INTRODUCTION:

The medication regimen of chronic illnesses like hypertension, diabetes, coronary artery disease, thyroid disorders, kidney diseases etc. demands long term drugs administration and following up. An estimated 33 to 50% of patients do not adhere to their medication regimens as they are prescribed.^[1]

It is commonly accepted that the treatment failure brought by poor medication adherence can lead to incessant re-hospitalizations, poor treatment outcome and extended health care costs. The term “non-adherence” is preferred to “non-compliance” because non-compliance infers a component of deficiency or fault with respect to the patient. The same principle applies to dietary regimens, lifestyle modifications and screening tests. Medication non- adherence has profound implications on the patient as well as on doctor-patient relationships and interactions, care plans, and the healthcare system. The most common reasons for not taking their medications that are given by the patients are forgetfulness (30%), other priorities (I6%), deciding to omit a dose (11%), lack of information (9%), and emotional reasons (7%); 27% of patients give no reason.^[2]The WHO report reminds that adherence is the result of a complex interaction between social conditions, patients and healthcare professionals. It has been portrayed that low adherence to long-term treatment often happens when the followed treatment regimen is complex or when the disease is asymptomatic (such as hypertension).

Utilization of endorsed medications is one of the key components in the management of health conditions. Three similarly significant components must be available and work synchronously so as to effectively treat an ailment with drugs. Firstly, the condition has to be diagnosed and analysed appropriately, secondly, medications that can be available and finally treatments must be as per the guidelines of the prescriber. Short mistakes in any of these elements will impinge on the realization of intended health outcome respective of the sufficiency of the other two.

Strong evidence shows that many patients with chronic illness have difficulty adhering to their medication routine that has been recommended. It is pivotal for health care professionals both to evaluate the patient and predict the potential causes of nonadherence and pursue a strategy for expanding prescription adherence and accomplishing the best health care outcome. ^[3-6] In order to have an impact on adherence, health care providers must comprehend the obstructions to adherence and tools and techniques that can be used to surpass these hindrances. Conquering one barrier or providing a solitary intervention will not ensure medication adherence.

Studies on medication adherence provide the following interpretations

For every I00 prescription written,

· 50-70 filled by the pharmacy.

· 48-66 picked up by the pharmacy.

· 25-30 taken properly.

· I5-20 refilled as prescribed.^[7]

Adherence is a multidimensional phenomenon dictated by the interchange of five sets of factors namely ^[5]

· Social and economic dimension

· Health care system dimension

· Condition-related dimension

· Therapy-related dimension

· Patient-related dimension

Adherence rates are typically higher among patients with chronic conditions, as compared against those patients with acute conditions. Studies uncover that patients with chronic ailments take only ~50% of medications prescribed for those conditions.^[7,8]The outcome of nonadherence is waste of medication, disease progression, reduced functional abilities, and a lower quality of life and personal satisfaction, increased use of medical resources such as nursing homes, hospital visits and hospital admissions.

Medication non-adherence is a multifaceted controversy, particularly for individuals with chronic diseases.^[8-10] Various investigations reveal that medicines improve clinical outcomes and reduce illness, disability, and death. Notwithstanding such findings, numerous people do not realize the complete potential benefits of their medications; and again this circumstance is the consequence of their inability to accept a few or all prescriptions as recommended.^[11-14] This study anticipated to monitor the level of medication adherence behaviour of chronic conditioned patients and to find out the major causes of medication non-adherence. The primary objective of the study was to evaluate the medication adherence behaviour among these patients and monitor the reasons and risk factors of nonadherence. Moreover, through patient counselling, the patient will be in a good association with the pharmacist thereby expanding medication adherence.^{[15, 16]}

METHODOLOGY:

The study was carried out at the inpatient setting of a 500 bedded private tertiary care referral hospital at the south-Indian region. This was a prospective observational study that aimed at monitoring medication adherence patterns in long term therapies using Morisky Green Levine Scale (MMAS-4) and finds out various causes of non-adherence in patients of general medicine department. This observational study was carried out over a period of 6 months, commencing from December 2018 to May 2019. This study was approved by the ethical committee of the institution and an official consent was also given for the purpose of performing the study. The nature, type or intention of the study was explained to the patients by direct patient interaction. Thereafter, participants were given the opportunity to decide whether to participate or not. If they decide to participate, written consent was obtained.

