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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 24-27

Adherence to medications among patients with diabetes mellitus (Type 2) at ballabgarh health and demographic surveillance system: A community based study


1 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Assistant Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Former Senior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Professor and Head, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission27-Nov-2017
Date of Acceptance05-Jun-2018
Date of Web Publication1-Feb-2019

Correspondence Address:
Puneet Misra
Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-2113.251344

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  Abstract 


Introduction: Burden of diabetes mellitus in India is on rise. Adherence to treatment is essential to diabetes control and prevention of complications. Objectives: To study the adherence to treatment of diabetes mellitus and its determinants among rural population Material and methods: A cross-sectional study was conducted in a rural community of north India. From a list of all self-reported diabetics (aged ≥18 years), 400 were randomly selected. Information about drug prescription and intake, socio-demographic factors, health seeking behaviors and disease status were obtained from the participants. Height, weight and blood pressure were recorded. Blood samples were collected to measure HbAlc levels Results: Out of 371 self-reported diabetic patients, 113 (30.4%) did not take any medication since last one month of the interview. Amongst 258 patients, who were taking treatment, 146 (39.4, 95%CI: 34.5-44.4) were found to have 100% drug adherence rate. Tobacco (p=0.03) and alcohol (p=0.04) use were significantly associated with drug adherence on bi variate analysis. Drug adherence rate was higher in group with HbA1c level more than 6.4gm%. Conclusion: A high proportion of diabetic patients were not adhering to the treatment prescribed to them by their consulting doctors. There is urgent need for awareness generation about diabetes treatment adherence and developing adherence monitoring mechanisms at community level.

Keywords: Adherence, diabetes mellitus, Rural India


How to cite this article:
Misra P, Salve HR, Srivastava R, Kant S, Krishnan A. Adherence to medications among patients with diabetes mellitus (Type 2) at ballabgarh health and demographic surveillance system: A community based study. Indian J Community Fam Med 2018;4:24-7

How to cite this URL:
Misra P, Salve HR, Srivastava R, Kant S, Krishnan A. Adherence to medications among patients with diabetes mellitus (Type 2) at ballabgarh health and demographic surveillance system: A community based study. Indian J Community Fam Med [serial online] 2018 [cited 2019 Dec 6];4:24-7. Available from: http://www.ijcfm.org/text.asp?2018/4/1/24/251344




  Introduction Top


The number of people with diabetes mellitus in India is increasing across geographic, ethnic and administrative boundaries.[1],[2],[3],[4],[5] The International Diabetes Federation estimates that the number of diabetic patients in India more than doubled from 19 million in 1995 to 40.9 million in 2007, projected to increase to 69.9 million by 2025.

As per WHO, average rate of non-adherence in patients with chronic disease is 50% in developed countries.[6] Adherence is the single most important modifiable factor that can render even best treatment ineffective.

Most of Indian studies on treatment adherence among diabetics’ are hospital based.[7],[8] Present study was conducted to know treatment adherence amongst diabetics and its association with various factors in a rural community.


  Material and Methods Top


It was a community based cross-sectional study conducted at Ballabgarh Health and Demographic Surveillance System (HDSS) site.[9] Study Population was self-reported diabetics aged > 18 years with records in Ballabgarh HMIS.

Sample size of 400 was calculated taking prevalence for adherence to diabetic treatment as 35%[10] with 5% absolute error and 15% refusal. Amongst 616 total diabetics in HMIS, 400 were selected randomly. All sampled adults were contacted at household. Information on was self-reported and obtained on pre-designed questionnaire. One-month treatment record was checked for the completion of the findings

Drug adherence was determined by both recall and pill count method. To minimize recall bias, drug intake was asked for last one week only. In recall method, patients were asked to recall individual drug intake in last one week prior to interview. Adherence to drug was calculated by dividing drug consumed with drug prescribed. Adherence was reported in the form of percentage. Patient was categorized as adhered to medication only if adherence was 100% by recall method. We have also calculated adherence by using pill count. Empty blister packs were counted for prescribed medications to estimate the drug intake. The reference period for pill count was one week. Taking no treatment despite being prescribed and missing even a single pill was considered as non-adherent. Fasting Blood sample was collected. Blood samples were analyzed for HBA1C estimation in the laboratory at Civil Hospital Ballabgarh. American Diabetic Association (ADA) Criteria was utilized for classification of HbA1C levels. Information about drug prescription and intake, socio-demographic factors, health seeking behaviors and disease status were obtained from the participants. Height, weight and blood pressure were recorded. Data was entered in Ms Excel and analyzed using STATA. t test was used for continuous variables and Chi square test was used for categorical variables.

