Adherence to Chemotherapy and Associated Factors Among Patients With Cancer in Amhara Region,Northeastern Ethiopia,2022. A Cross-Sectional Study

Abstract

Background

Cancer is the leading cause of death worldwide, and poor adherence to chemotherapy has become a public health issue in developing countries, including Ethiopia.

Objective

To assess chemotherapy adherence and associated factors among patients with cancer in the Amhara Region, Northeast Ethiopia.

Methods

A hospital-based prospective cross-sectional study design was employed, and a total of 460 cancer patients were enrolled using a systematic random sampling method at Felege Hiwot and Dessie comprehensive specialized hospitals from May 15, 2022, to July 15, 2022, in the Amhara region. The data was gathered through a review of medical records and a face-to-face interview and entered into Epi-Data version 4.6 before being exported to SPSS version 26 for analysis. Furthermore, at 95% confident interval (CI), multivariable binary logistic regression was used, and variables with P-values of <.05 were found to be significant.

Result

The overall response rate in this study was 94.1% (433), with 42.3% of patients adhering to chemotherapy. Moreover, having a family history of cancer [AOR = 3.58, 95% CI (2.22, 5.76)], being female [Adjusted Odds ratio (AOR) = 2.17, 95% CI: (1.31, 3.60)], having no history of comorbidity [AOR = 2.74, 95% CI (1.56, 4.81)], having side effects from chemotherapy [AOR = 3.50, 95% CI (1.55, 7.90)], and having social support [AOR = 1.52, 95% CI (1.21, 1.95)] were important predictors of chemotherapy adherence.

Conclusion

and recommendations: Patients' understanding of illness characteristics and treatment should be improved through health education. Involving family members in the treatment plan will also improve adherence to chemotherapy in this context.

Keywords

cancer chemotherapy adherence Amhara region

Introduction

Cancer is a group of diseases characterized by the uncontrolled proliferation and dispersal of abnormal cells.¹ Cancer is a leading cause of death and a major impediment to increasing life expectancy in every country on the planet.²

In 2020, an estimated 19.3 million new cancer cases and nearly 10.0 million cancer deaths occurred worldwide. Cancer is an increasing public health burden in every country on the planet, particularly in Africa at large. It is worth noting that the cumulative risk of death from cancer among women in Africa in 2020 is roughly comparable to the risks observed among women in Northern America and Europe.³ According to hospital records, there are more than 150000 cancer cases in Ethiopia each year, and cancer is responsible for 4% of all deaths.⁴ Nevertheless, if the issue is ignored Cancer cases are expected to rise by 65% globally, from 12.7 million in 2008 to 21 million in 2030.⁵

WHO adopts the following definitions of adherence from Haynes and Rand: “The degree to which a person’s behavior matches agreed-upon recommendations from a health-care provider about instructions regarding medication intake, medical device use, diet, exercise, lifestyle changes, rest, and attendance at scheduled appointments.”^6-8

Although cancer has numerous treatment options, chemotherapy is by far the most widely used.⁹ Chemotherapy adherence entails a collaborative effort and silent comprehension between care providers and patients about the level of compliance in day-to-day treatment in such things as dose, frequency, duration of therapy, and cessation.¹⁰

Adherence to cancer treatment is critical for achieving optimal health outcomes such as a cure or an improvement in quality of life. Despite the availability of cancer treatment options, patients are vulnerable to adverse drug reactions for a variety of reasons, including poor drug adherence and clinical conditions.¹¹ As a result, poor chemotherapy adherence leads to drug resistance, recurrence, and poor quality of life in patients, negatively impacting the nation’s health costs and ultimately resulting in mortality.¹²

Chemotherapy adherence is strongly related to patient-related factors, therapy-related factors, condition-related factors, healthcare system factors, and socioeconomic factors.^10,13-16

The World Health Assembly’s sixty-sixth session approved the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs), including Cancer, 2013-2020.¹⁷ Furthermore, Ethiopia has had the National Cancer Control Plan strategy in place since 2015 to promote cancer prevention and early detection, as well as improve diagnosis and treatment, including palliative care.¹⁸ Based on this, cancer treatment centers have been initiated in more than 10 public and teaching hospitals in Ethiopia.¹⁸ The Amhara region has Six treatment centers, particularly Dessie and Felegehiwot comprehensive specialized Hospitals with large catchments and clients were involved in this study.

