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144

J Gandhara Med Dent Sci

October - December 2026

ORIGINAL ARTICLE

How to cite this article

:

FACTORS ASSOCIATED WITH TREATMENT ADHERENCE AND SYMPTOM BURDEN AMONG

PATIENTS

RECEIVING MAINTENANCE HEMODIALYSIS IN PAKISTAN:

A CROSS-SECTIONAL STUDY

Muhammad Mamoon

1

,

Ifrah Riaz

2

, Fakhar Zaman

2

, Zahid Ullah

2

, Anum Essa

2

, Muhammad Haroon

2

Mamoon M, Riaz I, Zaman F, Ullah Z,

Essa A,

Haroon M. Factors Associated

with Treatment Adherence and

Symptom Burden Among Patients

Receiving Maintenance Hemodialysis

in Pakistan: A Cross-Sectional Study.

J Gandhara Med Dent Sci.

2026;13(4):144-150.

Date of Submission:

17-09-2026

Date Revised:

22-09-2026

Date Acceptance:

22-09-2026

2

Trainee Medical Ofcer, Department

Hospital, Kohat

Correspondence

1

Muhammad Mamoon, Consultant

Medical Specialist, Department of

Hospital, Kohat

+92-300-90940049

m.mamoon909@gmail.com

ABSTRACT

OBJECTIVES

This study aimed to assess treatment adherence, symptom burden, and factors

associated with adherence among adults receiving maintenance hemodialysis

in Pakistan.

METHODOLOGY

A

cross-sectional

study

was

conducted

from

January

to

July

2026

in

the

Dialysis Unit of District Headquarters Hospital, Kohat, Pakistan. A total of

141 adults receiving maintenance hemodialysis were recruited consecutively.

Data were collected using a structured questionnaire, the

End-Stage Renal

Disease

Adherence

Questionnaire

(ESRD-AQ),

and

the

Dialysis

Symptom

Index

(DSI).

Descriptive

statistics

were

used

to

summarise

participant

characteristics and adherence-related behaviours.

RESULTS

The mean age was 44.01 ± 14.40 years, and 55.3% of participants were male.

Self-rated overall treatment compliance was excellent in 69.5%, very good in

21.3%, and good in 9.2%. No dialysis session was missed by 74.5% of

participants during the reported period. Diculties were reported with

medication-taking (44.0%), uid restriction (68.8%), and dietary

recommendations (58.9%).

CONCLUSION

Most

participants

reported

high

overall

treatment

compliance;

however,

clinically

relevant

diculties

with

medication

use,

uid

restriction,

and

dietary

adherence

remained

common.

Structured

education,

individualised

counselling, and practical support for treatment barriers should be integrated

into routine dialysis care.

Validated DSI results and appropriately reanalysed

association

models

are

required

before

conclusions

regarding

symptom

burden and independent predictors can be nalised.

KEYWORDS:

Renal Dialysis, Kidney Failure, Medication Adherence,

Treatment Adherence, Hemodialysis, Pakistan

INTRODUCTION

Chronic kidney disease (CKD) is a major global public

health

problem

associated

with

substantial

morbidity,

mortality, disability, and healthcare expenditure. Global

analyses

show

a

continuing

increase

in

CKD

burden,

particularly

in

low-

and

middle-income

countries.

1,2

Progressive

CKD

may

culminate

in

kidney

failure

requiring kidney replacement therapy or comprehensive

conservative kidney management, depending on clinical

circumstances

and

patient

preferences.

3,4

Maintenance

hemodialysis remains the most widely available form of

kidney

replacement

therapy

in

many

resource-

constrained settings, where access to transplantation is

limited.

4

Hemodialysis

can

correct

major

metabolic

disturbances and reduce

uremic

manifestations, but its

effectiveness

depends

not

only

on

dialysis

delivery

itself but also on sustained engagement with the broader

treatment

regimen,

including

session

attendance,

medication

use,

dietary

recommendations,

and

uid

restriction.

5,6,7

Non-adherence

to

one

or

more

components

of

the

hemodialysis

regimen

is

common

and

is

associated

with

uid

overload,

electrolyte

disturbances,

hospitalisation,

and

poorer

clinical

outcomes.

7,8

At the same time, patients receiving long-

term hemodialysis frequently experience a high burden

of

physical

and

psychological

symptoms,

including

fatigue,

pruritus,

sleep

disturbance,

pain,

muscle

cramps,

gastrointestinal

symptoms,

anxiety,

and

depressive

symptoms.

