Factors responsible for noncompliance

to drug therapy in the elderly and the

impact of patient education on improving
compliance

Rima B. Shah, Sagun V. Desai, Bharat

M. Gajjar & Amit M. Shah

Drugs & Therapy Perspectives

ISSN 1172-0360
Volume 29
Number 11

Drugs Ther Perspect (2013) 29:360-366

DOI 10.1007/s40267-013-0075-3

1 23
Your article is protected by copyright and
all rights are held exclusively by Springer
International Publishing Switzerland. This e-
offprint is for personal use only and shall not
be self-archived in electronic repositories. If
you wish to self-archive your article, please
use the accepted manuscript version for
posting on your own website. You may
further deposit the accepted manuscript
version in any repository, provided it is only
made publicly available 12 months after
official publication or later and provided
acknowledgement is given to the original
source of publication and a link is inserted
to the published article on Springer's
website. The link must be accompanied by
the following text: "The final publication is
available at link.springer.com”.

1 23
 Author's personal copy
Drugs Ther Perspect (2013) 29:360–366
DOI 10.1007/s40267-013-0075-3
ORIGINAL RESEARCH ARTICLE
Factors responsible for noncompliance to drug therapy
in the elderly and the impact of patient education on improving
compliance
Rima B. Shah • Sagun V. Desai • Bharat M. Gajjar • Amit M. Shah
Published online: 12 September 2013
Ó Springer International Publishing Switzerland 2013
Abstract
Background Noncompliance to drug therapy, a common
problem in geriatric patients, adversely affects disease
outcomes. In India, data addressing noncompliance in
elderly patients, the factors responsible for it and possible
solutions for the problem are very limited.
Objective To evaluate the prevalence of drug noncom-
pliance among Indian geriatric patients, explore factors
affecting it and examine the impact of educating patients
about importance of adhering to drug therapy.
Study design A total of 200 geriatric patients from vari-
ous outpatient departments were randomly recruited.
Baseline information related to diseases and drug therapy
were recorded using a structured case-record form that
included a questionnaire for evaluation of drug compliance.
Patients were randomly divided in two groups of 100
individuals; the interventional group received education
about the importance of drug compliance and related
issues, and the control group did not. Changes in compli-
ance were evaluated at a follow-up visit 7–14 days later.
Results Noncompliance to drug therapy was reported in
77.5 % of patients, and was significantly associated with
socioeconomic status, prescription-related factors (number
R. B. Shah (&)
A. M. Shah
Department of Pharmacology, GMERS Medical College,
Gandhinagar, Gujarat, India
e-mail: rima_1223@yahoo.co.in
S. V. Desai
Department of Pharmacology, SBKS Medical Institute and
Research Centre, Piparia, Vadodara, Gujarat, India
B. M. Gajjar
Department of Pharmacology, Pramukh Swami Medical College,
Karamsad, Gujarat, India
of medicines prescribed, purchasing drugs from same
pharmacy, patients’ particularity in taking medicines on
time, instructions given by doctors); and drug-related fac-
tors (frequency and duration of administration, skewed
instructions for use, physical difficulties in taking drugs,
price of drug as perceived by patient, cost of therapy, risk
of adverse drug reactions as perceived by patient). At
follow-up, compliance had significantly improved in the
group who had received education relative to the group
who did not.
Conclusion Educating geriatric patients about their dis-
ease and drug therapy, and the importance of compliance to
therapy may improve their short-term compliance
behaviour.
Introduction
On World Health Day 7 April 2012, the World Health
Organization (WHO) called for urgent action to ensure
that, at a time when the world’s population is ageing rap-
idly, people reach old age in the best possible health. In the
next few years, for the first time, there will be more people
in the world aged [60 years than children aged \5 years.
By 2050, 80 % of the world’s older people will live in low-
and middle-income countries. The WHO has given an apt
slogan for the year 2012 as ‘Good health adds life to years’
[1].
Good health is not merely absence of disease. Effective
management of diseases, especially chronic ones, can lead
to good health for many years in the elderly. Effective
management of chronic disorders requires life-style modi-
fication, multiple long-term medication use and good drug
 Author's personal copy
compliance [2]. Compliance is defined as the extent to
which a person’s behaviour, with regard to taking medi-
cation, following a diet, and/or executing life-style chan-
ges, corresponds with recommendations agreed with a
healthcare provider [3]. Poor compliance to the treatment
of chronic disease is an important problem in elderly
patients worldwide. Recently researchers have found non-
adherence rates of C50 % in patients using medicines for
chronic diseases [4]. Compliance to drug therapy is a
