Medication adherence among children with heart failure at the University of Gondar Comprehensive Specialized Hospital Gondar Northwest Ethiopia – Nature.com 03:50 

Scientific Reports volume 15, Article number: 28069 (2025) Cite this article

Abstract

Children with heart failure take multiple medications, and adherence to the medicines plays a pivotal role in attaining maximal therapeutic benefits. However, the exact prevalence of medication adherence among children with heart failure is not well documented, especially in developing countries. Therefore, this study was conducted to assess the magnitude of poor medication adherence and its associated factors among children with heart failure. An institutional-based cross-sectional study was conducted among children with heart failure visiting the University of Gondar Comprehensive Specialized Hospital Pediatric Cardiac Follow-Up Clinic from January 1 to May 30, 2022. A pre-tested & structured questionnaire and medical record review were used for data collection. The data-collecting questionnaire includes socio-demographic characteristics, clinical parameters, and recorded medication. A systemic random sampling technique was used to select 203 participants from the sampling frame. Binary and multivariable logistic regressions were employed to determine factors associated with poor medication adherence. The statistical association between dependent and independent variables was declared at a p-value of < 0.05. A total of 203 respondents were included in the final analysis with a 93.5% response rate with male-to-female ratio of nearly 1:1. The mean age of the study participants was 9.53(± 5.2) years ranging from 3 months to 18 years. The magnitude of poor adherence was 23.15% (17.3–29.0%). Not having health insurance (AOR = 4.402, 95%CI, 1.95–9.938, P = 0.000), living far from hospital (AOR = 3.171, 95%CI, 1.373–7.327, P = 0.007), rural residence (AOR = 2.638, 95%CI, 1.092–6.369, P = 0.031) and low household income (AOR = 5.11, 95%CI 1.994–13.098, P = 0.001) were significantly associated with poor medication adherence. Nearly one-quarter of children with heart failure poorly adhere to their cardiovascular medications. The current study investigated that lack of health insurance, living far from the hospital, rural residence, and low household income were significantly associated with poor medication adherence. Providing follow-up care at hospitals closer to patients’ residence areas could improve medication adherence. In addition, awareness creation and access to health insurance are recommended to decrease poor medication adherence at the community level.

Introduction

Heart Failure (HF) is a progressive clinical and pathophysiological syndrome due to different etiology that may be structural or nonstructural1. It is one of the non-communicable diseases currently growing as a public health burden worldwide, especially in low and middle-income countries like Ethiopia2,3,4. The prevalence of cardiovascular disease in Ethiopia ranges from 1 to 20% with significant variation in the institution (about 8%) and at the community level(2%) with a cardiovascular age-standardized death rate of 40% for both sexes and all age groups per 100,000 population3,5.

To avert the devastating morbidity and mortality caused by heart failure, significant advancements have been made in diagnosis and treatment. Among these treatments, medical management is a cornerstone. Despite the crucial role of medication in managing heart failure, it requires long-term and consistent use of several drugs to reduce morbidity, mortality, and complications associated with heart failure specially in developing country where surgical cure is luxury6.

Literature on medication adherence rates are consistently suboptimal across different studies making poor adherence a significant public health problem that results in preventable hospitalization, premature deaths7, and unnecessary health care expenditure8 regardless of the underlying etiology. Intervention towards medication adherence significantly decreases mortality and hospitalization9.

The exact prevalence of medication non-adherence among heart failure patients is not well documented, especially in developing countries. Various studies in different settings shown that the prevalence of cardiac medication non-adherence ranges from (5–74.7%) in which 41.5% and 37% were in Gondar, Ethiopia10,11, 37% at Jimma, Ethiopia12, 52% at Georgia13 and 74.7% in Tanzania7 but almost all of these studies were done in adults.

The magnitude of poor medication adherence in the studies done in adults in northern Ethiopia (Gondar) and southwest Ethiopia (Jimma) was nearly 37% for benzathine penicillin prophylaxis and other heart failure medications10,12.

In previous studies, the contributing factors for medication non-adherence among heart failure patients were patient behavior related, health system related, clinical characteristics related and economical related factors. Significant patient behavior related factors that were found in Ethiopian study was the patients thinking that they are getting better from the illness10.

