Ghimire et al.

BMC Nephrology (2017) 18:167

DOI 10.1186/s12882-017-0583-9

RESEARCH ARTICLE Open Access

Medication adherence perspectives in

haemodialysis patients: a qualitative study
Saurav Ghimire1, Ronald L. Castelino1,2,3, Matthew D. Jose4,5 and Syed Tabish R. Zaidi1*

Abstract
Background: End-stage kidney disease patients undergoing haemodialysis are prescribed with multiple complex
regimens and are predisposed to high risk of medication nonadherence. The aims of this study were to explore
factors associated with medication adherence, and, to examine the differential perspectives on medication-taking
behaviour shown by adherent and nonadherent haemodialysis patients.
Methods: A qualitative exploratory design was used. One-on-one semi-structured interviews were conducted with
30 haemodialysis patients at the outpatient dialysis facility in Hobart, Australia. Patient self-reported adherence was
measured using 4-item Morisky Green Levine scale. Interview transcripts were thematically analysed and mapped
against the World Health Organization (WHO) determinants of medication adherence.
Results: Participants were 44–84 years old, and were prescribed with 4–19 medications daily. More than half of the
participants were nonadherent to their medications based on self-reported measure (56.7%, n = 17). Themes mapped
against WHO adherence model comprised of patient-related (knowledge, awareness, attitude, self-efficacy, action control,
and facilitation); health system/ healthcare team related (quality of interaction, and mistrust and collateral arrangements);
therapy-related (physical characteristics of medicines, packaging, and side effects); condition-related (symptom severity);
and social/ economic factors (access to medicines, and relative affordability).
Conclusions: 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.
Keywords: End-stage kidney disease, Haemodialysis, Medication adherence, Patients’ perspectives, Qualitative study

Background consequences of medication nonadherence are detrimen-

An estimated 2.6 million people worldwide received dialy- tal and costly in haemodialysis patients [4–6], as these
sis treatment for End-stage kidney disease (ESKD) in patients have increased burden of co-existing illness and
2010, and a two-fold increase is expected by 2030 [1]. De- prescribed with multiple complex regimens [7–10]. Youn-
veloping a new molecule into a medicine for clinical use ger age, higher comorbidities, frequent hospitalizations,
costs about $2.6 billion [2], whereas the cost of treating poly-pharmacy, and high pill burden have been consist-
complications from medication nonadherence averages ently reported as predictors of low medication adherence
about $100 billion a year [3]. Medication nonadherence is in haemodialysis patients [4, 11–13]. These adherence
highly prevalent in ESKD patients undergoing haemodi- predictors have been mainly identified through quantita-
alysis with an average prevalence rate of 52.5% [4]. The tive methods. However, these methods are less capable of
exploring patients’ perspectives on medication-taking
* Correspondence: [email protected] behaviour and the challenges they face while adhering to
1
Unit for Medication Outcomes Research and Education (UMORE), Pharmacy, their prescribed regimens [14]. There are limited number
School of Medicine, Faculty of Health, University of Tasmania, Hobart 7001,
Australia of studies that have examined patients’ perspectives on
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ghimire et al. BMC Nephrology (2017) 18:167 Page 2 of 9

