EVALUATION OF MEDICATION COMPLIANCE IN PATIENTS WITH CONGESTIVE HEART FAILURE IN YEMEN

Objective: Non-compliance with heart failure medication is related to the highest mortality, morbidity, and health-care costs. The objective of this study was to evaluate medication compliance with patients with congestive heart failure. Methods: Inpatients of the cardiac care unit and medical ward of Republican Hospital, German Hospital, Revolutionary Hospital, and Chinese– Yemeni Friendship Hospital were recruited for this study. The study was conducted on patients that were diagnosed as having congestive heart failure and were receiving treatment. Questionnaires were distributed and personal interviews to evaluate the patients’ compliance was conducted to determine the reasons for their non-compliance in taking drugs. Results: Of 86 patients, 44% (n = 38) reported compliance and 56% (n = 48) reported non-compliance. The distribution of the patients in terms of sex was as follows: among men, 41% (n = 24) were compliant and 59% (n = 35) were non-compliant; among women, 52% (n = 14) were compliant and 48% (n = 13) were non-compliant. In addition, smoking status was too significantly linked with non-compliance (P = 0.001). Furthermore, the status of chewing of khat tree leaves was also significantly associated with non-compliance (P = 0.007). Conclusion: This study indicates that the reasons for non-compliance with medications among patients can be attributed to lack of education, chewing of khat tree leaves, lack of health insurance, and cigarette smoking. Therefore, healthcare professionals should create strategies to address these reasons in order to increase medication compliance with patients in heart failure.


INTRODUCTION
Heart failure (HF) is a clinical syndrome observed by breathing trouble, ankle enlargement, and weakness that can be accompanied by elevated jugular venous pressure, pulmonary crackles, and peripheral edema [1].
More than 5.7 million general public in the United States and at least 23 million persons worldwide live with HF, which is related to considerable illness, death, and healthcare costs [2].
By 2030, the prevalence of HF in the United States is estimated to rise by 46% to about 8.5 million persons [3]. Numerous countries in the Middle East have experiential rises in the prevalence of the risk factors of the increase in HF [4]. Permitting to the HF guidelines on the European Society of Cardiology and the American Heart Association/American College of Cardiology, multiple medications (e. g., angiotensin-converting enzyme inhibitors [ACEIs], diuretics, beta-blockers, spironolactone, digoxin) are useful for patients with HF and should, therefore, was prescribed. Non-pharmacological routine changes, such as fluid and sodium restriction, regular weighing, movement adjustment, vaccination against influenza, stop smoking, and limiting alcohol intake, have been recommended. Compliance has long been documented as a significant matter in health care [5]. A significant first step to successful medication compliance is defining the factors that influence compliance. Accordingly, the aims at this study were to evaluate the medication compliance with patients with congestive heart failure.

MATERIALS AND METHODS
A prospective observational study with the purposive random sample was conducted at the cardiac inpatient department of four government hospitals Revolutionary Hospital, German Hospital, Republican Hospital, and Chinese-Yemeni Friendship Hospital in Sana'a, Yemen. Patients were registered prospectively for a period of 5 mo (from March 2016 to July 2016). A validated standard questionnaire assessing medication adherence was used to survey the patients, after its translation to the Arabic language. A total of 86 patients with congestive heart failure (CHF) underwent personal interviews, and related data were collected after a medical chart review. The diagnosis of HF was documented based on patient history, physical investigation, and echocardiography. The patients were aged>20 y, were confirmed to have a diagnosis of HF, and were receiving HF medications. Appropriate ethical approval was obtained from the involved hospitals. The data collection form was used to assemble the patients' associated with data (age, sex, education status, the status of chewing khat tree leaves, cigarette smoking, medical insurance status, and prescribed drugs).
Their current medication was obtained through the questionnaire. This questionnaire was offered in Arabic. Data were entered and examined by means of Microsoft Excel 2007 for Windows. Continuous data were statistically examined using Student's t-test, and categorical data were analyzed using the chi-square test. Descriptive analysis was used to summarize the data. The level of significance was assigned to P<0.05.

RESULTS
A total of 86 patients were recorded in the present study. 69% (n = 59) of the subjects were men, and 31% (n = 27) were women. The mean patient age was 56.9 (±16) years.
The patients' demographic characteristics are presented in table 1. In this study, 53(n = 46) patients were non-educated and 47% (n = 40) were educated. In addition, 45% (n = 39) patients were nonsmokers and 55% (n = 47) patients were smokers. On the other hand, 44% (n = 38) patients did not chew khat tree leaves and 56% (n = 48) patients were chewers of khat tree leaves. Among the patients, 83% (n = 71) did not have medical insurance and 17% (n = 15) had medical insurance. The results of this study showed that the patients' age had an influence on their compliance behavior (P<0.0001), as shown in table 2.
In the present study, educational status was significantly linked with non-compliance. In group 1, the percentage of non-educated patients was 33% (n = 15) and the percentage of educated patients was 57% (n = 23). On the other hand, in group 2, the percentage of non-educated patients was 67% (n = 31) and the percentage of educated patients was 43% (n = 17). In addition, smokers were more than non-smokers likely to belong to the compliance group, consequently, smoking status was too significantly linked with non-compliance (P = 0.001). Furthermore, the status of chewing of khat tree leaves was also significantly associated with noncompliance (P = 0.007) (table 3).
In general, using the Morisky Medication Adherence Scale [6] and the questionnaires used during the personal interviews for the patients in this study, it was determined that the percentage of patients with medication compliance was 44% (n = 38) and that of non-compliant patients was 56% (n = 48) (table 5).

