IMPACT OF PHARMACIST’S INTERVENTION ON PATIENTS’ KNOWLEDGE AND ATTITUDE TOWARDS THEIR DIABETES MANAGEMENT IN A TERTIARY HOSPITAL IN NIGERIA

ABSTRACT

Diabetes mellitus (DM) is the most common endocrine disorder. It is a chronic metabolic condition characterized by hyperglycaemia due to impaired insulin secretion with or without insulin resistance.Most diabetic patients have inappropriate knowledge of the clinical disorder and thus unaware of the health implications of non-adherence. This study was aimed at assessing knowledge and attitude of diabetics to the management of their clinical disorder and also further examined the effect of educational intervention on their attitude towards the disease management. The study site and population were Ahmadu Bello University Teaching Hospital and consenting diabetic out patients. An interviewer” administered questionnaire was used to obtain data from 340 selected participants, data collected were baseline demographics, participant’s knowledge about diabetes and their attitude towards its management, baseline blood glucose readings(documented) and medicine usage. Participants with active mobile phones 104 were followed up every two weeks for two months and were assessed post intervention using their glucose level to establish the outcome. Data generated were analysed using SPSS version 22. Descriptive statistics was used to describe data and paired T-test was used to compare pre and post intervention groups.The study showed that the overall patients’ knowledge about diabetes was good because 92.4% of subjects were aware it is a chronic disease, 89.4% know it’s complications, 81.8% could interpret blood glucose readings and 76.5% knew the signs of hypoglycaemia. The attitude however was not encouraging because 61.2% of them forget to take their drugs, 51.2% missed a dose two weeks pre assessment, 42.4% stopped drugs without consulting their doctors, 68.2% do not monitor their blood sugar level regularly, 67.1% stop their drugs when they feel their blood glucose level is under control while 63.5% complemented their drugs with traditional medications. In conclusion, diabetic patients of Ahmadu Bello University Teaching Hospital had good knowledge and relatively fair attitude towards their disease management. It also showed that patient education and counselling is very vital in the management of diabetes as followed up patients had remarkable improvement in their fasting blood glucose (p<0.01).

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background

Diabetes mellitus (DM) is the most common endocrine disorder, it is a chronic metabolic condition characterized by hyperglycaemia due to impaired insulin secretion with or without insulin resistance(Elizabeth et al.,2008). Knowledge can be defined as facts, information and skills acquired by a person through experience or education. It is theoretical or practical understanding of a subject. Attitude on the other hand can be defined as the way a person views something or tends to behave towards it, often in an evaluative way (Ursula, 2017). The prevalence of DM is increasing globally, the worldwide prevalence was 171 million in the year 2000 and is estimated to rise to 366 million in 2030, but in Nigeria, the prevalence is between 2-7% (WHO, 2016). Urbanization with the adoption of western lifestyles has been blamed for the increasing prevalence. Evidence shows that dietary and exercise modifications offered to non-diabetic adults can reduce or delay onset of type 2 diabetes. Diabetes mellitus is common in the elderly in the western countries. In developing countries, it largely affects those between 35-64years. Some studies have shown that there is a relationship between the knowledge of DM and certain socio-demographic variables (Gholamreza et al, 2010; Zanchetta et al, 2016) For example, being in high school or university, and high socioeconomic levels were found to be associated with higher levels of knowledge. Higher levels of education and higher incomes have also been associated with better knowledge (Frederick, 2016) Similarly, findings of some studies seem to suggest that there is a relationship between higher age and increased knowledge. Some studies have associated female gender with higher knowledge (Patricio Fernando et al, 2014), while some have associated it with poorer knowledge (Girish et al, 2015) and some have claimed that gender has no association with diabetic knowledge. Patients’ view or perception of their illness seem to be an important variable affecting their health behaviour and ultimately their overall management. Research has indicated that illness perceptions are important determinants of behaviours associated with adherence to treatment and functional recovery(Keogh et al., 2007; Joseph et al.,2009).Adherence is defined 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 (WHO, 2003).Type 2 diabetes is considered a disease of poor lifestyle with physical inactivity, obesity and urbanisation contributing to the increased prevalence of the disease in contrast to type 1 diabetes which is a genetically caused autoimmune disease (Levitt, 2008). Of concern is the predicted relative increase in sub Saharan Africa that will occur between 2000 and 2030 (Wild et al., 2004). Diabetes education and diabetes self-management education, as well as on-going support, are essential components of diabetes care. Patient participation is crucial in the management of diabetes. Education empowers people living with diabetes to manage their disease, improve health goals and outcome, as well as contributing to the care of other patients. Different aspects of diabetes management demand lifestyle changes, self-monitoring of treatment, and prevention of complications. A joint initiative of the World Health Organization (WHO) and International Diabetes Federation (IDF), “Diabetes Action Now”, aims to stimulate and support the adoption of effective measures for surveillance, prevention, and control of diabetes; as well as to achieve a substantial increase in global awareness about diabetes and its complications. It has 19 healthcare domains – screening and diagnosis, care delivery, education, psychological care, lifestyle management, glucose control level, clinical monitoring, self-monitoring, oral therapy, insulin therapy, blood pressure (BP) control, cardiovascular (CV) risk protection, eye screening, kidney damage, foot care, nerve damage, pregnancy, children, and in-patient care. Self-management education provides knowledge and practice of all the various aspects of diabetes care and support. Therefore, health workers must be trained on a regular and continuous basis to impart the correct information on diabetes, and also provide general information on networking and health systems. Some countries such as Canada, the USA, and Australia provide standard courses for certified diabetes health educators (who undergo regular recertification) to ensure that such educators have current best practice knowledge and skills. The use of diabetes guidelines and standards to teach people living with diabetes can improve health outcomes 8–10 of patients.

