
==== Front
BMC Psychol
BMC Psychol
BMC Psychology
2050-7283
BioMed Central London

1959
10.1186/s40359-024-01959-4
Research
Examining the influence of anxiety and depression on medication adherence among patients diagnosed with acute myocardial infarction
Ashour Audai M. 1
Masa’deh Rami r_masadeh@asu.edu.jo

1
Hamaideh Shaher H. 2
Elshatarat Rami A. 3
Yacoub Mohammed Ibrahim 4
Almagharbeh Wesam T. 5
Alhejaili Asim Abdullah 3
Alshahrani Bassam Dhafer 37
Sobeh Dena Eltabey 6
Eltayeb Mudathir M. 6
1 https://ror.org/01ah6nb52 grid.411423.1 0000 0004 0622 534X Faculty of Nursing, Applied Science Private University, Amman, Jordan
2 https://ror.org/04a1r5z94 grid.33801.39 0000 0004 0528 1681 Community and Mental Health Nursing Department, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
3 https://ror.org/01xv1nn60 grid.412892.4 0000 0004 1754 9358 Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
4 https://ror.org/05k89ew48 grid.9670.8 0000 0001 2174 4509 Department of Clinical Nursing, School of Nursing, The University of Jordan, Amman, Jordan
5 https://ror.org/04yej8x59 grid.440760.1 0000 0004 0419 5685 Medical Surgical Nursing Department, Faculty of Nursing, University of Tabuk, Tabuk, Saudi Arabia
6 https://ror.org/04jt46d36 grid.449553.a 0000 0004 0441 5588 Department of Medical Surgical Nursing, College of Nursing, Prince Sattam bin Abdulaziz University, AlKharj, Saudi Arabia
7 https://ror.org/00jtmb277 grid.1007.6 0000 0004 0486 528X Honorary Fellow, School of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
6 9 2024
6 9 2024
2024
12 47314 6 2024
20 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Effective medication adherence is vital for managing acute myocardial infarction (AMI) and enhancing patient well-being. This study aimed to evaluate medication adherence levels and associated factors among AMI patients using standardized assessment tools.

Methods

Employing a cross-sectional descriptive design, the study involved 210 patients diagnosed with acute myocardial infarction. Participants completed the General Medication Adherence Scale (GMAS), Hospital Anxiety and Depression Scale (HADS), and provided socio-demographic details.

Results

The study revealed partial adherence to medications among AMI patients, with mean scores of 24.89 (± 3.64) out of 33. Notably, good adherence was observed in non-adherence due to patient behavior (mean ± SD = 11.8 ± 2.3 out of 15) and additional disease burden (mean ± SD = 8.65 ± 2.21 out of 12), while partial adherence was noted in non-adherence due to financial constraints (mean ± SD = 4.44 ± 1.34 out of 6). Patients reported mild anxiety (mean ± SD = 8.38 ± 2.81) and no depressive symptoms (mean ± SD = 7.43 ± 2.42). Multiple linear regression analysis indicated that employed status, younger age, shorter duration of MI, lower anxiety, and depression levels were associated with higher medication adherence. However, factors such as monthly income, gender, educational level, and marital status did not predict medication adherence.

Conclusion

The study highlights the significance of addressing anxiety and depression levels and considering socio-demographic factors when designing interventions to enhance medication adherence among AMI patients. Further research is needed to explore additional determinants of medication adherence and develop tailored interventions to improve patient outcomes post-AMI.

Keywords

Medication adherence
Acute myocardial infarction
Anxiety
Depression
Patient outcomes
Jordan
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Cardiovascular diseases (CVDs) represent a significant health concern globally, encompassing a range of conditions affecting the heart and blood vessels, including coronary heart disease and acute myocardial infarction (AMI). According to the World Health Organization (WHO), CVDs are responsible for a substantial portion of global mortality, with nearly 18 million deaths annually, accounting for approximately 32% of all deaths worldwide [1]. In Jordan, CVD-related fatalities constitute a staggering 40% of total deaths, with an adjusted death rate of 136 per 100,000 population, positioning Jordan at 46th globally in terms of CVD mortality [2]. This high prevalence can be attributed to various factors, including a significant percentage of the population engaging in smoking, being overweight, neglecting cholesterol assessments, and having a family history of CVDs.

AMI, commonly known as a heart attack, is a critical medical condition characterized by restricted blood flow to myocardial tissue, resulting in tissue necrosis or death. The leading cause is typically a blockage in the coronary artery, often due to coronary artery disease, though coronary spasms induced by medication usage or uncontrolled hypertension can also contribute [3]. The treatment protocol for AMI patients is multifaceted and intricate, with pharmacological therapy serving as a cornerstone. Adherence to prescribed medications plays a pivotal role in symptom management, reducing hospital readmission rates, and enhancing survival prospects [4, 5].

Despite the acknowledged importance of medication adherence, previous research indicates suboptimal adherence rates among AMI patients, ranging from 40 to 60% 6. Various factors influence medication adherence, categorized by the WHO into five dimensions: patient-related, therapy-related, healthcare system-related, socioeconomic, and condition-related psychological factors [7]. Patient-related factors encompass physical and cognitive impairments, alongside low social support, which can hinder adherence [8, 9]. Therapy-related factors such as complex medication regimens and adverse effects can also pose challenges [10]. Effective patient-provider relationships within the healthcare system are crucial for fostering adherence, with supportive interactions positively influencing medication compliance [11].

Moreover, socioeconomic factors, including social support networks and economic status, significantly impact adherence to self-care management [12]. Psychological factors such as anxiety and depression, categorized under condition-related factors, further complicate adherence efforts. Studies have linked anxiety and depression to decreased medication adherence among CVD patients, including those with AMI, emphasizing the need for tailored interventions [13, 14]. Notably, non-adherence to medications has been documented in a substantial proportion of cardiovascular patients, with rates as high as 60%, underscoring the urgency of addressing this issue, particularly in the context of AMI [15].

