key: cord-0900766-ozyo8moe authors: Siraj, Jafer; Abateka, Turi; Kebede, Oliyad title: Patients’ Adherence to Anti-diabetic Medications and Associated Factors in Mizan-Tepi University Teaching Hospital: A Cross-Sectional Study date: 2021-12-21 journal: Inquiry DOI: 10.1177/00469580211067477 sha: c55ee0a25c9c10a51b561e98963f847cf1d77815 doc_id: 900766 cord_uid: ozyo8moe Introduction: A number of medications have been demonstrated to lower blood glucose. However, current-day management has failed to achieve and maintain the optimal glycemic level for diabetic patients. Patients’ non-adherence is among the most contributing factors. Therefore, the aim of this study was to explore the prevalence of non-adherence to anti-diabetic medications and associated factors. Methods: A hospital based cross-sectional study was conducted from November 2020 to January 2021. A systematic random sampling technique was used. Data were collected by structured questionnaire adapted from different literatures. Then, data were entered into SPSS version 25 and analyzed. To determine the association of dependent and independent variables, multiple logistic regression was done. P-value <.05 was considered statistically significant. Results: A total of 275 study participants were interviewed with a response rate of 100%. From this 53.8% were females, 59.3% were in the age group of 41-60 years, 35.3% were college/university graduates and 79.3% were not using social drugs. One hundred eighty-seven (68%) of them were adherent to their anti-diabetic medication. Factors found to be significantly associated with anti-diabetic medication adherence were age >60 years (AOR = .276, 95% CI = .124-.611) attending higher education (AOR = 6.203, 95% CI = 1.775-21.93), retired (AOR = 7.771, 95% CI = 1.458-41.427), housewife (AOR = 7.023, 95% CI = 1.485-33.215), average monthly income 1001birr-2000 birr (AOR = .246, 95% CI = .067-.911) and social drug use (AOR = 3.695, 95% CI = 1.599-8.542). Forgetfulness, not affording, side effects, misunderstanding of instructions, and poly-pharmacy were identified reasons for non-adherence. Conclusions and Recommendations: Patients’ adherence to anti-diabetic medications in the current study is sub-optimal. Age, monthly income, level of education, occupational status, and social drug use were associated with adherence. Forgetfulness, not affording, and side effects were reasons identified to contribute to non-adherence. Therefore, adherence counseling, use of alarms, and the way to mitigate non-affordability, including anti-diabetic medications into a program drug should be considered. Diabetes mellitus (DM), a collection of metabolic disorders, is rapidly escalating as a crucial public health issue. 1 Globally, the expected number of diabetic patients is swiftly escalating, with 591.9 million in 2035 and 642 million in 2040. 2, 3 The vast majority of these people live in low-and moderate-income countries. Diabetes Mellitus is increasing at a different rate in different parts of the world. The predicted proportional increment in the number of adults with diabetes is 108% for low-income countries and 28% for high-income countries. 4, 5 Like in other low-income countries, the prevalence of diabetes in Ethiopia is high, and the expected proportional increase in the adult population is also high. 6 Diabetes mellitus impose vast social, health, and economic impacts on individuals and countries in the long term. However, much of these impacts can be lessened by reducing diabetes complications. This can be done with anti-diabetic medications. Although a number of medications have been illustrated to lower blood glucose (glycemia), current-day management has failed to achieve and maintain the optimal glycemic control for diabetic patients. 7 Non-adherence to anti-diabetic medications is among the most contributing factors for poor glycemic control. 8 Non-adherence to antidiabetic medications has numerous consequences. Some of them were: increased out of the pocket expenditure, increased overall health care costs, worsening of morbidity, and increased mortality. [9] [10] [11] Increased prevalence of non-adherence with medical treatment continues to be a source of concern for medical professionals and social scientists. As a result, a significant number of patients do not receive adequate benefit from medical treatment, resulting in poor health outcomes, lower quality of life, and increased healthcare costs. 12 Despite these facts, as far as our knowledge is concerned, there is limited study around the current study area on non-adherence to anti-diabetic medications and associated factors. Therefore, the aim of this study was to explore the prevalence of non-adherence to anti-diabetic medications among patients attending chronic ambulatory care at Mizan-Tepi University Teaching Hospital and associated factors. This study can be a baseline data for the hospital management and pharmacy department to take appropriate action to increase adherence of their clients. It can also be helpful for future researchers and pharmacy professionals to identify areas that need improvement and tackle the identified factors. A hospital based cross-sectional study was conducted at Mizan-Tepi University Teaching Hospital, Mizan-aman. It is located at about 583 Km south-west of Addis Ababa, the capital of Ethiopia. It was conducted by interviewing patients on follow up at chronic ambulatory care using structured questionnaires. The study was conducted from November, 2020 to January, 2021. All diabetic patients, on follow up at Mizan-Tepi University Teaching Hospital chronic ambulatory care, were source population. The study populations were diabetic patients older than 18 years and who were able to provide information by their own. Critically ill patients were excluded. The sample size was determined by a single population proportion formula as follows n ¼ Zα 2 Where n= sample size for a population >10,000 p= 50% estimated population proportion of success (reflects assumption that impact is expected in 50% of the population) d=.05 margin of