Barriers to medication taking among Kuwaiti patients with type 2 diabetes: a qualitative study

Perspectives of older people with uncontrolled type 2 diabetes mellitus towards medication adherence: A qualitative study

BACKGROUND

Better medication adherence among people with diabetes mellitus was found to be associated with improved glycaemic control. However, medication non-adherence is a significant concern in older people with uncontrolled type 2 diabetes mellitus.

PURPOSE

To explore the perspectives of older people with uncontrolled type 2 diabetes mellitus towards medication adherence.

DESIGN

A qualitative descriptive exploratory study.

METHODOLOGY

A purposive sample of older people with uncontrolled type 2 diabetes mellitus living in the community was recruited. Snowball sampling was applied in community recruitment. In-depth telephone interviews were conducted using a semi-structured interview guide. Interviews were transcribed verbatim. Thematic analysis was used in data analysis. The consolidated criteria for reporting qualitative research (COREQ) guidelines were followed.

RESULTS

The emerged six themes were: (a) impact of knowledge, attitudes and practices on medication adherence, (b) treatment-related barriers to medication adherence, (c) impact of age-related changes on medication adherence, (d) person-related barriers to medication adherence, (e) impact of COVID-19 on medication adherence and, (f) role of support systems in medication adherence. Knowledge of the disease process and medications, attitudes towards medication adherence, the practice of different treatment approaches, self-medication and dosing, negative experiences related to medications, polypharmacy, changes in lifestyle and roles, the influence of work-life, motivation, negligence, family support, support received from health workers, facilities available and financial capability are the main factors influence medication adherence. Age-related memory impairment, visual disturbances and physical weaknesses affect medication adherence in older people. Additionally, COVID-19-related guidelines imposed by the government and healthcare system-related issues during the COVID-19 pandemic also affected medication adherence.

CONCLUSION

Adherence to medications among older people is hampered by a variety of factors, including their knowledge, attitudes and practices, person and treatment-related factors and age-related changes. The COVID-19 pandemic has brought additional challenges. Individualised patient care for older people with uncontrolled type 2 diabetes mellitus to improve medication adherence is timely. Strengthening support mechanisms for the above population is essential.

The status of stigma in patients with type 2 diabetes mellitus and its association with medication adherence and quality of life in China: A cross-sectional study

Type 2 diabetes mellitus (T2DM) is a chronic, lifelong disease that can negatively affect patients' mental health and quality of life (QoL). A notable proportion of patients with T2DM worldwide have experienced stigma through instances of discrimination, unfair social treatment and lack of promotion opportunities. Stigma refers to the negative emotional experience of people with illness, often mixed with self-stigmatization. Stigma remains an obstacle to patients' self-management, its association with patients with T2DM on medication adherence and QoL in China are unknown. Therefore, the objective of the study was to analyze the status of stigma in patients with T2DM and its association with medication adherence and QoL in China. A cross-sectional, observational study among 346 inpatients with T2DM in 2 tertiary-level hospitals in Chengdu, China, was conducted using a general data questionnaire, Chinese version type 2 diabetes stigma scale (DSAS-2), Morisky medication adherence scale (MMAS-8) and diabetic QoL specificity scale by convenient sampling method from January to August 2020. The total score and scores for the 3 dimensions of stigma, treated differently, blame and judgment, and self-stigma, were 54.30 ± 12.22, 16.57 ± 4.06, 20.92 ± 4.42, 16.82 ± 4.78, respectively. The scores for medication adherence and QoL were 5.43 ± 1.8 and 73.24 ± 9.38. Pearson correlation analysis showed that the total score of stigma and the scores of each dimension were negatively weak-correlated with the score of medication adherence (r = -0.158 to -0.121, P < .05), and positively moderate-correlated with the score of QoL (R = 0.073 to 0.614, P < .05). Stigma of patients with T2DM was negatively associated with medication adherence, and negatively associated with QoL, namely, the stronger the stigma, the worse the medication adherence and QoL. The results of the hierarchical regression analysis revealed that stigma independently explained 8.8% of the variation in medication adherence and 9.4% to 38.8% of the variation in QoL. The stigma of patients with T2DM was at a moderate degree and negatively correlated with medication adherence and QoL, it is necessary to pay more attention to relieve stigma and negative emotions timely, in order to improve patients' mental health and QoL.

Exploring of Determinants Factors of Anti-Diabetic Medication Adherence in Several Regions of Asia - A Systematic Review

BACKGROUND

The determinants of medication adherence in people with diabetes may differ between populations of an area due to social environment, cultural beliefs, socioeconomic conditions, education, and many other factors differences.

OBJECTIVE

Therefore, this study aims to explore, identify and classify the determinants of medication adherence in several Asian regions.

METHODS

A systematic literature review was conducted to gain insight into the determinants of medication adherence. Seven relevant databases (EBSCO, ProQuest, PubMed, ScienceDirect, Scopus, Wiley, dan Taylor and Francis) and hand searching methods were conducted from January 2011 to December 2020. Keywords were compiled based on the PICO method. The selection process used the PRISMA guidelines based on inclusion, and the quality was assessed using Crowe's critical assessment tool. Textual summaries and a conceptual framework model of medication adherence were proposed to aid in the understanding of the factors influencing medication adherence.

