ADHERENCE TO ANTI-DIABETICS: A CASE STUDY OF OUT-PATIENTS ATTENDING THE DIABETIC CLINIC OF THE KOMFO ANOKYE TEACHING HOSPITAL, KUMASI

ABSTRACT
BACKGROUND: Non-adherence to diabetes treatment leads to poor glucose control and increases the risk of disease complications. The prevalence and factors associated with non-adherence in resource limited settings should be determined so as to lower the impact of diabetes that is on the increase, on the health systems which are already overburdened with communicable diseases.
OBJECTIVE: The purpose of this study is to assess the level of adherence to antidiabetic medicines among patients attending the diabetic clinic and factors contributing to non-adherence at Komfo Anokye Teaching Hospital
METHODS: A cross-sectional study was conducted at the diabetic clinic of the KATH. A list of all patients attending the diabetic clinic for at least the past two years was obtained. A simple random method of sampling was used to select the desired sample size from the patient list. Data was collected via personal interviews using a structured questionnaire and also from the patient medical records. The structured questionnaire was administered to each patient after consenting to participate in the study. The questionnaire was in the form of exit interviews. Information provided by the respondents was counter checked with their medical records.
RESULTS: The level of adherence to anti-diabetic medication among the respondents revealed that majority of them; constituting 64.2% had a high adherence level. The correlation between patients’ socio-demographic and adherence rate to anti diabetic therapy indicated that adherence among women was high represented by 69.6%.
Adherence was high among participants less than 55 years (54.9%), among participants living with their family (90.1%), among participants who were knowledgeable about their disease condition and the effect of defaulting their anti-diabetic medication (64.5%) and high among participants who have been diagnosed of diabetes for less than 3 years (47.04%).
Conclusion: This study revealed a high level of adherence among the participants. Also patients with knowledge of default consequences are more likely to adhere to their antidiabetic medications (p = 0.046).


CHAPTER 1
1.0 INTRODUCTION
1.1 BACKGROUND
Diabetes is among the most difficult disease conditions to manage well. The management of this disease condition is quite a challenge for the diabetic patient. Good glycemic control can be attained if a diagnosed patient follows strict instructions given to him or her. The World Health Organization have stated that non-adherence with long-term antidiabetic medication coupled with comorbid disease states including dyslipidemia, hypertension and diabetes are deemed a common issues that results in serious health challenges coupled with loss of time, money, poorly managed disease condition and enhanced economic burden (World Health Organization,2003).

Adherence is a major challenge patient with diabetes faces and this has a detrimental effect on blood glucose control. Good adherence practices to prescribed treatment regimen reduce diabetic complications from occurring. It is quite a challenge for the health care provider when patient are non-adherent to their treatment recommendation(Fischer, et al. 2010). As a result of patient’s non-adherence to treatment regimen, complications set in and this affects the quality of life of the patient. Patients can easily avoid diabetic complications if they follow instructions and advice on adherence given by their care givers.(Coleman, et al. 2005).

Diabetes complications, death and serious health care losses also occur when patients decide not to adhere to their treatment regimen. (Mateo, et al. 2006; Shaw and Baker 2004). Attention should be given to patients with chronic disease conditions such as hypertension, diabetes etc. on their adherence to their medications.(Armour, et al. 2004; Fischer, et al. 2010).The World Health Organization (2003) has stated that non-adherence to medications is a challenge and is on the increase resulting in serious consequences. Finding lasting solutions to this issue is of importance worldwide than the introduction and development of new medicines for the management of diabetes. (Winkler et al., 2002). Even though series of studies have proved that taking prescribed medicines for the treatment of diseases improves one’s health status and prevents unavoidable deaths, patients with chronic diseases in advance countries have adherence rates ranging from 50%-60% (Fischer et al, 2010 ;Harris et al 1993). In the third world countries, access to health care is a problem, there is lack of proper diagnosis and limited drug availability; all these factors are considered when adherence becomes a problem during the management of chronic conditions like as diabetes, depression, and HIV/AIDS(Friedman, et al. 2010).