Similarly other literatures showed health system related factors that affected medication non-adherence ware cost of the drugs12, drug multiplicity10, refilling problems and poor communication with health workers about their drug therapy14.

Significantly associated sociodemographic and economic related characteristics affecting medication non-adherence were long-distance > 30 km from the health facility10,12, possession of insurance7, level of education15, economic status8, and residence(rural) areas11.

The other important associated factors with medication non-adherence are clinical related factors which includes early disease stage, presence of comorbidity and multiplicity of medication10 .

There are multiple direct effects of non-adherence on the patient’s level which include: decreased quality of life16, school absenteeism, increased risk of malnutrition, recurrence or disease progression with increased hospitalization rate, and early mortality7,17. In addition, non-adherence has a significant burden on health care professionals by creating treatment difficulties and demand of high resources. Non-adherence can also affect families and the country as a whole by increasing the health care cost and losses of young productive populations due to premature deaths5,18,19,20.

Evidence on the magnitude and associated factors of poor medication adherence among children with heart failure is limited, particularly in developing countries. While medication adherence plays a crucial role in the treatment of heart failure, existing literature in children with this topic from low- and middle-income countries, including Ethiopia, is scarce. This study can contribute to filling the knowledge gap and provide important insights relevant to the local contexts. This is particularly important in resource-constrained settings where access to healthcare and medications may pose additional challenges. Hence this study aimed to assess the magnitude and associated factors of poor medication adherence among children with heart failure visiting the University of Gondar Comprehensive Specialized Hospital (UOGCSH).

Methods

Study design and setting

An institutional-based prospective cross-sectional study was conducted among children with heart failure on follow-up at UOGCSH (University of Gondar Comprehensive Specialized Hospital) pediatric cardiac clinic from January 1 to May 30, 2022. UOGCSH is one of the oldest academic referral hospitals in the country, which is located 727 km Northwest of Addis Ababa, the capital city of Ethiopia. The pediatric cardiac follow-up clinic delivers care for about 150 children with heart failure each month which accounts for 38% of the chronic care burden on the pediatric side. Currently, there are over 450 cardiac patients enrolled in the cardiac follow-up clinic with appointments for each patient varying from 1 to 4 months depending on the severity of their illness. The follow-up care is provided by pediatric cardiologists, general pediatricians, pediatric residents, medical interns, and nurses.

Study participants

All children with heart failure on medication attended a follow-up at a pediatric cardiac clinic in UOGCSH during the study period was included but those children with incomplete documentation (documentation about the medication dose and frequency was not documented clearly to compare with mothers saying), children without guardians or unaccompanied children.

Sampling size and sampling techniques

The sample size was calculated by using a single population proportion formula assuming the prevalence of poor medication adherence was 50% (no previous studies in children21), 95% CI (Z = 1.96), and marginal error w = 0.05. Since the source population (about 450) is less than 10,000, correction formula was applied. By having the above assumption and adding 5% non-respondents, making the final sample size of 217. A systematic random sampling technique was used to select the study participants from the sampling frame of 450 patients during the study period. The interval of K was 2 and every other patient was taken from the sampling frame. The first sample was the first patient on the first date of data collection.

Variables of study

Dependent variable

Independent variables

Data collection tools and procedure

Data was collected by using pre-tested and structured questionnaires containing socio-demographic characteristics of the patients and parents, clinical variables, social and behavioral attributes of the participants after informed consent was taken from parents, legal guardians, or assent from the patient when applicable. Pretests were performed among 20 cardiac patients to see the data collection tools are clear and understandable among the patient or guardian before we start the main data collection.

The authors used the interviewing method to obtain data for sociodemographic characteristics of the patients and parents, social and behavioral features of the study participants using locally understandable language (Amharic) then translated to English, and chart review method for clinical variables and type of drug history in English language. All the study participants were approached during their respective appointment schedules for follow-up and interviewed in a separate room to maintain confidentiality and took around 30 min for each. The pill count from the monthly received pills in the previous one month was used to assess medication adherence among the study participants.

