Adherence to self-care practices, glycemic status and influencing factors in diabetes patients in a tertiary care hospital in Delhi

Assessment of adherence to dietary recommendations and associated factors among type 2 diabetic patients in selected hospitals in Addis Ababa, Ethiopia

Background

In Ethiopia, diabetes and its complications are significant causes of morbidity and mortality, with huge economic implications. Despite the high dietary non-adherence that has been reported in limited studies in Ethiopia. Moreover, there is a gap from the perspective of patients in the area of this topic.

Objectives

This study aimed to assess adherence to dietary recommendations and associated factors among type 2 diabetic patients in Addis Ababa Selected Hospitals, Addis Ababa, Ethiopia, 2024.

Methods and materials

An institution-based cross-sectional study was conducted in a 420 sampled population among four hospitals found in Addis Ababa, Ethiopia, from 24 June to 15 July 2024. Systematic random sampling was used to recruit individual study participants. The collected data were exported into SPSS version 25 software for analysis. A descriptive summary, including frequencies, percentages, and graphs, was used to present the study results. Binary logistic regression was used for statistical analysis. Finally, the results of bivariate and multivariable logistic regression analyses were presented using odds ratios with 95% confidence intervals. In the final model, a p-value of <0.05 was taken as statistically significant.

Results

A total of 406 participants were included, with a response rate of 96.7%. The study participants had an average age of 48 (± 11.4 years), and the overall adherence to dietary recommendations in this study was 62.8% among type 2 diabetic patients. Years of diagnosis of DM, having a family history of DM, having comorbidities, and having received diabetic nutrition education were significantly associated with adhering to diabetic dietary recommendations among type 2 diabetic patients.

Conclusion and recommendation

The study found that overall adherence to dietary recommendations among type 2 diabetic patients was relatively high at 62.8%, suggesting the need to develop and implement tailored dietary education and counseling programs for this patient population.

"Even though Doctor has Advised to Practice Foot Care I have not Practiced Soaking Feet in Lukewarm Water so Far" Self-care Practices, Enablers, and Barriers: A Mixed Methods Study among Individuals with Diabetes from a Rural Area of South India

Background

Self-efficacy is the ability by which a person confronts problems in day-to-day life with goal- centered attitude. The clinician plays a vital role in promoting self-care though a series of social, cultural and economic factors also contribute positively towards it. This study was conducted to assess the self-care practices among diabetic individuals aged 30 years and above and to understand its enablers and barriers.

Materials and Methods

Explanatory mixed method study was conducted from August 2018 to October2020. Quantitative assessment was done wherein a questionnaire was administered to 297 study participants enrolled by simple random sampling followed by in-depth interviews by purposive sampling as qualitative component. Multivariate logistic regression analysis was used to study the relationship of independent variables with various domains of self- care practice. P value <0.05 was considered as statistically significant.

Results

Study found educational status, occupation and religion had a statistically significant association with self-care practices. Regular physical activity, good dietary practices and family support were a few enablers, whereas lack of awareness, time constraints, co-morbidities and environmental factors were some of the barriers to self-care practice.

Conclusions

In the present study, self-care practice in terms of diet and physical activity were found to be good whereas blood sugar level monitoring and foot care practices were poor.

Measuring Diabetic Medication Adherence and Factors That Lead to Non-adherence Among Patients in Erbil