renal failure, treatment adherence, dietary constraints, and (Additional file 1: Appendix 2), and the median inter-
phosphate binding medications [14–16]. To date, little is view duration was 17.5 min (range, 6–41 min). All inter-
known about haemodialysis patients’ perceptions regard- view sessions were audio-recorded and transcribed
ing their prescribed regimen and the factors influencing verbatim; patients were not remunerated for their par-
their medication-taking behaviour. Understanding pa- ticipation. Data on socio-demographic and clinical char-
tients’ perspectives can help identify potentially modifiable acteristics were obtained during interviews and by
factors such as patients’ intention to adhere, beliefs about reviewing medical records. Adherence was determined by
medicines, features about treatment regimens, experiences self-reports using the 4-item Morisky Green Levine scale
of side effects, and provision of support mechanism [20]. Patients with a Morisky score of zero were consid-
required to facilitate adherence [17]. As such, we aimed ered adherent and those scoring 1–4 were considered
to qualitatively explore factors associated with medica- nonadherent, based on similar studies assessing self-
tion adherence, and examine the differential pers- reported adherence in haemodialysis patients [19, 21].
pectives on medication-taking behaviour shown by Interview transcripts were thematically analysed [22].
haemodialysis patients. Transcripts were repeatedly read for familiarization and
data immersion. Two investigators (SG and STRZ) inde-
Methods pendently coded and reviewed the first five transcripts
Study design to ensure concordance was reached. Remaining tran-
A qualitative exploratory design was used. The consoli- scripts were coded by SG and the final themes were
dated criteria for reporting qualitative research (COREQ) agreed upon by both SG and STRZ. The analysis was it-
guideline [18] was followed during the conduct and erative during data collection and carried out following
reporting of the study (Additional file 1: Appendix 1). each interview. Data saturation was assumed after 18 inter-
Ethics approval was granted by the Tasmanian Health and views however, all participants who consented for the study
Medical Human Research Ethics Committee (H0014506). were interviewed. Themes generated were mapped against
Written informed consent was obtained from all the the World Health Organization (WHO) determinants of
participants. medication adherence that included patient-related-,
health system/ healthcare team related-, therapy-related-,
Research team and reflexivity condition-related-, and social/ economic factors [23].
Interviews were conducted by a pharmacist researcher Patient-related factors within the WHO model was further
(SG). The interviewer was external to the study site, and sub-divided into aspects such as knowledge, awareness,
both the participants and the interviewer were unknown attitude, self-efficacy, action control, and facilitation; based
to each other before the study. The study aims and pro- on adherence support taxonomy of behaviour change
fessional status of the interviewer were discussed with techniques [24].
the participants prior to conducting the interviews.
Results
Participants Table 1 shows the study characteristics of the partici-
All adult (≥ 18 years), English speaking patients, under- pants. The median age was 71 years (range, 44–87 years),
going haemodialysis at the outpatient dialysis unit in and the patients were taking 4–19 medications daily.
Hobart, Australia were eligible to participate. Participant More than half of the participants were nonadherent to
recruitment was sought from patients who had earlier their medications based on self-reported measure
participated in a cross-sectional study [19] that investi- (56.7%, n = 17). The major themes classified according
gated association between medication regimen complex- to WHO determinants of adherence is presented below.
ity and medication adherence in haemodialysis patients. The exemplar quotes for each theme is provided in
This study had a good response rate of above 75%, with Table 2. Full compilation of quotations is supplied as
53 haemodialysis patients completing the study. These Additional file 1: Appendix 3. Please note the following
patients were re-invited for participation for the qualita- abbreviation for the section below: P = patient (with a
tive interview. Thirty haemodialysis patients consented number to indicate the interview sequence for example,
for the qualitative interview whereas nonparticipation by P5 is the fifth interviewed patient).
the rest was mainly due to lack of interest, fatigue or
inconvenience. Theme 1: Patient-related factors
Knowledge and belief about medicines
Data collection and analysis Patients assigned variable importance to their prescribed
One-to-one interviews were held during the dialysis medicines and it appeared that the patients who were less
session. All interviews were conducted by SG between informed of the purpose of their medicines see little for
February and June 2015, using the interview guide taking them regularly (P1; P5). This lack of understanding
Ghimire et al. BMC Nephrology (2017) 18:167 Page 3 of 9

Table 1 Characteristics of study participants (n = 30) perceived effectiveness (P12) of their medication therapy
Variables Number (%) and were therefore adherent.
Age, in years 69.6 ± 11.0
40–59 5 (16.7)
Awareness and attitude towards medicines
Being aware of the consequences of nonadherence such
60–79 18 (60.0)
as deterioration of medical condition and in rare cases,
≥ 80 7 (23.3) fear of death was found to be a motivator to be adher-
Gender, male 23 (76.7) ent. Motivated patients desiring to live longer (P12; P15;
Marital status, married 17 (56.7) P20; P21; P25) and those expressing positive attitude to-
Living with family 18 (60.0) wards taking medicines (P10; P11; P15; P21; P24; P28)
Level of education, ≥ high school 24 (80.0)
were thus found to be adherent. On the contrary, a pa-
tient who was not motivated to overcome the general
Smoking history, non-smoker 24 (80.0)
dislike of taking medicine was likely to demonstrate a
Number of medicines prescribed 11.4 ± 4.3 nonadherent behaviour (P13).
1–5 4 (13.3)
6–10 7 (23.3) Self-efficacy
≥ 11 19 (63.3) Patient’s ability to manage their medication in different
Daily pill burden 16.0 ± 6.1
situations also influenced their medication-taking behav-
iour. Disruption to daily routine, particularly the midday
1–9 4 (13.3)
dosing frequency, was identified as a practical barrier to
10–19 15 (50.0) medication adherence. This was pertinent in patients ex-
≥ 20 11 (36.7) pressing personal preferences of taking medications at
Years on dialysis 4.1 ± 4.1 their conveniences (P8), or in those prioritizing import-
<1 6 (20.0) ant life events of the day besides taking medicines (P18).
1–5 17 (56.7)
Also, some participants accentuated that carrying medi-
cines and remembering to take them was inconvenient
≥6 7 (23.3)
during their travel and outdoor activities (P3; P6).
Hospitalization (past 1 year)b 22 (73.3) Whereas, patients accustomed to their regimen after fol-
b
Dialysis session missed 5 (16.7) lowing a routine for a relatively longer span of time were
Diabetes 7 (23.3) found to be adherent (P15; P16; P20; P21; P27; P30)
Hypertension 17 (56.7) while, a patient who was unaccustomed with his recent
Cardiovascular disease 16 (53.3)
changes in medication regimen had a tendency to forget
a and was more likely to be nonadherent (P8).
Adherence to medication
Adherent 13 (43.3) Action control
Nonadherent 17 (56.7) Patient’s capacity to control medication intake as planned
For continuous variables, Mean ± SD; for categorical variables, numbers with was also influencing medication adherence. Participants
percentages in parentheses
a
Adherence to medication was based on self-reported measure using 4-item
expressed forgetfulness as an excuse for not taking medi-
Morisky Green Levine scale. Patients scoring zero were considered adherent cation and gave an impression that nonadherence was un-
b
At least one event of hospitalization or dialysis session missed in past 1 year intentional (P6; P8; P14). Adherent patients, though, made
prior to the month of data collection
their circumstances favourable for taking medicines by
using stimuli such as pill boxes (P15; P18; P25) or by vis-
ibly allocating their pills (P10; P12). Furthermore, some
also led to the misconception that some of their medicines patients related their meals and medicines together by
get washed out during dialysis and would remain ineffect- stating that skipping meals during the day might end-up
ive (P8). Such misconceptions triggered doubts about their with them not taking their medicines (P5; P6).
necessity, which led to prioritizing medication due to lack
of benefit (P1; P5), and relative importance given to some Facilitation
medicines (P6), thus encouraging nonadherence behav- Patients who were influenced and reinforced by their
iour. Furthermore, some patients acquired nonadherent family members (P12; P15; P21; P27) were better adher-
behaviour as they expressed safety concerns about their ing to their medications whereas, patients expressing
medications (P5; P6). On the other hand, patients having lack of support from their family members (P7) or those
better understanding about their disease process had who lived alone (P2) were found to be nonadherent to
higher perceived need (P11; P15; P16) and developed their medications.
Ghimire et al. BMC Nephrology (2017) 18:167 Page 4 of 9

