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Assessment of knowledge and adherence to therapy among chronic kidney disease patients attending nephrology department of tertiary care hospital, Kurnool city, Andhra Pradesh.

INTRODUCTION

Chronic kidney disease (CKD) is a non-communicable disease that affects 1 in 10 people worldwide. CKD is defined as kidney damage lasting for >3months characterized by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate. [1] The prevalence of CKD in the population is a considerable social and economic problem worldwide, and one that is increasing. CKD is much more widespread than people realize. It often goes undetected and undiagnosed until their kidney function is down to 25% of normal. [2]

It is a prolonged illness usually coexisting with diseases such as hypertension and diabetes. Consequently, these patients have to take a large pill burden on an average of around 8-10 tablets/day. [3] Hence, adherence is a major concern in the therapy of CKD.

Adherence to medication is defined as "the extent to which the patient's behavior matches agreed on recommendations from the prescriber." [4] Adherence to medication is a key component of effective disease management in CKD. The main goals of medication are to slow down the disease progression, monitor, and correct disease-associated complications and comorbidities while treating the underlying etiology.

Managing multiple medications and health-care appointments, along with dialysis for >2 times a week for some patients, are a challenging task. Not surprisingly, patients may miss medications, intentionally or unintentionally. This is a major obstacle to achieve treatment goals and increases the risk of morbidity, mortality, and hospitalization. High level of adherence to prescribed medication is very essential to obtain the desired outcomes in CKD patients. Hence, optimizing adherence to medicine is, therefore, a priority issue for health-care providers.

Assessment of medication adherence helps in identifying the various associated risk factors and developing the intervention to improve the adherence. Only a few studies on adherence to therapy among CKD patients have been carried out in India and Rayalaseema region. Hence, this study was planned to assess the adherence to therapy among CKD patients and study factors responsible for the non-adherence.

MATERIALS AND METHODS

Study Design

This was a cross-sectional study.

Study Period

The study was conducted from October 1, 2017, to March 31, 2018.

Study Setting

This study was conducted at the department of nephrology, tertiary care hospital of Kurnool City,

Andhra Pradesh, India.

Study Subjects

Patients aged >18 years, diagnosed with CKD and taking treatment for >3 months.

Ethical Issues

Ethical clearance was taken from the Ethical Committee of Kurnool Medical College before starting the study. Prior permission was obtained from the head of the department of nephrology unit and cooperation was sought. The purpose of the study was explained to all the study subjects in their local language and informed consent was taken.

Sample Size

All patients aged >18 years, diagnosed with CKD and on treatment for >3 months and given consent, attending to the Nephrology Department of Government General Hospital, Kurnool, from October 1, 2017, to March 31, 2018. This amounted to a total of 206 subjects.

Inclusion Criteria

Patients of either sex, aged >18 years diagnosed as CKD and on treatment for >3 months irrespective of the stage of CKD.

Exclusion Criteria

Patients who have not given consent to participate in the study.

Data Collection

Patients diagnosed with CKD and on treatment for >3 months, aged >18 years, of either gender, irrespective of the stage of CKD, whether on dialysis or not and irrespective of their co-morbid conditions were included. Briefing about the study and taking consent from the study participants was done prior to the start of study. Morisky Medication Adherence Questionnaire was used to calculate overall adherence. In addition to this, we have also used self-developed, prevalidated, semi-structured questionnaire. The questionnaire was designed to obtain information about demographic data, various issues concerned with medication non-adherence, dietary restriction, and fluid restrictions. Adherence was graded as high, medium, and low according to the Morisky Medication Adherence Scale (MMAS-8). Patients with non-adherence were evaluated for the cause.

Statistical Analysis

Data were entered into Microsoft Excel sheet, baseline characteristics of the study population were analyzed using descriptive statistics and their degree of adherence. Values are expressed as counts and percentage. Differences between categorical variables were tested using Chi-square test, R-value using statistical package EPI Info 7.2.2.2 version. MMAS-8 was used to calculate overall adherence. Scoring was done accordingly: High (score = 0), medium (score 1-2), and low (score >2).