complex problem and is affected by variety of factors.
In the last 25–30 years, thousands of articles have been
published on this issue, leading to conflicting conclusions
depending on the focus of the article. Areas of research
regarding noncompliance include identifying possible
causes and possible solutions, analysing adherence with
respect to specific ailments, and exploring the patient’s,
pharmacist’s and physician’s role. Despite the many years
of research, the optimal approach that insures high com-
pliance levels is not yet known. It is crucial to improve
understanding of this issue by healthcare professionals, as
patient noncompliance costs &$US100 billion a year due
to the consequences and adverse outcomes of noncompli-
ance, such as hospitalization, development of complica-
tions, disease progression, premature disability or death
[5, 6].
Different methods have been used for evaluating com-
pliance to therapy (e.g. direct questioning of patient, pill
counts/ tablet counts, rate of prescription refilling, assess-
ment of patients’ clinical condition, electronic medication
monitors, patient diaries, measurement of physiological
markers, questionnaire for care givers [6]). The ability of
geriatric patients to follow treatment plans is frequently
compromised by several factors, including the character-
istics of the disease (e.g. cognitive impairment), social
system, healthcare system, economic factors and patient-
related factors [5, 6].
Although the importance of drug adherence is well-
known, data concerning drug compliance among chronic
disease sufferers in India are limited. The primary objec-
tive of this study was to identify the prevalence of drug
noncompliance among Indian geriatric patients, to explore
factors that may affect drug noncompliance and to examine
the value of educating the patients about importance of
adhering to drug therapy.
Study design
A prospective, interventional study was conducted to
examine the prevalence of drug noncompliance among
geriatric patients and its relationship with selected risk
factors, and to measure the impact of patient education on
compliance in Shree Krishna Hospital, a private 550-bed
361
tertiary-care teaching rural hospital affiliated with Pra-
mukhswami Medical College in India. The study protocol
was approved by Human Research Ethics Committee of the
institute prior to commencement of the study. A focus
group discussion carried out prior to the educational
intervention would have helped frame the educational
intervention in a manner specific to the needs of the study
population.
A total of 200 patients of any gender aged C65 years
who attended various outpatient departments [e.g. medi-
cine, surgery, obstetrics and gynaecology, orthopaedics,
skin, tuberculosis and chest, ophthalmology, ear, nose and
throat (ENT), and oncology] between August 2007 and
August 2009 were randomly recruited. Patients who were
unable to communicate, were seriously ill and required
hospitalization, or who had psychiatric illnesses were
excluded from the study. The nature and purpose of the
study was clearly explained in a language they understood
and written informed consent was obtained.
Baseline information related to personal details, disease
and drug therapy were recorded using a structured case-record
form that included a questionnaire for evaluation of drug
compliance. The format of the case-record form was validated
by obtaining the opinion of two experts and its feasibility was
tested by administering it in a small group of 20 patients.
Compliance to therapy was evaluated by a questionnaire with
the assistance of the primary researcher (a doctor who was not
involved in any decisions related to patients’ treatment).
Patients were asked to describe their medication regimen (e.g.
the number, type, and frequency of each medication, and
number of pills/puff per intake). When necessary, patients
were given samples of their drugs to assist their recognition
process. Each interview lasted &10 min.
The recruited patients were randomly divided by a
computer-generated random number table into two groups
of 100 individuals. Patients in the interventional group
received 10 min of education related to compliance (e.g.
importance of taking drugs regularly, the impact of com-
pliance on disease outcomes, and the effect of noncom-
pliance on adverse outcomes) presented by the researcher.
Any questions that patients had that were related to com-
pliance to therapy were answered. Patients in the control
group were not given any compliance education. The pri-
mary objective of this study was to assess prevalence of
drug noncompliance among elderly participants. Assuming
a noncompliance rate in the current study of as high as
50 % [4] and a = 0.05 (two-tailed), 171 patients were
needed to give an estimate at a width of ±7.5 % and with a
95 % confidence interval (CI). Assuming a follow-up rate
of 85 %, 201 patients were to be recruited. Thus, sample
size was just adequate.
The dependent variables under study were patient drug
compliance (i.e. total compliance) and noncompliance
 Author's personal copy
362

