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The Journal of Nursing Research h VOL. 25, NO. 5, OCTOBER 2017
O R I G I N A L  A R T I C L E
Renal Transplant Recipients: The Factors
Related to Immunosuppressive Medication
Adherence Based on the Health Belief Model
Pen-Chen Kung1 & Mei Chang Yeh2* & Ming-Kuen Lai3 & HsuehYErh Liu4
ABSTRACT
Background: Kidney transplant failures are caused primarily by
lack of adherence to immunosuppressive medication regimens
by patients after transplantation. A number of studies have
indicated that health-related beliefs are an effective predictor of
health-related behavior.
Purpose: The aim of this study is to understand the influence
of the personal characteristics and health-related beliefs of
patients on adherence to treatment with immunosuppres
sive medication based on the Health Belief Model.
Methods: This cross-sectional study distributed questionnaires
to patients who had been recruited via purposive sampling at
one medical center in Taipei. All of the potential participants had
undergone kidney transplantation at least 6 months previously.
The self-developed questionnaire collected data in three areas:
personal characteristics, health-related beliefs regarding trans
plant rejection, and adherence to the immunosuppressive medi
cation regimen. One hundred twenty-two valid questionnaires
were received. The collected data were analyzed using descriptive
statistics, independent t test, one-way analysis of variance,
Pearson's correlation, and multiple regression.
Results: Participants who had received dialysis treatment or
had experienced rejection perceived susceptibility to rejection
more strongly than those who had not. Participants who had
undergone transplantation in Taiwan, had experienced more
drug-related symptoms, or had contracted severe to extremely
severe infections in the past showed lower rates of adherence
to treatment with immunosuppressive medication. Adherence
to medication regimens correlated negatively with length of
time since transplantation. Length of time since transplanta
tion, drug-related symptoms, perceived susceptibility to rejec
tion, and perceived benefits of treatment were identified as
major predictors of adherence to immunosuppressive medi
cation regimens.
Conclusions: The results partially conformed to the concepts
of the Health Belief Model. Perceived susceptibility to rejection
and perceived benefits of adherence to treatment were found
to predict adherence rates. Patient education should be enhanced
to reduce the risks of rejection and increase adherence rates to
improve outcomes.
KEY WORDS:
kidney transplant, immunosuppressive medication adherence,
health beliefs.
Introduction
Adherence to a treatment regimen involving immunosup
pressive medication after kidney transplantation is crucial
to the survival of the graft and is a basic self-care behavior
for renal transplant recipients. Renal transplantation is the
most common organ transplantation procedure performed
in Taiwan (Taiwan Organ Registry and Sharing Center,
2014) and is the best choice for treating end-stage renal
disease. Numerous studies have indicated that kidney trans
plant failure is primarily because of nonadherence to medi
cation regimens after surgery (Akchurin, Melamed, Hashim,
Kaskel, & Del Rio, 2014; Morrissey, Flynn, & Lin, 2007;
Prendergast & Gaston, 2010; Vasquez, Tanzi, Benedetti, &
Pollak, 2003).
Numerous studies on the issue of adherence to treatment
with immunosuppressive medication in renal transplant reci
pients have indicated that adherence rates relate to demo
graphics such as age, gender, race, marital status, educational
level, career status, and socioeconomic status (Greenstein
& Siegal, 1998; Spivey, Chisholm-Burns, Damadzadeh, &
Billheimer, 2014). Furthermore, adherence is also influenced
by medical variables such as the side effects of medication, se
verity  of  symptoms  (Habwe, 2006;  Jung, Kim, Han,  Kim,
& Chu, 2010; Simons, McCormick, Devine, & Blount,
2010; Wang et al., 2013), number of renal transplant expe
riences, time elapsed since renal transplantation (Tsapepas
et al., 2014), and number of immune rejection experiences
(Hilbrands, Hoitsma, & Koene, 1995).
Fear of rejection is a major stressor that is experienced
by transplant recipients (Sutton & Murphy, 1989). Research
by Hilbrands et al. (1995) on the treatment adherence of
renal transplant patients has shown that patients with past
rejection experiences have significantly higher adherence
rates to medication regimens. In addition, recipients also
worry about infection (Fallon, Gould, & Wainwright, 1997).