Introduction T2D is a chronic and progressive disorder characterized by persistent hyperglycemia resulting from inadequate insulin secretion or utilization. The global prevalence of T2D is increasing rapidly, posing a significant health burden in many regions. In the Kurdistan region of Iraq, T2D presents a significant health burden, exacerbated by socioeconomic changes, dietary shifts, and rising obesity rates. Poor adherence to antidiabetic medications is a major factor contributing to poor glycemic control, accelerating disease progression, and increasing complications. This study aims to assess medication adherence rates among adult T2D patients in Erbil using the Kurdish version of the Morisky Medication Adherence Scale-8 (MMAS-8) and identify factors associated with non-adherence. Methods We conducted a cross-sectional study at public and private clinics in Erbil City, Kurdistan, Iraq, between May 1 and September 30, 2023. A convenience sample of 300 adult Kurdish T2D patients, aged ≥ 25 years and on antidiabetic medications for three months or more, was recruited. Data were collected using a structured questionnaire comprising sociodemographic characteristics, clinical and anthropometric measures, and medication adherence assessed by the Kurdish version of the MMAS-8. Statistical analysis included analysis of variance, Kruskal-Wallis, chi-square, and logistic regression models to identify factors associated with medication adherence. Results Of the 300 participants, 81 (27%) demonstrated high adherence, 98 (32.6%) moderate adherence, and 121 (40.3%) low adherence based on the MMAS-8. Low adherence was significantly associated with lower education (56/121, 46.3% vs. 13/81, 16.0%, p < 0.001), unemployment (73/121, 60.3% vs. 29/81, 35.8%, p = 0.008), rural residence (41/121, 33.9% vs. 10/81, 12.3%, p < 0.001), and lower income (62/121, 51.2% vs. 12/81, 14.8%, p < 0.001). High adherence was linked to better diabetes knowledge, home glucose monitoring, and exercise. High adherence was also associated with better glycemic control, with 76/81 (93.8%) of highly adherent patients achieving glycated hemoglobin (HbA1c) <7%, compared to 15/121 (12.4%) in the low adherence group (p < 0.001). Multivariate analysis identified HbA1c, dyslipidemia, and home blood glucose monitoring as independent factors associated with high adherence. Conclusions This study highlights the substantial impact of socioeconomic, behavioral, and clinical factors on medication adherence among T2D patients in Erbil. Low adherence is associated with lower education, income, and awareness of diabetes management, while high adherence is linked to improved glycemic control and reduced complications. Targeted interventions addressing these factors are essential to enhance adherence and optimize T2D management in this population.

Self-care practices and its associated factors among adult diabetes mellitus patients in public hospitals of Sidama region, Southern Ethiopia: a cross-sectional study

Introduction

poor adherence to diabetes self-care practices can result in adverse health outcomes. Thus, it is important to adapt self-care behaviors to reduce and prevent complications from diabetes mellitus. Therefore, this study aimed to determine the level of diabetes self-care practices and associated factors among adults with diabetes in Ethiopia.

Methods

a health facility-based cross-sectional study was conducted from March to April 2021 in the Sidama region public hospitals. A systematic random sampling technique was used to select 437 diabetic patients. The data were entered using Epi data version 3.1 and analyzed using SPSS version 25. A binary logistic regression analysis was performed, and variables with a p-value <0.05 were considered statistically significant.

Results

in this study, a large number of diabetes patients had inadequate self-care practices. Therefore, it is important to strengthen and establish support systems, such as collaborating with healthcare providers, enlisting the support of family members, and providing health education to improve self-care practices.

Conclusion

this study found that 48.9% of participants had a good level of self-care practice. College graduates and above [AOR: 4.4, 95% CI (1.87, 10.4)], those with strong social support [AOR: 4.6, 95% CI (2.3,10.5)], attendees of health education [AOR: 2.33, 95% CI (1.38,4.6)], those who were on oral hypoglycemic drug [AOR: 0.45, 95% CI (0.24, 0.83)], those who perceived the benefits of self-care [AOR: 0.46, 95% CI (0.25,0.84)], and those who perceived the severity of complications [AOR: 0.56, 95% CI (0.29, 0.77)] were predictors of diabetes self-care practices.

Self-management of chronic, non-communicable diseases in South Asian settings: A systematic mixed-studies review

Self-management is crucial in mitigating the impacts of a growing non-communicable disease (NCD) burden, particularly in Low and Middle-Income countries. What influences self-management in these settings, however, is poorly understood. We aimed to identify the determinants of self-management in the high NCD region of South Asia and explore how they influence self-management. A systematic mixed-studies review was conducted. Key electronic databases [MEDLINE (1946+), Embase (1974+), PsycInfo (1967+) and CINAHL (EBSCOhost)] in March 2022 (and updated in April 2023) were searched for studies on the self-management of four high-burden NCD groups: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and depression. Study characteristics and quantitative data were extracted using a structured template, and qualitative information was extracted using NVivo. Quality appraisal was done using the Mixed Methods Assessment Tool (MMAT). Quantitative findings were organised using the Commission on Social Determinants of Health (CSDH) framework and synthesised narratively, supported by effect direction plots. Qualitative findings were thematically synthesised. Both were integrated in a mixed synthesis. Forty-four studies (26 quantitative, 16 qualitative and 2 mixed-methods studies) were included, the majority of which were conducted in urban settings and among individuals with diabetes and cardiovascular diseases. Higher age, education, and income (structural determinants), health-related knowledge, social support and self-efficacy (psychosocial determinants), longer illness duration and physical comorbidity (biologic determinants), and the affordability of medicine (health-system determinants) were key determinants of self-management. Qualitative themes highlighted the role of financial adversity and the social and physical environment in shaping self-management.A complex interplay of structural and intermediary social determinants shapes self-management in South Asian settings. Multi-component, whole-systems approaches could boost self-management in these settings. Key areas include empowerment and education of patients and wider community, design and delivery of bespoke behavioural interventions and a stronger emphasis on supporting self-management in healthcare settings.