Table 1 Baseline compliance of patients (pts) to drug therapy (n = 200)

Compliance to therapy Grade of noncompliance % of pts
Total compliance 0 = never forgets 22.5
Mild noncompliance 1 = once or less in month 12.5
Moderate noncompliance 2 = once or more in last 15–30 days 14
3 = once or more in last 7–15 days 9.5
4 = once in last 7 days 18.5
Severe noncompliance 5 = more than once in last 7 days 23

(defined as any deviation from the prescribed dosage reg-
imen or not consuming the drug therapy according to the
prescription, and graded as mild, moderate and severe)
(Table 1). Patient-, prescription- and drug-related potential
variables that might lead to drug compliance/noncompli-
ance were evaluated (Table 2).
The impact of educating patients about the importance of
compliance to therapy was evaluated by comparing the
change in compliance in the group that received educational
intervention with that in the control group. Compliance in
both groups was assessed by pill count (i.e. the empty
containers and strips of the drug formulations were checked
for determining the amount of the drug consumed) at a
follow-up visit at 7–14 days. Patients were categorized as
either compliant (patients who fully adhered to taking their
medication and did not miss any dose) or noncompliant (did
not adhere to instructions regarding drug administration or
those who missed taking even a single dose).
Patient demographic information and drug usage were
recorded as actual frequencies and percentages. Statistical
analysis was performed to test for factors that were asso-
ciated with drug noncompliance using the v2 test (for
categorical variables) or independent t test (for continuous
variables). A p value of \0.05 was considered statistically
significant. Data were analysed using the Statistical Pack-
age for the Social Sciences version 14 (SPSS 14).
Results
The mean age of the participants in the study was
74.0 ± 3.1 years. Patients had one or more acute and/or
chronic conditions, including those related to cardiology
(87 % of patients), the musculoskeletal system (32.5 %),
surgery (28.5 %), the respiratory system (25 %), endocri-
nology (20.5 %), ophthalmology (17.5 %), dermatology
(11 %), infectious diseases (16.5 %), the central nervous
system (8.5 %), ENT (6.5 %), gynaecology (5 %) and
oncology (3.5 %). Patient characteristics and their associ-
ation with compliance to drug therapy are summarized in
Table 2.
At baseline in the total population of 200 patients, only
45 (22.5 %) displayed full compliance to drug therapy, with
the remaining 155 (77.5 %) patients showing some degree
of noncompliance (12.5, 42 and 23 % with mild, moderate
or severe noncompliance) (Table 1). One hundred and ten
(55 %) of patients experienced one or more difficulties in
taking medicines Reasons for experiencing difficulties in
taking drugs included visual problems (47.5 % of patients),
forgetfulness (41 %), labeling errors (26.5 %), physical
disability (18 %) and other reasons (e.g. tremors, difficulty
in communication, difficulty in using dosage form (e.g.
inhaler), inability to coordinate different functions).
Socioeconomic status of patients was the only demo-
graphic parameter that was significantly (p = 0.039)
associated with drug noncompliance (Table 2). Noncom-
pliance to drug therapy was significantly (p \ 0.02) asso-
ciated with a number of prescription-related factors,
including the number of medicines that patients are cur-
rently taking, not purchasing of the drugs from the same
pharmacy every time, lack of instructions/advice provided
about the prescribed drugs by the doctor and patients’
particularity in taking medicines on time (Table 2). Among
the drug therapy-related factors, noncompliance was sig-
nificantly (p B 0.007) associated with duration of drug
therapy, frequency of administration of drugs, price of
individual drugs as perceived by patients, drugs causing
adverse reactions as perceived by the patients, prescribing
of drugs requiring skewed instructions [i.e. complicated
instructions that are difficult to remember (e.g. 4 tablets of
chloroquine now, followed by 2 tablets after 6 h, 2 tablets
on the next day and 2 tablets on the day after that)], drugs
which are more difficult to take physically, and actual cost
of therapy per month (Table 2). At the follow-up visit,
compliance to drug therapy significantly (p = 0.0001)
improved in the interventional group relative to the control
group (Table 3).
Discussion
Medication misadventures are endangering the health of
the geriatric population, filling emergency rooms and
hospitals, and contributing to escalating healthcare costs.
Polypharmacy, wherein elderly patients must manage
compliance with regimens of several prescription drugs
 Author's personal copy
363