RESULTS

Twenty-six articles from countries in several Asian regions were further analyzed. Most studies on type 2 diabetes patients in India used the MMAS-8 scale, and cross-sectional study is the most frequently used research design. The medication adherence rate among diabetic patients was low to moderate. Fifty-one specific factors identified were further categorized into twenty-three subdomains and six domains. Furthermore, the determinants were classified into four categories: inconsistent factors, positively related factors, negatively related factors, and non-associated factors. In most studies, patient-related factors dominate the association with medication adherence. This domain relates to patient-specific demographics, physiological feelings, knowledge, perceptions and beliefs, comorbidities, and other factors related to the patient. Several limitations in this review need to be considered for further research.

CONCLUSION

Medication adherence to diabetic therapy is a complex phenomenon. Most determinants produced disparate findings in terms of statistical significance. The identified factors can serve various goals related to medication adherence. Policymakers and health care providers should consider patient-related factors.

The Weakness of Will: The Role of Free Will in Treatment Adherence

Chronic disease prevention and management requires a lifelong commitment and adherence to lifestyle modifications, monitoring of symptoms, medication use, and other forms of therapy. Treatment adherence is a crucial and complex concept in patient care provision, and it requires the voluntary active involvement of patients for the best possible outcome. Multiple factors, which may or may not be under the patient's control, can influence treatment adherence. However, adherence or non-adherence to a certain treatment is predominantly influenced by one's sense of agency, values, beliefs, attitudes, and willpower. It is evident that mental states appear to influence patients' decision-making, and the best treatment outcome occurs when a patient identifies their goals, needs, and desires and exercises their decision-making and free will during the course of receiving care. The role of healthcare providers is critical in promoting treatment adherence, thereby enhancing patient outcomes. Thus, this paper highlights the importance of promoting a sense of agency and integrating patients' values, beliefs, attitudes, and intentions during the provision of healthcare. It is indispensable to recognize the individual's ability and initiative to control and manage their illness in the face of challenging socioeconomic and cultural reality. On logical grounds, it is not enough to appreciate the value of free will and mental states, it is also essential to empower and cultivate an individual patient's willpower to make a well-informed, free decision based on their mental state for the most optimal treatment outcomes.

Investigation of Barriers and Facilitators to Medication Adherence in Patients With Type 2 Diabetes Across Different Health Literacy Levels: An Explanatory Sequential Mixed Methods Study

Type 2 diabetes (T2D) incurs tremendous healthcare costs associated with various complications due to poor blood sugar control. Medication adherence, which is correlated with patients’ health literacy, should be consistently practiced to achieve optimal control of blood sugar. A comprehensive understanding of specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence. To understand barriers and facilitators to medication adherence in people with T2D across different health literacy levels, the Health Literacy Pathway Model was used to identify the psychosocial and communication factors that may influence medication adherence. This mixed methods study used an explanatory sequential design, including a quantitative survey followed by qualitative semi-structured interviews. Two hundred and five participants completed the survey questionnaire, and 23 participants completed semi-structured interviews. Confirmed by quantitative and qualitative data, having stronger self-efficacy and fewer concerns about medications, as well as experiencing fewer perceived barriers to medication-taking, are necessary for better medication adherence among those with low adherence. Our findings will be useful to tailor interventions for diabetes care through addressing concerns among low-adherent patients with low health literacy and emphasizing self-efficacy and perceived barriers to medication adherence among all low-adherent patients with T2D.

Perceptions among diabetic patients in the ultra-orthodox Jewish community regarding medication adherence: a qualitative study

BACKGROUND

Promoting a healthy lifestyle and achieving strict adherence to medical treatment among patients with diabetes are key objectives in public health. Yet health behaviors are often culturally driven, especially in closed religious communities. This study seeks to reveal key cultural-religious factors, attitudes and behaviors characterizing the lifestyle in one such closed community-the ultra-Orthodox Jewish community-by understanding the attitudes of ultra-Orthodox patients with diabetes toward coping with their illness and the factors impacting their adherence to medicinal treatment.

METHOD

Qualitative interviews were conducted with 16 ultra-Orthodox patients with diabetes using a semi-structured, in-depth questionnaire.

RESULTS

Three main themes emerged: 1) "The disease as a secret": Hiding the disease among patients with diabetes in ultra-Orthodox society; 2) "Distinguishing between sacred and secular occasions": ultra-Orthodox diabetes patients distinguish between treatment adherence on weekdays and treatment adherence on holidays or special occasions; 3) "Ask the rabbi": In cases of dilemmas that involved conflicts between halakhic rulings and doctors' instructions, the rabbi's decision was usually the final one.

CONCLUSIONS

The findings of this study may help provide an in-depth understanding of the obstacles and motives of ultra-Orthodox patients in adhering to medicinal treatment of diabetes in particular and to medicinal treatment in general, thus helping family physicians who treat this population provide optimal and appropriate treatment.

