16 / 78
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 6, November/December 2017
354
AFRICA
The present study shows that patients with high education
levels were more non-adherent compared to those with low–
intermediate education levels. This is in contrast with the
findings of previous studies, which reported that poor health
literacy was associated with medication non-adherence.
21,22
There
is considerable evidence that those with more years of education
tend to have better health and healthier behaviours; however, this
is not in agreement with our findings.
While the reasons for our apparently contrary findings are
unclear, it may be that participants with low–intermediate
education levels had better healthcare information to make
appropriate health decisions and follow instructions for treatment.
This better health information might be gained through health
messages, which are delivered through television and/or radio. On
the other hand, it is possible that respondents with high education
levels are honest to admit that they are human and may not always
follow instructions, while those with low–intermediate education
levels may not admit that they fail to take their medications to that
extent. Also an additional possible reason is that less than one-fifth
of the respondents in this survey had high education levels. Hence,
this finding highlights the need for further qualitative research to
provide better understanding of education level as a predictor of
non-adherence among cardiovascular patients in Sudan.
The current results revealed that non-adherence was
significantly greatest among those taking five ormoremedications
daily, which is consistent with previous studies.
11,23
It is evident
that reducing the total number of pills per day can improve
medication adherence. Hence, an approach needs to be taken to
reduce medication complexity through avoiding polypharmacy
and using regimens with fewer daily doses. This could be achieved
by maximally simplifying cardiovascular medication regimens by
combining medications from three or more medication classes
(e.g. aspirin, statin and antihypertensives) into a single daily
‘polypill’. The rationale is that the simpler medication regimen
leads to improved adherence.
24
These findings revealed that gender, co-morbidities and age
were not statistically significant predictors for non-adherence,
which contrasts with findings in some other studies, where
women, elderly individuals and those who had three or more
diseases had poorer adherence.
12,13
A systematic review of studies
conducted in developing countries revealed that patient factors
such as age, gender, lifestyle and lack of access to healthcare
services were not consistently associated with non-adherence.
14
The existence of conflicting information among various studies
suggests that assessment of non-adherence cannot be targeted to
specific patient populations or characteristics, and the established
predictors of adherence are often insufficient to identify individual
patients who are likely to be non-adherent, and they should be
used cautiously as a means of targeting high-risk populations.
25
Anotherapproachtounderstandingreasonsfornon-adherence
is to identify the barriers. In contrast with predictors of
adherence, barriers are restricted to potentially modifiable
factors that healthcare providers and/or the healthcare system
can attempt in order to reduce medication non-adherence. The
top two barriers reported by the study population were the high
cost of drugs and polypharmacy. These barriers reported by the
patients confirm the results obtained by the Morisky eight-item
scale adherence measure. These results underscore the urgent
need for the development and implementation of effective
strategies to overcome these barriers.
Lack of pharmacist’s communication regarding instructions
and the importance of taking the medication regularly, and lack
of physician’s communication regarding the disease and the
benefit that the medication will provide were reported as barriers
by half and two-fifths of respondents, respectively. These
results highlight a call for a more active role that healthcare
providers should take in assessment, education and strategic
implementation efforts to promote medication adherence. It
is evident that the time healthcare providers spend to achieve
good patient understanding about the disease and the rationale
for medication use fosters a partnership with their patients and
improves medication adherence.
26
Pharmacists need to develop counselling strategies that help
patients form strong habits regarding medication use, educate
patients about their medications, and provide regular follow up
to ensure that patients are taking medications as directed. The
value of pharmacists in adherence to cardiovascular medication
was illustrated in two studies, where patients were randomised
to intensive pharmacist-led intervention versus usual care. The
intervention resulted in significant improvements in adherence
and disease control.
27,28
Sudanese pharmacists must improve their
clinical knowledge and skills, demonstrate their willingness to be
responsible for the patient’s drug therapy, and develop a close
working relationship with other healthcare professionals.
Three in 10 responders indicated that the experienced side
effects associated with their medications and irregular availability
of the medication in their areas were barriers for adherence. This
underscores the need for more dialogue between patients and
healthcare providers about medications, including discussions
about the possible side effects and management strategies,
thus allowing patients to become part of the decision-making
process.
29
The irregular availability of cardiovascular medications
among those resident outside Khartoum State underscores the
need for multiple approaches to be used to address challenges
within the healthcare system that prevent the reliable availability
of essential medications, with a special focus on improving the
governance of the drug-delivery system to all states of Sudan.
We acknowledge that this type of study has its limitations. It
depends very much upon information given by respondents and
is open to bias by inaccurate patient recall or by social desirability.
The extent of truthful answers or verifying respondents’ claims
is not possible in this type of study, and answers were taken at
face value. A further limitation of the study is the cross-sectional
nature of the data that represented one point in time and
therefore does not reflect any changes in respondents’ adherence
to cardiovascular medications.
Conclusions
The findings of this study provide important information
about the prevalence, predicators and barriers of medication
non-adherence among out-patient cardiac patients. These results
allow for important comparative work with existing and future
investigations in Sudan and other developing countries. Our
results showed that the use of a validated self-report instrument
can provide immediate feedback to help healthcare providers
identify non-adherent patients. Such brief, inexpensive tools
should be more widely implemented as part of the daily care
plan in the out-patient clinics.
The study findings underscore the urgent need to establish