IMPACT OF HEALTH LITERACY ON CLINICAL OUTCOMES: THE MEDIATING ROLE OF MEDICATION ADHERENCE AMONG PATIENTS WITH HYPERTENSION IN MALAYSIA
DOI:
https://doi.org/10.66857/jirt.v3i2.55Keywords:
health literacy, medication adherence, clinical outcomes, hypertension, blood pressure control, Malaysia, Chronic Care ModelAbstract
Hypertension remains the leading modifiable cardiovascular risk factor in Malaysia, yet optimal blood pressure control continues to be a significant public health challenge. This paper develops a conceptual model examining the relationship between patient health literacy and clinical outcomes among Malaysian patients with hypertension, with medication adherence proposed as a mediating mechanism. Guided by health literacy theory and the Chronic Care Model, health literacy is conceptualised as the predictor, medication adherence as the mediator, and systolic and diastolic blood pressure control as clinical outcomes. However, limited evidence has examined whether medication adherence explains the relationship between health literacy and blood pressure control among Malaysian patients with hypertension. A structured synthesis of peer-reviewed literature from Malaysia and comparable settings indicates that higher health literacy is associated with greater medication adherence, while adherence is an established predictor of improved blood pressure control and cardiovascular outcomes. Evidence from a Malaysian randomised controlled trial at University Malaya Medical Centre further supports the proposed pathway. National Health and Morbidity Survey data show that hypertension control improved from 27.5% in 2006 to 37.4% in 2015 but remained below 40%, highlighting the continuing need for effective hypertension management. Based on the evidence, a conceptual framework and four hypotheses are proposed, with a quantitative cross-sectional design using validated measures of health literacy, medication adherence (via the MyMaat-12), and objectively measured blood pressure. PLS-SEM or SEM is proposed to test the hypothesised relationships and mediation pathway. The model provides a theoretically grounded framework for understanding how health literacy may influence hypertension outcomes through medication adherence and may inform health literacy-sensitive interventions in Malaysian primary care.
References
Institute for Public Health. (2023). National Health and Morbidity Survey (NHMS) 2023: Non-communicable Diseases and Healthcare Demand. Ministry of Health Malaysia.
Ab Majid, N. L., Omar, M. A., Khoo, Y. Y., et al. (2018). Prevalence, awareness, treatment and control of hypertension in the Malaysian population: Findings from the National Health and Morbidity Survey 2006-2015. Journal of Human Hypertension, 32(8-9), 617-624.
Abdul-Razak, S., Daher, A. M., Ramli, A. S., et al. (2016). Prevalence, awareness, treatment, control and socio demographic determinants of hypertension in Malaysian adults. BMC Public Health, 16, 351.
Alzoubi, M. M., et al. (2026). Health literacy and its role in promoting medication adherence among hypertension patients. Blood Pressure.
Baumgartner, P., Haynes, R. B., Hersberger, K. E., & Arnet, I. (2018). A systematic review of medication adherence thresholds dependent of clinical outcomes. Frontiers in Pharmacology, 9, 1290.
Delavar, F., Pashaeypoor, S., & Negarandeh, R. (2020). The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial. Patient Education and Counseling, 103(2), 336-342.
Elnaem, M. H., et al. (2021). Associations between socio-demographic factors and hypertension management during the COVID-19 pandemic: Preliminary findings from Malaysia. International Journal of Environmental Research and Public Health, 18(17), 9306.
Gultekin, E., et al. (2025). Association between health literacy and medication adherence in hypertensive patients. The European Journal of Public Health.
Guo, A., et al. (2023). Impact of health literacy and social support on medication adherence in patients with hypertension: A cross-sectional community-based study. BMC Cardiovascular Disorders, 23, 93.
Hamrahian, S. M., Maarouf, O. H., & Fülöp, T. (2022). A critical review of medication adherence in hypertension: Barriers and facilitators clinicians should consider. Patient Preference and Adherence, 16, 2749-2757.
Karakurt, P., et al. (2025). Association between health literacy and medication adherence in patients with hypertension: A cross-sectional study. Scientific Reports, 15.