Table 2 Determinants of medication adherence in haemodialysis patients

Themes based on WHO taxonomy Exemplar quotes
Patient-relateda
Knowledge and belief about medicines
- Lack of understanding about medicines “Well, I just don’t know what some of them are for.” (P1, male, 53 years, PSR NAD)
“I don’t know what’s really important and… if you missed [medication] once or
twice it wouldn’t matter, I’ve no idea.” (P5, female, 58 years, PSR NAD)
“As far vitamins are no much point for me because it all gets dialysed out of here
[pointing to the dialysis machine].” (P8, male, 71 years, PSR NAD)
- Lack of benefit “I don’t know if they doing any good? […] I thought well, you know, I am taking
all this in the morning, um… are they doing any good? I don’t know.” (P5, female,
58 years, PSR NAD)
- Safety concerns “There’s one medicine that is a statin which I’m very unhappy about. It’s Atorvastatin.
And, I’m unhappy about that… because they… they, ah, studies have shown that
there are lots of side effects of that.” (P6, female, 74 years, PSR NAD)
- Relative importance “I think blood pressure one is important. Yes, I think that is important to keep my
blood pressure down…” (P6, female, 74 years, PSR NAD)
- Perceived need “There’s something to do with my kidney and that. […] it’s not working very well. If
I started not taking them, I could for been… you know in trouble. They all they are
for a reason. Yeah.” (P15, male, 78 years, PSR AD)
- Perceived effectiveness “I put myself on that [medicine] because I didn’t have any arthritis or anything before
I started [dialysis] and all of a sudden my fingers going, and I put it on that now for
a month and it stopped the pain…” (P12, female, 80 years, PSR AD)
Awareness and attitude
- Motivation to live “I don’t know how much longer I got to live. But I want to get up to 80. If I become
80, that will be the longest lived in all our family. And if I make 80… I’m the champion.
” (P15, male, 78 years, PSR AD)
- Positive attitude “I got to take them as they keep me healthy. And I don’t have a problem with it.”
(P21, male, 84 years, PSR AD)
- General dislike “I don’t like the fact that I need to take them… Not happy about taking medications
but the alternatives not good.” (P13, female, 63 years, PSR NAD)
Self-efficacy
- Disruption to daily routine “Well it’s in the morning and night, I’m just used to doing that. It’s the middle one I have
to take care of… I take it at night. Take two at night instead of three, spreading three
during the day, which the doctor asked me to try, because it might be more effective. I
haven’t yet succeeded.” (P8, male, 71 years, PSR NAD)
- Inconvenience during travel “People don’t make it difficult for me, but it’s the fact that I’ve, I travel, I like to travel of
course make it difficult, because I’ve got to take all the stuffs with me, organize something
every day or whatever. Yes, traveling.” (P6, female, 74 years, PSR NAD)
- Accustomed regimen “I got all these medications every day, morning, evening, night. So, I never forget it, now.”
(P15, male, 78 years, PSR AD)
“I’ve been taking it for a long time and it’s just natural.” (P27, male, 79 years, PSR AD)
- Unaccustomed regimen “I’m supposed to take a medicine for my [restless leg], but I keep forgetting… So, um, I’ve
only been told this few days ago and I haven’t got used to it, to taking it.” (P8, male, 71
years, PSR NAD)
Action control
- Forgetfulness “Well, I think that I’m much more, I don’t know, forgetful then I used to be, I can’t think
this clearly… seems I pick but I don’t. Um. Remembering to take it. I think that’s the
biggest thing.” (P6, female, 74 years, PSR NAD)
- Stimuli or cues for action “I have a little pill boxes, it holds all morning, noon and night… I just take whatever is
required during dinner, or at meal in the night.” (P15, male, 78 years, PSR AD)
- Visual allocation of pills “I’ve got them [medicines] in the kitchen table, so I can’t forget.” (P10, female, 53 years,
PSR AD)
- Association with meals “If I don’t have lunch, I don’t remember my medicines, always. Lunch is sort of tied to the
medicines. So, if I wouldn’t eat, I wouldn’t take the medicines so regularly, I think.”
(P6, female, 74 years, PSR NAD)
Ghimire et al. BMC Nephrology (2017) 18:167 Page 5 of 9