Ethical clearance for the study was obtained from ethical committee of All India Institute of Medical Sciences, New Delhi.


  Results Top


Demographic details of study participants are given in [Table 1]. Out of total 371 study subjects, 325 (87.6%) blood samples were collected. Amongst 371 participants, 258(69.5%) had taken treatment for diabetes in last 1 month. Prevalence of drug adherence among all diabetics with recall method was 39.4% (95% CI 34.5-44.4). Amongst 258 study participants, who had taken any treatment for diabetes in last 1 month, 146 (56.6%, 95% CI: 50.5-62.5) had 100% adherence to the prescribed medicines for last seven days. The prevalence of drug adherence among diabetics with pill count methods was 39.2% (95% CI: 34.4-44.7).
Table 1: Demographic Profile of the study participants

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Figure 1: Flow of study participants

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Females (had a better drug adherence compared to males (44.1% Vs35.1%). Prevalence of drug adherence among tobacco and alcohol users was 32.4% and 27.1% respectively. A statistically significant association was found between tobacco consumption (p value=0.03) and alcohol use with drug adherence (p value=0.04). [Table 2]
Table 2: Adherence to treatment of DM with level of BMI, Duration, HbA1C and co morbidity of Hypertension

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With increase in duration of DM, adherence increased and it was statistically significant (p=0.02). Highest adherence rate was observed for HbA1c level of >6.4gm% while the lowest was with HbA1c level <5.7 gm%, Adherence to diabetic drug increased with increasing HBA1C, though it was statistically non-significant.

Highest drug adherence was observed for insulin (93.3%; 14) followed by Tab. Glimiperide (59.4%; 82), Tab. Metformin (56.2%; 127) and Tablet Glibenclamide (53.8%;7). Amongst 112 participants who were found non adherent to the diabetic drugs, forgetting to take drug was the most common reason for non-adherence followed by feeling of bitterness (30.6%), non-availability of drugs (13.9%), fear of side effects of the drugs (13%) and financial constraints (2.8%). 7% did not respond to the question.

Mean HbA1c level amongst those who had taken any treatment in last one month was 8.57 compared to 8.14 among those who were not taking any medicine. In the group who were taking treatment, mean HbA1c level was 8.57 among the drug adhered group as compared to 8.58 in non-adherence group.

In multivariate analysis with gender, caste, alcohol consumption, tobacco use, numbness, giddiness, polydypsia and medical prescription, none were found to be statistically significant. The R square value for the model was 0.08. Almost similar results were found during the sensitivity analysis where pill count method.


  Discussion Top


Present study reported 39.4% adherence to the treatment of diabetes mellitus in the rural community. A systematic review[10] of adherence to medication for diabetes both in developing and developed countries showed average adherence to oral hypoglycaemic medications from 36% to 93%, which might be due to different method of measurement.

Shobhana R et al[11] in hospital-based study in Chennai reported 25.0% adherence to the therapeutic regimen lesser then values reported in our study. In a study in a tertiary teaching centre in New Delhi, medication adherence was estimated with a 4-item Morisky scale was good (Morisky score >3) in only 47.7% of patients.[12] Higher adherence rate in this study might attribute to hospital based setting. A community study forms rural area in Thiruvananthapuram, Kerala reported 26% adherence to diabetic treatment.[13] This lower prevalence in this study might be due to two weeks recall period as compared to one week in the present study.