Medication Adherence in Type 2 Diabetes Mellitus: A Qualitative Exploration of Barriers and Facilitators From Socioecological Perspectives

Adherence to antidiabetic medications (ADMs) remains a serious challenge among type 2 diabetes mellitus (T2DM) patients. Factors affecting medication adherence are not fully understood in Nigeria. This qualitative study explored patients' views on barriers and facilitators of medication adherence. Data collection was through face-to-face, semistructured, in-depth interviews conducted on 25 purposively sampled patients attending a public tertiary hospital. The interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis based on socioecological framework. NVIVO version 10 identified more codes. Most commonly identified barriers were organizational (clinic structure), personal (perception of T2DM as a dangerous illness), interpersonal (lack of spousal support), and community (concerns about taking ADMs in social gatherings). It was observed that female patients received more spousal support than the males. The facilitators of adherence include perceiving medication-taking a routine, the need to live longer, having savings for ADMs, purchasing medications to last until the next clinic visit. This study identified barriers and facilitators unique to Nigerian T2DM patients. Interventions anchored on these factors would improve medication adherence.

Factors Contributing to Medication Adherence in Patients with a Chronic Condition: A Scoping Review of Qualitative Research

Introduction: Medication adherence continues to be a significant challenge in healthcare, and there is a shortage of effective interventions in this area. This scoping review studied the patient-related factors of medication adherence. Methods: We searched Medline Ovid, Scopus, and Cochrane Library from January 2009 to June 2021 to find the most recent original qualitative studies or systematic reviews that addressed the patient-related factors of medication adherence in treating chronic conditions. We used the PRISMA-ScR checklist to ensure the quality of the study. Results: The initial search revealed 4404 studies, of which we included 89 qualitative studies in the scoping review. We inductively organized the patient-related factors causing barriers, as well as the facilitators to medication adherence. The studies more often dealt with barriers than facilitators. We classified the factors as patient-specific, illness-specific, medication-related, healthcare and system-related, sociocultural, as well as logistical and financial factors. Information and knowledge of diseases and their treatment, communication, trust in patient-provider relationships, support, and adequate resources appeared to be the critical facilitators in medication adherence from the patient perspective. Discussion and conclusions: Patients are willing to discuss their concerns about medications. Better communication and better information on medicines appear to be among the critical factors for patients. The findings of this scoping review may help those who plan further interventions to improve medication adherence.

Evaluation of medication adherence among patients with chronic diseases in Saudi Arabia

BACKGROUND

Medication adherence in chronic diseases patients is a worldwide concern. Not achieving the goal of treatments because of non-adherence will lead to more complications and eventually may lead to death. In Saudi Arabia, we have insufficient data for interpretation. Hence, this study aims to have a better perspective at the number of the non-adherent patients with chronic diseases to their medications and its associated factors.

MATERIAL AND METHOD

Cross-sectional quantitative study was conducted among chronic diseases patients living in Saudi Arabia throughout social media and hospital visits from August 2018 to April 2019. A three-section questionnaire consists of patient's health, medications and adherence characteristics. Adherence to Refills and Medication Scale (ARMS) was used to identify the level of adherence among chronic diseases patients. Univariate descriptive statistics and independent sample t-test with one-way ANOVA were used as bivariate analysis. Finally, significant predictors of medical adherence with adjusted coefficient were determined by multivariable linear regression.

RESULTS

A total of 385 patients were included in the analysis for the current study. Overall, 96.62% (n = 372) were non-adherent to their medications according to ARMS scale. Multiple linear regression model found types of co-morbidities, medication dosage form and dosage regimen to be independent predictors of medical adherence.

CONCLUSION

Medication adherence is alarmingly low among chronic disease patients in Saudi Arabia. There is a clear need for in-depth understanding for barriers. It is therefore important to conduct a qualitative study. What's known Medication adherence is a critical factor in treatment success. Low adherence to the medication is a common problem among chronic disease patients. Moreover, the majority of the studies in Saudi Arabia showed low adherence rate, and it focused in one single chronic disease only despite that patient may have more. What's new Most patients had more than one single chronic disease, so this study aims to take a snapshot to capture the adherence rate among patients who are suffering from chronic disease Saudi Arabia and its associated factors. This can help in understanding medication adherence behavior in clinical practice.

"I try the one that they say is good." - factors influencing choice of health care provider and pathways to diabetes care for Syrian refugees in Lebanon

Background

Navigating health systems in host countries can be a challenge for refugees, particularly in a multi-provider system such as Lebanon. Syrian refugees in Lebanon face a high burden of Non-Communicable Diseases (NCDs) including diabetes mellitus. Evidence on how refugees navigate the health system is essential to improve provision of NCD services. We conducted a qualitative study amongst Syrian diabetes patients visiting Médecins Sans Frontières (MSF) clinics in one urban and one rural setting in Lebanon to explore factors influencing choice of and pathways to diabetes care.

Methods

In-depth interviews were conducted with male and female adult participants with DM type 1 or type 2 who were receiving treatment at MSF clinics. Participants were recruited using convenience sampling. Interviews were conducted in Arabic and directly transcribed and translated into English. Data were coded in NVivo and analyzed using an inductive thematic approach.

Results

A total of 29 in-depth interviews were conducted with 13 men and 16 women. Knowledge and understanding of diabetes management differed among participants. Syrian refugees in Lebanon gathered information about health services for diabetes largely from social networks of family and peers rather than through formal means. Pathways to care included different combinations of providers such as clinics, pharmacists and informal providers.

Conclusions

Syrian refugees with diabetes in Lebanon face considerable challenges in navigating the health care system due to their vulnerable status and limited knowledge of the host country systems. To ensure access to care for diabetes, efforts need to be made to support patients’ orientation in the Lebanese health system.