Factors influencing adherence to non-communicable disease medication in India: secondary analysis of cross-sectional data from WHO - SAGE2

Background: Non-communicable diseases (NCDs) are a leading cause of death globally and disproportionately affect those in low- and middle-income countries lower-middle-income countries. Poor medication adherence among patients with NCDs is prevalent in India due to lack of initiation, missed dosing or cessation of treatment, and represents a growing healthcare and financial burden. Objective: This study aimed to identify factors influencing medication adherence in adults with NCDs in India. Methods: We performed a cross-sectional study, conducting secondary data analysis on the second wave of the World Health Organisation's 'Study on global AGEing and adult health (SAGE)', a survey that collected data from predominantly older adults across India. Bivariate analysis and multivariate logistic regression modelling were conducted to specifically interrogate the reasons for lack of initiation and cessation of treatment. Reporting of this study was informed by the STROBE guidelines. Results: The average medication adherence rate was 51% across 2,840 patients with one or more NCDs, reflecting non-initiation and lack of persistence of treatment. The strongest factor significantly predicting non-adherence to medication across these components was multimorbidity (odds ratio 0.47, 95% CI 0.40-0.56). Tobacco use (OR = 0.76, CI 0.59-0.98) and never having attended school (OR = 0.75, CI 0.62-0.92) were significantly associated with poor medication adherence (p < 0.05) while rural living (OR = 0.70, CI 0.48-1.02), feelings of anxiety (OR = 0.84, CI 0.66-1.08) and feelings of depression (OR = 0.90, CI 0.70-1.16) were factors lacking statistically significant association with medication adherence on multivariate analysis. Older age (OR = 2.02, CI 1.51-2.71) was significantly associated with improved medication adherence whilst there was a weak association between increased wealth and improved medication use. Limitations: The SAGE2 survey did not capture whether patients were taking their medication doses according to prescribed instructions-as a result our findings may under-estimate the true prevalence of medication non-adherence. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Future large-scale surveys interrogating adherence should assess all components of adherence specifically, whilst public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and anxiety, and low educational status.

The associations between physical activity, health-related quality of life, regimen adherence, and glycemic control in adolescents with type 1 diabetes: A cross-sectional study

BACKGROUND

Adolescents with Type 1 Diabetes (T1D) display a greater than two-fold higher risk of developing diabetes-related complications compared with their healthy peers and the risk increases markedly as glycated hemoglobin (HbA1c) increases. The majority of the known factors associated with improved glycemic control in adolescents with T1D are geared toward Western populations. Therefore, this study examined the associations between Physical Activity (PA), Health-Related Quality of Life (HRQoL), and regimen adherence on glycemic control in a Middle Eastern population of adolescents with T1D METHODS: The study utilized a cross-sectional design of Jordanian adolescents (aged 12-18) with T1D (n = 74). Self-reported measures used were the Pediatric Quality of Life-Diabetes Module, the International Physical Activity Questionnaire, and the Summary of Diabetes Self-Care Activities. HbA1c values were obtained from the medical records. Correlation analyses were conducted using Pearson's and Spearman's correlation tests. Multiple regression analyses were conducted to determine if HRQoL, PA, and regimen adherence predict glycemic control.

RESULTS

Only 14.8 % of the participants demonstrated good glycemic control (HbA1c ≤ 7.5 %). Participants with poor control had a statistically significant lower mean PA of MET-minutes/week (3531.9 ± 1356.75 vs. 1619.81 ± 1481.95, p < .001) compared to those with good control. The total sample was found to demonstrate low HRQoL (47.70 ± 10.32). Participants were within the acceptable range of PA (1885.38 ± 1601.13) MET-minutes/week. HbA1c significantly inversely correlated with PA (r = -0.328, p = .010) and regimen adherence (r = -0.299, p = .018). The regression analysis revealed that PA significantly predicted glycemic control (β = -0.367, p < .01) as adherence (β = -0.409, p < .01) and disease duration did (β = 0.444, p < .01).

CONCLUSION

Better glycemic control was significantly associated with higher PA and regimen adherence levels. The correlation between PA and glycemic control depends highly on the level of regimen adherence or arguably, adherence acts as a buffer in the correlation between PA and glycemic control. There was no significant association between glycemic control and HRQoL.

