Compliance in Saudi Epileptic Patients: Determinants ...

Compliance in Saudi Epileptic Patients: Determinants of Compliance in Saudi Epileptic Patients Mohammad Abdul Jabbar, MBBS, MD, FRCP(C); Sulaiman A. Al-Shammari, MBBS, MSc, MRCGP From the Division of Neurology and Clinical Neurophysiology (Dr. Abdul Jabbar), and Primary Health Care Clinics, Department of Family and Community Medicine (Dr. Al-Shammari), College of Medicine, King Saud University, Riyadh. Address reprint requests and correspondence to Dr. Al-Shammari: Assistant Professor and Director of Primary Health Care Clinics, King Saud University, Department of Family and Community Medicine, College of Medicine, P.O. Box 2925, Riyadh 11461, Saudi Arabia.

Accepted for publication 18 May 1992.

A one year prospective study was conducted (July 1990 to June 1991) on 104 Saudi epileptic patients (aged 15 to 45 years) to assess the degree of anti-epileptic drug (AED) compliance and factors that influence their compliance. Onethird of the patients (30.8%) were non-compliant (NC). A logistic regression equation compared the data indicated. A low level of education and adverse effect of the disease on patients were the most important significant factors for poor compliance. Age, sex, marital status, family history, duration and type of seizure were not found to have a significant role in the patients' compliance to AED. MA Jabbar, SA Al-Shammari, Compliance in Saudi Epileptic Patients: Determinants of Compliance in Saudi Epileptic Patients. 1993; 13(1): 60-63 Patients who fail to comply with their medication are a source of constant confusion and frustration to doctors, but rarely has the problem of noncompliance (NC) been dealt with in any great detail. Antiepileptic drugs (AED) have a major role in the control of epileptic seizures. However, failure to take medication in the prescribed standard fashion may result in the loss of the treatment's efficacy. This may in turn lead to the administration of additional drugs and involvement of unnecessary diagnostic procedures or hospitalization to the patient. Non-compliant patients are a major source of financial concern in terms of time, money and resources which may adversely affect the relationship between both patient and doctor. Appropriate diagnostic or therapeutic plans are not possible without consideration of such factors including patients' attitude, family and living circumstances, past and predictable future behavior. When these factors are not integrated into the decision making process, it is unlikely that management plans based only on technical considerations will be effective [1]. Although these problems have been recognized for centuries, only recently has it become an issue of great importance as reported by Griffith in 1990 [2]. This has been a problem identified by managers, planners and doctors, but it is surprising to note how few studies have been reported on this topic. The major intent of our study was to try and discover the extent of NC by epileptic patients and factors influencing this attitude. Patients and Methods This study was carried out on 104 epileptic Saudi patients without obvious mental or psychological disorders attending the epilepsy clinic which was established in 1984 at King Khalid University Hospital (KKUH). These patients represent various socioeconomic classes in Saudi Arabia. They are seen every 2–3 months regularly by an experienced neurologist. The patients may see a primary care physician should the need arise between follow-up visits. Free health services as well as medications are provided to patients [3]. From the beginning of the study until its conclusion, none of the 104 patients seen were lost to follow-up. The prospective study was carried out between July 1990 and July 1991 to assess the sex, age, level of education, type of seizure, family history, degree of control, in addition to the AED level, side effects of prescribed drugs, effect of epilepsy on the patients' social life such as early school drop out rate and unemployment. For the purpose of this study, compliance has been defined as the extent to which the patients' behavior in terms of medications coincide with the clinical prescription as noted by

Compliance in Saudi Epileptic Patients: Determinants of Compliance in Saudi Epileptic Patients