Pharmacological treatment of type 2 diabetes in Saudi Arabia: A consensus statement from the Saudi Society of Endocrinology and Metabolism (SSEM)

BACKGROUND AND AIMS

The list of available treatment options for managing blood glucose in patients with type 2 diabetes (T2D) has grown over recent years making the task of choosing between traditional and newer glucose-lowering agents a difficult one for healthcare providers.

METHODS

We summarize treatment algorithms developed by popular professional societies and propose a patient-centered and culture-driven recommendations for selecting diabetes medications for people with T2D in Saudi Arabia.

RESULTS

Though most professional societies recognize patient's adherence to medications as an important factor in achieving glycemic targets, published algorithms schemes do not formally enlist adherence to medication as a deciding factor in the choice of glucose-lowering agents. Medication appeal to patients, an important determinant of medication adherence, is influenced by several factors including lifestyle, common beliefs, customs and traditions, health literacy, perception of health and disease, socioeconomic and cultural backgrounds, and religious commitments and obligations. In Saudi Arabia, poor adherence to therapy is a major obstacle to effective management of local people with T2D.

CONCLUSIONS

The Saudi population has a unique socioeconomic and cultural background that widely respect adherence to religion and culture; and the applicability of international guidelines for the management of T2D to the Saudi population has been called into question. In this consensus statement, we propose patient-centered and culture-driven recommendations that integrate medication-adherence and medication-cost into overall selection of diabetes medications for people with T2D in Saudi Arabia.

The association of illness perceptions and God locus of health control with self-care behaviours in patients with type 2 diabetes in Saudi Arabia

Objective: To investigate the associations between illness perceptions, God locus of health control (GLHC) beliefs, and self-care behaviours in Saudi patients with type 2 diabetes (T2D). Design: A cross-sectional study was conducted with 115 adults with T2D in a Saudi Arabian diabetes clinic. Illness perceptions, GLHC beliefs, and self-care behaviours were assessed using the Arabic versions of the Brief Illness Perception Questionnaire, God Locus of Health Control, and Summary of Diabetes Self-Care Activities. Logistic and linear regressions were conducted. Results: Greater perceptions of personal control (OR = 2.07, p = .045) and diet effectiveness (OR =   2.73, p = .037) were associated with higher odds of adhering to general diet. Greater perceptions of diet effectiveness (β = 0.27, p = .034) and better understanding of T2D (β = 0.54, p < .001) were significant independent predictors of fruit and vegetables intake and exercise respectively. Patients with lower GLHC beliefs (OR =  4.40, p = .004) had higher odds of adhering to foot care than those with higher GLHC beliefs. Illness perceptions and GLHC beliefs did not predict adherence to a low-fat diet, self-monitoring of blood glucose, or not smoking. Conclusion: Greater perceptions of personal control, coherence, diet effectiveness, and lower GLHC beliefs were associated with higher adherence to self-care behaviours in Saudi patients with T2D. Interventions designed to promote self-care behaviours in Saudi patients with T2D could focus on addressing these perceptions.

Self-Care Adherence And Barriers To Good Glycaemic Control In Nepalese Type 2 Diabetes Mellitus Patients: A Hospital-Based Cross-Sectional Study

Purpose

The patient believes in adherence to medication rather than to self-care adherence and lifestyle changes for the management of diabetes. This study was carried out to establish the association of self-care adherence and their barriers in poor glycemic control in our diabetic population.

Patients and methods

This cross-sectional study was conducted among 480 already diagnosed diabetes outpatients attended in our two hospitals. Glycaemic control was defined by levels of HbA_1c. Socio-demographic data, lifestyle variables and anthropometric measurements were recorded using a standard questionnaire. Fasting blood glucose, HbA_1c and lipid profiles were estimated using the manufacturer’s guideline. Student’s t-test and one-way ANOVA were used for comparison between different groups and the correlation was established by Spearman correlation. Risk factors associated with poor glycaemic control were verified by logistic regression analysis.

Results

The mean HbA_1c of the study population was 7.4±1.3% and 65.4% had poor glycaemic control with mean 8.0±1.1%. Higher HbA_1c levels were significantly associated with duration of diabetes, a number of drugs used, patient–physician relationship and knowledge about diabetes. The poor glycaemic control was significantly associated with low adherence of following the meal plan, regular medication and regular exercising (p<0.001). Among all the barriers, a too busy schedule for following the meal plan, taking medications and exercising regularly was significantly correlated with HbA1c levels. Multivariable logistic regression analysis showed irregular meal plan (OR=5.27), irregular exercise (OR=2.25), number of medication used (OR= 0.19) and lesser extent patient–physician relationship (OR=2.68) were independent risk factors for poor glycaemic control.

Conclusion

The poor glycaemic control was associated with poor adherence to self-care adherence and their barriers in our diabetic population. Integrated knowledge on diabetes management should be targeted to improve glycaemic control in our communities.

The determinants of anti-diabetic medication adherence based on the experiences of patients with type 2 diabetes

Background

The purpose of this study is to explain the experiences of patients with type 2 diabetes (T2DM) about medication adherence.