Table 2 Baseline demographic-, prescription- and drug-related factors and their association with compliance to drug therapy in 200 elderly
patients
Factor Category % of total patients p value
(% of total patients) Noncompliant Compliant
Patient-related factors
Age (years) 65–74 (68) 53 15 0.395
75–84 (23.5) 17 6.5
C85 (8.5) 7.5 1
Gender Male (57) 41.5 15.5 0.067
Female (43) 36 7
Literacy status Illiterate (30) 25 5 0.552
Up to 10th standard 38 12
(50)
Up to 12th standard 5 1.5
(6.5)
Graduate (10) 7.5 2.5
Postgraduate (3.5) 2 1.5
Family status Living alone (12) 10 2 0.466
Living in family (88) 67.5 20.5
Socioeconomic status (evaluated using the Kulshreshtha Lower (41) 33 8 0.039
classification [7]) Middle (49) 39 10
Higher (10) 5.5 4.5
Prescription-related factors
No. of medicines currently taking 1–5 (57.5) 40 17.5 0.005
6–10 (38) 33 5
[10 (4.5) 4.5 0
No. of doses per day 1–6 (42) 29.5 12.5 0.086
7–20 (56.5) 46.5 10
[20 (1.5) 1.5 0
No. of co-morbid diseases 1–3 (81.5) 61.5 20 0.21
[3 (18.5) 16 2.5
No. of doctors consulted C2 (90.5) 69.5 21 0.65
[2 (9.5) 8 1.5
No. of changes in instructions for medication use in previous None (40) 27.5 12.5 0.090
6 months One (58) 48.5 9.5
Two (1.5) 1 0.5
Three (0.5) 0.5 0
Knowledge about low therapeutic index drugs None (180) 59.5 20.5 0.109
Some (18) 16 2
Adequate (1.5) 1.5 0
Collection of medicines By others (97) 76 21 0.101
By self (3) 1.5 1.5
Medicines purchased from the same pharmacy No (44) 40 4 0.0001
Yes (56) 37.5 18.5
Instructions given by doctors about use of medicine No (43) 39 4 0.0001
Yes (157) 38.5 18.5
Patients particular about taking medicines on time No (19) 17.5 1.5 0.017
Yes (81) 60 21
Drug-related factors
Duration of therapy (no. of days) [15 [long-term] (61.5) 39 22.5 0.0001
\15 [short-term] 15.5 23
(38.5)
 Author's personal copy
364

Table 2 continued
Factor Category % of total patients p value
(% of total patients) Noncompliant Compliant
No. of times/day drug is administered Once (52) 29.5 22.5 0.0001
Twice (2) 2 0
Three (31) 31 0
Four (2) 2 0
Five (12.5) 12.5 0
Six (0.5) 0.5 0
Price of individual drugs as perceived by patients Compliance not 62.5 22.5 0.006
related to cost (85)
Costly (14) 14 0
Inexpensive (1) 1 0
Drug perceived by patients to cause adverse drug reaction No (89) 66.5 22.5 0.007
Yes (11) 11 0
Drug prescribed requires skewed instructions for use No (72.5) 50 22.5 0.0001
Yes (27.5) 27.5 0
Drug prescribed is physically difficult to administer No (77.5) 55 22.5 0.0001
Yes (22.5) 22.5 0
Patients developed an adverse drug reactions No (93) 71.5 21.5 0.445
Yes (7) 6 1
Cost (in Indian rupees) of drug therapy/month \100 (11.5) 5 6.5 0.0001
100–500 (55.5) 43.5 12
500–1,000 (25) 23 2
[1,000 (8) 6 2
Significant values are shown in bold

