Presented By: Dr Nithin Kumar Associate Professor Department of Community Medicine Kasturba Medical College Mangalore[Manipal University]

Effect of Distress on Adherence to Anti diabetic Medications among Type 2 Diabetic Patients Attending Tertiary Care Hospitals in Mangalore

INTRODUCTION

WHO defines adherence as the extent to which a person's behaviour taking medication, following a diet , and /or executing lifestyle changes corresponds with agreed recommendations from a health care provider.

According to WHO there are 5 factors influencing patient adherence: 1. Socioeconomic factors 2. Health system and health care team related 3. Therapy related for patient 4. Condition or disease related and 5. Patient related

Poor adherence is generally associated with bad outcomes of the disease

Diabetes Distress, Depression, and Subclinical Depression are all psychologic disorders which are known to affect patients with diabetes

Very limited studies are trying to find out association of distress with adherence to anti-diabetic medication

OBJECTIVES

To assess the level of adherence towards anti diabetic medication among patients with type 2 diabetes mellitus

To assess the level of distress and its effect on adherence among diabetic patients

To study the influence of patient related factors, medication related factors and health system related factors to adherence to anti-diabetic medications

MATERIALS AND METHODS

Study setting: - Kasturba Medical College Hospital, Attavar, and - Peripheral outreach clinics belonging to the Department of Community Medicine, Kasturba Medical College Mangalore.

Study design: Cross-sectional study

Study type: Analytical study

Study duration: 1st January 2015 to 31st January 2015

Study subjects: All type 2 diabetic patients on anti-diabetic therapy for more than 6 months

Sample size: 124

Sample size calculation:

The sample size was calculated taking level of adherence to anti diabetic medication as 47% based on previous study. Taking 20% relative precision and 95% confidence interval, the sample size was calculated to be 113. Adding 10% as non-response error, the final sample size is 124.

Data Collection Methodology:

Institutional ethics committee approval was obtained.

Study tool: Pretested semi structured questionnaire consisting of the following sections Section A - Socio demographic information of the patients Section B - Diagnosis treatment details and advice given Section C - Factors related to health Section D- Diabetes Distress Scale Section E - Morisky 8-Item Medication Adherence Questionnaire

DATA ANALYSIS:

The collected data was analysed using SPSS ver 11.5.

Descriptive statistics (Mean, Standard Deviation) and proportions.

We undertook both unadjusted and adjusted logistic regression to assess the various ( Patient related, Medication related and Health system related) factors favoring adherence to anti-diabetic medication among patients.

Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) are reported.

TABLE 1: Baseline characteristics of the participants

N=124Median age =

60(50-68)yrs

Variablesn(%) Age group (yrs)6538(30.6)GenderMale68(54.8)Female56(45.2)Marital statusMarried107(86.3)Widow012(09.7)Unmarried004(03.2)Divorced001(0.8)

Table 1 continued:N=124

Variablesn(%)Lower socioeconomic status100 (80.6)Family History of diabetes43 (34.7)Presence of comorbidities72 (58.1)Presence of diabetic complications51 (41.1)Smoker25 (20.2)Alcohol consumption16 (12.9)Experience of side effects48 (38.7)

72(58.1)Fig 1: Level of distress among diabetic patients

Chart1

58.1

29

12.9

36 (29)

16 (12.9)

N=124

Distress calculated susing diabetic distress scale

Sheet1

Distress calculated susing diabetic distress scale

Low distress58.1

Moderate distress29

High distress12.9

To resize chart data range, drag lower right corner of range.

Fig 2: Level of adherence to anti diabetic medications among diabetic patients

Chart1

27.4

29

43.5

36 (29.1)

54 (43.5)

34 (27.4)

N=124

Adherence calculated using Morisky 8 item scale

Sheet1

Adherence calculated using Morisky 8 item scale

High adherence27.4

Moderate adherence29

Low adherence43.5

To resize chart data range, drag lower right corner of range.