In the management of chronic diseases, the rate at which patients adhere to their medicines drops after 6 months into the management of the disease.(Klatt, et al. 2013; Sabaté 2003; Vermeire, et al. 2005) Studies conducted comparing the rates of adherence of chronic conditions such as diabetes and HIV shows that the adherence rates are 80% and 95% respectively, it concluded that the adherence rates for HIV is impressive.(Vermeire, et al. 2005). Past studies conducted between the years 1997 and 1999 showed that diabetic patients who were not religiously adhering to their medicines were 30% at risk of being hospitalized every year whiles those who were adherent to their medicines had a lower risk of 13% of hospitalization yearly.(Yusuff, et al. 2008). This same study showed that the total health cost burden on patients with poor adherence was double that of those who had good adherence rates.

It was approximated in the year 2001 that more than 89,000 cardiovascular deaths would have occurred in hypertensive patients who were 40 years and older and not on any antihypertensive medicines.(Morisky, et al. 1986). Patients who are diagnosed of both diabetes and hypertension as comorbid disease conditions and take their medicines as advised by their health provider are 48% less likely to die before their time from the disease.(Jackevicius, et al. 2008).Asthmatic patients who have good regimen adherence, have 11% less visits to the emergency wards or hospitals. (Delamater 2006).

In the process of counseling or advising patients on their treatment regimen in relation to serious disease conditions like hypertension, diabetes and others, importance should be placed on the implications of not treating the diseases well or appropriately and how it can lead to cardiovascular attacks, paralysis and possibly permanently affecting the patients quality of life. As pharmacists, we are encouraged to educate and advise our patients on proper medication adherence and the consequences the disease have on them when they do not adhere.

Clinical practices have shown that it is quite difficult for most patients to strictly adhere to their medicines after life style modifications have been prescribed for them by their health providers.


It have been observed that only a third of patients diagnosed with chronic diseases conditions like diabetes, hypertension etc. are adherent to their regimen.(Shaw and Baker 2004).

Findings from several studies have proved that most patients with chronic disease conditions normally stop taking their medicines for the mere fact that they have a feeling the medicines cannot cure them and are also worried about the side effects of the medicines they are taking.(Coleman, et al. 2005; Heissam, et al. 2015; Shi, et al. 2010). It is a common believe among patients with diabetes that as far as they do not experience any symptom of diabetes, there is no need to take treatment.

Various meanings have been assigned to adherence but it is simply taking less than 80% of prescribed medicines and following other prescribed treatment regimen given. Adherence is the representative of the final step of rational drug use.(Choudhry, et al. 2009; Trostle 1988).

Adherence may be influenced by many factors but there is no statistics on which one of it has the greatest effect. Care givers should initially find out whether their patients have access to their prescribed medicines. Patients adherence to drug therapy can be categorized into four main groups provided there is the availability of medicines, these categorizations are as follows, patient-related factors; factors related to patient-provider relationship, treatment regimen and factors related to the disease itself(Barber, et al. 2004; Trostle 1988).

One of the factors mostly used to determine patients adherence behaviors is the patient related factors(Organization 2003). Patients’ adherence to drug therapy is solely dependent on that patient and it usually paints a true picture of how difficult it is to understand how the other factors too affect a patient medication taking behavior and to adhere to the prescribed regimen. It is known that certain factors have strong effects on adherence and these factors are the environment where the patient resides in, the type of care the provider gives and the practice of the care giver.

Adherence is all about how informed and how knowledgeable the patient concerned is aware about the disease , being motivated to get involved in the management of the condition, how expectant the results of the management would be and how poor adherence to the regimen would affect the whole treatment outcome.(World Health Organization, 2003). It should be noted that a patient’s non-adherence to medication is influenced by a lot of factors.


Factors that affect a patient’s attitude to adhering to medication regimen changes over a period of time. Continues evaluation of the patient’s attitude to treatment adherence is of great importance. There is no specific or single approach in solving the problem of non-adherence in a patient.