RESULTS

A total of 206 patients aged >18 years, diagnosed with CKD and on treatment for >3 months were included in this study. Of which, 144 were men and 62 were women. Majority of them, 194 (94.17%) were currently married. The mean age of the respondents was 49.78 [+ or -] 12.21 years and it ranged from 21 to 80 years. Among them, 40 (19.42%) were <40 years of age, 69 (33.49%) were in the age group of 40-50 years, 57 (27.67%) were 51-60 years of age, and 40 (19.42%) were >60 years. Hindus were 157 (76.21%) followed by Muslims - 37 (17.96%) and Christians 12 (5.83%).

Majority, 50.97% (105) were illiterates. Around 11% (23) completed primary education, 19.90% (41) completed secondary education, 7.28% (15) studied up to intermediate, and 10.68% (22) had graduation and above education.

Around one-third of the subjects, 68 (33%) were unskilled workers followed by semi-skilled workers 50 (24.27%), 48 (23.30%) unemployed, 19 (9.22%) skilled workers, 19 (9.22%) semi-professional workers, and 2 (0.96%) patients were professional workers by occupation. Of majority of them, 74% (153) belonged to below poverty line.

Most of them 68.93% (142) were in Stage 5, 15.53% (32) Stage 4, 11% (23) were Stage 3, 2.91% (6) were Stage 2, and 1.46% (3) were in Stage 1 of CKD according to the National Kidney Foundation 2002 guidelines [Figure 1]. Nearly 14% (28) were overweight and 3.40% (7) were obese. An average number of medicines taken by each patient in a day was 5.746 [+ or -] 0.707. Nearly 40% (82) of the patients were taking >5 drugs. Many (85%) of the patients were found to be on hemodialysis. Around 32% were habituated to smoking and alcohol. At least one comorbidity was found among 84% (173) of patients. The comorbidities were hypertension 114 (55.33%), diabetes mellitus 13 (6.31%), anemia/severe anemia 9 (4.36%), etc. Two or more than two comorbidities were found among 17.96% (37) CKD patients [Figure 2].

A significant association was noted between adherence score and stages of CKD, number of medications taken, duration of treatment, patients on dialysis, smoking, and alcohol intake.

Age, gender, religion, educational status, occupation, marital status, socioeconomic status, body mass index (BMI), and associated comorbidities have no significant association with adherence score in this study [Table 1].

Although most of the patient's 87% (179) self-reported that they were aware of following the medicine schedules strictly as prescribed, MMAS-8 score revealed that only 23% showed "high" medication adherence.

Nearly 3/4ths (150) of the patients reported that they know the importance of each medicine. Knowledge of when to take medicine is lacking among 15% of patients. Awareness about adverse effects is very less accounting to only 12% (25) around 33.5% (69) aware that stopping medicine makes them feel ill [Table 2].

The medication adherence was categorized into high, "medium," and "low" on the basis of MMAS-8 score. Lower the score in MMAS-8, better is the adherence to medication. Among all enrolled patients, 34.47% and 42.23% showed "low" and "medium" medication adherence, respectively; only 23% showed "high" medication adherence. Majority, 76.7% of the patients were "non-adherent" to the drug therapy [Figure 3 and Table 4].

The present study shows that 89.32% of patients followed fluid and diet restrictions as advised by treating physician. They were also following advice regarding physical activity and taking other nutritional supplements as prescribed.

Patients who were found non-adherent (158) were then evaluated for the cause. Multiple reasons were given. The most common reason stated was forgetfulness 71.51% (113), followed by high cost of the medication, large pill burden, and fear of adverse effects 24.05% (38), 18.35% (29), and 10.12% (16), respectively. The other reasons were missed appointments in 5.06% (8), depression in 4 (2.53%), and others [Table 4].

