AN INTERVENTION STUDY ON MEDICATION ADHERENCE AND CLINICAL OUTCOME AMONG TYPE 2 DIABETIC PATIENTS IN A TERTIARY HEALTH FACILITY IN NIGER STATE NIGERIA

ABSTRACT

Diabetes is one of the leading causes of morbidity and mortality in adults globally. Type 2 diabetes is a disease associated with a huge burden of medication non-adherence due to complex regimens leading to complications that further increase morbidity and mortality among this population. The aim of this study was to assess medication adherence and the impact of mobile phone short message service (SMS) reminders on clinical outcome among type 2 diabetic patients in IBB Specialist Hospital Minna, Niger State Nigeria. A prospective intervention study with a control arm comparing standard of care with standard of care plus SMS reminders was conducted. The sample consisted of 423 patients with type 2 diabetes that were randomly sampled and assigned to two groups; an intervention group (n=213) and the control group (n=210). Morisky 8-Medication Adherence Scale (MMAS) was used to assess the medication adherence of patients. The SMS reminders were sent by the principal investigator thrice weekly for three months; the control group did not receive any SMS reminders. For three successive months FBS levels were recorded for both the intervention and control groups and compared to baseline. The collected data was categorized, coded and analyzed using Statistical Package for Social Sciences (SPSS) version 20 (SPSS Inc, Chicago, Illinois, USA). Chi-square test was used to ascertain associations between adherence to diabetic medication and patient related, medication related and disease related factors. Paired t-test was used to compare baseline and post intervention FBS levels. A P-value of less than 0.05 was considered statistically significant for this study. The result of the study showed that only about 15% of patients had good adherence to medication, the others range between the poor (10.7%) and non-adherent (74.3%) categories. The intervention group had significant reduction in FBS levels (P < 0.05) with a mean reduction of 1.3mmol/l compared to the control group in which there was no reduction in FBS (P > 0.05). It was concluded that medication adherence among type 2 diabetic patients in this study setting was suboptimal and intervention using mobile phone short message service (SMS) reminders slightly improves clinical outcome (FBS).

CHAPTER ONE

1.0 INTRODUCTION

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by chronic hyperglycemia, caused by an absolute or relative insulin deficiency or defective action or both resulting in disorder of carbohydrates, protein and fat metabolism (Alam et al., 2014; Ogbonna et al., 2005). It is associated with long-term damage, dysfunction and failure of various organs especially the eyes, kidneys, nerves, heart and blood vessels (WHO., 2010). The global burden of diabetes mellitus is enormous and glaring. The impact on health is substantial, yet this disease is assuming an epidemic proportion worldwide, with its global prevalence estimated at about 366 million today, and about 552 million by 2030 (WHO., 2010; Ekpenyong et al., 2012), meaning that the number of people with diabetes is increasing daily and in every country with the highest increase (80%) recorded in low and middle income countries (Alam et al., 2014). Currently, China has the highest estimated number of people with diabetes (90.0 million) with the projection to about 129.7 million by 2030 (Ekpenyong et al., 2012). It is predicted that the global prevalence of diabetes will increase by 65% over the next 20 year (Shrestha et al., 2013). DM is also an important problem in Africa. In Sub-Saharan Africa, like the rest of the world, diabetes prevalence coupled with both communicable and non-communicable diseases is on the rise (Rwegerera., 2014). According to International Diabetes Federation (IDF), it was estimated that as at 2010, about 12.1 million people were living with diabetes in Africa, and the number is projected to increase to 23.9 million by 2030 (Rwegerera., 2014). In Nigeria, about 1.7million people were affected in 2010, and the figure is expected to rise to 4.8million by 2030 (Nwaokoro et al., 2014). DM causes about 5% of all deaths globally each year (Ekpenyong et al., 2012), which represents 6 deaths attributable to diabetes or related conditions every minute, with 80% of diabetes deaths occurring in low- and middle-income countries (Ekpenyong et al., 2012).

Deaths related to diabetes in Nigeria in 2013 were estimated to be 105,091 cases. About two million of the cases of diabetes in Nigeria are undiagnosed (Oputa and Chinyere., 2013). The mainstay of diabetes management is aimed to obtain a good glycemic control and reduce the chronic complications of diabetes and the comorbid diseases such as cardiovascular, cerebrovascular diseases, which are preventable and manageable with proper punctual medication, good regular follow ups and investigations (Brahmbhatt et al., 2014).

Adherence is defined as “the extent to which a person‟s behavior and/or life style changes corresponds with agreed recommendations from a health care provider (Abdulaziz et al., 2014; Ogbonna et al., 2015). Patient‟s adherence to prescribed medicine regimen is essential to achieving targeted health outcomes. Medications are one of the most effective methods of prevention, treatment and management of diseases when used correctly (Ogbonna et al., 2015). Adherence is an interactive collaborative relationship between the patient and the clinicians/care givers and suggests that patients are involved in treatment planning and implementation unlike compliance which is unilateral and authoritarian and places the patient in a passive role (Ogbonna et al., 2015).

