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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 762-768
Medication adherence among adult patients on hemodialysis

1 College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences; National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Community and Mental Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
4 Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan

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Date of Web Publication24-Jun-2014


Medication adherence was assessed in 89 patients on hemodialysis (HD) at the King Abdul Aziz Medical City using an Arabic version of the Morisky Medication Adherence Scale (MASS-8). The results of the study revealed that 31.46% and 40.45% of the participants showed low and medium adherence, respectively, while 28.09% showed high medication adherence. Accordingly, 71.91% of the patients visiting the dialysis unit were considered medication non-adherent. While being of older age (P = 0.012), being married (P = 0.012) increased the level of adherence, being of medium level of education (P = 0.024) decreased adherence levels. On the other hand, gender, presence of a care-giver, number of members in the household and employment status seems to have no effect on the level of medication adherence. These results call upon the practitioners in HD units to develop intervention programs that can increase the level of medication adherence.

How to cite this article:
Alkatheri AM, Alyousif SM, Alshabanah N, Albekairy AM, Alharbi S, Alhejaili FF, Alsayyari AA, Qandil AM, Qandil AM. Medication adherence among adult patients on hemodialysis. Saudi J Kidney Dis Transpl 2014;25:762-8

How to cite this URL:
Alkatheri AM, Alyousif SM, Alshabanah N, Albekairy AM, Alharbi S, Alhejaili FF, Alsayyari AA, Qandil AM, Qandil AM. Medication adherence among adult patients on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2023 Feb 8];25:762-8. Available from: https://www.sjkdt.org/text.asp?2014/25/4/762/134990

   Introduction Top

Adherence, as an alternative term to com­pliance, is becoming popular because it enhan­ces the role of patients in the doctor-patient wrong foods and medications, taking expired and/or damaged medications, taking improperly stored medications and, finally, improperly using medicated devices such as inhalers. [3]

Fischer et al in 2010 analyzed more than 195,000 electronic prescriptions and found that less than 78% of all the e-prescriptions were filled, with even a lesser percentage for new e-prescriptions (72%). It was also interesting to find that patients with new prescriptions for chronic medications were the least adherent (hypertension, 28.4%; hyperlipidemia, 28.2%; and diabetes, 31.4%). [4] Patient medication non-adherence can be very costly. A report in 2009 by The New England Healthcare Institute (NEHI), a non-profit organization, estimated that poor adherence to medication costs the US health-care system $289 billion annually. [5] In addition to visits to doctors followed by diag­nostic tests and treatment, it was estimated that 23% of admissions to nursing homes and 10% of hospital admissions are caused by non-adherence to medications. [6] The cost of these avoidable events can be staggering if it is taken into consideration that as of 2009, the esti­mated average expenditure on nursing homes per resident was $13,761 and that the average cost of each hospital admission was $17,271. [5]

Another negative effect of patient non-adhe­rence to medication is the false impression that the doctor (or other health-care providers) might get about the effectiveness of the medi­cation regimen that was prescribed. In such cases, the doctor might prescribe a new re­gimen that might result in aggravation of the patients' disease. [7] In general, for many chronic conditions, poor medication adherence to pres­cribed medications and other aspects of the treatment regimen can adversely affect the treatment outcome leading to additional and unnecessary tests, dosage adjustments, changes in the treatment plan, visits to the emergency department or hospitalization, which ultimately results in increased cost of medical care.

Dialysis is a life-saving procedure, but at best it replaces only about 10% of the normal renal function. The average dialysis patient takes 6- 10 medicines a day in addition to many dietary restrictions. These complex therapeutic regimens place a significant burden on the patients and usually make them dependent on health-care providers for many aspects of their treatment.

