Evaluation of adherence to medications among hypertensive and diabetic patients in Fadasi ElHalimab Village, Gezira State, Sudan

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1 Evaluation of adherence to medications among hypertensive and diabetic patients in Fadasi ElHalimab Village, Gezira State, Sudan Mohamed Dafalla, MBBS, Islam Gasim Abdalla, MBBS Department of Surgery, Wad-Medani Heart Disease and Surgery Center, Wad-Medani, Sudan تق ى اإلنتضاو تانعالج ع ذ يشضى إستفاع ضغظ انذو انسك شي ف قش ح فذاس انحه اب ؽ ذ دكغ هللا, إعال هاع ػثذهللا ش ض د ذ ٢ أل شاض ظشاؼح ا و ة, د ذ ٢, ا غ دا يهخ ص:خهف ح: اإلذضا تا ؼالض ٣ ش ٤ ش إ ٠ ذ إذثاع ا ش ٣ ط رؼ ٤ اخ اإلسشاداخ ا طث ٤ ح تر ا ا ؼالض ا ز ١ ذ ذؽذ ٣ ذ ك ٢ ا صلح ا طث ٤ ح. ػذ اإل رضا ٣ ؤد ١ إ ٠ كش ا خط ح ا ؼالظ ٤ ح عاػلاخ ش ٣ ط, ػ ٠ ا ظا ا صؽ ٢. ا ؼ ا ا ر ٢ ذؤد ١ ؼذ إ رضا ا شظ ٠ تر ا ا ذ اء ذخر ق ع ػح ألخش, ٣ عة أ ذغروص ٠ ذذسط األعثاب ع ػح ػ ٠ ؼ ذج ص عاغ ا خط ح ا ؼالظ ٤ ح.األسان ة: ز دساعح سصذ ٣ ح وطؼ ٤ ح ذر 101 ش ٣ ط ٣ غ هش ٣ ح كذاع ٢ ا ؽ ٤ اب ظ ٤ ؼ شخ ص غثوا ت شض إسذلاع ظػ ا ذ ا شض ا غ ش ١. ذ اعرخذا ا ؼ ٤ ح ا ش ٣ ؽح, أظش ٣ د ا واتالخ شخص ٤ ا. ان تائح انخالصح: غثح اإل رضا تا ؼالض ك ٢ ا ذساعح ا د %39.6. ا غ ٤ ا, ؿالء عؼش ا ذ اء, األػشاض ا عا ث ٤ ح ذ اء, إظاكح إ ٠ ا شؼ س تا صؽح ػذ ا ؽ ظح ذ اء ا د أ األعثاب ؼذ اإل رضا تا ؼالض. ه ح ا ر ػ ٤ ح ا صؽ ٤ ح غر ا رؼ ٤ ؼة أ ٣ عا د سا ك ٢ ذو ٤ اإل رضا. Abstract Background Adherence is the extent to which patients take medications as prescribed by their health care providers. Non-adherence leads to treatment failure and profound consequences on the patient and the healthcare system. Factors leading to non-adherence differ from patient group to another, and each must be addressed in order to surmount them and attain the desired management goal. Methodology This is an observational cross-sectional study of 101 patients diagnosed with hypertension and/or diabetes residing in Fadasi Elhalimab Village, sampled conveniently and each were interviewed individually. Results and Conclusion The mean adherence rate of the study population was found to be 39.6%; with Corresponding author Mohamed Dafalla forgetfulness, feeling of self well-being, drug cost, and adverse-effects being the major contributors to non-adherence. Poor patient s knowledge and education about the treatment also played a role in reducing medication compliance. Keywords: Medication adherence, hypertension, diabetes, patient education Introduction Everyday, healthcare providers prescribe treatment regimens to patients. Most of them may be surprised that most patients take only between 33%-94% (1). The ability of physicians to recognize non-adherence is poor. The consequences of noncompliance were significant, specifically poor disease controlled and increased hospital admissions or readmissions (2). Adherence is defined as the extent to which patients take medications as prescribed by their health care providers, some further defined it to include taking the prescribed dose within a prescribed period (2). Rates of adherence were reported as a percentage of the prescribed doses taken over a specified 83