Eaton in 1981 [4]. With regard to the level of education, patients who had less than four years of formal education were considered as having low education while those who had four to nine years of formal education were considered to be moderately educated, and those with more than nine years of formal education were considered to be highly educated. Patients were asked to bring the medication containers during every. follow-up to the clinic where the quantity of drugs remaining were counted. Those patients who missed a total of three days' doses/month were considered to be non-compliant. This was devised specifically for the present study. On follow-up the blood level for each patient was checked for AED. Any patient who failed to show up for an appointment as scheduled was contacted by phone. In addition, patients were interviewed and assessed about their compliance and the reasons for NC. The main objective of the study was not discussed with any patient. The data obtained was computed and analyzed using SPSS PC software. The logistic regression model was used to describe the relationship between the outcome of the dichotomous variable—(compliance and noncompliance) and another set of independent variables called covariables. Results Table 1 shows the sociodemographic characteristics of these patients by compliance. Thirty-two (30.8%) patients were NC The best level of compliance was found among those aged 25-35 years. It was determined that the level of education played a significant role in compliance. In those who were highly educated, (84.4%) were compliant while a lower level of education correlated with NC The sex of the patient did not have any differential effect on compliance. We found married patients were less compliant than the non-married, but not at a statistically significant value. Table 2 shows various disease aspects and its management by compliance. Those patients who had a family history of epilepsy were more compliant than those without. Patients suffering from complex partial epilepsy for more than ten years' duration which was not controlled well and which had adversely affected the patients' academic performance due to frequent seizures showed the worst compliance. Those patients in need of more than one medication to control their seizures were found to be more compliant. Medications used in this study included phenobarbitone, phenytoin, carbamazepine and sodium valproate. The drug level in the patients were within the therapeutic range or below and no patient became intoxicated. Table 3 demonstrates the co-efficient and odds ratio from stepwise logistic regression of significant variables. The most contributory factor of compliance was education. As the level of education increased from illiterate (low) to secondary and university (high), compliance increased by more than double (odds ratio = 2.364). Those patients whose academic performance was not adversely affected by their disease were found to be more compliant (odds ratio = 1.665). Table 1. Relation of sociodemographic characteristics to compliance (N = 104).

Characteristics Age: 35 Sex: Male Female Education: Low Moderate High Marital Status: Single Married

N

Compliant (%) 72

Non- compliant (%) 32

53 33 18

36 25 11

(67.9) (75.8) (61.1)

17 8 7

(32.1) (24.2) (38.9)

64 40

43 29

(67.2) (72.5)

21 11

(32.8) (27.5)

18 54 32

9 36 27

(50.0) (66.7) (84.4)

9 18 5

(50.0) (33.3) (15.6)

52 52

37 35

(71.2) (67.3)

15 17

(28.8) (32.7)

Table 4 shows the reasons for NC obtained by patients that were interviewed. The major reasons for NC were the disbelief in the value and need of adherence to the prescribed drug regimen. This is the patient's own decision which does not depend on the effect of medication or physician advice. The second major reason was forgetfulness.

Annals of Saudi Medicine, Vol 13 No. 1; 1993


Discussion Anti-epileptic drugs have done a lot in controlling epilepsy during the past four decades. Each year huge sums of money and more time and effort have been expended on the study of the effects of drugs, yet little attention has been given to whether patients take the drugs as prescribed. Therefore, the present study is to make doctors and those involved in the health care of patients constantly aware of the possibility of non-compliance in an attempt at minimizing this condition. We have shown that the majority of the patients complied with the prescribed AED. Many of the patients were highly motivated and appreciated that the consequences would have a serious impact on their well-being if they became non-compliant. With the recent improvement in the socioeconomic status and community health care services in Saudi Arabia, it is expected that there will be better utilization of the health facilities among the population [5]. Previous researchers discovered that neurological problems were previously seen by local healers [6,7]. But recently, belief in local healers is waning and most of the patients now seek the help of orthodox-trained practitioners [8]. Only those with a low level of education or whether the disease adversely affected the patient's academic performance were found to be associated with NC. It is hoped that better education may help patients become more receptive to health care education efforts. This in turn may lead to better compliance. At the moment, health care education is gaining wide acceptance as it is one of the most important elements of primary health care services in Saudi Arabia [9]. Other sociodemographic data such as age, sex, and marital status did not affect compliance. In addition, the use of medication as prescribed was not affected by the presence of family history of the disease, duration of disease, type of epilepsy, level of control or the therapeutic regimen used. Table 2. Relationship of disease aspects to compliance: (N = 104). Disease Family History: Present Absent Duration: 10 Type: Complex partial Primary generalized Unclassified Control: Yes No No. of Medications One Two Effect on life: Yes No

N

Compliant (%)

Non- compliant (%)

11 93

9 63

(81.8) (67.7)