A critical review of the literature by Schmid et al concerning adherence of adult patients undergoing chronic hemodialysis (HD) to prescribed oral medications showed that more than half of the study patients included in their review reported a mean medication non-adherence of 67%. [8] Furthermore, it was found that 80.4% of chronic HD patients were non-adherent to diet, while 75.3% of them were non-adherent to fluid restriction. [9]

There are several factors that have been asso­ciated with mediation non-adherence in chro­nic patients such as those undergoing HD. [10] These factors were categorized by Jin et al into patient-centered factors, therapy-related factors, social and economic factors, health-care sys­tem factors and disease factors. Patient-cen­tered factors include demographic factors (age, ethnicity, gender, education, and marital status), psychosocial factors (beliefs, motivation and attitude), patient-prescriber relationship, health literacy, patient knowledge, physical difficul­ties, tobacco smoking or alcohol intake, forget-fulness and history of good compliance. The therapy-related factors include route of admi­nistration, treatment complexity, duration of the treatment, medication side-effects, degree of behavioral change required, taste of the medication and requirements for drug storage. The health-care system factors include lack of accessibility, long waiting time, difficulty in getting prescriptions filled and unhappy clinic visits. The social and economic factors include inability to take time off work, cost and in­come and social support. Finally, the disease factors include disease symptoms and severity of the disease. [11]

The aim of this study is to assess the patient medication adherence in patients on HD and to understand the factors that affect this adhe­rence, negatively or positively.

   Materials and Methods Top

This study was conducted in the HD unit at the King Abdulaziz Medical City (KAMC), Riyadh. The work load at this unit is divided into four shifts per day (morning, afternoon, evening and night), serving two groups of patients; Group A (Saturday, Monday and Wednesday) and Group B (Sunday, Tuesday and Thursday). Each HD patient is scheduled to come three times per week as part of Group A or B. Each group includes around 120 patients.

Adult patients (15-65 years) who visited the HD section regularly and were willing to com­municate were recruited into this study. The study was approved by the Institutional Review Board of the King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia. A verbal approval to participate in the study was ob­tained from all the participating patients. One hundred patients agreed to complete the ques­tionnaire.

The study design is a cross-sectional survey study. An Arabic version of the Morisky 8-item Medication Adherence Scale (MMAS-8) questionnaire was chosen for this study. In addition, demographic data such as age, gen­der, level of education, marital status and em­ployment status and relevant information such as period on dialysis, presence of a care-giver and number of people in the household were also collected. The original English version of the MMAS-8 was initially translated into Arabic by two bilingual professionals follo­wing which the two translations were amal­gamated into one Arabic version. This Arabic version was back translated into English by two different bilingual professionals and the back translations were compared and matched with the original MMAS-8 for wording, simi­larity in meaning and relevance.

The score of the MMAS-8 ranged from 0 to 8, and each item in the questionnaire carried one point. The first seven items required a yes (1) or no (0) answer, while the eighth was answered on a 5-point Likert scale that was dichotomized into "always," "usually," "some­times" or "every now and then" (0) or "never/ rarely" (1). The final score described the adhe­rence levels; a perfect eight meant high adhe­rence, a score from seven to six meant medium adherence and, finally, a score less than six meant low adherence. Furthermore, only pa­tients with high adherence scores were consi­dered adherent and those with low and me­dium adherence scores were considered non­adherent. The data were analyzed using SPSS version 18 by obtaining Pearson correlation for continuous variables and by one-way ANOVA for non-continuous variables.

   Results Top

Of the 100 participants, only 90 completed the questionnaire. One of these respondents was found to be a temporary patient and, hence, his responses were discarded. Accordingly, respon­ses from 89 participants were included in the descriptive statistics and analysis, with a res­ponse rate of 89%. The average age of the participants was 55.79 ± 17.69 years. The mean duration on dialysis was 37.27 ± 48.91 months. There were 47 male participants (52.8%) and 42 female participants (47.2%).

On the basis of the MMAS-8 score, 31.46% (N = 28) showed low adherence, 40.45% (N = 36) showed medium adherence and 28.09% (N = 25) showed high adherence [Figure 1]. This meant that 71.91% of the patients visiting the dialysis unit were non-adherent.
Figure 1: Distribution of patients based on adherence level.