The emotional dimensions of CVDs play a crucial role in patient outcomes, particularly in the context of self-care and medication adherence. Emotional regulation processes, anxiety, and depression significantly impact the quality of life and adherence behaviors in patients with AMI [16–18]. Studies have shown that emotional dysregulation can exacerbate cardiovascular risks, influencing both physical and psychological health outcomes [19–22]. For instance, the interplay between anxiety, emotional regulation, and cardiovascular risk factors underscores the need for tailored interventions to address these emotional dimensions in AMI patients [19, 23]. Additionally, the level of adherence to prescribed medication regimens, such as dual antiplatelet therapy, has been linked to the emotional well-being of patients, highlighting the importance of integrating psychological care into cardiovascular treatment plans [24]. By reinforcing the connection between emotional health and cardiovascular disease management, this study aims to provide a comprehensive understanding of the factors influencing medication adherence among AMI patients.

The role of self-care in the management of CVDs is increasingly recognized as a critical component in improving patient outcomes, particularly for those with AMI [20, 23]. Effective self-care practices, including adherence to medication and lifestyle modifications, are essential for managing symptoms and preventing disease progression. Psychological characteristics such as anxiety and emotional dysregulation significantly impact a patient’s ability to engage in self-care and adapt to their disease, affecting overall health outcomes. For instance, the interplay between cardiovascular risk factors and psychological states like anxiety underscores the need for holistic management approaches that address both physical and emotional health [23]. Furthermore, tailored interventions that focus on enhancing self-care behaviors have been shown to improve quality of life and reduce the burden of CVDs [19, 25, 26]. By incorporating insights from the literature on self-care and the psychological dimensions of CVDs, this study aims to deepen the understanding of factors influencing medication adherence among AMI patients, offering valuable implications for both clinical practice and future research [27, 28].

In Jordan, despite several studies addressing medication adherence in various populations, including psychiatric and hypertensive patients, research specific to CVDs, particularly AMI, remains scarce. Given the rising burden of CVDs and the prevalence of comorbidities, there is a pressing need to investigate medication adherence among AMI patients comprehensively. By identifying and addressing the multifaceted factors influencing adherence, tailored interventions can be developed to optimize treatment outcomes and mitigate the adverse impact of AMI.

In Jordan, there’s a significant gap in our understanding of how psychosocial factors, such as anxiety and depression, relate to medication adherence among AMI patients. This study aims to address this gap by investigating adherence levels and the factors that influence medication adherence among AMI patients in Jordan. Furthermore, the study endeavors to contribute to existing literature by conducting a comprehensive evaluation of medication adherence and its association with psychosocial factors, particularly anxiety and depression, among AMI patients in Jordan. The findings from this research will not only deepen our understanding of adherence behaviors within this population but also provide crucial insights for healthcare providers. This information can be utilized to develop targeted interventions and strategies aimed at promoting medication adherence among AMI patients. Additionally, the study aims to lay the groundwork for the development of programs tailored to meet the specific psychosocial needs of AMI patients. By addressing these needs, the study seeks to enhance overall treatment outcomes and improve the quality of life for AMI patients in Jordan.

Research objectives

The research objectives are as follows: (1) Determine the levels of medication adherence, anxiety, and depression among patients diagnosed with AMI in Jordan, and (2) Investigate whether anxiety, depression, and socio-demographic variables serve as predictors for medication adherence among patients diagnosed with AMI in Jordan.

Methods

Design

A cross-sectional descriptive design was employed to investigate the correlation between psychosocial factors (anxiety and depression) and medication adherence among AMI patients in Jordan.

Setting

The study is set within the multifaceted healthcare sector of Jordan, encompassing a spectrum of institutions managed by the Ministry of Health, university hospitals, private facilities, and military establishments [29]. Five hospitals were strategically selected to ensure a broad representation across geographical regions and healthcare sectors. Among these were two public hospitals overseen by the Ministry of Health, a university hospital renowned for its specialized services and research, a private hospital catering to diverse socio-economic backgrounds, and a military hospital addressing the healthcare needs of service personnel and their families. Each hospital, equipped with outpatient clinics specializing in CVDs, serves as a pivotal site for the study’s investigation into the correlation between psychosocial factors, such as anxiety and depression, and medication adherence among AMI patients.

This diverse selection of hospitals and specialized outpatient clinics not only ensures access to a wide range of AMI patients but also facilitates the recruitment of a sufficient number of participants for the study. By incorporating these varied healthcare settings, the study aims to provide a comprehensive understanding of the factors influencing medication adherence among AMI patients in Jordan. Through this approach, the research endeavors to shed light on the intricate interplay between psychosocial factors and adherence behaviors, ultimately contributing valuable insights to the enhancement of patient care and treatment outcomes within the Jordanian healthcare landscape.

Sample

Employing a convenient sampling method, participants were recruited from the accessible population due to its practicality and alignment with the study’s logistical constraints. To ensure the inclusion of representative and reliable participants, specific inclusion criteria were established. These criteria encompassed a diagnosis of AMI for more than six months to ensure consistent medication adherence, an age of 18 years or older, a minimum attendance of three months at the outpatient clinic to signify commitment to prescribed medications and clinic appointments, absence of chronic mental health disorders to mitigate potential confounding factors, and proficiency in Arabic reading, writing, and comprehension to accurately complete study instruments and questionnaires. By adhering to these stringent inclusion criteria, the study aimed to minimize biases and enhance the validity of its findings, thereby ensuring robust and meaningful conclusions.

Two co-authors, who hold PhDs in nursing and specialize in clinical research with a focus on psychosocial well-being and quality of life among CVD patients, were tasked with data collection. These researchers were actively involved in recruiting patients and gathering both demographic and clinical information. To ensure accuracy, they conducted health assessments during patient interviews, meticulously adhering to the study’s inclusion and exclusion criteria. The integrity of the data was further validated by cross-referencing with patients’ medical records. These same researchers also administered the psychological assessment tools, ensuring a consistent and professional approach throughout the data collection process.