Glycemic control and diabetes complications among adult type 2 diabetic patients at public hospitals in Hadiya zone, Southern Ethiopia

BACKGROUND

Diabetes is one of the biggest worldwide health emergencies of the 21st century. A major goal in the management of diabetes is to prevent diabetic complications that occur as a result of poor glycemic control. Identification of factors contributing to poor glycemic control is key to institute suitable interventions for glycemic control and prevention of chronic complications.

METHODS

A hospital-based cross-sectional study was conducted among 305 adult type 2 diabetic patients at public hospitals in Hadiya zone from March 1-30, 2019. The study participants were selected by systematic sampling technique. Data were collected using a pretested structured questionnaire and patient chart review; anthropometric and blood pressure measurements were taken. Multivariable logistic regression analysis was used to identify factors associated with poor glycemic control. Adjusted odds ratios (AOR) with respective 95% Confidence Interval (CI) and p < 0.05 were used to set statistically significant variables.

RESULTS

Out of 305 diabetic patients, 222 (72.8%) were found to have poor glycemic control. Longer duration of diabetes (5-10 years) [AOR = 2.24, 95% CI: 1.17-4.27], lack of regular follow-up [AOR = 2.89, 95% CI: 1.08-7.71], low treatment adherence [AOR = 4.12, 95% CI: 1.20-8.70], use of other alternative treatments [AOR = 3.58, 95% CI: 1.24-10.36], unsatisfactory patient physician relationship [AOR = 2.27, 95% CI: 1.27-4.04], and insufficient physical activity [AOR = 4.14, 95% CI: 2.07-8.28] were found to be independent predictors of poor glycemic control. Diabetes Mellitus (DM) complications were slightly higher among participants with poor glycemic control (39.2%), duration of DM 10 and above years (41.9%), low medication adherence (48.5%), taking oral anti-diabetics (54.3%), and DM patients having unsatisfactory patient provider relationship (72.4%).

CONCLUSION

A significant proportion of diabetic patients had poor glycemic control and DM complications. Therefore, appropriate interventions are required to maintain optimal glycemic control and prevent the development of life-threatening complications among DM patients.

Determinants of Treatment Adherence and Health Outcomes in Patients With Type 2 Diabetes and Hypertension in a Low-Income Urban Agglomerate in Delhi, India: A Qualitative Study

Background Diabetes and hypertension (HTN) are increasing threats to global public health. Despite evidence of effective management of diabetes and HTN by medications that help in the prevention and reducing mortality of the disease, a large proportion of people either remain undiagnosed or untreated, especially in low-resource countries. This study was conducted to explore the patient treatment pathway and their health-seeking behavior in a low-income urban area. Methodology We conducted 45 in-depth interviews of adult patients affected by type 2 diabetes mellitus (DM) and/or HTN on treatment for at least two years and attended the weekly clinic catering to an urban resettlement colony in the Northeast district of Delhi. Interviews were conducted and transcribed into Hindi and translated into English. Data analysis was done using Microsoft Excel. The patient treatment pathways were mapped, and their health-seeking behavior, treatment adherence, and experiences were described. Results Most patients reported taking treatment from the government primary health facilities due to optimal healthcare accessibility as the prescribed drugs for DM/HTN control were available free of cost at these healthcare facilities. Those who visited private facilities thought of shorter waiting times and the quality of drugs. Patients also had little knowledge of complications of diabetes and hypertensive disorders. Nearly 25% of patients had poor adherence to the medications, and lifestyle modification was rarely practiced by patients although they were aware of the same. Conclusions Expanding the role of community health workers or volunteers in providing information on noncommunicable diseases might help improve patient treatment pathways to care.

Down referral and assessing comprehensive diabetes care in primary care settings: An operational research from India

BACKGROUND AND AIMS

In this study, we aimed to refer eligible (patients with stable blood sugar and without any history of cardiovascular events or proliferative retinopathy) and willing persons with diabetes (PwDs) to primary healthcare centers (PHCs) from tertiary care and to compare the care indicators.

METHODS

This before-after interventional study was conducted among PwDs aged ≥18 years at a tertiary care hospital in South India. Care indicators (regularity to the clinic, waiting time, and blood sugar control status) were assessed before down referral and after three months of follow-ups at PHCs.