In Nigeria the prevalence of diabetes is 2.6 million, the high burden of diabetes mellitus in Nigeria is largely attributable to cardiovascular disease which account for 15% of all DM deaths. Kaduna is the state capital of Kaduna State in north-west Nigeria. Kaduna State forms a portion of the country’s cultural melting pot. Apart from six major ethnic groups found in the State including Zungeru, Kataf, Atachaat, Adara, Hausa, and Anghan (Wikipedia.org/wiki/kaduna state. 2017). There are over twenty other ethnic minority groups, each with its language and arts or religion different from the other. A study revealed that urban people of Kaduna State engage in sedentary lifestyle more than the rural counterparts, hence health problems suffered by the people of Kaduna state are significantly related to their sedentary lifestyle and public health education is recommended to reduce health problems like obesity, hypertension, stroke and other cardiovascular disease caused by sedentary lifestyle (Hamoudi, 2012).In the last decade, illness perception has been identified as an important factor that impact on the way people may change their behaviours (Petrie et al., 2007). Wilgen et al., (2008) state that “When patients are confronted with an illness or symptoms, they create a model and representation of the illness or symptom (Illness Perception) in order to make sense of or try to cope with it.” In addition, research based on health psychological theories have highlighted the importance of patients personal beliefs of their illness and treatment in their self-management for a range of chronic illnesses (Leventhal et al.,1980; Petrie et al., 1996).

In order to assess patients illness perception, (Weinman et al., 1996). developed Illness Perception Questionnaire IPQ that was later modified by Moss-Morris et al., (2002) into revised version, IPQ-R. Since then IPQ-R has been used for perception studies of many chronic illnesses including diabetes (Griva et al., 2000).Diabetes is one of the chronic diseases that affect both the young and old in our society. According to American Diabetes Association (2006), there were about 20.8 million people with diabetes in United States alone, while in developing countries, increase in prevalence is expected to occur especially in Africa, where most patients will likely be found by 2030. This increase in incidence of diabetes in developing countries follows the trend of urbanization and lifestyle changes perhaps most importantly a “Western – Style” diet (WHO, 2006). In Nigeria though no estimate of the individuals suffering from the disease has been made, a screening exercise carried out in Warri and Sapele by Urhobo National Association of North America in 2004, where 787 people attended 65% were diabetic and hypertensive (Okolie et al., 2009).Majority of studies on effectiveness of interventions to address suboptimal use of medicines focused on adherence aspect, either in a disease area or specific conditions, hence, adherence is the most important hurdle for medicines optimisation (Faria et al., 2014).Many studies on adherence to medication and the ways to improve it have been conducted yet it remain significantly low. However, non-adherence to treatment represents a missed opportunity for health gain and waste of resources (Atkins and Fallow field, 2006).

