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\begin{document}


\def\RunningAuthor{Nikhitha K et al.}
\firstPage{2922}
\articleType{Original Article}
\receivedDate{30 Jan 2020}
\acceptedDate{02 Mar 2020}
\revisedDate{01 Mar 2020}
\journalVolume{2020, 11}
\journalIssue{3}
\journalDoi{ijrps.v11i3.2376}
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\title{\textbf{Assessment of medication adherence in chronic diseases}}
\author{Nikhitha~K\textsuperscript{*}\textsuperscript{1},  
            Sai~kiran~S\textsuperscript{1},  
            Prasad~M\textsuperscript{1}, 
            Chinni~Eswaraiah~M\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Pharmacy practice, Anurag pharmacy college, Ananthagiri(V), Kodad(M), Suryapet(D), Telangana state, 508206, India}~\\{\textsuperscript{2}Department of Pharmacognosy, Anurag pharmacy college, Ananthagiri(V), Kodad(M), Suryapet(D), Telangana state, 508206, India}}

\begin{abstract}
Majority of people with chronic diseases have poor adherence to their therapeutic regimen. It can result in various complications physialogically with undesirable metabolic conditions. The main objective of this study is to assess the level of satisfaction attained after medication in comorbidities (either having diabetes only or having hypertension only or having Hypertension and Diabetes) and also focussed on creating awareness in patients who do not follow the medication. A prospective cross sectional study was conducted at tertiary care hospital, Khammam, Telangana. 200 patients were approached and were interviewed with their consent. The purpose of the same was to collect the information on socio demographics, medication that is followed, and behavioural characteristics. A structured questionnaire MMAS-8 an eight itemed scale was involved to identify individuals, determine their levels, the reliability and validity of the medication followed. The scrutiny of this study found that there is a better medication adherence in individual's diseases (Hypertension, Diabetes) whereas in hypertension and diabetes condition high and low adherence were reported because of their awareness, negligence and risk factors respectively. The study concludes that there is an increase in Medication adherence in individual diseases whereas in hypertension and diabetes there are equal ranges of both low and high adherence.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Chronic diseases,\newline Medication adherence,\newline Hypertension,\newline Diabetes,\newline MMAS-8
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Nikhitha~K~\\ Phone:\ ~\\  Email:\ kondanikhitha127@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Hypertension is a chronic disease. It is defined as the persistent elevation of arterial blood pressure with forceful blood against walls and it has another name `high blood pressure'. Hypertension is one of the non-communicable disease \unskip~\citep{770831:18333671} which is also called as `silent killer' and leads to major health issues. It is present across the world with 31.1\% [1.39 billion] and this can be estimated using the increase in people by 1.56 billion in 2025 \unskip~\citep{770831:18333667}. Hypertension is an avoidable risk factor for heart diseases which have mostly negative impacts on health that leads to morbidity and mortality \unskip~\citep{770831:18333672}. Most of the studies assess that the hypertension account 9.4 million deaths every year \unskip~\citep{770831:18333670} which makes the life expectancy less about 11.9\% \unskip~\citep{770831:18333672}. A study stated that the adult populations were diagnosed around 26\% of the world wide and it may increase with increase in age.

According to medical perspective diabetes belongs to a group of metabolic diseases. It is characterized by different functions of insulin secreted by pancreas in which the action may be sufficient or insufficient or it may cause resistance which makes acceleration of glucose levels in blood mainly noted as hyperglycemia \unskip~\citep{770831:18333666}. Diabetes is majorly classified into type I~and type II along with some new variants like LADA /type 1.5 and gestational diabetes \unskip~\citep{770831:18333664} some other types which include the monogenic diabetes like MODY that is inherited form of diabetes, cystic fibrosis and other hormonal disorders. IND stated that type II diabetes mellitus is 4\ensuremath{^{th}} leading cause of death \unskip~\citep{770831:18333664} globally, growing the global epidemic expect to accelerate 171 million cases in 2000 and in 2030 it is assessed up to 366 million along with morbidities like micro vascular damage, heart disease, stroke and obesity etc \unskip~\citep{770831:18333664}. 