Research on the health-related beliefs of heart transplant
patients has shown that 38% of nonadherence to medication
1MSN, RN, Project Teacher, Department of Gerontological Care and
Management, Chang Gung University of Science and Technology &
2EdD, RN, Associate Professor, School of Nursing, College of Medicine,
National Taiwan University & 3MD, Deputy Superintendent, Division
of Urology, Camillians Saint Mary's Hospital Luodong & 4PhD,
RN, Professor, School of Nursing, Collge of Medicine Chang Gung
University, and Researcher (joint appointment), Department of
Rheumatology, Chang Gung Memorial Hospital, Linkou.
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Medication Adherence of Renal Transplant Recipients
VOL. 25, NO. 5, OCTOBER 2017
is attributable to concerns regarding the increased probability
of infections (Herna ndez Mart n et al., 2010). These factors
may become barriers to medication adherence (Simons et al.,
2010; Talas & Bayraktar, 2004).
In their examination of the medication adherence behav
iors of 95 kidney transplant patients, Vasquez et al. (2003)
found that, although 90% of the patients admitted to under
standing the adverse effects of nonadherence on the grafted
kidney, this understanding did not appear to affect adher
ence rates. Butler et al. (2004) noted that beliefs regarding
medication were associated with adherence, with stronger
confidence in the medication associated with a stronger
motivation to comply. Loghman-Adham (2003) found an
association between patient perceptions of treatment bene
fits and compliance with a medication regimen; Raiz, Kilty,
Henry, and Ferguson (1999) pointed out in their research
that factors affecting treatment adherence rates for renal
transplant patients were subjective rather than objective.
Another study found that adherence rates were significantly
lower for recipients who had experienced rejection after
transplant and then later experienced medication-induced
physiological discomfort or psychological feelings of ill
ness or discomfort (Baines, Joseph, & Jindal, 2002; Kung,
Koschwanez, Painter, Honeyman, & Broadbent, 2012). As
noted, the subjective health-related beliefs of patients are a
more effective predictor of adherence to treatment than other
objective conditions.
Rosenstock's (1974) Health Belief Model presumes that
the perception of disease is influenced by perceived suscep
tibility to and severity of the disease, with the probability of
an individual taking preventive action dependent on the per
ceived benefits and barriers of doing so. Several studies have
shown that beliefs about health may effectively predict be
haviors and thus may be used to reduce noncompliance
(Ross & Guggenheim,1983; Telles-Correia, Barbosa, Mega,
Barroso, & Monteiro, 2007). One study that used the Health
Belief Model to investigate medication compliance among
kidney transplant patients found that noncompliance rates
increased for those who perceived relatively high barriers to
medical treatment and grafts failed more frequently for those
who perceived relatively low benefits of medical treatment
(Kiley, Lam, & Pollak, 1993). The factors that relate to
immunosuppressive medication adherence have been dis
cussed in the literature. Most of these factors are confined to
drug-induced symptoms or consider only the impact of demo
graphic variables. This study employed four basic concepts
of the Health Belief Model and found a significant correla
tion between the subjective beliefs about transplant rejection
and the rates of medication adherence.
Methods
We recruited 122 patients from the kidney transplant clinic
of a medical center in Taipei City between November 2010
and January 2011. The participants had undergone kidney
transplantation at least 6 months before the study and ex
hibited no signs of transplant rejection, infection, or severe
disease at the time of enrollment.
Instrument
The researcher developed the study questionnaire based on
Rosenstock's Health Belief Model. In addition, questionnaires
that were designed by Jang (2008) and Nexoe, Kragstrup,
and Sgaard (1999) and the researcher's clinical experiences
were referenced during the questionnaire development pro
cess. A 5-point Likert scale was used to measure each of the
beliefs, with higher scores indicating stronger beliefs. The re
liability of each questionnaire was tested using Cronbach's !
(immunosuppressive medication adherence = .617, per
ceived susceptibility to rejection = .771, perceived severity of
rejection = .883, perception of benefits = .888, perception of
barriers = .706). The questionnaires were reviewed by six
experts, including kidney transplant specialists and kidney
care specialists, supervisors in the urology department, and
senior nurses of urology with doctoral degrees. Most of the
questionnaire items presented content validity indexes of
greater than 0.8, and items with a content validity index of
less than 0.8 were revised based on the experts' opinions.
