Medication adherence is a major health behaviour noted to improve the quality of life of patients. However, non-adherence is often a predominant problem in the management of hypertension and other chronic conditions 1 . Even though the World Health Organization has estimated the non-adherence rate to pharmacotherapy for hypertension to be approximately 50%, Ghana, a developing country has recorded a very high non-adherence rate of 93% 2 .

Contrary to the availability of treatment for hypertension, most patients do not follow recommendations by their healthcare professionals and this results in poor hypertension management 3 . Most patients require one or more antihypertensive medications to achieve optimal blood pressure and this has been associated with an increased cost of hypertension management in Ghana 2 . A significant worsening of disease, treatment failures, increased hospitalizations, death, and increased health care costs remain the main consequences of medication non-adherence 4 . Patients with untreated and uncontrolled hypertension are at an increased risk of developing stroke, heart attack, and kidney or heart failure, which can eventually lead to death. Inadequate control of hypertension has also been associated with cognitive decline in elderly patients 5 resulting in both social and financial burdens 6 .

In explaining health behaviours, social determinants like spirituality and religiosity are increasingly identified as impacting health and treatment. Systematically, spirituality and religiosity have been introduced into the medical field implying a growing interest in the possible perceived health benefits connected with having a spiritual belief and following a religious lifestyle 7 .

Specifically, spirituality relates to feelings or experiences of reverence, peace, or attachment with a Supreme Being and is usually identified as that which gives a transcendent meaning to life where God takes the initiative in this typical divine-human relationship 8 . Notwithstanding varied descriptions of spirituality, the core concepts are the same 9 . It may well comprise the internal, personal, and emotional expression of the revered and is evaluated using spiritual wellbeing, peace, and comfort derived from faith, and spiritual coping 8 .

Religiosity relates more with cultural and social norms and refers to an outward prescribed system of beliefs and guidelines of conduct 10 . It is generally explained in a behavioural context where rituals and other related symbolic activities (e.g., meditations, prayers, fasting, reading religious scripts, attendance at services, etc.) are practised by individuals according to their specific beliefs and modes of social organization 9 11 . These activities have been noted to strengthen the faith of people and assist them with decision making in health-related practices.

Formerly, spirituality and religiosity were examined as a one-dimensional construct, yet, various researchers have attempted to categorize and distinguish particular aspects of the two constructs 12 . Nevertheless, religion is generally inter-related with spirituality since the former provides a structured environment for spiritual exploration and practices in life and the two constructs have been conceptualized to influence the development of each other 13 . For example, religious practices encourage spiritual growth and spiritual activities are often an important aspect of religious participation 9 14 .

Although there are still deliberations on possible association of spirituality/ religiosity with health and weaknesses in the definition and measurement of the constructs, attempts have been made to operationalize and conceptualize spirituality and religiosity to relate with health outcomes as well as its impact on the social domain 9 15 16 17 18 .

Various studies have explored the influence of spirituality/religiosity on positive health behaviours among college students, in the field of gerontology, in heart failure, mental health outcomes, blood pressures, cancer and mortality rates 19 20 21 22 23 24 25 with other researchers not observing this trend 26 27 .

The 2010 national population census indicated that over 90% of Ghanaians identified with a form of religion, yet, there is paucity of information regarding the spiritual/ religious inclination and the health seeking behaviours of Ghanaians. Additionally, a number of researchers have found spirituality and religiosity to be a primary resource among persons dealing with chronic disability and illness however, studies relating this specifically to medication adherence have been limited. Nevertheless, addressing spiritual and religious needs of patients could enhance their medication adherence behaviour and thus, improve their health outcome 28 .

In view of this, the study postulated that: Explored dimensions of spirituality/religiosity will significantly influence the adherence behaviour of hypertensive patients with the expectation that high scores of spiritual beliefs and religious practices will positively influence the decision by patients to adhere to their antihypertensive medications.

The study found that poor adherence to anti-hypertensive medication regimen was high, occurring in 93.25% of respondents. This corroborates findings from a previous study by Buabeng et al. (2004) 2 that observed non-adherence rates by hypertensive patients to be essentially the same (93%), but is double the worldwide estimate of 50% put forward by the WHO. Although associations were not measured, it is possible to project that such a great difference in non-adherence could negatively impact health outcomes and contribute considerably to worsening of disease, increased health care costs, and eventually death 4 .