In the study area, there is a limited document about chemotherapy adherence and associated factors. As a result, the purpose of this study is to assess chemotherapy adherence and associated factors among cancer patients by including some variables (substance use such as cigarette smoking, alcohol consumption, and Khat chewing, as well as the presence of co-morbidities), thereby filling a knowledge gap in the study area. It has the potential to improve patient care and predict patient outcomes. Furthermore, developing and improving chemotherapy adherence protocols, as well as promoting cancer palliative care and research, are critical.

Methods and Materials

Study Area and Period

The research was carried out in the Amhara region from May 15, 2022, to July 15, 2022. The region is divided into 13 administrative zones, with Bahir-Dar serving as the capital city. It is Ethiopia’s second most populous region, with approximately thirty million people, accounting for 27% of the Ethiopian population. There are six comprehensive specialized hospitals in the region, of which two (Felege Hiwot and Dessie Comprehensive Specialized Hospital) provide chemotherapy for cancer patients predominantly in the region. Felege Hiwot and Dessie Comprehensive Specialized Hospital began chemotherapy treatments in 2016 and 2018, respectively; the Dessie Comprehensive Specialized Hospital oncology unit treats approximately 563 patients, while Felege Hiwot Comprehensive Specialized Hospital treats 547 cancer patients. The reporting of this study conforms to STROBE guidelines.¹⁹

Study Design

A hospital-based prospective cross-sectional study design was employed.

Eligibility Criteria

The study included all cancer patients who received at least one cycle of chemotherapy treatment, and all cancer patients who were severely ill and unable to communicate during data collection were excluded.

Sampling Size

A single population proportion formula was used to calculate the sample size. The following assumptions were taken into account: At Tikur Anbessa Specialized Hospital, the proportion of chemotherapy adherence was 77.5%,²⁰ with a 95% level of confidence and a 4% margin of error. By including a 10% non-response rate, the total sample size increased to 460.

Sampling Procedure

A systematic random sampling method was used to select study participants. First, the total number of cancer patients who visited the oncology unit within two months at Falelege Hiwot Comprehensive Specialized Hospital (567) and Dessie Comprehensive Specialized hospital (371), was obtained, and the total number of patients per two months was calculated. The sample size was allocated proportionally. Based on this, 182 cancer patients on chemotherapy from Dessie Comprehensive Hospital and 278 cancer patients on chemotherapy from Falelege Hiwot Comprehensive Specialized Hospital were included. The first participant was chosen by the lottery method, and the subsequent participants were chosen using systemic random sampling every two intervals.

Data Collection Technique and Instrument

The data was collected through both face-to-face interviews and chart reviews and has four sections. The first section, such as socio-demographic characteristics (age, gender, marital status, educational level, region, place of residence, source of treatment, and employment status), was obtained directly from the patient via face-to-face interviews. Section two deals with clinical variables such as primary cancer diagnosis and type of cancer treatment (i.e., chemotherapy, radiotherapy, surgery, or a combination of these) that were obtained from medical charts at the oncology unit. The data extraction tool was developed based on a routine data registration protocol and the oncology center’s standardized chemotherapy entry and follow-up form. This oncology tool consisted of the weight of patients, diagnosis of disease, co-morbidity, stage of cancer, cycle and type of chemotherapy, appointment date, other medications given for patient problems, and name of physician (supplementary file 1). The medical records for cancer patients were obtained from the oncology ward registration book, and patient charts were obtained from the card room using a patient’s Medical Record Number (MRN). The third section also deals with patient adherence to chemotherapy, and the data was collected through a medication adherence tool. One of the largest and most commonly employed indirect methods of adherence assessment is patient self-report, and of these, the Morisky Medication Adherence Scale (MMAS-8) is an 8-item self-report scale that evaluates medication-taking behavior established from the earlier validated 4-item and augmented with extra questions to more accurately reflect obstacles related to compliance behavior.^21,22 As a result, the eight-item (MMAS-8) was used to collect data on chemotherapy in this study. The scale consists of eight questions, the first seven of which have a binary answer (yes or no) coded as 1 or 0, indicating whether the person is adherent or non-adherent in taking their medications.²² However, one item is different and has a 5-point Likert scale indicating how frequently he or she fails to take his or her medications.²³

The MMAS-8 internal consistency was found to be reliable (r = .88) in the previous study.²⁴ In this study, Face validity and content validity were assessed by four experts to determine the instrument’s validity. The content validity ratio (CVR) and content validity index (CVI) were calculated and found to be .23 and .84, respectively, indicating that the instrument is valid. And also, the instrument’s reliability was tested using Cronbach’s alpha among the 5% study population, which was .821, indicating that the instrument was reliable. The last section deals with the health-care system, social support, and personal habits like alcohol, chat chewing, and cigarette smoking.

