Barriers to Treatment Adherence to Hypertension: A Qualitative
Study with PBI and Non-PBI Patients of a Puskesmas in Surabaya
Hanni P. Puspitasari, Risa Septinia, Nur Cholifah, Mufarrihah Mufarrihah, and Umi Athijah
Department of Community Pharmacy, Faculty of Pharmacy, Airlangga University
Keywords: Hypertension, Treatment Non-adherence, BPJS Kesehatan, Community health centre (Puskesmas).
Abstract: Non-adherence to hypertension treatment has been reported as being a major problem, leading to an
increased incidence of cardiovascular diseases. A qualitative exploratory multi-case study has been designed
to identify factors influencing treatment non-adherence for BPJS Kesehatan members with hypertension at a
selected community health centre (Puskesmas) in Surabaya. Semi-structured interviews were conducted
with four patients who were beneficiaries of the contributions (PBI) and four non-PBI patients who were
purposively selected based on gender, age, blood pressure readings, and the frequency of visits to the
Puskesmas, as recorded in the Puskesmas’ system for information and management (SIMPUS). Thematic
analysis showed that patient-related factors, including misperception and poor knowledge about
hypertension, were mostly identified as the barriers to non-adherence. Such barriers were deemed as a
consequence of insufficient information given by the health providers. Lack of family support, common use
of herbal medicines and unhealthy traditional foods were reported as socio-cultural barriers. Finally, the
enormous number of patients served and the limited number of medicines received at the Puskesmas were
identified as the health system-related barriers. Additionally, unfamiliarity with the BPJS program for
patients with chronic conditions (PROLANIS) was found. The re-arrangement of national health insurance
programs, thus, is a considerable need in order to offer great benefits for hypertensive patients.
1 INTRODUCTION
The increased prevalence of hypertension, a primary
risk factor of cardiovascular disease, has been
reported in developed and developing countries as
the majority of patients with hypertension are less
likely to non-adhere to treatment (WHO, 2013). To
overcome such an issue, the long-term management
of chronic diseases in the primary health care setting
is crucial and well-developed organisational health
care by the government is expected to address the
challenges of chronicity (Beaglehole, et al., 2008).
The Indonesian government has implemented
universal health coverage since January 2014
organised by Badan Penyelenggaraan Jaminan
Sosial Kesehatan (BPJS Kesehatan) to help improve
access to health care services and to reduce out-of-
pocket health expenditure (WHO, 2014).
Pharmacists who participated in a previous study
expect that such a strategy may enhance the delivery
of continuity in care (Puspitasari, et al., 2015). For
example, through participation with BPJS
Kesehatan, members with chronic diseases can be
helped in the management of their chronic disease
(Program Pengelolaan Penyakit Kronis
[PROLANIS]). The participation of all family
members in BPJS Kesehatan and the involvement of
patients with hypertension in regular treatment has
been stated by the Ministry of Health in 2016 as 2
out of 12 healthy family indicators (Kementerian
Kesehatan RI, 2016).
BPJS Kesehatan memberships are classified into
beneficiaries of the government’s contribution
(Penerima Bantuan Iuran [PBI]) and non-PBI
(Indonesia Government, 2016). The government
covers monthly fees for PBI members, while the
non-PBI classification consists of members whose
monthly payment is made by their employer (BPJS
Askes) and members who make individual monthly
payments (BPJS Mandiri).
Despite the government’s existing strategies to
manage chronic diseases, the findings of a previous
study revealed that the majority of patients with
hypertension, including BPJS Kesehatan members,
at a community health centre (Pusat Kesehatan
Masyarakat (Puskesmas) with the highest
Puspitasari, H., Septinia, R., Cholifah, N., Mufarrihah, . and Athijah, U.
Barriers to Treatment Adherence to Hypertension: A Qualitative Study with PBI and Non-PBI Patients of a Puskesmas in Surabaya.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 325-329
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
325

prevalence of hypertension in Surabaya were
identified to non-adhere when it comes to visiting
the Puskesmas regularly (unpublished work) as
expected every 7-10 days. In comparison to patients
who were PBI members, non-PBI members were
less likely to adhere to make regular visits to the
Puskesmas. Although published articles show that
non-adherence to hypertension treatment can be
categorised into factors related to patient, the
disease, medicine, health provider, health-system
and socio-culture, it was unclear about the factors
affecting non-adherence to hypertension treatment
for BPJS Kesehatan members (WHO, 2013;
Tsiantou, et al., 2010; Albrecht, 2011; Osamor and
Owuni, 2011). Therefore, a study identifying the
factors influencing treatment non-adherence for
BPJS Health members with hypertension in
Puskesmas was designed.
