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PDF version. Roshi: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. Background : Evidence about the magnitude and determinants of medication intake adherence among patients and the general population in Southeastern Europe is scant. Aims : To assess the prevalence and sociodemographic correlates of medication intake adherence among adult primary health-care PHC users in Albania. A structured interviewer-administered questionnaire inquired about medication intake adherence prescribed by family physicians, and sociodemographic characteristics. Binary logistic regression was used to assess the sociodemographic correlates of medication intake adherence. Results : Three hundred In multivariable-adjusted logistic model, significant correlates of nonintake of medication included rural residence, low educational level, unemployment and low economic level. Conclusion : We found a high prevalence of nonintake of medication prescribed by family physicians. Decision-makers and policy-makers in Albania and elsewhere should consider the provision of essential drugs free of charge or at low cost to low socioeconomic groups and other vulnerable and marginalized population categories, because the costs of noncompliance will eventually be higher. Keywords : Albania, cost-related nonadherence, medication adherence, primary health care, sociodemographic factors. Prevalence and sociodemographic correlates of medication intake adherence among primary health-care users in Albania. East Mediterr Health J. Open Access. Some rights reserved. Health and pharmaceutical policies aim to achieve full coverage of all expenditure, including services and medications 1,2. Hence, effective reimbursement schemes are established globally to minimize out-of-pocket OOP expenditure, mainly for prescription-only drugs 3,4. Inability to achieve full coverage of expenses leads to copayments 5,6. Copayments for pharmaceuticals and other healthcare services, which are usually used by health insurers to reduce costs 4,7 , may nevertheless incur a heavy financial burden on the population 4,8. This may be especially true in low socioeconomic groups and vulnerable populations that usually suffer the most 8,9. There are many reasons for medication nonadherence. Older adults may forgo medication because of cost-related concerns, including lack of adequate prescription coverage by insurance programmes and OOP costs 12, Older age, female sex and unemployment may increase nonadherence, even after adjusting for possible confounding variables Healthcare providers consider that educated patients are more likely to be adherent than their less-educated counterparts Arguably, if a patient is highly educated, they should be able to receive the information and stick to it Cost-related nonadherence CRNA may be defined as having no access to necessary medication because of limited personal financial resources 16, Albania is a transitional country in the Western Balkans, characterized in the past few decades by rapid political and socioeconomic changes that have been associated with deleterious health effects 18, There has been a considerable change in the epidemiological profile of Albania, with a marked increase in noncommunicable diseases 20, The main risk factors responsible for the overall burden of disease include arterial hypertension, dietary factors and smoking 20, In Albania, medical reimbursement is based on the type of patients and medication prescribed 22, Not all patients are entitled to full reimbursement for medication because of their category, or because some specific drugs may not be part of the government-approved reimbursement list Regardless of the situation involving medication intake prescribed vs over the counter , there are many cases where Albanian patients must make copayments 8, Many patients are sensitive to even modest increases in OOP expenses 2 , whereas others do not reduce their medication because of cost concerns, even when they have a limited ability to pay This situation often raises the question of whether to take the medication prescribed, mainly because of financial reasons 9,26, There is scant evidence about the scale and determinants of medication adherence among Albanian patients at different levels of care, as well as in the general population. The issue of nonadherence to prescribed medication may be of particular concern to several vulnerable and marginalized population subgroups, especially those of low socioeconomic status Such information is necessary to evaluate the implementation of ongoing reforms aimed at ensuring universal health coverage of the Albanian population The aim of our study was to assess the prevalence and sociodemographic correlates of medication intake adherence among adult primary healthcare PHC users in postcommunist Albania. We hypothesized a significantly higher prevalence of medication intake adherence among PHC users with higher socioeconomic status employed, highly educated and wealthier individuals , and lower adherence among older patients and those with lower socioeconomic status. During data collection between December and January , there were eligible individuals, and 96 were not included in the study: 39 were too sick to be interviewed, and 57 refused to participate. Hence, the study included individuals: men and women; overall mean age: The overall response rate was A structured interviewer-administered questionnaire was given to all individuals who agreed to participate. There were 15 interviewers involved in the field work in the 5 regions. All study participants were asked about adherence to medication prescribed by their family physicians. Demographic data included age trichotomized into: Before conducting the survey, the whole questionnaire was initially pretested in November in 2 PHC centres in urban and rural areas of Tirana region. All survey questions were clearly understood by participants in different sociodemographic categories. All participants included in this analysis gave their consent after being informed about the aims and procedures of the study. Binary logistic regression was used to assess the demographic and socioeconomic correlates predictor variables of medication