Data quality assurance

To ensure the quality of the data, supervisors and data collectors were trained on the how to inform the patient and take informed consent or assent, what data are going to be collected, ethical issues, and risk of poor data quality for two days before we proceed to data collection. In this process we include two interns and two pediatric nurses to collect data under the supervision of two pediatric residents and principal investigators for completeness and consistency data. Data completeness was checked by assessing missing value, presence of outlier and by checking clinical plausibility of collected data by considering other patient characteristics.

Data compilation and analysis

After data collection, data were entered into Epidata V.4.6 and exported to STATA version 15.1 for cleaning and analysis after it was double-checked for consistency and completeness.

Descriptive statistics like mean, median, and proportions were computed to summarize the baseline socio-demographic and clinical characteristics of the study participants. A binary logistic regression model was fitted to identify factors associated with poor medication adherence. A p-value of less than 0.2 was used to select candidate variables for analysis. On multivariable analysis, variables with a p-value less than 0.05 were considered significantly associated factors with poor medication adherence among children with heart failure. Model fitness was tested using the Hosmer Lemeshow goodness of fit test (p = 0.2025).

Operational definition

Medication: drug for heart failure management which includes diuretics, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), beta blockers, benzathine penicillin, and amoxicillin.

Medication adherence: assessed based on the number of missed pills from the monthly received pills and calculated the missed pills percentage to decide whether it is good or poor adherence. The medication adherence was checked based on the number of missed pills for the previous one month.

Poor medication adherence: patients took less than 85% of their prescribed medications22. Good adherence: took greater or equal to 85% of their prescribed medications. Far: distance from the hospital greater than 30 km12. Near: distance from the hospital less than 30 km. Low household income: those below the median (2300ETB). High household income: those above the median (2300ETB).

Community-based health insurance is a prepaid healthcare financing mechanism where community members collectively pool their resources to cover the costs of healthcare services23.

Result

Socio-demographic characteristics of children with heart failure and their parents

Of 217 selected patients, 203 respondents were included in the final analysis and 14 were excluded (8 with incomplete documentation, 6 without guardians or caretakers) with a 93.5% response rate. The male-to-female ratio of the participants was 1.01:1. The mean (± SD) age of children was 9.53(± 5.2) years ranging from 3 months to 18 years. The level of education of the family was assessed and it shows nearly three quarter (71.43%) of mothers are unable to read and write while more than 50% (51.7%) of the fathers have a primary and above level of education. Of those who are unable to read and write, nearly three-quarter of them were from rural areas in both sexes which are 73.1% and 76.53% respectively (Table 1).Table 1 Socio-demographic characteristics of children with heart failure on follow-up at pediatric cardiac clinic 2022, UOGCSH, Ethiopia (n = 203).

Full size table

Clinical characteristics of the study participants

Nearly 14% of the participants have advanced cardiac diseases in the New York Heart Association (NYHA stage three and four). Most of the respondents 197(97%) mentioned at least one sign and symptom of the disease. More than half of 115(56.6%) participants took three or more medications (Table 2). Furosemide 186 (91.6%) and spironolactone 121 (59%) are the two most prescribed drugs in this study (Fig. 1). Twenty-three (11.33%) patients out of the total had a comorbid illness, the commonest comorbid condition was Down syndrome 13 (56.5%) followed by hypothyroidism 6 (26.1%) (Supplementary Table 1).Table 2 Clinical characteristics of children with heart failure on follow-up at UOGCSH cardiac clinic 2022, Ethiopia (n = 203).

Full size table

figure 1
Fig. 1

Social and behavioral characteristics of the study participants

Most of the study participants, 178(88%) lived with both parents and 0.9% were orphans. More than half of the respondents 135(59.6%) got counseling about medication from pharmacists. And 124(59.11%) of the participants have health insurance either governmental or non-governmental (Table 3).Table 3 Social and behavioral factors of the study participants (n = 203) at pediatric follow-up clinic UOGCSH, 2022.

Full size table

Magnitude of poor medication adherence among the study participants

The overall magnitude of poor medication adherence was found to be 23.15% (17.3–29.0%) with approximately similar distribution among male and female sex. From the total 203 patients, the highest proportion is found in the category of 5–10 years that is also the highest proportion of non-adherent which is nearly one-third of the category.