Table 3 Effect of educational intervention on drug compliance in 200 elderly patients (pts)
Group (no. of patients) Change from baseline in No. of patients lost to follow up p value (v2 test)
compliance (no. of patients)
Improved Unchanged Worsened
Educational intervention (100) 58 21 0 21 0.0001
Control (100) 8 45 9 38
Total (200) 66 66 9 59

and concurrently may be self-medicating with over-the-
counter products, should be of concern of all members of
the healthcare team who work with geriatric patients [8].
Compliance to therapy by patients is very vital for
achieving effective treatment. This study is one of the
initial steps for addressing health issues related to medi-
cation compliance in geriatric population in India.
In this study, total compliance to therapy was shown in
only 22.5 % patients, leaving a large number of patients
(77.5 %) noncompliant to drug therapy, with is consistent
with the results of other studies that indicate 50–80 % of
elderly patients are noncompliant to drug therapy [4]. Since
many factors are likely to influence medication compliance
in elderly, it is prudent to explore what could be considered
as good or acceptable compliance in clinical practice.
Although it must be acknowledged that this is still con-
troversial, good medication compliance has commonly
been defined as taking 80–120 % of the medication as
prescribed [23, 24]. We found that almost the same pro-
portions of patients demonstrated total compliance and
severe noncompliance (22.5 vs. 23 %), with the remaining
patients demonstrating mild to moderate noncompliance
(Table 1). According to previous reports, the causes of
noncompliance include problems in vision, hearing and
memory, and difficulty in following instructions due to
cognitive impairment or other physical difficulties (e.g.
problems in swallowing tablets, opening drug containers,
handling small tablets, distinguishing colours or identifying
 Author's personal copy
markings on drugs) [6]. We also found that visual problems
followed by forgetfulness, labeling errors and physical
disabilities interfered with regular intake of medicines
leading to noncompliance.
A number of patient-, prescription- and drug-related
factors that seem to play a role in noncompliance were
identified in this study. Among different demographic
parameters, drug noncompliance was found to be signifi-
cantly associated with socioeconomic status of the patient
and was more prevalent in the lower socioeconomic class
of patients. This finding correlates well with those from
other studies showing a clear association between low
income and noncompliance [9, 10]. These patients might
not have enough money to refill the prescription because of
poverty, family circumstances, education level and cultural
factors which may contribute to the problem of noncom-
pliance. In contrast to this, few researchers had reported
that income was not related to compliance level [11, 12].
There is a need to carry out further studies to clarify this
issue, especially in a developing country like India where
29.8 % people live below the poverty line [13].
We found a significant association between the number
of medicines currently taken by patients and the frequency
of administration with drug noncompliance. Complex
treatment is believed to threaten the patient’s compliance.
This is also illustrated by one study where compliance was
assessed by pill counts and self-reports that non-compliance
increased with an increase in the frequency of prescribed
dosing: 20, 30, 60 and 70 % for once, twice, three times and
four times daily, respectively [14]. Many elderly patients
have several co-morbid conditions requiring the use of a
number of drugs. Therefore, drug therapy should be indi-
vidualized as per the requirement for this special group of
patients considering the number of diseases, number of
drugs required and level of noncompliance to therapy.
This study revealed that the patients collecting their
medicines from the same pharmacy each time were more
compliant than those who did not. Individual behavioural
aspects such as this play a very important role in compli-
ance to drug therapy [6]. A good relationship between
patients and their pharmacists also affects compliance to
therapy. Educational programmes directed towards phar-
macists may help in improving compliance to drug therapy
by elderly patients.
The patient-prescriber relationship has emerged as