Table 2 Determinants of medication adherence in haemodialysis patients (Continued)

Facilitation
- Role of support “My wife makes sure I take them... she helps. She gets all medicines ready, tablets ready…
she does all, mostly.” (P27, male, 79 years, PSR AD)
“Some medicines make me dizzy. It is a problem. Especially when I get no support at
home. Coz my husband, he works at night, and I got to be careful. Coz I got no support
at home.” (P7, female, 65 years, PSR NAD)
Health system/ HCT-related
Quality of interaction with HCT
- One-way communication “[Asking Dr. about the need of so many medicines…] I saw doctor at the clinic last time
and he said, “No, they are all good”. He went through one by one [medicines] and no,
that’s good, you need that, you need that, so…” (P7, female, 65 years, PSR NAD)
- Lack of engagement “[Consultations are] never very long usually, you know. Just checks the figures, just look
at your blood figures and everything’s ok and you know.” (P2, male, 61 years, PSR NAD)
- Lack of time “I really need to speak to the pharmacist. Um, but they’re very busy, but I will, I must
speak to, I want to know what every medicines, especially 12 medicines in the morning
are for.” (P5, female, 58 years, PSR NAD)
- Support from HCT “It’s always great with my GP. I’ve been going to him for 15 years and we’re quite informal
and he’s very helpful and if I complained about what these things, he investigates them
properly.” (P11, male, 84 years, PSR AD)
“You know, just, give all your tablets to the chemist and he’ll sort them out. Makes it so
much easier. He puts them in [Webster-Pak] … for 2 weeks and you got a just twist and
pop a tablets… so I don’t need to worry about what one of this, one of this, anymore.”
(P16, male, 65 years, PSR AD)
Mistrust and collateral arrangements
- Pressure to hide “I forgot to say [doctor] about it [not taking phosphate binders]. Because, I think what
they will gonna tell me is, I have to take it. I’m frightened obvious the doctor’s gonna say,
which they probably will, because it’s very important, the phosphate, I know that.”
(P5, female, 58 years, PSR NAD)
- Being a good patient “I don’t. I don’t know I take it because I’ve been told to take it, and I do that. But I don’t
take it very seriously. And if I miss it, I don’t get panic, so.” (P8, male, 71 years, PSR NAD)
- Personal control of treatment “I discuss it with myself. Or, I go to [doctor] who gets upset because I decide to take more
than what I’m prescribed. Like the Sifrol, it wasn’t holding, so I lifted the [dose] up to two.
And checked it [in the internet] and it was okay to do that and then she [doctor] got
most upset because she said it effects the kidney, and I said well they’re pretty shot
already, and she said they can always get worse.” (P8, male, 71 years, PSR NAD)
- Trust in HCT “I take my medicines. They give me the right thing, so I just take them. Except when I’m
allergic to.” (P10, female, 53 years, PSR AD)
“I keep taking them until my doctor takes me out of it. I just take the dose that’s on the
charts I got.” (P25, male, 72 years, PSR AD)
Therapy-related
Physical characteristics of medicines
- Pill size “I’ve got the one [medicine], got to cut it half, I’ve got a cut five or six in half so I’ve got
half for in the morning and half at night.” (P9, female, 63 years, PSR NAD)
- Palatability “Some of them, as soon as you get them on the tongue…I swear it, dissolves straight
away and it tastes disgusting! First thing in the morning they, oh! […] Just bitter, you
know, one of them.” (P5, female, 58 years, PSR NAD)
Medicine packaging “One I have very hard to get it out. A little capsule, that for pain. Yeah. Very hard to put
out. The capsules are completely crushed by the time it gets out of its thing! That’s the
only problem.” (P11, male, 84 years, PSR AD)
Side effects of medicines “Sometimes they work, sometimes really make me sick. Makes me dizzy. It’s a bit stronger.
I don’t take them. If they are not too strong, I’ll take them… but if they make me dizzy, I
don’t.” (P7, female, 65 years, PSR NAD)
“I don’t like taking them, the [antibiotics], they give me toilet all the time.” (P29, male, 65
years, PSR NAD)
Ghimire et al. BMC Nephrology (2017) 18:167 Page 6 of 9

Table 2 Determinants of medication adherence in haemodialysis patients (Continued)