The content of the questionnaires was the following:
1. Personal characteristics included demographic var
iables (age, gender, marital status, educational level,
monthly household income, nature of work) and medi
cal variables (time elapsed since transplant, location
of transplant, source of kidney, previous dialysis expe
rience, experience with rejection after transplant, and
experience with drug-induced symptoms). Data on the
number of drug-induced symptoms were collected by
asking patients to mark the symptom checklist. The
checklist was designed by the researcher using the com
monly observed symptoms of renal transplant patients.
2. The items for immunosuppressive medication adherence
included knowledge regarding medication name, adher
ence to medication schedule and dosage, remembering
to take medication, and knowledge regarding excess or
insufficient medication. The questionnaires used a 5-point
Likert scale to measure each behavior item, with higher
scores associated with better adherence.
3. The questionnaire on health-related beliefs regarding
transplant rejection included (a) perceived susceptibility
to transplant rejection (participants' self-awareness of
the possibility of transplant rejection), (b) perceived
severity of rejection (participants' individual awareness
of the impact of renal transplant on survival and on
life), (c) perceived benefits of adherence to treatment
with immunosuppressive medication (participants'
subjective beliefs regarding whether correct adherence
lowers the possibility of transplant rejection), and (d)
perceived barriers to adherence (e.g., adherence to medi
cation regimen is time consuming and requires effort,
and the side effects of medication include discomfort
and changes in physical appearance).
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The Journal of Nursing Research
Pen-Chen Kung et al.
Statistical Analysis
IBM SPSS Statistics Version 19.0 (IBM Inc., Armonk, NY,
USA) was used for statistical analysis, which was divided
into three parts. The status of adherence to treatment with
immunosuppressive medication and health-related beliefs
regarding transplant rejection were analyzed using descrip
tive statistics. Relationships among the basic characteristics,
health beliefs, and adherence to medication regimen were
analyzed using Student's t test, analysis of variance, and
Pearson productYmoment correlation. Multiple regression
analysis was performed on the predictive factors for adher
ence to immunosuppressive medication. A p value of less
than .05 was considered to be significant.
Ethical Considerations
The study was approved by the institutional review board
of the medical institution (20100903R). Participation was
strictly voluntary. We explained the importance of the study
to participants, confirmed that they fully understood the
study, and gained their informed consent before asking them
to complete the questionnaire.
Results
Participant Characteristics
One hundred twenty-two patients met the criteria for enroll
ment. The mean age of the sample was 51.73 years (SD =
1.76 years). There were 57.4% men and 42.6% women;
72.1% were married; and one third were high school grad
uates (32.8%), and one quarter were college graduates
(24.6%). Only variables that were statistically meaningful to
health-related beliefs regarding transplant rejection and ad
herence to medication regimen were presented (Table 1).
The Relationship Among Medication
Adherence and Health Beliefs or Individual
Characteristics
No significantly statistical relationship was found between
treatment adherence and rejection-related health beliefs. Medi
cation adherence correlated negatively with the time that had
elapsed since transplantation.
An analysis of variance showed that perceived susceptibil
ity to rejection was significantly influenced (p G .05) by having
undergone dialysis treatment (t = 2.43, p = .017) and having
a previous rejection experience (t = 3.38, p = .001). Partici
pants in these two categories had stronger perceptions re
garding their susceptibility to rejection than other participants
(Table 2).
The location of the facility where the kidney transplant
was performed significantly influenced the perceived bar
riers to adherence to immunosuppressive medication (t =
2.34, p = .021). Patients who had received transplants in
TABLE 1.
Participant Characteristics (N = 122)
Variable
n
%
Age (years), M and SD
51.73
1.76
27Y40
24
19.7
41Y50
24
19.7
51Y60
49
40.2
61Y70
25
20.5
Gender
Male
70
57.4
Female
52
42.6
Time elapsed since transplant (years), M and SD
6.78
4.41
G1
13
10.7
1Y5
37
30.3
6Y10
52
42.6
910
20
16.4
Location of transplant
Taiwan
102
83.6
Mainland China
20
16.4
Previous dialysis experience
No
10
8.2
Yes
112
91.8
Experience of rejection after transplant
No
97
79.5
Yes
25
20.5
Degree of infection
Mild
17
56.7
Slightly severe
7
23.3
Severe
3
10.0
Extremely severe
3
10.0
Missing
92
Number of drug-induced symptoms
1
28
24.3
2
26
22.6
3
28
24.3
4
20
17.4
Q5
13
11.4
Missing
7
Taiwan reported a stronger perception of barriers to adher
ence than those who had received transplants in Mainland
China. Patients who experienced three or more drug-induced
symptoms reported more barriers than those who experi
enced two or fewer drug-induced symptoms (t = 10.18,
p = .00). Furthermore, the severity of past infection incidents
significantly affected the perception of barriers to adherence
to a medication regimen (F = 4.30,  p = .027). Using Scheffe's
post hoc analysis, we discovered that patients who had ex
tremely severe infections were less likely to achieve adherence
than those who had experienced mild infections (Table 3).