adherence outcome variable among survey participants. Subsequently, multivariable-adjusted logistic regression models were constructed, controlling simultaneously for all the sociodemographic factors age, sex, marital status, residence, education, employment and economic status. The multivariable logistic regression model met the goodness-of-fit criterion as appraised by the Hosmer—Lemeshow test All statistical analyses were performed using SPSS version Of these, Table 1 presents the sociodemographic characteristics of PHC according to medication adherence. There was no significant difference in prevalence of medication adherence between men and women, or married versus unmarried individuals. In crude unadjusted logistic regression models Table 2 , there was evidence of a positive and significant association of medication nonadherence with middle age 40— In multivariable-adjusted logistic regression models, significant correlates of medication nonadherence were: nonmarried status, rural residence, low education level, unemployment, and especially, low economic status. Among participants who reported nonintake of medication prescribed by their respective family physicians Conversely, there were 7 2. One out of 5 PHC users in not receiving their prescribed medication is a cause for concern. Significant independent correlates of nonintake of medication included rural residence, low educational level, unemployment and, in particular, low economic status. Importantly, these findings persisted upon adjustment for a wide range of demographic characteristics and socioeconomic factors. Evidently, poor and unemployed people can afford less to buy the prescribed drugs. Several socioeconomic factors included in logistic regression models were interconnected e. Nonetheless, each of the 3 main socioeconomic factors education, employment and economic status turned out to be independent correlates of medication adherence in multivariable-adjusted models. Therefore, regardless of potential collinearity a condition in which independent variables are highly correlated , each of these 3 key socioeconomic factors was a strong and significant independent predictor of medication adherence in this study population. Similar to our findings, a previous study has reported no effect of sex, age, place of residence, body mass index, income, smoking, alcohol consumption, comorbidity and disease activity on medication adherence On multivariate analysis, the predictors of adherence were the combined category of education, occupation and socioeconomic status, and disease duration Another study showed that sex and socioeconomic status do not appear to influence nonadherence Several studies have shown reduced adherence in ethnic minorities. Factors that may predict nonadherence include forgetfulness, illiteracy, inability to understand the purpose of treatment, not perceiving the treatment as necessary, lack of trust in the treatment, a lack of knowledge about the effects of treatment Most countries ranged between 1. Of note, the outcome in the study by Morgan and Lee year prevalence was not exactly the same, but is nevertheless comparable with our operational definition of medication adherence, as they defined it as having reported CRNA at least once during the last 12 months In our study, the outcome variable medication adherence referred to recently prescribed medication, thus, our estimate may be even higher if we include nonadherence during the past year. Possible reasons for the higher prevalence of CRNA in Albania compared to other countries may include lack of coverage or partial coverage of drug costs by the health insurance scheme Also, another driving factor may consist of the fact that medicines are relatively more expensive in Albania compared to developed countries. Indeed, assessment of prices of some defined drug categories including antidiabetic and antihypertensive medication in relation to the general cost of living indicates an unfavourable position of Albania compared to Western countries 26, The opposite is evident in countries such as the Netherlands where socioeconomic status is not a predictor of nonadherence, nonpersistence or reinitiation This can be explained by the health insurance coverage of prescribed antihypertensive drugs, a study says The same was shown in the study conducted on medication adherence, nonpersistence and reinitiation of antihypertensive drugs among patients on oral antidiabetic drugs in the Netherlands where, lower noadherence and nonpersistence rates can be expected, since patients are obliged to have health insurance, which covers most of the costs for prescribed antihypertensive drugs A previous literature review has reported that the reduction of drug expenses through better insurance coverage can improve drug adherence Although we did not assess this outcome, it is worth mentioning a study that showed that many patients reported the inability to understand the prescription or inadequate information about their treatment as a hindrance to medication adherence Our finding regarding a higher CRNA rate among people with a weaker financial background is not surprising. A study reported that CRN levels were higher among younger individuals, women, poor people and those with serious mental illness Conversely, a survey conducted in Israel in reported that adherent patients were comparable to nonadherent patients in their demographic and socioeconomic characteristics There were several limitations to the current study including the possibility of selection and information bias as wells as the study design. This study included a probabilistic nationwide sample of PHC users in several regions of Albania, which points to an almost representative sample of the adult population attending PHC services. Nonetheless, nonusers may be different from users of PHC services regarding selected sociodemographic characteristics. Therefore, our findings cannot be generalized to the overall population, but should be confined to adult PHC users in Albania. Data collection consisted of a straightforward interviewer-administered questionnaire. All the interviewers were properly trained during a 2-day intensive course, and the questionnaire was initially pretested. There