faculty of Medicine, Kandahar Uni-
versity) approved this study (Certificate # 17, Dated 15/July/2022). We obtained informed
consent either in written form or in oral form (if the participant was illiterate). We declare that
we carried out all methods in light of relevant guidelines and regulations. We also assert that
all procedures contributing to this work adhere to established guidelines for medical research
involving human subjects and with the Helsinki Declaration of 1975, as revised in 2008.

Results
A total of 669 patients with hypertension were enrolled in the present analyses (response rate,
93.1%). The mean age (±SD) was 47.5 (± 9.62) years. Of them, 52% (348) were male, and 53.5%
(358) were urban residents. Moreover, 606 (90.6%) were married, 449 (67.1%) had no formal
education, and 421 (62.9%) were unemployed. The monthly median average household income
was 9000 Afghani (IQR: 6000–13,000), which is equivalent to approximately USD 100 (August
2023). Their mean BMI (±SD) was 23.3 (±3.36), and about a fourth (23.8%) of them were over-
weight/obese. Table 1 depicts the detailed socio-demographic characteristics of our participants.
The majority (79.5%; 532) of them were physically inactive, 28.9% (193) were current ciga-
rette smokers, and 33.0% (221) reported adding salt to their food at the table. Table 2 summa-
rizes the behavioral characteristics of our participants.
The median duration of hypertension diagnosis was 6.88 years (IQR 3.4–12.1 years), and
nearly half of the patients (47.5%, 318) had a positive family history of hypertension. A large
percentage (38.9%) of the patients had some type of comorbid health condition, and one-third
(32.6%, 218) had no awareness of hypertension-related complications. Of all treated hyperten-
sive patients, 24.8% (166) monitored their BP at home, 38.7% (259) were on �3 AHMs, and
71.2% (476) had poor control of their BP. Overall, 345 (51.6%) patients had depressive symp-
toms, including 70 (10.5%) mild, 183 (27.4%) moderate, 89 (13.3%) severely moderate, and 3
(0.4%) severe cases (Table 3).

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

Table 1. Socio-demographic characteristics of the study participants (n = 669).

Variables Frequency (%)
Age (In completed years)
18–29 16 (2.4)
30–39 98 (14.6)
40–49 297 (44.4)
50–59 186 (27.8)
� 60 72 (10.8)
Sex
Male 348 (52.0)
Female 321 (48.0)
Residence
Urban 358 (53.5)
Rural 311 (46.5)
Marital status
Single 15 (2.3)
Married 606 (90.6)
Widowed 3 (0.4)
Divorced 45 (6.7)
Educational Status
No formal education 449 (67.1)
Primary 73 (10.9)
Secondary 80 (12.0)
High school graduate 54 (8.1)
Higher studies 13 (1.9)
Employment stauts
Self-employed 191 (28.6)
Public employed 34 (5.1)
Private/NGO employed 23 (3.4)
Housewife 216 (32.3)
Unemployed 205 (30.6)
Household members
�8 359 (53.7)
>8 310 (46.3)
Monthly household income (in Afghanis)
� 10000 446 (66.7)
11000–20000 164 (24.5)
> 21000 59 (8.8)
BMI status
Under weight 5 (0.7)
Normal weight 505 (75.5)
Over weight 113 (16.9)
Obese 46 (6.9)

Abbreviations: BMI, Body Mass Index; NGO, Non-Governmental Organizations.

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Out of 669 participants, 341 were non-adherent to their AHMs according to the Hill-Bone
Medication Adherence scale, giving a non-adherence prevalence of 47.9% (95%CI: 44.1–
51.8%).
Table 4 lists the results of univariate and multivariable analyses. For each independent vari-
able in the table, the category marked with "1" represents the reference category against which
odds ratios for other categories are compared. After controlling for age and sex, the likelihood
of non-adherence to AHMs was significantly higher for patients living in households with an
income of <10000 Afghanis/month (AOR = 1.70: 1.13–2.55). For clinical characteristics, daily
intake of multiple AHMs (AOR = 2.02: 1.29–3.16), presence of comorbid medical conditions

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

Table 2. Behavioral characteristics of the study participants (n = 669).

Variables Frequency (%)
Current cigarette smoking
Yes 193 (28.9)
No 476 (71.1)
Physical activity
Yes 137 (20.5)
No 532 (79.5)
Level of physical activity (n = 137)
Low 33 (24.1)
Moderate 70 (51.1)
High 34 (24.8)
Fruits consumption
Rarely 313 (46.8)
Sometimes 330 (49.3)
More often 26 (3.9)
Vegetables consumption
Rarely 273 (40.8)
Sometimes 321 (48.0)
More often 75 (11.2)
Meat consumption
Rarely 522 (78.0)
Sometimes 85 (12.7)
More often 62 (9.3)
Added table salt
Yes 221 (33.0)
No 448 (67.0)

Notes: Rarely (less than once a week); Sometimes (1–3 times a week); More often (4–7 times a week).

