Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers

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Abstract

Background

Levels of non-adherence to antipsychotic medication in persons with schizophrenia in rural African settings have been shown to be comparable to those found in high-income countries. Improved understanding of the underlying reasons will help to inform intervention strategies relevant to the context.

Methods

A qualitative study was conducted among persons with schizophrenia (n = 24), their caregivers (n = 19), research field workers (n = 7) and health workers (n = 1) involved in the ongoing population-based cohort study, ‘The Butajira Study on Course and Outcome of Schizophrenia and Bipolar Disorder’, based in rural Ethiopia. Six focus group discussions and 9 in-depth interviews were conducted to elicit perspectives on non-adherence to antipsychotic medication. Thematic analysis was used to identify prominent perspectives.

Results

Predominant reasons for non-adherence specific to a low-income country setting included inadequate availability of food to counter appetite stimulation and the perceived strength of antipsychotic medications. The vital role of the family or other social support in the absence of a statutory social safety net was emphasised. Expectations of cure, rather than need for continuing care, were reported to contribute to non-adherence in the longer-term.

Many of the factors associated with non-adherence in high-income countries were also considered important in Ethiopia, including lack of insight, failure to improve with treatment, medication side effects, substance abuse, stigma and dissatisfaction with the attitude of the care provider.

Conclusion

This study identifies additional barriers to medication adherence faced by persons with schizophrenia in Ethiopia compared to those in high-income countries. In this era of scaling up of mental health care, greater attention to provision of social and financial assistance will potentially improve adherence and thereby enable patients to benefit more fully from medication.

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Most cited references 38

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The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness.

Daniel Carpenter, Andy J P Docherty, Dawn I Velligan … (2009)

Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Adherence problems are complex and multidetermined. The experts recommended customized interventions focused on the underlying causes. (c) Copyright 2009 Physicians Postgraduate Press, Inc.

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Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: the P-MaMiE population-based cohort study.

Charlotte Hanlon, Girmay Medhin, Atalay Alem … (2009)

To examine the impact of antenatal psychosocial stressors, including maternal common mental disorders (CMD), upon low birth weight, stillbirth and neonatal mortality, and other perinatal outcomes in rural Ethiopia. A population-based sample of 1065 pregnant women was assessed for symptoms of antenatal CMD (Self-Reporting Questionnaire-20: SRQ-20), stressful life events during pregnancy (List of Threatening Experiences: LTE) and worry about the forthcoming delivery. In a sub-sample of 654 women from six rural sub-districts, neonatal birth weight was measured on 521 (79.7%) singleton babies within 48 h of delivery. Information about other perinatal outcomes was obtained shortly after birth from the mother's verbal report and via the Demographic Surveillance System. After adjusting for potential confounders, none of the psychosocial stressors were associated with lower mean birth weight, stillbirth or neonatal mortality. Increasing levels of antenatal CMD symptoms were associated both with prolonged labour (>24 h) (SRQ 1-5: RR 1.4; 95% CI 1.0-1.9, SRQ >or= 6: RR 1.6; 95% CI 1.0-2.6) and delaying initiation of breast-feeding more than eight hours (SRQ 1-5: RR 1.4; 95% CI 0.8 to 2.4, SRQ >or= 6: RR 2.8; 95% CI 1.3-6.1). Worry about delivery was also associated with labour longer than 24 h (RR 1.5; 95% CI 1.0-2.1). This study provides preliminary evidence of important public health consequences of poor maternal mental health in low-income countries but does not replicate the strong association with low birth weight found in South Asia.

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Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals.

R. P. Bentall, Anne Rogers, Alan P Rae … (2005)

Nonadherence to antipsychotic medication is a major cause of psychotic relapse and is strongly influenced by attitudes toward treatment. Although patient variables such as insight and symptoms that contribute toward attitudes have been identified, the contributions of relationship and service factors have not been adequately studied. To determine relations between clinical and service variables and attitudes toward medication in people with a diagnosis of schizophrenia and schizoaffective disorder. Consecutively admitted patients were approached to take part; 23 refused. Measures included symptoms, insight, drug adverse effects, self-reported adherence, attitudes toward treatment, perceived relationship with the prescriber, ward atmosphere, and admission experience. Data were analyzed by a proportional odds model and structural equation modeling to test predicted paths between experience of admission, relationship variables, attitudes toward treatment, and self-reported adherence to medication. Twenty-eight inpatient wards at 8 hospitals in North Wales and the Northwest of England. Sites included hospitals with inner-city and rural catchment areas. Patients Two hundred twenty-eight patients meeting DSM-IV criteria for schizophrenia or schizoaffective disorder, assessed during acute admission. Attitudes toward treatment and self-reported adherence to medication. The data fit a model in which attitudes toward treatment were predicted by insight, relationship with staff (especially the physician-prescriber), and the patient's admission experience (maximum likelihood chi(2)(49) = 89.3, P<.001). A poor relationship with the prescriber, experience of coercion during admission, and low insight predicted a negative attitude toward treatment. The quality of relationships with clinicians during acute admission appears to be an important determinant of patients' attitudes toward treatment and adherence to medication. Enhancing such relationships may yield important clinical benefits.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Psychiatry

Journal ID (iso-abbrev): BMC Psychiatry

Title: BMC Psychiatry

Publisher: BioMed Central

ISSN (Electronic): 1471-244X

Publication date Collection: 2013

Publication date (Electronic): 17 June 2013

Volume: 13

Page: 168

Affiliations

[1 ]Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

[2 ]Division of Psychiatry, Department of Clinical Sciences, Umeå University, Umeå, Sweden

[3 ]Centre for Global Mental Health, Institute of Psychiatry, King’s College London, London, UK

Article

Publisher ID: 1471-244X-13-168

DOI: 10.1186/1471-244X-13-168

PMC ID: 3686587

PubMed ID: 23773362

SO-VID: 5f44ca62-ec8f-43a1-85b3-87e000f71a26

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers

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Most cited references 38

The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness.

Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: the P-MaMiE population-based cohort study.

Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals.

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