2 METHODS
A qualitative multi-case study was applied to
explore the barriers to treatment adherence for
patients with hypertension who were members of
BPJS Kesehatan and visited Puskesmas to receive
health services. A Puskesmas in Surabaya with the
highest prevalence of hypertension (unpublished
work) had been approached to obtain a list of
patients with hypertension who were non-adherent
when it came to visiting the Puskesmas for
treatment. The Puskesmas’ system for information
and management (SIMPUS) was utilised to identify
the patients with hypertension who met the selection
criteria: 1) members of BPJS Kesehatan, either PBI
or non-PBI; 2) having a frequency of Puskesmas
visits between 3 and 24 times during the study
period from March to August 2016; 3) having
unstable blood pressure readings (normal/grade
1/grade 2) as recorded in SIMPUS; 4) full home
address was recorded in SIMPUS to enable visit for
conducting the interviews; and 5) willing to
participate in the study. A participant information
sheet was directly handed to each selected patient,
followed with an explanation about the study. Once
a patient had agreed, a date and time for a face-to-
face, semi-structure interview was arranged at their
convenience and a consent form was completed. An
interview protocol that was developed based on a
literature review of published articles on the factors
related to non-adherence was used during the
interviews (WHO, 2013; Tsiantou, et al., 2010;
Albrecht, 2011; Osamor and Owuni, 2011). All
interviews were audio-recorded and transcribed ad
verbatim. Coding was conducted using thematic
analysis, followed by a verification of the themes by
the researchers.
3 RESULTS
A total of 1,240 patients with hypertension were
recorded in the Puskesmas’ SIMPUS, consisting of
199 members of BPJS Kesehatan PBI and 542
members of BPJS Kesehatan non-PBI. After
considering the study’s selection criteria, 22 and 40
members of BPJS Kesehatan PBI and non-PBI,
respectively, were likely to be participants. Prior to
home visits to conduct the interviews, a list of
priority participants was prepared. The decision was
then made to finally select the informants, including
four members of PBI and four members of non-PBI,
representing different gender and groups of age (≤60
or >60 years old).
Case 1. A 61-year old female, member of PBI
who was diagnosed with hypertension since she was
25 years old and who has been diagnosed with
diabetes mellitus in the last four years. As captopril
25mg tablets had been previously prescribed causing
side effects that led to her non-adherence, her doctor
replaced them with nifedipin tablets. Taking several
different tablets did not affect her adherence to take
medicines. She believed that antihypertensive agents
should not be taken when normal blood pressure was
reached. As a house wife, she had plenty of time to
make frequent visits to the Puskesmas. Despite that,
she felt uncomfortable in doing so as she had to
spend an additional budget for public transport.
When her prescribed medicines were running out,
she usually depended on the mobile Puskesmas. She
was not aware of PROLANIS.
Case 2.A 45-year old male, member of PBI who
was diagnosed with hypertension two years ago.
Experiencing side effects of several antihypertensive
agents affected his adherence, therefore his doctor
replaced his medicines with amlodipin 5mg tablets.
He understood that hypertension required regular
treatment, but he often forgot to take his medicine.
He also could not stop taking his favourite unhealthy
food that was a trigger for his hypertension.
Although his doctor often reminded him to visit the
Puskesmas regularly, he objected as there was often
a long wait due to the great number of patients being
served at the Puskesmas which was time-consuming.
Moreover, he expressed his dissatisfaction at the
limited number of medicines that he received from
the Puskesmas for only a 7-10 day treatment course.
As a result, he preferred to get his medicine at a
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
326

nearby community pharmacy or consume
individually-made herbal medicines. He was not
aware of PROLANIS.
Case 3.A 45-year old female, member of PBI
who was diagnosed with hypertension since she was
27 years old. Her doctor prescribed captopril 25mg
tablets. She understood that hypertension required
regular treatment, but she often felt lazy when it
comes to take the same medicine for a long period of
time. Due to the great number of patients being
served at the Puskesmas that made her have a long
wait, she decided to get her medicine at a nearby
community pharmacy or consume individually-made
herbal medicines. She was not aware of PROLANIS,
but might be interested in participating in the
program.
Case 4.A 69-year old male, heavy smoker,
member of PBI who was diagnosed with
hypertension and hypercholesterolemia nine years
ago. He realised that his favourite unhealthy food
had caused hypertension, but he could not stop
eating them. Because of his physical disabilities, he
often failed to adhere to his doctor’s suggestion to
make regular visits to the Puskesmas without the
help from family members. When he felt that he had
increased blood pressure, he consumed individually-
made herbal medicines. He was not aware of
PROLANIS and was not interested in participating
due to his physical disabilities.
Case 5. A 49-year old male, member of non-PBI
(Askes) who has lived with hypertension for the last
year. His doctor had prescribed captopril 12,5mg
tablets and hidrochlorothiazide 25mg tablets. The
unpleasant taste of the medicine often made him
avoid taking his medicines routinely. He also often
felt lazy and bored to do with taking his medicine
for a long period. He believed that antihypertensive
medicines should not be taken when reaching
normal blood pressure readings. To avoid taking the
prescribed medicines, he frequently consumed
traditional medicines, either individually-made or
bought at a nearby traditional medicine stall. The
long distance away from the Puskesmas and the
numerous patients served at the Puskesmas caused
him to not visit the Puskesmas regularly. He
sometimes visited a nearby community health sub-
centre (Puskesmas Pembantu) that served a fewer
number of patients, but only provided the most basic
health services. As a consequence, he usually paid
for the blood pressure checking service and got his
medicine at a nearby community pharmacy. He was
aware of PROLANIS, but never received a proper
explanation about the program.
