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Medication Adherence among Adult Patients on Hemodialysis

Article in Saudi Journal of Kidney Diseases and Transplantation · July 2014

DOI: 10.4103/1319-2442.134990

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Saudi J Kidney Dis Transpl 2014;25(4):762-768

© 2014 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Medication Adherence among Adult Patients on Hemodialysis

Abdulmalik M. Alkatheri1,2, Sarah M. Alyousif1,2, Najla Alshabanah2, Abdulkareem M.
Albekairy1,2, Shemylan Alharbi1,2, Fayze F. Alhejaili2, Abdullah A. Alsayyari2,
Abeer MA. Qandil3, Amjad M. Qandil1,4
1
College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh,
2
National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia, 3Department
of Community and Mental Health Nursing, Faculty of Nursing, 4Department of Medicinal
Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science and
Technology, Irbid, Jordan

ABSTRACT. 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.

Introduction relationship.1 The World Health Organization

Adherence meeting in June 2001 defined adhe-
Adherence, as an alternative term to com- rence as “the extent to which the patient fol-
pliance, is becoming popular because it enhan- lows medical instructions.”2 According to The
ces the role of patients in the doctor–patient American Society on Aging and the American
Correspondence to: Society of Consultant Pharmacists Foundation
joint Adult Meducation document, medication
Dr. Abdulmalik M. Alkatheri, non-adherence includes the following acts:
College of Pharmacy, Either intentionally or inadvertently failing to
King Saud bin Abdulaziz University for fill or refill a prescription, omitting one or
Health Sciences, King Abdulaziz Medical more doses, taking more of a medication than
City, National Guard Health Affairs, prescribed, discontinuing a medication, taking
Riyadh, 11426, Saudi Arabia a dose at the wrong time, taking medication of
E-mail: [email protected] other(s), taking a dose concurrently with the
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Medication adherence among HD adult patients 763

wrong foods and medications, taking expired place a significant burden on the patients and
and/or damaged medications, taking improperly usually make them dependent on health-care
stored medications and, finally, improperly providers for many aspects of their treatment.
using medicated devices such as inhalers.3 A critical review of the literature by Schmid
Fischer et al in 2010 analyzed more than et al concerning adherence of adult patients
195,000 electronic prescriptions and found that undergoing chronic hemodialysis (HD) to
less than 78% of all the e-prescriptions were prescribed oral medications showed that more
filled, with even a lesser percentage for new e- than half of the study patients included in their
prescriptions (72%). It was also interesting to review reported a mean medication non-
find that patients with new prescriptions for adherence of 67%.8 Furthermore, it was found
chronic medications were the least adherent that 80.4% of chronic HD patients were non-
(hypertension, 28.4%; hyperlipidemia, 28.2%; adherent to diet, while 75.3% of them were
and diabetes, 31.4%).4 Patient medication non- non-adherent to fluid restriction.9
adherence can be very costly. A report in 2009 There are several factors that have been asso-
by The New England Healthcare Institute ciated with mediation non-adherence in chro-
(NEHI), a non-profit organization, estimated nic patients such as those undergoing HD.10
that poor adherence to medication costs the US These factors were categorized by Jin et al into
health-care system $289 billion annually.5 In patient-centered factors, therapy-related factors,
addition to visits to doctors followed by diag- social and economic factors, health-care sys-
nostic tests and treatment, it was estimated that tem factors and disease factors. Patient-cen-
23% of admissions to nursing homes and 10% tered factors include demographic factors (age,
of hospital admissions are caused by non- ethnicity, gender, education, and marital status),
adherence to medications.6 The cost of these psychosocial factors (beliefs, motivation and
avoidable events can be staggering if it is taken attitude), patient–prescriber relationship, health
into consideration that as of 2009, the esti- literacy, patient knowledge, physical difficul-
mated average expenditure on nursing homes ties, tobacco smoking or alcohol intake, forget-
per resident was $13,761 and that the average fulness and history of good compliance. The
cost of each hospital admission was $17,271.5 therapy-related factors include route of admi-
Another negative effect of patient non-adhe- nistration, treatment complexity, duration of
rence to medication is the false impression that the treatment, medication side-effects, degree
the doctor (or other health-care providers) of behavioral change required, taste of the
might get about the effectiveness of the medi- medication and requirements for drug storage.
cation regimen that was prescribed. In such The health-care system factors include lack of
cases, the doctor might prescribe a new re- accessibility, long waiting time, difficulty in
gimen that might result in aggravation of the getting prescriptions filled and unhappy clinic
patients’ disease.7 In general, for many chronic visits. The social and economic factors include
conditions, poor medication adherence to pres- inability to take time off work, cost and in-
cribed medications and other aspects of the come and social support. Finally, the disease
treatment regimen can adversely affect the factors include disease symptoms and severity
treatment outcome leading to additional and of the disease.11
unnecessary tests, dosage adjustments, changes The aim of this study is to assess the patient
in the treatment plan, visits to the emergency medication adherence in patients on HD and to
department or hospitalization, which ultimately understand the factors that affect this adhe-
results in increased cost of medical care. rence, negatively or positively.
Dialysis is a life-saving procedure, but at best
it replaces only about 10% of the normal renal Materials and Methods
function. The average dialysis patient takes 6–
10 medicines a day in addition to many dietary This study was conducted in the HD unit at
restrictions. These complex therapeutic regimens the King Abdulaziz Medical City (KAMC),
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764 Alkatheri AM, Alyousif SM, Alshabanah N, et al