Social/ economic
Access to medicines
- Acquiring script “I’m taking a lot of pain tablets at the moment… I was taking patches, but you can’t get
more than a month’s supply. So, that means going back on doctors, and when I get out
of here [dialysis], I don’t want… to get to the doctors on my days off [from dialysis], so
I’m just taking Panadol and Panadol with Codeine. But, is not really enough, to be honest.”
(P2, male, 61 years, PSR NAD)
- Clinic and pharmacy location “Because I live out of town… and about 40 min from the chemist, just kind of be aware
how many more medicines I’ve got, it’s nothing worse than running out and having to
drive especially for that, yeah.” (P3, male, 44 years, PSR NAD)
“Some of the scripts you can’t get from [local pharmacy]. So, I’ve had issues actually getting
them in the past… When my doctor goes on holidays, I can’t acquire a script without
doing it a 100 km drive. [Dialysis staffs] refused to help me, and the doctors refused to
give scripts over the phone. I can’t acquire a script over the phone…” (P1, male, 53
years, PSR NAD)
Relative affordability “Well, they’re quite expensive! So they do affect me, the cost. I don’t have a health care
card. I’ve to pay the full subsidised price… I’ve retired and so I’m living of an allocated
pension from my superannuation.” (P4, male, 56 years, PSR NAD)
“The only thing that worries me is, coz I’m in a wheel chair and I need to get to the
hospital to get the scripts, it means for $ 30 to get in the taxi to go in there and pick up
the script or I drive my mobility scooter all the way in there, which means 2 hours and
an hour of each waiting to pick them up.” (P2, male, 61 years, PSR NAD)
Condition-related
Symptom severity “Have you seen me 12 months ago, I am on a 100% better [condition] after this year but
last year and a year before, no, I didn’t really think I’m gonna make it. Not even everybody
else also gonna make it either.” (P12, female, 80 years, PSR AD)
“I don’t notice any [improvement] from my medications, whatsoever.” (P1, male, 53 years,
PSR NAD)
Abbreviations: AD, Adherent; NAD, nonadherent; BP, blood pressure, HCT, healthcare team; PSR, patient self-reports
a
Patient-related factors further classified based on adherence support taxonomy by de Bruin et al., 2010 [24]

Theme 2: Health system/ healthcare team related factors medications will not be attended to by their doctors pre-
Quality of interaction with healthcare team ferred either hiding their concerns (P5) or portrayed
Few patients expressed dissatisfaction from their inter- themselves as a good patient (P6; P8). Dissatisfaction
action and engagement with the healthcare team and and mistrust, following unpleasant interaction with
were likely to demonstrate nonadherent behaviour. physicians, may have further aggravated patients in
Some of the issues raised by these patients include, one- making parallel or collateral arrangements for them-
sided communication by their physician (P7); lack of selves by surpassing physicians’ decision and recom-
engagement during consultation visits (P2; P4); and lack mendation regarding their medications. Patients thus
of time for medication counselling (P5). Some patients exerted a sense of personal control over their treat-
avoided discussing adherence related issues with their ment (P2; P7; P8). In contrast, patients who were hav-
doctor as they had a preconceived notion about what ing a satisfying and trustworthy relationship with their
their doctors would say. This might have occurred doctors seemed to have followed the prescribed in-
due to a prior unpleasant interaction with their doc- structions in a relatively unopposed fashion (P10; P11;
tor. For instance, a participant remembered an occa- P15; P20; P25).
sion where doctor showed less empathy towards her
unresolved symptoms despite taking medicines (P5).
On the other hand, patients expressing satisfaction Theme 3: Therapy-related factors
from their interaction and engagement with the Physical characteristics of medicines
healthcare professionals tend to be adherent to their Physical characteristics of medicines were considered to
medications (P11; P16). hinder adherence in some patients. Pharmaceutical
make-ups such as size of pills especially the larger ones
Mistrust and collateral arrangements (for e.g. phosphate binders) were considered difficult to
A general lack of trust on healthcare team particularly swallow (P9; P10). Also, few patients complained about
towards medical profession was observed in some pa- palatability of medicines to be a nuisance when they
tients. Those who perceived that their concerns towards have to be taken early in the morning (P5; P13; P22).
Ghimire et al. BMC Nephrology (2017) 18:167 Page 7 of 9

Side effects of medicines to pay out-of-pocket. The relative affordability of these

Some patients complained about side effects such as dizzi- medicines when considering the cost of acquiring script,
ness, nausea, vomiting and diarrhoea after taking their transportation, and medicine costs itself restrained patients
medicines (P5; P7; P29). They experimented on their own to access their medicines (P2; P4; P5).
by skipping doses and observing if the symptoms per-
sisted. When patients were convinced that their past expe- Theme 5. Condition-related factors
riences of untoward symptoms were the results of taking Symptom severity
their medicines (P5; P7; P29), they would prefer avoiding Severity of symptoms had an influence on patient’s risk
those medicines such that they would not suffer from perception, importance of following treatment regimen,
similar adverse effects in the future. and the priority they placed on medication adherence. A
patient who observed decreased symptom severity over
Packaging of medicines time was found to be adherent with her prescribed regi-
A patient considered one of his medicine packaging to men (P12). However, another patient who didn’t see any
be non-user-friendly (P11), posing it to be a practical improvement of his health condition was found to be
barrier that impeded adherence. nonadherent (P1).

