Introduction
Respiratory diseases manifest as cough and dyspnoea and are broadly divided into obstructive lung diseases, restrictive disorders, and vascular abnormalities. Among these obstructive lung diseases are the most common and primarily disorders of the airways.1 This group includes bronchial asthma, COPD (emphysema, chronic bronchitis) and bronchiectasis. All these disorders have various clinical features but overlapping symptoms are common, 2 which makes diagnosis and management complicated.
COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of airways &/or alveoli that cause persistent, often progressive airflow limitation. 3 This condition is associated with exacerbations that cause impaired health-related quality of life. 4 According to the World Health Organization, the organization predicts COPD will become the third leading cause of death globally by 2030, which puts a necessity for proper management strategies to avoid such a scenario. 5
Asthma is an important chronic inflammatory airway disease affecting more than 300 million people worldwide. Its prevalence is steadily increasing in developing nations, including India.6 Adherence refers to the degree a patient's actions reflect recommended medical recommendations and is key for appropriate disease self-management.7 According to various research findings, even though taking drugs correctly plays a most significant role in the handling of chronic respiratory diseases; up to 50% of patients suffering from any chronic conditions are reported as non-adhering to their prescribes.8 There are lots of barriers to adherence arising from low knowledge of illness, socio-economic factors or even improper use of the inhaler.
Nonadherence to prescribed therapies is a serious challenge and thus increases morbidity, the use of healthcare, and mortality. 9
In our study conducted at MGM Muthoot Medical Centre, we are trying to find out the level of drug adherence among adults diagnosed with obstructive airway diseases in a semi-urban setting. We hope to identify some potential interventions that may improve treatment compliance and then eventually lead to better outcomes for patients through association between adherence levels and socio-economic status and gender.
Aim & Objectives
Aim
To study the drug adherence in adults with Obstructive Airway Diseases and its association with Socio-economic status and Gender, visiting a multi-specialty hospital in a semi-urban set up.
Materials and Methods
Study area
The present study was conducted at the Department of Pulmonology/ Internal Medicine, MGM Muthoot Medical Centre, Pathanamthitta.
Study design
A cross-sectional, observational study is undertaken, using a structured questionnaire and collecting direct primary data related to drug adherence and socio-demographic factors.
Sample size
The sample size was drawn by the formula 10
Where, n is the Sample Size
(1-α/2) – Confidence level
Z1-α/2 – 1.96 at 5% level of significance
p – Incidence of desired variable of interest
d – Allowable error
Sample size was calculated to be 87 OAD cases using low adherence at 65%, confidence level of 95%, and allowable error at 10%.
Data collection
Data collection was done through outpatient visits or hospital admissions using a standardized data collection form. It included collection of demographic information, clinical diagnosis, details regarding drugs, and socioeconomic status, which was scored using the Modified Kuppuswamy's Grading System. 11 Adherence to drugs was accessed using Morisky's Medication Adherence Scale (MMAS-8). 12
Statistical analysis
All the data collected has been entered into MS Excel and statistically analysed. All qualitative data have been reported in frequency and percent. Association between level of adherence and socio-economic status, gender and polypharmacy has been analysed through Chi-square test. A 'p' value of less than 0.05 is taken to be statistically significant.
Observation & Results
Table 1
Demographic and clinical characteristics
Table 2
Adherence levels
|
Adherence Level |
Frequency (n=100) |
Percentage (%) |
|
Low |
49 |
49% |
|
Medium |
28 |
28% |
|
High |
23 |
23% |
Factors influencing drug adherence
Socio-economic status
There was a very high correlation of SES with drug adherence levels. Lower adherence was more predominant among the lower socio-economic categories, p = 0.007.
Table 3
Association between Drug adherence level and Socio-economic status
Gender and age
There was no gender, p = 0.249, or age, p = 0.375, correlation with adherence levels.
Table 4
Drug adherence level: Relationship between drug adherence level and gender.
|
Gender |
Low |
Medium |
High |
Total |
|
Male |
22 (44.0%) |
13 (26.0%) |
15 (30.0%) |
50 |
|
Female |
27 (54.0%) |
15 (30.0%) |
8 (16.0%) |
50 |
|
Total |
49 |
28 |
23 |
100 |
Smoking: There was no significant impact on adherence: (p = 0.299).
Number of Inhalers: Patients on single inhaler therapy had a higher proportion of low adherence in comparison to patients on dual inhaler therapy, though not statistical-significant (p = 0.38).