Method

A qualitative content analysis study was conducted at the Institute of Endocrinology and Metabolism Research and Training Center of Firoozgar Academic Hospital, affiliated to Iran University of Medical Sciences in Tehran, Iran during April–June 2017. Twenty-six semi-structured in-depth interviews were conducted with diabetic patients and their families. The participants were asked about their experiences of medication adherence. After the first round of the interviews, content analysis of data started and continued up to the data saturation.

Results

Four main themes including perceived barriers (with 6 subthemes including inadequate knowledge, situational influences, inadequate perceived threat about diabetes, treatment characteristics, personality traits and medication cost), perceived social support (with 3 subthemes including family, doctor and community supports), medication beliefs (with 3 subthemes including belief in the effectiveness of treatment, belief in the more effectiveness of complementary therapies than medication use and prioritizing the use of the pills instead of the insulin injection) and cues to action (with 2 subthemes including internal and external cues to action) emerged as the experiences of the participants in terms of anti-diabetic medications adherence which should be considered in developing medication adherence interventions for the patients with T2DM.

Conclusion

The patients with T2DM had more barriers for regular drugs consumption. They had incorrect beliefs about anti-diabetic drugs. In addition, they were in need of abroad support community, surroundings and also health professionals. Health systems should consider medication adherence training to be added to the treatment protocols of the diabetic patients.

Illness Perceptions, HbA1c, And Adherence In Type 2 Diabetes In Saudi Arabia

PURPOSE

Little is known about predictors of adherence to diabetes medication in Saudi Arabia. This study aimed to investigate whether illness perceptions, beliefs about medicine, and God locus of health control beliefs were associated with adherence to medication and glycaemic control (HbA1c) in Saudi patients with type 2 diabetes (T2D).

PATIENTS AND METHODS

A convenience sample of 115 adults with T2D were recruited from a diabetes outpatient clinic. Validated self-reported measures of adherence to medication, illness perceptions, beliefs about medicine, and God locus of health control were administered. Patients' most recent HbA1c levels were extracted from medical records. Multivariable logistic and linear regressions were used to examine the association between illness perceptions, beliefs about medicine and adherence to medication and HbA1c.

RESULTS

More than two thirds of patients (69%) reported poor adherence to medication. All illness perceptions domains, beliefs about medicine, and God locus of health control beliefs were associated with adherence. Multivariable logistic regression revealed that older age (OR= 3.76, p= 0.023), worse consequences perceptions (OR= 0.21, p= 0.011), worse illness identity (OR= 0.23, p= 0.010), and greater illness coherence (OR= 3.24, p= 0.022) were independent predictors of adherence. Two thirds of patients (67%) had suboptimal HbA1c; and perceptions of a cyclical timeline and lower insulin effectiveness were associated with higher HbA1c. In multiple linear regression, perceptions of a cyclical timeline (β= 0.19, p= 0.040) were an independent significant predictor of HbA1c.

CONCLUSION

In Saudi Arabia, patients' perceptions of T2D, beliefs about medicine, and God locus of control beliefs are associated with adherence. These results inform the development of interventions based on the Common-Sense Model (CSM) to encourage improved adherence and glycaemic control among Saudi patients with T2D. Further research with larger and more diverse samples is warranted to expand the generalizability of these findings.

The perspectives of patients and physicians on the role of pharmacists in improving medication adherence in type 2 diabetes: a qualitative study

BACKGROUND

Pharmacy practice has been expanded to include responsibility for the outcomes of medication therapy. However, in developing countries the pharmacist's role is still limited to dispensing medications. The aim of this study is to explore the perspectives of patients and physicians on the pharmacist's role in improving medication adherence in type 2 diabetes.

METHODS

Data were collected via semi-structured interviews with patients and physicians. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

A total of 40 patients and 21 physicians were interviewed. The interviews revealed different pharmacy-related issues that negatively affected patients' adherence, such as a lack of pharmacist counselling and inappropriate scheduling of refills. Various recommendations to improve adherence were emphasised such as dedicating some pharmacists to counselling patients and providing pharmacists with the appropriate training.

CONCLUSION

From the perspectives of patients and physicians, the pharmacist's role in the management of type 2 diabetes is still limited to dispensing medications. In order to improve medication adherence and consequently patient outcomes, policy-makers need to be aware of the importance of supporting pharmacists and providing them with the appropriate training.

Medication adherence among patients with Type 2 diabetes: A mixed methods study

Objective

Oral hypoglycemic agents (OHAs) are highly effective in managing Type 2 diabetes if taken appropriately. This study assessed adherence to OHAs among patients with Type 2 diabetes and explored factors associated with adherence behaviour.

Research design and methods

Mixed methods were used comprising a cross-sectional study using the Arabic version of the Morisky Medication Adherence Scale followed by semi-structured interviews using the Theoretical Domain Framework to explore key determinants of adherence.

Results

The cross-sectional study included 395 patients of whom 40% achieved a high level of OHA adherence. Lower adherence was associated with younger age (Odds Ratio (OR) 1.084; 95% CI 1.056 to 1.112), higher numbers of non-OHAs (OR 0.848; 95% CI 0.728 to 0.986) and higher HbA1c levels (OR 0.808; 95% CI 0.691 to 0.943). Semi structured interviews based on the Theoretical Domain Framework were completed with 20 patients and identified a wide range of factors potentially associated with OHA adherence, particularly behavioural related factors (e.g. scheduling medication intake, ability to develop a habitual behaviour), social influences (e.g. acting as a role model, the effect of family support), and gaps in knowledge about diabetes and its management with OHAs.