In 2016 WHO, estimated that 422 million people were diagnosed worldwide in 2014 \unskip~\citep{770831:18333666} and sheer in low and middle income countries \unskip~\citep{770831:18333665,770831:18333669}. Micro, macro vascular damage, organs dysfunctions like eye-retinopathy, nerves-neuropathy, kidney-nephropathy and hyperlipidemia, ulcer on feet and infection, may also decline in quality of life, risk if heart diseases along with hypertension. Cardio vascular complications are the permanent stress marker for diabetes \unskip~\citep{770831:18333666}.

WHO-2003 defined medication adherence as a patient's medication consuming behaviour by accepting the statements of health care provider. \unskip~\citep{770831:18333671} It is a key element for disease specific management. \unskip~\citep{770831:18333668} Over the past 25 years, studies have been stated that non adherent to medication for long term diseases has a great negative impact on health. In this study we decided to scrutinise the Medication Adherence in chronic diseases, especially in both Hypertension and Diabetes because these are the world's most common and snuffled out diseases.
    
\section{\textbf{PURPOSE OF THE STUDY }}
The need of this study is to set the non-adherence patients to an adherence, which is used for gaining good therapeutic outcome and also to understand the better illness of the disease condition and to their therapeutic management. 
    
\section{Materials and Methods}
A prospective cross sectional survey based study was conducted at tertiary care hospitals. Sample size of 200 patients was taken. The study had been conducted within six months of period between August 2019 and January 2020. All the patients who were admitted in inpatient department have been approached to start prolific conversation and were followed up at the time of study duration. Eligible patients were invited and requested to participate in the study. Medication history interview was conducted on the patients above 16 years who suffered either with Hypertension or Diabetes or both. Self reports were collected to ensure the data of patient medication records.The limitation of the study was not to take the pregnant or postpartum women along with pre diabetic conditions and emergency care patients. A structured questionnaire was developed to collect information about Socio demographics and Medication adherence questionnaire. Morisky Medication Adherence Scale (MMAS-8) was taken to assess the behavior of the patient taking medication. Statistical data was drawn from a structured questionnaire which executed in Microsoft Excel 2007.
    
\section{Results and Discussion}
\textbf{Socio demographics and health related characteristics}

Table~\ref{tw-ba312f2f11b7} shows that out of 200 participants 105 were male (52.5\%) and participants with the sum average age of adults 20-49(39.5\%) and 50-89(60.5\%) were considered as geriatrics. By assuming the data we found that 176 married (88\%), 3 single (1.5\%) and 21 widowed (10.5\%). Most of the patients were uneducated (54.5\%), graduated (34.5\%) and up to school (11\%). Majority of them are with different other occupations (48.5\%), self employed (21.5\%), farmer (30\%).