DISCUSSION

In this study, the medication adherence among the CKD patients using the MMAS-8 and various factors affecting it was evaluated. High, medium, and low adherence was reported by 23.30%, 42.23%, and 34.47% of patients, respectively. A significant association was noted between adherence score and stages of CKD, number of medications taken, duration of treatment, patients on dialysis, smoking, and alcohol intake. Average number of medicines taken in a day by each patient was 5.746 [+ or -] 0.707 (mean [+ or -] SD). More than 1/4th of study subjects reported that they do not know the importance of each medicine they were taking. Non-adherence was found to be associated with >5 medication (P < 0.05). This study finds forgetfulness as the most common factor responsible for non-adherence in 72%. High cost of medication was found as another cause of non-adherence to drug therapy (24.05%). Missed appointment was found to be responsible for non-adherence in 1.4%. This study shows that 89.32% of patients followed fluid and diet restrictions as told by treating physician. They were also following exercise and taking other nutritional supplements as prescribed.

A study was done by Ahlawat et al. [5] (n = 150) revealed that 22%, 23%, and 55% of the patients had high, medium, and low adherence which is nearly similar to our study. A study was done by Sontakke et al. [6] revealed high, medium, and low adherence to be 7.3%, 55.3%, and 37.3% of patients, respectively. The adherence was found lower than the present study. Kefale et al. [7] showed that 157 (61.3%), 51 (19.9%), and 48 (18.8%) patients exhibited high, medium, and poor adherence to the prescribed regimens, respectively. Adherence was found higher than the present study. The measure of adherence to drug therapy in different studies using different tools varies from 38 to 83%. [8-12] Ahlawat et al. [5] reported that the level of medication adherence was found to be significantly associated with sex, socioeconomic status, treatment funding, stages of CKD, dialysis, and among different stages of BMI. The present study shows that significant association was noted between adherence score and stages of CKD, number of medications taken, duration of treatment, patients on dialysis, smoking, and alcohol intake. A study was done by Ahlawat et al., [5] Magacho et al. [11] also reported >5 pills as a major contributing factor for non-adherence (n = 149). According to Moreira et al.,[13] pill burden ([greater than or equal to]4) was significantly associated with non-adherence which is similar to the present study. A study was done by Sontakke et al. [6] revealed that 68% of patients were not aware about the importance of each medicine they were taking, which is lower than the present study. Varleta et al. [14] reported forgetfulness as the most common factor responsible for non-adherence in 67% of the patients (n = 310) using Morisky-Green questionnaire; Frankenfield et al. [15] have also reported that cost is a major factor for non-adherence in 23% of the end-stage renal disease patients. A study was done by Ahlawat et al. [5] revealed 4% non-adherence due to missed appointment. Van Servellen et al. [16] also reported similar findings. A study was done by Magar et al. [17] shows that 76% of patients followed fluid and diet restrictions as told by treating physician.

The strength of this study is that almost all the patients who are eligible for inclusion criteria and given consent were interviwed. Limitation of the study is that it is done for limited period.

Recommendations

Our results suggest that there is a need for periodic health checkups and counseling sessions for all the CKD patients. Addressing the possible conflicts between the patients' agenda and therapeutic targets should be a part of routine clinical practice if non-adherence is to be tackled effectively.

Creating awareness about the importance of taking each medicine regularly and possible side effects to the patients, and patient attendants and family members as well is necessary which would improve the adherence to therapy and also reduce the cost of care and adverse outcomes.

Affordability of treatment remains a major issue for these patients. This can be addressed by increasing the universal insurance coverage for CKD patients.

From the above findings, it appears that pill burden decreases the medication adherence. However, the number of medications in CKD patients cannot be reduced. Therefore, other strategies have to be explored to increase the medication adherence. One can decrease the frequency of drug using the long-acting medications, long-acting insulin, and drug combinations if available.

CONCLUSIONS

This study shows that nearly three-fourths of the patients were non-adherent. A significant association was noted between adherence score and stages of CKD, number of medications taken, duration of treatment, patients on dialysis, habituated to smoking, and alcohol intake. More than a quarter of the patients do not know the importance of each medicine they were taking. Nearly 15% of patients were not aware about how to take each medicine they were taking. Among the reasons for non-adherence, forgetfulness, high cost of medicine, and large pill burden were found to be the most common causes.

DOI: 10.5455/ijmsph.2019.0101523012019

ACKNOWLEDGMENT

The authors are grateful for the support given by the Department of Nephrology, B-Brawn Dialysis Unit Medical Officers, GGH, Kurnool, and the cooperation extended by the patients who participated in the study.