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(AOR = 1.68: 1.05–2.67), lack of awareness of hypertension-related complications

(AOR = 2.40: 1.59–3.63), and presence of depressive symptoms (AOR = 1.65: 1.14–2.38) were
significantly associated with higher of odds of non-adherence to medications (Table 4).

Discussion
This study assessed hypertension medications non-adherence and its predictors among hyper-
tensive patients attending a regional hospital at the six months follow-up in southwest Afghan-
istan. We found that 47.9% of hypertension patients were non-adherent in their AHMs use.
Factors that mainly led to non-adherence were low monthly household income, antihyperten-
sive regimens requiring multiple medications, presence of comorbid medical conditions, lack
of awareness of hypertension-related complications, and presence of depressive symptoms.
Additionally, the majority (71.2%) of the patients had poor control of their BP.
We found that 47.9% of our subjects were non-adherent for AHMs, with a 95% CI of 44.1%
to 51.8%. This figure is higher than the non-adherence rates claimed in many studies con-
ducted in other developing countries, such as Pakistan, Nigeria, Ethiopia, and Nepal
[13,15,16,18]. Therefore, our findings signify an outstanding example of an LMIC country
with limited resources and lagging behind the adherence rates to AHMs of the developed
world [14,18]. Since non-adherence to AHMs inevitably predicts uncontrolled hypertension
and subsequent cardiovascular complications, authorities should plan interventions to
improve medication adherence among hypertensive patients. Such interventions could include

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

Table 3. Disease related characteristics of the study participants (n = 669).

Variables Frequency (%)
Duration of hypertension (years)
1–5 311 (46.5)
�5 358 (53.5)
Family history of hypertension
Yes 318 (47.5)
No 351 (52.5)
Comorbid medical disease
Yes 260 (38.9)
No 409 (61.1)
BP monitoring at home
Yes 166 (24.8)
No 503 (75.2)
NSAIDs use
Yes 205 (30.6)
No 464 (69.4)
Number of AHMs
Monotheraphy 190 (28.4)
Dual theraphy 220 (32.9)
�3 259 (38.7)
Hospitalization in the last six months
Yes 135 (20.1)
No 534 (79.9)
Source of AHMs
Private pharmacies 607 (90.7)
Public 62 (9.3)
BP level
Controlled 193 (28.8)
Uncontrolled 476 (71.2)
Knowledge about hypertension complications
Yes 451 (67.4)
No 218 (32.6)
Severity of depression (PHQ-9)
None/minimal depression 324 (48.4)
Mild depression 70 (10.5)
Moderate depression 183 (27.4)
Moderately severe depression 89 (13.3)
Severe depression 3 (0.4)

Abbreviations: BP, Blood Pressure; NSAIDs, Non-Steroidal Anti-Inflammatory Drugs; AHMs, Anti-Hypertensive
Medications; PHQ-9, Patient Health Questionnaire-9.

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patient education, simplifying medication regimens, implementing reminder systems, and

encouraging regular follow-up appointments.
Consistent with relevant literature, we found that patients with low monthly household
incomes were more susceptible to non-adherence to AHMs. Moreover, private pharmacies
provided medicines for a vast majority (90.7%) of the patients. Similar studies have shown that
low income could interfere with good medication adherence among hypertensive patients
[11,22,24]. It may epitomize the difficulty low-income patients encounter while bearing the
economic burden of especially long-term hypertension treatment. Furthermore, the harsh eco-
nomic conditions in the country might plunge many hypertensive patients into poverty.
Therefore, low-income patients require adequate financial support from family members by