Operational Definition

Good adherence: Patients were considered to have good adherence if their MMAS-8 sum score reached 8.²⁴

Poor adherence: Patients were considered to have poor adherence if they responded with a sum score of 1-7 on the MMAS-8.²⁴

Adverse effect: if the patient reported at least one of the following chemotherapy-related adverse effects: nausea, vomiting, fatigue, loss of appetite, taste changes, hair loss, mouth dryness, loss of weight, sleep disorder, hot flashes, and constipation.^25,26

Social support: is the perceived and received support of a patient’s social network, such as familial relations, friends, neighbors, colleagues, fellow patients, or even pen pals and internet relationships, to reduce the emotional strain response, alleviate mental strain, and enhance social adaptability.²⁷

Data Quality Management and Analysis

The tool has been translated into the local Amharic language. Data collectors and supervisors were trained, and a pre-test of 5% of the sample size was conducted. The data was cleaned, encoded, and entered into Epi-Data software version 4.7 before being exported to SPSS version 26 of the statistical package for analysis. The level of chemotherapy adherence was calculated and assessed using descriptive statistics. A bivariable logistic regression analysis was performed to select variables for multivariable analysis. A variable with a P-value less than .05 was declared statistically significant. The adjusted odds ratio with its 95% confidence interval was used to demonstrate the strength of association between each explanatory variable and the outcome variable.

Result

This study included 433 cancer patients from a total of 460 study participants, with a response rate of 94.1%.

Socio-Demographic Characteristics of the Respondents

The mean age of respondents was 48 (SD ± 15.80) years, and more than half of the 247 participants (57.0%) were females. Two hundred ninety-nine (67.0%) of those polled were married, while 78 (18.0%) were widowed. 282 (65.1%) of the total participants lived in cities. In terms of educational status, 203 (46.9%) of participants were unable to write or read, and 114 (26.3%) of cancer patients had a primary education (Table 1).

Table 1.

Socio-demographic characteristics of cancer patients on chemotherapy in the Amhara region, north-east Ethiopia, 2022 (n = 433).

Variables	Category	Frequency	Percent
Sex	Male	186	43.0
Sex	Female	247	57.0
Age in year	<20	3	0.7
	21-30	88	20.3
	31-40	102	23.6
	41-50	110	25.4
	>50	130	30.0
Place of resident	Rural	282	65.1
Place of resident	Urban	151	34.9
Educational status	Unable to read and write	203	46.9
	Primary education	114	26.3
	Secondary education	58	13.4
	College and above	58	13.4
Marital status	Single	47	10.9
	Married	290	67.0
	Widowed	78	18.0
	Separated	18	4.2
Occupation	Housewife	68	15.7
	Private employee	43	9.9
	Businessmen	54	12.5
	Manual laborer	66	15.2
	Merchant	33	7.6
	Government employee	36	8.3
	Farmer	90	20.8
	Student	27	6.2
	Others	16	3.7

Keynote: Others*: daily labor, housewife.

Disease-Related Characteristics

One hundred eighty-two (42.0%) of the total number of participants had a cancer family history, and more than half of the 281 (64.9%) cancer patients had no history of co-morbidity. One hundred fourteen (26.3%) of the participants have breast cancer. 159 (39.7%) of the total cancer patients were in stage 4. Approximately 311 (71.8%) of the total number of participants have metastasized cancer (Table 2).

Table 2.

Disease-related characteristics of cancer patients on chemotherapy in the Amhara region, north-east Ethiopia, 2022 (n = 433).