A pilot observational study was conducted before the onset of the proposed study. All the patients in the general medicine department were observed during the study period and suitable selection criteria were adopted. Patients who visited the general medicine department either as an inpatient or outpatient and with a history of any chronic disease, who are on medications for more than one year, who are not known to have cognitive impairment and aged 18 years or older were included in the study. Patients who were unable to understand spoken words due to hearing loss, severe visual impairment hindering reading, inability to pass Mini-cog test, being assisted in consumption of medication by family members were excluded from the study.

All details were recorded in well-structured data collection form which was proposed to collect details like patient demographics, comorbidities, family history, type of therapy, past medication history, the reason for admission, provisional diagnosis, patient medication chart, medication-taking behaviour (MMAS-4), socioeconomic status (Kuppasamy socioeconomic scale), reasons/ dimension of nonadherence.

Reasons for nonadherence were assessed on the basis of five dimensions of WHO factors affecting adherence.^[5]

They were:

A] Social/ economic

Age and Race

Socio-economic status

Illiteracy

Cost of medications

B] Patient related

Forgetfulness

Treatment anxiety

Misunderstood of instructions

Fear of dependence

C] Therapy related

Complexity of regimen

Duration of treatment

Side effects/ADR

Changes in therapy

D] Condition related

Comorbidities (such as depression etc.)

Level of disability

Severity of symptoms

Drug/alcohol abuse or use

E] Health care system

Patient-provider relationship

Overworked health care provider

Lack of incentives

Lack of knowledge

Patient case records were reviewed to collect the details regarding patient condition, medications being used, and the reason for current hospital visit etc. The patient interview was carried out for understanding the adherence patterns, reasons for non-adherence and socioeconomic status. All details were recorded in the well-structured data collection form. The recorded results and data were analysed using SPSS Software version 20 and chi-squared tests.

RESULTS:

Respondent characteristics:

Out of 237 patients, 139 (58.6%) were male patients and 98(41.4%) were female patients. In this study, 237 patients on long term medications were selected, and the patients under the age group of 70-79(32.07%) were significantly higher when compared to other age groups followed by patients under 60-69 (27%). The minority was seen under the age group below 50 years (7.17%). 181(76.4%) patients admitted to the inpatient department and 56(23.6%) patients from the outpatient department were enrolled in the study. (Table No-1)

Table No -1 – Respondent Characteristics

Characteristic	Frequency (n)	Percentage (%)
Sex
Male	139	58.6
Female	98	41.4
Age
≤50 years	17	7.17
51-59 years	41	17.3
60-69 years	64	27
70-79 years	76	32.07
≥80 years	39	16.45
Employment status
Employed	59	24.9
Unemployed/Retired	178	75.1
Family History status
No Known Family History	70	29.5
Known family History	167	70.5
Residence
Urban	49	20.7
Rural	188	79.3
Marital status
Single	14	5.9
Married	170	71.7
Widow/Widower	50	21.1
Divorced	3	1.3
Socioeconomic status
Upper	26	11.0
Upper Middle	84	35.4
Lower Middle	88	37.1
Upper Lower	39	16.5
Lower	0	0
Number of self-reported chronic diseases
1-3 Diseases	188	79.3
≥4 Diseases	49	20.7
Type of therapy
Only allopathic medicine	184	77.6
Multiple systems of medicine	53	22.4
Number of prescription drugs currently taking
≥ 4 Medications	140	59.30
3 Medications	60	25.50
2 Medications	23	9.50
1 Medication	14	5.7

Medication adherence:

Using the standard cut-offs for the Morisky scale, out of 237 patients, 66 showed high adherence (27.8%) followed by 68 showed medium adherence (28.7%) and 103 showed low adherence (43.5%). Low adherence group tend to have statistically significantly younger age, male gender, being employed, urban residence, decreased the number of medications, comparatively less number of disease conditions and higher socioeconomic status etc. (Table No-2)