Theme 4: Social/ economic factors Discussion

Access to medicine This qualitative study explored factors associated with
Medicines in Australia are supplied at a subsidised cost medication adherence in haemodialysis patients, and ex-
through the Pharmaceutical Benefits Scheme (PBS). How- amined their perceptions on medication-taking behaviour.
ever, access to some specialised medicines routinely used A dissonance of perceptions with respect to adherence
in dialysis patients (such as Lanthanum, Erythropoietin, behaviour was observed between adherent and nonadher-
Cinacalcet etc.) is restricted to specialised pharmacies and ent patients. Factors mostly influencing medication-taking
hospital based clinicians. This particularly becomes an behaviour were patient-related. Some of the factors identi-
issue while acquiring scripts when the patients are living fied corroborated with past findings such as safety con-
far away from the major town or cities where they are of- cerns of medicines [10, 14, 25], disruption to daily routine
fered limited access to professional medical services [14], forgetfulness [10, 25], use of reminders [14, 16], and
(P1; P3). Besides, patients are also constrained with filling role of social support [16, 21].
their prescription to not more than a month’s supply Knowledge and beliefs about medicines was an essen-
under the PBS, which makes a frequent consultation visit tial patient-specific factor potentially impeding adher-
for acquiring scripts inconvenient in patients having dialy- ence behaviour. Prioritization of medicines due to poor
sis fatigue and chronic incapacitation (P2; P23). This understanding, perceived necessity and concerns was a
results into medicine shortage and the patients are com- major reason for nonadherence. These findings in rela-
pelled to choose readily available over-the-counter medi- tion to patients’ beliefs regarding their medication can
cines that may not always be an effective alternative (P2). be further studied through various behavioural model on
Besides acquiring scripts, the clinic and pharmacy location adherence (for e.g. Medication Adherence Model, Health
also posed a limitation to access medicines in patients Belief Model, Theory of Planned Behaviour) [26–28]. Be-
living in remote areas (P1; P3). lief components such as necessity and concerns can be
specifically targeted by utilizing tool such as Beliefs
Relative affordability about Medicines Questionnaires (BMQ), particularly the
The relative affordability of medicines due to cost or finan- Specific-Necessity and Specific-Concerns scale [29].
cial constraints was another factor that impede access to Patients’ belief about necessity and concerns related to
medicines and ultimately contributed to nonadherence. medicine can be overcome through psycho-educational
Some of the haemodialysis patients were over the retire- interventions [30]. Thus, our study re-emphasizes on the
ment age, and mainly lived on disability support pension need for providing medication-related information to
or superannuation disability benefits (P2; P4). Although pa- combat patient ignorance about medications in haemo-
tients were getting medicines in a highly subsidized price dialysis patients [14, 31].
through the PBS, these tend to cover only the partial costs Patients reporting poor interaction with healthcare
for prescription medicines. However, due to the complexity providers displayed a compromised adherence behav-
of disease treatment and associated symptom burden, pa- iour. In particular, patients were less satisfied from the
tients often required additional over-the-counter medicines consultations that lack inquiry about their experiences
including multi-vitamin preparations, vitamin D, iron and of taking medicines and any adverse effects they might
mineral supplements, pain medicines etc., which are not be suffering. Although patients reporting medication-
covered by the benefit schemes and patients needed them related symptoms to their physician is less frequent,
Ghimire et al. BMC Nephrology (2017) 18:167 Page 8 of 9

