Adherence - determinants - diabetes - India
Introduction
Medication adherence is a leading issue and a huge burden in our current healthcare
system. In the limited resource-country like India, the preponderance of economic
instability, low literacy level, and restricted access to healthcare facilities might
have led to the increase incidence of medication non-adherence. Medication compliance
has been defined by the International Society for Pharmacoeconomics and Outcomes Research
as the “extent to which a patient acts in accordance with the prescribed interval
and dose of a dosing regimen”.[1] Diabetes related morbidity and mortality are becoming more prevalent in India.[2] Medication adherence in diabetic patients significantly varies from 36% to 93%.[3] Treatment effectiveness decreases with non-adherence to prescribed medications thereby,
increasing healthcare costs of diabetes.[4]
[5]
[6]
[7]
[8] Globally, full compliance to the treatment for chronic illness is 50%, and this
is far less in case of developing countries like India.[9] With every 10% increase in medication adherence there is a decrease in HbA1c by
0.16 %.[5] Elderly patients are more likely to be non-compliant and so educational programs
on diabetes self management should be conducted for which there is a growing need
for more research in this area.[7] To the best of our knowledge, there is a scarcity of literature appraising medication
adherence and determinants of non-adherence among type 2 diabetes patients in India.
Thus, the need of this study is to assess medication adherence of diabetes patients
in south Indian hospital.
Materials and Methods
A cross-sectional observation study was conducted including both inpatients and outpatients
for a period of 6 months (February-July 2012), in diabetic clinic at a superspeciality
hospital. Diabetic patients of both sex and age above 18 years were included in the
study. The study was approved by the hospital committee prior to the study initiation.
The structured medication adherence questionnaires (MAQ) was framed and validated
by committee of experts of healthcare providers such as two physicians who are experts
in the field of diabetology and three pharmacists who are experienced in diabetes
pharmacotherapy. The structured MAQ was designed in English and translated into Telugu
language, and was administered to the patients. Patients were asked to answer the
questionnaire in point of view of their previous medication usage pattern. The MAQ
mainly consists of socio-demographics such as age, gender, height, weight, education,
occupation, smoking habit, medical and social history, determinants of non-adherence
with drug therapy like pattern of drug use, reason for missed dose, factors for non-adherence,
type of daily medication remainder, knowledge of complications due to poor glycemic
control, regular home blood glucose measurement, knowledge of optimal blood glucose
target, and identification of medications. The collected data was entered into Microsoft©
Excel to a Microsoft Excel worksheet to obtain the result, which was expressed as
number and percentage.
Results
Sociodemographic details of the patients
During the study period, a total of 140 patients were enrolled. Out of 140 patients,
most of them were females (n = 79, 56.57%), than males (n = 61, 43.57%). Among them
(n = 49, 35%) patients were in the age group greater than or equal to 61 years, followed
by (n = 42, 30%) patients between 51-60 years and others. In the present study, (n
= 77, 55%) patients were illiterates, duration of diabetic history was in the range
of one to five years (n = 69, 49.28%), and hypertension (n = 100, 71.42%) were the
most common co-morbid conditions. The detailed summary of sociodemographic details
of the patients presented in [Table 1].
Table 1
Sociodemographic details of the patients
|
Demographic details
|
No. patients (%)
|
Demographic details
|
No. patients (%)