Table 2: Univariate analysis showing the Patient related factors associated with adherence to anti-diabetic medication [N=124]

Table 3:Univariate analysis showing the Health system related associated with adherence to anti-diabetic medication [N=124]

VariablesAdherenceUnadjustedOR (95%C.I)P valueGood (n=70)Poor(n=54)Distance from hospital (km)228(62.2)17(37.8)0.7(0.3-1.5)0.329>242(53.2)37(46.8)Cost of drugsFree36(63.2)21(36.8)0.6(0.3-1.2)0.166Paid34(50.7)33(49.3)Frequency of blood glucose monitoringRegular58(61.7)36(38.3)0.4(0.2-0.9)0.040Occasional12(40.0)18(60.0)Means of conveyanceWalking22(71.0)9(29.0)0.4(0.2-1.0)0.063 Use Transport48(51.6)45(48.4)

Table 4: Univariate analysis showing Medication related factors associated with adherence to anti diabetic medication [N=124]

VariablesAdherenceUnadjustedOR (95%C.I)P valueGood (n=70)Poor(n=54)Number of anti diabetic medications taken239(52.0)36(48.0) 0.6(0.3-1.3) 0.217>231(63.3)18(36.7)Side effects experiencedYes21(43.8)27(56.2) 0.4(0.2-0.8) 0.025No49(64.5)27(35.5)Insulin injection takenYes20(57.1)15(42.9) 0.9(0.4-2.1) 0.922No50(56.2)39(43.8)

VariablesAdherenceUnadjustedOR (95%C.I)P valueGood (n=70)Poor(n=54)Duration of diabetes (yrs)545(57.7)33(42.3)Diabetic complications Yes27(52.9)24(47.1) 0.8 (0.4-1.6) 0.510No43(58.9)30(41.1)Fasting Blood Glucose Level12656(80.0)06(11.1) 0.5 (0.2-1.4) 0.188>12614 (20.0)48(88.9)

Table 5: Univariate analysis showing association between diabetic distress and adherence to anti-diabetic medication [N=124]

VariablesAdherenceUnadjustedOR (95%C.I)P ValueGood (n=70)Poor(n=54)Diabetic distressLow67 (95.7)41 (75.9)0.1 (0.0-0.5)0.004High03 (04.3)13 (24.1)Emotional BurdenLow49 (70.0)25 (46.3)0.4 (0.2-0.8)0.008High21 (30.0)29 (53.7)Regimen distressLow69 (98.6)35 (64.8)0.0 (0.0-0.2)0.001High01 (01.4)19 (35.2)InterpersonalLow60 (85.7)41 (75.9)0.5 (0.2-1.3)0.168High10 (14.2)13 (24.1)

Table 6:Factors associated with adherence to antidiabetic medication [N=124]

FactorsUNADJUSTEDOR (95% CI)P valueADJUSTEDOR (95% CI)Pvalue

Absence of Side effects 0.4 (0.2-0.9)0.0250.4 (0.2-1.0) 0.06Regular blood monitoring0.4 (0.2-0.9)0.0400.7 (0.3-2.1) 0.570Low Diabetic distress0.1 (0.0-0.5)0.0040.6 (0.0-5.9)0.620Low Emotional burden0.4 (0.2-0.8)0.0080.7 (0.3-1.7)0.442Low Regimen distress0.0 (0.0-0.2)0.0010.0 (0.0-0.3)0.006

CONCLUSION AND RECOMMENDATIONS

In our study , experiencing any side-effects , non-monitoring of blood glucose and diabetic distress were found to be significantly associated with good adherence behaviour Not one factor can be solely held responsible for influencing non-adherence among patients

The regimen distress could be minimized by prescribing fixed-dose or combined preparations.

Health education and awareness about regular monitoring of blood glucose levels must be promoted.

Uninterrupted Government supply of anti diabetic drugs will benefit the patients