Access and adherence to medication among people with diabetes in Brazil: evidences from PNAUM

Awareness of the diagnosis, treatment, and control of diabetes mellitus in Brazil

OBJECTIVE

To estimate the proportions of awareness, treatment, and control of diabetes mellitus (DM) in the Brazilian adult population.

METHOD

This is a cross-sectional study, with data from a representative sample of the Brazilian population, taken from the National Health Survey(PNS 2014/2015). Outcomes were defined based on glycated hemoglobin (HbA1c) measurements, self-reported DM diagnosis, and use of hypoglycemic agents or insulin. The proportion of DM awareness, treatment, and control was estimated according to sociodemographic characteristics, health conditions, and access to health services, and their respective 95% confidence intervals.

RESULTS

DM prevalence in the Brazilian population was of 8.6% (95%CI: 7.8-9.3): 68.2% (95%CI: 63.9-72.3) were aware of their diagnosis, 92.2% (95%CI: 88.6-94.7) of those who were aware were undergoing drug treatments, and, of these, 35.8% (95%CI: 30.5-41.6) had controlled HbA1c levels. The proportions of DM awareness, control, and treatment were lower in men aged 18 to 39 years, individuals with low education, without health insurance, and beneficiaries of the Bolsa Família program.

CONCLUSION

Approximately one in ten Brazilians has DM. A little more than half of this population is aware of their diagnosis, a condition measured by HbA1c dosage and clinical diagnosis. Among those who know, the vast majority are undergoing drug treatments. However, less than half of these have their HbA1c levels controlled. Worse scenarios were found in subgroups with high social vulnerability.

Glycemic outcomes of people with diabetes mellitus in Brazilian primary health care

Background

The capillary blood glucose monitoring program at home a challenge in primary health care. Therefore, it is fundamental to identify the glycemic control of people with diabetes mellitus through HBA1c and to analyze its associated factors.

Objective

To identify the glycemic profile of people with Diabetes Mellitus (DM) through HbA1c and analyze factors associated.

Materials & methods

Cross-sectional study developed in Ribeirão Preto, São Paulo, Brazil. Secondary data from the electronic health record of people registered in the Primary Health Care system were used. A sample of 3181 participants was obtained. People with HbA1c < 7.0% (53 mmol/mol) were considered to have adequate glycemic control. For people aged ≥ 55 years, a less stringent target, < 8.0% (64 mmol/mol), was also considered. The odds ratio was the measure of effect analyzed with their respective 95% Confidence Intervals (95% CI).

Results

Adequate glycemic control with HbA1c < 7.0% (53 mmol/mol) was found in 44.8% of people and, when using the less rigid target, HbA1c < 8.0% (64 mmol/mol) for people aged ≥ 55 years-old, 70.6% had adequate glycemic control. Age and drug therapy were associated with adequate glycemic control (p < 0.001), which was more frequent among older people and those who used only metformin.

Conclusion

The study shows that the achievement of adequate glycemic control is still a challenge, especially with regard to younger people and those who use insulin.

Demographic variables, anthropometric indices, sleep quality, Metabolic Equivalent Task (MET), and developing diabetes in the southwest of Iran

Propose

The present study has sought to investigate the prevalence of diabetes and its related risk factors, to examine the relationship between demographic variables, anthropometric indices, sleep quality, and Metabolic Equivalent Task (MET) with diabetes in Khuzestan province, southwest Iran.

Methods

The present study has a cross-sectional design (the baseline data of the Hoveyzeh cohort study as a sub-branch of the Persian Prospective Cohort Study). Comprehensive information from 10,009 adults (aged 35–70 years) was collected from May 2016 to August 2018 through a multi-part general questionnaire containing general characteristics, marital status, education, smoking, sleep quality, MET, and anthropometric indices. Data analysis was performed by SPSS software version 19.