REFERENCES

[1.] Ritz E, Drueke TB. Chronic kidney disease. In: Oxford Textbook of Medicine. Oxford: Oxford University Press; 2001.

[2.] Nordqvist C, Stephens C. Symptoms, Causes, and Treatment of Chronic Kidney Disease. Available from: https://www. medicalnewstoday.com/articles/172179.php. [Last accessed on 2017 Dec 13].

[3.] Manley HJ, Garvin CG, Drayer DK, Reid GM, Bender WL, Neufeld TK, et al. Medication prescribing patterns in ambulatory haemodialysis patients: Comparisons of USRDS to a large not-for-profit dialysis provider. Nephrol Dial Transplant 2004;19:1842-8.

[4.] Nunes V, Neilson J, O'Flynn N. Clinical Guidelines and Evidence Review for Medicines Adherence: Involving Patients in Decisions about Prescribed Medicines and Supporting Adherence. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009. p. 1-325.

[5.] Ahlawat R, Tiwari P, Cruz SD. Prevalence and predictors of medication non-adherence in patients of chronic kidney disease: Evidence from a cross sectional study. J Pharm Care Health Syst 2016;3:152.

[6.] Sontakke S, Budania R, Bajait C, Jaiswal K, Pimpalkhute S. Evaluation of adherence to therapy in patients of chronic kidney disease. Indian J Pharmacol 2015;47:668-71.

[7.] Kefale B, Tadesse Y, Alebachew M, Engidawork E. Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur anbessa specialized hospital: A hospital-based cross-sectional study. PLoS One 2018;13:e0200415.

[8.] Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol 2009;4:1089-96.

[9.] Neri L, Martini A, Andreucci VE, Gallieni M, Rey LA, Brancaccio D, et al. Regimen complexity and prescription adherence in dialysis patients. Am J Nephrol 2011;34:71-6.

[10.] Sanchez-Gili M, Toro-Chico P, Perez-Encinas M, Gomez-Pedrero AM, Portoles-Perez JM. Pharmaceutical intervention on the therapeutic adherence in patients with chronic renal disease. Rev Calid Asist 2011;26:146-51.

[11.] Magacho EJ, Ribeiro LC, Chaoubah A, Bastos MG. Adherence to drug therapy in kidney disease. Braz J Med Biol Res 2011;44:258-62.

[12.] Weng FL, Chandwani S, Kurtyka KM, Zacker C, Chisholm-Burns MA, Demissie K, et al. Prevalence and correlates of medication non-adherence among kidney transplant recipients more than 6 months post-transplant: A cross-sectional study. BMC Nephrol 2013;14:261.

[13.] Moreira L, Fernandes P, Monte S, Martins A. Medication compliance in patients with chronic kidney disease. J Bras Nefrol 2008;30:113-9.

[14.] Varleta P, Akel C, Acevedo M, Salinas C, Pino J, Opazo V, et al. Assessment of adherence to antihypertensive therapy. Rev Med Chil 2015;143:569-76.

[15.] Frankenfield DL, Howell BL, Wei II, Anderson KK. Cost-related nonadherence to prescribed medication therapy among medicare part D beneficiaries with end-stage renal disease. Am J Health Syst Pharm 2011;68:1339-48.

[16.] van Servellen G, Chang B, Garcia L, Lombardi E. Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women. AIDS Patient Care STDS 2002;16:269-81.

[17.] Magar YB, Hiray RS, Ghongane BB. Evaluation of adherence, knowledge, and practices towards the therapy in patients of chronic kidney disease. J Med Sci Clin Res 2017;5:18337-42.