In determining the sample size for this study, a meticulous calculation based on a power of 0.80, an α-level of 0.05, and an anticipated medium-size effect indicated that a total of 210 participants would be necessary to detect statistically significant differences for the nine predictors under investigation. The researchers interviewed 247 participants and collected data from them. However, 21 participants did not complete the interviews or questionnaires and chose to withdraw. Additionally, 16 participants did not answer all questionnaire items; these incomplete questionnaires were excluded from the final analysis due to potential impact on results. Thus, the final data analysis included 210 participants, meeting the calculated effective sample size.

The target population encompassed all individuals diagnosed with AMI within the Jordanian healthcare system. From this broader target pool, the accessible population consisted specifically of those AMI patients who sought treatment at outpatient clinics between July and September 2022 within the selected hospital settings.

Data collection procedure

Two PhD co-authors in nursing gathered data through structured self-reports during direct interviews, using valid and reliable questionnaires. They validated this information against medical records and administered health and psychological assessments to ensure accuracy. The data collection procedure commenced with the researcher seeking approval and access from the medical department at the selected study settings, ensuring compliance with institutional protocols. Subsequently, data collection was conducted within the waiting rooms of outpatient clinics at designated hospitals, targeting patients seeking treatment for AMI. An informed consent process was meticulously followed, wherein potential participants received information sheets detailing the study’s purpose and procedures, accompanied by consent forms to indicate voluntary participation. Upon obtaining consent, participants were administered a paper-based questionnaire covering various aspects such as medication adherence, anxiety, depression, socio-demographic factors, and more.

Throughout the questionnaire administration, participants were offered assistance and clarification by the researcher as needed, fostering a supportive environment conducive to accurate data collection. Following completion, filled-out questionnaires were collected, and participant identifiers were removed to maintain confidentiality. Data handling procedures adhered to ethical guidelines, ensuring secure storage and protection of participant information. Overall, this structured approach aimed to gather comprehensive and reliable data from AMI patients, prioritizing ethical standards to uphold the integrity and validity of the study.

Instruments

The data collection instrument for this study comprises three main parts, meticulously designed to capture relevant information essential for the research objectives.

Socio-demographic characteristics

The first part of the instrument focuses on gathering socio-demographic data pertinent to the participants. This includes variables such as age, gender, marital status, educational level, employment status, monthly income, and the duration of Myocardial Infarction (MI) in months. These details provide valuable context and insights into the characteristics of the study population.

General medication adherence scale (GMAS)

The second part of the instrument utilizes the GMAS, developed by Naqvi et al. (2018) [30]. This scale comprises 11 items aimed at assessing the level of medication adherence among patients. GMAS consists of three subscales: non-adherence due to patient behavior (5 items), non-adherence due to additional diseases and pill burden (4 items), and non-adherence due to financial constraints (2 items). Each item is scored on a scale from 0 to 3, with higher scores indicating better adherence [30, 31].

The scores on the GMAS were categorized as follows: For the first subscale, a score of 13–15 indicated high adherence, 11–12 denoted good adherence, 8–10 signified partial adherence, 5–7 represented low adherence, and 0–4 indicated poor adherence. Similarly, on the second subscale, scores of 11–12 reflected high adherence, 9–10 indicated good adherence, 6–8 represented partial adherence, 4–5 signified low adherence, and 0–3 indicated poor adherence. For the third subscale, a score of 6 indicated high adherence, 5 denoted good adherence, 3–4 represented partial adherence, 2 signified low adherence, and 0–1 indicated poor adherence. Overall scoring categorized participants into high adherence (30–33), good adherence (27–29), partial adherence (17–26), low adherence (11–16), and poor adherence (0–10). Additionally, a participant scoring 27 or above was considered adherent, while a score of 26 or lower was considered non-adherent [31].

The scale has been validated for reliability and validity in its Arabic version by Naqvi et al. (2020), with Cronbach’s alpha for GMAS in the current study reaching 0.84, with subscales ranging between 0.68 and 0.78 [32]. Scoring criteria are provided for each subscale, enabling categorization of adherence levels ranging from high to poor adherence.

Hospital anxiety and depression scale (HADS)

The third component of the instrument employs the HADS to evaluate participants’ experiences of anxiety and depressive symptoms within the previous week. Originally developed by Zigmond and Snaith in 1986 [33, 34], the HADS comprises two distinct subscales: one focusing on anxiety and the other on depression. Each subscale consists of seven items, which participants rate using a Likert-Type scale ranging from 0 to 3. Higher scores on the scale indicate heightened levels of anxiety and depression. The HADS generates scores ranging from 0 to 21 for each subscale, with established guidelines categorizing scores as normal (0–7), mild (8–10), moderate (11–14), and severe (15–21) based on the severity of symptoms [34, 35].

The scale has demonstrated strong psychometric properties, including good internal consistency and convergent validity. In this study, the Arabic version of HADS was utilized, ensuring reliability and validity with Cronbach’s alpha for anxiety subscale at 0.85 and for depression subscale at 0.82 [36]. Participants’ scores are categorized to delineate levels of anxiety and depression severity, facilitating a comprehensive assessment of psychosocial factors influencing medication adherence among AMI patients.

Ethical considerations and consent to participate

The study upheld rigorous ethical standards, receiving approval from both the Institutional Review Board (IRB) affiliated with the principal investigator’s (Applied Science Private University [IRB approval No.: 2022-NC-254]) in Amman, Jordan and all relevant data collection settings. The research adhered strictly to relevant guidelines and regulations, including the ethical principles of the Declaration of Helsinki [37]. Prior to participation, all participants provided formal written informed consent. We ensured they fully understood the study’s purpose, procedures, potential risks and benefits. We emphasized confidentiality and took steps to anonymize all participant information used in the manuscript and supplementary materials. Moreover, participant confidentiality was paramount. To protect their anonymity, we did not collect any identifying information and anonymized all data throughout the research process. Furthermore, the study did not involve violence, any physically or psychologically harmful procedures, or the collection of sensitive personal or clinical details that could compromise anonymity.

