**9. Adherence to medications**

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

self-management outcomes than a lecture-based usual care education.

patients and caregivers to participate in their own care. These may include:

b.Assess patients understanding and their educational needs

g.How to measure one's blood pressure correctly (if appropriate);

is used for when to take it, what to avoid and how it is stored)

i. Return with the remaining medicines in each clinic visit

the diary or calendar and share with healthcare workers

n.Self-referral and preferred method of communication

j. How to lift one's feet to reduce swelling

k.How to manage food and fluids;

l. How to manage with stress and

c.Identify patients' barrier to receive information

d.Need to involve a caregiver

e.How to take one's own pulse;

ing on);

a.Gargets to use and how to use them and what readings mean (BP machine etc.)

f. How to take weight accurately (at the same time each day, with the same cloth-

h.How to manage one's medications (which includes the name of drug; purpose it

m. How to keep a record of weight, blood pressure and any other information on

In summary self-efficacy and self-management of cardiovascular diseases will encourage patients to be in control of their diseases, and their treatment. This will

and self-efficacy. While secondary outcomes are measured through self-management health behavior (symptom control, physical activity, medication adherence), healthrelated quality of life, and treatment satisfaction. Meng and colleagues [53] concluded that a patient-centered self-management might be more effective regarding certain

Hinderlang [58] suggests that the material for patient education should be developed bearing in mind patients' cultural and language barriers. Patients' preferences should also be considered before embarking on patient education that may not be effective [59]. The content of patient education material should be broken down into concise, manageable sessions that do not overwhelm with vast amounts of facts and details and be free of medical jargon. The learning environment should be free of stress, environmental distractions, cultural conflicts, and value judgments all should be eliminated if possible. Timing should be based on the available time, attention span, and readiness for learning without rushing or taking too much time. The patients have to be actively involved in the process of learning and understand the value of the information and procedures being taught for improving the quality of his or her life [58]. Patients increasingly demand access to medical information, this has improved the patient-physician relationship and consequently improved patient care. The disease management education plan should also include practical skills for

**308**

Non-communicable diseases (NCDs) are chronic diseases where adherence to medication is essential to controlling these diseases. Patients with NCDs such as cardiovascular diseases, diabetes mellitus and hypertension are put on long-term therapy to manage their conditions. The health outcomes of these patients depend mainly on how they adhere to medication as well as on lifestyle modification. The World Health Organization (WHO) defined adherence as the extent to which the behavior of a person, such as taking medication, following a diet or lifestyle modification, corresponds with the agreed recommendations from a health care provider [60].

Although adherence is important to patients with NCDs who are on medication, non-adherence to medications is a concern in Africa. In a study conducted among patients with NCDs in Puducherry, South India, the prevalence of low adherence to medication was 32.7% [61]. In contrast, prevalence of poor adherence to diabetes mellitus medication in rural Kerala, South India was 74% [62]. A study conducted in a health facility in a peri-urban district in the Ashanti region of Ghana found that the overall prevalence of medication noncompliance among patients with chronic diseases was 55.5% [63]. Inadequate medication possession ratios and thereby treatment adherence was observed in hypertensive patients at two private outpatient health clinics in Sierra Leone, with more than 80% of patients assessed not having medication for more than 40% of the time period studied [64]. In a specialist clinic and general outpatient clinic in Nigeria, the overall self-reported high medication adherence was low among Nigerian hypertensive subjects [65]. Adherence level of hypertensive patients at Jimma University specialized hospital, Ethiopia, to antihypertensive medications was found to be sub-optimal due to daily alcohol intake, comorbidity, number of antihypertensive medications and availability of medications without fee [66]. A study conducted in Kampala (Uganda) among hypertensive stroke patients found that 17% of the patients were adherent to antihypertensive medications, and the main cause of non-adherence was lack of knowledge [67].

Non-adherence is when patients do not take their medications at all, are taking reduced amounts, or are taking doses at the prescribed frequencies but not taking into consideration medication to food requirements [68]. Non-adherence can either be intentional or unintentional. Intentional non-adherence is when a patient makes a rational decision not to use treatment or follow treatment recommendations [69–72]. Intentional adherence includes patient-related, therapy-related, and conditionrelated factors [69–72]. Unintentional non-adherence is unplanned patient behavior and is less strongly associated with beliefs and the level of cognition as compared to intentional non-adherence [69–72]. Unintentional non-adherence may be caused by forgetfulness and not knowing when and how to take medicines [69–72]. Factors affecting adherence of patients to their medicines such as therapy-related and condition-related factors are associated with unintentional non-adherence [69–72].

Barriers of adherence to medication are discussed in the subsequent subsection and mainly include categories of factors affecting patients' adherence to their medicines.