Several approaches used to solve or manage the problem of non-adherence highlights on the importance of increasing the patients knowledge on the disease condition, reducing the amount of medicine to be taken at a specified time and how frequent is should be taken. Even though this approach is theoretically practicable, it does not necessarily mean it will improve the adherence attitude or behavior of a patient who have made up his or her own mind about how well the disease condition should be managed. (World Health Organization, 2003).

Studies conducted have proved that a one way approach to solving the adherence problem does not yield any good results as compared to using more than one or multiple approaches. It have been cited in studies that the main reason for non-adherence can be identified when the provider continually make follow-ups during the period of treatment.(Krueger, et al. 2003). A detailed approach is needed to be used in solving this non-adherence problem, various issues such as providing information about the disease condition, encouraging the patient to be adherent and specific regimen should be based on individual needs, all these are to be addressed.(Krueger, et al. 2003; McDonald, et al. 2002). The appropriate time to start adherence interventions is when the patient starts or begins his or her initial treatment regimen. When interventions are started earlier during the course of treatment it gives older patients the opportunity to ask questions, especially questions on the disease condition, the medicine they have been put on and their side effects.(McDonald, et al. 2002)

Multiple factors come together to affect a patient’s adherence to a prescribed treatment regimen and also contribute to non-adherence of other patients diagnosed with chronic disease conditions like diabetes. (Barber, et al. 2004)

Non adherence to antidiabetic has been a major health issue for researchers and health providers and all resources are being channeled in that directions to solve this issue and to better understand why these patients do not adhere. Researchers are having problems in tackling this issue because patient’s attitude to treatment is quite difficult to deal with. Attention should be given to this non adherence issue to understand the patient’s attitudes to why they do not adhere to their treatment regimen. (Emslie-Smith, et al. 2003; Trostle 1988)

The importance of regimen adherence does not only include patients religiously taking their medicines but it also includes positive life style changes or modifications.(Murray, et al. 2007). The most important aspect of every treatment regimen is to achieve success at the end of the day and to see your patient fulfilled and satisfied with the prescribed treatment outcome. Efforts on the part of the health care provider to give the best care to patient might not yield any results when the patient is not adhering to the various therapies prescribed. Shortfalls like these might go a long way to have a negative effect on the management of the disease.(Jin, et al. 2008).

When it comes to the management of chronic disease conditions, non-adherence to medication regimen is a major problem worldwide. In the management of chronic disease conditions like diabetes, medication adherence is about 50% of the of the treatment regimen whiles that of life style modification is lower as cited by a study.(Barber, et al. 2004; Coleman, et al. 2005). Devoted time and energy is mostly needed in the management of chronic disease conditions but the management of diabetes is among the most demanding among the group.(Trostle 1988)..Management of diabetes involves routine measurement of one’s blood glucose, life style modification and the timely administration of prescribed medicines.(Trostle 1988). Studies have reiterated the importance of achieving optimal glucose control through strict adherence to medications, diet, and exercise in order to minimize serious long term complications (Coleman, et al. 2005; Emslie-Smith, et al. 2003; Trostle 1988).

Chronic disease condition like diabetes, without the necessary treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or non-ketotic hyperosmolar coma. Serious long term complications include cardiovascular disease, chronic renal failure, and retinal damage. Thus, adequate treatment of diabetes is important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight.

These complications affect the well-being of the patient, increases death among patients and bring a greater burden on the economic cost.(Coleman, et al. 2005; Peyrot, et al. 2010; Trostle 1988). To reduce or decrease the health burden of the disease on the system diabetic patients are advised to adhere strictly to their treatment regimen.(Coleman, et al. 2005; Peyrot, et al. 2010).A patient diagnosed with a chronic disease condition adhering to less than 80% of any prescribed treatment regimen is described as being non-adherent. (Barber, et al. 2004)

Factors considered to be important such as services provided and issues related to medicines have been stated in literature, these factors are the number of tablets to be ingested at a sitting and the troubling side effects, bad relationships among the patient and the care giver and the delay observed when it comes to educating the patients on the disease condition.