Variables	Category	Frequency	Percent
Family history of cancer	Yes	182	42.0
Family history of cancer	No	251	58.0
Type of cancer	Hematologic (NHL & Hl)	48	11.1
	Lung cancer	33	7.6
	Breast cancer	114	26.3
	Gastrointestinal malignancy	72	16.6
	Gynecological malignancy	84	19.4
	Others	82	18.9
Stage of cancer	Early I	99	24.7
	Early II	90	22.4
	Late III	53	13.2
	Late IV	159	39.7
History of co-morbidity	Yes	152	35.1
History of co-morbidity	No	281	64.9
Type of co-morbidity	Diabetes mellitus	14	10.0
	HIV	41	29.3
	Heart problem	30	20.7
	Respiratory problem	18	12.9
	More than one co-morbidity	12	4.8
	Others	37	26.4
Presence of metastatic	Yes	311	71.8
Presence of metastatic	No	122	28.2

NHL stands for (Non-Hodgkin’s Lymphoma) and HL (Hodgkin’s Lymphoma).

Medication-Related Characteristics

From the total number of participants, 295 (68.1%) of cancer cases were treated solely with chemotherapy, while 381 (88.0%) of cancer patients received more than one chemotherapy. Approximately 322 (74.4%) of the participants use two drugs per day. 387 (89.4%) cancer patients experience side effects while taking medication, and approximately 266 (61.4%) cancer patients are admitted to the hospital more than once (Table 3).

Table 3.

Medication-related characteristics of cancer patients on chemotherapy in the Amhara region, north-east Ethiopia 2022 (n = 433).

Variables	Category	Frequency	Percent
Treatment modality	Chemotherapy only	295	68.1
Treatment modality	Chemotherapy and surgery	138	31.9
Number of chemotherapies	Mono chemotherapy	52	12.0
Number of chemotherapies	Poly chemotherapy	381	88.0
Number of chemotherapy cycle	1st cycle	3	.78
	2nd cycle	130	30.0
	3rd cycle	153	35.3
	Greater than three	147	33.9
Type of chemotherapy medication	Paclitaxel	29	6.7
	Cyclophosphamide + doxorubcine	168	38.9
	Paclitaxel + cisplatine	107	24.8
	Paclitaxel + carboplatine	17	3.9
	Cyclophsphamde + doxorubcine + vincristine	50	11.6
	Cisplatine + gemcitabine	21	4.9
	Leucovorin +5-fluorouracil (FU)+ oxaliplatin (FOLFOX)	30	6.9
	Others	10	2.3
Total number of medications taken a day (including chemotherapy drugs, anti-pain drugs, and others)	One	53	12.2
	Two	322	74.4
	Three	55	12.7
	Four	2	0.5
	Polypharmacy	1	0.2
Number of chemotherapy medication	One	75	17.3
	Two	305	70.4
	Three	49	11.3
	Four	3	0.7
	Polypharmacy	1	0.2
Side effect	Yes	387	89.4
Side effect	No	46	10.6
Number of hospitalizations	None	4	0.9
	Two	163	37.6
	More than two	266	61.4
Type of payment	Free of charge	309	71.4
	Out-of-pocket money	90	20.8
	Medical insurance	34	7.9

Note: Polypharmacy refers to using five or more medications at the same time.

Healthcare System and Personal-Related Characteristics

Among the total participants, 389 (89.8%) cancer patients had not smoked in the previous month, and 189 (43.6%) cancer patients had to travel more than 7 hours to get their medication from the hospital. 304 (70.2%) of the total participants receive therapeutic communication from their healthcare provider (Table 4).

Table 4.

Health-care system and personal-related characteristics of cancer patients on chemotherapy in the Amhara region, north-east Ethiopia, from May 2022 to July 2022 (n = 433).

Variables	Category	Frequency	Percent
Availability of hormonal therapy	Yes	376	86.8
Availability of hormonal therapy	No	57	13.2
Therapeutic communication	Not at all	16	3.7
	Sometimes	304	70.2
	Very well	113	26.1
Travel to the hospital	<3Hrs	110	25.4
	3 to 6 Hrs	134	30.9
	≥7Hrs	189	43.6
Cigarette smoking within 30 days	Yes	44	10.2
Cigarette smoking within 30 days	No	389	89.8
Cigarette smoking in the lifetime	Yes	176	40.6
Cigarette smoking in the lifetime	No	257	59.4
Alcohol drinking within 30 days	Yes	89	20.6
Alcohol drinking within 30 days	No	344	79.4
Alcohol drinking in the lifetime	Yes	228	52.7
Alcohol drinking in the lifetime	No	205	47.3
Khat chewing in 30 days	Yes	66	15.2
Khat chewing in 30 days	No	367	84.8
Khat chewing in a lifetime	Yes	151	34.9
Khat chewing in a lifetime	No	282	65.1
Social support	Yes	415	95.8
Social support	No	18	4.2

Proportion of Chemotherapy Adherence

Of the total participants, 42.3% (95% CI, 37.6-46.7) of cancer patients adhered well to their chemotherapy regimens. Among participants with good chemotherapy adherence, 135 (73.8%) were female (See Figure 1).

