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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