RESULTS

Of 204 PwDs referred to PHCs. Among them, 88% (n = 180) registered at PHCs for care and 46% (n = 94, 95% CI 39.1-53.2%) were lost to follow-ups at PHCs. The main reason for loss to follow-ups was the unavailability of medicines at PHCs(n = 41, 44%). Among those who were on regular follow-ups at PHCs, there was no significant difference in fasting blood glucose (FBG) control status compared to tertiary (52%-64.6%, p = 0.083). However, there was a significant improvement in the regularity of clinic visits (75% vs. 100%, p < 0.001), consultation waiting time (90 vs. 60 min, p = 0.028), and waiting time at pharmacy queues (120 vs. 30 min, p < 0.001) between tertiary care and PHCs. However, among those registered at PHCs, only 40.6% (n = 73, 95% CI 33.3-48.1) were willing to continue care at PHCs for their diabetes management.

CONCLUSION

Primary care was better than tertiary care in terms of PwD's regularity of clinic visits and waiting time for care.

Adherence and Barriers to Medical Nutrition Therapy and the Effect on Glycemic Control Among Individuals With Type 2 Diabetes in India

Medical Nutrition Therapy (MNT) has a remarkable effect on glycemic control among individuals with Type 2 Diabetes. However, the extent of adherence to MNT isn't hundred percent. Therefore, we aim to determine the adherence level towards the MNT advised by a Registered Dietitian (RD); to identify the barriers and associated contributing factors and strategies to improve the compliance towards the MNT among people with Type 2 Diabetes. A cross-sectional study was conducted among people with Type 2 Diabetes visiting the out-patient diabetes clinic from Kolhapur city, India. A structured questionnaire was used to capture the adherence and non-adherence, reasons and barriers to adhering the MNT. Out of 293 participants, 41.6% were adhering to the MNT. There was a significant association between the non working group (p = 0.01), presence of co-morbidities (p = 0.03) and diabetes duration < 10 years (p = 0.05) with the increased adherence level. Similarly, there was a significant reduction of 26.7%, 38.1%, and 30.9% in the fasting, postprandial blood glucose and HbA1c values respectively in adhering group post MNT advice. More than 50% of the participants in the adhering group gave ‘To Improve overall health’ and ‘To control sugar’ as reasons to adhere. ‘Habitual to what they eat’ (64.3%), ‘Does not satisfy hunger’ (42.1%) and ‘Lack of willpower’ (42.1%), were the common barriers identified in our study. Our study shows that the MNT advised by an RD is effective in reducing the socio-cultural barriers to adherence and improves glycemic control. Strategies like making the workplace more diabetes-friendly and adopting behavior changing techniques should be implemented to increase adherence.

Adherence to Dietary Recommendation and Its Associated Factors among People with Type 2 Diabetes: A Cross-Sectional Study in Nepal

Introduction

Intensive lifestyle modification including a healthy diet changes the diagnostic status of patient from prediabetes to nondiabetes. In type 2 diabetes, improper eating habits increase insulin resistance. This study is aimed at assessing adherence to the dietary recommendation and its associated factors among people with type 2 diabetes.

Methods

A cross-sectional descriptive study was conducted among systematically sampled type 2 diabetic patients using interview on Gandaki Medical College Teaching Hospital and Diabetes, Thyroid, and Endocrinology Care Center, Pokhara. The Perceived Dietary Adherence Questionnaire was used to assess dietary adherence. Data was entered in EpiData version 3.1 and analyzed on SPSS version 20. Logistic regression with adjusted odds ratio and the corresponding 95% confidence intervals were used to find out significance of association.

Results

Among 204 participants, only 15.7% of the participants had good dietary adherence. The mean age and standard deviation were 53.03 ± 11.90 years. Factors such as participants living in single family (AOR 2.7, 95% CI 1.0-7.4), participants who could afford recommended diet (AOR 2.9, 95% CI 1.0-8.3), participants having self-control on food (AOR 4.1, 95% CI 1.2-14.1), participants who were engaged in moderate to heavy physical activities (AOR 3.3, 95% CI 1.2-9.2), and participants who had adherence to medication (AOR 3.5, 95% CI 1.2-10.1) were significantly associated with adherence to dietary recommendation.

Conclusions

Adherence to dietary recommendation among people with type 2 diabetes was low. Factors such as family type, affordability of recommended diet, self-control on food, physical activity, and medication adherence were significantly associated with adherence to dietary recommendations among people with type 2 diabetes. These factors should be considered by nutrition counselors and clinical decision-makers in patient counseling regarding dietary adherence.

