Development and Testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale

Miyong T. Kim, RN, PhD; Martha N. Hill, RN, PhD; Lee R. Bone, RN, MPH; David M. Levine, MD


Prog Cardiovasc Nurs. 2000;15(3) 

In This Article

Abstract and Introduction

The Hill-Bone Compliance to High Blood Pressure Therapy Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: 1) reduced sodium intake; 2) appointment keeping; and 3) medication taking. This scale is comprised of 14 items in three subscales. Each item is a four point Likert type scale. The content validity of the scale was assessed by a relevant literature review and an expert panel, which focused on cultural sensitivity and appropriateness of the instrument for low literacy. Internal consistency reliability and predictive validity of the scale were evaluated using two community based samples of hypertensive adults enrolled in clinical trials of high blood pressure care and control. The standardized alpha for the total scale were 0.74 and 0.84, and the average interitem correlations of the 14 items were 0.18 and 0.28, respectively. The construct and predictive validity of the scale was assessed by factor analysis and by testing of theoretically derived hypotheses regarding whether the scale demonstrated consistent and expected relationships with related variables. In this study, high compliance scale scores predicted significantly lower levels of blood pressure and blood pressure control. Moreover, high compliance scale scores at the baseline were significantly associated with blood pressure control at both baseline and at follow up in the two independent samples. This brief instrument provides a simple method for clinicians in various settings to use to assess patients' self reported compliance levels and to plan appropriate interventions.

High blood pressure (HBP) is among the most prevalent and important risk factors for cardiovascular, cerebrovascular, and renal disease. Effective care and control of HBP cannot be achieved without compliance to treatment regimen recommendations by patients, providers, and organizations.[1] Estimates of controlled blood pressure (BP) among identified HBP patients typically ranges from 20%-30%[2,3] in the U.S., in large part, because only one half of the individuals diagnosed with hypertension are in treatment and one half of these are not receiving treatment adequate to control BP. In a critical review, Rogers and Bullman[4] found that noncompliance rates with prescribed therapeutic regimens range from 30%-60%, and at least 50% of patients for whom drugs are prescribed failed to receive full benefit through inadequate compliance. The high noncompliance rates in HBP treatment have multiple implications at the individual and societal levels. These rates jeopardize patients' health and well being, result in suboptimal health outcomes, lead to inefficient use of health resources, and incur costly treatment for the complications of untreated or inadequately treated HBP.[1,5,6] In spite of the critical role played by compliance in the treatment of HBP, clinicians are not routinely assessing patient's compliance level and patients rarely volunteer this information to their clinician.[5,7]

Several types of measures have been used to assess compliance in HBP research studies, including biological measures, such as drug assays, pill counts (both manual and electronic monitoring), treatment outcomes, physician estimates, and patient reports. Each method of measuring compliance has advantages and disadvantages.[6] Drug assays and pill counts are considered to be more objective measures of compliance than provider estimates and patient self report. However, assays and pill counts, to a lesser extent, are expensive, relatively invasive, and time consuming to administer. Thus, they are not practical strategies for use in routine clinical practice. Although compliance levels reported by patients tend to over-estimate the level of compliance, self report has the advantages of being the most economical and simplest way to gather information and provides a ready opportunity for teaching and feedback.[6]

Prior development of instruments to measure patient self reported compliance was found to be limited. The most commonly used instrument, developed by Morisky et al,[8] was a four item tool assessing medication compliance with yes/no response categories and an internal consistency alpha of 0.64.[9] Shea et al[10] in later work added a fifth item ("Do you have a doctor for HBP care?"). In recognition of the need to more comprehensively assess HBP treatment adherence we undertook the challenge of developing a new instrument.

The American Heart Association recently issued a medical/scientific statement on the multilevel compliance challenge.[1] In the statement, the authors called for future research to improve compliance, including identifying persons at highest risk for noncompliance, methods for monitoring and improving compliance, and strategies to sustain recommended health behaviors over time. Researchers and clinicians interested in improving health outcomes for patients with HBP need reliable, valid, efficient, and cost effective assessment tools to assess the critical domains of HBP care during the screening, diagnosis, monitoring, and feedback processes.


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