Throughout the research process, ethical principles rooted in respect for human dignity guided every aspect, ensuring the protection of participants’ rights and well-being. Prior to participation, individuals received detailed information about the study’s objectives, procedures, and potential risks and benefits through an informative sheet, empowering them to make informed decisions. Participation was entirely voluntary, with participants having the autonomy to withdraw at any stage without repercussions. Written consent was obtained from each participant before completing the questionnaire, affirming their informed agreement to partake in the study.

To safeguard participants’ privacy and confidentiality, stringent measures were implemented. All data collection activities were conducted in private settings, and participants’ identities were anonymized using assigned codes. Data were securely stored and accessible only to authorized researchers, ensuring confidentiality. Additionally, participants’ rights were prioritized throughout the study, with measures in place to minimize any potential risks or discomfort. Participants were assured that their decision to participate or withdraw would not affect their ongoing medical care or relationship with healthcare providers. By adhering to these ethical considerations, the study upheld the highest standards of integrity and transparency, fostering trust and ensuring the well-being of all participants involved.

Data analysis

The data analysis for this study was conducted using IBM-SPSS version 26, beginning with thorough screening to address any missing data or outliers that could potentially bias the results. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were computed to elucidate the levels of medication adherence, anxiety, and depression among the participants. Multiple linear regression analysis was then employed to investigate the predictors of medication adherence, exploring the relationships between adherence and various factors such as socio-demographic variables, anxiety levels, and depression levels. Factors entered into the model included employment status, age, duration of MI, gender, educational level, monthly income, marital status, anxiety, and depression. Dummy variables were created for categorical variables with more than two categories (employment, monthly income, educational level, and marital status), with specific coding for each: Employment status (employed vs. retired), Gender (male vs. female), Educational level (≤ school vs. ≥ high diploma), Marital status (single vs. has been married), Monthly income (< 600 JD [$ 845] vs. ≥ 600 JD [$ 845]).

Before conducting the regression analysis, critical assumptions were assessed, including checks for multicollinearity and evaluation of the normal distribution of the adherence variable using the Kolmogorov-Smirnov Test. This rigorous methodology ensured the reliability and integrity of the study’s findings, providing valuable insights into the factors influencing medication adherence among AMI patients, including the complex interplay between socio-demographic factors and psychosocial variables such as anxiety and depression.

Results

Description of socio-demographic characteristics

The demographic profile of the study participants, as outlined in Table 1, encompasses various aspects of their background. Among the 210 individuals involved, the mean age was 53.59 years, with a standard deviation of 9.81. Gender distribution showed a slight majority of males, constituting 53.3% (n = 112), while females accounted for 46.7% (n = 98) of the sample. Regarding marital status, the majority were married (76.7%, n = 161), with smaller proportions reporting being single (2.4%, n = 5), divorced (8.1%, n = 17), or widowed (12.9%, n = 27). Educational attainment varied among participants, with 6.2% (n = 13) categorized as illiterate, 21.0% (n = 44) having an education level of ≤ high school, 26.7% (n = 56) holding a high diploma, 34.8% (n = 73) possessing a bachelor’s degree, and 11.4% (n = 24) holding a post-graduate degree. Employment status indicated that 41.9% (n = 88) worked in the public sector, 43.3% (n = 91) in the private sector, and 14.8% (n = 31) were retired. Concerning monthly income, the majority (80.5%, n = 169) reported earnings below 600 JD ($ 845), with the remaining 19.5% (n = 41) having an income of 600 JD ($ 845) or above. The average duration of AMI among participants was 5.20 months, with a standard deviation of 2.48. These demographic insights provide a foundational understanding of the study population, facilitating further exploration and interpretation of the research outcomes.

Table 1 Participants’ demographics (N = 210)

Variable	n (%) or
Mean ± SD	
Age	53.59 ± 9.81	
Gender		
 Male	112 (53.3%)	
 Female	98 (46.7%)	
Marital status		
 Single	5 (2.4%)	
 Married	161 (76.7%)	
 Divorced	17 (8.1%)	
 Widowed	27 (12.9%)	
Educational level		
 Illiterate	13 (6.2%)	
 ≤ high school	44 (21.0%)	
 High diploma	56 (26.7%)	
 Bachelor degree	73 (34.8%)	
 Post-graduate degree	24 (11.4%)	
Employment status		
 Public sector	88 (41.9%)	
 Private sector	91 (43.3%)	
 Retired	31 (14.8%)	
Monthly income		
 < 600 JD ($ 845)	169 (80.5%)	
 ≥ 600 JD ($ 845)	41 (19.5%)	
Duration of MI (months)	5.20 ± 2.48	

Participants’ adherence to medication

The analysis of participants’ adherence to their prescribed medication regimen revealed insightful patterns across various factors, as detailed in Table 2. Participants exhibited diverse responses regarding the difficulty in remembering to take medications and forgetting doses due to a busy schedule or other commitments. Notably, 16.7% (n = 35) reported “Always” experiencing difficulty remembering, while 21.4% (n = 45) stated they “Never” had this issue. Similarly, responses concerning forgetting doses due to a hectic schedule showed variation, with 19.5% (n = 41) reporting “Always” forgetting, and 44 (21%) never experiencing this. Moreover, a considerable proportion of participants acknowledged discontinuing medication when feeling well (21.9%, n = 46) or experiencing adverse effects (22.4%, n = 47). Additionally, 24.8% (n = 52) admitted to stopping medication without informing their healthcare provider. The total of non-adherence due to patient behavior, measured on a scale of 0 to 15, ranged from poor to good-high adherence. Specifically, 21% (n = 44) demonstrated poor adherence, while 17.6% (n = 37) showed good to high adherence.

