International Journal of Clinical Pharmacy

, Volume 37, Issue 4, pp 626–635 | Cite as

Primary non-adherence in Portugal: findings and implications

  • Filipa Alves da CostaEmail author
  • Ana Rita Pedro
  • Inês Teixeira
  • Fátima Bragança
  • José Aranda da Silva
  • José Cabrita
Research Article


Background Portugal is currently facing a serious economic and financial crisis, which is dictating some important changes in the health care sector. Some of these measures may potentially influence patients’ access to medication and consequently adherence, which will ultimately impact on health status, especially in chronic patients. Aims This study aimed at providing a snapshot of adherence in patients with chronic conditions in Portugal between March and April 2012. Setting Community pharmacy in Portugal. Method A cross-sectional pilot study was undertaken, where patients were recruited via community pharmacies to a questionnaire study evaluating the number of prescribed and purchased drugs and, when these figures were inconsistent, the reasons for this. Main outcome measures Primary and secondary adherence measures. Failing to purchase prescription items was categorized as primary nonadherence. Secondary nonadherence was attributed to purchasing prescription items, but not taking medicines as prescribed. Results Data were collected from 375 patients. Primary nonadherence was identified in 22.8 % of patients. Regardless of the underlying condition, the most commonly reported reason for primary non-adherence was having spare medicines at home (“leftovers”), followed by financial problems. The latter appeared to be related to the class of medicines prescribed. Primary non-adherence was associated with low income (<475 €/month; p = 0.026). Secondary non-adherence, assessed by the 7-MMAS was detected in over 50 % of all patients, where unintentional nonadherence was higher than intentional nonadherence across all disease conditions. Conclusion This study revealed that more than one fifth of chronic medication users report primary nonadherence (22.8 %) and more than 50 % report secondary nonadherence. Data indicates that the existence of spare medicines and financial constraints occurred were the two most frequent reasons cited for nonadherence (47, 6–64, 8 and 19–45.5 %, depending on the major underlying condition, respectively).


Diabetes Hyperlipidemia Hypertension Medication adherence Portugal 




Conflicts of interest

All authors are part of the Portuguese Observatory of Health Systems (OPSS), which is an independent body that annually develops research looking at the impact of political measures taken on the health sector. Research is conducted independently of their academic institutions and is evaluated by peers from other institutions in order to ensure unbiased results are published. For all the above reasons, the authors declare there are no conflicts of interests to be declared. More information about the OPSS can be obtained at

Supplementary material

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Supplementary material 1 (PDF 38 kb)