Patient preferences for the treatment of type 2 diabetes in Australia: a discrete choice experiment

Background

Australia has a high proportion of migrants, with an increasing migration rate from India. Type 2 diabetes is a chronic condition common amongst the Indian population. The decision to initiate and continue medication therapy (conventional or ayurvedic medicine) is complex and is influenced by a wide range of factors.

Objective

To determine preferences for conventional vs. ayurvedic medicines in Indian migrants with diabetes, and to identify the factors that may influence their preferences.

Methods

A discrete choice experiment was conducted with participants in Australia who were migrants from India with type 2 diabetes (n=141). Each respondent evaluated eight choice tasks consisting of eight attributes describing medicines and outcomes of medication taking; and were asked to choose 'conventional', or 'ayurvedic' medicine. A mixed multinomial logit model was used to estimate preferences.

Results

Overall, respondents' preference to initiate a medicine was negative for both conventional (β=-2.33164, p<0.001) and ayurvedic medicines (β=-3.12181, p<0.001); however, significant heterogenicity was noted in participants' preferences (SD: 2.33122, p<0.001). Six significant attributes were identified to influence preferences. In decreasing rank order: occurrence of hypoglycaemic events (relative importance, RI=24.33%), weight change (RI=20.00%), effectiveness of medicine (RI=17.91%), instructions to take with food (RI=17.05%), side effects (RI=13.20%) and formulation (RI=7.49%). Respondents preferred to initiate a medicine despite potential side effects.

Conclusions

There was a greater preference for conventional medicine, though neither were preferred. Medicine attributes and medication-taking outcomes influenced people's preferences for an antidiabetic medicine. It is important to identify individual preferences during healthcare consultations to ensure optimal medication-taking.

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.

A systematic review and meta-analysis of non-adherence to anti-diabetic medication: Evidence from low- and middle-income countries

BACKGROUND

Non-adherence to anti-diabetic medication is an important cause of uncontrolled blood glucose that leads to complications of diabetes. However, there is a lack of evidence on the burden of and factors associated with non-adherence to anti-diabetic medication among individuals living with diabetes in low-and middle-income countries (LMICs).

OBJECTIVES

This systematic literature review and meta-analytic synthesis aims to estimate non-adherence to anti-diabetic medication reported among individuals in LMICs and explores factors affecting non-adherence.

METHODS

We systematically searched MEDLINE and Embase to identify studies investigating non-adherence to anti-diabetic medications published from January 2000 to May 2020. Two authors carried out study selection, screening, and data extraction independently. Cross-sectional studies that had been conducted among individuals with diabetes in LMICs were eligible for the selection process. Critical appraisal of the included studies was carried out using the Newcastle Ottawa Scale. Meta-analysis was carried out using Stata 14.2. Random effects model was used to compute the pooled proportion at a 95% confidence interval (CI).

RESULTS

Forty-three studies met the inclusion criteria, of which 13 studies were used in meta-analysis. The pooled proportion of non-adherence to anti-diabetic medications using the eight-item Morisky Medication Adherence Scale (MMAS-8) was 43.4% (95% CI: 17.5-69.4; P < 0.001) and 29.1% (95% CI: 19.8-38.4; P < 0.001) when using the cut-off at 80 or 90%. The pooled proportion of non-adherence was 29.5% (95% CI: 25.5-33.5; P = .098) when using the four-item Morisky Medication Adherence Scale (MMAS-4). Using the World Health Organization (WHO) five dimensions of medication adherence framework, the factors contributing to non-adherence were varied, including disease factors, therapy-related factors, healthcare system factor, patient-centred factors, and socio-economic factors.

CONCLUSIONS

Non-adherence to anti-diabetic medication remains an ongoing challenge in LMICs and several factors operating at different levels were cited as reasons. Comprehensive intervention strategies are urgently needed to address these factors in effectively tackling medication non-adherence in LMICs.

A Qualitative Study on Medication Taking Behaviour Among People With Diabetes in Australia

Background: Australia has a high proportion of migrants with an increasing migration rate from India. Type II diabetes is a long-term condition common amongst the Indian population.

Aims: To investigate patients’ medication-taking behaviour and factors that influence adherence at the three phases of adherence.

Methods: Semi-structured interviews were conducted with a convenience sample of 23 Indian migrants living in Sydney. All interviews were audio-recorded, transcribed verbatim and thematically analysed.