9

Symptom

burden

can

interfere

with

daily

functioning

and

self-management

and

may

coexist

with

negative

medication

beliefs

and

non-

adherence.

10

Adherence

is

multidimensional.

Patient-

health

literacy,

treatment

complexity,

transportation,

aordability,

family

support,

and

the

quality of communication with healthcare professionals

may

all

inuence

adherence

behaviours.

8,10,11

These

barriers

are

particularly

relevant

in

settings

where

http://doi.org/10.37762/jgmds.13-4.955

of Internal Medicine, DHQ Teaching

Internal Medicine, DHQ Teaching

145

J Gandhara Med Dent Sci

October - December 2026

patients travel long distances for dialysis, have limited

household

resources,

and

have

restricted

access

to

multi-disciplinary

renal

services.

11,12,13

South

Asian

populations also experience substantial cardiometabolic

risk

and

may

develop

CKD

at

comparatively

younger

ages,

increasing

the

long-term

treatment

burden.

14

Pakistan faces a substantial and growing CKD burden,

while

access

to

nephrology

services,

transplantation,

and

long-term

dialysis

remains

uneven.

12

Local

evidence

describing

adherence

behaviours

and

the

practical

challenges

faced

by

patients

on

maintenance

hemodialysis

is

therefore

important

for

service

planning.

studies

have

reported

variable

adherence

across

dialysis

attendance,

medication,

diet,

and

uid

restriction,

but

locally

contextualised

data

remain

limited.

7,15

The

present

study was designed to assess treatment adherence and

symptom

burden

among

adults

receiving

maintenance

hemodialysis at

a

public-sector dialysis unit

in Kohat,

Pakistan,

and

to

examine

factors

associated

with

treatment

adherence.

The

objectives

were

to:

describe

treatment

adherence

among

adults

receiving

maintenance

hemodialysis;

quantify

symptom

burden

using

the

Dialysis

Symptom

Index;

and

examine

demographic,

clinical,

dialysis-related,

and

self-

management

factors

associated

with

treatment

adherence.

METHODOLOGY

A

hospital-based

cross-sectional

observational

study

was

conducted

from

January

to

July

2026

in

the

Dialysis Unit of District Headquarters (DHQ) Hospital,

Kohat,

Khyber

Pakhtunkhwa,

Pakistan.

The

unit

provides maintenance hemodialysis services to patients

from Kohat and surrounding districts. Eligible patients

attending

the

outpatient

dialysis

unit

during

the

study

period

were

approached

consecutively

and

invited

to

participate after written informed consent. Adults aged

18-70 years with kidney failure who had been receiving

maintenance

hemodialysis

for

at

least

three

months

were eligible if they could communicate in Urdu and/or

English

and

were

able

to

provide

written

informed

consent. Patients who were critically ill, had cognitive

or

communication

impairment

that

prevented

completion

of

the

questionnaires,

or

declined

participation were excluded. The supplied study record

states

that

the

minimum

sample

size

was

calculated

using

OpenEpi

with

a

95%

condence

level

and

5%

margin of error, and that the target was increased to 141

participants

to

allow

for

approximately

10%

nonresponse or incomplete questionnaires. Consecutive

non-probability

sampling

was

used

until

the

target

sample

was

reached.

A

structured

questionnaire

captured

sociodemographic,

clinical,

dialysis-related,

and treatment-related information. Treatment adherence

was

assessed

using

the

46-item

End-Stage

Renal

Disease

Adherence

Questionnaire

(ESRD-AQ),

which

evaluates

hemodialysis

attendance,

medication

use,

fluid

restriction,

and

dietary

recommendations.

16

Symptom

burden

was

assessed

using

the

Dialysis

Symptom

Index

(DSI),

a

30-item

patient-reported

instrument

developed

for

people

receiving

chronic

hemodialysis;

higher

scores

indicate

greater

symptom

burden.

17

Trained

investigators

administered

the

questionnaires face-to-face before or after participants'

scheduled

dialysis

sessions.

The

purpose

of

the

study

was

explained,

and

written

informed

consent

was

obtained

before

data

collection.

Clinical

and

dialysis-

was

veried from

medical

records

when required. Completed questionnaires were checked

immediately for completeness and internal consistency

to

minimise

missing

data.