Table No-2: Characteristics of study participants and their level of adherence

Characteristic	Medication Adherence
	High		Medium		Low
	n	%	n	%	n	%
Total (n=237)	66	27.8	68	28.7	103	43.5
Sex
Male	39	28.1	37	26.6	63	45.3
Female	27	27.6	31	31.6	40	40.8
Age
≤50 years	5	29.4	5	29.4	7	41.2
50-59 years	8	19.5	8	19.5	25	61
60-69 years	21	32.8	18	28.1	25	39.1
70-79 years	23	30.3	19	25	34	44.7
≥80 years	9	23.1	18	46.2	12	30.8
Employment status
Employed	12	20.3	16	27.1	31	52.5
Unemployed/ Retired	54	30.3	52	29.2	72	40.4
Residence
Urban	14	28.6	8	16.3	27	55.1
Rural	52	27.7	60	31.9	76	40.4
Marital status
Single	3	21.4	5	35.7	6	42.9
Married	51	30	46	27.1	73	42.9
Widow/Widower	12	24	15	30	23	46
Divorced	0	0	2	66.7	1	33.3
Socioeconomic status
Upper	6	23.1	2	7.7	18	69.2
Upper Middle	8	9.5	14	16.7	62	73.8
Lower Middle	29	33.0	39	44.3	20	22.7
Upper Lower	23	59	13	33.3	3	7.7
Lower	0	0	0	0	0	0
Number of self-reported chronic diseases
1-3 Diseases	51	27	54	28.6	83	44.4
≥4 Diseases	14	29.3	14	28.7	21	42.6
Type of therapy
Only allopathic medicine	52	30.4	50	27.2	82	44.6
Multiple systems of medicine	13	24.5	17	32.1	23	43.4
Number of prescription drugs currently taking
≥ 4 Medications	42	30.3	43	30.7	55	39
3 Medications	17	28.6	19	31.4	24	40
2 Medications	6	28.1	7	29.3	10	42.6
1 Medication	3	23.8	5	33.2	6	43

Causes of medication non-adherence:

Among the major 5 reasons for nonadherence, 42.93% were of patient-related (n=149), 20% were of therapy-related (n=71), 16.13% were of social/economic related (n=56), 11% were of health care system related (n=38) and 9.51% were of condition related (n=33). Among the total patients, the most observed individual patient-related reason for nonadherence was forgetfulness 18.60% (n=44), followed by fear of dependence in 16.90% (n=40). The most commonly observed therapy-related reason for nonadherence was the duration of treatment in 21.1% (n=50). Highest frequent reason among social/economic related causes included illiteracy in 12.1% (n=29). Among the health care system associated reasons patient-provider relationship was the most frequent (8.4%, n =20). The most observed condition related reason was the severity of symptoms in 11.4% (n=27). (Table No-3)

Table No-3: Distribution based on reasons for non-adherence

Reason for non-adherence	Frequency (n)	Percentage (%)
Patient related (n=149)
Forgetfulness	44	18.6
Treatment anxiety	33	13.9
Misunderstood of Instructions	32	13.5
Fear of Dependence	40	16.9
Therapy related (n=71)
Complexity of regimen	5	2.1
Duration of treatment	50	21.1
Side effects/ADR	16	6.8
Changes in therapy	0	0
Social/ economic related (n=56)
Age and Race	23	9.7
Socio-economic status	0	0
Illiteracy	29	12.2
Cost of medications	4	1.7
Health care system-related (n=38)
Patient –provider relationship	20	8.4
Overworked health care provider	1	0.4
Lack of incentives	0	0
Lack of knowledge	17	7.2
Condition related (n=50)
Comorbidities (depression)	18	7.6
Level of disability	5	2.1
Severity of symptoms	27	11.4
Drug/alcohol abuse or use	0	0

DISCUSSION:

The study was useful in finding medication adherence behaviour of patients taking long term therapies, reasons for nonadherence, the relation between adherence and various socio-demographic variables. The study revealed that the low adherence rate is 43.5% with respect to long term treatment and 28.7% showed medium adherence followed by 27.8% showed high adherence. These results were concordant with the Feehan M et.al 2017 study in the USA.^[16] It is lower than the medication adherence reported in Egypt (74.1%), Malaysia (44.2%), Gambia (27%), Pakistan (57%) and Korea (61.1%), Scotland (91%) respectively.^[17-22] The difference is the adherence rate could be due to the changes in the cost of medical care and drugs, better care services and patient awareness about medication adherence.^[23]One of the real explanation for such variable rates of nonadherence reported in different investigations is that there is no standard, universally accepted the meaning of adherence due to which patients may report adherence indicated by their very own definitions rather than conventional medical concepts of non-adherence.^[24,25] Another reason might be an overestimation of adherence by patients which is hard to study and presently inadequately documented. Reasons for overestimation are obvious and may include trouble in recollecting the details of taking medicines, to satisfy the health care professionals, to avoid conflict or a combination of all of these.