Results

The mean age of the sample was 52.97 ± 8.99 years. 60.3% of the population were women and 67.7% were illiterate. Out of the 10,009 people surveyed, 1,733 stated that they have diabetes (17%). In 1,711 patients (17%) the amount of FBS was ≥126 mg/dl. There is a statistically significant relationship between diabetes and MET. More than 40% had BMI above 30. Anthropometric indices in diabetic and non-diabetic individuals were different. Also, there was a statistically significant difference between the mean duration of sleep and the use of sleeping pills in diabetic and non-diabetic groups (p &lt; 0.05). Based on logistic regression, marital status [OR = 1.69 (95% CI, 1.24, 2.30)], education level [OR = 1.49 (95% CI, 1.22, 1.83)], MET [OR = 2.30 (95% CI, 2.01, 2.63)], height [OR = 0.99 (95% CI, 0.98, 0.99)], weight [OR = 1.007 (95% CI, 1.006, 1.012)], wrist circumference [OR = 1.10 (95% CI, 1.06, 1.14)], waist circumference [OR = 1.03 (95% CI, 1.02, 1.03)], waist-to-hip ratio [OR = 3.41 (95% CI, 2.70, 4.29)], and BMI [OR = 2.55 (95% CI, 1.53, 4.25)], are good predictors for diabetes.

Conclusion

The results of this study showed that the prevalence of diabetes in Hoveyzeh city, Khuzestan, Iran, was almost high. and emphasize that preventive interventions should focus on risk factors, especially socioeconomic status, and anthropometric indicators along with lifestyle.

Inequalities in unmet need for health care services and medications in Brazil: a decomposition analysis

Background

Unmet need is a metric used to assess the performance of health care systems throughout the world. One of the primary objectives of the Brazilian health care system is to identify ways to improve the health outcomes of all citizens. To accomplish this challenging goal, the health care system in Brazil will need to identify and eliminate barriers and provide timely and adequate access to health care services to all.

Methods

This study assessed the performance of the Brazilian health care system by focusing on the unmet need for health care services and medications. We evaluated the Brazilian National Health Survey data collected in 2013 and 2019 to determine the magnitude of socioeconomic-related inequalities associated with unmet health care needs. Primary contributing factors were identified via decomposition analysis of the calculated concentration indices (CInds).

Findings

Despite the availability of universal health care, 3.8% and 7.5% of the population in Brazil reported unmet needs for health care services and medications, respectively in the 2019 survey. Although the overall unmet need for medications remained unchanged between 2013 and 2019, CInd analysis revealed significant pro-poor inequalities with respect to unmet needs for both health care services and medications. The overall magnitude of these inequalities was higher in the poorer regions of the country. The use of private health insurance as well as individual health and socioeconomic status contributed significantly to the inequalities associated with unmet needs for health care services and medication throughout Brazil.

Interpretations

Policy interventions should focus on improving access to health care services, extending coverage to include pharmaceuticals, and targeting both financial and non-financial barriers to obtaining care, particularly those experienced by the poor and vulnerable populations in Brazil.

Funding

None.

Can pharmacotherapeutic follow-up after allogeneic hematopoietic stem cell transplantation improve medication compliance?

BACKGROUND

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is currently one of the most effective therapies in onco-hematology. For the treatment of the disease and prevention of such complications, a complex pharmacotherapeutic regimen is employed. Non-compliance is prevalent among adolescents and young adults with chronic hematological diseases, being reported by up to 50% of the patients.

OBJECTIVE

To evaluate the results of pharmacotherapeutic follow-up on medication compliance and on the knowledge about pharmacotherapy of patients who underwent allo-HSCT.

METHODS

A single-arm, open-label and non-randomized intervention study developed in an allo-HSCT outpatient clinic. The participants attended pharmaceutical consultations and had their knowledge about pharmacotherapy and medication compliance measured by MedTake and Brief Medication Questionnaire (BMQ), respectively.