Table 2 The participants’ adherence to medication

Variables	Always (0)	Mostly (1)	Sometimes (2)	Never (3)	Mean ± SD	
Do you have difficulty in remembering to take your medications	35 (16.7%)	82 (39%)	48 (22.9%)	45 (21.4%)	2.49 ± 1.00	
Do you forget to take your medication due to your busy schedule, traveling, meeting, events at home, marriage, religious celebrations, etc.	41 (19.5%)	80 (38.1%)	45 (21.4%)	44 (21%)	2.43 ± 1.03	
Do you discontinue your medication when you feel well	46 (21.9%)	82 (39%)	43 (20.5%)	39 (18.6%)	2.35 ± 1.02	
Do you stop taking medications when you feel adverse effects such as gastric discomfort, etc.	47 (22.4%)	91 (43.3%)	42 (20%)	30 (14.3%)	2.26 ± 0.96	
Do you stop taking medications without informing the doctor	52 (24.8%)	81 (38.6%)	49 (23.3%)	28 (13.3%)	2.25 ± 0.98	
Total of non-adherence due to patient behavior (out of 15)	0–4 (poor adherence)	5–7 (low adherence)	8–10 (partial adherence)	11–15 (good to high adherence)	11.8 ± 2.30	
44 (21%)	83 (39.6%)	46 (21.9%)	37 (17.6%)	
Do you discontinue your medicines due to other medicines that you have to take for your additional disease?	57 (27.1%)	78 (37.1%)	45 (21.4%)	30 (14.3%)	2.23 ± 1.00	
Do you find it is a hassle to remember your medications due to medication regime complexity?	66 (31.4%)	81 (38.6%)	44 (21%)	19 (9%)	2.07 ± 0.94	
During the last month, had there been any occasion when you missed your medicines due to the progression of the disease or addition of new medicines?	54 (25.7%)	83 (39.5%)	39 (18.6%)	34 (16.2%)	2.25 ± 1.01	
Do you alter the medication regimen, dose and frequency by yourself?	61 (29%)	89 (42.4%)	40 (19%)	20 (9.5%)	2.09 ± 0.93	
Total of non-adherence due to additional disease and pill burden (out of 12)	0–3 (poor adherence)	4–5 (low adherence)	6–8 (partial adherence)	9–12 (good to high adherence)	8.65 ± 2.21	
59 (28.1%)	83 (39.5%)	42 (20%)	26 (12.4%)	
Do you discontinue these medications because they are not worthy of the money you spent on them	56 (26.7%)	81 (38.6%)	43 (20.5%)	30 (14.3%)	2.22 ± 0.99	
Do you find it difficult to buy your medicines because they are expensive	47 (22.4%)	96 (45.7%)	39 (18.6%)	28 (13.3%)	2.22 ± 0.95	
Total of non-adherence due to financial constraints (out of 6)	0–1 (poor adherence)	1.01-2 (low adherence)	3–4 (partial adherence)	5–6 (good to high adherence)	4.44 ± 1.34	
52 (24.8%)	88 (41.9%)	41 (19.5%)	29 (13.8%)	
Overall score of medication adherence scale (out of 33)	0–10 (poor adherence)	11–16 (low adherence)	17–26 (Partial adherence)	27–33 (Good or high adherence)	24.89 ± 3.64	
52 (24.8%)	88 (41.9%)	41 (19.5%)	29 (13.8%)	

The analysis investigated the extent of non-adherence among participants, focusing on factors such as additional diseases and pill burden, using a scoring system ranging from 0 to 12 to gauge adherence levels. Results revealed that 28.1% of participants fell into the category of poor adherence, indicating minimal compliance with their medication regimen due to challenges associated with additional diseases or pill complexity. Furthermore, 39.5% exhibited low adherence levels, suggesting some compliance but still falling short of optimal adherence. Approximately 20% demonstrated partial adherence, indicating moderate compliance despite facing challenges. A minority of participants, comprising 12.4%, achieved good to high adherence scores, showcasing commendable compliance despite the presence of additional diseases and pill burden. The mean score for non-adherence due to additional disease and pill burden was 8.65, with a standard deviation of 2.21, providing an overall assessment of participants’ adherence levels in this regard. These findings underscore the diverse spectrum of adherence behaviors observed among participants and highlight the impact of additional diseases and pill burden on medication adherence. Addressing these challenges through tailored interventions and support mechanisms is crucial to enhancing medication adherence and ultimately improving patient outcomes.

The analysis delved into participants’ adherence to medication, particularly examining the influence of financial constraints on adherence levels. Utilizing a scoring system ranging from 0 to 6, participants’ adherence levels due to financial limitations were categorized into four groups. Results indicated that a notable proportion of participants experienced challenges in adhering to their medication regimen due to financial constraints. Specifically, nearly a quarter of the participants (24.8%) demonstrated poor adherence, while a significant portion (41.9%) exhibited low adherence levels. However, some participants showed moderate adherence despite financial limitations, with approximately 19.5% demonstrating partial adherence. Moreover, a minority of participants (13.8%) showcased commendable adherence levels despite facing financial challenges. The mean score for non-adherence due to financial constraints was 4.44, indicating an overall assessment of participants’ adherence concerning financial obstacles.

Additionally, an overall medication adherence score was computed on a scale of 0 to 33, encompassing various factors influencing adherence beyond financial constraints. The findings revealed a diverse spectrum of adherence behaviors among participants. While a quarter of participants fell into the category of poor adherence, similar proportions exhibited low adherence levels. A moderate level of adherence was observed in approximately 19.5% of participants, with a minority achieving good to high adherence scores. The study determined that patients with AMI demonstrated partial adherence to medications, as indicated by a mean overall medication adherence score of 24.89 (± 3.64).