\begin{table*}[!htbp]
\caption{\boldmath {Demographic details of age, gender and their studies} }
\label{tw-ba312f2f11b7}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3335\linewidth-2\tabcolsep}p{\dimexpr.3265\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack  Age (years) & \cAlignHack Frequency (n=200) & \cAlignHack Percentage\\
\tblmidrule 
\cAlignHack 20-29 &
  \cAlignHack 2 &
  \cAlignHack 1\%\\
\cAlignHack 30-39 &
  \cAlignHack 26 &
  \cAlignHack 13\%\\
\cAlignHack 40-49 &
  \cAlignHack 51 &
  \cAlignHack 25.5\%\\
\cAlignHack 50-59 &
  \cAlignHack 51 &
  \cAlignHack 25.5\%\\
\cAlignHack 60-69 &
  \cAlignHack 47 &
  \cAlignHack 23.5\%\\
\cAlignHack 70-79 &
  \cAlignHack 21 &
  \cAlignHack 10.5\%\\
\cAlignHack 80-89 &
  \cAlignHack 2 &
  \cAlignHack 1\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Gender} &
  \cAlignHack \\
\cAlignHack Male &
  \cAlignHack 105 &
  \cAlignHack 52.5\%\\
\cAlignHack Female &
  \cAlignHack 95 &
  \cAlignHack 47.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Marital status} &
  \cAlignHack \\
\cAlignHack Married &
  \cAlignHack 176 &
  \cAlignHack 88\%\\
\cAlignHack Single &
  \cAlignHack 3 &
  \cAlignHack 1.5\%\\
\cAlignHack widow &
  \cAlignHack 21 &
  \cAlignHack 10.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Educational status} &
  \cAlignHack \\
\cAlignHack Uneducated &
  \cAlignHack 109 &
  \cAlignHack 58.5\%\\
\cAlignHack Up to school &
  \cAlignHack 22 &
  \cAlignHack 11\%\\
\cAlignHack graduated &
  \cAlignHack 69 &
  \cAlignHack 34.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Occupation} &
  \cAlignHack \\
\cAlignHack Farmer &
  \cAlignHack 60 &
  \cAlignHack 30\%\\
\cAlignHack  Self employee &
  \cAlignHack 43 &
  \cAlignHack 21.5\%\\
\cAlignHack Other [retired, housewives etc] &
  \cAlignHack 97 &
  \cAlignHack 48.5\% \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution of data regarding diet, exercise, alcohol and smoking status} }
\label{tw-bb0ef94318fe}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3508\linewidth-2\tabcolsep}p{\dimexpr.29880000000000003\linewidth-2\tabcolsep}p{\dimexpr.3504\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack Diet plan}\\
\tblmidrule 
\cAlignHack Diabetic &
  \cAlignHack 42 &
  \cAlignHack 21\%\\
\cAlignHack no diet &
  \cAlignHack 71 &
  \cAlignHack 35.5\%\\
\cAlignHack low cholesterol &
  \cAlignHack 16 &
  \cAlignHack 8\%\\
\cAlignHack low salt &
  \cAlignHack 37 &
  \cAlignHack 18.5\%\\
\cAlignHack weight reduction &
  \cAlignHack 19 &
  \cAlignHack 9.5\%\\
\cAlignHack Vegetarian &
  \cAlignHack 15 &
  \cAlignHack 7.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Exercise} &
  \cAlignHack \\
\cAlignHack Daily &
  \cAlignHack 41 &
  \cAlignHack 20.5\%\\
\cAlignHack Irregularly &
  \cAlignHack 30 &
  \cAlignHack 15\%\\
\cAlignHack Occasionally &
  \cAlignHack 13 &
  \cAlignHack 6.5\%\\
\cAlignHack None &
  \cAlignHack 116 &
  \cAlignHack 58\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Alcohol status} &
  \cAlignHack \\
\cAlignHack Regular &
  \cAlignHack 35 &
  \cAlignHack 17.5\\
\cAlignHack Irregular &
  \cAlignHack 41 &
  \cAlignHack 20.5\\
\cAlignHack Occasional &
  \cAlignHack 51 &
  \cAlignHack 25.5\\
\cAlignHack None &
  \cAlignHack 73 &
  \cAlignHack 36.5\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Smoking status} &
  \cAlignHack \\
\cAlignHack Regular &
  \cAlignHack 42 &
  \cAlignHack 21\%\\
\cAlignHack Irregular &
  \cAlignHack 30 &
  \cAlignHack 15\%\\
\cAlignHack Occasional &
  \cAlignHack 29 &