was no evidence of any information bias, given the initial pretesting of the instrument and also the proper training of all the interviewers regarding data collection and recording. Many factors are associated with nonadherence and they were not included in this study. Also, we did not include individuals who were seriously ill. The specific types of medication prescribed by the family physicians were not assessed in this study. A limitation of this study relates to the impossibility of defining the threshold for taking or not taking the prescribed medication i. It would be interesting knowing if the patients refused to take relevant or essential medicines; information which was not retrieved in the current study. Finally, associations pertinent to cross-sectional studies are not assumed to be causal and, therefore, should be interpreted with caution. Our study provides valuable and novel evidence about the extent and sociodemographic determinants of medication adherence among adult PHC users in a transitional South Eastern European population. Our findings should be replicated and confirmed in future studies and in different settings. Apparently, the magnitude of nonintake of medication is primarily linked to financial constraints, affecting especially the low socioeconomic groups and other vulnerable and marginalized population categories. Decision-makers and policy-makers in Albania and elsewhere should consider the provision of essential medication free-of-charge or at very low cost to poor and lowly educated people, because the costs of noncompliance will be eventually higher. From market access to patient access. Overview of evidence-based approaches for the reimbursement and pricing of pharmaceuticals in 36 European countries. Health Res Policy Syst. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. Cochrane Database Syst Rev. Vogler S. The impact of pharmaceutical pricing and reimbursement policies on generics uptake: implementation of policy options on generics in 29 European countries — an overview. GaBI Journal. Lessons Learned from European Countries. Appl Health Econ Health Policy. Pharmaceutical policies: effects of cap and co-payment on rational use of medicines. May 8; 5 :CD Pharmaceutical policies in European countries in response to the global financial crisis. South Med Rev. Pharmaceutical policies: Effects of reference pricing, other pricing, and purchasing policies. Srivastava D, McGuire A. Analysis of prices paid by low-income countries - How price sensitive is government demand for medicines? BMC Public Health. Primary health care in Albania: rapid assessment. Osteberg L, Blaschke T. Adherence to medication. N Engl J Med. Medication compliance and persistence: terminology and definitions. Value Health. Attitudes, beliefs, and cost-related medication nonadherence among adults aged 65 or older with chronic diseases. Prev Chronic Dis. Morgan SG, Lee A. Cost-related non-adherence to prescribed medicines among older adults: A cross-sectional analysis of a survey in 11 developed countries. BMJ Open. Prevalence of medication adherence and its associated factors among patients with noncommunicable disease in rural Puducherry, South India — a facility-based cross-sectional study. J Family Med Prim Care. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence. S PMID Doucet J. Cost-related nonadherence to medications and pharmacare. Canadian Oncol Nursing. Burazeri G, Kark JD. Negative attitudes to transition in post-communist Albania and acute coronary syndrome. Health Psychol. Financial loss in pyramid savings schemes, downward social mobility and acute coronary syndrome in transitional Albania. J Epidemiol Community Health. National health report: health status of the Albanian population. Albanian National Health Strategy — Republic of Albania. Law No. Beneficiary categories from the compulsory health insurance scheme in Albania. Decree No. For a change in the Decree No. Out-of-pocket payments and utilization of health care services in Albania: evidence from three districts. Health Policy. Tomini S, Packard TG. Catastrophic and impoverishing effects of out-of-pocket payments for health care in Albania: evidence from Albania Living Standards Measurement Surveys , and Health Policy Plan. Paying Out-of-pocket and informally for health care in Albania: the impoverishing effect on households. Front Public Health. Computer programs for epidemiologists: PEPI version Salt Lake City: Sagebrush Press; Higher education, professional occupation, and upper socioeconomic status are associated with lower adherence to medications in patients with inflammatory bowel disease. JGH Open. Pharmacy-based predictors of nonadherence, non-persistence and reinitiation of antihypertensive drugs among patients on oral diabetes drugs in the Netherlands. PLoS One. A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers. The differential rates in cost-related non-adherence to medical care by gender in the US adult population. J Med Econ. Determinants of cost-related nonadherence to medications among chronically ill patients in maccabi healthcare services, Israel. Value Heal Reg Issues. Subscribe via RSS. Volume 30, number 8 August WHO Bulletin. Pan American Journal of Public Health. Main Search Contact. YouTube Rss feeds Twitter Facebook. Eastern Mediterranean Health Journal All issues Volume 27 Volume 27 issue 5 Prevalence and sociodemographic correlates of medication intake adherence among primary health-care users in Albania. Abstract Background : Evidence about the magnitude and determinants of medication intake adherence among patients and the general population in Southeastern Europe is scant. Data collection A structured interviewer-administered questionnaire was given to all individuals who agreed to participate. Results The overall response rate was Conclusion Our study provides valuable and novel evidence about the extent and sociodemographic determinants of medication adherence among adult PHC users in a transitional South Eastern European population. Competing interests : None declared. References 1. S PMID PMID Hosmer D, Lemeshow S. Applied logistic regression. Current issue Volume 30, number 8 August

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