The findings reveal the complex nature of medication adherence influenced by forgetfulness, discontinuation patterns, regimen complexity, and financial constraints. Addressing these nuances is crucial for effective interventions, with financial constraints notably impacting adherence, requiring targeted support to enhance patient outcomes.

Participants’ anxiety symptoms

The anxiety subscale of the HADS (Table 3) was administered to gauge participants’ emotional states over the preceding week, categorizing responses based on symptom severity. The majority of respondents experienced feelings of being tense or ‘wound up’ occasionally (31%, n = 65) or not at all (38.5%, n = 81), with smaller cohorts reporting these sensations more frequently. Similarly, responses varied regarding feelings of impending doom, with a substantial proportion reporting no such feelings, while others experienced them to varying degrees, ranging from mild to intense.

Table 3 Items of the anxiety subscale of HADS

Participants’ feeling in the past week	Responses’ score	n (%)	
I feel tense or ‘wound up’:			
 Most of the time	3	23 (11%)	
 A lot of the time	2	41 (19.5%)	
 From time to time, occasionally	1	65 (31%)	
 Not at all	0	81 (38.5%)	
I get a sort of frightened feeling as if something awful is about to happen:			
 Very definitely and quite badly	3	35 (16.7%)	
 Yes, but not too badly	2	33 (15.7%)	
 A little, but it doesn’t worry me	1	54 (25.7%)	
 Not at all	0	88 (41.9%)	
Worrying thoughts go through my mind:			
 A great deal of the time	3	28 (13.3%)	
 A lot of the time	2	43 (20.5%)	
 From time to time, but not too often	1	56 (26.7%)	
 Only occasionally	0	83 (39.5%)	
I can sit at ease and feel relaxed:			
 Definitely	0	80 (38.1%)	
 Usually	1	66 (31.4%)	
 Not Often	2	40 (19%)	
 Not at all	3	24 (11.4%)	
I get a sort of frightened feeling like ‘butterflies’ in the stomach:			
 Not at all	0	76 (36.2%)	
 Occasionally	1	64 (30.5%)	
 Quite Often	2	43 (20.5%)	
 Very Often	3	27 (12.9%)	
I feel restless as I have to be on the move:			
 Very much indeed	3	27 (12.9%)	
 Quite a lot	2	43 (20.5%)	
 Not very much	1	59 (28.1%)	
 Not at all	0	81 (38.6%)	
I get sudden feelings of panic:			
 Very often indeed	3	22 (10.5%)	
 Quite often	2	42 (20%)	
 Not very often	1	55 (26.2%)	
 Not at all	0	91 (43.3%)	
Severity of anxiety symptoms			
 Normal (no anxiety)	0–7	83 (39.5%)	
 Mild	8–10	60 (28.6%)	
 Moderate	11–14	41 (19.5%)	
 Severe	15–21	26 (12.4%)	
Total score of anxiety sub-scale (out of 21)	Mean ± SD	
8.38 ± 2.81	

Participants also disclosed the frequency of worrying thoughts, with the highest percentage reporting occasional occurrences, followed by varying degrees of frequency. The participants’ ability to feel relaxed showed diversity, with a notable portion indicating regular relaxation, while others reported infrequent or nonexistent feelings of relaxation. Moreover, participants reported different frequencies of sensations such as butterflies in the stomach, restlessness, and sudden panic feelings.

The severity of anxiety symptoms was categorized based on the total score of the anxiety subscale of HADS. Results indicate that 39.5% (n = 83) had normal anxiety levels, 28.6% (n = 60) experienced mild anxiety, 19.5% (n = 41) had moderate anxiety, and 12.4% (n = 26) had severe anxiety. The mean total score for the anxiety subscale was 8.38, with a standard deviation of 2.81. These findings provide valuable insights into the prevalence and severity of anxiety symptoms among the participants, contributing to a comprehensive understanding of their mental health status.

Participants’ depressive symptoms

The depression sub-scale of the HADS (Table 4) was employed to evaluate participants’ emotional states over the preceding week, assigning scores to responses to gauge the severity of depressive symptoms. Many participants (40.5%, n = 85) reported continued enjoyment of activities previously found pleasurable, while others noted a reduction in enjoyment levels to varying degrees.

Table 4 Items of the depression sub-scale of HADS

Participants’ feeling in the past week	Responses’ score	n (%)	
I still enjoy the things I used to enjoy:			
 Definitely as much	0	85 (40.5%)	
 Not quite so much	1	53 (25.2%)	
 Only a little	2	38 (18.1%)	
 Hardly at all	3	34 (16.2%)	
I can laugh and see the funny side of things:			
 As much as I always could	0	80 (38.1%)	
 Not quite so much now	1	64 (30.5%)	
 Definitely not so much now	2	37 (17.6%)	
 Not at all	3	29 (13.8%)	
I feel cheerful:			
 Not at all	3	33 (15.7%)	
 Not often	2	26 (12.4%)	
 Sometimes	1	61 (29%)	
 Most of the time	0	90 (42.9%)	
I feel as if I am slowed down:			
 Nearly all the time	3	30 (14.3%)	
 Very often	2	34 (16.2%)	
 Sometimes	1	56 (26.7%)	
 Not at all	0	90 (42.9%)	
I have lost interest in my appearance:			
 Definitely	3	31 (14.8%)	
 I don’t take as much care as I should	2	41 (19.5%)	
 I may not take quite as much care	1	63 (30%)	
 I take just as much care as ever	0	75 (35.7%)	
I look forward with enjoyment to things:			
 As much as I ever did	0	80 (38.1%)	
 Rather less than I used to	1	55 (26.2%)	
 Definitely less than I used to	2	44 (21%)	
 Hardly at all	3	31 (14.8%)	
I can enjoy a good book or radio or TV program:			
 Often	0	94 (44.8%)	
 Sometimes	1	53 (25.2%)	
 Not often	2	37 (17.6%)	
 Very seldom	3	26 (12.4%)	
Severity of depression symptoms			
 Normal (no depression)	0–7	85 (40.5%)	
 Mild	8–10	58 (27.6%)	
 Moderate	11–14	37 (17.6%)	
 Severe	15–21	30 (14.3%)	
Total score of depression sub-scale (out of 21)	Mean ± SD	
7.43 ± 2.42	