2 period (3). Non-adherence can be linked to 125,000 deaths per year in the USA, and costs around $177 billion annually (4). In the Federal Study of Adherence to Medication in the Elderly (FAME) trial, the mean adherence rate at baseline was 61.2% (5). The Boehringer Ingelheim Pharmacy Satisfaction 2009 Medication Adherence Study concluded that non-compliance rate was 58% (6). Non-adherence has been likened to a chronic illness and referred to as an epidemic (7). Investigators found that an age<65 years, negative beliefs about medications, low selfefficacy scores, depressive symptoms, and economic reasons were significant predictors of lower compliance (8,9). Typical reasons cited by patients for poor adherence in a number of publications include forgetfulness, other priorities, decision to omit doses, lack of information, emotional factors, and failure to involve patients in the decision making process (10,11). Although side effects have not been found to be an important reason for nonadherence, they may contribute (12). Egede et al found a 2% higher adherence rate among rural versus urban patients (13) while another study showed no difference in adherence between rural and urban patients despite demographic differences (14). Some interventions may be effective for patients with complicated dosing regimens or with memory barriers that reduce adherence, but these are likely to be less effective where other issues are at the forefront (15). Innovation in treatment methods and better understanding of adherence are needed to achieve the maximum benefits from therapies (16). Patients and Methods This is a non-interventional descriptive crosssectional, community based-study conducted in Fadasi ElhalimabVillage (~30 km north of Wad-Medani), Hasahisa district, Gezira State, Sudan. One hundred and one diabetics and hypertensive patients residing in Fadasi Elhalimab were interviewed individually at their homes after verbal consent was taken. A pre-formed questionnaire was used to assess adherence rate which was defined as taking more than 95% of the prescribed medication doses. Other items included barriers to poor adherence, relation between adherence and disease duration, presence of health insurance, and prescribed daily doses. The knowledge of patients about their drugs (drug name, dose, and side effects); satisfaction with treatment and follow-up visits to the patient s healthcare provider were also assessed. Convenience sampling was used. The data was analyzed using a computerized statistical analysis program (PASW). Results One hundred and one subjects were interviewed directly (46 women and 55 men). Twenty-five of the interviewed patients were in the year-old range, 50 were between 50 and 75, and 26 were above 75 years of age. The jobs of 35 and 16 of the interviewed subjects were housewives and teachers respectively; jobs of others ranged from retired workers, merchants and government employees. Primary education constituted the greatest percentage (39.6%) followed by illiteracy, secondary, and higher education at 21.8%, 20.8%, and 17.8% respectively. Thirty-four of the 101 patients included in the study have had the illness for 2-5 years while 30 had it for more than 10 years. The distribution of diseases in the sample between both sexes were as follows:25 men and 15 women had diabetes, 20 men and 21 women had hypertension, and10 men and 10 women were diagnosed with both hypertension and diabetes. More than half of the study subjects do not have health insurance constituting about 51.5%. Only one person took the medication as a self prescription, i.e. not prescribed by a healthcare provider. Forty point six percent bought their medication from the nearby city, the vast majority of whom have insurance, while 48.5% bought it from the local 84

3 pharmacy. The mean number of daily doses was 2.72 with 37.6% of the study population taking 1 dose/day. Medication adherence was generally poor. Sixty point four percent of the 101 patients were not adherent to their medication. Of whom 21 missed less than 20% of their daily dose, 26 missed 20%-40% of their prescribed dosages, 6 patients missed 50-70%, and 8 subjects missed more than 70% of their prescribed daily dose. Non-adherence was higher among patients with hypertension alone versus those with diabetes alone, with 26 hypertensive and 22 diabetics being nonadherent. Adherence rate in patients with both diseases was taken as a whole and not assessed based on individual disease specific medication. The most common stated reason by the study population for non-adherence was forgetfulness (35.5%), followed by a feeling of self well-being (29%), then high drug cost (19.4%) and the least frequently reported cause was medication side-effects (16.1%). Among the interviewed patients, only 11.9% had good knowledge about their medication, 59.4% knew little if any about their medication, and the rest having fair knowledge. The effect of each stated cause on the rate of non-adherence is shown in (Table 1). Table 1: Reasons for poor adherence and percentage of missed doses amongst non-adherent Reasons for poor adherence High drug cost Side effects Forgetfulness Feeling of self Total well-being Percentage < 20% of Missed 20%-40% doses per 50%-70% week > 70% Total It is worth noting that higher missed doses were associated with high drug cost and feeling of self well-being. Presence of health insurance did not significantly improve adherence to medication (p=0.291) neither did a lower number of doses/day (Table 2). Table 2: Adherence to prescribed medication vs. daily dose cross-tabulation p=0.332 Daily dose Total Adherence to prescribed medication Yes No Total Sixty percent of the study population had poor knowledge with regard to their prescribed medication, 30% had fair knowledge, and only 10% had good knowledge about their medication in terms of drug name, dose, and possible side effects. 46.5% of the patients were not educated by their healthcare provider about the importance of adherence and the consequences of non-adherence. Treatment choice was mutual between the patient and provider in only 14 of the 101 subjects, all of whom were satisfied with the treatment plan agreed upon with the healthcare provider. Fortunately, more than 55% of the patients 85