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There was no correlation between age in general and the adherence score (P = 0.083, r = 0.185), nor was there a correlation between the duration on dialysis and the adherence score (P = 0.653, r = 0.048). Age was also categorized into three groups (15-35, 36-55 and more than 55 years old) or two groups (≤45 and >45 years). Both categorizations were analyzed by one-way ANOVA to determine whether there are differences in the means of the adherence scores. Indeed, and in both cases, there were significant differences in adherence between the age categories (P = 0.012), in which higher adherence was asso­ciated with older age [Table 1].
Table 1: Mean of the adherence score for the various age categories.

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With regard to the other variables, there was a significant difference in adherence (P = 0.012) between married and single participants (6.40 ± 1.50 and 5.13 ± 2.33, respectively). Also, there was a significant difference in adherence (P = 0.024) between participants who had no or less than high school education, par­ticipants who have high school education and those with a BSc degree (6.34 ± 1.62, 4.92 ± 2.30 and 6.50 ± 1.31, respectively). On the other hand, there was no difference in adhe­rence (P = 0.471) between males and females (6.30 ± 1.67 and 6.02 ± 1.88, respectively), nor was there a difference in adherence (P = 0.061) between those participants who had care-givers and those who did not (6.55 ± 1.41 and 5.84 ± 1.95, respectively). Also, no diffe­rence in adherence (P = 0.415) was found bet­ween patients who live in households of less than three members and those who live in house-holds of three or more members (5.67 ± 1.80 and 6.18 ± 1.77, respectively). Finally, there was no difference in adherence (P = 0.198) between participants who were em­ployed and those who were not employed (7.00 ± 1.41 and 6.20 ± 1.76, respectively).

   Discussion Top

Measuring and assessing medication adhe­rence in patients on HD is complex and re­quires certain criteria to obtain accurate re­sults. Beside tablet counting that is used to assist patient compliance, there are several methods that could be used to assess com­pliance, including laboratory measurement, pa­tient self-report and dialysis staff-report. There are several factors that have been associated with medication non-adherence in chronic pa­tients such as those undergoing HD. [10] These factors were categorized by Jin et al into pa­tient-centered factors, therapy-related factors, social and economic factors, health-care sys­tem factors and disease factors. [11] Among these categories, this work studied the demographics from the patient-centered factors (age, gender, education, employment, presence of care-giver, number of persons in the household and mari­tal status) and the duration on dialysis from the therapy-related factors.

In this study, we tested for the effect of age as a continuous variable and as discrete age-groups. Although there was no correlation bet­ween age (as a continuous variable) and adhe­rence score, the results of this study showed that older age is associated with better adhe­rence. These results are contrary to the results of Kutner and Cardenas who reported that patients aged 25-34 years were found to have the best overall adjustment to chronic dialysis therapy. [12] On the other hand, our results agree with overwhelming evidence that medication adherence in dialysis patients improves with older age. [13],[14],[15],[16],[17],[18] Furthermore, it has also been been reported that dietary adherence of dialysis patients improves with older age, [19],[20] and the odds of missing at least one dialysis session in a month were higher in patients aged <55 years. [21]

With regard to marital status, being married was shown to enhance medication adherence, which is in agreement with a very recent report that found that adherence score was higher in Greek married women than single ones. [22] Being married might be associated with better family support, which was found to also en­hance adherence to fluid regimens in HD patients. [23]

This study has found that patients with the highest (BSc) and the lowest levels of edu­cation (lower than high school) were the most adherent, while those with high school educa­tion were least adherent. Schmid et al, in a re­view of available reports on medication adhe­rence by HD patients, have concluded that higher adherence is associated with higher le­vel of education. [8] It seems that patients with a higher level of education have more con­fidence in the benefits of their medication regimen. [24] Another study showed that lower level of education was associated with better dietary adherence in HD patients. [25] Acceptance of the disease state seems to be associated with higher levels of medication adherence. [25] In this context, older and less-educated patients may have the highest acceptance of their disease states and, hence, show better adherence. It is worth mentioning that level of adherence of patients with high school degree has been pre­viously found to be different from those with lower or higher education levels. [26]

We found a lack of correlation between du­ration on dialysis and medication adherence in this study. Similarly, it has been previously reported that the duration of end-stage renal disease (ESRD) and duration on dialysis does not significantly affect medication adherence. [27] In our study, the lack of correlation might be due to the extreme heterogeneity in the data as the standard deviation was actually larger than the mean.

