anti-diabetic medication adherence and associated ...

NTI-DIABETIC MEDICATION ADHERENCE AND SSOCIATED FACTORS AMONG PATIENTS ATTENDING TERTIARY CLINIC IN GABORONE, BOTSWANA.

esenter: Godfrey Mutashambara Rwegerera her collaborators: Thato Moshomo, Marea Gaenamong, Taibat deronke OYEWO, Sivasomnath Gollakota, Francis Apolinary Mhimbira

Faculty of Medicine, University of Botswana Gaborone, Botswana 27th July 2016

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Introduction

Diabetes mellitus (DM), the most common endocrine disease in the world, i a major global public health problem.

The increase in burden of diabetes mellitus in Sub-Saharan Africa is critical as it complicates cost, morbidity and mortality associated with preexisting high prevalence of communicable

The problem of nonadherence to medical treatment remains a challenge fo the medical professions and social scientists.



Introduction

As a result, significant numbers of patients are not adequately benefited fro medical treatment, which in turn end up with poor health outcomes, and increased health care costs

Previous studies have underlined several factors contributing to optimum disease management included age, gender, complexity of treatment, duration of disease, depression, and psychosocial issues

Education including adherence counseling to create awareness towards D and its medications is mandatory.



Objective

This study was conducted to assess the magnitude of antidiabetic medication adherence and assess associated factors among both patients with type 1 and 2 DM attending block 6 clinic;- a tertiary center in Gaborone South East Botswana.



Methods

Study design: A cross-sectional study was carried out from July to September 2015 among 380 randomly selected known diabetic patients attending block 6 Clinic in Gaborone, Botswana Study setting: Block 6 clinic located in the West side of Gaborone is the satellite clinic specialized in attending patients with both Type 1 and Type 2 diabetes mellitus.Gaborone,the Capital City of Botswana has a population o about 200,000 people, and forms the core of most patients attending the clinic. The clinic offers various services to patients. Services include;-doctors consultations, health education, eye and foot screening and issuing medications. On average 1800 – 2000 diabetic patients visit the clinic monthly for various reasons, of which an average 1400 patients are doctors’ consultations



Methods (Data collecting tools)

Eight item Morisky Medication adherence questionnaire was used to asses antidiabetic medication adherence. A structured questionnaire was used to collect information on factors influencing adherence including;- age, gender, level of education, type of diabetes, duration of diabetes, modality of treatment, documented complications and HIV status Results of glycemic control were extracted from Integrated Patient Management System (IPMS).



orisky 8-Item Medication Adherence uestionnaire

Do you sometimes forget to take your medicine? (Y=1,N=0) People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine? (Y=1,N=0) Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? (Y=1,N=0) When you travel or leave home, do you sometimes forget to bring along your medicine? (Y=1,N=0) Did you take all your medicines yesterday?(Y=0,N=1) When you feel like your symptoms are under control, do you sometimes stop taking your medicine? (Y=1,N=0) Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to yo treatment plan? (Y=1,N=0) How often do you have difficulty remembering to take all your medicine? (A=0,B-E=1) A. Never/rarely B. Once in a while C. Sometimes D. Usually E. All the time Total score>2 for low adherence,1 and 2 for medium adherence and 0 for high adherence

Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence.Med Care. 1986;24:67-74.



Methods Ethical clearance to conduct the study was obtained from the University of Botswana Ethics Committee and the Institutional Review Board (IRB) and Ethics Committee at Princess Marina Hospital. Ethical clearance was also be secured from Botswana Ministry of Health Research Department



Methods (Data analysis) Data were entered and analyzed using STATA Version 14.

To assess the association between antidiabetic medication adherence and other variables, logistic regression with OR and 95% CI was done .A p-valu of < 0.05 or less was considered statistically significant.



Results



e 1: Sociodemographic characteristic of the study participants (age, gender, marital status, l of education, BMI) Characteristic

N(%)

Sex Female

264 (69.5)

Male

116 (30.5)

Age, mean (sd)

56.5 (13.7)

=66

103 (27.1)

Education level No formal school

70 (18.4)

Less than primary school

78 (20.5)

Primary school completed

103 (27.1)

Secondary school completed

79 (20.8)

College/University completed

44 (11.6)

Post-graduate degree

6 (1.6)

Marital status Never married

102 (26.8)

Currently married

157 (41.3)

Separated

2 (0.5)

Divorced

13 (3.4)

Widowed

76 (20)

Cohabiting

30 (7.9)

BMI, median (IQR) Underweight

5 (1.5)

Normal weight

65 (19.3)

Overweight

98 (29.2)

