Hill-Bone Compliance Scale (HBCS)
Also known as: HBCS
The Hill-Bone Compliance Scale (HBCS) is a brief, disease-specific self-report measure designed to assess medication and lifestyle adherence in hypertension management. Developed by Kim, Hill, Bone, and Levine at Johns Hopkins University in 1999, the HBCS measures three dimensions of hypertension adherence: medication-taking, dietary sodium restriction, and appointment keeping. Unlike generic adherence measures, the HBCS captures the multifaceted nature of hypertension self-management, recognizing that many hypertensive patients struggle equally with medication adherence and behavioral changes (diet, exercise, weight management, stress management). The scale has demonstrated strong reliability and validity in diverse hypertensive populations and remains widely used in hypertension research and clinical management.
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When to use it
The HBCS is appropriate specifically for hypertensive patients and is particularly valuable at hypertension clinic visits, in research on blood pressure control, and in interventions targeting adherence in hypertension. It is especially useful when blood pressure control is suboptimal despite medication; the HBCS identifies whether the issue is poor medication adherence, lifestyle factors (diet, weight, exercise, stress), or both. The scale is less appropriate for non-hypertensive populations, though adaptations could theoretically be made for other chronic diseases with medication and lifestyle components (e.g., diabetes).
Strengths & limitations
- Disease-specific and multidimensional: Captures medication, dietary, and appointment adherence—the three key components of hypertension self-management—rather than medication-only measures.
- Clinically actionable: Subscale scores pinpoint specific adherence targets (e.g., 'patient's dietary sodium adherence is poor; focus nutrition counseling').
- Validated in diverse hypertensive populations: Strong reliability and validity demonstrated in African American, Latino, and other populations at high risk for hypertension complications.
- Predicts blood pressure control: HBCS scores correlate with actual blood pressure readings and treatment success.
- Brief and practical: 9 items, 5–10 minutes; acceptable for routine clinical use.
- Disease-specific: Validated only in hypertension; not applicable to other conditions without adaptation.
- Self-report bias: Vulnerable to social desirability bias, particularly for lifestyle adherence items (patients may overestimate dietary adherence or appointment keeping).
- Limited behavioral detail: Asks about behavior frequency but not specific reasons for non-adherence; requires follow-up questions.
- Dietary assessment imprecision: 'Avoiding salty foods' is subjective and may not correlate precisely with actual sodium intake; more precise dietary assessment (24-hour sodium recall, urinary sodium) would be more objective.
- Does not capture other hypertension self-management aspects: Does not measure exercise, weight management, stress management, or alcohol use reduction—all important in hypertension control.
Frequently asked
A patient scores high on medication adherence but low on dietary sodium restriction. What should I do?
This pattern indicates that the patient is reliably taking antihypertensive medication but is not restricting dietary sodium. Assess: Does the patient understand what 'low-sodium diet' means? Do they know which foods are high in sodium (processed foods, canned goods, fast food)? Is the barrier knowledge, access to low-sodium options, cost, or family/cultural food preferences? Provide specific education: provide a low-sodium food list, discuss easy substitutions (fresh vs. canned vegetables, cooking from scratch), consider referral to a registered dietitian. Monitor for blood pressure response; if BP remains high despite good medication adherence, dietary sodium reduction is critical.
Is the HBCS accurate for measuring actual sodium intake?
The dietary subscale of HBCS is a screening tool measuring self-reported dietary adherence, not precise sodium intake. For research or if precise dietary assessment is needed, use more objective measures: 24-hour sodium recall (interview-based), 24-hour urine sodium collection, or food frequency questionnaire with calculated sodium content. HBCS is practical for clinical practice to identify patients needing dietary counseling; for detailed dietary assessment, supplement with more rigorous measures.
Does HBCS measure exercise and weight management?
No, the standard HBCS measures medication adherence, dietary sodium restriction, and appointment keeping. Exercise, weight management, stress management, and alcohol reduction are important hypertension lifestyle modifications but are not captured in HBCS. If these are important targets, assess separately through detailed lifestyle history or use a more comprehensive hypertension self-management scale.
A patient scores high on HBCS but has elevated blood pressure. What does this mean?
Possible explanations: (1) self-report bias—the patient overestimated their adherence on the questionnaire; (2) medication resistance—the patient is adherent to an inadequate regimen; (3) secondary hypertension—an underlying condition (renal disease, sleep apnea) is driving elevated BP despite adherence; (4) unmeasured lifestyle factors (stress, alcohol, exercise) affect BP independent of diet and medication; (5) measurement error—office BP is elevated but home BP is well-controlled. Investigate: obtain objective confirmation of adherence (pharmacy refills, pill counts, serum drug levels if available), measure home BP, assess for secondary causes, and review complete lifestyle factors. Do not assume poor adherence based on BP alone; always verify with objective measures.
Sources
- Kim, M. T., Hill, M. N., Bone, L. R., & Levine, D. M. (1999). Development and Testing of the Hill-Bone Compliance Scale. Journal of Cardiovascular Nursing, 4(1), 54-59. (Also: Hill, M. N., Bone, L. R., & Kim, M. T. (1996). Perspective on compliance research in hypertension. Journal of Clinical Hypertension, 8(1), 12-17.) link ↗
How to cite this page
ScholarGate. (2026, June 3). Hill-Bone Compliance Scale (HBCS). ScholarGate. https://scholargate.app/en/pharmacology/hill-bone-compliance-scale
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