Siva Kala T (1), Arepalli Sreedevi (1), Hari Prasad M V (2), Jikki P N (3)

(1) Department of Community Medicine, Kumool Medical College, Kurnool, Andhra Pradesh, India, (2) Department of Orthopaedics, District Hospital, Markapuram, Prakasam district, Andhra Pradesh, India, (3) Department of Nephrology, Government General Hospital, Kurnool, Andhra Pradesh, India

Correspondence to: Arepalli Sreedevi, E-mail: sreedevispm@gmail.com

Received: January 04, 2019; Accepted: January 33, 2019
Table 1: Baseline characteristics of CKD patients and medication
adherence status based on MMAS-8 score

Variable                                 Total      Low adherence
                                       n=206 (%)       n=71(%)
Age
 <40 years                             40 (19.42)      14 (35)
 40-50 years                           69 (33.49)      21 (30.43)
 51-60 years                           57 (27.67)      24 (42.11)
 >60 years                             40 (19.42)      12 (30)
Sex
 Male                                 144 (69.90)      54 (37.5)
 Female                                62 (30.10)      17 (27.42)
Religion
 Hindu                                157 (76.21)      55 (35.03)
 Muslim                                37 (17.96)      13 (35.14)
 Christians                            12 (5.83)        3 (25)
 Educational status
 Illiterate                           105 (50.97)      37 (35.24)
 Primary                               23 (11.17)       7 (30.43)
 Secondary                             41 (19.90)      20 (48.78)
 Intermediate                          15 (7.28)        5 (33.33)
 Graduate and above                    22 (10.68)       2 (9.09)
Occupation
 Professional                           2 (0.96)        1 (50)
 Semi-professional                     19 (9.22)        6 (31.58)
 Skilled worker                        19 (9.22)       10 (52.63)
 Semi-skilled                          50 (24.27)      18 (36)
 Unskilled worker                      68 (33)         21 (30.89)
 Unemployed                            48 (23.30)      15 (31.25)
 Marital status
 Not married                            3 (1.46)        1 (25)
 Married and                          194 (94.17)      67 (34.53)
 Widowed living with Spouse             9 (4.37)        3 (33.33)
Socioeconomic status
 Below poverty line                   153 (74.27)      52 (33.99)
 Above poverty line                    53 (25.73)      19 (35.85)
BMI
 Underweight<18                         9 (4.37)        4 (44.44)
 Normal range 18-24.9                 162 (78.64)      49 (30.25)
 Overweight (>25) and                  35 (16.99)      18 (51.43)
 obese>30
CKD stages
 1-3                                   32 (15.53)      13 (40.62)
 4                                     32 (15.53)      16 (50.00)
 5                                    142 (68.94)      42 (29.57)
Number of medications
 [less than or equal to]5             113 (54.85)      45 (39.82)
 >5                                    93 (45.15)      26 (27.96)
 Hemodialysis                         175 (84.96)      58 (33.14)
 No dialysis                           31 (15.04)      13 (41.94)
Smoking and alcohol habits
 Present                               66 (32.04)      29 (43.94)
 Absent                               140 (67.96)      42 (30)
Comorbidities
 Absent                                33 (16.02)      15 (45.46)
 Present                              173 (83.98)      56 (32.37)
Duration of treatment
 <1 years                              42 (20.39)      14 (33.33)
 1-2 years                             31 (15.05)       6 (19.36)
 2-5 years                             88 (42.72)      29 (32.95)
 [greater than or equal to]5 years     45 (21.84)      22 (48.89)