Figure 1.

Proportion of chemotherapy adherence among cancer patients on chemotherapy in the Amhara region, North-East Ethiopia 2022.

Factors Associated With Chemotherapy Adherence

After entering those variables into a multivariable logistic regression, only five variables (sex, family history, history of co-morbidity, experienced side effects, and social sport) were found to be significantly associated with chemotherapy adherence. Females were two times more likely than males to have good adherence [AOR = 2.17, 95% CI (1.31, 3.60)]. Cancer patients with a family history of cancer were about 3.5 times more likely to adhere to their treatment than those without a family history of cancer [AOR = 3.58, 95% CI (2.22, 5.76)]. and people with no history of co-morbidity were 2.7 times more likely to stick to chemotherapy than people with a history of co-morbidity [AOR = 2.74, 95% CI (1.56, 4.81)]; cancer patients who did not experience side effects were at least 3.5 times more likely to adhere to chemotherapy than those who did [AOR = 3.50, 95% CI (1.55, 7.90)]. And cancer patients with social support were 1.5 times more likely to adhere to their treatment than patients without family support [AOR = 1.52, 95% CI (1.21, 1.95)] (Table 5).

Table 5.

Factors associated with chemotherapy adherence among cancer patients Amhara region, North-East Ethiopia, 2022 (n = 433).

Variable	Category	Adherence		Odds Ratio		P value
Variable	Category	Poor	Good	COR (95%CI);	AOR (95% CI);	P value
Sex	Male	138	48	1	1	1
Sex	Female	112	135	3.46(2.29, 5.238)	2.17(1.31, 3.60)	.002*
Travel time to hospital	<3 h	68	89	2.46 (1.49, 3.93)	1.04(.57, 1.90)	.887
	3-6 h	51	59	1.86(1.18, 2.93)	1.38(.79, 2.41)	.255
	≥7 h	71	63	1	1	1
Place of residence	Rural	173	109	1.52(1.02, 2.27)	1.12(.540-2.32)	.761
Place of residence	Urban	77	74	1	1	1
Drinking alcohol in 30 days	Yes	75	14	1
Drinking alcohol in 30 days	No	175	169	5.17(2.81, 9.50)	1.96(.93, 4.13)	.076
Family history of cancer	Yes	63	119	5.51(3.63, 8.37)	3.58(2.22, 5.76)	.000*
Family history of cancer	No	187	64	1	1	1
Number of chemotherapy medication	Mono chemotherapy	26	26	.70(.39, 1.25)	2.17(.91, 4.51)	.056
Number of chemotherapy medication	Poly chemotherapy	224	157	1	1	1
History of comorbidity	Yes	121	31	1	1	1
History of comorbidity	No	129	152	4.59(2.90, 7.27)	2.74(1.56, 4.81)	.000*
Social support	Yes	242	173	1.74(.67, 4.521)	1.52(1.21, 1.95)	.036*
Social support	No	8	10	1	1	1
Availability of chemotherapy	Yes	174	202	4.59(2.19,9.63)	2.73(.92, 6.64)	.057
Availability of chemotherapy	No	9	48	1	1
Experienced side effect	Yes	238	149	1	1	1
Experienced side effect	No	12	34	4.52 (2.27, 9.01)	3.50(1.55, 7.90)	.003*
TherapeuticCommunication	Not at all	12	4	.40(.12, 1.33)	.37(.097,1.44)	.156
	Sometimes	176	128	.88(.57, 1.36)	.92 (.53, 1.57	.768
	Very well	62	51	1	1	1
Types of payment	Free of charge	190	119	1.31(.61, 2.78)	.82(.30, 2.21)	.695
	Out-off-pocket	37	53	2.99(1.30 6.88)	1.95(.65, 5.87)	.232
	Medical insurance	23	11	1	1	1

Keynote: COR: Crude odd ration, AOR: Adjusted odd ratio, CI: Confidence interval index, housewife, *: Significant variable at P-value <.05.