  1. 1.
    Portugal. Instituto Nacional de Estatística.Censos 2011: resultados provisórios. Lisboa: Instituto Nacional de Estatística; 2011. p. 1–145. ISBN 978-989-25-0148-2.Google Scholar
  2. 2.
    OECD. How’s life? measuring well-being. Paris: OECD Publishing; 2011. ISBN 9789264201392.Google Scholar
  3. 3.
    WHO. Portugal health system: performance assessment. Copenhagen: WHO Regional Office for Europe; 2010. p. 1–74.Google Scholar
  4. 4.
    Gardete-Correia L, Boavida JM, Fragoso de Almeida JP, Massano Cardoso S, Dores J, Sequeira Duarte J, et al. Diabetes: factos e números 2012: relatório anual do Observatório Nacional da Diabetes. Lisboa: Sociedade Portuguesa de Diabetologia; 2012. p. 1–64. ISBN: 978-989-96663-1-3.Google Scholar
  5. 5.
    Cortez-Dias N, Martins S, Belo A, Fiúza M. Prevalence and patterns of treatment of arterial hypertension in primary health care in Portugal: results of the VALSIM Study. Rev Port Cardiol. 2009;28:499–523.PubMedGoogle Scholar
  6. 6.
    Cortez-Dias N, Martins S, Belo A, Fiúza M. Characterization of lipid profile in primary health care users in Portugal. Rev Port Cardiol. 2013;32(12):987–96.PubMedGoogle Scholar
  7. 7.
    Johnson MJ, Williams M, Marshall ES. Adherent and nonadherent medication-taking in elderly hypertensive patients. Clin Nurs Res. 1999;8:318–35.PubMedCrossRefGoogle Scholar
  8. 8.
    Jackevicius CA, Mamdami M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J. VA Naltrexone Study Group. Medication compliance feedback and monitoring in a clinical trial: predictors and outcomes. Value Health. 2003;6:566–73.PubMedCrossRefGoogle Scholar
  10. 10.
    Haynes RB, McKibbon KA, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet. 1996;348(9024):383–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Sherbourne CD, Hays RD, Ordway L, Dimatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med. 1992;15:447–68.PubMedCrossRefGoogle Scholar
  12. 12.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.PubMedCrossRefGoogle Scholar
  13. 13.
    Kardas P, Lewek P, Matyjaszczyk M. Determinants of patient adherence: a review of systematic reviews. Front Farmacol. 2013;4(91):1–16. doi: 10.3389/fphar.2013.00091.Google Scholar
  14. 14.
    Mathes T, Pieper D, Antoine S-L, Eikermann M. 50% adherence of patients suffering chronic conditions—where is the evidence? GMS Ger Med Sci. 2012;10.Google Scholar
  15. 15.
    Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27(5):1218–24.PubMedCrossRefGoogle Scholar
  16. 16.
    Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288:455–61.PubMedCrossRefGoogle Scholar
  17. 17.
    Primatesta P, Poulter NR. Lipid concentrations and the use of lipid lowering drugs: evidence from a national cross sectional survey. BMJ. 2000;321(7272):1322–5.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Tsuyuki RT, Bungard TJ. Poor adherence with hypolipidemic drugs: a lost opportunity. Pharmacotherapy. 2001;21(5):576–82.PubMedCrossRefGoogle Scholar
  19. 19.
    Bramlage P, Hasford J. Blood pressure reduction, persistence and costs in the evaluation of antihypertensive drug treatment—a review. Cardiovascu Diabetol. 2009;8:18.CrossRefGoogle Scholar
  20. 20.
    Coleman CI, Limone B, Sobieraj DM, Lee S, Roberts MS, Kaur R, Alam T. Dosing frequency and medication adherence in chronic disease. J Manag Care Pharm. 2012;18(7):527–39.PubMedGoogle Scholar
  21. 21.
    Fischer MA, Stedman MR, Lii J, Vodeli C, Shrank WH, Brookhart MA, et al. Primary medication nonadherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284–90.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Solomon MD, Majuumdar SR. Primary nonadherence of medications: lifting the veil on prescription-filling behaviours. J Gen Intern Med. 2010;25:280–1.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the necessity-concerns framework. PLoS ONE. 2013;8(12):e80633.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Dipollina L, Sabaté E. Adherence to long-term therapies in the elderly. In: Sabaté E, editor. WHO adherence report: a review of the evidence. Geneva: World Health Organisation; 2003. ISBN 92-4-154599-2.Google Scholar
  25. 25.
    Lehane E, McCarthy G. An examination of the intentional and unintentional aspects of medication nonadherence in patients diagnosed with hypertension. J Clin Nurs. 2007;16:698–706.PubMedCrossRefGoogle Scholar
  26. 26.
    Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. 2005;39:1198–203.PubMedCrossRefGoogle Scholar
  27. 27.