Conclusions

This unique mixed-methods study has highlighted possible reasons for the low levels of OHA adherence in this patient population. Whilst the theoretically-derived determinants of behaviour illustrate the complexities associated with OHA adherence, they also provide a robust underpinning for future intervention(s) development to improve adherence and maximise patient health outcomes.

Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes

AIMS

To evaluate the influence of age at diabetes diagnosis, diabetes duration, BMI, comorbidity with hypertension and medication regimen on glycaemic control in native Kuwaiti Arab patients with T2D.

METHODS

This cross-sectional study considered 7657 patients from Kuwait Diabetes Registry and analysed data from their laboratory and hospital records.

RESULTS

HbA1c and prevalence of hypertension increased significantly with diabetes duration. Duration of diabetes (β=0.034; P<0.001) and age at diagnosis (β=-0.03; P<0.001) were independently associated with HbA1c. Inadequate glycaemic control was more likely in patients diagnosed at <60 than in those ≥60 years of age (OR:1.80, 95%-CI:1.39-2.31). Increasing duration of diabetes witnessed decrease in metformin prescription and increase in sulfonylureas prescription; proportion of patients treated with insulin increased from 5.6% to 44.4% in 9 years of diagnosis. Patients with 9-years duration of diabetes or with combination therapy of insulin-metformin-sulfonylureas differed in mean BMI for adequate or inadequate glycaemic control (29.5 versus 31.2kg/m²; P<0.001 and 29.8 versus 33.2; P<0.01, respectively).

CONCLUSIONS

Only 25.6% of the T2D patients in this ethnic cohort exhibited adequate glycaemic control. The delineated relationship of inadequate glycaemic control with diabetes duration, onset age, obesity and hypertension prevalence has a bearing on diabetes management programs for Arabs.

"Antibiotics kill things very quickly" - consumers' perspectives on non-prescribed antibiotic use in Saudi Arabia

Background

In recent decades, the Kingdom of Saudi Arabia has seen an exponentially growing antibiotic resistance, which is exacerbated by the use of antibiotics without a prescription and other various factors. However, no published data are available on factors influencing non-prescription use of antibiotics among the general public in Saudi Arabia using an in-depth interview technique.

Methods

Semi-structured interviews were carried out with 40 Saudi participants from the Eastern Province of Saudi Arabia, selected via snowball sampling technique. Participants were enrolled based on the following inclusion criteria: 18 years of age or older and had self-medicated themselves with antibiotics in the past two years. Data collection was continued until data saturation was attained. Interviews were audiotaped, transcribed verbatim and analysed using NVivo 10 software.

Results

Participants (80% female) had a mean (SD) age of 30 years (10.2). Self-medication with antibiotics was associated with various inappropriate antibiotic use behaviours and negative outcomes such as antibiotic resistance, treatment failures and adverse events. Interviews revealed that different reasons contribute to the rise of self-medication with antibiotics, ranging from difficulty accessing healthcare services, participant’s cultural beliefs and practices, lack of knowledge about antibiotics and antibiotic resistance, and weak regulatory enforcement.

Conclusions

The findings of the present study will aid in generating data that may provide an insight when designing future interventions to promote public health awareness regarding safe and effective use of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6088-z) contains supplementary material, which is available to authorized users.

Identifying and Understanding Barriers and Facilitators to Medication Adherence Among Marshallese Adults in Arkansas

Background: Significant health disparities are present in Marshallese adults residing in the United States, most notably a high incidence of type 2 diabetes and other chronic conditions. There is limited research on medication adherence in the Marshallese population. Objective: This study explored perceptions of and experiences with medication adherence among Marshallese adults residing in Arkansas, with the aim of identifying and better understanding barriers and facilitators to medication adherence. Methods: Eligible participants were Marshallese adults taking at least one medication for a chronic health condition. Each participant completed a brief survey and semistructured interview conducted in Marshallese by a bilingual Marshallese staff member. Interviews were recorded, transcribed, and translated from Marshallese to English. Qualitative data were coded for a priori and emergent themes. Results: A total of 40 participants were included in the study. The most common contributing factor for nonadherence was forgetting to take medication (82%). A majority of participants (70%) reported difficulty paying for medicine, 45% reported at least one form of cost-related nonadherence, and 40% engaged in more than one cost-related nonadherence practice. Family support and medication pill boxes were identified as facilitators for medication adherence. The majority of the participants (76.9%) stated that they understood the role of a pharmacist. Participants consistently desired more education on their medications from pharmacy providers. Conclusion: This is the first study to explore barriers and facilitators to medication adherence among Marshallese patients. The findings can be used to develop methods to improve medication adherence among Marshallese.

Reasons for Nonadherence to Psychiatric Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder Patients Living in Puerto Rico: A Qualitative Study

Latinos with bipolar disorder (BD) have a high rate of nonadherence to psychiatric medication and treatment for other medical conditions such as cardiovascular disease (CVD) risk factors than non-Latinos with BD. The aim of this study is to identify patients' perspectives on the reasons for nonadherence to psychiatric medication and for CVD risk factors conditions in outpatients with BD. Three focus group sessions were held for a total of 22 adults ranging from 23 to 60 years old. Participants had BD, Type I/II and CVD risk factors. Audio-recordings of focus groups were transcribed and a content analysis was performed. Reasons identified as barriers to adherence were somewhat different for BD medications in comparison to CVD risk factors suggesting the need for integrated interventions targeting these barriers to adherence for both BD and CVD risk factors.

