A Systems-Level Approach to Improving Medication Adherence in Hypertensive Latinos: a Randomized Control Trial

  • Antoinette SchoenthalerEmail author
  • Franzenith de la Calle
  • Maria Pitaro
  • Audrey Lum
  • William Chaplin
  • Jazmin Mogavero
  • Milagros C. Rosal
Original Research



Despite numerous interventions targeting medication adherence in patients with uncontrolled hypertension, practice-based trials in Latino patients are scant.


To evaluate the effect of a systems-level adherence intervention, delivered by medical assistants (MAs), versus a comparison condition on medication adherence and blood pressure (BP) in 119 hypertensive Latino patients who were initially non-adherent to their antihypertensive medications.

Study Design

Randomized control trial.


Patients (50% women; mean age, 61 years) were recruited from April 2013 to August 2015 in a community-based practice in New York.


Systems-level approach that included an office system component built into the electronic health record and a provider support component consisting of nine MA-delivered health coaching sessions for improving medication adherence. The comparison group received the standard health coaching procedures followed at the clinic.

Main Outcome Measures

The primary outcome was rate of medication adherence measured by an electronic monitoring device (EMD) across 6 months. The secondary outcomes were self-reported medication adherence measured by the eight-item Morisky Medication Adherence Scale (MMAS-8) and BP reduction from baseline to 6 months.

Key Results

Adherence as measure by EMD worsened for both groups (p = 0.04) with no between-group difference (− 9.6% intervention and − 6.6% control, p = 0.66). While systolic BP improved in both groups, the difference between groups was not significant (− 6 mmHg in intervention vs. − 2.7 mmHg in control, p = 0.34). In contrast, the intervention group had a greater improvement in self-reported adherence (mean change 1.98 vs. 1.26, p = 0.03) when measured using the MMAS-8.


Among Latinos with poorly controlled BP who were non-adherent to their antihypertensive medications, a systems-level intervention did not improve adherence as measured by EMD nor blood pressure. However, many patients reported challenges to using the EMD. Improvements in self-reported adherence suggest that this measure captures different aspects of adherence behavior than EMD.

Clinical Trial Registration



medication adherence hypertension Latino team care 



The authors would like to thank the Health Coaches (Palmira Brown, Cindy Ruiz, Ana Ventura, Jacqueline Camacho, and Luis Carrasco) at Union Health Center for their dedication to this project in the delivery of the intervention. Morisky Widget™, MMAS™, MMAS4™, MMAS-8™, Morisky Medication Adherence Protocol™, and Morisky Medication Adherence Scale™ content, name, and trademarks are protected by U.S. and International Trademark and Copyright laws. Permission for use of the scale and its coding is required. A license agreement is available from Donald E. Morisky, ScD, ScM, MSPH, 14735 NE 20th St Bellevue, WA 98007, USA; or

Funding Information

This work was financially supported by grant 12GRNT11670001 from the American Heart Association (PI: Schoenthaler).

Compliance with Ethical Standards

The study was approved by the NYU Institutional Review Board.