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Table 4. Factors associated with non-adherence to AHMs; crude and adjusted odds ratio with 95% CI.
Independent Variables Non-adherence COR P-Value AOR P-Value
Categories Yes No (95% CI) (95% CI)
Age < 40 49 65 1 0.21 - -
�40 272 283 1.27 (0.84–1.91)
Marital status Currently married 286 320 1 0.20 - -
Currently unmarried 35 28 1.35 (0.84–2.17)
Employment Employed 210 243 1 0.21 - -
Unemployed 111 105 1.22 (0.88–1.69)
Monthly household income <10000 241 205 2.10 (1.50–2.92) <0.001 1.70 (1.13–2.55) 0.01
�10000 80 143 1 1
Physical activity Yes 47 90 1 <0.001 - -
No 274 258 2.03 (1.37–3.08)
Smoking Yes 102 91 1.31 (0.94–1.83) 0.10 - -
No 219 257 1
Added table salt Yes 120 101 1.46 (1.05–2.01) 0.02 - -
No 201 247 1
Duration of hypertension 1–5 years 125 186 1 <0.001 - -
> 5 years 196 162 1.80 (1.32–2.44)
Number of medications Single 67 123 1 <0.001 1 0.02
Multiple 254 225 2.07 (1.46–2.93) 2.02 (1.29–3.16)
Comorbid disease Yes 134 126 1.51 (1.03–2.22) 0.03 1.68 (1.05–2.67) 0.01
No 187 222 1 1
Hospitalization in the last six months Yes 76 59 1.26 (0.92–1.72) 0.06 - -
No 245 289 1
Family history of hypertension Yes 164 154 1.31 (0.97–1.78) 0.07 - -
No 157 194 1
Knowledge of hypertension complications Yes 201 250 1 0.01 1 <0.001
No 120 98 1.52 (1.1–2.10) 2.40 (1.59–3.63)
Depression Yes 196 149 2.09 (1.53–2.85) <0.001 1.65 (1.14–2.38) 0.007
No 125 199 1 1

Abbreviations: COR, Crude Odds Ratio; AOR, Adjusted Odds Ratio, CI, Confidence Interval; BP, Blood Pressure; AHMs, Anti-Hypertensive Medications.

https://doi.org/10.1371/journal.pone.0295246.t004

providing money for drugs and transportation. In addition, government or non-profit organi-
zations can offer assistance programs to help low-income patients access affordable
medications.
Our finding of the positive association between non-adherence and daily intake of multiple
AHMs is consistent with studies from Korea [20], Malaysia [39], Lebanon [23], and elsewhere
[11,18,21,24]. The everyday use of multiple daily medications is an essential intervention to
decrease cardiovascular complications in patients with poorly controlled hypertension. Also,
their benefits in treating hypertensive patients with comorbidities have been shown in the liter-
ature [40,41]. However, regimens with more than one medication per day are inconvenient,
and as a consequence, patients find them difficult to follow, and potentially compromising the
effectiveness of the treatment. Hence, the combination and preparation of the two AHMs as
one tablet, known as a fixed-dose combination (FDC), might improve patient adherence
[21,41]. Before prescribing FDCs, healthcare providers should carefully consider the medical
history of patients, their current health status, and potential drug interactions. It is also worth
mentioning that the presence of side effects from multiple medications and limited financial
resources may also contribute to non-adherence in such cases.
The association between comorbidity and risk of non-adherence to AHMs is well docu-
mented. We found that patients with a comorbid medical condition were 1.6 times more likely

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

to be non-adherent to AHMs than their counterparts with no comorbidity. The increased dif-
ficulty of treating numerous illnesses simultaneously sometimes may cause patients to priori-
tize one over another or to feel overwhelmed, affecting their adherence. Similar findings from
Korea [20] and Ethiopia [21] revealed comorbidity as a valid factor in tackling adherence. A
possible reason for this could be a complicated treatment regimen. Besides, concomitant pre-
scription of several medications prescribed for both hypertension and comorbidities that
might result in a pill burden that inevitably leads to non-adherence. Another limitation associ-
ated with comorbidities is the potential for drug-drug interactions, which can hinder medica-
tion adherence. It is crucial for healthcare providers to effectively communicate the risks and
benefits of each medication, especially when potential interactions exist [21]. By understanding
the significance, patients may be more motivated to adhere to the prescribed regimen and
report any unusual side effects promptly [21,40]. Therefore, hypertensive patients with a
comorbidity warrant adequate care, supervision and counseling during their treatment.
Lack of awareness about hypertension complications showed an association with non-
adherence to AHMs. This finding aligns with similar studies conducted in Eastern Ethiopia
[25], Nigeria [42], and Congo [43]. Crucially, while this study did not provide gender-disag-
gregated data concerning the role of education in adherence, we must highlight the profound
implications of the recent ban on education for Afghan women. Such bans can severely limit
women’s access to critical health information and potentially compound their vulnerability to
diseases due to a lack of awareness. Given the socio-cultural landscape of Afghanistan, it is
likely that women are disproportionately affected by such bans, leading to heightened risks
regarding medication non-adherence. A lack of good knowledge about the nature of the dis-
ease might affect the patients’ motivation. Educational interventions that provide patients with
clear information about their condition, its progression, the potential risks of non-adherence,
and the benefits of following the treatment plan can significantly improve medication adher-
ence and overall disease management.
Depression is common in patients with hypertension and is associated with a poorer prog-
nosis and higher healthcare costs [44,45]. As previously reported in other studies [11,23,24,26],
the presence of depressive symptoms was associated with non-adherence to AHMs. Given the
high prevalence of depression in Afghan society, this effect is highly relevant [46]. The rela-
tionship between mental and physical health is complex. Addressing mental health concerns
such as depression is important for the patient’s general well-being and may also be a catalyst
for increasing adherence to physical health medical treatments [23,24]. Hence, screening and
early identification of hypertensive patients with depressive symptoms are paramount to cir-
cumvent non-adherence to AHMs and their bio-psycho-social sequelae.
In this study, we found that 71.2% of the patients had poor control of their BP. This finding
is consistent with previous studies conducted in Afghanistan [4,10] and other developing
countries [7–9]. There are several examples in the literature that non-adherence to AHMs also
plays a significant role in the suboptimal control of hypertension [9–11]. In Afghanistan, the
high prevalence of uncontrolled hypertension compounded with poor adherence to AHMs
raises causes for concern and action.