Knowledge they say is power, it is the greatest tool in the fight against diabetes. Providing information can help people assess their risk of diabetes, motivate them to seek proper treatment and care, and inspire them to take charge of their disease for their lifetime. Due to increasing incidence of complications associated with diabetes, it would be prudent to assess the perception the patient have about the disease. Proper management requires life style changes and adequate diabetes knowledge of which is considered a key component of diabetes management. Differences in the level of knowledge have been described depending on level of education, gender and social status of the patient. Measuring how well diabetic patients are knowledgeable about diabetes can help in targeting public health efforts to reduce diabetes related complications (Choudhry, et al. 2009; Coleman, et al. 2005; Delamater, et al. 2001).

1.2 PROBLEM STATEMENT
Non-adherence to the treatment regimen for diabetes results in avoidable suffering for the patients and excess costs to the health system as a whole. Managing diabetes requires more than just taking medicine, other aspects of self-management such as self-monitoring of blood glucose, dietary restrictions, regular foot care and eye examinations have all been shown to markedly reduce the incidence and progression of complications of diabetes. Not adhering to recognized standards of care is the principal cause of the development of complications of diabetes and their associated individual, societal and economic costs. On-adherence has been defined in the literature as a patient’s passive failure to follow a prescribed therapeutic regimen. This principle also applies to dietary regimens, screening tests, and lifestyle modifications. Non-adherence to appropriate treatment regimen has profound implications on the patient as well as on doctor-patient relationships and interactions, plans of care, and the healthcare system as a whole.

Deliberately not taking medications as prescribed, the patient will not benefit from the medication, adequate drug serum levels will not be achieved, and the medication will not have an effective therapeutic intervention as required to. For example, if a patient with diabetes mellitus is prescribed an oral agent but is not consistently adhering to the regimen, only suboptimal intermittent glucose control will be achieved instead of the continuous control which is required for optimal prevention of the long-term consequences of diabetes. In addition, physicians may erroneously interpret the inadequate glucose control as indicating a need for more medication and thus potentially over-prescribe, putting the patient at risk for hypoglycemia.

Finally, non-adherence leads to increased healthcare utilization through under treatment of chronic and acute problems. Chronic disease conditions like diabetes, without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or non-ketotic hyperosmolar coma. Serious long term complications include cardiovascular disease, chronic renal failure, and retinal damage. Thus, adequate treatment of diabetes is important, as well as blood pressure control and lifestyle modifications such as smoking cessation and maintaining a healthy body weight.

At the Komfo Anokye Teaching hospital there have not been any studies conducted to determine the level of adherence to antidiabetic medications among diabetic patients so this study aims at determining the level of adherence among these patients who attends the diabetic clinic at KATH.

1.3 RESEARCH QUESTIONS
What is the level of adherence to antidiabetic medicines among patients attending the clinic at KATH?

What are the contributing factors to the non-adherence to antidiabetic medicines among patients attending The Diabetic Clinic at KATH?

1.4 MAIN OBJECTIVE
To assess the adherence levels of antidiabetic medicines among patients attending the diabetic clinic and factors contributing to non-adherence at Komfo Anokye Teaching Hospital.

1.4.1 SPECIFIC OBJECTIVES
To assess the level of adherence to antidiabetic medicines among patients attending the clinic at KATH

To assess how contributing factors affect non-adherence to antidiabetic medicines among patients attending clinic at KATH.

1.5 RATIONALE
The purpose of this research is to assess how diabetic patients attending the Diabetic Clinic at KATH strictly adhere to their antidiabetic medicines and to find ways of improving adherence. The findings of this research will be used to increase scientific knowledge base to the scientific world and to inform the practice and policy makers (Ministry of Health and the Board of the KATH).This is aimed at planning interventions to improve patient adherence to antidiabetic therapy to reduce the impact of diabetes and its complications and also improve upon the quality of life of the patients and the health cost burden in general.

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Item Type: Ghanaian Postgraduate Material  |  Attribute: 64 pages  |  Chapters: 1-5
Format: MS Word  |  Price: GH50  |  Delivery: Within 30Mins.
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