Results: 1) Initiation: The majority of participants were initially prescribed oral antidiabetic medicine and only two were started on insulin. Most started taking their medicine immediately while some delayed initiating therapy due to fear of side-effects. 2) Implementation: Most participants reported taking their medicine as prescribed. However, some reported forgetting their medicine especially when they were in a hurry for work or were out for social events. 3) Discontinuation: A few participants discontinued taking their medicine. Those who discontinued did so to try Ayurvedic medicine. Their trial continued for a few weeks to a few years. Those who did not receive expected results from the Ayurvedic medicine restarted their prescribed conventional medicine.

Conclusion: A range of medication-taking behaviours were observed, ranging from delays in initiation to long-term discontinuation, and swapping of prescribed medicine with Ayurvedic medicine. This study highlights the need for tailored interventions, including education, that focus on factors that impact medication adherence from initiation to discontinuation of therapy.

Assessment of Factors Associated With Non-Compliance to Self-Management Practices in People With Type 2 Diabetes

Aim and objective Diabetes mellitus is a chronic metabolic disorder that requires continuous self-management practices. The aim of our study is to assess the factors resulting in non-compliance with self-management practices in people with type 2 diabetes mellitus (T2DM). Methods This cross-sectional study was conducted at Baqai Institute of Diabetology and Endocrinology (BIDE), a tertiary care center in Karachi, Pakistan, from March 2019 to May 2019. People with T2DM diagnosed for at least six months were included. A predesigned questionnaire was used to assess various components of self-management such as the use of oral hypoglycemic agents (OHAs) and insulin, self-monitoring of blood glucose (SMBG), physical activity, and daily foot care. Certified diabetes educators conducted interviews on a one-to-one basis. Data were entered and analyzed by using SPSS (version 20; IBM Corp., Armonk, NY). Results Better glycated hemoglobin (HbA1c) levels were observed in compliant persons and a statistically significant difference was noted in those who were compliant with insulin use. Good compliance with self-management was observed in people who were given diabetes education previously. A total of 205 people with T2DM were included in the study, with a mean age of 52.66 ± 11.2 years and a mean duration of diabetes of 8.9 ± 7.5 years. There were 62.9% males and 37.1% females. Oral hypoglycemic agents (OHAs) were prescribed to 62.9% while 33.9 % were on both OHAs and insulin. Non-compliance with the intake of OHAs was 33.3%, insulin injection 21%, SMBG 25.7%, physical activity 69.5%, and foot care practice 34.3%. Various reasons identified for non-compliance included forgetfulness (negligence) (88%), fear of hypoglycemia (10.6%), time constraints (48%), and lack of foot care knowledge (84.8%). Conclusion Non-compliance with T2DM self-management is multifactorial and needs continuous reinforcement of structured diabetes education sessions. The study showed that the provision of diabetes education is directly proportional to self-management compliance levels.

Evaluation of Self-Care Practice and Its Associated Factors in Adult Diabetic Patients, Ayder Diabetic Clinic, Mekelle, Ethiopia

BACKGROUND

Self-care activities in patients with diabetes mellitus are behaviors undertaken by people with or at risk of diabetes in order to successfully manage the disease on their own. Even though self-care practice plays a critical role in preventing as well as delaying diabetes-related complications, there is poor self-care practice by patients with diabetes mellitus. In Ethiopia, especially in Tigray, there are few studies assessing self-care practice of patients with diabetes mellitus and thus this study will have an input in this area.

OBJECTIVE

To evaluate self-care practice and its associated factors in adult patients with diabetes mellitus having follow-up in Ayder Comprehensive Specialized Hospital, Diabetes Clinic.

METHODS

A hospital-based cross-sectional analysis was made from March to May, 2015. A total of 410 patients with diabetes mellitus were included. The study participants were selected by a systematic random sampling method. Characteristics of study participants were analyzed using descriptive statistics, while bivariate and multivariable logistic regression was used to identify the association between dependent and independent variables.

RESULTS

Two hundred and eighty-eight (70.2%) study participants were above 30 years of age and 254 (62.9%) study participants were males. More than half (52.9%) of the study participants were type-2 diabetes patients. This study showed 207 (50.5%) had poor diabetes self-care practice. In multivariate logistic regression, low income (AOR = 0.518, 95% CI: 0.288-0.929) and poor knowledge about diabetes (AOR = 5.026, 95% CI: 2.893-8.734) were found to be significantly associated with poor self-care practice.

CONCLUSION

The proportion of poor self-care practice was high, implying the need for regular follow-up as an integral component of the long-term management of diabetes mellitus.