error (5%) (The precision of measurement) Z α/2 = Confidence interval (1.96) n ¼ ð1:96Þ 2 ð0:5Þð1 À 0:5Þ ð0:05Þ 2 ¼ 384 Since the total population of diabetic patients on follow up in the current hospital was 975, finite population correction formula was used to obtain the final sample size Where N i = final sample size n = sample size The Systematic random sampling technique was employed. Sampling interval was determined by: K=N/N i = 975/ 275 =4 Therefore, the data was collected every 4 th person and the first person was selected by lottery method from the first four patients. Patients' adherence to anti-diabetic medication was dependent variable. Socio-demographic factors (age, sex, religion, educational status, occupation, income and marital status), Clinical characteristics (duration of treatment, type of DM, Insulin use, co-morbidity, and complication), and social drug use were independent variables. Structured questionnaires adapted from similar literature with minor revisions were used to collect data. [13] [14] [15] This questionnaire was used after conducting a pre-test on 5% of the sample size in Wacha primary hospital. Cronbach alpha was calculated to test the validity and reliability of the questionnaire, and the value was .78. The questionnaire had socio- demographic characteristics and adherence measurement scale questions. It was prepared in the English language and translated into Amharic by principal investigators. Then, the principal investigators gave a 1-day training for data collectors on the data collecting procedure and COVID-19 protocols. Then, the data collectors filled the questionnaire by interviewing patients, keeping their distance, having a face mask for themselves and patients. The collected data were checked for completeness, accuracy, and clarity every day by principal investigators. It was translated back to English by principal investigators and entered into the Statistical Package for Social Science (SPSS) version 25 for analysis. Independent variables with a P-value less than .25 in bivariate logistic regression were fitted for multiple logistic regression models to determine factors associated with adherence, and P-value <.05 was considered statistically significant. Four non-adherence measuring questions were used to measure the patients' level of adherence. One point was given to each "yes" answer and the total score were calculated for each patient. Then, patients who scored ≥2 points were classified as non-adherent and those who scored <2 points were classified as adherent. Accordingly, 187 (68%) of assessed patients were found to be adherent to their antidiabetic medicines (Figure 1 ). This study also explored reasons for patients' non-adherence to anti-diabetic medicines. Among these, 102 (37.1%) patients reported that they miss their medication due to forgetting, while 91(33.1%) due to not affording the drug (Figure 2 ). Multivariate logistics regression analysis was done to determine the association between independent and dependent variables. Accordingly, age >60 years (AOR=.276, 95% Drug therapy is a cornerstone of diabetes management. However, many patients fail to adhere to their drug therapy. Poor adherence to medications is a single major reason for uncontrolled blood sugar, diabetic complications, and health care financial wastage. 16 Several factors were identified as contributing factors for not taking medicines as prescribed. Therefore, this study emphasized on assessing the DM patients' adherence to anti-diabetes medication and associated factors. The prevalence of adherence to anti-diabetes medications in this study was 68%. This result is similar to the studies done in Iran and Ethiopia (Adama referral hospital). 15, 17 However, it is slightly less than the results of studies conducted in east Uganda (83.3%) and north-west Ethiopia, University of Gondar hospital (85.1%). 12, 18 The difference could be due to differences in the method used to measure adherence and the study setting. The study conducted in east Uganda used different metrics from the current study. On the other hand, the University of Gondar hospital has specialized services and professionals, which could generally improve services and could be brought better adherence. Moreover, the current result is better than the study conducted in general hospitals in Cameroon, Sudan, and different hospitals in Ethiopia (Dilla university referral hospital, Jimma university specialized hospital, and Zewditu memorial hospital). [19] [20] [21] [22] [23] Adherence to anti-diabetic medicines had a significant association with attending higher education and using social drugs (like cigarette smoking, chewing khat, and alcohol use). Similar findings were reported by studies conducted in United Arab Emirates, Saudi Arabia, and Ethiopia(University of Gondar Hospital), which showed attending higher education is associated with non-adherence to anti-diabetic medicines. 12, 16, 24 This might be because individuals, who attended higher education, understand the complex anti-diabetic regimen; and the complications of not taking anti-diabetic medicines. Again, study done in Tanzania, Dar es Salaam, reported social drug use (especially cigarette smoking) is one of the factors affecting adherence to anti-diabetic medications. 25 Being elderly (>60 years) and an average monthly income of 1001 ETB to 2000 ETB was also negatively associated with adherence to anti-diabetic medication. This could probably be because of forgetting and not affording. Elderly people are more forgetful than younger people. Moreover, people with low monthly income might not afford medicines, as respondents also raised not affording as one of the reasons for non-adherence. These findings are in line with other studies findings. 