2 30

(18.2) (32.3)

43 40 21

28 30 14

(65.1) (75.0) (66.7)

15 10 7

(34.9) (25.0) (33.3)

37

26

(70.3)

11

(29.7)

61 6

41 5

(67.2) (83.3)

20 1

(32.8) (16.7)

58 46

54 18

(93.1) (39.1)

4 28

(6.9) (60.9)

83 21

56 16

(67.5) (76.2)

27 5

(32.5) (23.8)

20 84

10 62

(50.0) (73.8)

10 22

(50.0) (26.2)



Table 3. Coefficient and odds ratio from stepwise logistic regression of significant variables. (Dependent variable = compliance status coded as 1 for compliance and 0 for noncompliance). Significant variable

Coefficient

Odds ratio

Level of significance

Constant

–0.462

Education Moderate Low Adverse effect on life

0.056 0.860

0.9458 2.364

0.06

0.503

1.655

0.07

P = level for removal and entrance of variables = 0.15, 0.10.

Table 4. Reasons patients gave for non-compliance (N = 32).

Reasons Never told to continue Side effect Ran out of supply Forgot to take it No need

Number of patient (%) 1 (3.1) 2 2 10 17

(6.3) (6.3) (31.2) (53.1)

It is worth noting that our patients continue to take their medication regularly, but were reluctant to do so when they were seizure-free and hence self discontinuation of AED was attempted by the patients. Doctors have provided evidence proving that poor compliance regarding treatment may reflect inadequate patient education [10,11]. It is suggested that continuous use of drugs should be encouraged at the time when the first prescription is provided and continuously reinforced on subsequent follow-up. Counselling patients and helping them become partners in their own health care may help them in making healthy choices when complying with medication prescribed to them. A part of the physician's role in patient health care education and counselling is to try to explain to patients that AED may control seizures, but may not cure them completely. Failure to comply with a prescribed regimen may lead to the return of seizures in dangerous circumstances such as during driving or operating machines. In addition, patients and family members should be educated about what to do during a seizure. In addition to monitoring blood levels, "pill counting" by a doctor on follow-up can be used as an adjuctive method of monitoring the degree of compliance. Other causes of NC include the side effects of prescribed drugs and exhaustion of the supply of tablets. These problems were seen in four patients only. Acknowledgment The authors are grateful to Professor El-Shabrawy Ali and Dr. Bamgboye, Associate Professor and Statistician Department of Family and Community Medicine, College of Medicine, Riyadh for their constructive comments. We are also thankful to Mr. Ejaz for his secretarial help. References 1. Mushlin AI, Appel FA. Diagnosing potential noncompliance: physician's ability in a behavioural dimension of medical care. Arch Intern Med 1977;137:318-21. 2. Griffith S. A review of the factors associated with patient compliance and the taking of prescribed medicines. Br J Gen Pract 1990;40:114-6. 3. Sebai ZA. Health in Saudi Arabia. Riyadh: Tihama Publication 1985;33-7. 4. Eaton G. Non-compliance: prescribing practice and drug usage. London: Groom Helm 1981;201-13. 5. Ministry of Health of Saudi Arabia. Annual Report, Riyadh. Riyadh: Farazdak Press 1990;23-6. 6. Moloney GE. Local healers in Qassim. Community health in Saudi Arabia. 2nd ed. Sebai ZA, ed. Jeddah: Tihama Publication, 1984;87-98.



7. Al-Sabaie A. Psychiatry in Saudi Arabia: cultural perspectives: overview. Transcultural Psychiatric Research Review 1989;26:245-62. 8. Al-Shammari SA. Help seeking behaviour of adults with health problems in Saudi Arabia. Family Practice Research J 1992;12:75-82. 9. WHO, Primary Health Care: report of the international conference on Primary Health Care, Alma-Ata, USSR, 1978. Geneva: World Health Organization, 1978:23-4 ("Health for All" Series No. 1). 10. Davidson DLW. Management of the adult with poorly controlled epilepsy. Hospital Update 1990;16:981-9. 11. Collier JAB, Longmore JML. Prescribing and compliance. In: Oxford Handbook of Clinical Specialties, 2nd ed. Oxford: Oxford University Press 1989:460.