Case 6. A 53-year old female, diagnosed with
hypertension about eight years ago who become a
member of non-PBI (Mandiri) in the last two years.
Her doctor had prescribed amlodipin 5mg tablet, to
be taken once at night. Despite this, she often missed
taking the medicines. Prior to being a member of
non-PBI, she often could not afford to pay for her
prescribed brand-name medicines, leading to non-
adherence. Her daily activities including taking care
of her grandchildren made her miss visiting the
Puskesmas. As a consequence, she visited a nearby
community pharmacy to pay for the medicine. She
also reported that she lacked support from her family
members to regularly visit the Puskesmas and to
take her medicine. She was not aware of PROLANIS
and was not interested in participating in the
program.
Case 7.A 70-year old male, member of non-PBI
(Askes) who has been diagnosed with hypertension
since he was 45 years old. His doctor had prescribed
him amlodipin 5mg tablets to be taken once at night,
and hidrochlorothiazide 25mg tablets to be taken
once in the morning. Prior to receiving information
from his doctor, he believed that the
antihypertensive agents were to be taken only when
needed. The symptoms of hypertension were
unrecognised, therefore he often felt that the
medicines were not required. He also reported that
he frequently forgot to take his medicine due to the
lack of support and reminders from his family
members. He was not aware of PROLANIS but was
interested in participating in the program.
Case 8.A 73-year old female, member of non-
PBI (Mandiri) who has lived with hypertension for
the last few years. Her doctor had prescribed
captopril 25mg tablets, to take a half tablet twice
daily. Her physical disabilities prevented her making
routine visits to the Puskesmas, particularly when no
family members could help her to do so. When the
prescribed medicines were running out, she
consumed herbal medicines that were bought at a
nearby herbal medicine stall. She was not aware of
PROLANIS and was not interested in participating in
the program.
4 DISCUSSIONS
The findings of this study showed that non-
adherence to hypertension treatment for BPJS
Kesehatan members was influenced by six factors as
reported in the previous studies (WHO, 2013;
Tsiantou, et al., 2010; Albrecht, 2011; Osamor and
Owuni, 2011). Despite that, the factors related to the
Barriers to Treatment Adherence to Hypertension: A Qualitative Study with PBI and Non-PBI Patients of a Puskesmas in Surabaya
327

patient, health provider, health-system and socio-
culture were found to be predominant.
Patient-related factors that were commonly
found in this study included the patients’ likelihood
to miss their medicine due to laziness, busyness,
forgetfulness and boredom, as mostly reported in
other studies (WHO, 2013; Tsiantou, et al., 2010;
Albrecht, 2011; Osamor and Owuni, 2011). Poor
knowledge about the need of long-term treatment for
the hypertension condition was also revealed, and
interestingly, it seemed to be related to the lack of
information provided by the healthcare
professionals. Pharmacists were expected to provide
full responsibility for the rational use of medicines
were also reported to not highlight the importance of
adherence to hypertension treatment.
A weak tendency for interactions between health
providers and patients was understandable when a
large number of the patients at the Puskesmas should
be served by a small number of health providers
(BPJS, 2017).
Moreover, many informants in this
study reported that the number of medicines they
received was normally only for a 7-10 day course of
treatment. As a result, only patients who were
unemployed were more likely to adhere to make
regular visits as suggested. The Puskesmas, as a
government health facility to support the success
implementation of health insurance, therefore,
should consider their policies about procurement and
the delivery of medicines, particularly for patients
who required long-term treatment to enhance their
adherence as international studies have shown the
impact of social health insurance on the management
of chronic diseases (Cockerham, et al., 2017; Hamar,
et al., 2013; Kim & Richardson, 2014).
The PROLANIS program that was designed to
manage chronic disease was thought to fail due to a
low participation from BPJS Kesehatan members
and their unfamiliarity with the program. Harnessing
the untapped potential of health providers, such as
community pharmacists, could be an innovative
solution to supporting chronic disease management
(Puspitasari, et al., 2015) through such a structured
program.
Another important factor to consider was the
likelihood of the informants consuming herbal
medicines. The common use of herbal medicines for
patients with hypertension in Indonesia, as also
reported earlier, could lead to further problems, not
only causing an irregular use of prescribed
medicines which challenges the monitoring by
health providers, but it also increases the potential
for interaction between the prescribed and herbal
medicines, particularly when scientific evidence was
insufficient (Pujianto, 2007).
5 CONCLUSIONS
The management of chronic diseases, including
hypertension, has been developed by the Indonesian
government through the implementation of universal
health coverage organised by BPJS Kesehatan.
Despite that, barriers related to health-system were
reported as one of predominant factors influencing
non-adherence to hypertension treatment. Therefore,
the government along with health professionals
should take special considerations to improve
health-system to enable reaching the obvious
improvements needed in the health services for all
Indonesians.
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