Analysis of age-wise distribution showed the predominance of geriatric patients under the age group of 70-79 (32.07%) followed by 60-69 (27%). This result implied that the geriatric patients were more prone to multiple chronic conditions which are observed similar in several studies, as patients under this age group would be more prone to many diseases. These study results were found to be concordant with a study conducted by Hedna K et.al 2015.^[26] Age-wise adherence among patients revealed that low adherence was the most among the patients aged between 50-59 years (61%). Comparatively elder ones have better adherence rates. Moreover, in developing countries like Pakistan, it was reported that elder patients showed better compliance and consistency and it was chiefly due to better social support structure upheld by an extended family system which has brought about improved medication adherence.^[20]Age may also be related to more consistently having a continuous association with the provider, something that isn't generally observed with younger healthy individuals. This study additionally centred associating medication adherence with gender and it was found that in male patients’ non-adherence to medications was on a higher side as contrasted to their female counterparts (45.3% vs. 40.8%). This finding is in line with a Chinese study Wong MC et.al 2010 where participants showed that female patients were more positively associated with medications.^[27]This is because most men are ignorant of their ailment condition and the individuals who know are more averse to take their prescription in a manner as recommended to them. Conversely, another examination led in the US, where sex was a noteworthy indicator of adherence and men were bound to higher adherence than women. Other studies also reported that the adherence rate between men and women were almost equal (61.4% vs. 60.9).^[21,28] 55.10% of patients residing in urban areas had low adherence. This study supports this statement as an inconvenience of taking medicines outside the home may be the reason behind intentional non-adherence. This result is also uniform with another past research Nair K. V et.al 2011 which has shown that a busy lifestyle is an important barrier to medication adherence in the patient population.^[29]Forgetfulness was the most reported non-intentional non-adherence factor (18.6 %). This result was consistent with the M. U. Khan et.al 2014 and Vervloet M et.al 2011 which reported the same.^[30,31]This could some of the time demonstrate to be exceptionally risky for patients as they frequently depend on self-thought approaches and attempt to twofold the dose to make up for the missed dose. This could amplify the danger of potential adverse effects of an individual drug.

Moreover, low adherence was reported more among patients with higher levels of socioeconomic status (69.2%). This could be due to the effect of social desirability predisposition as those with lower socio-demographic level were helped more by the questioner and they were bound to report high adherence; another conceivable reason is that patients with low proficiency level might be unconscious about potential issues and symptoms of medications. Acharya J.P et.al 2014 study also documented that the nonadherence is again predictable in higher socioeconomic status.^[32]The number of diseases and drugs being consumed did not show a measurably noteworthy distinction in paces of adherence. But some literature also showed high adherence patterns with an increased number of diseases and drugs.

Our study also found that 52.5% of employed persons have low adherence. This is probably due to busy work schedules, omitting doses, lesser access to health care facilities etc. As per existing literature, compliance to prescribed medication is not much influenced by certain demographic features like the family type, family size, and marital and residential status; though Venugopal et al. 2012 do relate compliance to the occupation.^[33]

This study has certain confinements such as; self-reporting was the only technique utilized in this study which is subjective in nature and may have underestimated the status of non-adherence when compared to objective measures of non-adherence such as pill count and prescription refills. However, it has been reported that the self-report approach of estimating adherence is a basic, modest and valuable method for distinguishing non-adherence in the clinical setting. Self-viability was excluded in this examination; however, patients who were assisted in taking their medication were viewed as ineligible. In addition, strict inclusion criteria were applied and response bias was not a problem in this study. Care was taken to be non-judgmental during the meeting, yet questioner inclination can't be precluded yet it is accepted to minimally affect study legitimacy. At last, care ought to be taken about the generalizability of this examination findings since it was led on patients who had, for the most part, uncomplicated asymptomatic sicknesses and the majority of the patients' drugs had a generous reaction profile.

Although several studies regarding the adherence rates are accessible, such investigations just centre on explicit diseases or explicit populaces. This investigation has generalizability in that sense, and it fills the knowledge gap in the adherence patterns of the typical Indian chronic disease population. During the study significance of adherence and potential complications with non-adherence were disclosed to patients. This could likely improve adherence rates.