Assessing prevalence of and barriers to medication adherence in patients with uncontrolled diabetes attending primary healthcare clinics in Qatar

BACKGROUND

Studies conducted in Qatar have reported a high prevalence of diabetic nephropathy, retinopathy, and neuropathy. These complications are often associated with poor medication adherence and uncontrolled diabetes. The objectives of this study were to determine the rate of medication adherence among patients with uncontrolled diabetes, and to compare the characteristics and identified barriers between patients with good and those with poor medication adherence.

METHOD

A cross-sectional quantitative study was conducted among patients living in Qatar with uncontrolled diabetes attending primary healthcare clinics from October 2016 to January 2017. An interviewer-administered questionnaire comprising three sections was utilized in the study: patients' characteristics, Adherence to Refill and Medications Scale in Diabetes (ARMS-D), and barriers to medication adherence. ARMS-D is a validated tool that is used to identify adherence level among patients with diabetes. Descriptive and inferential statistics including regression analysis were used for data analysis.

RESULTS

A total of 260 patients were included in the analysis. Overall, 73% (n=191) were nonadherent to their diabetes medications (ARMS-D score above 11). Nonadherent patients reported the majority of the pre-determined barriers to medication adherence with forgetfulness being the most commonly reported barrier. Multivariate linear regression analysis found age, ethnicity, education level, income level and HbA1c to be independent predictors of adherence.

CONCLUSION

The findings of this study reaffirm the notion that non-adherence to medications among patients with uncontrolled diabetes within primary care setting is higher than the general diabetes population. This high prevalence is concerning and necessitates urgent interventions. Nonetheless, an in-depth understanding of barriers to medication adherence often requires qualitative research approach as these barriers are very complex and multifactorial in nature.

Assessing the influence of health systems on Type 2 Diabetes Mellitus awareness, treatment, adherence, and control: A systematic review

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.

METHODS AND FINDINGS

A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.

CONCLUSIONS

This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers

PURPOSE

To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives.

PARTICIPANTS AND METHODS

A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives.

CONCLUSION

Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.

Medication adherence in chronic illness: do beliefs about medications play a role?

BACKGROUND

Several medicines are prescribed for chronic disease management; however, adherence to long-term therapy remains poor. Culture influences beliefs about medications and, ultimately, adherence to treatment. There is a paucity of data with regard to beliefs about medications in the Middle East region, and it remains to be determined how these beliefs would impact treatment adherence.

OBJECTIVES

To investigate the relationship between patients' beliefs about medications with self-reported adherence to treatment among a chronically ill multicultural patient population.

METHODS

A prospective cross-sectional study was conducted among patients treated for chronic illnesses in the Ministry of Health primary care clinics in Kuwait. Patients completed a questionnaire that consisted of questions to collect information about their health status and demographics using validated instruments: the Beliefs about Medication, Sensitive Soma Assessment Scale, and Medication Adherence Report Scale-5 items. The main outcome measures were self-reported adherence to medications, beliefs, and perceived sensitivity toward medications.

RESULTS

Of the 1,150 questionnaires distributed, 783 were collected - giving a response rate of 68.1%. Of the 783 patients, 56.7% were male, 73.7% were married, 53.3% were non-Kuwaitis, and 49.4% had low income (<1,000 KD/3,350 USD monthly). Patients self-reported having a cardiovascular illness (80.2%), diabetes mellitus (67.7%), respiratory disease (24.3%), or mood disorder (28.6%). Participants had a mean of two comorbid illnesses and indicated taking an average of four prescription medicines to treat them. A structural equation model analysis showed adherence to medications was negatively impacted by higher negative beliefs toward medications (beta = -0.46). Factors associated with negative beliefs toward medications included marital status (being unmarried; beta = -0.14), nationality (being Kuwaiti; beta = 0.15), having lower education level (beta = -0.14), and higher illness severity (beta = 0.15). Younger age (beta = 0.10) and higher illness severity (beta = -0.9) were independently associated with lower medication adherence. Income and gender did not influence medication adherence or beliefs about medications. The combined effect of variables tested in the model explained 24% of the variance in medication adherence.

CONCLUSION

Medication adherence is a complex, multifaceted issue and patient beliefs about medications contribute significantly, although partially, to adherence among a multicultural Middle Eastern patient population.

Factors associated with medication adherence among patients with diabetes in the Middle East and North Africa region: A systematic mixed studies review

Multiple systematic reviews were conducted investigating factors associated with medication adherence worldwide. However, investigations from the Middle East and North Africa (MENA) region were largely underrepresented in those reviews. Therefore, the objective of this systematic review is to identify the factors influencing medication adherence among patients with diabetes in the MENA region. A systematic literature search was conducted through Cochrane Library, EBSCO, EMBASE, Google Scholar, ISI Web of Science, PubMed, ScienceDirect, SCOPUS, and ProQuest. Studies were included if they determined factors associated with medication adherence among patients with diabetes within the MENA region. Quality was assessed using Crow Critical Appraisal Tool. Thirty primary studies from 10 MENA countries were included. The factors associated with medication adherence were categorized into demographics-related; disease- and medication-related; perception, attitude and psychological feelings-related; and societal-related factors. Positively associated factors included knowledge about the disease and medications, regular follow-up visits, and patients' positive beliefs about effectiveness and motivations about medications, while negatively associated factors included forgetfulness, side effects, and polypharmacy. Factors associated with medication adherence among patients with diabetes in the MENA region are highly diverse. The identified factors can serve as potential targets for culturally-relevant interventions to improve medication adherence and overall health outcomes.