26, 27 Other factors that were significantly associated with adherence to anti-diabetes medicines were being retired from work and being housewife. The possible justification for this can be, their medication schedule will not overlap with working time and they spent majority of their time around their residency so that they might not forget taking their medications. This study also revealed several reasons for non-adhering to anti-diabetic medications among study participants. This includes forgetfulness, not affording, misunderstanding instructions, side effects, poly-pharmacy, and schedule overlap with working time. Previous studies also reported similar reasons for non-adherence. [28] [29] [30] [31] The statistical analysis also showed being older age and earning low monthly income were negatively associated with adherence. Other studies also revealed forget fullness and not affording medications as a common reason for non-adherence. 23, 24 Limitations: Even though, this study revealed prevalence of non-adherence to anti-diabetic medicines and associated factors, it has limitations. First, since the results were obtained from patients' self-reported adherence, adherence might be overestimated, and subjective. Secondly, it did not assess the outcome of non-adherence. Therefore, future researchers can fill these gaps, by considering different metrics and further investigate the outcome of non-adherence to antidiabetic medicines. Patients' adherence to anti-diabetic medications in the current study is below most of the previous studies. It has a significant association with age >60 years, retired and housewife, attending higher education, and social drug use. Forgetfulness, not affording, and side effects of medications were reasons identified for non-adherence to anti-diabetics. Therefore, the prescribers and dispensers should improve adherence counseling by encouraging the use of alarms and time arrangements for taking medications. Since nonaffordability was among the reasons for non-adherence, the Ethiopian Ministry of Health and its partners should consider including anti-diabetic medications in program drugs. We would like to thank Mizan-Tepi University for facilitating the study. We are also grateful to Mizan-Tepi Teaching hospital for providing us necessary assistance and data collectors for their unreserved commitment. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article. The study was conducted following the declaration of Helsinki. Accordingly, a formal letter was taken from Mizan-Tepi University, College of Medicine and Health Sciences, School of Pharmacy ethical review committee to Mizan-Tepi University teaching hospital (Ref. no CP019/13). Then, data collectors collected data after obtaining written consent from each participant. Data collectors also assured each respondent about the confidentiality of the information, and the personal identifiers were not presented in the study. The data sets generated and/or analyzed during the present study are available from the corresponding author on reasonable request. Diabetes mellitus -definition, klassifikation, diagnose, screening und prävention (update 2019) [Diabetes mellitus-definition, classification, diagnosis, screening and prevention Global estimates of diabetes prevalence for 2013 and projections for 2035 IDF diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040 Global estimates of diabetes prevalence for 2013 and projections for 2035 The double burden of diabetes and global infection in low and middle-income countries Increasing prevalence of diabetes mellitus in a developing country and its related factors Current antidiabetic agents and their molecular targets: a review Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions A systematic review of adherence, treatment satisfaction and costs, in fixed-dose combination regimens in type 2 diabetes Impact of medication adherence on hospitalization risk and healthcare cost The "cost" of medication nonadherence: consequences we cannot afford to accept Adherence and associated factors towards antidiabetic medication among type ii diabetic patients on follow-up at university of gondar hospital Adherence to diabetes medication among diabetic patients in the Bisha governorate of Saudi Arabia -a cross-sectional survey Validity and reliability of anti-diabetic medication adherence scale among patients with diabetes in Baghdad, Iraq: a pilot study Nonadherence and contributing factors among ambulatory patients with antidiabetic medications in Adama Referral Hospital Factors contributing to non-compliance among diabetics attending primary health centers in the Al Hasa district of Saudi Arabia Adherence to glyburide and metformin and associated factors in type 2 diabetes in Isfahan, Iran Adherence to anti diabetic medication among patients with diabetes in eastern Uganda a cross sectional study Adherence to antidiabetic medication and factors associated with nonadherence among patients with type-2 diabetes mellitus in two regional hospitals in Cameroon An evaluation of adherence to anti-diabetic medications among type 2 diabetic patients in a sudanese outpatient clinic Medication adherence in diabetes mellitus and self management practices among type-2 diabetics in Ethiopia The magnitude of non-adherence and contributing factors among adult outpatient with Medication adherence and its associated factors among diabetic patients at Zewditu Memorial Hospital Patients' adherence to anti-diabetic medications in a Hospital at Ajman. UAE Predictors of poor glycemic control in type 2 diabetic patients attending public hospitals in Dar es Salaam The determinants of anti-diabetic medication adherence based on the experiences of patients with type 2 diabetes Medication non-adherence and associated factors among diabetic patients visiting general hospitals in the eastern zone of Tigrai, Northern Ethiopia Blood glucose control and medication adherence among adult type 2 diabetic Nigerians attending a primary care clinic in under-resourced environment of eastern Nigeria Adherence to diabetes medication: a systematic review Medication adherence among ambulatory patients with type 2 diabetes in a tertiary healthcare setting in Southwestern Nigeria Poor adherence to treatment: A major challenge in diabetes Jafer Siraj  https://orcid.org/0000-0002-1928-984X Oliyad Kebede  https://orcid.org/0000-0001-6806-4623