Introduction

Medication adherence is defined by the World Health Organization (WHO) as “the degree to which the person’s behavior corresponds with the agreed recommendations from a health care provider.1 This is influenced by multiple factors which is clearly depicted in multidimensional adherence model by WHO with five dimensions including social and economic, patient, condition related, therapy related, and health care system factors.2 Effects of poor medication adherence results in disease progression with its complications such as myocardial infarction and stroke, increased out-of-pocket expenditure for emergency hospitalization, reduced quality of life, and increased mortality.3 Out of the 17 million premature deaths (under the age of 70 years) due to noncommunicable diseases, 82% occurred in low- and middle-income countries, of which 37% were contributed by cardiovascular diseases (CVDs).4 In addition, the average age of CVD patients in India is about a decade lower than in the Western world, with a greater proportion experiencing myocardial infarction and poor outcomes.5 Recommended guidelines to reduce the morbidity and mortality associated with CVDs were lifestyle modifications such as maintenance of body weight, increased physical activity, dietary modifications and cessation of smoking along with prescribed intake of antihypertensive, antiplatelets, and statins. Among these the most critical determinant is adherence to medication at the secondary level of prevention.6

Nonadherence to cardiovascular medications has become increasingly documented across patient populations and cardiovascular drug classes throughout the world. A meta-analysis of 20 studies involving 376,162 patients illustrates a nonadherence prevalence of 43% throughout multiple drug classes, as measured by pharmacy refill data.7 This is well supported by WHO, where medication adherence accounts to 50% in developed countries and the situation seems to be much worse in developing countries, like India, due to poor access to health care services, poor affordability, and poor knowledge of the disease outcome.8 One of the most common method used to measure this medication adherence was self-reported medication taking behavior using validated the Morisky medication adherence scale-4 (MMAS-4).9

Indian studies have also found varied prevalence with low adherence among women.10 11 12 Gender specific could be attributed more to patient-related determinants wherein the chances of forgetfulness to take medicine could be high due to her increased roles and responsibilities along with other factors. There is also paucity of studies, specifically among women in our set up to understand the interplay of various determinants influencing the medication adherence. This early identification of the determinants which are amenable for modification can be addressed in clinical practice to reduce the poorer outcome. Therefore, this study has been taken up especially among women with an objective to ascertain the magnitude of level of medication adherence and also assess various determinants influencing its level.

Material and Methods

A hospital-based cross-sectional study was conducted at a tertiary care hospital located at Hyderabad. The study includes women patients who were already diagnosed with CVD, such as coronary artery diseases, hypertension, and stroke (with at least 3 months of medication), above the age of 18 years, and those who gave written consent for participation and attending as outpatients (OPD). Those who were not willing to be a part of this study, below the age of 18 years, pregnant, and lactating women were excluded. The sample size was calculated using the formulae 4PQ/L 2 with prevalence assumed as 50% from previous studies conducted in India10 and was rounded to 175. Simple random sampling method was adopted to select the women cases attending general medicine and cardiology OPD during 3 months of study period. Institutional ethical committee permission was obtained prior to the study. The Purpose of the study was explained and written informed consent was obtained from all the participants before administrating the questionnaire. Pilot study was conducted prior to the study and modifications were done in the questionnaire accordingly. Semistructured questionnaire was used consisting of sociodemographic variables, family history of hypertension/diabetes/coronary artery disease, reasons of good adherence and adherences, and personal habits. Clinical variables, such as type and duration of CVD, type and duration of medications, used by the patient were also detailed. The MMAS-4 was used to estimate the level of medication adherence which consisted of four questions. For each question with answer as “Yes” was allotted one point and with answer “No” was allotted zero points. Based on the score from these four questions, they were classified as high adherence with score of 0, medium adherence with score of 1 or 2, and low adherence with score of 3 or 4. Comprehensive WHO multidimensional adherence model classified the factors/determinants, such as socioeconomic determinants, which included poverty, unemployment, illiteracy, limited drug supply, and cost of medicines which were evaluated by probing questions like out of pocket expenditure. Patient-related determinants were assessed through their personal unwillingness, forgetfulness, taken alternative medicine, such as native medicine, ayurvedic, unani, or homeopathy medicines, and then felt better and stopped the medicines on their own. Health system–related determinants included irregular supply of drugs from the government, irregular follow-up and were not informed by the physician to continue as a life-long medication. Therapy-related determinants are long duration of treatment, too many drugs to be taken, fear of dependency on drugs, side-effects of drugs, unknown about the disease, and its complications. Condition-related determinants included usage of tobacco, alcohol, and other comorbidities associated obtained from previous reports and medications being taken were evaluated in the questionnaire.