"Patients' understanding is the problem": physicians' views of nonadherence among Arabs with type 2 diabetes

PURPOSE

Nonadherence to diabetes medication is a significant barrier toward achieving positive treatment outcomes. There is an abundance of research looking at the problem from the patient perspective, but less from the provider perspective. The Middle East region has one of the highest prevalences of type 2 diabetes in the world, with special cultural characteristics, which require research attention. The aim of this study was to explore the views of primary-care physicians on medication nonadherence among type 2 diabetes patients.

MATERIALS AND METHODS

A descriptive qualitative study was performed using one-on-one semistructured interviews of 21 primary-care physicians who were selected using stratified and random sampling from polyclinics in the five health districts in Kuwait. The interviews elicited the participants' views about barriers and facilitators of medication adherence in type 2 diabetes patients. The interviews were audio-recorded and transcribed verbatim. Thematic content analysis with constant comparison was used to generate the codes and themes to arrive at a core category.

RESULTS

Patient understanding, including knowledge, beliefs, and attitudes, was identified by respondents as the core determinant of medication nonadherence in type 2 diabetes. This was composed of six major themes: four against understanding and two for understanding. The ones against were "Patients do not understand diabetes", "Patients do not understand the importance of medications", "What the patient hears from friends is more important than what the doctor says", "Patients are in denial (or difficult)". Themes for understanding were "I need to educate more" and "Patients must hear it from other sources".

CONCLUSION

That lack of understanding among patients results in medication nonadherence is the dominant view of primary-care physicians. This finding has implications in relation to the evolution of diabetes care toward more patient-centeredness within the cultural context.

Patients' empowerment, physicians' perceptions, and achievement of therapeutic goals in patients with type 1 and type 2 diabetes mellitus in Mexico

BACKGROUND

Physicians' perception may not parallel objective measures of therapeutic targets in patients with diabetes. This is an issue rarely addressed in the medical literature. We aimed to analyze physicians' perception and characteristics of adequate control of patients with diabetes.

PATIENTS AND METHODS

We studied information on physicians and their patients who participated in the third wave of the International Diabetes Management Practices Study registry in Mexico. This analysis was performed on 2,642 patients, 203 with type 1 diabetes mellitus (T1DM) and 2,439 with type 2 diabetes mellitus (T2DM), treated by 200 physicians.

RESULTS

The patients perceived at target had lower hemoglobin A1c (HbA1c) and fasting blood glucose than those considered not at target. However, overestimation of the frequency of patients with HbA1c <7% was 41.5% in patients with T1DM and 31.7% in patients with T2DM (underestimation: 2.8% and 8.0%, respectively). The agreement between the physicians' perception and the class of HbA1c was suboptimal (κ: 0.612). Diabetologists and endocrinologists tested HbA1c more frequently than primary care practitioners, internists, or cardiologists; however, no differences were observed in mean HbA1c, for both T1DM (8.4% vs 7.2%, P=0.42) and T2DM (8.03% vs 8.01%, P=0.87) patients. Nevertheless, insulin users perceived at target, who practiced self-monitoring and self-adjustment of insulin, had a lower mean HbA1c than patients without these characteristics (mean HbA1c in T1DM: 6.8% vs 9.6%, respectively; mean HbA1c in T2DM: 7.0% vs 10.1%, respectively).

CONCLUSION

Although there is a significant physicians' overestimation about the optimal glycemic control, this global impression and characteristics of patients' empowerment, such as self-monitoring and self-adjustment of insulin, are associated with the achievement of targets.

Patients' management of type 2 diabetes in Middle Eastern countries: review of studies

The increased prevalence of diabetes in Middle Eastern countries is a health policy priority. Important risk factors for diabetes have been identified. Lifestyle interventions and adherence to medications are central to disease prevention and management. This review focuses on the management of type 2 diabetes mellitus in Middle Eastern countries. The aim is to identify the ways in which knowledge, health beliefs, and social and cultural factors influence adherence to medication and lifestyle measures. Thirty-four studies were identified following a systematic search of the literature. The studies describe the influence of knowledge, health beliefs, culture, and lifestyle on the management of type 2 diabetes mellitus in the Middle East. Findings indicate a lack of health knowledge about diabetes among populations, which has implications for health behaviors, medication adherence, and treatment outcomes. Many identified health beliefs and cultural lifestyle factors, such as religious beliefs, beliefs about fasting during Ramadan, and sedentary lifestyles played a role in patients' decisions. For better management of this disease, a collaborative approach between patients, their families, health care professionals, and governments should be adopted. Implementing behavioral strategies and psychological interventions that incorporate all health care professionals in the management process have been shown to be effective methods. Such services help patients change their behavior. However, the utilization of such services and interventions is still limited in Arabian countries. Physicians in the Middle East are the health care professionals most involved in the care process.