Other demographic characteristics including gender, number of people living in the house­hold and employment status had no effect on the medication adherence in this current sam­ple. A review by Karamanidou about deter­minants of non-adherence to phosphate bin­ding medication in patients with ESRD con­cluded that gender is commonly associated with medication adherence, but not employ­ment status. [28] The number of members in the household was reported to negatively correlate with medication adherence in patients on car­diovascular medications, [29] because it might affect the timing of doses. [30] The lack of adhe­rence in this current work might be attributed to the fact that 79 participants (88.76%) repor­ted living in household of three members or more. Finally, the presence of a care-giver was found to positively affect medication adhe­rence, but can be overshadowed by the overall environment that the patient lives in. [30]

   Conclusions Top

This work assessed medication adherence among HD patients. Less than one-third of the study sample showed high adherence. Medica­tion adherence was found to be positively associated with older age and being married and negatively associated with having medium level of education. One the other hand, the duration on dialysis, gender, the presence of a care-giver, employment status and number of household members were not found to be associated with medication adherence. The results of this study call on the practitioners in HD units to develop intervention and edu­cational programs to increase the level of medication adherence.

   References Top

1.Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 2001;26:331-42.  Back to cited text no. 1
2.Sabate E. WHO Adherence Meeting Report. Geneva: World Health Organization; 2001.  Back to cited text no. 2
3.American Society on Aging and American Society of Consultant Pharmacists Foundation. Adult Meducation, Improving Medications Adherence in Older Adults 2006 23rd Sept 2012. p. 96. Available from: http://www.adultmeducation.com/downloads/Adult_Meducation.pdf .  Back to cited text no. 3
4.Fischer MA, Stedman MR, Lii J, et al. Primary Medication Non-Adherence: Analysis of 195, 930 Electronic Prescriptions. J Gen Intern Med 2010;25:284-90.  Back to cited text no. 4
5.The New England Healthcare Institute (NEHI). Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. August 2009: USA: The New England Healthcare Institute; 2009. p. 21.  Back to cited text no. 5
6.World Health Organization. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.  Back to cited text no. 6
7.Smith DL. Compliance packaging: A patient education tool. Am Pharm 1989;NS29:42-5, 49-53.  Back to cited text no. 7
8.Schmid H, Hartmann B, Schiffl H. Adherence to prescribed oral medication in adult patients undergoing chronic hemodialysis: A critical review of the literature. Eur J Med Res 2009;14:185-90.  Back to cited text no. 8
9.Kugler C, Maeding I, Russell CL. Non-adherence in patients on chronic hemodialysis: An international comparison study. J Nephrol 2011;24:366-75.  Back to cited text no. 9
10.Theofilou P. Factors affecting level of com-pliance in chronic patients. Intern Med Open Access 2012;2:e106.  Back to cited text no. 10
11.Jing Jin, Sklar GE, Min Sen Oh V, Cheun Li S. Factors affecting therapeutic compliance: A review from the patient′s perspective. Ther Clin Risk Manag 2008;4:269-86.  Back to cited text no. 11
12.Kutner NG, Cardenas DD. Rehabilitation status of chronic renal disease patients under-going dialysis: Variations by age category. Arch Phys Med Rehabil 1981;62:626-30.  Back to cited text no. 12
13.Cummings KM, Marshal HB, Kirscht JP, Levin NL. Psychological factors affecting adherence to medical regimens in a group of haemodialysis patients. Med Care 1982;10: 567-81.  Back to cited text no. 13