Responses regarding the ability to find humor varied, with a notable portion (38.1%, n = 80) reporting no change in their capacity to perceive the lighter side of life, while others experienced varying levels of reduced enjoyment. Feelings of cheerfulness also exhibited diversity, with a significant proportion (42.9%, n = 90) expressing a sense of cheerfulness most of the time, contrasting with others who reported feeling cheerful less frequently or hardly at all. Participants reported feeling slowed down with varying frequency, reflecting differing levels of symptom severity, while responses regarding interest in appearance ranged from significant loss of interest to maintaining usual levels of care.

Additionally, participants expressed varying levels of anticipation for enjoyable activities, indicating diverse levels of depressive symptom severity, and reported different frequencies of being able to derive pleasure from activities, underscoring the complexity of their emotional experiences.

The severity of depressive symptoms, as assessed by the depression subscale of HADS, revealed varying degrees of impact among participants. Results indicated that 40.5% (n = 85) exhibited normal levels of depressive symptoms, while 27.6% (n = 58) experienced mild depression, 17.6% (n = 37) reported moderate depression, and 14.3% (n = 30) demonstrated severe depression. The mean total score for the depression subscale was 7.43, with a standard deviation of 2.42, indicating a predominance of normal (no depression) depressive symptoms. These findings offer valuable insights into the prevalence and severity of depressive symptoms within the studied population, contributing significantly to a comprehensive understanding of their mental health status.

Predictors of adherence to medications

The analysis utilized multiple linear regression to explore predictors of medication adherence among patients diagnosed with AMI (Table 5). The final regression model demonstrated statistical significance (p-value = 0.005), elucidating 21.9% of the total variance in medication adherence (adjusted R² = 0.219). Significant predictors of adherence encompassed employment status, age, duration of MI, anxiety, and depression, all with p-values less than 0.05. Specifically, the analysis unveiled a positive association between employment status and adherence, with employed participants demonstrating heightened adherence levels (β = 0.235, p = 0.002). Conversely, older age was correlated with diminished adherence (β = -0.177, p = 0.025), alongside a longer duration of MI (β = -0.172, p = 0.015). Additionally, higher levels of anxiety (β = -0.150, p = 0.030) and depression (β = -0.146, p = 0.034) were linked to poorer adherence. However, variables such as gender, educational level, and marital status did not significantly associate with adherence (p > 0.05), nor did monthly income (p = 0.238).

Table 5 Predictors of adherence to medications using multiple linear regression analysis

Variable	Standardized coefficient	p value	
Beta	T	
Employment status	0.235	3.108	0.002*	
Age	-0.177	-2.255	0.025*	
Gender	-0.059	-0.852	0.395	
Educational level	-0.057	-0.802	0.423	
Marital status	-0.047	-0.625	0.533	
Monthly income	0.081	1.184	0.238	
Duration of MI (months)	-0.172	-2.447	0.015*	
Anxiety	-0.150	-2.192	0.030*	
Depression	-0.146	-2.131	0.034*	
Dummy variables: Employment status (employed vs. retired), Gender (male vs. female), Educational level (≤ school vs. ≥ high diploma), Marital status (single vs. has been married), Monthly income (< 600 JD [$ 845] vs. ≥ 600 JD [$ 845])

* Significant p value at 0.05 is bold

Discussion

The findings of this study shed light on the complex interplay of factors influencing medication adherence among patients diagnosed with AMI in Jordan. By employing a comprehensive approach that assesses medication adherence across different subscales and explores the prevalence of anxiety and depression, as well as demographic predictors such as employment status and age, this study contributes significantly to the existing literature on medication adherence in cardiac patients. The identification of partial adherence patterns, particularly in relation to financial constraints, underscores the multifaceted nature of medication adherence challenges post-AMI. Moreover, the observed associations between adherence levels and psychological factors like anxiety and depression highlight the importance of addressing mental health in interventions aimed at improving medication adherence and overall patient outcomes. Furthermore, the study’s findings regarding demographic predictors such as employment status and age provide valuable insights into potential targets for tailored interventions to enhance medication adherence among AMI patients in Jordan. Overall, this study’s comprehensive examination of medication adherence and its determinants offers valuable implications for clinical practice and underscores the need for holistic approaches to improve patient care and outcomes in this population.

The study findings indicated good adherence in the first two subscales, related to patient behavior and additional disease/pill burden, while partial adherence was observed in the third subscale, attributed to financial constraints. These results align with previous studies [6, 38, 39], which similarly highlighted challenges in medication adherence post-AMI. For instance, Pietrzykowski et al. (2020) reported a decrease in medication adherence among two-thirds of patients over time [38], while Hussain et al. (2018) found declining adherence rates over a one-month follow-up period in Karachi [39]. Additionally, Shang et al. (2019) reported a significant decline in medication adherence among post-AMI patients in China after one year of follow-up, consistent with the current study’s findings on partial adherence [15].

Moreover, the study investigated the prevalence of anxiety and depression among AMI patients in Jordan. While nearly one-third of participants exhibited normal anxiety levels, the majority reported mild to severe anxiety. This contrasts with previous studies reporting higher anxiety levels among AMI patients [40, 41]. Notably, the current study attributed the lower anxiety levels to good medication adherence, suggesting a potential relationship between adherence and reduced anxiety [42–45]. Similarly, depression levels varied among participants, with a significant portion experiencing mild to severe depression [41, 46, 47]. These findings corroborate previous research highlighting the prevalence of depressive symptoms among cardiac patients and their impact on medication adherence [13, 14, 28, 48].