Riyadh. The work load at this unit is divided meant low adherence. Furthermore, only pa-
into four shifts per day (morning, afternoon, tients with high adherence scores were consi-
evening and night), serving two groups of dered adherent and those with low and me-
patients; Group A (Saturday, Monday and dium adherence scores were considered non-
Wednesday) and Group B (Sunday, Tuesday adherent. The data were analyzed using SPSS
and Thursday). Each HD patient is scheduled version 18 by obtaining Pearson correlation for
to come three times per week as part of Group continuous variables and by one-way ANOVA
A or B. Each group includes around 120 patients. for non-continuous variables.
Adult patients (15–65 years) who visited the
HD section regularly and were willing to com- Results
municate were recruited into this study. The
study was approved by the Institutional Review Of the 100 participants, only 90 completed the
Board of the King Abdullah International questionnaire. One of these respondents was
Medical Research Center, National Guard found to be a temporary patient and, hence, his
Health Affairs, Riyadh, Saudi Arabia. A verbal responses were discarded. Accordingly, respon-
approval to participate in the study was ob- ses from 89 participants were included in the
tained from all the participating patients. One descriptive statistics and analysis, with a res-
hundred patients agreed to complete the ques- ponse rate of 89%. The average age of the
tionnaire. participants was 55.79 ± 17.69 years. The mean
The study design is a cross–sectional survey duration on dialysis was 37.27 ± 48.91 months.
study. An Arabic version of the Morisky 8- There were 47 male participants (52.8%) and
item Medication Adherence Scale (MMAS-8) 42 female participants (47.2%).
questionnaire was chosen for this study. In On the basis of the MMAS-8 score, 31.46%
addition, demographic data such as age, gen- (N = 28) showed low adherence, 40.45% (N =
der, level of education, marital status and em- 36) showed medium adherence and 28.09% (N
ployment status and relevant information such = 25) showed high adherence (Figure 1). This
as period on dialysis, presence of a care-giver meant that 71.91% of the patients visiting the
and number of people in the household were dialysis unit were non-adherent.
also collected. The original English version of There was no correlation between age in
the MMAS-8 was initially translated into general and the adherence score (P = 0.083, r
Arabic by two bilingual professionals follo- = 0.185), nor was there a correlation between
wing which the two translations were amal- the duration on dialysis and the adherence
gamated into one Arabic version. This Arabic score (P = 0.653, r = 0.048). Age was also
version was back translated into English by categorized into three groups (15–35, 36–55
two different bilingual professionals and the and more than 55 years old) or two groups
back translations were compared and matched (≤45 and >45 years). Both categorizations were
with the original MMAS-8 for wording, simi- analyzed by one-way ANOVA to determine
larity in meaning and relevance. whether there are differences in the means of
The score of the MMAS-8 ranged from 0 to the adherence scores. Indeed, and in both
8, and each item in the questionnaire carried cases, there were significant differences in
one point. The first seven items required a yes adherence between the age categories (P =
(1) or no (0) answer, while the eighth was 0.012), in which higher adherence was asso-
answered on a 5-point Likert scale that was ciated with older age (Table 1).
dichotomized into “always,” “usually,” “some- With regard to the other variables, there was
times” or “every now and then” (0) or “never/ a significant difference in adherence (P =
rarely” (1). The final score described the adhe- 0.012) between married and single participants
rence levels; a perfect eight meant high adhe- (6.40 ± 1.50 and 5.13 ± 2.33, respectively).
rence, a score from seven to six meant medium Also, there was a significant difference in
adherence and, finally, a score less than six adherence (P = 0.024) between participants who
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Medication adherence among HD adult patients 765

Figure 1. Distribution of patients based on adherence level.

