title: A systematic review of adherence to cardiovascular medications in resource-limited settings.
abstract: BACKGROUND
  Medications are a cornerstone of the prevention and management of cardiovascular disease. Long-term medication adherence has been the subject of increasing attention in the developed world but has received little attention in resource-limited settings, where the burden of disease is particularly high and growing rapidly. To evaluate prevalence and predictors of non-adherence to cardiovascular medications in this context, we systematically reviewed the peer-reviewed literature.
  
  
  METHODS
  We performed an electronic search of Ovid Medline, Embase and International Pharmaceutical Abstracts from 1966 to August 2010 for studies that measured adherence to cardiovascular medications in the developing world. A DerSimonian-Laird random effects method was used to pool the adherence estimates across studies. Between-study heterogeneity was estimated with an I(2) statistic and studies were stratified by disease group and the method by which adherence was assessed. Predictors of non-adherence were also examined.
  
  
  RESULTS
  Our search identified 2,353 abstracts, of which 76 studies met our inclusion criteria. Overall adherence was 57.5% (95% confidence interval [CI] 52.3% to 62.7%; I(2) 0.98) and was consistent across study subgroups. Studies that assessed adherence with pill counts reported higher levels of adherence (62.1%, 95% CI 49.7% to 73.8%; I(2) 0.83) than those using self-report (54.6%, 95% CI 47.7% to 61.5%; I(2) 0.93). Adherence did not vary by geographic region, urban vs. rural settings, or the complexity of a patient's medication regimen. The most common predictors of poor adherence included poor knowledge, negative perceptions about medication, side effects and high medication costs.
  
  
  CONCLUSIONS
  Our study indicates that adherence to cardiovascular medication in resource-limited countries is sub-optimal and appears very similar to that observed in resource-rich countries. Efforts to improve adherence in resource-limited settings should be a priority given the burden of heart disease in this context, the central role of medications in their management, and the clinical and economic consequences of non-adherence.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA.
authors.forename: Ashna D K
authors.initials: AD
authors.lastname: Bowry
authors.forename: William H
authors.initials: WH
authors.lastname: Shrank
authors.forename: Joy L
authors.initials: JL
authors.lastname: Lee
authors.forename: Margaret
authors.initials: M
authors.lastname: Stedman
authors.forename: Niteesh K
authors.initials: NK
authors.lastname: Choudhry
mesh_terms: D002317:Cardiovascular Agents / Q000191:economics* / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology; D003906:Developing Countries / Q000191:economics* / Q000706:statistics & numerical data; D006295:Health Resources / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D016903:Drug Monitoring
chemical_list: D002317:Cardiovascular Agents