Furthermore, the study identified demographic factors influencing medication adherence among AMI patients in Jordan. Employed individuals demonstrated significantly higher adherence, likely due to factors such as financial stability and access to healthcare. Similarly, younger age was associated with better adherence, attributed to factors like forgetfulness among elderly patients. These findings are consistent with previous studies highlighting the influence of employment status and age on medication adherence among chronic disease patients [10, 49, 50].

Additionally, the study found that a lower duration of MI predicted significantly higher medication adherence. This aligns with previous research indicating a decline in adherence over time post-AMI [15, 50]. Furthermore, lower levels of anxiety and depression were associated with higher adherence levels, highlighting the impact of psychological factors on medication adherence. These findings are supported by previous studies exploring the relationship between anxiety, depression, and medication adherence among cardiac patients [43, 44].

In conclusion, the study provides valuable insights into medication adherence patterns and associated factors among AMI patients in Jordan, contributing to the existing literature on this topic. These findings underscore the pivotal role of employment status, age, duration of MI, anxiety, and depression as predictors of medication adherence among AMI patients. Thus, targeted interventions are warranted to bolster adherence, particularly among demographic groups susceptible to lower adherence rates and individuals confronting psychological distress.

Research implementations and recommendations

The findings of this study have several implications for research and clinical practice in the context of medication adherence among patients diagnosed with AMI in Jordan. Firstly, future research endeavors could focus on exploring the underlying mechanisms contributing to partial adherence, particularly concerning financial constraints, which emerged as a significant barrier in this study. Investigating the specific financial challenges faced by patients, such as medication costs and access to healthcare services, can provide valuable insights for developing targeted interventions aimed at alleviating these barriers. Additionally, longitudinal studies could be conducted to further elucidate the temporal dynamics of medication adherence post-AMI, allowing for a more nuanced understanding of adherence patterns over time and the identification of critical intervention points.

Furthermore, given the observed associations between medication adherence and psychological factors such as anxiety and depression, integrating mental health screening and support services into cardiac care settings is recommended. Collaborative care models that involve interdisciplinary teams comprising cardiologists, psychiatrists, and clinical psychologists can facilitate the early detection and management of mental health issues, thereby improving medication adherence and overall patient outcomes. Moreover, tailored interventions incorporating behavioral strategies, psychoeducation, and cognitive-behavioral therapy techniques could be developed to address the specific needs of patients with AMI who experience anxiety and depression.

In terms of clinical practice, healthcare providers should prioritize routine assessment of medication adherence and its determinants during patient consultations following AMI diagnosis. Utilizing validated screening tools to identify patients at risk of non-adherence and providing targeted education and counseling can help mitigate adherence barriers and promote treatment adherence. Additionally, interventions aimed at enhancing patient empowerment, such as medication reminder systems, adherence monitoring tools, and patient education materials, should be integrated into routine care practices to support patients in adhering to their prescribed medication regimens.

Overall, by addressing the multifaceted nature of medication adherence challenges and adopting a patient-centered approach that considers individual needs and preferences, healthcare providers can optimize treatment outcomes and improve the quality of care for patients with AMI in Jordan.

Study limitations

While this study offers valuable insights into medication adherence among patients with AMI in Jordan, it faces several limitations. Firstly, its cross-sectional design hinders the establishment of causal relationships between variables. Future longitudinal studies are needed to uncover the temporal dynamics of medication adherence post-AMI. Secondly, reliance on self-reported measures may introduce response bias and measurement error, suggesting the need for objective measures like medication refill rates. Additionally, the study’s single-center recruitment approach may limit generalizability, urging the need for multicenter studies with larger and more diverse samples. Moreover, the study overlooks cultural and contextual factors influencing medication adherence in Jordan, suggesting the need for qualitative exploration and culturally tailored interventions. Despite these limitations, the study provides valuable insights, laying a foundation for future research and clinical interventions in this field.

Conclusion

This study sheds light on the complex dynamics of medication adherence among patients diagnosed with AMI in Jordan. Despite facing limitations, such as its cross-sectional design and reliance on self-reported measures, the findings underscore the importance of addressing medication adherence post-AMI. The study highlights the need for longitudinal research to establish causal relationships and objective measures to validate adherence levels. Moreover, multicenter studies with diverse samples are crucial for enhancing generalizability. Culturally tailored interventions addressing sociocultural determinants of adherence are also imperative. Despite these challenges, this study contributes valuable insights, laying the groundwork for future research and clinical interventions aimed at improving medication adherence and ultimately enhancing patient outcomes post-AMI in Jordan.

Acknowledgements

The authors express their gratitude to the patients who contributed to the study. They acknowledge the Applied Science Private University in Amman, Jordan, for providing formal ethical approval and supporting the research project. This study is supported via funding from Prince Sattam Bin Abdulaziz University project number (PSAU/2023/R/1445).

Author contributions

O.A., R.M., S.H., and R.E. had the major input into the design, analysis and interpretation of the data. O.A., R.M., S.H., R.E., M.Y., W.M. A.A., B.A., D.S., and M. E. were drafting the article or revising it critically for important intellectual content. All authors have seen and approved the final version of the manuscript.

Funding

The authors received no financial support for publication of this article.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study upheld rigorous ethical standards, receiving approval from both the Institutional Review Board (IRB) affiliated with the principal investigator’s (Applied Science Private University [IRB approval No.: 2022-NC-254]) in Amman, Jordan and all relevant data collection settings. The research adhered strictly to relevant guidelines and regulations, including the ethical principles of the Declaration of Helsinki. Prior to participation, all participants provided formal written informed consent. The authors ensured that the participants were fully understood the study’s purpose, procedures, potential risks and benefits. Moreover, the authors emphasized confidentiality and took steps to anonymize all participant information used in the manuscript and supplementary materials.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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