1.2 Statement of Research Problem

Diabetes Mellitus is a public health concern worldwide. Most diabetic patients have inappropriate knowledge of their clinical disorder and thus, unaware of the health implications of non-adherence to its management. Most patients are also unaware of life style modifications necessary to achieve normoglycemic status (Bhutani, 2014).DM is a pandemic of major public health importance. It is the biggest endocrine driver for global burden of diabetes (GBD), it directly led to 1,281,300 deaths in 2010, a 92.7% rise over the 1990 figure of 665,000 for lost lives (WHO, 2016).

WHO (2016)global reports on diabetes demonstrate that the number of adults living with diabetes has almost quadrupled since 1980 to 422 million adults. DM is one of the leading causes of death in the world. In 2012, diabetes was the direct cause of 1.5million deaths globally. The majority of diabetes deaths occur in low and middle income countries (WHO, 2016).The WHO has projected diabetes to be the 7th leading cause of death in 2030.It is very disturbing that 35 – 44% of people with diabetes do not know they have it (D’Cunha et al., 1999).Diabetes is a major cause of premature death, blindness, kidney disease, heart disease, stroke, limb amputation and other significant health problems.The estimated prevalence of diabetes in Africa is 1% in rural areas, and ranges from 5-7% in urban sub-Saharan Africa.(Kengne et al.,2005).One of the hidden impacts of diabetes is the loss of productivity from disability, sickness, premature retirement and premature death (D’Cunha et al., 1999).

Currently, few health programs educate the public about preventing diabetes. Despite educational programs for preventing complications, the proven effectiveness of lifestyle changes, and advances in treatment, some people remain unaware or unconvinced of the seriousness of this disease (D’Cunha et al., 1999). Research advances in diabetes, including new drug therapies, are often not communicated effectively (D’Cunha et al., 1999). Type 2 diabetes patients attending a tertiary care hospital lacked knowledge about their disease in all aspects: symptoms, complications, prevention and control (Mukhopadhyay et al., 2010). Canada spends 9 billion dollars annually on healthcare, disability, work loss, and premature death costs related to diabetes. Diabetes is estimated to cost the Ontario health system just under 1 billion dollars annually. An American study suggest that 14% of the US healthcare budget (1 in 7 US healthcare dollars) is spent on diabetes (D’Cunha et al., 1999). Ben Abdelaziz et al., (2007) in their cross‐sectional study concluded that Tunisian patients with type 2 diabetes lacked knowledge regarding the definition and pathophysiology of diabetes. Interestingly, the knowledge by Zimbabwean diabetics‟ about their health and illness was strongly underlined by traditional and religious beliefs (Hjelm & Mfunder, 2010.) Odili et al., (2011) found that Nigerian type 2 diabetics also lacked knowledge of their disease regarding diets and lifestyle changes. A cross sectional study conducted in the Indian city of Kolkata found that people with type 2 diabetes attending a tertiary care hospital lacked knowledge about their disease in all aspects: symptoms, complications, prevention and control (Mukhopadhyay et al., 2010).

1.3 Justification of the Study

The increase prevalence of diabetes and its complications indicates the sub-optimal level of diabetes knowledge among the patients and the population at large. This inadequate knowledge affects quality of life, causes therapeutic failure, poor prognosis and increased morbidity and mortality rates. Patients‟ views or perceptions of their illness seem to be an important variable affecting their health behaviour and problem management. Research has indicated that illness perceptions are important determinants of behaviour which are associated with adherence to treatment and functional recovery (Keogh et al., 2007; Joseph et al., 2009) In a qualitative study conducted in Malaysia with a specific focus on medication, it was found that patients had a moderate knowledge about their illness and it was recommended that more attention be given to improving provider and patient relationships, providing more education on medication adherence and self care (Al‐Qazzaz et al., 2011). The French DIABASIS survey highlighted the importance of understanding patient’s perceptions of type 2 diabetes as it enhances education strategies (Mosnier‐Pudar et al.,2009). Patients perceptions of their illness impacts greatly on their disease management and self-care. However, a longer duration of disease was associated with a higher knowledge score. It is thus hoped that this study will be the initiation of research into this pertinent aspect of diabetes in Northern Nigeria.

1.4 Aim of the Study

The aim of this study is to assess the knowledge and attitude of patients with diabetes towards the management of their disease and also, to evaluate the impact of pharmacist intervention on their clinical outcome.

1.4.1 Objectives of the Study

1. To assess patients‟ knowledge and attitude towards diabetes management.

2. To evaluate the impact of an educational intervention on patients attitude towards diabetes management using FBG and 2HPP as indices.