DISCUSSION
In patients with HF, medication non-compliance adversely affects their qualities of life, increases mortality and morbidity, which is one of the major causes of recurrent hospitalizations [7]. Some studies indicated that up to 60% of all medications prescribed were taken incorrectly, or not at all [8,9]. The present study showed that the non-compliance rates were 56%. The study by Ni et al. found a noncompliance rate of 23% [10]. On the other hand, Evangelista et al. reported a non-compliance rate of only 4% [11]. In contrast, data on the Asian population reported by Sayed et al. [12] showed a noncompliance rate of 72.7%, which is high when compared with that was found in our study. There are different methods of assessing compliance with medications, and various studies have used different compliance assessment methods that involve different procedures in different patient populations, which make comparisons between them inaccurate. This could be a partial reason for the variation in compliance rates. In this study, education status was significantly linked with non-compliance. In group 1 in this study, the percentage of non-educated patients was 33% (n = 15) and the percentage of educated patients was 57% (n = 23). On the other hand, in group 2, the percentage of non-educated patients was 67% (n = 31) and the percentage of educated patients was 43% (n = 17  [14]. Our results confirmed those of the above-mentioned studies, showing that lack of education was the main reason for non-compliance. Additionally, the present study showed a strong significant relationship to cigarette smoking with non-compliance. The results confirm the findings of two previous studies suggesting that current smokers were more likely to be noncompliant than current non-smokers [15,16]. Several studies have reported that increases to HF rate and blood pressure were associated with chewing of khat tree leaves [17,18]. This study showed that 56% (n = 48) patients were chewers of khat tree leaves, and most of them were non-compliant in taking medications. The present study found that patients that did not have health insurance comprise 83% of the total population, indicating that most of the population did not have health insurance coverage. Furthermore, this study showed that the compliance rates were higher in patients with health insurance coverage than in those without. This indicated that a health insurance scheme can improve medication compliance with patients. The study by Chi-Kwon et al. showed that patients who had no insurance coverage or who had a low salary were more likely to be non-compliant with medication [19]. The results of the present study confirmed the findings of Chi-Kwon et al. However, it is difficult to compare various studies because of differences in the study population, measurement instruments, and in interventions that were used to improve compliance. Evaluating these differences might explain the different outcomes. In this study, diuretics were the most prescribed medication (about 89.3%), followed by ACEIs, digoxin, aspirin, anticoagulants, nitrates, and beta-blockers(76.5%, 63.5%, 61.6%, 57%, 30.3%, and 28%, respectively).
A similar study by Sayed et al. showed treatment rates of 60.2% for diuretics, 56.1% for ACEIs, and 38.2% for digoxin, which were lower than the ratios reported in this study [20]; however, their rates for beta-blockers (45.3%) and aspirin (78.6%) were higher than those of our study. According to European, American, and Canadian studies, 28-75% of patients with HF are prescribed with ACEIs and only 11.8-41% are prescribed with beta-blockers [21,22]. These were confirmed in our study, in which the prescription rate of betablockers was 28% and that for ACEIs was 76.5%. Current guidelines recommend the routine use of ACEIs or ARBs, and beta-blockers in patients with HF, owing to their proven effectiveness in improving morbidity, mortality, and hospitalization rates [23]. In the present study, the compliance rate of ACEIs was 82%, which is low when compared to another study that showed a compliance rate of 92.9% to ACEIs [24]. Another study by Parameswaran et al. reveals that the rates of continued therapy with beta-blockers at 6, 12, and 24 mo were 69%, 70%, and 74%, respectively [25]. The outcomes of the present study found a compliance rate of 32% for beta-blockers, which is low compared to that in the previous study. The present study showed that the compliance rates for digoxin among patients with HF were 58%, which is higher than the 10% rate reported by Monaneet al. [26].

CONCLUSION
This study indicates that the reasons for non-compliance with medications among patients can be attributed to lack of education, chewing of khat tree leaves, lack of health insurance, and cigarette smoking. Therefore, healthcare professionals should create strategies to address these reasons, and learn to recognize the risk and of lack of education, cigarette smoking, and chewing of khat leaves to increase medication compliance with patients in CHF.
Increasing the patients' knowledge about their disease is extremely useful and advisable, and might ultimately lead to a reduction in the incidence and prevalence of HF, which, in turn, would contribute to the overall improvement in the population's health status.

RECOMMENDATIONS
Following is a list of recommendations specified to a medical doctor in a work to improve compliance: Create it clear to patients that they themselves take in the drug as being significant. The clinical pharmacist can make available best medication therapy to increase a patient's quality of natural life by treatment of disease. The community-founded pharmacist is one that has a direct contribution to a patient's treatment strategy, has direct and repeated communication with the medical doctor. The communityfounded pharmacist can develop compliance and shares this evidence of the medical doctor to develop patient's carefulness and medication compliance (Dunbar-Jacobet al., 2001) [28].

ACKNOWLEDGMENT
Ali Ahmed Al-Zaazaai, express his immense gratitude to his supervisor, Prof. Dr. Xiao Jian. He will never forget everyone that helped him and offered their lovely companionship and care. Once again, I am extremely indebted to my supervisors who relentlessly comprehensive their advice and guidance during the course of this study and afterward.

FUNDING
This study established no definite grant from any funding organization of the community, commercial, or not-for-profit subdivisions.

LIST OF ABBREVIATIONS
ACEI, an angiotensin-converting enzyme inhibitor, ARB, angiotensin receptor blocker, CCB, calcium channel blocker, CHF, congestive heart failure, HF, heart failure AUTHORS CONTRIBUTIONS