|
|
Age (years)
|
Inpatients (n = 43)
|
Out patients (n = 97)
|
Overall (n = 140)
|
Duration of Diabetes
|
Inpatients (n = 43)
|
Out patients (n = 97)
|
Overall (n = 140)
|
|
18-30
|
2 (4.65)
|
-
|
2 (1.42)
|
Less than 1 year
|
—
|
—
|
—
|
|
31-40
|
2 (4.65)
|
05 (5.15)
|
7 (5)
|
1-5 years
|
25 (58.13)
|
44 (45.36)
|
69 (49.28)
|
|
41-50
|
9 (20.93)
|
31 (31.95)
|
40 (28.57)
|
5-10 years
|
10 (23.25)
|
40 (41.23)
|
50 (35.71)
|
|
51-60
|
14 (32.55)
|
28 (28.86)
|
42 (30)
|
More than 10 years
|
08 (18.60)
|
13 (13.40)
|
21 (15)
|
|
≥61
|
16 (37.02)
|
33 (34.02)
|
49 (35)
|
Co-morbid condition
|
|
|
|
|
Gender
|
|
|
|
Hypertension
|
28 (65.11)
|
72 (74.22)
|
100 (71.42)
|
|
Males
|
28 (65.11)
|
33 (34.02)
|
61 (43.57)
|
Ischemic stroke
|
02 (4.65)
|
30 (30.92)
|
32 (23.85)
|
|
Females
|
15 (34.88)
|
64 (65.97)
|
79 (56.42)
|
Dyslipidemia
|
09 (20.93)
|
35 (36.08)
|
44 (31.42)
|
|
Educational status
|
|
|
|
Ischemic heart disease
|
01 (2.32)
|
01 (1.03)
|
2 (1.42)
|
|
Illiterate
|
16 (37.20)
|
61 (62.88)
|
77 (55)
|
Chronic renal failure
|
01 (2.32)
|
—
|
1 (0.71)
|
|
High school
|
19 (44.18)
|
27 (27.83)
|
46 (32.08)
|
Retinopathy
|
10 (23.25)
|
3 (3.09)
|
13 (9.28)
|
|
Board of Intermediate
|
03 (6.97)
|
07 (7.21)
|
10 (7.14)
|
Urinary tract infection
|
—
|
11 (11.34)
|
11 (7.85)
|
|
U.G & P.G
|
05 (11.62)
|
02 (2.06)
|
7 (5)
|
Monthly income (INR)
|
|
|
|
|
Body mass index (kg/m2)
|
|
|
|
2000-5000
|
27 (62.79)
|
60 (61.86)
|
87 (62.14)
|
|
Under weight (<18.50)
|
02 (4.65)
|
09 (9.27)
|
11 (7.85)
|
5001-7500
|
06 (13.95)
|
14 (14.43)
|
20 (14.28)
|
|
Normal weight (18.51 - 24.99)
|
30 (69.76)
|
58 (59.79)
|
88 (62.85)
|
>7500
|
10 (23.25)
|
23 (23.71)
|
33 (23.57)
|
|
Over weight ( 25.00 - 29.99)
|
09 (20.93)
|
28 (28.86)
|
37 (26.42)
|
Community
|
|
|
|
|
Obese ( ≥30)
|
02 (4.65)
|
02 (2.06)
|
4 (2.85)
|
Rural
|
29 (67.44)
|
59 (60.82)
|
88 (62.85)
|
|
Social habits
|
|
|
|
Urban
|
14 (32.55)
|
38 (39.17)
|
52 (37.14)
|
|
Smokers
|
10 (23.25)
|
14 (14.43)
|
24 (17.14)
|
|
|
|
|
|
Alcoholics
|
05 (11.62)
|
07 (7.21)
|
12 (8.5)
|
|
|
|
|
|
Both smokers and Alcoholics
|
09 (20.93)
|
50 (51.54)
|
59 (42.14)
|
|
|
|
|
Medication adherence rate and determinants of non-adherence
In the present study of 140 patients, 69.28% are aware of optimal blood glucose levels,
but only 7% of patients regularly check their blood sugars at home. When questioned
regarding medication identification, 47.14% of patients identify their medications
with brand or generic names, 38.57% identify with color, shape and size, while 14.28%
with medication wrapper. It was found that 47.85% patients never missed doses; 28.57%
patients missed daily dose sometimes (less than 5 doses per week), whereas 23.57%
of patients frequently missed daily doses (more than 5 doses per week). It was found
that 47.85% patients were adherent to medications. The main factors for non-adherence
were lack of finance (n = 43, 55.84%), forgetfulness (n = 36, 46.75%), being busy
(n = 34, 44.15%), medicines inaccessibility (n = 15, 19.48%) and others. The detailed
summary of determinants of non-adherence is presented in [Table 2].
Table 2
Determinants of non-adherence with drug therapy
|
Questions
|
Inpatients N (%)
|
Out patients N (%)
|
Overall n = 140 N (%)
|
|
Knowledge of optimal blood glucose target
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
Yes
|
31 (72.09)
|
66 (68.04)
|
97 (69.28)
|
|
No
|
12 (27.90)
|
31 (31.95)
|
43 (30.71)
|
|
Regular home blood glucose measurement
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
Yes
|
6 (13.95)
|
1 (1.03)
|
7 (5)
|
|
No
|
37 (86.06)
|
96 (98.96)
|
133 (95)
|
|
Knowledge of complications due to poor glycemic control
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
Poor visibility
|
37 (86.04)
|
70 (72.16)
|
107 (76.42)
|
|
Foot ulcer
|
1 (2.32)
|
2 (2.06)
|
3 (2.14)
|
|
Others
|
5 (11.62)
|
25 (25.77)
|
30 (21.42)
|
|
How will you identify your medicines?