14.Bame SI, Petersen N, Wray NP. Variation in haemodialysis patient compliance according to demographic characteristics. Soc Sci Med 1993;37:1035-43.  Back to cited text no. 14
15.Christensen AJ, Wiebe JS, Smith TW, Turner CW. Predictors of survival among haemo-dialysis patients: Effect of perceived family support. Health Psychol 1994;13:521-5.  Back to cited text no. 15
16.Sensky T, Leger C, Gilmour S. Psychological and cognitive factors associated with adhe-rence to dietary and fluid restriction regimens by people on chronic haemodialysis. Psychother Pshychosom 1996;65:36-42.  Back to cited text no. 16
17.Leggat JE, Orzol SM, Hulbert-Shearon TE, et al. Non-compliance in haemodialysis: Predic-tors and survival analysis. Am J Kidney Dis 1998;32:139-45.  Back to cited text no. 17
18.Stamatakis MK, Pecora PG, Gunel E. Factors influencing adherence in chronic dialysis patients with hyperphosphatemia. J Ren Nutr 1997;7:144-8.  Back to cited text no. 18
19.Vlaminck H, Maes B, Jacobs A, Reyntjens S, Evers G. The dialysis diet and fluid non-adherence questionnaire: Validity testing of a self-report instrument for clinical practice INFORMATION POINT: Kendall′s Tau. J Clin Nurs 2001;10:707-15.  Back to cited text no. 19
20.Wiebe J, Christensen A. Health beliefs, perso-nality, and adherence in hemodialysis patients: An interactional perspective. Ann Behav Med 1997;19:30-5.  Back to cited text no. 20
21.Obialo CI, Hunt WC, Bashir K, Zager PG. Relationship of missed and shortened hemo-dialysis treatments to hospitalization and mortality: Observations from a US dialysis network. Clin Kidney J 2012;5:315-9.  Back to cited text no. 21
22.Theofilou P. Medication Adherence in Greek hemodialysis patients: The contribution of depression and health cognitions. Int J Behav Med 2013;20:3111-8.  Back to cited text no. 22
23.Christensen AJ, Smith TW, Turner CW, Holman JM, Gregory MC, Rich MA. Family support, physical impairment, and adherence in hemodialysis: An investigation of main and buffering effects. J Behav Med 1992;15:313-25.  Back to cited text no. 23
24.Reynolds NR, Testa MA, Marc LG, et al. Factors influencing medication adherence beliefs and self-efficacy in persons naive to antiretroviral therapy: A multicenter, cross-sectional study. AIDS Behav 2004;8:141-50.  Back to cited text no. 24
25.McGee HM, Rushe H, Sheil K, Keogh B. Association of psychosocial factors and dietary adherence in haemodialysis patients. Br J Health Psychol 1998;3:97-109.  Back to cited text no. 25
26.Singh N, Squier C, Sivek C, Wagener M, Nguyen MH, Yu VL. Determinants of com-pliance with antiretroviral therapy in patients with human immunodeficiency virus: Pros-pective assessment with implications for enhancing compliance. AIDS Care 1996;8: 261-70.  Back to cited text no. 26
27.Horne R, Sumner S, Jubraj B, Weinman J, Frost S. Haemodialysis patients′ beliefs about treatment: Implications for adherence to medi-cation and fluid-diet restrictions. International J Pharm Pract 2001;9:169-75.  Back to cited text no. 27
28.Karamanidou C, Clatworthy J, Weinman J, Horne R. A systematic review of the preva-lence and determinants of nonadherence to phosphate binding medication in patients with end-stage renal disease. BMC Nephrol 2008; 9:2.  Back to cited text no. 28
29.Dunbar-Jacob J, Bohachick P, Mortimer MK, Sereika SM, Foley SM. Medication adherence in persons with cardiovascular disease. J Cardiovasc Nurs 2003;18:209-18.  Back to cited text no. 29
30.van Vliet MJ, Schuurmans MJ, Grypdonck MH, Duijnstee MS. Improper intake of medi-cation by elders - insights on contributing factors: A review of the literature. Res Theory Nurs Pract 2006;20:79-93.  Back to cited text no. 30

Correspondence Address:
Abdulmalik M Alkatheri
College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.134990

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