The most common reasons for missing medication in the study participants were forgetting the medication 86(42.36%) followed by carelessness of the patients 57(28.07%) (Fig. 2).

figure 2
Fig. 2

Factors associated with poor medication adherence in the study participants

Multivariable logistic regression indicated that far distance (> 30 km) from the hospital, low household monthly income, lack of health insurance, and rural residency were significantly associated with the magnitude of poor medication adherence. Those who are more than 30 km away from the hospital were 3.17 times (AOR = 3.17; 95%CI: 1.37, 7.33) at more likely for poor medication adherence compared to those who are near the hospital. The odds of poor medication adherence among children with heart failure who had no health insurance were 4.40 times higher (AOR = 4.40; 95%CI: 1.95, 9.94) as compared to those who had health insurance. Children with heart failure who had low household monthly income had 5.11 times (AOR = 5.11; 95%CI: 1.09, 13.10) higher odds of poor medication adherence as compared to those who had higher household monthly income and also those children with heart failure from rural residency had 2.64 times (AOR = 2.64; 95%CI: 1.09–6.37) higher odds of having poor medication adherence compared to those from urban setting (Table 4).Table 4 Multivariable logistic regression analysis of factors associated with poor medication adherence among heart failure on follow-up at UOGCSH pediatric cardiac clinic, 2022 (n = 203).

Full size table

Discussion

To our best knowledge, this is the study in our country among children with heart failure to evaluate their level of non-adherence to cardiovascular medications and to identify factors associated with their non- adherence. This study revealed that the magnitude of poor medication adherence among heart failure patients at pediatric cardiac follow-up clinic was 23.15% (17.3–29.0%). The current finding was similar to a nationwide survey in Poland among pediatric patients that the non-adherence rate was 28.9% (± 18.8%)17 and in other longitudinal subgroup analysis done to identify patterns of non-adherence demonstrated that the non-adherence rate was 29.9 ± 11% among deteriorating subgroups24 and also in other multicenter study conducted on adults in different countries, the burden of medication non-adherence was 23.86 (23.64–24.16) in Netherlands17,24,25 and 23.7%) in Gondar, Ethiopia among adults10.

Our study finding was lower than the studies done in the three largest cardiac centers in Khartoum State 51%14, in a prospective study done in Tanzania 74.7%7, and in a Cochrane literature review in 2008 of 77%26 and in a study done in Italy 60.7%15. This variation in the prevalence of medication non-adherence might be due to the difference in characteristics of the study population ( the majority studied in adults while we studied exclusively in children), sample size, the definition of medication adherence, the quantity and quality of health insurance system, accessibility of the health service and method of assessing medication adherence (we used number of pills missed per month while others used MARS-5, MMAS-4 and other scoring systems).

In our study, respondents living far from the hospital were nearly three times more at risk of having poor medication adherence to their prescribed medication compared to those living near the hospital. This finding was supported by other study result in Ethiopia, living greater than 30 km from the health facility were associated with poor medication adherence12. The significance of this variable could be due to increased transportation costs and struggle to reach to the hospital which could result in the canceling of appointment dates and inability to access the prescribed drugs regularly.

In the current study, those who had low household income were approximately five times more at risk of having poor medication adherence to their prescribed medications compared to those who had high income. This finding was similar to the study done in a prospective epidemiological study in Khartoum, Sudan14 and Jimma, Ethiopia12 but in a study done in Australia among asthmatic children, annual family income has no association with medication adherence27.

In current study, lack of health insurance was approximately four times increased risk of having poor medication adherence to their prescribed medication compared to those having health insurance which is in line with studies in Georgia13 and Tanzania7. In two studies in Ethiopia health service utilization in a household was high in those having community-based health insurance23,28. This could be due to increasing the cost of medication and transportation for those having chronic illnesses. The habit of having community-based health insurance is low in people living in resource limited countries like Ethiopia29,30,31. It is because of the financial support from health insurance, the community health-seeking behaviors are higher if they have the insurance23.