Variable                               Moderate adherence
                                            n=87(%)
Age
 <40 years                                  15 (37.5)
 40-50 years                                29 (42.03)
 51-60 years                                24 (42.10)
 >60 years                                  19 (47.5)
Sex
 Male                                       55 (38.19)
 Female                                     32 (51.61)
Religion
 Hindu                                      66 (42.04)
 Muslim                                     15 (40.54)
 Christians                                  6 (50)
 Educational status
 Illiterate                                 42 (40)
 Primary                                    10 (43.48)
 Secondary                                  12 (29.27)
 Intermediate                                9 (60)
 Graduate and above                         14 (63.64)
Occupation
 Professional                                1 (50)
 Semi-professional                          11 (57.89)
 Skilled worker                              7 (36.84)
 Semi-skilled                               19 (38)
 Unskilled worker                           32 (47.06)
 Unemployed                                 17 (35.42)
 Marital status
 Not married                                 2 (75)
 Married and                                80 (41.24)
 Widowed living with Spouse                  5 (55.56)
Socioeconomic status
 Below poverty line                         63 (41.18)
 Above poverty line                         24 (45.28)
BMI
 Underweight<18                              4 (44.44)
 Normal range 18-24.9                       70 (43.21)
 Overweight (>25) and                       13 (37.14)
 obese>30
CKD stages
 1-3                                        12 (37.50)
 4                                           6 (18.75)
 5                                          69 (48.60)
Number of medications
 [less than or equal to]5                   49 (43.36)
 >5                                         38 (40.86)
 Hemodialysis                               80 (45.72)
 No dialysis                                 7 (22.58)
Smoking and alcohol habits
 Present                                    28 (42.42)
 Absent                                     59 (42.14)
Comorbidities
 Absent                                      9 (27.27)
 Present                                    78 (45.09)
Duration of treatment
 <1 years                                   20 (47.62)
 1-2 years                                  11 (35.48)
 2-5 years                                  40 (45.45)
 [greater than or equal to]5 years          16 (35.56)

Variable                               High adherence
                                          n=48 (%)
Age
 <40 years                                11 (27.5)
 40-50 years                              19 (27.54)
 51-60 years                               9 (15.79)
 >60 years                                 9 (22.5)
Sex
 Male                                     35 (24.31)
 Female                                   13 (20.97)
Religion
 Hindu                                    36 (22.93)
 Muslim                                    9 (24.32)
 Christians                                3 (25)
 Educational status
 Illiterate                               26 (24.76)
 Primary                                   6 (26.09)
 Secondary                                 9 (21.95)
 Intermediate                              1 (6.67)
 Graduate and above                        6 (27.27)
Occupation
 Professional                              0 (0)
 Semi-professional                         2 (10.53)
 Skilled worker                            2 (10.53)
 Semi-skilled                             13 (26)
 Unskilled worker                         15 (22.05)
 Unemployed                               16 (33.33)
 Marital status
 Not married                               0 (0)
 Married and                              47 (24.23)
 Widowed living with Spouse                1 (11.11)
Socioeconomic status
 Below poverty line                       38 (24.83)
 Above poverty line                       10 (18.87)
BMI
 Underweight<18                            1 (11.12)
 Normal range 18-24.9                     43 (26.54)
 Overweight (>25) and                      4 (11.43)
 obese>30
CKD stages
 1-3                                       7 (21.88)
 4                                        10 (31.25)
 5                                        31 (21.83)
Number of medications
 [less than or equal to]5                 19 (16.82)
 >5                                       29 (31.18)
 Hemodialysis                             37 (21.14)
 No dialysis                              11 (35.48)
Smoking and alcohol habits
 Present                                   9 (13.64)
 Absent                                   39 (27.86)
Comorbidities
 Absent                                    9 (27.27)
 Present                                  39 (22.54)
Duration of treatment
 <1 years                                  8 (19.05)
 1-2 years                                14 (45.16)
 2-5 years                                19 (21.60)
 [greater than or equal to]5 years         7 (15.55)

Variable                              [chi square]-value    P-value

Age
 <40 years                                    4.22            0.64
 40-50 years
 51-60 years
 >60 years
Sex
 Male                                         3.33            0.18
 Female
Religion
 Hindu                                 Yates [chi square]-    0.99
 Muslim                                      *0.177
 Christians
 Educational status
 Illiterate                                 * 10.774         0.2148
 Primary
 Secondary
 Intermediate
 Graduate and above
Occupation
 Professional                                * 6.738          0.74
 Semi-professional
 Skilled worker
 Semi-skilled
 Unskilled worker
 Unemployed
 Marital status
 Not married                                 * 0.723          0.948
 Married and
 Widowed living with Spouse
Socioeconomic status
 Below poverty line                           0.798           0.670
 Above poverty line
BMI
 Underweight<18                              * 5.779          0.216
 Normal range 18-24.9
 Overweight (>25) and
 obese>30
CKD stages
 1-3                                          10.31           0.03
 4
 5
Number of medications
 [less than or equal to]5                     6.67            0.03
 >5
 Hemodialysis                                 6.25            0.043
 No dialysis
Smoking and alcohol habits
 Present                                      6.42            0.04
 Absent
Comorbidities
 Absent                                       3.72            0.155
 Present
Duration of treatment
 <1 years                                     14.11           0.028
 1-2 years
 2-5 years
 [greater than or equal to]5 years

