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NON ADHERENCE TO MANAGEMENT REGIMEN AMONG ADULTS WITH TYPE 2 DIABETES MELLITUS ATTENDING OUTPATIENT CLINIC OF UNIVERSITY OF NIGERIA TEACHING HOSPITAL ENUGU.

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ABSTRACT

Chronic diseases such as diabetes mellitus require daily self management and long term therapies. Regimen adherence poses a unique challenge for patients with chronic illnesses including diabetics resulting to repeated hospital admissions, amputations and even death. There is paucity of information on regimen adherence behaviour among diabetic patients attending diabetic clinic at University of Nigeria Teaching Hospital (UNTH) Enugu. Thus the study was done to determine the prevalence and associated factors of non adherence among adults with type 2 diabetes mellitus in UNTH Enugu. A cross sectional study was done and a researcher- developed- questionnaire was used to collect data from October and December 2010. Majority, 63.5% of the respondents were females while 36.5% were males. Their mean age was 60.1 years and 88% were married.  The  prevalence of non adherence to medication was 24.5%, while 57.5% of the respondents did not have glucometer for self monitoring of blood glucose. Majority, (86.1%) of those on oral hypoglycaemic agent (OHA) could not monitor their blood glucose level at least twice weekly,  49.0% of the respondents  missed hospital appointments and most of them, 63.5% were eating irregularly.  Age (p 0.006, C I 0.025 – 0.544) and marital status (p 0.025, C I 1.250 – 25.792)  were found to be associated with non adherence to medication. This showed that age and marital status militated against adherence to medication in the respondents. Cost of transportation (p  0.000, C I 0.069 – 0.472) ,discouraging attitudes of health workers (p 0.003, C I 0.006 – 0.353) and late commencement of clinics (p 0.006, C I 0.007 – 0.448) were associated with non adherence to coming for checkups. Based on these findings, it was concluded that there was non adherence to various aspects of management regimen  among the respondents. Recommendations included that healthcare providers (physicians, nurses, pharmacists ) should screen patients for non adherence when they report no improvement with their prescribed therapy. Also communication and patient- provider relationship should be improved and clinic activities commenced on time.

 

CHAPTER ONE

INTRODUCTION

Background to the study

Poor adherence to prescribed protocols of long term therapies is a pervasive and costly problem in the care of patients with chronic illnesses (Chang,  Yeh, Lo & Shih, 2007). Poorer health outcomes and higher healthcare costs result when a patient does not adhere to recommended medication and lifestyle changes such as exercise, smoking  cessation or prescribed non pharmacologic interventions such as physical therapy or dietary plans (Eckland 2013)

Chronic diseases such as diabetes mellitus, hypertension and arthritis require daily self management and long term therapies. Diabetes mellitus is a serious chronic condition that is assuming epidemic proportions worldwide, as more than 230 million people are living with diabetes (Silink, 2007). This number is expected to escalate to 350 million (which is about 6.3% of the world population) within 20years (Silink, 2007).

In United States, 800,000 new cases of diabetes are diagnosed yearly with type 2 diabetes accounting for 90%-95% of the diagnosed cases (Mokdad & Ford, 2008). Chronic diseases like diabetes mellitus contribute to over 70% of the disease burden in Australia and an increase of up to 80% is expected by 2020 while China is having 30 million out of its 1.3 billion population as diabetics. (Oputa & Chinenye, 2012).

The traditional rural communities of Africa still have low prevalence of diabetes of about 1-2% while in urban communities you can have up to 1-13% (Sobngwi, Jarvis, Vexian, Mbanya & Gautier 2007). Nigeria is reported to have up to 7% of its population as diabetics with a prevalence of 7.2% in the urban communities of Lagos Mainland, 4.7% in Lagos island and 6.8% in Port Harcourt (Oputa & Chinenye 2012; Ajibade, Abdullahi & Oyedele 2010).

The American Diabetic Association’s Clinical Practice recommendation for the management of diabetes include tight plasma glucose control of 80120mg/dl for fasting glucose measurement, eat as recommended for each individual by their dietician, take medication as prescribed, engage in physical exercises, go for checkups and perform other self care activities like foot and eye care. (Silink, 2007).

It has been reported that regimen adherence poses a unique challenge for diabetic children, adolescents and adults and thus will negatively impact on achieving management goals, negates the effectiveness of treatment and results in repeated hospital admissions, amputations and death (Eckland, 2013). Some patients in DAWNS study were found not to adhere to insulin therapy, others modify their regimen in an unprescribed  way and some did not monitor their blood sugar level, did not eat as instructed and did not exercise (Rubin & Peyrot, 2005).

In view of the rate at which diabetes is now increasing, especially in the developing countries and with its short term and long term complications, there is urgent need for diabetic patients to adhere to and maintain their management regimen. This will help to achieve diabetic management goals, retard the progress of diabetic complications and improve  their quality of life (Kalyango, Owino &Nambuya, 2008). Non adherence to management regimen should

therefore be a concern to all healthcare givers and all factors associated with it should be considered while caring for patients with diabetes.