    Gadkari AS, McHorney CA. Unintentional nonadherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res. 2012;12:98.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Khatib R, Schwalm J-D, Yusuf S, Haynes RB, McKee M, Khan M, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS ONE. 2014;9(1):e84238.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Donovan JL, Blake DR. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507–13.PubMedCrossRefGoogle Scholar
  30. 30.
    Hughes CM, Hawwa AF, Scullin C, Anderson C, Bernsten CB, Bjornsdottir I, et al. Provision of pharmaceutical care by community pharmacists: a comparison across Europe. Pharm World Sci. 2010;32(4):472–87.PubMedCrossRefGoogle Scholar
  31. 31.
    Nakash RA, Hutton JL, Jorstad-Stein EC, Gates S, Lamb SE. Maximising response to postal questionnaires—a systematic review of randomised trials in health research. BMC Med Res Methodol. 2006;6(5):111. doi: 10.1186/1471-2288-6-5.Google Scholar
  32. 32.
    Delgado AB, Lima ML. Contributo para a Validação Concorrente de uma Medida de Adesão aos Tratamentos. Psicologia, Saúde e Doenças. Sociedade Portuguesa de Psicologia da Saúde. 2001;II(002):81–100.Google Scholar
  33. 33.
    Ramalhinho I, Cordeiro C, Cavao A, Cabrita J. Assessing determinants of self-medication with antibiotics among Portuguese people in the Algarve Region. Int J Clin Pharm. 2014;36(5):1039–47. doi: 10.1007/s11096-014-9992-z.PubMedCrossRefGoogle Scholar
  34. 34.
    Pombo Romero J, Portela Romero M, Vizoso Hermida JR, TasendeSouto M. Evaluation of the pilot program of medicine dispensation in customized doses in Galicia [Spain]. Gac Sanit. 2007;21(1):18–23 (article in Spanish).PubMedCrossRefGoogle Scholar
  35. 35.
    Villaverde-Cabral M, Silva PA. A adesão à terapêutica em Portugal: atitudes e comportamentos da população portuguesa perante as prescrições médicas. Lisboa: Imprensa de Ciências Sociais. Instituto de Ciências Sociais da Universidade de Lisboa; 2010. ISBN 9789726712572.Google Scholar
  36. 36.
    Portaria no. 924-A/2010. DR. Iª Série. 182. (2010-09-17) 4122-(2)-4122-(5).Google Scholar
  37. 37.
    Shah NR, Hirsch AG, Zacker C, Taylor S, Wood GC, Stewart W. Factors associated with first-fill adherence rates for diabetic medications: a cohort study. J Gen Intern Med. 2008;24:233–7.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Shah NR, Hirsch AG, Zacker C, et al. Predictors of first-fill adherence for patients with hypertension. Am J Hypertens. 2009;22:392–6.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Kiss Z, Nagy L, Reiber I, Paragh G, Molnar MP, Rokszin G, et al. Persistence with statin therapy in Hungary. Arch Med Sci. 2013;9(3):409–17.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Murphy GK, McAlister FA, Weir DL, Tjosvold L, Eurich DT. Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis. BMC Public Health. 2014;14:544.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Aguiar JP, Silva PC, da Costa FA. Análise do perfil de utilização da terapêutica empírica antibiótica instituída em Infeções do Trato Urinário Adquiridas na Comunidade (ITU-AC). Rev Port Farmacoter. 2014;6(1):24–30.Google Scholar
  42. 42.
    Martins AP, Miranda AD, Mendes Z, Soares MA, Ferreira P, Nogueira A. Self-medication in a Portuguese urban population: a prevalence study. Pharmacoepidemiol Drug Saf. 2002;11:409–14.PubMedCrossRefGoogle Scholar
  43. 43.
    Costa FA, Guerreiro JP, Melo MN, Miranda AC, Martins AP, Garção J, et al. Effect of reminder cards on compliance with antihypertensive medication. Int J Pharm Pract. 2005;13:205–11.CrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  • Filipa Alves da Costa
    • 1
    Email author
  • Ana Rita Pedro
    • 2
  • Inês Teixeira
    • 3
  • Fátima Bragança
    • 2
  • José Aranda da Silva
    • 4
  • José Cabrita
    • 5
  1. 1.Instituto Superior de Ciências da Saúde Egas Moniz, Centro de Investigação Interdisciplinar Egas MonizObservatório Português dos Sistemas de SaúdeCaparicaPortugal
  2. 2.Escola Nacional de Saúde Pública, Grupo de Investigação em Políticas e Administração de SaúdeObservatório Português dos Sistemas de SaúdeLisbonPortugal
  3. 3.Centre for Health Evaluation and Research (CEFAR), Contract Research Organization (CRO), Grupo/Group Associação Nacional das Farmácias (ANF)Observatório Português dos Sistemas de SaúdeLisbonPortugal
  4. 4.FormifarmaObservatório Português dos Sistemas de SaúdeEstorilPortugal
  5. 5.Faculdade de Farmácia, Sub-grupo de Sócio-farmáciaUniversidade de Lisboa, Observatório Português dos Sistemas de SaúdeLisbonPortugal

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