* Yates [chi square], CKD: Chronic kidney disease, MMAS-8: Morisky
Medication Adherence Scale-8, BMI: Body mass index

Table 2: Patients knowledge regarding treatment (n=206)

Question                                      Number of respondents (%)

                                                  Yes           No

Are you aware that you should strictly        179 (86.89)   27 (13.11)
follow medicine schedule as prescribed
by doctor
Do you know the importance of each medicine   150 (72.82)   56 (27.18)
Aware about how to take each medicine         176 (85.44)   30 (14.56)
they were taking
Are you aware of adverse effects              25 (12.14)    181 (87.86)
Are you aware that stopping medicine          69 (33.50)    137 (66.50)
make you feel sick

Table 3: Response to the MMAS-8 questionnaire observed in therapeutic
drug monitoring based on adherent and non-adherent patients

MMAS-8 adherence questions                  Patient response (Yes/No)

                                                Yes           No

1. Do you sometimes forget to take          91 (41.175)   115 (55.83)
your medicine?

2. People sometimes miss taking their       27 (13.11)    179 (86.89)
medicines for reasons other than
forgetting. Thinking over the past 2
weeks, were there any days when you did
not take your medicine?

3. Have you ever cut back or stopped        25 (12.14)    181 (87.86)
taking your medicine without telling
your doctor because you felt worse when
you took it?

4. When you travel or leave home, do you    51 (24.76)    155 (75.24)
sometimes forget to bring along your
medicine?

5. Did you take all your medicines         181 (87.86)     25 (12.14)
yesterday?

6. When you feel like your symptoms are     14 (6.80)     192 (93.20)
under control, do you sometimes stop
taking your medicine?

7. Taking medicine every day is a real      49 (23.79)    157 (76.21)
inconvenience for some people. Do you
ever feel hassled about sticking to your
treatment plan?

8. How often do you have difficulty
remembering to take all your medicine?

A. Never/rarely                             98 (47.57)
B. Once in a while                          93 (45.15)
C. Sometimes                                13 (6.31)
D. Usually                                   2 (0.97)
E. All the time                                  0

MMAS-8: Morisky Medication Adherence Scale

Table 4: Reasons for non-adherence to medication in
patients of CKD (n=158)

Reasons for non-adherence         Number of respondents (%)

Forgetfulness                            113 (71.51)
High cost of medicine                    38 (24.05)
Difficulty to take large number          29 (18.35)
of pill
Fear of adverse effects                  16 (10.12)
Missed appointments                       8 (5.06)
Poor access to medication                 5 (3.16)
Depression                                4 (2.53)
Other illnesses                           2 (1.26)

CKD: Chronic kidney disease

Figure 1: Distribution of study subjects according to the stage of
chronic kidney disease

Stage 1     3 (1.46%)
Stage 2     6 (2.91%)
Stage 3    23 (11.17%)
Stage 4    32 (15.53%)
Stage 5   142 (68.93%)

Note: Table made from bar graph.

Figure 2: Comorbidities in patients with chronic kidney disease

No co-morbidities    33
HTN alone           114
Diabetes alone       13
Both HTN & DM        28
Anemia                6
severe Anemia         3
Renal caliculi        4
IHD/CVD               4
BPH                   3
Obesity               3
Hypothyroidism        2
Pylonephritis         2

Note: Table made from bar graph.

Figure 3: Adherence scale (Morisky Medication Adherence
Questionnaire scale)

Low adherence      71 (34.47%)
Medium adherence   87 (42.23%)
High adherence     48 (23.30%)

Note: Table made from bar graph.
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Title Annotation:Research Article
Author:Kala T., Siva; Arepalli Sreedevi; Hari Prasad M.V.; Jikki P.N.
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Mar 1, 2019
Words:4434
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