How to Measure Medication Adherence in a Patient Support Program in Saudi Arabia
Measure adherence with more than one method, because no single measure is a gold standard. In a Saudi patient support program, combine patient self-report on a validated scale, programme engagement data and, where lawfully available, refill or dispensing records, and report each separately with its limits. Decide the method before launch, not when the first sponsor report is due.
Key takeaways
- The World Health Organization stated in 2003 that adherence among patients with chronic diseases in developed countries averages only 50%, and is lower in developing countries.
- A review of 19 Middle East studies (Eastern Mediterranean Health Journal, 2011), six of them from Saudi Arabia, found nonadherence ranging from 1.4% to 88%, mostly measured by self-report, with no single gold standard.
- The method changes the answer: in one study in that review, physicians estimated 29% nonadherence while patient self-report showed 48%.
- A reminder response is not adherence. Report engagement, self-reported adherence and refill-based adherence as separate indicators.
On this page
Why measurement is the weak point of adherence programmes
Every pharma adherence programme promises improvement, and most are asked to prove it within a year. The difficulty is that "adherence" is not one number. It depends on who is asked, what is counted and over what period. A programme that cannot explain how it measured adherence cannot defend what it reports to its sponsor, to medical affairs or to a regulator-facing team.
The baseline is also unforgiving. The WHO's 2003 statement that adherence in developed countries averages only 50% for chronic disease is still the most-quoted benchmark, and it was explicit that rates are lower in developing countries. For Saudi Arabia there is no single national figure to borrow, which is why the measurement plan matters more than any benchmark.
What the Middle East and Saudi evidence shows
Al-Qasem, Smith and Clifford reviewed 19 English-language studies (1993 to 2007) on medication adherence in chronic conditions across the Middle East, six of them from Saudi Arabia and four from Egypt. Sample sizes ranged from 104 to 1,000 patients. Reported nonadherence ranged from 1.4% to 88% overall, from 23% to 49.5% in hypertension and from 1.4% to 27.1% in diabetes. Self-report was used in 17 of the 19 studies, pill counts were combined with self-report in several, and the authors found no gold standard. Physician-administered questionnaires generally produced lower nonadherence than patient self-report, and in one study physicians estimated 29% where patients reported 48%. The review is now fifteen years old, so treat its ranges as a picture of measurement variability, not a current Saudi prevalence.
A more recent Saudi example shows what a single-centre measurement looks like. A cross-sectional study at King Fahd University Hospital in Khobar (March to April 2019) surveyed 212 patients with type 2 diabetes using the 11-item General Medication Adherence Scale. It classified 35.8% as high adherence, 22.6% good, 34.9% partial, 4.7% low and 1.9% poor, and reported a correlation of about -0.41 between adherence score and HbA1c. It also reported sub-scores for behaviour-related, disease and pill-burden-related and cost-related non-adherence. This is one outpatient centre in the Eastern Province, so it illustrates a method; it does not describe the Kingdom.
Four measurement layers, and what each can and cannot tell you
1. Patient-reported adherence
A validated scale (the Morisky scale and the General Medication Adherence Scale both appear in the literature above) is cheap, scalable by phone or app and, crucially, captures reasons. Its limits are recall bias and over-reporting. Check the licensing terms and the validated Arabic version of any scale before building it into a programme.
2. Programme engagement
Reminder responses, completed check-ins and educator contacts show that the programme is reaching patients. They are proxies for engagement, not for taking medicines. Reporting them as adherence is the most common way programmes overstate results.
3. Refill or dispensing records
Refill-based measures such as proportion of days covered describe medicine supply rather than ingestion, but they are less vulnerable to self-report bias. Whether a programme can lawfully use dispensing data depends on the data source, the patient's consent and the contract; confirm the route with counsel before promising it to a sponsor.
4. Clinical markers
HbA1c, blood pressure and similar markers belong to the treating clinician. A programme can display them only through an appropriate, consented route, and should avoid attributing a change in a marker to the programme without a design that supports the claim.
Capture the reason, not just the status
The Middle East review lists the reasons patients gave for not taking medicines: forgetfulness was the most frequently reported (six studies), followed by side effects (five studies), with feeling well, drug shortages, cost, treatment complexity, stigma, concerns about dependency and lack of health education also reported. Nonadherence was higher in hypertension than in diabetes in the studies reviewed, possibly because hypertension is often symptomless. The practical point for a programme: every non-adherent contact should end in a coded reason, because the reason decides the action, whether that is a reminder, an educator call, a pharmacist conversation or a referral back to the physician.
A measurement plan to agree before launch
Write down, and have medical affairs and the sponsor sign off: who is in the denominator (enrolled, consented, active); which method or methods are used and at what cadence; the definition and cut-offs for each adherence category; who owns each data source and under what consent; how missing data is handled; and how the programme will report engagement, self-reported adherence and refill-based adherence as separate lines. Pair this with the data quality checks and consent flows described in our PSP articles on PDPL-compliant enrolment.
An illustrative design (not a client case)
A pharma team launching a once-daily therapy for chronic hypertension in Saudi Arabia plans a twelve-month programme. At enrolment the patient gives consent and completes a baseline self-report scale. The programme sends reminders and runs a short check-in monthly, recording a coded reason whenever a patient reports missed doses. Engagement is reported monthly. Self-reported adherence is reported quarterly on the same scale, with the denominator stated. If a lawful dispensing data source is agreed, refill-based adherence is added as a third line. The sponsor receives three indicators with their limits, not one headline percentage.
What not to claim
Do not present a before-and-after change as a programme effect without a comparison that supports it. Do not report reminder response as adherence. Do not quote an improvement percentage from another country or condition as a Saudi expectation. Any statement about clinical outcomes should be reviewed by medical affairs before it is published.
Where CareSync PSP Connect fits
CareSync PSP Connect is a white-label platform for pharma patient support programmes, supporting enrolment, consent, reminders and follow-up in Arabic and English. Measurement design stays with your medical, brand and regulatory teams; the platform's role is to capture the data consistently so the plan can be followed.
Frequently asked questions
What is a good adherence rate for a patient support program in Saudi Arabia?
There is no universal benchmark. The WHO stated in 2003 that chronic-disease adherence in developed countries averages 50%, and Middle East studies reviewed in 2011 reported nonadherence from 1.4% to 88% depending on condition and method. Set a target from your own baseline, using a stated method.
Which adherence scale should we use?
The Morisky scale and the General Medication Adherence Scale both appear in the Middle East and Saudi literature. Both are self-report tools. Check licensing and the validated Arabic version before use.
Can a patient support program use pharmacy refill data?
It depends on the data source, the patient's consent and the contract. Confirm the lawful route with counsel before offering refill-based measures to a sponsor.
Why do patient and physician estimates of adherence differ?
In one study in a 2011 review of Middle East research, physicians estimated 29% nonadherence while patients self-reported 48%. Physicians tend to overestimate adherence, which is why programmes should not rely on clinician impression alone.
Does a reminder response prove a patient is taking their medicine?
No. It shows engagement with the programme. Report it as engagement and measure adherence separately.
Sources
- World Health Organization, "Failure to take prescribed medicine for chronic diseases is a massive, world-wide problem" (1 July 2003)
- Al-Qasem A, Smith F, Clifford S. "Adherence to medication among chronic patients in Middle Eastern countries: review of studies." Eastern Mediterranean Health Journal 2011;17(4):356–363
- "Assessment of Medication Adherence in Saudi Patients With Type II Diabetes Mellitus in Khobar City, Saudi Arabia" (King Fahd University Hospital, 2019 data)