physicians not necessarily always respond to them, even settings to develop behavioural and educational interven-
if they were reported [32, 33]. Suboptimal patient- tions for examining patient concerns associated with
physician interaction may lead to patients losing trust on medication adherence.
physicians’ recommendations and hiding their concerns Study limitations need a mention. This is a single-
while trying to be a good patient [10]. This may also lead centred study that may limit the generalizability of the
to patients making collateral arrangement for their medi- findings. Interviews were conducted with English speaking
cations to exert a flawed sense of control over their treat- patients only, thus, the findings may not be generalizable
ment, resulting in nonadherence. Thus, it is extremely to non-English speaking patients. Although the partici-
important for the healthcare professionals to routinely in- pants were interviewed in an outpatient setting of a ter-
stigate dialogs on medication issues with patients and en- tiary care metropolitan hospital, some of the patients
courage them to volunteer such information if they were came from rural areas driven by access limited healthcare
not being asked for during consultations [32]. services and support mechanisms. Hence, the access bar-
Socio-economic factors such as access to medicines rier gained attention in our themes, which may only be
and its affordability also raised concerns that hindered true for patients living in rural areas [25]. As interviews
adherence. Access to prescribed medicines and profes- were conducted during dialysis sessions, patients may
sional medical services gradually declines when moving have been hesitant in responding freely while sharing their
away from metropolitan cities through rural and remote experiences. Furthermore, interviews for research purpose
locations [34]. Although our study site was located in may have facilitated social desirability response [37],
the metropolitan city, some patients visiting the dialysis though it was unlikely as a wide-ranging viewpoints were
centre lived in rural areas and were required to travel to expressed. Despite limitations, we used a purposive
the city where they could access to professional advice sampling method to identify participants of different demo-
for acquiring prescriptions or repeat them from the graphic characteristics, and showing different medication-
pharmacy. Though eligible patients benefitted from the taking behaviour that best represented the perspectives of
government subsidy schemes for the cost reductions in patients regarding the phenomenon under study.
prescription medicines [35], the large financial burden
accumulated from the number of prescription and non-
prescription medicines, the cost of acquiring scripts, Conclusions
transportation, and out-of-pocket payments annulled the Haemodialysis patients expressed a number of concerns
cost benefits from the subsidy in haemodialysis patients. that led to nonadherence behaviour. Many of the issues
Medicine affordability can be much more challenging identified were patient-related and potentially modifiable
for patients in developing countries where public health- by using psycho-educational or cognitive-behavioural in-
care system does not guarantee subsidy of prescription terventions. Healthcare professionals should be more vigi-
medicines and the patients generally does not subscribe lant towards identifying these concerns to address
to health coverage schemes [36]. adherence issues. Future research should be aimed at un-
This study finding have both clinical and research im- derstanding healthcare professionals’ perceptions and
plications. As dialysis patients, coupled with comorbid practices of assessing medication adherence in dialysis pa-
illness and dialysis-associated complications continually tients that may guide intervention to resolve this signifi-
demands high pill burden for treatment, we tend to lose cant issue of medication nonadherence.
considerations on how polypharmacy, regimen complex-
ity, and adherence issues should be addressed. As such,
Additional file
this study provides a subjective account of patients’ con-
cerns that may lead to nonadherence. Healthcare profes- Additional file 1 Appendix 1 Consolidated criteria for reporting
sionals may routinely instigate dialogs and encourage qualitative studies (COREQ): 32-item checklist. Appendix 2 Interview
patients to volunteer information concerning their current guide. Appendix 3. Summary of interpretation of themes with exemplar
quotes. (DOCX 32 kb)
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 Abbreviations
medication therapy may be facilitated by providing BMQ: Beliefs about Medicines Questionnaires; COREQ: Consolidated Criteria
personalized education by capitalising on the need and for Reporting Qualitative Research; ESKD: End-Stage Kidney Disease;
PBS: Pharmaceutical Benefits Scheme; WHO: World Health Organization
importance of taking medicines. Improving access to pro-
fessional medical and pharmaceutical services and
developing dialysis centre-based intervention programs Acknowledgements
We thank all the patients and the dialysis unit staffs of Nephrology South,
focussing on the psycho-educational support may be ef- Hobart, Tasmania, Australia for their participation and support during the
fective. The same framework may be utilized in research conduct of the study.
Ghimire et al. BMC Nephrology (2017) 18:167 Page 9 of 9