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
By brand name/drug name
|
23 (53.48)
|
43 (44.32)
|
66 (47.14)
|
|
By medication wrapper
|
6 (13.95)
|
14 (14.43)
|
20 (14.28)
|
|
By colour, shape and size
|
14 (32.55)
|
40 (41.23)
|
54 (38.57)
|
|
Cannot identify
|
—
|
—
|
—
|
|
Pattern of drug use
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
Never missed
|
8 (18.6)
|
59 (60.82)
|
67 (47.85)
|
|
Missed daily dose sometimes
|
12 (27.9)
|
28 (28.86)
|
40 (28.57)
|
|
Missed daily dose frequently
|
23 (53.4)
|
10 (10.30)
|
33 (23.57)
|
|
Reason for missing dose
|
[IP n = 35; OP n = 38]
|
n = 73
|
|
Lack of finance
|
19 (54.28)
|
24 (57.14)
|
43 (55.84)
|
|
Forgetfulness
|
21(60)
|
15(35.71)
|
36 (46.75)
|
|
Being busy
|
11 (31.42)
|
23(54.76)
|
34 (44.15)
|
|
Medicines inaccessibility
|
7 (20)
|
8 (19.04)
|
15 (19.48)
|
|
Side effect of drug
|
6 (17.14)
|
5 (11.90)
|
11 (14.28)
|
|
Multiple drug therapy
|
3 (8.57)
|
5 (11.90)
|
8 (10.39)
|
|
Decision to omit
|
2 (5.71)
|
02 (4.76)
|
4 (5.19)
|
|
Others
|
1 (2.85)
|
02 (4.76)
|
3 (3.8)
|
|
Type of daily medication reminder
|
[IP n = 26, OP n = 47]
|
n = 73
|
|
Morning time
|
—
|
2 (4.25)
|
2 (2.74)
|
|
Meal time
|
3 (11.53)
|
3 (6.38)
|
6 (8.21)
|
|
Bed time
|
3 (11.53)
|
5 (10.63)
|
8 (10.95)
|
|
Both moring and meal
Time
|
15 (57.69)
|
28 (59.57)
|
43 (58.90)
|
|
Three times a day
|
5 (19.23)
|
9 (19.14)
|
14 (19.17)
|
|
Special instructions from doctor taking medications
|
[IP n = 43; OP n = 97]
|
n = 140
|
|
Yes
|
38 (88.37)
|
67 (69.07)
|
105 (75)
|
|
No
|
5 (11.62)
|
30 (30.92)
|
35 (25)
|
|
If Yes, then how often do you follow them?
|
[IP n = 38; OP n = 67]
|
n = 105
|
|
Some times
|
25 (65.78)
|
36 (53.73)
|
61 (58.08)
|
|
Most of the times
|
8 (21.05)
|
21 (31.34)
|
29 (27.61)
|
|
All the times
|
5 (13.15)
|
10 (14.92)
|
15 (14.28)
|
Discussion
In the present study, the overall medication adherence rate was found to be 47.85%,
which was less than the study conducted by Wabe et al., and Grant et al.[10]
[11] About 30.71% patients have no knowledge about optimal blood glucose levels; 95%
patients were not aware of Self Monitoring of Blood Glucose (SMBG) at home. Thirty-five
percent of patients were from age group greater than or equal to 61 years; 46.75%
patients had difficulty in remembering time of dosing, and this could be due to forgetfulness,
which is most common in this age group. As most of the patients belong to a rural
community (62.85%), the percentage of illiterate patients were found to be more (55%),
and 33% of patients had a problem in accessing medicines. The average cost per diabetic
patient with and without complications in a south Indian hospital during their hospital
stay is 16,956 INR (314.15 USD) and 1622 INR (29.91USD), respectively.[2] The lack of finance, which is evident from their monthly income falling between
2000 to 5000 INR, could be the reason for non-adherence to medications in 55.84% patients,
whereas the results of a study conducted by Santhosh et al. shows that almost same
percent of patients are in the same age group and percentage of illiterate patients
were low.[12] Hypertension (71.42%) and dyslipidemia (31.42%) were the co-morbidities frequently
present among our study population, while hypertension and obesity were the most frequent
co-morbidities in studies done by Wabe et al. and Isomaa et al.[10]
[13] Challenging factors like lack of finance (55.84%), forgetfulness (46.75%), being
busy (44.15%), inaccessibility of medicines (19.48%), attribute to poor adherence
to anti-diabetics, whereas the results of a similar kind of study conducted in Ethiopia
shows that study forgetfulness (50.2%), lack of finance (37.1%), side-effect of drug
(29.2 %), inaccessibility of medicines (5.6%) are influencing the medication adherence.[10] About 52.14% of patients use Daily Medication Reminder (DMR), to remind them to
take their prescribed medication; among them most of the patients (58.90%) use it
as morning and meal time doses. These likely increase the chance of achieving high
patient adherence with prescribed medications and subsequent optimal glycemic control.
As evident from various studies, medication adherence can be improved by dosage simplification,
educating the patients on aspects of drugs, disease state and lifestyle modifications,
using reminder systems like weekly pill boxes and packaged calendars, telephonic and
pager reminder.[14]
[15]
[16]
[17] Newly developed smart phone applications can improve medication adherence, but their
reliability is not yet studied.[18]
Conclusion
This study is helpful in understanding non-adherence in diabetic patients in South
Indian Hospital. Most of the patients from rural areas are not properly educated about
diabetes and its debilitating long-term complications; due to which morbidity and
mortality are increased as seen from other studies. The overall medication adherence
rate was unsatisfactory. Most of the patients in our study do not monitor sugars at
home. Diabetic patients must be aware of SMBG, as it has significant effect in achieving
glycemic targets. Medical community needs health professionals to educate the patients
about their disease states and compliance to prescribed medications.
How to cite this article: Medi RK, Mateti UV, Kanduri KR, Konda SS. Medication adherence and determinants of
non-adherence among south Indian diabetes patients. J Soc Health Diabetes 2015;3:48-51.
Source of Support: Nil.