RESULTS

A total of 27 patients attended pharmaceutical consultations (4.81 consultations/patient; SD = 1.80). There was an improvement in medication compliance and in knowledge between the first and last consultations (p < 0.05). In the final consultation, 70.37% of the patients showed compliance, with a knowledge rate of 98.35% (SD = 3.63). Non-compliant individuals presented a greater tendency to hospital readmissions. There was no relationship between medication compliance and sociodemographic variables, graft-versus-host disease, and knowledge about pharmacotherapy.

CONCLUSIONS

Pharmacotherapeutic follow-up contributed to improving medication compliance. Knowledge about pharmacotherapy alone does not translate into behaviors, which corroborates the complexity of the biopsychosocial factors associated with medication compliance.

Amazon Amandaba-Prevalence, Risk Factors and Self-Care Perception Associated with Diabetic Peripheral Neuropathy in Patients with Type 2 Diabetes: A Cross-Sectional Study

BACKGROUND

Diabetic peripheral neuropathy (DPN) is one of the most common complications of type 2 diabetes mellitus. There is a gradual loss of protective sensation in the skin and the function of the foot joints, increasing the risk of injury as the disease progresses. The objective of this study was to verify whether socioeconomic factors, health risk factors, and self-care are associated with DPN.

METHODS

Observational cross-sectional with 228 individuals of ≥30 years in Family Health Strategies in a city in the eastern Amazon, in northern Brazil, using questionnaires containing socioeconomic information, clinical and laboratory parameters, the Summary of Diabetes Self-Care Activities Questionnaire, and the Michigan Neuropathy Screening Instrument.

RESULTS

The prevalence of DPN was 66.6%. The presence of neuropathy is associated with male gender, dyslipidemia, and increased microalbuminuria. Logistic regression analysis revealed male subjects' increased BMI and altered HDL levels were associated with DPN.

CONCLUSIONS

In men with altered BMI, and dysregulation in biochemical parameters, neuropathy is more prevalent.

Assessment of potential in vitro toxicity of Cissus sicyoides L. and Wedelia paludosa DC. leaves water extracts

Medicinal plants have been employed as an alternative method to treat diabetes. One is Cissus sicyoides, a plant from the Amazon region (Northern Brazil), which is morphologically similar to Wedelia paludosa, a plant easily found in Southern Brazil. Thus, this study aimed to assess the potential toxicity of C. sicyoides and W. paludosa's leaves water extracts. Through phytochemical screening, phenolic compounds and alkaloids were observed in both species and coumarins only W. paludosa's aqueous extract. Phenolic compounds were quantified in both extracts and C. sicyoides presented 1.36 ± 0.04 mg/pyrogalic acid equivalent (PAE), whereas W. paludosa presented 3.27 ± 0.07 mg/PAE. Total antioxidant power was measured by the ferric reduction assay. Cissus sicyoides exhibited total antioxidant activity of 748.0 ± 104.5 μM and W. paludosa, 1971.5 ± 141.0 μM. Cissus sicyoides showed an inhibition rate for the alpha-glucosidases enzyme assay of 55.2 ± 1.7% and W. paludosa, 85.8 ± 9.7%. The formation of reactive oxygen species was evaluated by the DCFH-DA method, its formation being higher in W. paludosa's water extracts than in C. sicyoides. Cell viability was evaluated by the Sulforhodamine B and MTT assays. Wedelia paludosa's extracts' exposure presented a cell viability close to positive control starting from 2 mg/mL to 30 mg/mL, whereas C. sicyoides demonstrated statistical significant low viability at the highest concentration when compared with the negative control. Moreover, cell death mechanism was investigated, having W. paludosa's extract indicated death by necrosis. The results suggest low toxicity for C. sicyoides' extract and high toxicity for W. paludosa's extract.

Sources of medicines for hypertension and diabetes in Brazil: results from the National Health Survey

This study aims to analyze the sources people over 18 years of age use to obtain medication for the treatment of hypertension and diabetes, according to sociodemographic characteristics from 2013 to 2019. Data from the Brazilian National Health Survey were analyzed. Most individuals with diagnosis and prescription to pharmacological treatment reported obtaining medicines exclusively from one type of source. The percentage of people who acquired hypertension medicine exclusively from public pharmacies decreased, from 24.5% in 2013 to 16.2% in 2019; while there was an increase in those obtaining from the Popular Pharmacy program, from 23.5% to 31.4%; as well as for out-of-pocket payment, which rose from 30.9% to 35.5% The percentage of people who acquired diabetes medication exclusively from public pharmacies increased from 7.4% to 18.6% and with out-of-pocket payment increased from 21.6% to 26.8%, while the percentage of those who acquired from the Popular Pharmacy program decreased from 47.2% to 36.4%. The percentage of those who acquired medication from various sources decreased for both hypertension and diabetes. For men, white, and those with higher education, the source of medication acquisition, for both conditions, was mostly by out-of-pocket payment. The high number of medicine acquisition from public sources represents an advance in Brazil’s response to the treatment of these conditions, but reducing regional differences still represents a challenge to be overcome by the healthcare system.

Use and access to medications for type 2 diabetes mellitus in elderly: a population-based household survey

The objective of this study was to analyze the use and access to medications for type 2 diabetes among older people registered in the family health strategy in Ribeirão Preto, São Paulo. A population-based household survey was undertaken with 338 older adults selected using two-stage cluster sampling. Pharmacotherapy of diabetes and access to medications was investigated using a structured questionnaire administered by means of face-to-face interviews. The number of medicines used to treat diabetes ranged between 1 and 4. Respondents predominantly used only oral antidiabetic agents. The use of metformin and sulfonylureas on their own was reported by 37.9% and 9.8% of respondents, respectively. Frequency of insulin use was greatest in the 80 years and overage group (38.9%). The large majority of respondents (96.4%) had full access to medicines. Means of payment was "free of charge" in 78.1% of the respondents and public pharmacies were the main source of medication (74.8%). The most commonly used oral antidiabetic was metformin, which is consistent with current treatment guidelines. However, the findings show inappropriate medication use among older people, more specifically the use of sulfonylureas on their own. The findings of this study highlight the important role played by the public health service in providing medications for type 2 diabetes.

Tendency of use and sources for obtaining oral antidiabetic drugs for treatment of diabetes in Brazil from 2012 to 2018: analysis of the Vigitel survey

OBJECTIVE

To estimate the prevalence of use of oral medications for the treatment of diabetes, as well as the distribution of sources for obtaining according to sociodemographic variables, in the Brazilian states' capitals and in the Federal District, and their evolution from 2012 to 2018.

METHODS

Cross-sectional and population-based study with individuals aged ≥ 20 years who reported a medical diagnosis of diabetes, interviewed through Vigitel from 2012 to 2018. We estimated the prevalence of use and the distribution of sources for obtaining according to sociodemographic variables (95%CI). We checked differences among proportions using the Pearson's χ2 test (Rao-Scott), with a significance level of 5%.

RESULTS

There was an increase in the prevalence of use of oral medications for the treatment of diabetes from 77.4 to 85.2% between 2012 and 2018, and a decrease in obtaining in the Health Unit Pharmacies of the Unified Health System (SUS), while there was an increase in obtaining in Popular Pharmacies.

CONCLUSIONS

In Brazil, SUS remained the main source for obtaining oral antidiabetic drugs, financing more than 70% of them in the country, considering the Health Unit Pharmacies and Popular Pharmacies, thereby showing the importance of public Pharmaceutical Policies in guaranteeing the access to medications by the Brazilian population, as well as in reducing inequities in the country. Nevertheless, the migration of obtaining by users from SUS Health Units to Popular Pharmacies suggests the weakening the responsibility of Primary Health Care in the provision oral antidiabetic drugs, thereby undermining the bond and the longitudinal care.