Karami, M., et al. (2023). The effect of health literacy intervention on adherence to medication of uncontrolled hypertensive patients using the M-health. BMC Medical Informatics and Decision Making, 23, 249.
Kengne, A. P., et al. (2023). Impact of poor medication adherence on clinical outcomes and health resource utilization in patients with hypertension and/or dyslipidemia: Systematic review. Expert Review of Pharmacoeconomics & Outcomes Research, 23(6), 631-643.
Kim, H.-J., et al. (2025). Impact of blood pressure and medication adherence on clinical outcomes in patients with hypertension. Frontiers in Medicine, 12.
Lenggogeni, D. P., et al. (2024). Health literacy and medication adherence among patients with hypertension. Jurnal Keperawatan Soedirman.
Lor, M., Koleck, T. A., Bakken, S., et al. (2019). Association between health literacy and medication adherence among Hispanics with hypertension. Journal of Racial and Ethnic Health Disparities, 6(3), 517-524.
Ministry of Health Malaysia / Pharmaceutical Services Programme. (2021). Malaysian Medication Adherence Assessment Tool (MyMAAT). Ministry of Health Malaysia. (or the relevant journal validation article for MyMAAT-12).
Mustara, et al. (2025). Key contents of health education and their impact on improving medication adherence among hypertensive patients: A systematic review and meta-analysis. Narra J.
Naing, C., et al. (2016). Hypertension in Malaysia. Medicine, 95(2), e2417.
Ng, C. W., et al. (2017). Universal coverage of hypertension treatment services in Malaysia is still an elusive goal. Health Systems & Reform, 3(1), 38-47.
Qin, N., et al. (2023). Association between medication literacy and blood pressure control among hypertensive patients. International Journal of Nursing Practice, 29(4), e13139.
Rampal, L., Rampal, S., Azhar, M. Z., & Rahman, A. R. (2007). Prevalence, awareness, treatment and control of hypertension in Malaysia: A national study of 16,440 subjects. Public Health, 122(1), 11-18.
Rana, R., et al. (2026). Structural analysis of causal pathways between adherence, satisfaction and clinical outcomes in hypertensive patients using a mobile adherence intervention: A SEM-NCA-cIPMA approach. Journal of Human Hypertension.
Salim, H., Ramdzan, S. N., Ghazali, S. S., et al. (2019). The self-care profiles and its determinants among adults with hypertension in primary health care clinics in Selangor, Malaysia. PLoS ONE, 14(12), e0224649.
Schäfer, C. (2024). Reimagining medication adherence: A novel holistic model for hypertension therapy. Patient Preference and Adherence, 18, 1-15.
Shah, S. A., et al. (2022). Prevalence and determinants of unmet needs for hypertension care among the older population in Selangor: Cross-sectional study. Health Research Policy and Systems, 20, 45.
Teh, X. R., Lim, M. T., Tong, S. F., et al. (2020). Quality of hypertension management in public primary care clinics in Malaysia: An update. PLoS ONE, 15(9), e0237083.
Teh, X. R., et al. (2026). Primary health care interventions targeting diabetes, hypertension or dyslipidemia in Malaysia: A scoping review. PLOS ONE.
Wilhelm, M., et al. (2017). It's all a matter of necessity and concern: A structural equation model of adherence to antihypertensive medication. Patient Education and Counseling, 100(11), 2088-2095.
Yu, J., et al. (2026). Effectiveness of health literacy interventions for blood pressure control, medication adherence, and self-efficacy in older adults with hypertension: A systematic review and meta-analysis. Journal of Evaluation in Clinical Practice.
Zaki, N. A. M., et al. (2021). The prevalence of hypertension among Malaysian adults and its associated risk factors: Data from Malaysian Community Salt Study (MyCoSS). Journal of Health, Population, and Nutrition, 40(Suppl 1), 20.
Zhang, M., et al. (2025). Exploring the impact of three-dimensional patient satisfaction structure on adherence to medication and non-pharmaceutical treatment: A cross-sectional study among patients with hypertension in rural China. BMC Primary Care, 26.
Zhou, B., Perel, P., Mensah, G. A., & Ezzati, M. (2021). Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nature Reviews Cardiology, 18(11), 785-802.
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