  \cAlignHack 14.5\%\\
\cAlignHack None &
  \cAlignHack 99 &
  \cAlignHack 49.5\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Details of diseases, duration of disease, checkups, and drugs prescribed} }
\label{tw-2142e839784d}
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\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3477333333333334\linewidth-2\tabcolsep}p{\dimexpr.3449333333333333\linewidth-2\tabcolsep}p{\dimexpr.30733333333333334\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & \cAlignHack Disease & \\
\tblmidrule 
\cAlignHack Diabetes mellitus &
  \cAlignHack 24 &
  \cAlignHack 12\%\\
\cAlignHack Hypertension &
  \cAlignHack 45 &
  \cAlignHack 3.75\%\\
\cAlignHack both Diabetes and hypertension &
  \cAlignHack 131 &
  \cAlignHack 65.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Duration of disease} &
  \cAlignHack \\
\cAlignHack 1-4years &
  \cAlignHack 69 &
  \cAlignHack 34.5\%\\
\cAlignHack 5-9years &
  \cAlignHack 62 &
  \cAlignHack 31\%\\
\cAlignHack 10-14years &
  \cAlignHack 42 &
  \cAlignHack 21\%\\
\cAlignHack 15-20years &
  \cAlignHack 27 &
  \cAlignHack 13.5\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Checkups} &
  \cAlignHack \\
\cAlignHack Monthly &
  \cAlignHack 39 &
  \cAlignHack 19.5\%\\
\cAlignHack every 3-4months &
  \cAlignHack 32 &
  \cAlignHack 16\%\\
\cAlignHack every 6months &
  \cAlignHack 61 &
  \cAlignHack 30.5\%\\
\cAlignHack once a year &
  \cAlignHack 68 &
  \cAlignHack 34\%\\
 &
   &
  \\
\cAlignHack  &
  \cAlignHack \textbf{Total number of drugs} &
  \cAlignHack \\
\cAlignHack {\textless}2 &
  \cAlignHack 91 &
  \cAlignHack 45.5\%\\
\cAlignHack 3-{\textless}5 &
  \cAlignHack 90 &
  \cAlignHack 45\%\\
\cAlignHack {\textgreater}5 &
  \cAlignHack 19 &
  \cAlignHack 9.5\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Estimation of medication adherence levels} }
\label{tw-02a48c61d596}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.36809999999999995\linewidth-2\tabcolsep}p{\dimexpr.3092\linewidth-2\tabcolsep}p{\dimexpr.3227\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack Diabetes}\\
\tblmidrule 
\cAlignHack \textbf{Range } &
  \cAlignHack \textbf{Parameter} &
  \cAlignHack \textbf{N}\\
\cAlignHack {\textless}6 &
  \cAlignHack Low &
  \cAlignHack 9\\
\cAlignHack 6-7 &
  \cAlignHack Moderate &
  \cAlignHack 1\\
\cAlignHack 8,{\textgreater}8 &
  \cAlignHack High &
  \cAlignHack 14\\
 &
   &
  \\
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{Hypertension}}\\
\cAlignHack {\textless}6 &
  \cAlignHack Low &
  \cAlignHack 11\\
\cAlignHack 6-7 &
  \cAlignHack Moderate &
  \cAlignHack 9\\
\cAlignHack 8,{\textgreater}8 &
  \cAlignHack High &
  \cAlignHack 25\\
 &
   &
  \\
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{Hypertension and diabetes}}\\
\cAlignHack {\textless}6 &
  \cAlignHack Low &
  \cAlignHack 57\\
\cAlignHack 6-7 &
  \cAlignHack Moderate &
  \cAlignHack 16\\
\cAlignHack 8,{\textgreater}8 &
  \cAlignHack High &
  \cAlignHack 58\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Participants followed a diet diabetic (21\%), no diet (35.5\%), low cholesterol (8\%), low salt (18.5\%), weight reduction (9.5\%) and vegetarian (7.5\%) as in Table~\ref{tw-bb0ef94318fe}. The participants who done daily exercise (20.5\%), irregular (15\%), occasional (6.5\%), no exercise (58\%) Alcohol consumed patients with regular (17.5\%), irregularly (20.5\%), occasionally (25.5\%), none (36.5\%), and smokers were regular (21\%), irregular (15\%), occasional (14.5\%), none (49.5\%).