Duration of treatment: More subjects receiving long-term treatment ≥30 years reported lower adherence. Still, this was not statistically significant at p = 0.172.
Discussion
The aims of this study involve determining levels of drug adherence for adults diagnosed with OAD and attempting to identify associations between the adherence levels and socio-demographic factors such as SES and gender. Differences in adherence between patients using single inhaler and multiple inhaler therapies were also to be measured.
Socio-demographic profiles
Our results reveal that the age range for majority of the participants was over 60 years while the mean age was 65.6 years. This, therefore, means increased prevalence of respiratory diseases among the elderly. Participants were further classified by the smoking status. Where in 43% of participants confirmed to be smokers and 30% reported exposure to passive smoking and all these are confirmed risk factors for the causation and exacerbation of OADs.
Nearly 70% of all the respondents fell in the Middle SES category (Lower-middle class or Upper-middle class).
Clinical characteristic
The investigation found that 65% were diagnosed with COPD, while the rest was bronchial asthma.60% of them have been admitted to one or more hospitals in their treatment period. The treatment periods varied by quite a wide margin between 1 to 40 years. About 38% had been in treatment for over 10 years.
Mohsen et al 13 concluded his study that the duration of the disease has affected the treatment nonadherence. Cramer et al 14 in his study said that it is a fact that the patient treatment persistence was low for long term treatment.
Drug adherence levels
We used the Morisky Medication Adherence Scale (MMAS) and found that 49% of respondents had low adherence, while only 23% of respondents had high adherence. These results are not dissimilar to other studies in the literature; for example, Montes de Oca et al, 15 reported similar adherence rates of COPD patients. While a study conducted by Humenberger et al 16 ended with 33.6% complete adherence to inhaled therapy.
In another study by Galal et al,17 they found that in asthma and COPD, low adherence was 71.7 and 79.4%, medium adherence in 19.8 and 13.6%, and high adherence in 8.4 and 7.1%, respectively.
To et al 18 conducted a study and reported that 40.0% showed a high degree of adherence with the inhalation therapy, 25.0% patients belonged to a risk group of nonadherence, i.e., "at medium level," and 35.0% low level of adherence.
Our study's findings related to reasons for non-adherence, such as felt better so stopped and forgetting medications, concur with previous research that identifies patient-related beliefs and behaviors as one of the biggest barriers to adherence.
Association with socio-economic status
One of the most striking findings from our research was that SES classes strongly correlated with adherence levels whereby the lower classes had poor adherence levels (p=0.007). This is supported by Tøttenborg et al studies indicating that disposable income is of importance for adherence to drug. 19
Some have argued that, on the contrary, better educational levels may lead to an even poorer prognosis since they rely on their judgment instead of following the regimens prescribed, as for instance was indicated in a Danish follow-up study by Ingebrigtsen et al.20 This complexity underlines the demand for using tailored interventions with consideration of individual socio-economic circumstances.
Gender and drug adherence
Our study did not find an association between gender and levels of drug adherence (p=0.249). This is in line with several studies that have equally agreed on the fact that no serious impact of gender on medication adherence like in a study conducted by To et al. 18
However, research by Laforest et al 21 reveals that given the higher incidence of depression among women more interruptions might occur in therapy; thus, deeper research over gender factors influencing adherence would be a better recommendation.
Single dose vs Multidose inhaler therapy
Concerning the inhaler therapy, this study revealed that, in terms of adherence levels, there is no statistical difference between patients on single inhaler therapy (51.9% of low adherence) and those on dual inhaler therapy (39.1% of low adherence). This has been quite contrary to what Bogart et al. found wherein higher adherence is associate with single use of an inhaler. 22 The lack of significance may thus be indicative of differences in patient population sizes or methodologies used.
Limitations
There are several limitations to this study. Its sample size was relatively small and limits the generalizability of our findings. Moreover, given that it is a cross-sectional design, the ability to infer causal correlations between drug adherence and sociodemographic characteristics was significantly limited.
Conclusion
In conclusion, our study found nearly half of adults with OADs have low medication adherence, which is determined significantly by socio-economic status. Adherence was not substantially correlated with either gender or kind of inhaler medication. Patient education and interventions for improving adherence should focus on low-SES groups.
Recommendation
Patient Education: Tailor the counselling to the needs of the low-SES group
Adherence Follow-Up: Every visit follows the patient up for adherence to the schedule of treatment.
More Simplified Communication Tools For interactive learning, handouts and visual aids are provided
Future Research Longitudinal researches must be conducted on potential performances of adherence programs in influencing clinical outcomes.
Article
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