CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 2, March/April 2010
AFRICA
91
in this study were similar to most other reports (i.e.
>
90%
appointment adherence).
7,14
Alternatively, our data on daily
weight monitoring were generally lower than that of other reports
(ranging from 12 to 75%).
23,24
The fact that only 19% of our study
patients had a scale at home is an important factor in this regard.
In respect of fluid management, 56% of our study patients
reported adhering to the recommended fluid intake of less than
two litres per day. In comparison, Artinian
et al
. (23%)
18
and
Jaarsma
et al
. (37%)
19
reported lower, while van der Wal (73%)
25
reported higher adherence rates to fluid restriction.
With 38% of participating patients performing some form
of regular exercise (especially walking 20 to 30 min per day),
our results were lower than results from other studies (equiva-
lent range 39 to 67%).
7,8,14,19,26
Concerning smoking abstinence,
16% of our participating patients persisted in smoking tobacco.
In comparison Evangelista
et al
. and Carlson
et al
. found less
than 10% of their study patients to be non-compliant in this
regard,
7,14,26
whereas higher smoking rates have been reported by
Artinian
et al
. (46%) and also by Evangelista
et al
. (55%) in a
study on veterans with CHF.
18,27
Overall, 98% of all study participants were compliant with
regard to reduced alcohol intake. This result is higher than in
studies led by Evangelista
et al
. where adherence to alcohol
limitation varied between 64 and 94%,
7,14,27
compared to 56% in
a cohort studied by Artinian
et al
.
18
Our finding that men tended to be more compliant with
prescribed medication is both supported
15,28
and refuted
22,29
by
other studies, with no clear pattern in the literature. Although
it is logical to suggest that those with greater symptoms are
more likely to be non-compliant, this association is not a regular
feature in the literature.
It is now largely accepted that greater CHF-related knowledge
has a positive impact on adherence behaviours.
9,25
Unfortunately,
our data imply that patient education at the cardiology out-patient
department of the Chris Hani-Baragwanath Hospital is subopti-
mal in respect of a number of key educational areas. A similar
result was found in another study from South Africa focusing
on patients with hypertension.
12
There were some encouraging
results with regard to the provision of CHF information, but
this may be due to the fact that study participants had to decide
only whether a statement on CHF management was correct or
incorrect.
In a study lead by Ni
et al
., the percentage of patients choos-
ing the correct answer on eight questions concerning CHF
management varied between 43 and 90% versus a range of 29 to
89% in our study.
9
By self-report, 68% of our patients said they
knew a little or nothing about CHF. Ni
et al
. found that only 38%
of their study participants reported that they knew only a little or
nothing about CHF.
9
It is clear from this and other studies from the western world
that poor adherence to treatment and CHF-related self-care
behaviour exposes the patient to an increased risk of clinical
instability and increased symptoms.
16,30
This can result in higher-
than-expected hospital admission rates, which place a substantial
(cost) burden on the healthcare system.
16,31
In order to prevent the
deterioration of the patient’s condition, adherence to medication
and other self-care behaviour needs to be ameliorated.
In the western world, CHF management programmes have
had a positive effect on outcomes of adherence, using various
strategies.
19,32,33
These data certainly support the potential for CHF
management programmes to improve health behaviours and
outcomes in South Africa. We plan to use these data to undertake
one of the first randomised, controlled trials of CHF manage-
ment in Africa with interventions suited to the local culture and
environment.
Limitations
There are a number of study limitations that require comment.
Although, pill counts are a fairly objective method to measure
medication adherence, it is still prone to errors such as the
assumption that a pill was truly taken if it is not in the medica-
tion box. Serum bioassays or electric monitoring advices may
be more objective and thus more accurate.
14
However, in our
settings, pill counts and interviews were the only options for
measuring adherence.
As we also based our adherence figures on the results from
the pill counts, the findings may be biased, given that those
patients who returned for the pill count were already more likely
to be compliant in following instructions and were therefore
more prone to follow advice concerning medication adherence.
Similarly, as the interview took place before the pill count,
patients might have paid more attention to taking their medica-
tion regularly during the following month. As a result, medica-
tion adherence may be overestimated in our study. In future stud-
ies, pill counts could be conducted at one, three and six months
after the interview to obtain more accurate results.
As self-reporting is always subjective and biased, adherence
rates to self-care behaviour and the measured knowledge on CHF
and its management may have been affected. We also defined
behavioural adherence in accordance with the European Society
of Cardiology guidelines, even though they might not be appli-
cable to our study population, considering the different disease
profiles, cultural and socio-economic profiles and financial
backgrounds.
Another limitation to our study was the diversity of languages
in South Africa (11 official languages). A translator was used in
various interviews.
Finally, it is difficult to ascertain how representative these
data are in relation to other African centres. For example, there
was a relatively large number of patients with ischaemic CMO, a
generally uncommon cause of CHF in Africa. However, we have
recently reported a rise in such cases,
34
and the other common
causes of CHF in Africa (idiopathic CMO and hypertensive heart
failure) were well represented. Given that this was a relatively
small group of patients (although large for Africa), we were
most probably underpowered to fully explore predictors of non-
adherence.
Despite these limitations, our study is the first study of this
dimension on medication adherence in South Africa. These
data indicate the need for interventions that have already been
established in the western world to improve health outcomes.
These data therefore support the need for culturally sensitive
and affordable CHF management programmes that can improve
treatment adherence and optimise self-care behaviours and
knowledge, in order to improve CHF-related health outcomes
overall in South Africa.
Conclusion
As in many other regions of the world, non-adherence to complex