In our study, people living in rural areas were nearly 2.5 times more at risk of having poor adherence to their prescribed medication when compared to those living in urban areas which is in line with different studies7,8,12. This could be due to the majority of our patients coming from rural areas (62.56%), which could have multiple risk factors for their poor medication adherence. The possible reasons for such association with the address could be multiple. As a 1st, nearly three quarter (74.8%) of the study patients who are unable to read and write were from a rural area, 2nd more than half of the rural population have an average monthly income of less than 2300 ETB, 3rd more than 40% are uninsured, 4th nearly half of rural patients were coming from far (47.24%). All the above factors could contribute to an increment in the cost of transportation and medication in addition to far from health facility.

In different studies, level of education, health care professional counseling, sex of the patient, duration of illness since diagnosis, having early stage of the disease (stage I and II), having the comorbid condition, and number of medications the patient taking were significantly associated with poor medication adherence. In this study, these factors were not associated with poor medication adherence. The difference might be due to higher health insurance coverage, accessibility of health facilities nearby, and economic differences among the study population with our setup7,10,12.

Strength

This study was the first study done in our set up to assess medication non-adherence among children this will new insight and baseline for clinical practice and large scale studies. The other strength of the study was to assess factors associated with non-adherence in detail with after searching different literature in four thematic areas.

Limitation

Adherence in this study was assessed by self-report using the number of missed pills in the last one month which was affected by recall bias and an intentional false report by study participants. It would have been better to use a validated tool than pill count to minimize this recall bias.

Conclusion

The current study showed that nearly one-fourth of the cardiac patients had poor adherence to their cardiovascular medications. Lack of health insurance, living far from the hospital, rural residence, and low household income were significantly associated with poor medication adherence.

Recommendation

We recommend that follow-up is better to be arranged at a nearby hospital for cardiac patients on medications. Encourage parents to have health insurance for those who do not have it during their follow-up contact. Policymakers need to consider expanding community-based health insurance coverage and ensure more families and children with chronic diseases can benefit from financial protection and healthcare access. This is the area that is not touched and any interested individuals who need to work in the areas could use the findings of this study as baseline information for their further work.

Data availability

the data used to support the finding of this study are available from the corrsponding author upon reasonable request.

Abbreviations

AOR:

Adjusted odds ratioACEI:

Anti- Convertase Enzyme InhibitorARB:

Angiotensin receptor blockerCOR:

crude odds ratioCHD:

Congenital heart diseaseCI:

Confidence intervalCVS:

Cardiovascular disorderETB:

Ethiopian BirrKM:

KilometerMMAS-4:

Modified Morisky Adherence Scale-4NYHA:

New York Heart AssociationUOGCSH:

University Of Gondar Comprehensive Specialized Hospital

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Acknowledgements

The authors like to acknowledge the study participants, data collectors, colleagues, Department of Pediatrics & Child Health and the University of Gondar.

Funding

The authors received no funds for this work.

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Authors and Affiliations

  1. Department of Pediatrics and Child Health, School of Medicine, University of Gondar, Gondar, EthiopiaAlemu Azizew, Addisu Ginbu Dubie, Teshome Geletaw Zamanuel & Geta Bayu Genet

Contributions

AA, AGD TGZ and GBG participated to design the study, performed data analysis, visualization, validation of the whole work, and prepared the manuscript. AA took part in study proposal development, data collection and others help in supervision, software data manegment and other resources. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Geta Bayu Genet.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical consideration

Ethical clearance was obtained from the Ethical committee of the school of medicine, University of Gondar and the study was conducted in accordance with declaration of Helsinki. The ethical review committee provided an approval letter with a reference number- SOM/1267/2014 Ethiopian Calendar. Informed consent was obtained from all the participants and/or their parents or legal Guardians. All participants were informed of their right to withdraw from the study at any stage of the research. All participants’ personal information was kept confidential their name was not mentioned in the study.

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Azizew, A., Dubie, A.G., Zamanuel, T.G. et al. Medication adherence among children with heart failure at the University of Gondar Comprehensive Specialized Hospital Gondar Northwest Ethiopia. Sci Rep 15, 28069 (2025). https://doi.org/10.1038/s41598-025-99745-8

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