Ethical

approval

was

obtained

from

the

Institutional

Ethics

Committee

of

DHQ Hospital, Kohat. All participants provided written

informed

consent.

Participation

was

voluntary,

withdrawal

did

not

aect

clinical

care,

and

study

information

was

handled

condentially

in

accordance

with the principles of the Declaration of Helsinki. Data

were entered into Microsoft

Excel and analysed using

IBM SPSS Statistics version 22.0 (IBM Corp., Armonk,

NY,

USA).

A

two

-sided

p-value

<

0.05

should

be

considered statistically signicant.

RESULTS

A

total

of

141

patients

receiving

maintenance

hemodialysis were included. The mean age was 44.01 

14.40

years,

and

the

mean

body

weight

was

56.86



11.20

kg.

Males

comprised

55.3%

(n=78)

of

the

sample.

Most

participants

were

married

(73.0%),

had

no

formal

education

(60.3%),

lived

in

rural

areas

(57.4%), were unemployed (52.5%), belonged to joint

families

(84.4%),

and

lived

with

family

members

(84.4%).

Hypertension

was

the

most

frequently

reported

comorbidity

(54.6%),

followed

by

diabetes

mellitus (32.6%) and kidney stone disease (12.8%). All

participants

had

an

arteriovenous

stula,

and

none

reported

dialysis

or

kidney

transplantation.

Most

participants

used

personal

transport

to

reach

dialysis

(59.6%).

A

total

of

83.7%

received two or fewer dialysis sessions per

week, and

90.1% considered their dialysis schedule convenient.

Factors Associated with Treatment Adherence and Symptom Burden

146

J Gandhara Med Dent Sci

October - December 2026

Table: Baseline Sociodemographic, Clinical, and Dialysis

Characteristics of Hemodialysis Patients (n = 141)

Variable

Category

n (%age)

Prescribed medications

Yes

141 (100.0)

Treatment initiated at

diagnosis

Yes

141 (100.0)

Overall treatment

compliance

Good

13 (9.2)

Very good

30 (21.3)

Excellent

98 (69.5)

Last education by sta

Never

16 (11.3)

This week

17 (12.1)

One

month

ago

46

(32.6)

>1 month ago

62 (44.0)

Frequency of sta

education

Never

26 (18.4)

Rarely

14 (9.9)

Every dialysis

treatment

101 (71.6)

Importance of dialysis

schedule

Highly important

141 (100.0)

Reason for following

schedule

Understand kidney

disease

83 (58.9)

Keeps body healthy

58 (41.1)

Difculty during

dialysis

None

82 (58.2)

A little

10 (7.1)

Moderate

23 (16.3)

A lot

26 (18.4)

Missed dialysis

treatments

None

105 (74.5)

One

26 (18.4)

≥4

10 (7.1)

Reason for missed

dialysis

None

105 (74.5)

Transportation

26 (18.4)

Family/Financial

10 (7.1)

Minutes shortened

Not applicable

89 (63.1)

2130 minutes

39 (27.7)

≥31 minutes

13 (9.2)

Medication adherence

Very seldom

33 (23.4)

Sometimes

26 (18.4)

Most of the time

40 (28.4)

All of the time

42 (29.8)

Reason for medication

adherence

Understand kidney

disease

106 (75.2)

26 (18.4)

Previous illness

9 (6.4)

Difculty taking

medicines

No

79 (56.0)

Yes

62 (44.0)

Level of diculty

None

79 (56.0)

Mild

23 (16.3)

Moderate

13 (9.2)

Severe

26 (18.4)

Missed medicines (past

week)

None

89 (63.1)

Continue...

One dose

26 (18.4)

Two doses

26 (18.4)

Reason for missed

medicines

Not applicable

89 (63.1)

Factors Associated with Treatment Adherence and Symptom Burden

147

J Gandhara Med Dent Sci

October - December 2026

Medication side eects

None

99 (70.2)

Headache

29 (20.6)

Gastrointestinal

symptoms

13 (9.2)

Fluid restriction

adherence

At initiation of dialysis

72 (51.1)

About half of the

time

40 (28.4)

Most of the

time

29 (20.6)

Reason for limiting

uids

Understand kidney

disease

76 (53.9)

Medical advice

30 (21.3)

Became sick

26 (18.4)

Keeps body healthy

9 (6.4)

Difculty limiting uid

intake

No

44 (31.2)