Multiple Regression Analysis of Adherence
to Immunosuppressive Medication
Table 4 shows the results of multiple regression analysis
using health-related beliefs, experienced rejections, number
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Medication Adherence of Renal Transplant Recipients
VOL. 25, NO. 5, OCTOBER 2017
TABLE 2.
Relationship Between Participant
Characteristics and Perceived
Susceptibility of Rejection
Item
Mean
t/F
Previous dialysis experience
2.43*
No
8.00
Yes
9.64
Experience of rejection after transplant
3.38**
No
9.00
Yes
10.72
*p G .05. **p G .01.
of drug-induced discomfort symptoms, and time elapsed since
transplant as the independent variables and adherence to
treatment with immunosuppressive medication as the depen
dent variable. The results show that the joint explanatory
power of these dependent variables is 21%. The number of
drug-induced symptoms, time elapsed since transplant, per
ceived susceptibility to rejection, and perceived benefits of
adherence to treatment with immunosuppressive medication
were identified as apparent predictors (p G .05).
Discussion
Adherence to treatment with immunosuppressive medica
tion was significantly and negatively correlated with the time
elapsed since renal transplant, suggesting that adherence
rates declined over time. This echoes the findings of previous
studies, which associated increased levels of medication non-
adherence with increased time since transplant (Germani et al.,
2011; Massey et al., 2013).
Participants who had received their transplants in Taiwan
experienced more difficulty with medication adherence than
TABLE 3.
Relationship Between Participant
Characteristics and Perceived Barriers
of Immunosuppressive Medication
Adherence
Item
Mean
t/F
Location of transplant
t = 2.34*
Taiwan
6.57
Mainland China
5.47
Degree of infection
F = 4.30*
Mild
5.25
Slightly severe
5.83
Severe/extremely severe
8.00
Drug-induced symptoms
t = 10.18**
Two or fewer
5.45
Three or more
7.32
*p G .05. **p G .01.
TABLE 4.
Results of Multiple Regression Analysis
of Adherence to Immunosuppressive
Medication
Independent Variable
B
p
Constant
16.204
.000
Experience of rejection
after transplant
Number of drug-induced
symptoms
Time elapsed since
transplant
j.579
j.289**
j.077**
j.182
j.296
j.256
.055
.006
.005
Perceived susceptibility
to rejection
.139*
.228
.024
Perceived severity of
rejection
j.010
j.025
.783
Perceived benefits of
.231*
.230
.016
medication adherence
Perceived barriers to
.104
.148
.175
medication adherence
Note. R2 = .214, adjusted R2 = .160, F = 3.93, and p = .001.
*p G .05. **p G .01.
peers who had received transplants in Mainland China. Un
dergoing kidney transplantation outside Taiwan presents
many additional challenges and dilemmas, including finan
cial pressures, uncertainty about transplantation outcomes,
lack of trust in the quality of medical care, and frustrations
in seeking medical care (Chen, Hu, Shih, & Shih, 2012). In
view of this, we speculate that patients who had undergone
surgery in China experienced greater difficulties overall, which
made them more appreciative of their transplants and more
motivated to overcome barriers to keep their new kidney.
The participants who had experienced severe to extremely
severe infections showed lower rates of adherence to treat
ment with immunosuppressive medication than did those
who had experienced minor infections, perhaps because the
former were more concerned that medication might impair
immunity and result in infection. This is similar to the find
ings that heart transplant patients failed to adhere to treat
ment with medication partly to avoid infection (Herna ndez
Mart n et al., 2010).
The participants who experienced a greater number of
drug-induced symptoms showed lower rates of adherence to
treatment. This result is similar to the finding of Baines et al.
