title: Multilevel Correlates of Non-Adherence in Kidney Transplant Patients Benefitting from Full Cost Coverage for Immunosuppressives: A Cross-Sectional Study.
abstract: BACKGROUND
  Adherence is the result of the interaction of the macro, meso, micro, and patient level factors. The macro level includes full coverage of immunosuppressive medications as is the case in Brazil. We studied the correlates of immunosuppressive non-adherence in post kidney transplant patients in the Brazilian health care system.
  
  
  METHODS
  Using a cross-sectional design, adherence to immunosuppressives was assessed in a sample of 100 kidney transplant patients using a composite non-adherence score consisting of three methods (self-report [i.e., The Basel Adherence Scale for Assessment of Immunossupressives-BAASIS], collateral report, and immunosuppressive blood levels). Multilevel correlations of non-adherence were assessed (macro, meso, micro and patient level). Univariate and multivariate logistic regression was applied to assess the correlates of non-adherence.
  
  
  RESULTS
  Our sample consisted primarily of male (65%), Caucasians (72%) with a mean age of 45.0 ± 13.5 years old, who received grafts from a living donor (89%), with a mean time after transplantation of 72.3 ± 44.4 months. Prevalence of non-adherence was 51%. Family income higher than five reference wages (21.6 vs. 4%; OR 6.46 [1.35-30.89], p = 0.009; patient level), and having access to private health insurance (35.3% vs. 18.4%; OR 2.42 [0.96-6.10], p = 0.04; meso level) were associated with non-adherence in univariate analysis. Only the higher family income variable was retained in the multiple logistic regression model (OR 5.0; IC: 1.01-25.14; p = 0.04).
  
  
  CONCLUSIONS
  Higher family income was the only factor that was associated with immunosuppressive non-adherence. In Brazil, lower income recipients benefit from better access to care and coverage of health care costs after transplantation. This is supposed to result in a better immunosuppressive adherence compared to high-income patients who have experienced these benefits continuously.
authors.affiliation: Renal Transplantation Unit, Division of Nephrology, School Hospital of Federal University of Juiz de Fora, Minas Gerais, Brazil.|Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Elisa Oliveira
authors.initials: EO
authors.lastname: Marsicano
authors.affiliation: Centre for Public Policy and Education Evaluation (CAED), Federal University of Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Neimar Silva
authors.initials: NS
authors.lastname: Fernandes
authors.affiliation: Renal Transplantation Unit, Division of Nephrology, School Hospital of Federal University of Juiz de Fora, Minas Gerais, Brazil.|Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Fernando Antônio Basile
authors.initials: FA
authors.lastname: Colugnati
authors.affiliation: Renal Transplantation Unit, Division of Nephrology, School Hospital of Federal University of Juiz de Fora, Minas Gerais, Brazil.|Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Natalia Maria Silva
authors.initials: NM
authors.lastname: Fernandes
authors.affiliation: Institute of Nursing Science, University of Basel, Basel, Switzerland.|Department of Public Health and Primary Care, Faculty of Medicine, KU-Leuven, Belgium.
authors.forename: Sabina
authors.initials: S
authors.lastname: De Geest
authors.affiliation: Renal Transplantation Unit, Division of Nephrology, School Hospital of Federal University of Juiz de Fora, Minas Gerais, Brazil.|Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Helady
authors.initials: H
authors.lastname: Sanders-Pinheiro
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000191:economics; D019458:Insurance Coverage; D007348:Insurance, Health; D016030:Kidney Transplantation; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000601:surgery
chemical_list: D007166:Immunosuppressive Agents