Yes

97 (68.8)

Level of

diiculty

None

35 (24.8)

Mild

35 (24.8)

Moderate

71 (50.4)

Weight monitoring at

home

Never

40 (28.4)

Once

49 (34.8)

Twice

19 (13.5)

Three times

16 (11.3)

>4 times

17 (12.1)

Importance of daily

weight monitoring

Moderate

46 (32.6)

High

95 (67.4)

Reason for dietary

adherence

Understand kidney

disease

106 (75.2)

Medical advice

26 (18.4)

Keeps body healthy

9 (6.4)

Difculty following

dietary

recommendations

No

58 (41.1)

Yes

83 (58.9)

Table

4:

ANOVA

of

sociodemographic,

clinical,

and

dialysis

variables versus overall treatment compliance.

Variable

F-value

p-value

Gender

29.193

<0.001

Age (years)

24.622

<0.001

Weight (kg)

103.159

<0.001

Marital status

30.031

<0.001

Education level

14.876

<0.001

Residence

9.557

<0.001

Occupation

9.557

<0.001

Monthly family income

8.604

<0.001

Type of family

2.706

0.070

Living arrangement

2.706

0.070

Duration on hemodialysis

25.513

<0.001

Comorbidity

12.640

<0.001

Transportation

77.741

<0.001

Accompanying person

14.349

<0.001

Dialysis sessions/week

3.575

0.031

Dialysis duration/session

29.079

<0.001

Dialysis schedule convenience

3.507

0.033

Last education by sta

5.109

0.007

Frequency of sta education

14.339

<0.001

Correlation between Overall Treatment Complian

Table 6:

ce and

Selected

Sociodemographic,

Clinical,

Dialysis,

and

Self-

management Variables among

Hemodialysis Patients (n = 141)

Variable

Pearson's correlation (r)

p-value

Gender

-0.021

0.801

Age (years)

0.386

<0.001

Weight (kg)

0.144

0.088

Marital status

0.394

<0.001

Education level

-0.045

0.598

Residence

0.349

<0.001

Occupation

0.348

<0.001

Monthly family income

0.333

<0.001

Type of family

-0.022

0.794

Living arrangement

-0.022

0.794

Duration on hemodialysis

(years)

0.197

0.019

Comorbidity

0.024

0.776

Transportation

-0.549

<0.001

Accompanying person

0.350

<0.001

Dialysis sessions/week

0.004

0.963

Dialysis duration/session

-0.540

<0.001

Dialysis schedule convenience

-0.203

0.016

Last education by dialysis sta

-0.212

0.012

Frequency of sta education

-0.382

<0.001

Difculty during dialysis

0.477

<0.001

Missed dialysis treatments

-0.133

0.116

Reason for missed dialysis

-0.376

<0.001

Minutes shortened

-0.561

<0.001

Medication adherence

0.121

0.153

Difculty taking medicines

-0.030

0.722

Level of diculty taking

medicines

0.063

0.459

Missed medicines (past week)

-0.111

0.189

Medication side eects

-0.506

<0.001

Fluid restriction adherence

-0.058

0.496

Difculty limiting uid intake

-0.199

0.018

Level of diculty limiting uid

intake

-0.430

<0.001

Weight monitoring at home

-0.216

0.010

Importance of daily weight

monitoring

0.575

<0.001

Difculty following dietary

recommendations

-0.311

<0.001

Table 5: ANOVA of adherence and self-management variables

versus overall treatment compliance.

Variable

F-value

p-value

Difculty during dialysis

25.236

<0.001

Missed dialysis treatments

1.858

0.160

Reason for missed dialysis

12.287

<0.001

Minutes shortened

45.646

<0.001

Medication adherence

5.462

0.005

Difculty taking medicines

28.832

<0.001

Level of diculty taking medicines

12.713

<0.001

Missed medicines (past week)

2.534

0.083

Medication

side

eects

26.875

<0.001

Fluid restriction adherence

31.528

<0.001

Difculty limiting uid intake

3.521

0.032

Level of diculty limiting uid intake

16.355

<0.001

Weight monitoring at home

22.260

<0.001

Importance of daily weight monitoring

34.039

<0.001

Difculty following dietary recommendations

7.487

0.001

Medication cost

26 (18.4)

Hospitalisation

13 (9.2)

Side effects

13 (9.2)

Factors Associated with Treatment Adherence and Symptom Burden

148

J Gandhara Med Dent Sci

October - December 2026

DISCUSSION

The

present study aimed to thoroughly assess treatment

adherence

and

symptom

burden

among

patients

on

maintenance hemodialysis at a tertiary care hospital in

Pakistan.