(2002) that transplant patients who experience medication
related physical or mental discomfort had less incentive regarding
adherence to treatment with immunosuppressive medication.
The participants who had received dialysis and those who
had experienced rejection had relatively strong perceived sus
ceptibility to rejection. These individuals expressed a strong
motivation for adherence to treatment with medication be
cause they were afraid of experiencing rejection, which would
Copyright (c) 2017 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
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Page 5
The Journal of Nursing Research
Pen-Chen Kung et al.
lead to renal failure, dependence on dialysis, and a low quality
of life (Butler et al., 2004; McAllister, Buckner, & White-
Williams, 2006; Orr, Orr, Willis, Holmes, & Britton, 2007).
No significant finding was obtained when the health-
related beliefs that were related to rejection were used as
independent variables in the multiple regression analysis of
adherence to treatment. However, when additional items such
as ''experience of rejection after transplantation,'' ''number of
drug-induced symptoms,'' and ''time elapsed since trans
plant'' were included as independent variables, ''perceived
susceptibility to rejection'' and ''perceived benefits of adher
ence to immunosuppressive medication'' became apparent
predictors for adherence to medication. This result indicates
that ''perceived susceptibility to rejection'' and ''perceived
benefits of adherence to immunosuppressive medication''
have explanatory power for treatment adherence in some
subgroups of participants (Table 4). This is probably because
patients with certain experiences deeply understood that it
was very difficult to obtain and keep their kidneys and thus
appreciated the benefits of treatment with immunosuppres
sive medication. Therefore, these patients had better rates of
adherence because of their desire to prevent rejection.
Interestingly, although many previous studies have found
perceived barriers to treatment adherence to be the strongest
predictor of compliance (Carpenter, 2010; Wang, Charron-
Prochownik, Sereika, Siminerio, & Kim, 2006), it was not
identified as a significant predictor in the current study. This
different result may be because of the relatively high number
of questions about perceived barriers that were related to
drug-induced side effects. This led to a higher correlation
between ''perceived barriers to adherence to treatment with
immunosuppressive medication'' and ''number of drug-
induced symptoms,'' which then led to the lack of significance
of ''perceived barriers to adherence to treatment with im
munosuppressive medication'' that was found in the multi
ple regression analysis.
Conclusions
Our results are consistent with the many studies that have
associated length of time since transplant with lower adher
ence to treatment with immunosuppressive medication be
cause of the increasing severity of drug-induced symptoms.
We recommend that clinical care providers dedicate more
attention to patients with older transplants. Moreover, for
patients experiencing discomfort because of drug-induced
symptoms, care providers should assist them with timely
symptom management. This assistance allows patients to
strike a viable balance between adherence to treatment and
adaptation to the side effects to maintain renal functions and
quality of life. It is possible to predict the adherence of pa
tients to treatment with immunosuppressive medication by
evaluating the perceived susceptibility of rejection and the
perceived benefits of adherence to the treatment regimen. In
clinical practice, these findings may be applied to identify
groups that face higher risks of medication nonadherence.
The results of the current study help clearly identify patients'
beliefs regarding adherence to treatment with immunosup
pressive medication and target those beliefs to improve clini
cal outcomes.
Limitations
Because purposive sampling was used to recruit patients who
were receiving follow-up care in the kidney transplant clinic
of one medical center in Taipei City, the number of partici
pants was limited. Therefore, the results may not be directly
applicable to cases at other hospitals. Furthermore, data on
''immunosuppressive medication adherence'' behavior were
collected using self-reporting questionnaires. Thus, there may
be some discrepancies with the actual situation because of
memory errors. We suggest that the method of data collec
tion be adjusted in the future to improve the measurement of
adherence behavior.
Accepted for publication: December 7, 2015
*Address correspondence to: Mei Chang Yeh, No. 1, Jen-Ai Rd.
Sec. 1, Taipei City 10051, Taiwan, ROC.
Tel: +886 (2) 2312-3456 ext. 88427; Fax: +886 (2) 23418274;
E-mail: mchang@ntu.edu.tw
The authors declare no conflicts of interest.
Cite this article as:
Kung, P. C., Yeh, M. C., Lai, M., K. & Liu, H. E. (2017). Renal
transplant recipients: The factors related to immunosuppressive
medication adherence based on the health belief model.
The Journal of Nursing Research, 25(5), 392Y397. doi:10.1097/
jnr.0000000000000181
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