Low education status, female gender and low income were documented as factors responsible for non-adherence to the treatment of diabetes.[11] Due to inadequate sample size these relationship were not statistically significant in the present study. Association of uncontrolled diabetes status and adherence to the treatment was also non-significant in this study. In this study, adherence to the treatment was studied for a recent one week period. Hence there might be chance that recently non-adherent participants might have good glycemic control in previous three months which was reflected in HbA1C levels or those with mild diabetes might be reluctant to take drugs. Major reasons given by the patients for missing doses were symptom free period and non-availability of drugs due to lack of purchasing power comparable with various published studies[11],[12],[13]

Strengths of this study were community setting and short duration of recall period. Due to limitation of recall method adherence measurement in this study was done by two different methods which showed almost similar results. Limitation of this study was less power to document impact of adherence on diabetes control.


  Conclusion Top


Present study documented the low prevalence of adherence to treatment of diabetes mellitus in rural community of north India (Ballabgarh HDSS). Low adherence to treatment in the context of increasing burden of Diabetes mellitus adds to the major public health problem in the country. There is a need to focus on measure to increase compliance to DM treatment through multipronged public health approach under national program for control of cancer, diabetes, CVD and stroke (NPCDCS) in India.



 
  References Top

1.
Mohan V, Sandeep S, Deepa R, Shah B, Varghere C. Epidemiology of type 2 diabetes: Indian scenario. Indian JMed Res 2007; 125: 217-30.  Back to cited text no. 1
    
2.
Sridhar GR, Rao PV, Ahuja MMS. Epidemiology of diabetes and its complications In: Ahuja MMS, Tripathy BB, Moses SGP, Chandalia HB, Das AK, Rao PV, editors. RSSDI textbook of diabetes Hyderabad: Reseach Society for the Study of Diabetes in India; 2002 p. 95-112.  Back to cited text no. 2
    
3.
Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia2001; 44: 1094-101.  Back to cited text no. 3
    
4.
Huizinga MM, Rothman RL. Addressing the diabetes pandemic: A comprehensive approach Indian J Med Res2006; 124: 481-4.  Back to cited text no. 4
    
5.
Sadikot SM, Nigam A, Das S, Bajaj S, Zargar AH, Prasannakumar KM, et al The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: prevalence of diabetes in India study (PODIS). Diabetes Res ClinPract2004; 66: 301-7.  Back to cited text no. 5
    
6.
Sabate E (2003) Adherence to long-term therapies: evidence for action. Geneva, Switzerland: WHO  Back to cited text no. 6
    
7.
Shobhana R et al Patients’ adherence to diabetes treatment Journal of Association of Physician of India 1999;47(12):1173-5.  Back to cited text no. 7
    
8.
Joshi PP, Salkar RG, Heller RF Determinants of poor blood pressure control in urban hypertensive of central India. journal of human hypertension, 1996 May;10(5):299-303  Back to cited text no. 8
    
9.
Kant S, Misra P, Gupta S, Goswami K, Krishnan A, Nongkynrih B, Rai SK, Srivastava R, Pandav CS. The Ballabgarh Health and Demographic Surveillance System (CRHSP-AIIMS). Int J Epidemiol. 2013 Jun;42(3):758-68.  Back to cited text no. 9
    
10.
Cramer JA. A systematic review of adherence with medications for diabetes, Diabetes Care 2004;27:1218-1224.  Back to cited text no. 10
    
11.
Shobhana R, Begum R, Snehalatha C, Vijay V, Ramachandran A. Patients’ adherence to diabetes treatment J Assoc Physicians India. 1999 Dec;47(12):1173-5  Back to cited text no. 11
    
12.
Sultana G, Kapur P, Aqil M, Alam MS, Pillai KK Drug utilization of oral hypoglycemic agents in a university teaching hospital in India, J Clin Pharm Ther 2010;35:267-277.  Back to cited text no. 12
    
13.
Sankar UV, Lipska K, Mini GK, Sarma PS, Thankappan KR The Adherence to Medications in Diabetic Patients in Rural Kerala, India Asia Pac J Public Health. 2013 Feb 14. [Epub ahead of print]  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Material and Methods
Results
Discussion
Conclusion
References
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