The

overall

average

of

the

participants

showed

good

adherence

behaviours,

with

69.5%

reporting

excellent

compliance

with

treatment,

and

relatively

few

participants

reported

poor

adherence.

Also,

the

majority

of

patients

were

regular

at

the

set

appointments for dialysis, took medications as ordered,

and understood the importance of restricting their food

and

uid

intake.

However,

many

remained

with

symptoms

and

treatment-related

challenges,

highlighting

the

importance

of

optimising

adherence,

but not necessarily being able to eliminate the symptom

burden

for

patients

receiving

long-term

hemodialysis.

Most of the study population was middle-aged (44.0 

14.4

years)

and

male.

Hypertension

(54.6%)

and

diabetes

(32.6%)

were

the

most

common

comorbid

conditions.

These

results

are

similar

to

the

Global

Burden

of

Disease

analyses,

which

showed

that

hypertension and diabetes were the top contributors to

CKD

and

ESRD

around

the

world.

16,17

The

relatively

low

age

of

patients

versus

European

and

North

American

studies

may

be

due

to

the

fact

that

CKD

occurs earlier in South Asian populations, as diabetes,

uncontrolled

hypertension

and

poor

access

to

preventive

nephrology

services

are

early

drivers

of

disease progression. The ndings were encouraging, as

almost

70%

of

the

patients

reported

excellent

overall

treatment

compliance,

whereas

90.1%

of

patients

thought

their

dialysis

schedule

was

convenient

and

83.7%

attended

dialysis

at

least

two

times

per

week.

These

ndings

are

similar

to

which

reported

that

the

adherence

of

maintenance

hemodialysis

patients

in

India

in

general

was

satisfactory

with

the

ESRD-AQ

and

varied

in

each

treatment domain.

19

In a similar study, it was found that

structured

dialysis

programs,

regular

counselling,

and

family

support

were

signicant

factors

for

better

adherence

to

treatment

in

patients

with

chronic

hemodialysis.

20

A relatively high adherence was found

in the present study, which might be associated with the

frequent education of the patient by the health care sta

involved in dialysis, because 71.6% of the participants

indicated

that

they

received

patient

education

every

time

they

went

for

dialysis.

Despite

favourable

adherence,

symptom

burden

remained

substantial.

Approximately

42%

of

participants

experienced

varying degrees of diculty during dialysis, while 44%

reported

diculty

taking

prescribed

medications,

and

58.9%

experienced

diculty

following

dietary

recommendations.

Similar

observations

were

reported

in the previous research study, which demonstrated that

fatigue,

pain,

sleep

disturbances,

and

gastrointestinal

symptoms

remain

highly

prevalent

among

CKD

patients

despite

ongoing

dialysis

treatment.

11

A

previous research study reported that greater symptom

burden

was

associated

with

poorer

medication

adherence

and

negative

treatment

beliefs

among

maintenance

hemodialysis

patients.

21

These

ndings

emphasise

that

symptom

management

should

accompany

adherence-promoting

interventions

to

optimise

patient

outcomes.

In

the

current

study,

medication adherence was generally good, with 63.1%

of participants indicating that they had not missed any

medications

over

the

past

week;

however,

44%

had

some diculties when taking their medications, mainly

because

of

the

cost

of

the

medications

and

hospitalisation. The results are similar to earlier

studies

showing

that

adherence

to

medications

is

one

of

the

most

dicult

aspects

of

ESRD

management

due

to

complicated

drug

regimens

and

pill

burden.

22

Additionally,

Hamza

et

al.

(2025)

found

that

nancial

constraints,

lack

of

health

literacy,

and

patient

education were found to always have a negative impact

on

adherence

to

medication

among

patients

on

long-

term

hemodialysis.

21

Likely,

the

same

barriers

play

a

role

in

medication

problems

seen

with

Pakistani

patients.

Other

challenges

included

uid

and

dietary

adherence.

While

all

the

participants

recognised

the

need for uid restriction and dietary advice, 68.8% and

58.9%

reported

challenges

with

limiting

uids

and

following

dietary

advice,

respectively.