Adherence to Treatment and Glycemic Control in Patients with Type 2 Diabetes Mellitus: A 4-Year Follow-up PTM Bogor Cohort Study, Indonesia

PURPOSE

Large-scale evaluation of the treatment adherence in patients with type 2 diabetes mellitus (DM) in Indonesian is limited. We aim to evaluate the treatment adherence of Indonesian type 2 DM patients using national "big data" and investigate its association with glycemic parameters.

PATIENTS AND METHODS

We analyzed baseline and fourth-year data sets from 2011 to 2018 obtained from the Indonesian Ministry of Health Cohort Study of Non-Communicable Disease Risk Factors in Bogor, West Java (the PTM Bogor Cohort Study). This was a retrospective cohort study in which the sample was divided into two groups. One group adhered to treatment from primary health centers and followed the prescribed medicine/treatment regimen (treated group), while the other did not follow the treatment (untreated group). We evaluated changes in fasting blood glucose (FBG) and post-prandial blood glucose (PPBG) by controlling for other variables.

RESULTS

From 5690 subjects, 593 were type 2 DM diagnosed and 342 were eligible at the baseline. At 4-year observation, 212 eligible patients remained, consisting of 62 subjects who adhered to treatment, and more than double that number who were untreated (150 subjects). More significant decreases in FBG and PPBG were found in the treated group (FBG 80.6%, PPBG 90.3%) than in the untreated group (FBG 42.0%, PPBG 67.3%). The results of the multivariate analysis showed that after 4 years observation, treated patients have reduced FBG 3.304 times more and PPBG 3.064 times more than untreated patients, with control factors such as decrease in LDL levels and use of oral drugs.

CONCLUSION

There were less than half as many treated patients as untreated patients involved in the PTM Bogor Study Group. At the fourth-year follow-up, treated patients experienced three times more significant decreases in FBG and PPBG than those who were untreated, even after being controlled by several confounding factors. Given the importance of these findings, it is suggested that immediate strategic action be taken to improve Indonesian patients' adherence to treatment.

Predictors of Adherence Toward Specific Domains of Diabetic Self-Care Among Type-2 Diabetes Patients

BACKGROUND

Adequate knowledge, awareness, and adherence to diabetic self-care practices are vital tools to protect patients from risks of disease complications, developing comorbidity and mortality. Therefore, this study aimed to assess specific domains of diabetic self-care practice and associated factors among patients with type-2diabetes in Hawassa University Comprehensive Specialized Hospital, Sidama regional state.

MATERIALS AND METHODS

A hospital-based cross-sectional study design was conducted on 217 patients with type 2 diabetes from January 01 to April 30, 2020. A structured questionnaire and the Summary of Diabetes Self-Care Activities (SDSCA) tool were used to collect relevant data through interviewer administration. Statistical analysis was done using SPSS version 23.

RESULTS

A total of 207 patients with type-2 diabetes were participated in the study with a 95% response rate. Overall 47.8% (95%CI: 41.2-55) of patients adhered to diabetic self-care practice. Concerning the specific domain of self-care practice, 54.6%, 39.1%, 28%, and 65.2% of patients adhered to a healthy diet, physical exercise, self-monitoring blood glucose (SMBG), and diabetic foot care practices, respectively. Besides, all patients received at least 80% of the prescribed doses and frequency of anti-diabetic agents and 60.4% had good glycemic control. Receipt of advice from treating physicians and having no familial history of diabetes were significantly associated with adherence toward eating a healthy diet, diabetic foot care, and SMBG. While male sex was associated with adherence toward healthy diet management. Moreover, having glucometer, age, male sex, diabetes duration ⩾ 5 years, and anti-diabetic treatment modality were associated with adherence toward SMBG.

CONCLUSION

This study indicates 52.2%, 72%, and 60.1% of diabetes patients did not adhere to diabetic self-care, SMBG, and physical exercise, respectively. Improving awareness and regular diabetic education is imperative to scale up patients' adherence toward diabetic self-care practice.

Medication Adherence Assessment Among Patients with Type 2 Diabetes Mellitus Treated Polytherapy in Indonesian Community Health Center: A Cross Sectional-Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic disease where most of the patients usually need polytherapy. This could affect their medication adherence (MA). However, other complex factors may also associate with MA, which are important to identify.

AIM

The purpose of this study was to evaluate the MA of patients with T2DM who received polytherapy and to identify other factors that can affect the MA.

MATERIALS AND METHODS

This was a cross-sectional study conducted in seven community health centers in Jakarta with HbA1C representing their MA level. