Effect of Family Support on Medication Adherence and Glycemic Control of Type 2 Diabetes Outpatients in a Tertiary Hospital in South-eastern Nigeria
CHAPTER ONE
OBJECTIVES OF THE STUDY
Aim
To determine the influence of family support on medication adherence in type 2 diabetes mellitus patients attending General Outpatient department of Bingham University Teaching Hospital (BHUTH), with a view to recommending family support as an important component in the management of type 2 diabetes mellitus.
Objectives
- To determine the mean adherence score using the Morisky Medication Adherence Scale, among type 2 diabetes patients attending G.O.P.D. at BHUTH.
- To determine the pattern and level of family support using the Duke Social Support Scale, among type 2 diabetes patients attending G.O.P.D. at BHUTH.
- To compare the mean adherence score among type 2 diabetes patients attending G.O.P.D. at BHUTH at baseline and at the end of the study.
- To determine the influence of family support on adherence to oral glucose lowering agents among type 2 diabetes patients attending G.O.P.D. at BHUTH.
CHAPTER TWO
LITERATURE REVIEW
DIABETES MELLITUS
Diabetes mellitus (DM) is a group of common metabolic disorders that present with hyperglycaemia which result from defects in insulin secretion, insulin action, or both.1,2 DM has also been defined as a chronic disorder characterized by fasting and/or postprandial hyperglycaemia with plasma glucose levels that are above defined limits during oral glucose tolerance testing or random blood glucose measurements, as defined by established criteria.31DM is often caused by a complex interaction of genetic and environmental factors. Depending on the aetiology, factors contributing to hyperglycaemia include, reduced insulin secretion, decreased glucose utilization, and increased glucose production.
In 2013, the International Diabetes Federation (IDF) reported a total of 382 million people living with diabetes worldwide.9 The majority of the 382 million people with diabetes were aged between 40 and 59, with 80% of them living in low- and middle-income countries like Nigeria.9 All types of diabetes are on the increase particularly, type 2 diabetes. An additional 21 million cases of high blood glucose in pregnancy were estimated to contribute to the global burden of diabetes. That is equivalent to 17% of live births in 2013. According to the same report, another 316 million people had impaired glucose tolerance and were at high risk from the disease. This number at risk from the disease could reach 471 million by 2035.9
WHO reported that there were over 422 million people in the world living with diabetes as at 2014.4 This represented a prevalence of 8.5% among the adult population. The prevalence of diabetes has been steadily increasing for the past three decades and is growing more rapidly in low- and middle-income countries than in high-income countries.4
A group of scholars used studies from 91 countries to calculate age- and sex-specific diabetes prevalences.32 The figures were applied to national population estimates, to determine national diabetes prevalences for all 216 countries for 2010 and 2030. Studies were identified using Medline, and contact with all national and regional IDF offices. They included studies where diabetes prevalence was assessed using a population-based methodology, and was based on WHO or American Diabetes Association (ADA) diagnostic criteria for at least three separate age-groups within the 20–79 year range. Self-report or registry data were used if blood glucose assessment was not available. The final selection included 133 studies from 91 countries. For those countries that did not have their own suitable study, a study, (or studies), from another country was used, with selection of that study based on the ethnic and socioeconomic similarity of the population, as well as geographical proximity. The study found world prevalence of diabetes among adults (aged 20–79 years) to be 6.4%, affecting 285 million adults in 2010, and expected to rise to 7.7% and 439 million adults by 2030. The study reported that between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries. These predictions, based on a larger number of studies than previous estimates, indicate a growing burden of diabetes, particularly in developing countries.
According to the Centers for Disease Control and Prevention (CDC), the number of persons with type 2 diabetes in the United States will more than triple by 2050 from the current estimate of 26 million which represents about 8.3% of the US population.33
In a systematic review of all papers published on diabetes in Sub-Saharan Africa between January 1999 and March 2011,5 an electronic search was done on PubMed for articles providing data from Sub-Saharan Africa on diabetes prevalence, diabetes outcomes (chronic diabetes complications, infections, and mortality), access to diabetes diagnosis and care, and the economic burden caused by diabetes. A total of 1102 papers were identified. Type 2 diabetes accounted for over 90% of diabetes cases in Sub-Saharan Africa, whilst Type 1 diabetes, gestational diabetes, and variant forms such as atypical diabetes and malnutrition related diabetes constituted the remainder. Prevalence in the general population of T2DM recorded in these studies ranged from 0.6% in rural Uganda, to 12% in urban Kenya. A low to medium prevalence (0-7%) was recorded in Cameroon, Ghana, Guinea, Kenya, Nigeria, South Africa and Uganda, and a very high prevalence (> 10%) was recorded in Zimbabwe. Variation in prevalence recorded within countries was common. Prevalence estimates varied considerably between different studies for some countries, with estimates for rural South Africa ranging from 3.9% to 8.8%. However, Erasmus in a cross sectional study found an unusually high prevalence of 28.2% in Cape Town, South Africa.8 Variation between urban and rural populations was frequently observed, with a generally higher prevalence recorded in urban populations. The prevalence in Kenya ranged from 2% in rural areas to 12% in urban areas. The reported prevalence of DM in Nigeria varies from less than 1% in rural areas to over 10% in some urban areas.5,7,31,34-6 A cross sectional study was carried out in Uyo metropolis, south eastern Nigeria among type 2 diabetes patients, to determine the prevalence of type 2 Diabetes Mellitus (T2DM) and associated risk factors of the disease among the state civil servants.36The researchers found the overall prevalence of diabetes to be 10.51%; 9.60% in males and 11.20% in females. However, a much lower prevalence was found by Okonkwo et al in Eastern Nigeria, North Central Nigeria. In that cross- sectional study, a total of 998 individuals aged 25-70 years comprising of 487(48.8%) men and 511(51.2%) women were recruited for the study.
CHAPTER THREE
MATERIALS AND METHOD
Study Population
The study population consisted of all consenting adult Type 2 diabetes mellitus patients attending the GOPD at BHUTH during the research period who satisfied the inclusion criteria.
Study Design
The study was a hospital based prospective cohort study which lasted for a total of 16 weeks.
Sampling Method
Systematic random sampling technique was used. Subjects who met the inclusion criteria and were willing to participate in the study were sampled. Based on hospital records, 10 T2DM patients were expected daily, 50 per week, 200 per month and 2400 per annum giving a total of about 400 patients expected to be seen over the recruitment period. Hence, an assumed sampling frame of 400 was used since the recruitment was expected to be done over 2 months (8 weeks). Since the calculated sample size was 132, sampling interval was every third patient (sampling fraction of 1/3). The first patient was selected by simple ballot among the first three patients who satisfied the inclusion criteria. Subsequently, every third patient was selected until the sample size was achieved for both groups. In the course of the study, the recruitment into the group with good family support was completed while the required sample size for the group with poor family support was not yet completed. At this point, some patients were sampled but not recruited once their family support score qualified them as having good family support. Eventually, a total of 456 patients were sampled.
CHAPTER FOUR
RESULTS
The study was conducted from January 2016 to April 2016. A total of 456 T2DM patients were seen during the study. Thirty two (7.0%) did not meet the inclusion criteria (27 on insulin and five declined consent). Eventually, a total of 424 respondents were sampled out of which 132 were recruited using systematic random sampling technique. Two patients from the group with poor family support did not attend the 8 weeks visit and were not analyzed for 8 weeks.
SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS (TABLE 1).
The mean age of the study participants was 60.6±11.3. The mean age in the good family support group was 58.8±10.6 years while it was 62.1±12.0 years in the poor family support group. Majority of the respondents 111(84.1%) were between 45 to 74 years. There was no statistically significant difference in age between the two groups (p=0.57).
Out of the 132 respondents, 80 (60.6%) were females while 52 (39.4%) were males. The group with good family support had 30 (45.5%) females and 36 (54.5%) males, while the group with poor family support had 50 (75.8%) females and 16 (24.2%) males. The difference between the groups was statistically significant (p= <0.001).
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
CONCLUSION
This study determined the mean adherence score for type 2 diabetes mellitus patients and found that it was poor at baseline (5.54±1.7), but good (6.42±1.6) at the end of the study. The level of family support was determined using the Duke Social Support and Stress Scale and was found to be good in the group with good family support (8.77±1.54) but poor in the group with poor family support (4.83±1.17). It was found that the most supportive family members were children.
The mean adherence score was higher in respondents with good family support compared to those with poor family support at baseline and at the end of the study but the difference was only significant at 8 weeks.
Family support significantly improved medication adherence in type 2 diabetics. Age groups 45-54 years, 55-64 years and good family support scores were found to be independent predictors of good medication adherence.
RECOMMENDATIONS
The following recommendations have been made based on the study findings:
- Routine assessment of medication adherence should be made a component of diabetes care.
- Routine assessment of the level of family support available to diabetic patients should be done in primary care.
- Efforts should be made to mobilize family support for type 2 diabetes patients, especially those with poor family support.
- Further research will be required to determine if the positive influence of family support on medication adherence continues indefinitely or reaches a plateau, and at what point it stops increasing.
SUGGESTION FOR FURTHER STUDIES
Matched cohort studies should be carried out to overcome the confounders in this study.
Experimental studies should be carried out to further research the influence of family support on medication adherence in type 2 diabetes to add more strength of evidence to the findings made by this study.
REFERENCES:
- Longo D, Kasper D, Jameson L, Fauci A, Hauser S, Loscalzo J, editors. Harrison’s Principles of Internal Medicine, 18th ed. McGraw-Hill, New York. 2012. Page 2968
- American Diabetes Association. Standards of medical care in diabetes—2015 abridged for primary care providers. Clin Diabetes. 2015;33(2):97-111.
- Garcia-P L, Alvarez M, Dilla T, Gil- Guillen V, Orozco D, Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Ther. 2013; 4(2):175–94
- World Health Organization. Global report on diabetes. WHO. Geneva, Switzerland. 2016:4-88.
- Hall V, Thomsen RW, Henriksen O, Lohse N. Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review. BMC public health. 2011;11(1):1-12.
- Unachukwu C, Uchenna D, Young E. Mortality among diabetes in-patients in PortHarcourt Nigeria. Afr J Endocrinol Metab 2008;7(1):1-4.