Published online May 15, 2018. doi: 10.4239/wjd.v9.i5.72
Peer-review started: March 7, 2018
First decision: April 2, 2018
Revised: April 7, 2018
Accepted: April 15, 2018
Article in press: April 15, 2018
Published online: May 15, 2018
Nearly 80% of the global burden of diabetes is concentrated in the developing world. India has 69 million diabetic patients which is the second highest in the world after China. Management of diabetes requires lowering of blood glucose to optimal levels to prevent or delay the onset of diabetic complications which risk end organ damage. Patient adherence to anti-diabetic medication, healthy diet, and regular physical activity constitutes the mainstay of diabetes treatment. However, poor treatment adherence is a major public health challenge globally but especially in the resource-constrained settings concentrated in the developing world which undermines efforts in controlling diabetes. A complex array of factors influences medical adherence and glycemic control in diabetes patients.
There is paucity of evidence ascertaining the determinants of treatment adherence and glycemic control in diabetes patients attending public health facilities in the developing world.
The study was conducted with the objective of assessing the extent of adherence to self-care practices including medication intake and the influencing factors among diabetic patients undergoing treatment in the outpatient setting of a tertiary care hospital in Delhi. Understanding the determinants of medical adherence through this study would facilitate engineering tailored interventions promoting medical adherence and improved health outcomes among diabetic patients in resource-constrained settings.
Diabetic patients aged between 18 to 65 years and on diabetes treatment for at-least 1 year were included while those with serious comorbid ailments (advanced cardiovascular disease, history of cardiovascular accident, renal failure requiring dialysis, cancer, patients on psychotropic drugs, dementia and blindness) were excluded from the study. The patients were selected consecutively with a maximum of 12 patients being enrolled in a clinic day. Data was collected using a pretested patient interview schedule. The Summary of Diabetes Self-care activities measure (SDSCA) by Toobert et al was used to assess medical adherence in the diabetic patients. Open ended questions were used to identify facilitators and inhibitors of medication, exercise and dietary adherence. The subjects who reported missing their anti-diabetic medications on at-most 1-d in the previous 7 d equivalent to ≥ 80% medication rate were classified as adherent to their prescribed anti-diabetic medication. The subjects who reported adherence to a healthy diet on at-least 5 d were classified as adherent to diet. The subjects who reported engaging in moderate physical activity as part of work, travel or household chores for at-least 150 min interspersed over 3 to 5 d were classified as adherent to physical activity. The cut-off for optimal glycemic control in the present study was accepted at fasting blood glucose levels ≤ 130 mg/dL. The knowledge of diabetes in the patients was assessed using the 10 item Spoken Knowledge in Low Literacy in Diabetes Scale by Rothman et al.
A total of 309 (82.4%) subjects were adherent to the intake of their prescribed anti-diabetic medication (SDSCA medication score ≥ 6) while 66 (17.6%) were non-adherent. Among the adherent subjects, 254 (67.8%) reported missing none of their prescribed anti-diabetic medication on any occasion in the previous 7 d while 55 (14.2%) reporting missing their dose on only a single day. On bivariate analysis, low education level (below primary school completion), living in joint family, patient not on insulin therapy, absence of hypertension comorbidity and lack of family assistance for taking medication were found to be significantly associated with medication non-adherence. On adjusted analysis, low education level (below primary school completion) and absence of hypertension comorbidity were found to be significant predictors of medication non-adherence. A total of 254 (67.7%) subjects reported low levels of physical activity. Female gender, living in joint family and low educational level (below primary school completion) were significantly associated with lower physical activity. The mean HbA1c in the sample population was 8.39 ± 2.0 (n = 354). Only 116 (31%) subjects showed optimal glycemic control (FBS ≤ 130 mg/dL). On bivariate analysis, insulin therapy was found to be significantly associated with suboptimal glycemic control (P = 0.006). Knowledge of diabetes in the study subjects was low with mean score of 3.1 ± 2 (maximum score = 10). The knowledge score was significantly lower in patients with low education level (below primary school) compared to those educated beyond primary school (P < 0.001).
Our study found a large gap exists between the self-reported medication adherence (82.7%) and attainment of optimal glycemic control (31%) patients. These findings suggest the possibility of significant clinical inertia prevalent in the study setting. A dual burden of medication non-adherence and clinical inertia could undermine efforts in effective diabetes management in the resource-constrained settings of the developing world. Understanding the factors driving clinical inertia in these settings requires assessment through future studies. The present study also found patients on Insulin tend to report higher medication adherence but show suboptimal glycemic control compared to patients only on oral hypoglycemic agents. This indicates overestimation of insulin adherence when based on single item self-report measures. Future studies should assess insulin adherence through self-report based on correctness of the steps executed in the process of insulin administration. In this study, family support was found to improve medication adherence and adoption of healthy lifestyle. This indicates the need of the treating physician to enlist valuable family support whenever available for the diabetic patient.
The study shows improving medication adherence in diabetic populations does not necessarily correlate with improvement in glycemic status due to the possibility of clinical inertia which requires reduction through enhanced physician focus on patient outcomes.