CONCLUSION:

This study demonstrated a very high level of self-reported low medication adherence in the general population, reinforcing the WHO report of non-adherence as a significant public health problem. The study encompasses that male gender, younger age, urban residence, employed status and higher socioeconomic status as predictors of medication nonadherence in chronic illness. The number of diseases and drugs being consumed did not exhibit a statistically significant correlation with rates of adherence. From our study, we can conclude that major reasons for non-adherence are mostly patient-related reasons and amongst it, forgetfulness is the major reason followed by fear of dependence, treatment anxiety and misunderstood instructions respectively. Patient education, counselling and healthcare policy initiatives directed to addressing low medication adherence should be priorities for research and interventions. One such step could be to focus healthcare resources towards how to engage patients in a meaningful, continuous, and quality patient-provider relationship, that is, medication adherence-centric.

FUNDING:

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

CONFLICTS OF INTEREST:

The authors declare that none of them has conflicts of interest regarding the publication of this paper.

REFERENCES:

1. Latif S, McNicoll L. Medication and Non-Adherence in the Older Adult. Medicine and health, Rhode Island. 2009; 92(12):418-419.

2. H. B. Bosworth. Enhancing Medication Adherence: The Public Health Dilemma. Springer Healthcare 2012; chapter 2: 7-8

3. Antonia Kalogianni. Factors affecting patient adherence to medication regimen. Health Sci. J; 5(3): 157-158

4. Archana S, Mohan Ram, MBBS, D.A. A Prospective Study on Assessment of Medication Adherence of Patients Towards Antihypertensive Medications. Research J. Pharm. and Tech 2017; 10(11): 3779-3782.

5. Farida Islahudin, Siti Zubaidah Hasan. Medication Adherence and Satisfaction among Patients in Malaysia. Research J. Pharm. and Tech. 2019; 12(3): 1051-1054.

6. Juveriya Fatima, Safa Mohammed Sadiq, Saniya Ahmed, Rana Khan, Mohammed Nayeem Uddin. Patient Medication Adherence and the Health Outcome. Asian J. Pharm. Res. 2018; 8(2):78-82.

7. Overcoming Barriers to Medication Adherence for Chronic Diseases [Internet]. 2017 [cited 2019May15]. Available from: https://www.cdc.gov/grand-rounds/pp/2017/20170221 presentation-medication-adherence-H.pdf

8. Overview Medication Adherence– Where Are We Today? [Internet]. [Cited 2019May15]. Available from: http://adultmeducation.com/downloads/Adult_Med_Overview.pdf

9. Joyline Michelle Sunita, Theresa Leonilda Mendonca. A Study to Assess the Psychological Adjustment in Children with Chronic Medical Conditions in Selected Hospitals at Mangalore. Int. J. Nur. Edu. and Research 2014; 2(4):304-308.

10. S. K. Mohanasundari. Mata Synthesis on psychosocial, Psychomotor and Neurocognitive Challenge of Chronically ill Children and their Parents and Siblings. Asian J. Nur. Edu. and Research.2017; 7(4): 555-560.

11. Aida Chacko, Larissa Martha Sams. Assessment of Adherence of COPD Patients to Respiratory drug Therapy in a Tertiary care Hospital in Mangalore. Asian J. Nur. Edu. and Research 2015; 5(1): 35-37.

12. Steffy Sam, Santhi Appavu, Sheeba Chellappan. Effect of counselling on burden and coping among caregivers of cancer patients with terminal illness. Asian J. Nur. Edu. and Research. 2019; 9(3):331-336.

13. Sajel S, Saranya P. Quality of Life in patients experiencing Diabetic Foot Ulcer: A cross sectional study in a Clinical Pharmacist’s Perspective. Research J. Pharm. and Tech. 2017; 10(1): 219-222.

14. P. Maheshwari, S. Nirenjen, R. V. Bibi Bergin, M. Pavithradevi, Sanjana Arun, P. Shanmugasundaram. Improvement of Patient Compliance through Patient Counselling in Patients with Diabetic Foot Ulcer. Research J. Pharm. and Tech 2018; 11(6): 2248-2250

15. Laila Ali Layqah, Yousif S. Alakeel, Jinan Z. Shamou. The Practice of Counseling in Pharmacy: Patients’ Perspectives. Asian J. Res. Pharm. Sci. 2018; 8(3):170-176.