another strong factor which affects patients’ compliance [15,
16]. A healthy relationship is based on patients’ trust in
prescribers and empathy from the prescribers. Studies have
found that compliance is good when doctors are emotionally
supportive, give reassurance or respect, and treat patients as
an equal partner [15, 17]. We also found that patients’ per-
ception of a better relationship and dialogue with their pre-
scriber had a positive effect on patients’ compliance.
365
We found a significant association between the duration
of drug therapy and noncompliance in this study. Acute
illnesses, requiring short-term therapy, were associated
with higher compliance than chronic illnesses that required
long-term treatment. This is very similar to findings of a
study by Gascon et al. [18]. This suggests that longer
duration of the disease and treatment may adversely affect
compliance. In the present study, noncompliance was also
significantly associated with patient perceptions that the
drug caused adverse drug reactions. Many studies have
found that adverse effects of drugs threaten patient’s
compliance [19, 20]. The effect of adverse effects on
compliance may be explained in terms of physical dis-
comfort, scepticism about the efficacy of the medication
and decreasing trust in physicians.
In this study, patient perception of the price of an
individual drug and the actual total cost of therapy per
month were found to be significantly associated with
noncompliance to drug therapy. As the cost increased,
noncompliance also increased. Cost is a crucial issue in
patient’s compliance especially for patients with chronic
disease, as the treatment period could be life-long [19, 21].
Healthcare expenditure could be a large proportion of liv-
ing expenses for patients suffering from chronic disease.
Cost and income are two interrelated factors. Healthcare
cost should not be a big burden if the patient has a rela-
tively high income or health insurance. A number of
studies found that patients who had no insurance cover
[22], or who had low income [9, 10] were more likely to be
noncompliant to treatment. In elderly, the source of income
decreases. The only source could be the pension or mon-
etary support given by children or other family members.
Therefore, healthcare personnel should be aware of
patient’s economic situation and help them use medication
cost effectively.
Our study has clearly indicated that lack of education
about the importance of compliance is a major cause of
noncompliance. We found a significant improvement in-
compliance in the group of patients who received educa-
tional intervention relative to the control group. A similar
study from UK has also reflected on the importance of
educational intervention in improving medication adher-
ence in older patients [25]. The medicine regimen of the
intervention group was changed in approximately half the
patients in our study. The amount of medication education
needed by patients varied considerably and reflected the
wide variations in baseline knowledge. The educational
intervention in our study had worked well irrespective of
baseline knowledge of patients about the need of taking
medication as advised by the doctors. We suggest that the
doctors’ role, along with other things, should also include
educating his patients about the importance of adhering to
drug therapy in their own interest.
 Author's personal copy
366
Overall, this study has highlighted a very important
issue of noncompliance to drug therapy in geriatric
patients. Various factors associated with noncompliance to
therapy were also identified as patient-, prescription- and
drug-related factors. The positive impact of patient edu-
cation on the compliance behaviour of the patient was also
established. However, the small sample size and inclusion
of the patients from single hospital were major limitations
of this study. A longer duration of follow-up of patients to
ascertain the value of education for continued compliance
would have been a desirable aspect of the study.
Conclusion
Noncompliance to drug therapy is a widespread and
important issue in geriatric patients, with the problem
being related to numerous factors. Educating geriatric
patients about their disease and drug therapy, and the
importance of compliance to therapy may improve their
short-term compliance behaviour. In order to deliver good-
quality healthcare services, programmes designed to