These

ndings

corroborate

those

of

the

which

found

that uid and dietary restrictions were among the most

challenging

symptoms

of

lifelong

hemodialysis

management

due

to

cultural

dietary

habits,

poor

nutritional

education

and

psychological

stress.

20

The

multivariable

analysis

showed

that

there

were

several

demographic

and

treatment

factors

that

independently

inuenced

adherence

to

treatment.

Higher

age,

education, dialysis duration, number of sta education,

medication adherence and regular self-care behaviours

were

positively

correlated

with

medication

adherence,

while transportation challenges, medication side eects

and higher symptom burden were negatively correlated

with

adherence.

They

are

congruent

with

earlier

research, which has shown that adherence to treatment

is

a

multifaceted

phenomenon

that

is

inuenced

by

a

combination

of

socioeconomic,

behavioural,

psychological,

and

health

care

factors

rather

than

one

factor.

22

This

means

continued

patient

education

and

supportive communication from the healthcare provider

continues

to

be

a

vital

part

of

dialysis

care.

A

correlation

analysis

also

found

that

adherence

to

treatment

was

signicantly

various

patient

factors. Regular attendance at dialysis, sta education,

taking medications, and awareness of the disease were

positively

associated

with

adherence,

while

burden

of

symptoms,

transportation

problems,

medication

Factors Associated with Treatment Adherence and Symptom Burden

149

J Gandhara Med Dent Sci

October - December 2026

problems,

and

dietary

problems

were

negatively

associated

with

adherence.

These

ndings

are

in

line

with

the

ndings

of

the

study,

in

which

the

authors

found

that

symptom

burden

and

medication

beliefs

were

signicant

factors

aecting

adherence among maintenance hemodialysis patients.

21

Put

together,

these

ndings

support

the

multidimensionality

of

adherence

and

indicate

that

interventions

targeting

a

single

factor

may

be

less

effective.

In

Pakistan,

the

present

study

oers

much-

needed

local

evidence

on

adherence

behaviours

of

maintenance hemodialysis patients. The burden of CKD

keeps

on

increasing

in

Pakistan,

with

a

shortage

of

dialysis

infrastructure,

nephrology

services,

nancial

support,

and

patient

education.

While

the

majority

showed good compliance, transportation issues, cost of

medications, symptom burden and problems with uid

and

dietary

restrictions

were

still

signicant

barriers.

The

results

highlight

the

need

for a

multi-disciplinary

approach with nephrologists, dialysis nurses, dietitians,

the pharmacist, and members of the family to enhance

patient education and self-management and to improve

long-term clinical outcomes.

LIMITATIONS

The

single-centre

cross-sectional

design

limits

generalizability

and

prevents

causal

inference.

Adherence

measures

were

self-reported

and

are

susceptible

to

recall

and

social-desirability

bias.

Objective

indicators

such as

interdialytic

weight

gain,

serum

phosphate

or

potassium,

dialysis

adequacy

(Kt/V),

and

prescription-refill

data

were

not

reported.

Depression,

anxiety,

health-related

quality

of

life,

and

formal social-support measures were also not assessed

in

the

supplied

results.

In

addition,

the

sample-size

basis,

ESRD-AQ

scoring,

DSI

results,

and

inferential

statistical

analyses

require

clarification

or

reanalysis

before submission.

CONCLUSIONS

Participants

generally

reported

high

overall

treatment

compliance

and

regular

dialysis

attendance,

but

substantial

diculties

remained

with

medication-

taking, uid

restriction, and dietary recommendations.

These

ndings

support

routine,

repeated

education

combined with individualised counselling and practical

support

for

treatment

barriers.

Conclusions

regarding

symptom

burden

and

independent

predictors

of

adherence should

be

nalised

only

after the

DSI

data

and

statistically appropriate

multivariable

analyses are

incorporated.

CONFLICT OF INTEREST:

None

FUNDING SOURCES:

None

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COPYRIGHTS:

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Muhammad Mamoon

-

Concept & Design; Data

Acquisition;

Drafting Manuscript; Final Approval

Ifrah

Riaz

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Fakhar

Zaman

-

Concept

&

Design;

Data

Acquisition;

Drafting

Manuscript;

Critical

Revision;

Supervision;

Final

Approval

Zahid

Ullah

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Anum

Essa

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Muhammad

Haroon

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Drafting

Manuscript;

Final

Approval

Factors Associated with Treatment Adherence and Symptom Burden