Obese

168 (50)



e 2: Clinical and medication characteristic of study participants (Type of diabetes, duration of diabetes, tion of attending block 6 clinic, modality of clinic, number of oral hypoglycemic agents, presence of plications) Clinical and Medical characteristics Type of Diabetes mellitus Type 1 Type 2 Duration of diabetes 10yrs Missing Modality of treatment for diabetes Diet Oral hypoglycemic agents (OHA) Insulin Both OHA and Insulin Number of OHA currently in use One Two Missing Diabetic complications no yes Diabetic complications (multiple response)

N (%) 23 (6.1) 357 (93.9) 178 (46.8) 91 (23.9) 93 (24.5) 18 (4.7) 4 (1.1) 220 (57.9) 55 (14.5) 101 (26.6) 164 (43.2) 161 (42.4) 55 (14.5) 69 (18.2) 311 (81.8)

Eye complications-retinopathy Kidney complications-nephropathy Heart failure Neuropathy Skin complications with or without itching

142 (37.4) 18 (4.7) 32 (8.4) 55 (14.5) 133 (35)

Diabetic foot/hand with or without ulcer

23 (6.1)

Stroke Gastroparesis Postural hypotension Palpitations

3 (0.8) 77 (20.3) 116 (30.5) 113 (29.7)



e 3: Adherence to antidiabetic medications according to Morisky scale (high, medium, low) Morisky score

N (%)

High adherence

219 (57.6)

Medium adherence

91 (23.9)

Low adherence

66 (17.4)

Unknown

4 (1.1)



e 4—Odds ratios, 95% CI, and P values for multivariate model of factors associated with diabetes medication adherence or nonadherence (define nonadherence as either low or medium adherence according to Morisky scale)

Characteristics Age group =66 Sex Female Male Education level Secondary or higher No/Primary Marital status Married/Cohabiting Single/Divorced HIV status Negative Positive Unknown Type of diabetes Type 1 Type 2 Diabetes duration 10yrs Missing Modality of treatment Diet OHA Insulin Both OHA and Insulin


Crude OR (95% CI)

p-value 0.1

1 (Ref) 2.58 (1.04-6.43) 1.93 (0.82-4.56) 2.72 (1.12-6.62) 0.3 1 (Ref) 0.79 (0.5-1.23) 0.5 1 (Ref) 0.87 (0.56-1.33) 0.9 1 (Ref) 0.97 (0.64-1.46) 0.006 1 (Ref) 0.3 (0.13-0.69) 0.71 (0.44-1.13) 0.10 1 (Ref) 2.12 (0.82-5.5) 0.05 1 (Ref) 1.56 (0.93-2.62) 1.86 (1.11-3.11) 2.38 (0.89-6.33) 0.079 1 (Ref) 1.08 (0.24-4.93) 0.46 (0.09-2.31) 1.03 (0.22-4.84)

Adjusted OR OR (95% CI) p-value 0.3 1 (Ref) 2.76 (0.83-9.19) 2.05 (0.59-7.07) 2.6 (0.7-9.63) 0.5 1 (Ref) 0.82 (0.5-1.35) 0.1 1 (Ref) 0.66 (0.38-1.13) 0.8 1 (Ref) 1.06 (0.68-1.65) 0.017 1 (Ref) 0.31 (0.13-0.74) 0.69 (0.42-1.14) 0.40 1 (Ref) 0.53 (0.12-2.45) 0.10 1 (Ref) 1.57 (0.91-2.72) 1.82 (1.01-3.25) 2.54 (0.88-7.36) 0.2 1 (Ref) 1.15 (0.24-5.64) 0.45 (0.08-2.61) 1.07 (0.21-5.49)


Results

According to Morisky scale; - 57.6%, 23.9% and 17.4% of patients had high medium and low antidiabetic medication adherence respectively.

The studied sociodemographic characteristics and clinical variables were n associated with antidiabetic medication adherence.

HIV positive status was associated with a statistically significant bette medication adherence at multivariate analysis (p-value=0.017, AOR = 0.31, 95% CI = 0.13-0.74) .



Conclusion Adherence to antidiabetic medication was found to be quite low at block 6 Clinic, especially when the fact those medications are provided monthly at no cost. Only HIV positivity was found to be significantly associated with better medication adherence, probably due to effect of being on multiple medications with more support and counseling offered at HIV clinics.



Conclusion

Psychosocial factors contributing to medication non-adherence may include;- Health literacy, Possibility of cognitive decline, Language factors, Psychological factors (Identity, Social factors (Social support, cultural factor stigma)

Go ka bo go ne go le botoka go nna le HIV gona le bolwetse jwa sukiri’ (‘It would have been better if I had HIV instead of diabetes’) (Reid MJ, Tsima B S Afr Med J 2014;104(5):325. There is a need to carry further studies to understand better patterns of medication adherence that are pertinent to Botswana setting.