16. Feehan M, Morrison MA, Tak C, et al Factors predicting self-reported medication low adherence in a large sample of adults in the US general population: a cross-sectional study BMJ Open 2017;7:e014435

17. Youssef RM, Moubarak II. Patterns and determinants of treatment compliance among hypertensive patients. E Mediterr Health J. 2002; 8(4-5):579–92.

18. Ambaw, A.D., Alemie, G.A., W/Yohannes, S.M. et al. Adherence to antihypertensive treatment and associated factors among patients on follow up at University of Gondar Hospital, Northwest Ethiopia. BMC Public Health. 2012; 12:282.

19. Van der Sande MA, Milligan PJ, Nyan OA, Rowley JT, Banya WA, Ceesay SM, et al. Blood pressure patterns and cardiovascular risk factors in rural and urban Gambian communities. J Hum Hypertens. 2000; 14(8):489–96.

20. Fogarty J, Youngs GA., Psychological reactance as a factor in patient noncompliance with medication taking: A field experiment. J Appl Soc Psychol. 2000; 30(1):2365–91.

21. Park KA, Kim JG, Kim BW, Kam S, Kim KY, Ha SW, et al. Factors that affect medication adherence in elderly patients with diabetes mellitus. Korean Diabetes J. 2010; 34(1):55–65.

22. Inkster ME, Donnan PT, MacDonald TM, Sullivan FM, Fahey T. Adherence to antihypertensive medication and association with patient and practice factors. J Hum Hypertens. 2006; 20(4):295–7.

23. Yiannakopoulou ECh, Papadopulos JS, Cokkinos DV, Mountokalakis TD. Adherence to antihypertensive treatment: A critical factor for blood pressure control. Eur J Cardiovasc Prev Rehabil. 2005; 12(3):243–9.

24. Lemay J, Waheedi M, and Al-Sharqawi S, Bayoud T. Medication adherence in chronic illness: do beliefs about medications play a role? Patient Prefer Adherence. 2018; 12:1687–98.

25. Zhang Y, Li X, Mao L, Zhang M, Li K, Zheng Y, et al. Factors affecting medication adherence in community-managed patients with hypertension based on the principal component analysis: evidence from Xinjiang, China. Patient Prefer Adherence. 2018; 12:803–12.

26. Hedna K, Hakkarainen KM, Gyllensten H, Jönsson AK, Andersson Sundell K, Petzold M, et al. Adherence to Antihypertensive Therapy and Elevated Blood Pressure: Should We Consider the Use of Multiple Medications? PLoS ONE. 2015: 10(9): e0137451.

27. Wong MC, Jiang JY, Griffiths SM. Factors associated with antihypertensive drug compliance in 83,884 Chinese patients: A cohort study. J Epidemiol Community Health. 2010; 64(10):895–901.

28. Degoulet P, Menard J, Vu HA, Golmard JL, Devries C, Chatellier G, et al. Factors predictive of attendance at clinic and blood pressure control in hypertensive patients. Br Med J (Clin Res Ed) 1983; 287(6385):88-93.

29. Nair KV, Belletti DA, Doyle JJ, Allen RR, McQueen RB, Saseen JJ, et al. Understanding barriers to medication adherence in the hypertensive population by evaluating responses to a telephone survey. Patient Prefer Adherence. 2011; 5:195–206.

30. Khan, M. U., Shah, S., & Hameed, T. Barriers to and determinants of medication adherence among hypertensive patients attended National Health Service Hospital, Sunderland. J Pharm Bioall Sci 2014; 6(2): 104–108.

31. Vervloet M, Van Dijk L, Santen-Reestman J, van Vlijmen B, Bouvy ML, de Bakker DH. Improving medication adherence in diabetes type 2 patients through Real Time Medication Monitoring: A randomized controlled trial to evaluate the effect of monitoring patients’ medication use combined with short message service (SMS) reminders. BMC Health Serv Res. 2011; 11(1):5.

32. Acharya JP, Acharya I. Sociodemographic factors influencing compliance of medication in an urban OPD setting. J Sci Soc. 2014; 41(2):101-7.

33. Venugopal R, Narasimha Murthy NS, Gopinath D. Factors influencing compliance to treatment among people with chronic illness in an urban area of South India. Int J Biol Med Res. 2012; 3(2):1495-7.

Received on 13.09.2019 Modified on 28.10.2019

Research J. Pharm. and Tech 2020; 13(5): 2420-2426.

DOI: 10.5958/0974-360X.2020.00434.5