Participants suffered with a disease of Diabetes mellitus (12\%), Hypertension (3.75\%) and Diabetes and Hypertension (65.5\%). Patients experiencing the disease from 1-4 years (34.5\%), 5-9 years (31\%), 10-14years (21\%), and 15-20years (13.5\%). Participants visited hospital for check-up (19.5\%) monthly, (16\%) every 3-4 months, (30.5\%) every 6 months, (34\%) once in a year. Among these (45.5\%) participants were prescribed with {\textless}2drugs, (45\%) 3-{\textless}5drugs and (9.5\%) {\textgreater}5 drugs are seen in Table~\ref{tw-2142e839784d}.

\textbf{Determination of Medication Adherence Level}

To determine the patient taking medication pattern MMAS -8 scale is used and the levels of individual patients were identified with score ranging of {\textless}6 shows low adherence, 6-8 indicates moderate adherence and 8,{\textgreater}8 determine the high adherence. In this study we focused on assessing the adherence ranges according to the diseases in which shown in Table~\ref{tw-02a48c61d596}. Respondents out of 200 patients 24 (12\%) diabetic patients had (14) high adherence, (9) low adherence and (1) moderate adherence as scale score ranges and 45 (22.5\%) hypertension patients with (11) low adherence, (25) high adherence, (9) moderate adherence. However, 131 (65.5\%) participants are diagnosed with both co morbidities like Hypertension and Diabetes where there adherence levels are with (58) high adherence, (57) low adherence and (16) moderate adherence with results shown in Table~\ref{tw-02a48c61d596}.

Chronic conditions hypertension and diabetes are included in our study and assessed medication adherence (either having diabetes only or hypertension only or both diabetes and hypertension). However, patients with chronic diseases (especially diabetes and hypertension) are prone to risk factors which may lead to deaths because of their medication pattern used i.e., adhere to their medication. Many studies stated that half of the patients were not adhering to their long therapies. 

Here we assessed medication adherence not only in individual long term diseases but also in both hypertension and diabetes in order to assess the effect of interaction of disease type and adherence level. Many studies stated that half of the patients did not adhere to their long therapies. However, in current study the low and higher rates of adherence in both hypertension and diabetes were reported due to low educational level and other specific occupations like living with pension. Whereas, low adherence rates shows the therapeutic failure which worsened the disease condition as in current study shows high number of participants with long term disease (hypertension and diabetes-n=131) was largely related to medication adverse effects. As most of the participants were geriatrics 50-89(60.5\%) suffered with long term disease, seasonal disease [dengue fever] having less ability to tolerate environmental condition and also to improve their health. Most of the participants were uneducated having poor knowledge towards medication and disease related diet, physical stress, frequent visits to hospital etc. because of their work plan, negligence as most of them were housewives, retired officers, farmers. This study estimates that there might be an association between education level and adherence to medication seen in participant's adherence to their long term therapies. 

Low and high levels of medication adherence was observed because most of the participants suffered with both diabetes and hypertension (65.5\%), as diabetic patients having more risk for hypertension. Even though participants prescribed with drugs {\textless}2(45.5\%), 3-5 drugs(45\%) in prescription were affected due to multiple disease conditions with lack of knowledge, awareness, negligence towards prescribed drugs, which had an impact on the disease and led to other co morbidities finally resulting an increase in morbidity chances. The results showed that age, marital status, occupation, visits to the hospital were vulnerable to non-adherence. In conclusion, we are reported that a proximity of higher rate of adherence to prescribed medications among participants with individuals having chronic diseases is by their understanding levels related to medication, disease complications, and health fitness. The current study noticed that still some graduates, farmers who lack in awareness about medications suffer with co morbidities like cardiovascular disease. In order to educate or to create awareness in them, a clinical pharmacist is needed to play an essential role in delivering good medication adherence practices in chronic disease patients. To ensure the medication adherence, various activities like focused group discussion, self engagement activities, open forum discussion etc are proposed.
    
\section{Conclusion}
By this study we conclude that when compared to non medication adherence patients, the patients who are adherent are more likely to enjoy their life with a better health status. Anyway self care is needed to prevent the hypertension and diabetes related morbidities and mortality. Still some participants were unaware of true causes of diabetes and hypertension. In fact, there is some lack of trust in physician, health providers or other health care professionals and acceptance of superstitious beliefs. To avoid this, health care professional should monitor the patient on their health illness and strictly suggest the patients about their diseased drugs to make them strictly adhere to their medication.

\textbf{Ethical Approval}

The study was approved by the institutional ethical committee.
\section*{Acknowledgement}The authors thank Dr. M. Chinni Eshwaraiah, Principal of Anurag Pharmacy College for granting the necessary permission for the study. The authors also thank all the faculty of Anurag Pharmacy College for their constant support and guidance.

\textbf{Abbreviations}

MMAS- Morisky Medication Adherence Scale

MODY-Maturity Onset Diabetes of Young

LADA -Latent Autoimmune Diabetes of Adulthood

IND -International Diabetes Federation

\textbf{Conflict of Interest}

None.

\textbf{Funding Support}

None.
    

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