Conflict of Interest

The authors declare that they do not have a conflict of interest


  1. 1.
    Centers for Disease Control and Prevention. Racial/Ethnic disparities in the awareness, treatment, and control of hypertension - United States, 2003-2010. MMWR Morb Mortal Wkly Rep. 2013;62(18):351-355.Google Scholar
  2. 2.
    Gu A, Yue Y, Desai RP, Argulian E. Racial and Ethnic Differences in Antihypertensive Medication Use and Blood Pressure Control Among US Adults With Hypertension: The National Health and Nutrition Examination Survey, 2003 to 2012. Circ Cardiovasc Qual Outcomes. 2017;10(1).Google Scholar
  3. 3.
    Sorlie PD, Allison MA, Aviles-Santa ML, et al. Prevalence of Hypertension, Awareness, Treatment, and Control in the Hispanic Community Health Study/Study of Latinos. Am J Hypertens. 2014; 27:793-800.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P. Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis. Hypertension (Dallas, Tex : 1979). 2011;57(6):1101-1107.CrossRefGoogle Scholar
  5. 5.
    Guzman NJ. Epidemiology and management of hypertension in the Hispanic population: a review of the available literature. Am J Cardiovasc Drugs 2012;12(3):165-178.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Sudano JJ, Jr., Baker DW. Antihypertensive medication use in Hispanic adults: a comparison with black adults and white adults. Med Care 2001;39(6):575-587.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Raebel MA, Ellis JL, Carroll NM, et al. Characteristics of patients with primary non-adherence to medications for hypertension, diabetes, and lipid disorders. J Gen Intern Med 2012;27(1):57-64.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Ishisaka DY, Jukes T, Romanelli RJ, Wong KS, Schiro TA. Disparities in adherence to and persistence with antihypertensive regimens: an exploratory analysis from a community-based provider network. J Am Soc Hypertens 2012;6(3):201-209.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ. Patient characteristics associated with medication adherence. Clin Med Res. 2013 Scholar
  10. 10.
    Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter? J Gen Intern Med 2010;25(11):1172-1177.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Natarajan S, Santa Ana EJ, Liao Y, Lipsitz SR, McGee DL. Effect of treatment and adherence on ethnic differences in blood pressure control among adults with hypertension. Ann Epidemiol 2009;19(3):172-179.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Lai LL. Community pharmacy-based hypertension disease-management program in a Latino/Hispanic-American population. Consult Pharm 2007;22(5):411-416.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Schoenthaler A, De La Calle F, Barrios-Barrios M, et al. A practice-based randomized controlled trial to improve medication adherence among Latinos with hypertension: study protocol for a randomized controlled trial. Trials. 2015;16(1):290.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Nelson K, Pitaro M, Tzellas A, Lum A. Practice profile. Transforming the role of medical assistants in chronic disease management. Health Aff (Millwood) 2010;29(5):963-965.CrossRefGoogle Scholar
  15. 15.
    Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol 2011;64(3):255-257; discussion 258-263.PubMedCrossRefGoogle Scholar
  16. 16.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;10(5):348-354.CrossRefGoogle Scholar
  17. 17.
    Berlowitz DR, Pajewski NM, Kazis LE. Intensive Blood-Pressure Treatment and Patient-Reported Outcomes. N Engl J Med 2017;377(21):2097.PubMedCrossRefGoogle Scholar
  18. 18.
    Bellg AJ, Borrelli B, Resnick B, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol 2004;23(5):443-451.PubMedCrossRefGoogle Scholar
  19. 19.
    Resnick B, Bellg AJ, Borrelli B, et al. Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go. Ann Behav Med 2005;29 Suppl:46-54.PubMedCrossRefGoogle Scholar
  20. 20.
    Meyer D, Leventhal H, Gutmann M. Common-sense models of illness: the example of hypertension. Health Psychol 1985;4(2):115-135.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Baumann LJ, Leventhal H. “I can tell when my blood pressure is up, can’t I?”. Health Psychol 1985;4(3):203-218.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Leventhal H. The role of theory in the study of adherence to treatment and doctor-patient interactions. Med Care 1985;23(5):556-563.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Leventhal H, Cameron LD. Behavioral theories and the problem of compliance. Patient Educ Couns 1987;10:117-138.CrossRefGoogle Scholar
  24. 24.
    Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med 2009;32(3):278-284.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Brown SA, Becker HA, Garcia AA, Barton SA, Hanis CL. Measuring health beliefs in Spanish-speaking Mexican Americans with type 2 diabetes: adapting an existing instrument. Res Nurs Health 2002;25(2):145-158.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    van Servellen G, Nyamathi A, Carpio F, et al. Effects of a treatment adherence enhancement program on health literacy, patient-provider relationships, and adherence to HAART among low-income HIV-positive Spanish-speaking Latinos. AIDS Patient Care STDs 2005;19(11):745-759.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Ailinger RL, Martyn D, Lasus H, Lima Garcia N. The effect of a cultural intervention on adherence to latent tuberculosis infection therapy in Latino immigrants. Public Health Nurs 2010;27(2):115-120.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Kronish I, Leventhal H, Horowitz CR. Understanding Minority Patients’ Beliefs About Hypertension to Reduce Gaps in Communication Between Patients and Clinicians. J Clin Hypertens 2012;14:38-44.CrossRefGoogle Scholar
  29. 29.
    Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653):1114-1117.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med 2007;5(5):457-461.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Ogedegbe G, Chaplin W, Schoenthaler A, et al. A practice-based trial of motivational interviewing and adherence in hypertensive African Americans. Am J Hypertens 2008;21(10):1137-1143.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Erlbaum; 1988.Google Scholar
  33. 33.
    Deschamps AE, Van Wijngaerden E, Denhaerynck K, De Geest S, Vandamme A-M. Use of electronic monitoring induces a 40-day intervention effect in HIV patients. J Acquir Immune Defic Syndr 2006;43(2):247-248.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther 1999;21(6):1074-1090; discussion 1073.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Wetzels GE, Nelemans PJ, Schouten JS, van Wijk BL, Prins MH. All that glisters is not gold: a comparison of electronic monitoring versus filled prescriptions--an observational study. BMC Health Serv Res 2006;6:8.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Wetzels GE, Nelemans P, Schouten JS, Prins MH. Facts and fiction of poor compliance as a cause of inadequate blood pressure control: a systematic review. J Hypertens 2004;22(10):1849-1855.PubMedCrossRefGoogle Scholar
  37. 37.
    Waeber B, Leonetti G, Kolloch R, McInnes GT. Compliance with aspirin or placebo in the Hypertension Optimal Treatment (HOT) study. J Hypertens 1999;17(7):1041-1045.PubMedCrossRefGoogle Scholar
  38. 38.
    Knafl GJ, Schoenthaler A, Ogedegbe G. Secondary analysis of electronically monitored medication adherence data for a cohort of hypertensive African-Americans. Patient Prefer Adherence 2012;6:207-219.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Lam WY, Fresco P. Medication Adherence Measures: An Overview. Biomed Res Int 2015;2015:217047-217047.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Kreys E. Measurements of Medication Adherence: In Search of a Gold Standard. J Clin Pathways 2016;2:43-47.Google Scholar
  41. 41.
    Thom DH, Willard-Grace R, Hessler D, et al. The impact of health coaching on medication adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: a randomized controlled trial. J Am Board Fam Med 2015;28(1):38-45.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Garber MC, Nau DP, Erickson SR, Aikens JE, Lawrence JB. The concordance of self-report with other measures of medication adherence: a summary of the literature. Med Care 2004;42(7):649-652.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028-3035.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42(3):200-209.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Margolius D, Bodenheimer T, Bennett H, et al. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med 2012;10(3):199-205.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med 1990;150(9):1881-1884.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Antoinette Schoenthaler
    • 1
    Email author
  • Franzenith de la Calle
    • 1
  • Maria Pitaro
    • 2
  • Audrey Lum
    • 2
  • William Chaplin
    • 3
  • Jazmin Mogavero
    • 3
  • Milagros C. Rosal
    • 4
  1. 1.Department of Population Health, Center for Healthful Behavior ChangeNew York University School of MedicineNew YorkUSA
  2. 2.Union Health CenterNew YorkUSA
  3. 3.Department of PsychologySt. Johns UniversityJamaicaUSA
  4. 4.Preventive and Behavioral Medicine, Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterUSA

Personalised recommendations