1.1 Statement of Research Problem

Understanding how to recognize medication non-adherence to prescribed medication and factors that affect adherence is important in the success of interventions designed to address diabetes which is now a public health problem (Ogbonna et al., 2015). Many patients experience difficulties in adhering to long-term treatment, although patients reasons for not being adherent are diverse, one of the most commonly reported barriers is forgetfulness (Vervloet et al., 2012).

Patients often forget or delay their consumption of medication or neglect the instructions of healthcare providers (Huang et al., 2013). Non-adherence rates for diabetic therapies are high with estimates ranging from 36% to 93% (Sheikh et al.,2014), and averaging only 50% in developing countries such as Nigeria. Failure to attain the desired therapeutic goal might be related to inadequate adherence. Instead of changing the prescription, increasing the drug dosage, or adding a new drug, adherence assessment to the treatment should be considered first in most patients (Sharma et al., 2014). Such low medication adherence by various patient groups with chronic diseases has compelled the worldwide medical community to increasingly focus on applying technology to remedy this situation (Huang et al., 2013). Poor adherence compromises the effectiveness of medication treatment and results in suboptimal illness control. This can lead to increased use of healthcare services, reduction in patients quality of life (Vervloet et al., 2012). Studies linking glycemic control, hypoglycemia medications, and complications of diabetes have shown that good glycemic control is important in preventing micro vascular complications of this condition (Parsons et al., 2014).

1.2 Justification of the Research

For some decades now, patients‟ adherence to therapeutic regimen has been recognized as a key to the successful delivery of healthcare. Drug treatment relies heavily on the adherence of the patient for self-administration, as patients adherence in ambulatory care is an important link between medical process and treatment outcome (Abdulazeez et al., 2014).

DM is a challenging disease to manage successfully, although the treatment regimen is mostly complex, patients with good diabetes self-care behaviors can attain excellent glycemic control (Alam et al., 2006). However, many patients do not achieve good glycemic control and continue to suffer health problems as a result. Diabetes health care providers know that if only their patients adhered to their treatment recommendations, they could do well and avoid diabetes-related complications. The fact that so many patients do not can be very frustrating (Alam et al., 2006). As a group, patients with diabetes are especially prone to substantial regimen adherence problems (Alam.,2006). In general, research has shown that the diabetes regimen is multidimensional, and adherence to one regimen component may be unrelated to adherence in other regimen areas. For example, research has shown better adherence for medication use than for lifestyle change (Alam., 2006). DM is a serious condition for an individual and on a global scale. There is rapidly increasing prevalence and as such, patients‟ adherence to diabetic medication is a great cause for concern (Abdulazeez et al., 2014). In Nigeria, there are sparse and inadequate information on the prevalence of diabetes mellitus. However, available data suggest that the disease is emerging as a major and most challenging health problem in this region (Ekpenyong et al., 2012). This study is the first of its kind in Niger State. Therefore, there is no data that exist currently on medication adherence and use of short message service (SMS) reminders among type 2 DM patients in Niger State. Mobile phone text messaging has rapidly become a socially popular form of communication. It is personal, highly transportable, and widely used, particularly in the Western countries (Abbas.et al., 2015). However, text messaging coupled with specific management strategies has yet to be utilized effectively in developing countries with high prevalence of diabetes (Abbas et al., 2015). Mobile phone SMS have been shown to be an effective tool for providing diabetes health education, clinic and appointment reminders, medication reminders and for building awareness about the disease. However, no data on the effects of such an approach on patient outcomes in resource-limited settings are available to date (Islam et al., 2014). Numerous interventions aimed at improving adherence have been conducted, but these were mostly complex and not very effective (Haynes et al.,2008). An example of a simple intervention is reminding patients of their medication intake. Reminders can especially provide a solution for patients who are unintentionally non-adherent, ie, patients who are willing to take their medication but forget it or are inaccurate with their timing. Forgetfulness is commonly reported as a barrier to adherence in various patient populations (Marcia et al., 2012).

1.3 Aim and Objectives

The aim of the study was to assess the medication adherence and evaluate the effect of mobile phone short message service (SMS) reminder on clinical outcome (FBS) among type 2 diabetic patients in a tertiary health facility.

The specific objectives of the study include the following;

I. To assess anti-diabetic drug utilization among type 2 diabetic patients in the facility.

II.To assess medication adherence and to identify potential predictors of adherence.

III.To examine the patients clinical outcome after the intervention.

1.4 Statement of Research Questions

I. What is the level of medication adherence among type 2 diabetic patients?

II. What is the impact of mobile phone short message services (SMS) reminder on clinical outcome (FBS) among these patients?