Results

Our study included 175 women above the age of 18 years diagnosed with any of the CVDs such as hypertension, coronary artery disease, and stroke. Women diagnosed with hypertension, coronary artery disease, and stroke were 145 (83%), 18 (10%), and 12 (7%), respectively (Fig. 1).

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Fig. 1 Distribution of study subjects according to CVD. CVD, cardiovascular diseases.

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Fig. 1 Distribution of study subjects according to CVD. CVD, cardiovascular diseases.

Prevalence of Medication Adherence among Women of Cardiovascular Diseases Using the Morisky Scale

Prevalence of medication adherence among women of CVDs using MMAS-4 was found high, medium, and low among 68 (39%), 89 (51%), and 18 (10%), respectively (Fig. 2).

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Fig. 2 Prevalence of medication adherence among study subjects using the Morisky medication adherence scale-4 (MMAS-4).

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Fig. 2 Prevalence of medication adherence among study subjects using the Morisky medication adherence scale-4 (MMAS-4).

Discussion

In our study, approximately 61% of the women were found to have low-to-medium level of medication adherence for the secondary prevention of CVDs at a tertiary care hospital of Hyderabad. Thakur et al, in their study at Chandigarh, found 48.1% of women to have low-to-medium level of medication adherence for the coronary artery disease using MMAS-8.10 In their study at Puducherry, to assess adherence among hypertensive patients, Shankar et al also found 63% of women to have reported nonadherence using MMAS having seven question with four-point response format.4 Ramli et al, in their study at primary health care clinics of Malaysia, found 43.7% of women with hypertension to have nonadherence to medication using MMAS-8.5 All these variations can be explained by varying sociodemographic regions and also varying scales used to measure the adherence.

Complex interplay of multiple factors determine adherence to medication. In the present study, it was found that the most common reasons for poor adherence were forgetfulness (11%), poverty (9.1%), irregular supply (8%), and limited supply of drugs (7.4%). Statistically significant association was found with socioeconomic determinants which included poverty, unemployment, illiteracy, limited drugs supply, and high cost of medicines. Among the patient-related determinants, unwillingness and forgetfulness were found to be statistically significant. Health system–related determinants were irregular supply, not informed by the physician about life-long intake of medicines, and irregular follow-up. Therapy-related determinants, such as long duration, adverse events of drugs, and no knowledge about complications, were also found statistically significant among our study patients.

Similar findings were found by Awad et al, in their study among Sudanese, where the most common reasons for low-medication adherence were high cost of drugs, polypharmacy, lack of pharmacist’s communication with them regarding the instructions and importance of taking the drug, lack of physician’s communication with them regarding their illness, side-effects associated with their medications, and irregular availability of the drugs in their areas.6 Van der Laan et al among the Netherland patients also found older age, forgetfulness, too many pills, and insufficient knowledge on what to do when a dose is forgotten as the common factors for determining medication adherence.7 In Indian set up, similar findings were also reported by Gupta et al with main factors as forgetfulness and absence of symptoms of hypertension, drugs side-effects, and out of supply as reasons for their medication adherence which accounted to 20% medium and 21.4% low-medication adherence.8 Socioeconomic determinants seem to play a predominant role in low- and middle-income countries compared with high-income countries. And also the self-reported behavior of noncompliance needs to be changed to reduce the morbidity and mortality.

Conclusion

Low-to-medium medication adherence was found to be more than half among our study patients which needs to be addressed by targeting the common determinants, such as forgetfulness, which can be reduced by putting reminders in mobile phones, creating health education about the importance of intake of drugs, and thereby preventing complications with regular follow–up, and also the physician’s utmost need to explain the life-long intake along with lifestyle modifications.