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  • Bridges M&C team

Why Asian Hypertension Patients Don't Take Their Medication

Updated: Jun 25

Poor medication adherence is a critical issue among hypertension patients and must be addressed to prevent more disastrous consequences.


Hypertension, or high blood pressure, is a major public health concern worldwide. It is the single most important leading cause of cardiovascular disease mortality globally and in Southeast Asia.



Modern lifestyle leads to rise in hypertension

Malaysia’s most recent National Health and Morbidity Survey (NHMS) 2023 revealed that one in three (29.2%) adults are diagnosed with hypertension, while in Singapore, the total prevalence was 37% according to the National Population Health Survey 2022.


Some of the risk factors that contribute to the escalating rates of hypertension in the region include a diet that is high in salt and saturated fats – perpetuated by a culture where dining out is affordable and convenient – coupled with a sedentary lifestyle. As many as 65% of Malaysian adults are said to consume too much sodium, a known risk factor for hypertension, as a result of eating out frequently. Meanwhile, the average Singaporean consumes as much as 3,600mg of sodium daily – almost double the World Health Organisation’s (WHO) daily recommendation of 2,000mg of sodium. 

Dr Navin Sukilan

According to Dr Navin Sukilan, Consultant Cardiologist from Subang Jaya Medical Centre (SJMC), “Rapid urbanisation and economic development have led to lifestyle changes that raise risks of hypertension, such as the increased consumption of processed foods and reduced physical activity."

"This has been further compounded by the recent shift to online or remote work post-pandemic, where many individuals have become less active as they spend longer hours seated, or confined to the same location, in the absence of commuting to the office or different physical locations for face-to-face meetings,” he adds.


The impact of hypertension on public health is profound, leading to a significant economic burden.

In Singapore, the societal cost associated with the burden of hypertension is the highest, compared to other metabolic diseases, at an estimated S$929 million (US$690 million). While the economic burden for hypertension in Malaysia is unknown, the cost incurred by the Ministry of Health (MOH) for anti-hypertensive medication has steadily increased from MYR570.3 million (US$121.3 million) in 2014 to MYR608.8 (US$129.7) million in 2016.


Poor medicine adherence a barrier in managing hypertension


“In younger patients who are pre-hypertensive or in Stage 1 of hypertension, we usually prescribe lifestyle modifications and regular monitoring of blood pressure, as their levels can be adequately controlled without introducing medicines. However, patients who present with Stage 3 hypertension or blood pressure reading of more than 160mmHg, have a higher risk of organ damage and complications such as heart attack or stroke, we prescribe medications immediately. Unfortunately, poor adherence to medication is a significant barrier in managing hypertension in Malaysia,” says Dr Navin.


His observation echoes the broader statistics in the Asian region, where poor treatment adherence adds another layer to the complexities in managing hypertension, in addition to other challenges such as disparities in socioeconomic backgrounds, education levels, as well as lack of access to affordable generic drugs.  


Untreated hypertension also leads to higher healthcare burdens and increased cost, as patients require more intensive treatments. In Singapore, stroke and ischaemic heart disease are the top causes of death which may be attributed to uncontrolled hypertension from poor medication adherence.  


Dr Rohit Khurana

Dr Rohit Khurana, Senior Consultant Cardiologist at the Harley Street Heart & Vascular Centre, Gleneagles Hospital, Singapore, says: “Untreated or uncontrolled hypertension leads to more serious complications later on. As increased blood pressure can place excessive force on artery walls, in the long run it can lead to continual damage of the blood vessels and organs, causing a range of other complications including heart attacks and strokes due to blood clot formation, brain aneurysm, heart failure from increased stress to the heart’s muscles, and ultimately kidney failure or vision loss.”


Factors impacting treatment adherence

Medication adherence is a multi-faceted and complex behaviour involving patient, practitioner, therapeutics and systemic factors.

“Many patients struggle with medication adherence due to a lack of understanding about the importance of adherence and misinformation about potential side effects. Patients often obtain false information regarding the adverse effects of taking certain medicines for the long term through social media or WhatsApp, despite scientific data proving otherwise. This is occuring even among highly educated professionals,” says Dr Navin.



“The addition of these anti-hypertensive medications leads to increased pill burden for the patients, which further drives non-adherence due to factors such as forgetfulness or difficulty taking the medication at different times throughout the day, as stipulated."

"Hypertensive patients sometimes also do not fully understand the chronic nature of hypertension with need for lifelong medication, leading them to discontinue treatment prematurely or skip their medications,” asserts Dr Navin.


Improving medication adherence


In Singapore, for example, the establishment of the ‘Healthier SG’ initiative enables patients with chronic diseases such as hypertension to discuss their condition with their preferred family doctor to obtain a tailored management plan which includes personalised blood pressure targets, sustainable lifestyle intervention, and pharmacotherapy when required. In addition, the recent publication of the ACE Clinical Guidance 2023 encourages physicians to discuss factors influencing medication adherence with the patient, including their ability to tolerate existing medications, side effects from increasing the dose, if any, cost, and patient preferences such as time of dosing.



Dr Khurana elaborates, “Checking your blood pressure at home is an important part of managing hypertension and preventing potential symptoms of cardiovascular diseases. The only way to know if medications or lifestyle changes are working is by checking your blood pressure regularly. Monitoring blood pressure at home helps you and your doctor make decisions about further treatments, including adjusting medicines and dosages to improve adherence and exercise/diet plans, where required.”


“Almost all pharmacies sell home blood pressure monitors. When purchasing one, ensure that its cuff fits properly and that the display shows clear, easy-to-read measurements. Then, test the device in front of your doctor to check if you are using it correctly. If your blood pressure monitor doesn’t automatically log blood pressure readings, write them down and share them with your doctor during your next check-up,” explains Dr Khurana.


Single Pill Combinations (SPC) helps promote treatment adherence as it reduces the patient’s pill burden and simplifies their treatment regimen. /Photo Credit: Dreamstime

The availability of Single Pill Combinations (SPC) has also helped in promoting treatment adherence, according to Dr Navin, as it reduces the patient’s pill burden and simplifies their treatment regimen.

“Simplification of the treatment regimen using SPC is one strategy that I have found, which improves adherence in patients. However, cost is a critical factor for many patients, and in Malaysia, patented SPCs are only available in private facilities for now. Many patients are unable to afford long-term care at private facilities, or they may go for routine check-ups or medicine top-ups to public facilities. These patients do not have access to SPCs and must rely on the conventional multiple pill therapy for effective blood pressure control,” explains Dr Navin.


Finally, the use of digital tools such as mobile health applications, telemedicine, and smart devices offer innovative solutions to enhance medication adherence among patients.

Electronic patient portals, such as HealthHub in Singapore, are increasingly being used to support chronic disease management including appointment scheduling, bill payments, reminders to refill medicines, laboratory results, health parameter recording, and providing evidence-based information. Singaporean patients using HealthHub demonstrated higher self-efficacy scores, defined as ‘the confidence to adopt the necessary behaviours to reach a desired goal.


In Malaysia, the rise in telemedicine services has been beneficial in providing patients with timely medical advice and support, although they are not yet widely adopted. A recent study revealed that there was a notable surge in demand for e-prescriptions particularly for chronic conditions such as hypertension, diabetes and hyperlipidaemia, following the COVID-19 pandemic. This demonstrated that more patients are prioritising convenient access to healthcare services, which could potentially lower barriers to medication adherence.


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