Study limitations
We acknowledge the limitations of this study as follows: First, the cross-sectional nature of our
study means that causal relationships between the reasons for non-adherence and the out-
comes can’t be firmly established. Second, our reliance on self-reported medication non-
adherence might introduce errors due to recall biases or participants’ desire to be viewed
favorably, also known as social desirability bias. Third, we have not assessed the complex

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

interplay of social and cultural factors that can influence medication adherence in Afghanistan.
Fourth, the unknown prevalence of non-adherence to AHMs among hypertensive patients lost
to follow-up may have introduced bias in the analysis of predictors for non-adherence. Fifth,
we lack knowledge regarding the type of AHMs our participants were taking for their medical
conditions, which could affect the degree of non-adherence and the particular causes of non-
adherence. Sixthly, our data epitomize a single regional hospital; therefore, making any gener-
alization calls for caution. Finally, our results reflect a deficiency of assessing diverse levels
(low, medium, or high) of medication non-adherence.

Conclusion
About half of hypertensive patients, in our cohort, failed in their AHM adherence. Non-adher-
ence to AHMs is a potential risk factor for uncontrolled hypertension and subsequent cardio-
vascular complications. Factors associated with non-adherence to AHMs included a monthly
household income below 10,000 Afghanis, multiple daily AHMs, comorbid medical condi-
tions, lack of awareness about hypertension complications, and the presence of depressive
symptoms. Given the current socio-economic climate in Afghanistan, with widespread unem-
ployment and the majority living below the poverty line compounded by constraints from
international donors, the issue of medication adherence takes on an even graver significance.
This situation underscores the need for innovative, locally appropriate, and economically sen-
sitive solutions tailored to the unique challenges of Afghanistan. Thus, policymakers, clini-
cians, international partners should collaboratively prioritize and implement evidence-based
interventions that not only address the specific barriers to AHMs adherence in the country but
also provide sustainable, long-term solutions.

Supporting information
S1 Dataset. Microsoft excel file with minimal dataset.
(XLS)

Acknowledgments
We express our gratitude to the officials in Mirwais Regional Hospital. We offer special thanks
to our subjects and data collectors of making this study possible through their generous
contribution.

Author Contributions
Conceptualization: Muhammad Haroon Stanikzai, Mohammad Hashim Wafa, Essa Tawfiq,
Abdul Wahed Wasiq, Charuai Suwanbamrung.
Data curation: Muhammad Haroon Stanikzai, Bilal Ahmad Rahimi.
Formal analysis: Bilal Ahmad Rahimi, Ahmad Haroon Baray, Charuai Suwanbamrung.
Funding acquisition: Muhammad Haroon Stanikzai, Cua Ngoc Le, Charuai Suwanbamrung.
Investigation: Mohammad Hashim Wafa, Essa Tawfiq, Charuai Suwanbamrung.
Methodology: Muhammad Haroon Stanikzai, Massoma Jafari, Cua Ngoc Le, Abdul Wahed
Wasiq, Ahmad Haroon Baray, Charuai Suwanbamrung.
Project administration: Massoma Jafari, Ahmad Haroon Baray, Temesgen Anjulo Ageru,
Charuai Suwanbamrung.

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PLOS ONE Predictors of non-adherence to antihypertensive medications in Afghanistan

Supervision: Charuai Suwanbamrung.

Validation: Charuai Suwanbamrung.
Writing – original draft: Muhammad Haroon Stanikzai, Mohammad Hashim Wafa, Essa
Tawfiq, Massoma Jafari, Cua Ngoc Le, Abdul Wahed Wasiq, Bilal Ahmad Rahimi, Temes-
gen Anjulo Ageru, Charuai Suwanbamrung.
Writing – review & editing: Muhammad Haroon Stanikzai, Mohammad Hashim Wafa, Essa
Tawfiq, Massoma Jafari, Cua Ngoc Le, Bilal Ahmad Rahimi, Charuai Suwanbamrung.

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