address this aspect of drug therapy need to be developed,
especially in developing countries.
Acknowledgments The authors would like to thank Dr. Gaurav
Modi for his help in statistical analysis of the data.
Disclosure No sources of funding were used to conduct this study
or prepare the manuscript. The authors have no conflicts of interest
that are directly relevant to the content of the study.
References
1. World Health Organization. World health day 2012: good health
adds life to years. http://www.who.int/mediacentre/news/releases/
2012/whd_20120403/en/index.html. Accessed 10 Apr 2012.
2. Mar J, Rodriguez-Artalejo F. Which is more important for the
efficiency of hypertension treatment: hypertension stage, type of
drug or therapeutic compliance? J Hypertens. 2001;19(1):149–55.
3. Sabate E. Adherence to long-term therapies: evidence for action.
Geneva: World Health Organization; 2003.
4. Brown MT, Bussell JK. Medication adherence: WHO cares?
Mayo Clin Proc. 2011;86(4):304–14.
5. Benner JS, Glynn RJ, Mogun H, et al. Long-term persistence in
use of statin therapy in elderly patients. JAMA. 2002;288(4):
455–61.
6. Thrall G, Lip GYH, Lane D. Medication compliance research:
still so far to go. J Appl Res Clin Exp Ther. 2003;3(3):254–61.
7. Kulshreshtha SP. Manual for socio-economic status scale. Agra:
National Psychological Corporation; 1975.
8. Chong CK, Chan JC, Chang S, et al. A patient compliance survey
in a general medical clinic. J Clin Pharm Ther. 1997;22(5–6):
323–6.
9. Conry M. Polypharmacy: Pandora’s medicine chest? Geriatric
Times. 2000;1:1–4.
10. Hernández-Ronquillo L, Téllez-Zenteno JF, Garduño-Espinosa J,
et al. Factors associated with therapy noncompliance in type-2
diabetes patients. Salud Publica Mex. 2003;45(3):191–7.
11. Stilley CS, Sereika S, Muldoon MF, et al. Psychological and
cognitive function: predictors of adherence with cholesterol
lowering treatment. Ann Behav Med. 2004;27(2):117–24.
12. Wai CT, Wong ML, Ng S, et al. Utility of the Health Belief
Model in predicting compliance of screening in patients with
chronic hepatitis B. Aliment Pharmacol Ther. 2005;21(10):
1255–62.
13. Balchand K. Now, planning commission lowers the poverty line.
The Hindu 2012 Mar 20. http://www.thehindu.com/news/
national/article3013870.ece. Accessed 5 Nov 2012.
14. Cramer JA, Mattson RH, Prevey ML, et al. How often is medi-
cation taken as prescribed? A novel assessment technique.
JAMA. 1989;261(22):3273–7.
15. Moore PJ, Sickel AE, Malat J, et al. Psychosocial factors in
medical and psychological treatment avoidance: the role of the
doctor-patient relationship. J Health Psychol. 2004;9(3):421–33.
16. Gonzalez J, Williams JW Jr, Noël PH, et al. Adherence to mental
health treatment in a primary care clinic. J Am Board Fam Pract.
2005;18(2):87–96.
17. Lawson VL, Lyne PA, Harvey JN, et al. Understanding why
people with type 1 diabetes do not attend for specialist advice: a
qualitative analysis of the views of people with insulin-dependent
diabetes who do not attend diabetes clinic. J Health Psychol.
2005;10(3):409–23.
18. Gascon JJ, Sanchez-Ortuno M, Llor B, et al. Why hypertensive
patients do not comply with the treatment: results from a quali-
tative study. Fam Pract. 2004;21(2):125–30.
19. Ponnusankar S, Surulivelrajan M, Anandamoorthy N, et al.
Assessment of impact of medication counseling on patients’
medication knowledge and compliance in an outpatient clinic in
South India. Patient Educ Couns. 2004;54(1):55–60.
20. O’Donoghue MN. Compliance with antibiotics. Cutis. 2004;73(5
Suppl):30–2.
21. Ellis JJ, Erickson SR, Stevenson JG, et al. Suboptimal statin
adherence and discontinuation in primary and secondary pre-
vention populations. J Gen Intern Med. 2004;19(6):638–45.
22. Choi-Kwon S, Kwon SU, Kim JS. Compliance with risk factor
modification: early-onset versus late-onset stroke patients. Eur
Neurol. 2005;54(4):204–11.
23. Avorn J, Monette J, Lacour A, et al. Persistence of use of lipid-
lowering medications: a cross national study. JAMA. 1998;
279(18):1458–62.
24. Hope CJ, Wu J, Tu W, et al. Association of medication adher-
ence, knowledge, and skills with emergency department visits by
adults 50 years or older with congestive heart failure. Am J
Health Syst Pharm. 2004;61(19):2043–9.
25. Lowe CJ, Raynor DK, Purvis J, et al. Effects of a medicine
review and education programme for older people in general
practice. Br J Clin Pharmacol. 2000;50(2):172–5.