Fatores associados à não adesão à farmacoterapia em pessoas idosas na atenção primária à saúde no Brasil: uma revisão sistemática

Resumo Objetivos Identificar os fatores associados à não adesão à farmacoterapia em pessoas idosas brasileiras no âmbito da atenção primária à saúde (APS) através da realização de uma revisão sistemática da literatura. Método Trata-se de uma revisão sistemática da literatura nos idiomas inglês, espanhol e português, realizada na biblioteca eletrônica SciELO e nas bases de dados eletrônicas MEDLINE - via PubMed, LILACS, Embase e Web of Science no período de janeiro de 2010 a junho de 2020. A seleção dos estudos foi realizada de maneira independente por dois revisores, por meio do aplicativo de seleção Rayyan. Resultados Após a aplicação dos critérios de elegibilidade, foram incluídos nove estudos na revisão sistemática. O principal método utilizado para mensurar o desfecho foi a Escala de Morisky-Green (4-itens). Os resultados apontam as dificuldades de acesso aos medicamentos, as multimorbidades, a polifarmácia, o uso de medicamentos potencialmente inapropriados para idosos, o grau de confiança no profissional médico, as crenças, a autopercepção de saúde negativa e a incapacidade funcional como os principais fatores associados à não adesão à farmacoterapia na APS. Conclusões No âmbito da APS, a não adesão à farmacoterapia pela população idosa se apresenta como um problema muito frequente, sendo desencadeado por múltiplos fatores e com consequências negativas para o controle das condições de saúde, para o uso racional de medicamentos e para um envelhecimento saudável. Destaca-se ainda que parte dos fatores associados são passíveis de intervenção nesse nível de atenção à saúde.

Medication non-adherence in patients with type 2 diabetes mellitus with full access to medicines

Purpose

The pharmacological treatment for Type 2 diabetes mellitus (T2DM) is continuous and adherence to medication is critical for disease control. Restricted access to medicines is one of the most important barriers to adherence to T2DM treatment. This study aimed to evaluate other factors for medication non-adherence by studying patients with full access to oral hypoglycemic agents.

Methods

Cross-sectional study with 300 patients receiving their medication without costs from a referral center for diabetes care in Crato, Ceará (Brazil). Participants were recruited from January to December 2017. Information was obtained by self-applied questionnaires, and the drugs used were confirmed in the prescription. Adherence to medication was determined by the Morisky Medication Adherence Scale (MMAS-4). Patient perceptions of drugs were assessed by the Beliefs about Medicines Questionnaire (BMQ).

Results

Only 22.7% of participants met the criterion of high adherence to medication. The most frequent characteristics in the low adherence group were married; hypertension; no regular physical activity; therapy based on the combination of two or more oral antidiabetic agents without insulin; low score in the BMQ necessity scale. Necessity score in BMQ increased with age and the number of medications used and decreased if the patient had family members with the same disease and had children.

Conclusions

Full access to medicines did not assure high adherence to pharmacological treatment of type 2 diabetes mellitus. Distinctive factors to medication non-adherence may be found and specific barriers should be considered when planning actions for improving adherence in such populations.

Relationship between marital status and incidence of type 2 diabetes mellitus in a Brazilian rural population: The Baependi Heart Study

Many factors influence the incidence of type 2 diabetes mellitus (T2DM). Here, we investigated the associations between socio-demographic characteristics and familial history with the 5-year incidence of T2DM in a family-based study conducted in Brazil. T2DM was defined as baseline fasting blood glucose ≥ 126 mg/dL or the use of any hypoglycaemic drug. We excluded individuals with T2DM at baseline or if they did not attend two examination cycles. After exclusions, we evaluated a sample of 1,125 participants, part of the Baependi Heart Study (BHS). Mixed-effects logistic regression models were used to assess T2DM incident given different characteristics. At the 5-year follow-up, the incidence of T2DM was 6.7% (7.2% men and 6.3% women). After adjusting for age, sex, and education status, the model that combined marital and occupation status, skin color, and familial history of T2DM provided the best prediction for T2DM incidence. Only marital status was independently associated with T2DM incidence. Individuals that remained married, despite having significantly increased their weight, were significantly less likely to develop diabetes than their divorced counterparts.