Discussion

The magnitude of cancer patients who adhered to chemotherapy was relatively low in this study. Sex, cancer family history, co-morbidity history, side effects experienced, and social support were positive predictors of chemotherapy adherence. Accordingly, the overall proportion of chemotherapy adherence among cancer patients in the Amhara region of north-east Ethiopia was [42.3% (95% CI, 37.6-46.7)] in this study. Chemotherapy adherence was higher among cancer patients in the Amhara region of North-East Ethiopia compared to studies conducted in Nigeria (19.1%) and India (21.1%).^28,29 One possible explanation is that the majority of participants in this study were female, and female cancer patients were more adherent than males, so the proportion may be higher.

However, the results were lower when compared to studies conducted in the United States (85.57%), Japan (56.4%), and Brazil (85.2%).^29-31 This difference could be explained by a change in assessment tools; in this study, the Morisky Medication Adherence Measurement Scale-8 was used to assess medication adherence, whereas in most other studies, the Morisky Medication Adherence Measurement Scale-4 was used to assess medication adherence. However, the results of this study were consistent with the results of a study conducted in Brazil (46.43%).³²

In this study, a significant relationship between sex and adherence level was discovered. As a result, men were found to be less adherent than women. This finding is consistent with a study conducted in India³³ in which men had a nearly threefold increase in the risk of non-adherence when compared to women. This is due to the fact that men are burdened by outdoor activities that keep them busy and cause them to forget their medications. Alcohol consumption, which is common among men, could also be a barrier to treatment adherence.

History Co-morbidities can worsen a patient’s condition and make it difficult for them to take their chemotherapy medications. According to this study, the number of co-morbidities among cancer patients had a significant impact on adherence behavior. Patients who had no or one co-morbidity were more likely to stick to their treatment than those who had two or more co-morbidities. This finding is consistent with the findings of a Brazilian study.³² This association may be due to the fact that patients with a greater number of co-morbidities are more likely to experience serious complications and complex treatment regimens, which are favorable conditions for patients not to adhere to their medications.

This study also discovered that social support is linked to medication non-adherence. Cancer patients who were satisfied with their family and friends' support were 1.5 times more likely to adhere to their medication than those who were not. This study’s findings are consistent with previous research conducted in southern Brazil and other parts of the world.^34,35 This could be because those who received motivation and encouragement were psychologically well and were able to strictly adhere to prescribed medication.

According to this study, having a history of side effects from chemotherapy drugs was associated with non-adherence to medication. According to this study, cancer patients who do not experience side effects from chemotherapy are at least 3.5 times more likely to have good adherence than those who do. Previous studies on cancer patients in Japan, Taiwan, and India found similar results.^29,36,37 A possible explanation for this association could be that participants had a history of side effects that caused treatment interruptions due to concerns about worsening symptoms, which increased the burden of taking prescribed medications and their side effects. As a coping mechanism for the diminished symptoms combined with worsening side effects, some cancer patients decide to discontinue treatment; as a result, some of the patients in the medication non-adherence group may have decided to stop taking their medications to cope with side effects, as in the past.

This study also found a link between a family history of cancer and adherence to chemotherapy. Cancer patients with a cancer family history were about 3.5 times more likely to have good adherence than those without a cancer family history. This finding is consistent with a study conducted in Brazil.³¹ One possible explanation is that patients with a cancer family history have more information about chemotherapy medication and the importance of good adherence, which increases adherence among cancer patients with a family history.

Conclusion

In this study, the proportion of cancer patients who adhered to chemotherapy was relatively low. Sex, family history of cancer, history of co-morbidity, experienced side effects, and social support were the main factors associated with the development of chemotherapy adherence. Health education about the disease and its treatment is important for improving patient adherence, and involving family members in the treatment plan and improving patients' understanding of the illness are critical in achieving high adherence to medication in this context.