had no or less than high school education, par- Discussion

ticipants who have high school education and
those with a BSc degree (6.34 ± 1.62, 4.92 ± Measuring and assessing medication adhe-
2.30 and 6.50 ± 1.31, respectively). On the rence in patients on HD is complex and re-
other hand, there was no difference in adhe- quires certain criteria to obtain accurate re-
rence (P = 0.471) between males and females sults. Beside tablet counting that is used to
(6.30 ± 1.67 and 6.02 ± 1.88, respectively), nor assist patient compliance, there are several
was there a difference in adherence (P = methods that could be used to assess com-
0.061) between those participants who had pliance, including laboratory measurement, pa-
care-givers and those who did not (6.55 ± 1.41 tient self-report and dialysis staff-report. There
and 5.84 ± 1.95, respectively). Also, no diffe- are several factors that have been associated
rence in adherence (P = 0.415) was found bet- with medication non-adherence in chronic pa-
ween patients who live in households of less tients such as those undergoing HD.10 These
than three members and those who live in factors were categorized by Jin et al into pa-
house-holds of three or more members (5.67 ± tient-centered factors, therapy-related factors,
1.80 and 6.18 ± 1.77, respectively). Finally, social and economic factors, health-care sys-
there was no difference in adherence (P = tem factors and disease factors.11 Among these
0.198) between participants who were em- categories, this work studied the demographics
ployed and those who were not employed from the patient-centered factors (age, gender,
(7.00 ± 1.41 and 6.20 ± 1.76, respectively). education, employment, presence of care-giver,
Table 1. Mean of the adherence score for the various age categories.
Age N Mean (adherence score) Significance
Three categories
15 to 35 years 18 5.06 ± 2.04
36 to 55 years 18 6.33 ± 1.61
Above 55 years 53 6.45 ± 1.60 0.012
Total 89 6.15 ± 1.77
Two categories
≤45 years old 24 5.3750 ± 2.06
>45 years old 65 6.4308 ± 1.57 0.012
Total 89 6.1461 ± 1.77
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766 Alkatheri AM, Alyousif SM, Alshabanah N, et al

number of persons in the household and mari- states and, hence, show better adherence. It is
tal status) and the duration on dialysis from the worth mentioning that level of adherence of
therapy-related factors. patients with high school degree has been pre-
In this study, we tested for the effect of age as viously found to be different from those with
a continuous variable and as discrete age- lower or higher education levels.26
groups. Although there was no correlation bet- We found a lack of correlation between du-
ween age (as a continuous variable) and adhe- ration on dialysis and medication adherence in
rence score, the results of this study showed this study. Similarly, it has been previously
that older age is associated with better adhe- reported that the duration of end-stage renal
rence. These results are contrary to the results disease (ESRD) and duration on dialysis does
of Kutner and Cardenas who reported that not significantly affect medication adherence.27
patients aged 25–34 years were found to have In our study, the lack of correlation might be
the best overall adjustment to chronic dialysis due to the extreme heterogeneity in the data as
therapy.12 On the other hand, our results agree the standard deviation was actually larger than
with overwhelming evidence that medication the mean.
adherence in dialysis patients improves with Other demographic characteristics including
older age.13-18 Furthermore, it has also been gender, number of people living in the house-
been reported that dietary adherence of dialysis hold and employment status had no effect on
patients improves with older age,19,20 and the the medication adherence in this current sam-
odds of missing at least one dialysis session in ple. A review by Karamanidou about deter-
a month were higher in patients aged <55 minants of non-adherence to phosphate bin-
years.21 ding medication in patients with ESRD con-
With regard to marital status, being married cluded that gender is commonly associated
was shown to enhance medication adherence, with medication adherence, but not employ-
which is in agreement with a very recent report ment status.28 The number of members in the
that found that adherence score was higher in household was reported to negatively correlate
Greek married women than single ones.22 with medication adherence in patients on car-
Being married might be associated with better diovascular medications,29 because it might
family support, which was found to also en- affect the timing of doses.30 The lack of adhe-
hance adherence to fluid regimens in HD rence in this current work might be attributed
patients.23 to the fact that 79 participants (88.76%) repor-
This study has found that patients with the ted living in household of three members or
highest (BSc) and the lowest levels of edu- more. Finally, the presence of a care-giver was
cation (lower than high school) were the most found to positively affect medication adhe-
adherent, while those with high school educa- rence, but can be overshadowed by the overall
tion were least adherent. Schmid et al, in a re- environment that the patient lives in.30
view of available reports on medication adhe-
rence by HD patients, have concluded that Conclusions
higher adherence is associated with higher le-
vel of education.8 It seems that patients with a This work assessed medication adherence
higher level of education have more con- among HD patients. Less than one-third of the
fidence in the benefits of their medication study sample showed high adherence. Medica-
regimen.24 Another study showed that lower tion adherence was found to be positively
level of education was associated with better associated with older age and being married
dietary adherence in HD patients.25 Acceptance and negatively associated with having medium
of the disease state seems to be associated with level of education. One the other hand, the
higher levels of medication adherence.25 In this duration on dialysis, gender, the presence of a
context, older and less-educated patients may care-giver, employment status and number of
have the highest acceptance of their disease household members were not found to be
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Medication adherence among HD adult patients 767

associated with medication adherence. The review from the patient’s perspective. Ther
results of this study call on the practitioners in Clin Risk Manag 2008;4:269-86.
HD units to develop intervention and edu- 12. Kutner NG, Cardenas DD. Rehabilitation
cational programs to increase the level of status of chronic renal disease patients under-
going dialysis: Variations by age category.
medication adherence.
Arch Phys Med Rehabil 1981;62:626-30.
13. Cummings KM, Marshal HB, Kirscht JP,
Conflict of interest: None Levin NL. Psychological factors affecting
adherence to medical regimens in a group of
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