Availability of data materials 12. Manley HJ, Cannella CA, Bailie GR, St Peter WL. Medication-related problems
All data related to this study are available in the Division of Pharmacy, in ambulatory hemodialysis patients: a pooled analysis. Am J Kidney Dis.
School of Medicine, University of Tasmania, Hobart, Australia and can be 2005;46(4):669–80.
provided from the corresponding author upon request. 13. Browne T, Merighi JR. Barriers to adult hemodialysis patients' self-
management of oral medications. Am J Kidney Dis. 2010;56(3):547–57.
Funding 14. Lindberg M, Lindberg P. Overcoming obstacles for adherence to phosphate
None. binding medication in dialysis patients: a qualitative study. Pharm World Sci.
2008;30(5):571–6.
Authors’ contributions 15. Krespi R, Bone M, Ahmad R, Worthington B, Salmon P. Haemodialysis
SG, RLC, and STRZ conceived and designed the study; SG recruited patients patients' beliefs about renal failure and its treatment. Patient Educ Couns.
and conducted interviews; SG, RLC, MDJ, and STRZ analysed the data; SG 2004;53(2):189–96.
wrote the manuscript. All authors read and approved the final manuscript. 16. Griva K, Ng HJ, Loei J, Mooppil N, McBain H, Newman SP. Managing treatment
for end-stage renal disease–a qualitative study exploring cultural perspectives
Competing interests on facilitators and barriers to treatment adherence. Psychol Health.
The authors do not have any competing interests. 2013;28(1):13–29.
17. Rebafka A. Medication adherence after renal transplantation- a review of the
Consent for publication literature. J Ren Care. 2016;42(4):239–56.
Not applicable. 18. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups. Int J
Ethics approval and consent to participate Qual Health Care. 2007;19(6):349–57.
The Tasmanian Health and Medical Human Research Ethics Committee granted 19. Ghimire S, Peterson GM, Castelino RL, Jose MD, Zaidi ST. Medication regimen
ethics approval for this study (approval no. H0014506). Written informed consent complexity and adherence in Haemodialysis patients: an exploratory study. Am
was obtained from all the participants. J Nephrol. 2016;43(5):318–24.
20. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a
self-reported measure of medication adherence. Med Care. 1986;24(1):67–74.
Publisher’s Note 21. Neri L, Martini A, Andreucci VE, Gallieni M, Rey LA, Brancaccio D. Regimen
Springer Nature remains neutral with regard to jurisdictional claims in published complexity and prescription adherence in dialysis patients. Am J Nephrol.
maps and institutional affiliations. 2011;34(1):71–6.
22. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
Author details 2006;3(2):77–101.
1
Unit for Medication Outcomes Research and Education (UMORE), Pharmacy, 23. Sabaté E. Adherence to long-term therapies- evidence for action. Geneva:
School of Medicine, Faculty of Health, University of Tasmania, Hobart 7001, World Health Organisation; 2003.
Australia. 2Sydney Nursing School, University of Sydney, Sydney, Australia. 24. de Bruin M, Viechtbauer W, Schaalma HP, Kok G, Abraham C, Hospers HJ.
3
Blacktown Hospital, Western Sydney Local Health District, Sydney, Australia. Standard care impact on effects of highly active antiretroviral therapy
4
School of Medicine, Faculty of Health, University of Tasmania, Hobart, adherence interventions: a meta-analysis of randomized controlled trials.
Australia. 5Department of Nephrology, Royal Hobart Hospital, Hobart, Arch Intern Med. 2010;170(3):240–50.
Australia. 25. Williams AF, Manias E, Walker R. Adherence to multiple, prescribed
medications in diabetic kidney disease: a qualitative study of consumers'
Received: 3 November 2016 Accepted: 12 May 2017 and health professionals' perspectives. Int J Nurs Stud. 2008;45(12):1742–56.
26. Johnson MJ. The medication adherence model: a guide for assessing medication
taking. Res Theory Nurs Pract. 2002;16(3):179–92.
References 27. Rosenstock IM. The health belief model and preventive health behavior.
1. Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, Zhao MH, Lv J, Health Educ Behav. 1974;2(4):354–86.
Garg AX, Knight J, et al. Worldwide access to treatment for end-stage 28. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process.
kidney disease: a systematic review. Lancet. 2015;385(9981):1975–82. 1991;50(2):179–211.
2. Avorn J. The $2.6 billion pill–methodologic and policy considerations. N 29. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire:
Engl J Med. 2015;372(20):1877–9. the development and evaluation of a new method for assessing the
3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005; cognitive representation of medication. Psychol Health. 1999;14(1):1–24.
353(5):487–97. 30. Matteson ML, Russell C. Interventions to improve hemodialysis adherence: a
4. Ghimire S, Castelino RL, Lioufas NM, Peterson GM, Zaidi ST. Nonadherence systematic review of randomized-controlled trials. Hemodial Int. 2010;14(4):
to medication therapy in Haemodialysis patients: a systematic review. PLoS 370–82.
One. 2015;10(12):e0144119. 31. Parham R, Riley S, Hutchinson A, Horne R. Patients' satisfaction with
5. Cleemput I, Kesteloot K, Vanrenterghem Y, De Geest S. The economic information about phosphate-binding medication. J Ren Care. 2009;
implications of non-adherence after renal transplantation. PharmacoEconomics. 35(Suppl 1):86–93.
2004;22(18):1217–34. 32. Wilson IB, Schoen C, Neuman P, Strollo MK, Rogers WH, Chang H, Safran DG.
6. Hirth RA, Greer SL, Albert JM, Young EW, Piette JD. Out-of-pocket spending Physician-patient communication about prescription medication nonadherence:
and medication adherence among dialysis patients in twelve countries. a 50-state study of America's seniors. J Gen Intern Med. 2007;22(1):6–12.
Health Aff. 2008;27(1):89–102. 33. Weingart SN, Gandhi TK, Seger AC, Seger DL, Borus J, Burdick E, Leape LL,
7. Mason NA. Polypharmacy and medication-related complications in the chronic Bates DW. Patient-reported medication symptoms in primary care. Arch
kidney disease patient. Curr Opin Nephrol Hypertens. 2011;20(5):492–7. Intern Med. 2005;165(2):234–40.
8. Ingersoll KS, Cohen J. The impact of medication regimen factors on 34. National Rural Health Alliance (2014) Access to medicines and pharmacy
adherence to chronic treatment: a review of literature. J Behav Med. 2008; services in rural and remote Australia Available from http://ruralhealth.org.
31(3):213–24. au. Accessed 18 Apr 2016.
9. Hsu KL, Fink JC, Ginsberg JS, Yoffe M, Zhan M, Fink W, Woods CM, Diamantidis 35. Searles A, Doran E, Faunce TA, Henry D. The affordability of prescription
CJ. Self-reported medication adherence and adverse patient safety events in medicines in Australia: are copayments and safety net thresholds too high?
CKD. Am J Kidney Dis. 2015;66(4):621–9. Aust Health Rev. 2013;37(1):32–40.
10. Rifkin DE, Laws MB, Rao M, Balakrishnan VS, Sarnak MJ, Wilson IB. 36. Jafar TH. The growing burden of chronic kidney disease in Pakistan. N Engl
Medication adherence behavior and priorities among older adults with J Med. 2006;354(10):995–7.
CKD: a semistructured interview study. Am J Kidney Dis. 2010;56(3):439–46. 37. Neeley SM, Cronley ML. When research participants don’t tell it like it is:
11. Karamanidou C, Clatworthy J, Weinman J, Horne R. A systematic review of pinpointing the effects of social desirability bias using self vs. indirect-questioning.
the prevalence and determinants of nonadherence to phosphate binding Adv Consum Res. 2004;31:432–3.
medication in patients with end-stage renal disease. BMC Nephrol. 2008;9:2.