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 Variables n(%)

Age group (yrs)<45 14(11.3)46-55 33(26.6)56-65 39(31.5)>65 38(30.6)GenderMale 68(54.8)Female 56(45.2)

Marital statusMarried 107(86.

3)Widow 012(09.

7)Unmarried 004(03.

2)Divorced 001(0.8)

N=124

Median age =

60(50-68)yrs

Variables n(%)

Lower socioeconomic status 100 (80.6) 

Family History of diabetes 43 (34.7) 

Presence of comorbidities 72 (58.1)

Presence of diabetic complications 51 (41.1) 

Smoker 25 (20.2)

Alcohol consumption 16 (12.9)

Experience of side effects 48 (38.7) 

Table 1 continued:N=124

72(58.1)

Fig 1: Level of distress among diabetic patients

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

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

Variables Adherence UnadjustedOR (95%C.I)

P value

Good (n=70)

Poor(n=54)

Distance from hospital (km) 

≤2 28(62.2) 17(37.8)0.7(0.3-1.5)

 0.329

 >2 42(53.2) 37(46.8)

Cost of drugs   Free 36(63.2) 21(36.8)

0.6(0.3-1.2) 0.166Paid 34(50.7) 33(49.3)

Frequency of blood glucose monitoring 

Regular 58(61.7) 36(38.3)0.4(0.2-0.9) 0.040

Occasional 12(40.0) 18(60.0)

Means of conveyance 

Walking 22(71.0) 9(29.0)0.4(0.2-1.0) 0.063

Use Transport 48(51.6) 45(48.4)

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

VariablesAdherence

UnadjustedOR (95%C.I)

P value

Good (n=70)

Poor(n=54)

Number of anti diabetic medications taken 

≤2 39(52.0) 36(48.0) 0.6(0.3-1.3) 0.217

>2 31(63.3) 18(36.7)

Side effects experienced

Yes 21(43.8) 27(56.2) 0.4(0.2-0.8) 0.025

No 49(64.5) 27(35.5)

Insulin injection taken

Yes 20(57.1) 15(42.9) 0.9(0.4-2.1) 0.922

No 50(56.2) 39(43.8)

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

Variables AdherenceUnadjusted

OR (95%C.I)

P value

Good (n=70)

Poor(n=54)

Duration of diabetes (yrs) 

<5 25(54.3) 21(45.7) 0.6 (0.3-1.3)

0.217>5 45(57.7) 33(42.3)

Diabetic complications    

Yes 27(52.9) 24(47.1) 0.8 (0.4-1.6)

0.510

No 43(58.9) 30(41.1)

Fasting Blood Glucose Level

≤126 56(80.0) 06(11.1) 0.5 (0.2-1.4)

0.188

>126 14 (20.0) 48(88.9)

Variables Adherence UnadjustedOR (95%C.I)

P Value

Good (n=70)

Poor(n=54)

Diabetic distress

Low 67 (95.7) 41 (75.9)0.1 (0.0-0.5) 0.004

High 03 (04.3) 13 (24.1)

Emotional Burden

Low 49 (70.0) 25 (46.3)0.4 (0.2-0.8) 0.008

High 21 (30.0) 29 (53.7)

Regimen distress

Low 69 (98.6) 35 (64.8)0.0 (0.0-0.2) 0.001

High 01 (01.4) 19 (35.2)Interpersonal

Low 60 (85.7) 41 (75.9)0.5 (0.2-1.3) 0.168

High 10 (14.2) 13 (24.1)

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

FactorsUNADJUSTE

DOR (95%

CI) 

P value

ADJUSTEDOR (95% CI)

Pvalue

Absence of Side effects

0.4 (0.2-0.9) 0.025 0.4 (0.2-1.0)

0.06

Regular blood monitoring

0.4 (0.2-0.9) 0.040 0.7 (0.3-2.1)

0.570

Low Diabetic distress

0.1 (0.0-0.5) 0.004 0.6 (0.0-5.9) 0.620

Low Emotional burden

0.4 (0.2-0.8) 0.008 0.7 (0.3-1.7) 0.442

Low Regimen distress

0.0 (0.0-0.2) 0.001 0.0 (0.0-0.3) 0.006

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

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