Which patients keep on taking their medicine

Armen Hareyan's picture
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Aga Khan University (AKU) is proud to share a peer-reviewed article, "Factors Associated with Adherence to Anti-Hypertensive Treatment in Pakistan," which will appear in the March 14 issue of PLoS ONE, the international, open-access online journal from the Public Library of Science. The study on which the article is based is in line with the University's ethos: that research at AKU focuses on topics of direct relevance to developing countries. The study was initiated by Dr Philippe M Frossard, Professor and Chair, Department of Biological and Biomedical Sciences at AKU and the 9-member team was led by Dr Usman Ahmad, presently at Yale University in the US.

We are living at the time of a paradigm shift in what constitutes the practice of medicine and its implications on our societies' ways of life. Medicine is indeed moving from a traditional approach, preoccupied with treating the manifestations of disease, to a preventive approach.

Is the individual - the future patient - ready for true prevention, even if this means adopting sometimes drastic measures way before the onset of any disease? This pivotal question is particularly pertinent in an emerging country such as Pakistan because this country could have the extraordinary ability to move straight into the practice of 21st century medicine within a very short time.

One powerful angle to address the issue of the individual's putative readiness for prevention is to evaluate the adherence to treatment in existing patients. This has become a particularly topical field worldwide. How good patients are at taking their medications tells us a lot on how best to manage their health and disease. Poor adherence is one of the biggest obstacles in therapeutic control of high blood pressure; improving adherence decreases the risk of relapse, improves outcomes and lessens costs. The team opted to start probing this issue with the study of patients' adherence to anti-hypertensive treatments. Hypertension is known as the 'silent killer' because the insidious damages of blood pressure elevation start long before symptoms appears. The treatment of essential hypertension (EHT) therefore constitutes directly a true form of prevention.

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The goal was to assess how good Pakistani patients are at taking their prescribed anti-hypertensive medications, how they compare to patients in other parts of the world, and what lessons can be drawn today and for the future.

A cross-sectional study was conducted on a simple random sample of 460 patients at Aga Khan University Hospital (AKUH) and National Institute of Cardiovascular Diseases, Karachi, from September 2005 till May 2006. Adherence was assessed using the Morisky Medication Adherence Scale (MMAS), with scores ranging from 0 (non-adherent) to 4 (adherent). In addition to MMAS, patient self-reports about the number of pills taken over a prescribed period, were used to obtain adherence as a percentage. The AKU Anxiety and Depression Scale (AKU-ADS) was incorporated to find any association between depression and adherence. The questionnaires were pilot-tested on 50 patients, who were not included in the final cohort of 460 subjects.

The surprising result was that 77 per cent of the cases were adherent. Indeed, low education and socio-economic status have been recurrently reported to affect negatively adherence, and in this context, the proportion of adherent patients is surprisingly large in the Pakistani population investigated here.

As for the associated factors, similarly to what has been reported worldwide, younger age, poor awareness, and symptomatic treatment adversely affected adherence to antihypertensive medication in this population. In contrast, mono-therapy reduced adherence (and the larger the number of pills, the greater the adherence), whereas psychosocial factors such as depression showed no association. One powerful contributing factor to adherence may lay in the social and extended family structures of the country. These findings may be used to identify the subset of population at risk of low adherence who should be targeted for interventions to achieve better blood pressure control and hence prevent complications.

Implications for large-scale introduction of preventative medicine are obvious. Although age was associated with adherence (and preventative measures should be started as early as possible), the Pakistani population at large seems to be very receptive to adherence (and prevention); furthermore, unique social and family fabrics of the Pakistani society should be the direct targets of campaigns aimed at improving both adherence and prevention.

The University appreciates that the endemic problems of a region beset with financial difficulties and low development indicators can be addressed only through relevant research focusing on producing low cost, accessible and innovative solutions.

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