Medication adherence perspectives in haemodialysis patients: a qualitative study

An estimated 2.6 million people worldwide received dialysis treatment for End-stage kidney disease (ESKD) in 2010, and a two-fold increase is expected by 2030 [1]. Developing a new molecule into a medicine for clinical use costs about $2.6 billion [2], whereas the cost of treating complications from medication nonadherence averages about $100 billion a year [3]. Medication nonadherence is highly prevalent in ESKD patients undergoing haemodialysis with an average prevalence rate of 52.5% [4]. The consequences of medication nonadherence are detrimental and costly in haemodialysis patients [4‐6], as these patients have increased burden of co-existing illness and prescribed with multiple complex regimens [7‐10]. Younger age, higher comorbidities, frequent hospitalizations, poly-pharmacy, and high pill burden have been consistently reported as predictors of low medication adherence in haemodialysis patients [4, 11‐13]. These adherence predictors have been mainly identified through quantitative methods. However, these methods are less capable of exploring patients’ perspectives on medication-taking behaviour and the challenges they face while adhering to their prescribed regimens [14]. There are limited number of studies that have examined patients’ perspectives on renal failure, treatment adherence, dietary constraints, and phosphate binding medications [14‐16]. To date, little is known about haemodialysis patients’ perceptions regarding their prescribed regimen and the factors influencing their medication-taking behaviour. Understanding patients’ perspectives can help identify potentially modifiable factors such as patients’ intention to adhere, beliefs about medicines, features about treatment regimens, experiences of side effects, and provision of support mechanism required to facilitate adherence [17]. As such, we aimed to qualitatively explore factors associated with medication adherence, and examine the differential perspectives on medication-taking behaviour shown by haemodialysis patients.

Table 1 shows the study characteristics of the participants. The median age was 71 years (range, 44–87 years), and the patients were taking 4–19 medications daily. More than half of the participants were nonadherent to their medications based on self-reported measure (56.7%, n = 17). The major themes classified according to WHO determinants of adherence is presented below. The exemplar quotes for each theme is provided in Table 2. Full compilation of quotations is supplied as Additional file 1: Appendix 3. Please note the following abbreviation for the section below: P = patient (with a number to indicate the interview sequence for example, P5 is the fifth interviewed patient).

This qualitative study explored factors associated with medication adherence in haemodialysis patients, and examined their perceptions on medication-taking behaviour. A dissonance of perceptions with respect to adherence behaviour was observed between adherent and nonadherent patients. Factors mostly influencing medication-taking behaviour were patient-related. Some of the factors identified corroborated with past findings such as safety concerns of medicines [10, 14, 25], disruption to daily routine [14], forgetfulness [10, 25], use of reminders [14, 16], and role of social support [16, 21].

Knowledge and beliefs about medicines was an essential patient-specific factor potentially impeding adherence behaviour. Prioritization of medicines due to poor understanding, perceived necessity and concerns was a major reason for nonadherence. These findings in relation to patients’ beliefs regarding their medication can be further studied through various behavioural model on adherence (for e.g. Medication Adherence Model, Health Belief Model, Theory of Planned Behaviour) [26‐28]. Belief components such as necessity and concerns can be specifically targeted by utilizing tool such as Beliefs about Medicines Questionnaires (BMQ), particularly the Specific-Necessity and Specific-Concerns scale [29]. Patients’ belief about necessity and concerns related to medicine can be overcome through psycho-educational interventions [30]. Thus, our study re-emphasizes on the need for providing medication-related information to combat patient ignorance about medications in haemodialysis patients [14, 31].

Patients reporting poor interaction with healthcare providers displayed a compromised adherence behaviour. In particular, patients were less satisfied from the consultations that lack inquiry about their experiences of taking medicines and any adverse effects they might be suffering. Although patients reporting medication-related symptoms to their physician is less frequent, physicians not necessarily always respond to them, even if they were reported [32, 33]. Suboptimal patient-physician interaction may lead to patients losing trust on physicians’ recommendations and hiding their concerns while trying to be a good patient [10]. This may also lead to patients making collateral arrangement for their medications to exert a flawed sense of control over their treatment, resulting in nonadherence. Thus, it is extremely important for the healthcare professionals to routinely instigate dialogs on medication issues with patients and encourage them to volunteer such information if they were not being asked for during consultations [32].

Socio-economic factors such as access to medicines and its affordability also raised concerns that hindered adherence. Access to prescribed medicines and professional medical services gradually declines when moving away from metropolitan cities through rural and remote locations [34]. Although our study site was located in the metropolitan city, some patients visiting the dialysis centre lived in rural areas and were required to travel to the city where they could access to professional advice for acquiring prescriptions or repeat them from the pharmacy. Though eligible patients benefitted from the government subsidy schemes for the cost reductions in prescription medicines [35], the large financial burden accumulated from the number of prescription and non-prescription medicines, the cost of acquiring scripts, transportation, and out-of-pocket payments annulled the cost benefits from the subsidy in haemodialysis patients. Medicine affordability can be much more challenging for patients in developing countries where public healthcare system does not guarantee subsidy of prescription medicines and the patients generally does not subscribe to health coverage schemes [36].

This study finding have both clinical and research implications. As dialysis patients, coupled with comorbid illness and dialysis-associated complications continually demands high pill burden for treatment, we tend to lose considerations on how polypharmacy, regimen complexity, and adherence issues should be addressed. As such, this study provides a subjective account of patients’ concerns that may lead to nonadherence. Healthcare professionals may routinely instigate dialogs and encourage patients to volunteer information concerning their current medicines, readiness to start new therapy, changes with dose or dosage requirements, and side-effects or safety concerns they might be dealing with. Any transitioning of medication therapy may be facilitated by providing personalized education by capitalising on the need and importance of taking medicines. Improving access to professional medical and pharmaceutical services and developing dialysis centre-based intervention programs focussing on the psycho-educational support may be effective. The same framework may be utilized in research settings to develop behavioural and educational interventions for examining patient concerns associated with medication adherence.

Study limitations need a mention. This is a single-centred study that may limit the generalizability of the findings. Interviews were conducted with English speaking patients only, thus, the findings may not be generalizable to non-English speaking patients. Although the participants were interviewed in an outpatient setting of a tertiary care metropolitan hospital, some of the patients came from rural areas driven by access limited healthcare services and support mechanisms. Hence, the access barrier gained attention in our themes, which may only be true for patients living in rural areas [25]. As interviews were conducted during dialysis sessions, patients may have been hesitant in responding freely while sharing their experiences. Furthermore, interviews for research purpose may have facilitated social desirability response [37], though it was unlikely as a wide-ranging viewpoints were expressed. Despite limitations, we used a purposive sampling method to identify participants of different demographic characteristics, and showing different medication-taking behaviour that best represented the perspectives of patients regarding the phenomenon under study.

Haemodialysis patients expressed a number of concerns that led to nonadherence behaviour. Many of the issues identified were patient-related and potentially modifiable by using psycho-educational or cognitive-behavioural interventions. Healthcare professionals should be more vigilant towards identifying these concerns to address adherence issues. Future research should be aimed at understanding healthcare professionals’ perceptions and practices of assessing medication adherence in dialysis patients that may guide intervention to resolve this significant issue of medication nonadherence.