Strengths and limitations

The Morisky Medication Adherence Scale-8 (MMAS-8) was used in this study as a standardized, expert-reviewed, and pre-tested data collection tool with high reliability and validity. There were some additional variables (alcohol consumption, cigarette smoking, and khat chewing) to assess associated factors for chemotherapy adherence. However, this study may have methodological flaws such as face-to-face interviews, which may lead to social desirability bias by overestimation or underestimation of the result, and recall bias may be exposed to obtain appropriate information from each participant, and cause and effect relationships for the factors dealt with in the study were not possible to establish because it is difficult to know which occurred first, the exposure or outcome variable.

Footnotes

Appendix

Acknowledgments

The author would like to thank Dessie and Felegehiwot Comprehensive Specialized Hospital staff, study participants, and the Merton office for their kind cooperation. We are also thankful to data collectors.

Author Contribution

The authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the only institutional support from the hospitals and Alkan health science college.

Ethical Approval

The review committee of the College of Medicine and Health Science, Wollo University, Dessie, Ethiopia, vetted and approved the study procedures (WU/CMHS/140/2022) on April 20, 2022, and ethical approval was obtained. Dessie and Felegehiwot hospitals in the Amhara region also provided explicit consent letters. Having fully understood the purpose of the study, each respondent provided written consent prior to the interview. In addition, the study was carried out in accordance with the Declaration of Helsinki. Recalcitrant study participants were excluded from the survey.

Informed Consent

Anonymized data was collected, and participant information was kept confidential.

ORCID iD

Muluken Amare Wudu

Data Availability Statement

All generated or analyzed during this study are included in the manuscript and are also available from the corresponding author upon request.

References

Aggarwal

Chawla

Singh

Rana

. Evaluation of anticancer drug utilization and monitoring of adverse drug reaction in the indoor patients receiving cancer chemotherapy in a Tertiary Care Hospital in New Delhi. J Basic Clin Pharm. 2018;9(2):11.

World Health Organization (WHO) . Global Health Estimates 2020: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2019. WHO; 2020.

Sung

Ferlay

Siegel

, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71:209-249. DOI: 10.3322/caac.21660

Woldu

Legese

Abamecha

Berha

. The prevalence of cancer and its associated risk factors among patients visiting oncology unit, TikurAnbessa Specialized Hospital, Addis Ababa-Ethiopia. J Cancer Sci Ther. 2017;9(04):11.

H-S

Harden

. Symptom burden and quality of life in survivorship: a review of the literature. Cancer Nurs. 2015;38(1):E29-E54.

Sabate

. WHO Adherence Meeting Report. Geneva: World Health Organization; 2001.

Haynes

. Determinant of compliance: The disease and the mechanics of treatment. Compliance in Health Care. Online ahead of print. 1979.

Rand

. Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia. Am J Cardiol. 1993;72(10):D68-D74.

Chen

, et al. Anticancer drugs induced severe adverse cutaneous drug reactions: an updated review on the risks associated with anticancer targeted therapy or immunotherapies. Journal of immunology research. 2018;11:2018.

10.

Ganesan

Sagar

Dubashi

, et al. Nonadherence to imatinib adversely affects event-free survival in chronic phase chronic myeloid leukemia. Am J Hematol. 2011;86(6):471-474.

11.

Rout

Panda

Mishra

Parida

Mohanty

. Pharmacovigilance in cancer chemotherapy in regional cancer center of Eastern India: prospective observational study. Int J Basic Clin Pharmacol. 2017;6(8):1910.

12.

Greer

Amoyal

Nisotel

, et al. A systematic review of adherence to oral antineoplastic therapies. Oncol. 2016;21(3):354-376.

13.

Efficace

Baccarani

Rosti

, et al. Investigating factors associated with adherence behaviour in patients with chronic myeloid leukemia: an observational patient-centered outcome study. British journal of cancer. 2012;107(6):904-909.

14.

Spoelstra

Given

, et al. An intervention to improve adherence and management of symptoms for patients prescribed oral chemotherapy agents: an exploratory study. Cancer Nurs. 2013;36(1):18-28.

15.

Bhatia

Landier

Shangguan

, et al. Nonadherence to oral mercaptopurine and risk of relapse in Hispanic and non-Hispanic white children with acute lymphoblastic leukemia: a report from the children's oncology group. J Clin Oncol. 2012;30(17):2094.

16.

Makubate

Donnan

Dewar

Thompson

McCowan

. Cohort study of adherence to adjuvant endocrine therapy, breast cancer recurrence, and mortality. British journal of cancer. 2013;108(7):1515-1524.