In Enugu there is paucity of information on non adherence to management regimen among diabetic patients, the extent of the problem and factors that may be contributing to it. This underscores the need to ascertain the prevalence of non adherence to management regimen among adults with type 2 diabetes and to determine the factors associated with it in Enugu. Thus if the magnitude of the problem is ascertained, then appropriate intervention strategies can be initiated.

Statement of the problem

Currently there is no known cure for diabetes but the major element in diabetes care is tight glycaemic control which is achieved by strict adherence to medication, informed dietary modification, appropriate physical exercise and other instructions (Kalyango et al, 2008;Eckland 2013).

In clinical practice both in developed and developing countries, reports have shown that most of the patients were poorly controlled due to non adherence to regimen  (Huther, Wolff & Stange 2013). A non adherence rate of up to 66% in patients with diabetes was reported by John et al (2005) in South South zone of Nigeria while Kalyango et al (2008) recorded 28.9% prevalence rate in Uganda. To the best of the researcher’s knowledge, no empirical work was found on non adherence to management regimen among adults with

diabetes at University of Nigeria teaching Hospital Enugu as at the time of this study.

However the researcher’s observation as a clinical nurse in medical wards showed that majority of adult patients with diabetes were admitted or readmitted either in a comatose state or with uncontrolled high glucose levels. The question that stimulated this study is: to what extent could non adherence account for these patients’ conditions. This study has attempted to address this question.

Purpose of the study

 The purpose of the study is to assess the prevalence and associated factors of non adherence to management regimen among adults with

type 2 diabetes at the outpatient clinic of University of Nigeria Teaching  hospital Enugu.

Objectives of the study are:

  1. To determine the prevalence of non adherence to prescribed medication, diet modification, self monitoring of blood glucose level and coming for checkups in adults with type 2 diabetes.
  2. To identify demographic factors associated with non adherence.
  3. To establish psychosocial factors associated with non adherence.
  4. To identify health system/regimen related factors associated with non adherence.

Research questions to be addressed are:

  1. What is the prevalence of non adherence to prescribed management regimen among adult patients with type 2 diabetes?
  2. To what extent can the prevalence be explained by the respondents’
  3. What psychosocial factors are associated with non adherence.
  4. Are there health system/regimen related factors associated with non adherence.

Significance of the study

Findings from this study will add to the existing knowledge about extent of non adherence to management regimen among diabetic patients. This knowledge will help healthcare givers to think of assessing non adherence when a regimen seems not to be effective thereby enhancing adherence and reduce the rate of developing complications.

Survival skills are essential for patients with diabetes. Findings from this study will give information on factors militating against adherence which the healthcare givers need in order to prioritize education programme in which  the patients need to be active participants.

Further research can emanate from this study.

Scope of the study

The study is delimited to non adherence and associated factors among adults with type 2 diabetes attending  out patient diabetic clinic at University of

Nigeria Teaching hospital Enugu from October to December 2010.

Operational definition of terms

Non adherence is defined as the extent to which a person’s behaviour  (in taking medication, following diet, or executing lifestyle changes) coincides with medical or health advice (Kara, Caglar & Kilie, 2007). It includes failure to enter a treatment programme, premature termination of therapy, incomplete implementation of instructions and non attendance at appointment (Barbin, Grey& Tansella, 2008).

In this study non adherence to the following treatment regimen among type 2 diabetics is defined and assessed in the following  ways:

Non adherence to prescribed medication entails an adult with type 2 diabetes not taking up to 80% of the prescribed dose of injection insulin or oral hypoglycaemic  agents (OHA). This is calculated as:

No of drugs taken100

No prescribed            1

Non adherence to diet modification entails taking less than three meals daily and the needed in between snacks; taking the meals at irregular times and not varying the choice of food from the six food groups.

Non adherence to self monitoring of blood glucose entails not having the meter for measuring blood glucose level at home; not measuring blood glucose level every other day or at least twice in a week for those on oral hypoglycaemic agent (OHA) and before each meal or at least daily for those on injection.

Non adherence to out patient clinic attendance entails patients not coming for appointments as booked.

Adults with type 2 diabetes are those patients who are  40years and above who have been diagnosed and confirmed as having type 2 diabetes and placed on treatment by a medical officer.

Associated factors to non adherence are those factors, features or circumstances within the patient, his environment or within the healthcare system or in the regimen that will make an adult with type 2 diabetes not to follow their management recommendations. For the purpose of this study the factors of interest are grouped into demographic, psychosocial and health system/regimen-related factors.

Prevalence of non adherence is the proportion of adults with type 2 diabetes who were not able to follow the instructions given to them about the management of their illness within the study period of October to December 2010 as it concerns medication, diet, self monitoring of blood glucose and keeping appointment.

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