4 under study attended more than 5 follow-up visits per year to review their treatment plan. Discussion This study was designed to assess the level of adherence to medications amongst patients residing in a rural area. The primary target was patients with chronic diseases, since treatment adherence is a strong determinant of them having complications of the illness. Compared to the Federal Study of Adherence to Medication in the Elderly (FAME) trial (5), the mean percentage of medication adherence was less, the former concluding a 61% baseline adherence rate, while in this study, the percentage of study subjects who were adherent was only 39.6%, with more than 22% of non-adherent subjects missing at least half of the required dosages. As was established by previous researches (2,11), the strongest barrier to adherence in this review was forgetfulness, this in part being due to the complicated dosing regimens according to the patients intellectual levels, most of them being illiterate or of primary level education. Feeling of self well-being was also a strong determinant of adherence, as many patients felt they have no need for the medicament, a product of poor knowledge. The reality that most of the patients know little or none about their medication proves that the drug regimen is too complicated; and prescribers do not ensure patient education as part of their prescription, cumulating to poorer compliance. Drug cost was found to be an obstacle for adherence in 19.4% of those who were non-adherent, and it was associated with a higher percentage of missed doses. This is of concern, as drug costs are ever-increasing due to poor economic conditions, moreover the lack of funding and support to reduce medication costs to consumers, a majority of whom are at or below the poverty level. As this trend continues, non-adherence rates will likely follow. Duration of illness was also found to be inversely proportionate with better compliance, as earlier demonstrated by Osterberg & Blaschke (2). Thus, as disease duration progresses, perhaps decades in the case of diabetes and hypertension, adherence rates drop; further compounding to lack of disease control and its associated complications. Although having health insurance was not a strong predictor of good adherence (p=0.29), the fact that not all medications are covered by insurance which provides the possibility of drug cost being a cause for poor adherence even for those who have health insurance. Less dosage amount in this trial was not associated with a better adherence rate (p=0.33). Therefore, it is pertinent to scrutinize the barrier to adherence in each individual in order to implement the proper intervention accordingly (15). Simplifying instructions and medication schedules are essential, and minimizing the total number of daily doses has been found to be more important in promoting adherence than minimizing the total number of medications (10). A mutual choice, of the drug, between the doctor and patient was shown to ensure 100% treatment satisfaction in this study. Patients must actively participate in the selection and adjustment of drug treatment and in changes in lifestyle in order to maximize the usefulness of the therapeutic regimen. Poor patient adherence dictates the development and use of effective methods to measure treatment adherence. Patient education during prescription and follow-up should be assured, to eliminate the negative beliefs about medications in the patient. Adherence must be stressed, even if the patient feels no symptoms. Because improved medication adherence can produce better health outcomes for diabetic patients and moreover save national healthcare resources; governmentsponsored healthcare policies to improve medication adherence among newly diagnosed patients are urgently required especially those less fortunate. This can be done by including 86

5 more drugs in the umbrella of health insurance. The media can have a role in providing information about the importance of taking medication on time and the consequences of not doing so. Public service announcements, talk shows, and even children s programs can be made to target the topic. Innovations made by pharmaceutical companies must be amplified to reduce the medication load on the patient as well as the adverse side-effects of these drugs, and this can contribute greatly in improving treatment compliance (16). References 1. Billups SJ, MaloneDC, Carter BL. Relationship between drug therapy noncompliance and patient characteristics, health-related quality of life, and health care costs (Accessed August 2011 at 2. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353: Vijayn A, Morrison A. Washington Manual of Medical Theraputics 32 nd Ed. St.Louis, Lippincott: Williams & Wilkans; 2007.p National Council on Patient Information and Education. Enhancing prescription medication adherence: a national action plan. Available at: aboutrx.org/documents/enhancingprescript ion medicine adherence.pdf (Accessed Jan 2012). 5. Gibson M, Murphey SA. Federal study of adherence to medication-fame trial. AmericanCollege of Cardiology Cardiosource Available at: (Accessed Jan 2012) 6. Boehringer Inglheim Pharmacy Satisfaction Medication adherence study. Available at: com/resources/pdf/2009med-adherencereport.pdf (Accessed Jan 2012). 7. The American Society of Aging and the American Society of Consultant Pharmacists Foundation. Overview of medication adherence. Available at: OverviewofMedicationAdherence.html. (Accessed Jan 2012). 8. Chao J, Nau DP, Aikens JE, Taylor SD. The mediating role of health beliefs in the relationship between depressive symptoms and medication adherence in persons with diabetes. Res Social Adm Pharm 2005 Dec;1(4): Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm 2009; 66: Cramer J. Identifying and improving compliance patterns. In: Cramer JA, Spilker B, eds. Patient compliance in medical practice and clinical trials. New York: Raven Press; 1991.p Moser M, Setaro JF. Resistant or difficultto-control hypertension. N Engl J Med 2006;355: Wong MC, Kong AP, So WY, Jiang JY, Chan JC, Griffiths SM. Adherence to oral hypoglycemic agents in chinese patients. A Cohort Study J Clin Pharmacol [Epub]2011 Oct;51(10): Egede LE, Gebregziabher M, Hunt KJ, et al. Regional, geographic, and ethnic differences in medication adherence among adults with type 2 diabetes. Ann Pharmacother Rodrguez D, Cox M, Zimmer LO, Olson DM, Goldstein LB, Drew L, Peterson ED, Bushnell CD. Similar secondary stroke prevention and medication persistence rates among rural and urban patients. J Rural Health 2011; 27(4):

6 15. Case Management Society of America. Case Management Adherence Guidelines, Version 2.0. Available at: Default.aspx (accessed on Feb 12,2012). 16. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2005;Issue 4. Art. No.: CD DOI: / CD pub2 88