17.

World Health Organization . Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020.2013. Geneva: World Health Organization.

18.

Federal Ministry of Health Ethiopia . Disease Prevention, and Centers Control Directorate, National Cancer Control Plan 2016-2020. Federal Ministry of Health Ethiopia; 2015:1-85.

19.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147:573-577.

20.

Wako

Mengistu

Dinegde

Asefa

Wassie

. Adherence to adjuvant hormonal therapy and associated factors among women with breast cancer attending the Tikur Anbessa Specialized Hospital, Addis Ababa Ethiopia, 2019: a cross-sectional study. Breast Cancer. 2021;13:383.

21.

Morisky

DE. ScD*

Green

Lawrence W. DrPH

Levine

David M. MD‡

, Concurrent and Predictive Validity of a Self-reported Measure of Medication Adherence. Medical Care. 1986;24(1):67-74.

22.

Morisky

Ang

Krousel-Wood

Ward

. Predictive validity of a medication adherence measure in an outpatient setting. The journal of clinical hypertension. 2008;10(5):348-354.

23.

Janežič

Locatelli

Kos

. Criterion validity of 8-item Morisky Medication Adherence Scale in patients with asthma. PLoS One. 2017;12(11):e0187835.

24.

Chew

B-H

Hassan

N-H

Sherina

M-S

. Determinants of medication adherence among adults with type 2 diabetes mellitus in three Malaysian public health clinics: a cross-sectional study. Patient Prefer Adherence. 2015;9:639.

25.

Anderson

Matey

. Overview of cancer and cancer treatment. In: Olsen

LeFebvre

Brassil

, eds. Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice. Pittsburgh, PA: Oncology Nursing Society; 2019:25-50.

26.

Altun

Sonkaya

. The most common side effects experienced by patients were receiving first cycle of chemotherapy. Iran J Public Health. 2018;47(8):1218-1219.

27.

Zhao

, et al. Association of Social Support and Medication Adherence in Chinese Patients with Type 2 Diabetes Mellitus. Int J Environ Res Public Health. 2017;14(12):1522. doi: 10.3390/ijerph14121522

28.

Adisa

Lawal

Adesunkanmi

. Evaluation of patients\'adherence to chemotherapy for breast cancer. Afr J Health Sci. 2008;15(1):22-27.

29.

Hirao

Mikoshiba

Shibuta

, et al. Adherence to oral chemotherapy medications among gastroenterological cancer patients visiting an outpatient clinic. Jpn J Clin Oncol. 2017;47(9):786-794.

30.

Jacobs

Ream

Pensak

, et al. Patient experiences with oral chemotherapy: adherence, symptoms, and quality of life. J Natl Compr Cancer Netw. 2019;17(3):221-228.

31.

Guedes

JBR

Guerra

Alvim

Leite

ICG

. Factors associated with adherence and persistence to hormonal therapy in women with breast cancer. Rev Bras Epidemiol. 2017;20:636-649.

32.

Souza

Moraes

Inocenti

Santos

Silva

AEBC

Miasso

. Mujeres con cáncer de mama en tratamiento con quimioterapéuticos: síntomas depresivos y adhesión al tratamiento. Rev Latino-Am Enferm. 2014;22:866-873.

33.

Kumar

Gudhoor

Ganachari

. Parallel assessment of chemotherapy adherence and supportive therapy adherence on occurrence and minimization of adverse drug reactions among cancer patients: a clinical-based observational study. Journal of Pharmacy Technology. 2020;36(2):72-77.

34.

Oliveira

Primeira

Santos

Paula

Padoin

SMM

. Association between social support and adherence to anti-retroviral treatment in people living with HIV. Revista Gaúcha de Enfermagem. 2020;1:41.

35.

Shahin

Kennedy

Stupans

. The association between social support and medication adherence in patients with hypertension: a systematic review. Pharm Pract. 2021;19(2):11

36.

Tsai

Y-F

Huang

W-C

Cho

S-F

, et al. Side effects and medication adherence of tyrosine kinase inhibitors for patients with chronic myeloid leukemia in Taiwan. Medicine. 2018;97(26):415.

37.

Dwajani

Prabhu

Ranjana

Sahajananda

. Importance of medication adherence and factors affecting it. IP International Journal of Comprehensive and Advanced Pharmacology. 2020;3(2):69-77.