The study has also demonstrated that a major proportion of hypertensive patients exhibited a high sense of spiritual belief and followed consistent religious lifestyles. Of the 400 hypertensive patients, about 90% were Christians, 5% were Muslims, while 1% identified with the Traditional religion. This trend is comparable to findings from the national population census in 2010, in which approximately 71%, 18% and 5% of the Ghanaian population were Christians, Muslims, and Traditionalists respectively. Similarly, a great proportion of patients regularly (once or more than once a week) attended church or other religious meetings, and a major percentage of the patients frequently (daily or more than once a day) engaged in non-organized religious activities like prayer, meditation, or Bible study. It was also apparent from the Spiritual Perspective Scale that very high proportions of patients frequently engaged in spiritually related activities. These spiritual activities formed noteworthy aspects of their daily lives. With regard to establishing a relationship between spirituality/ religiosity and anti-hypertensive medication adherence, we observed that while spirituality significantly influenced non-adherence, organized and non-organized religiosity did not. Likewise, after controlling for demography and co-morbidities, patients with high spirituality were 2.68 times more likely to be poorly adherent than patients who place lower emphasis on the association between spirituality and health.

This means that the lower likelihood of adhering to treatment was a result of high spiritual beliefs of patients and not behavioural religious characteristics. These outcomes directly contradict our postulation that ‘spirituality/religiosity will significantly influence medication adherence positively’. The results also contradict findings by Simoni, Frick, and Huang (2006) 33 and Raghavan et al. (2013) 34 whose studies have shown a positive impact of spirituality/ religiosity on medication adherence. It is worth noting that these studies were not conducted with a sub-Saharan African population. Spirituality/religiosity is an important component of the cultural beliefs of Africans, but to date there is little information examining how sub-Saharan Africans, and specifically Ghanaian adults with hypertension, relate spirituality/religiosity to medication adherence. For example, in examining barriers to antiretroviral therapy (ART) adherence in Uganda, Wanyama et al. (2007) 35 noted that some patients discontinued ART because of a belief in spiritual healing. In our study, we have demonstrated that although hypertensive patients exhibited high spiritual beliefs and engaged in frequent religious activities, spirituality and not religiosity influenced medication non-adherence. Thus, beliefs and practices can be treated as separate domains. These results seem to suggest that hypertensive patients related more to experiences of peace, and reverence or attachment with a Supreme Being 36 . Potentially, they may place more trust in the divine expectation of healing and not on conventional orthodox medications. The patients may tend to believe in God or a Supreme Being for possible healing, knowing the chronic and in most cases incurable nature of hypertension 35 . This further suggests that some patients would risk not taking their medications while anticipating divine healing outcomes. The observation is in line with spiritual causal theories strongly underlining chronic conditions in Ghana 37 . In a related study on medication adherence among persons with mental illness in Ghana, a similar trend was observed. Patients and their families sought spiritual interventions for their mental illness because they perceived the conventional antipsychotic medications failed to achieve a complete cure 38 .

It is thus imperative for health professionals to be holistic in their approach to healthcare by taking into consideration the importance of the spirituality of their patients while providing care.

In spite of the above findings, the study was limited in the fact that the main target participants were derived from tertiary hospitals only, yet, hypertensive patients in Ghana are managed in various hospitals, not only the two tertiary hospitals used for this study.

This study anticipated filling the knowledge gap in relation to establishing an association between spirituality/ religiosity and medication adherence among hypertensive patients in Ghana and by extension sub-Saharan Africans. The study outcome has demonstrated that while high spiritual and religious beliefs form core components of the lifestyles of hypertensive patients, spirituality, not religiosity, related directly to medication non-adherence, a highly prevalent risk behaviour of the patients. Thus, religiosity ought not to be equated to spirituality. Our study suggests that the reverence, experiences, and attachment of patients with a supreme being may potentially increase their trust or expectation of divine healing to the detriment of reliance on conventional orthodox anti-hypertensive medications. Thus, the study suggests that when treating patients or implementing medication non-adherence intervention programmes, considerable emphasis should be on the dynamics of the effects of spirituality, not necessarily religiosity.

The authors declare that they have no competing interests.

IK was involved with research concept, data collection, data analysis, interpretation of results, and writing of manuscript. FO contributed to research concept, study design and review of manuscript. SD participated in research concept and study design. All authors reviewed and approved the final manuscript.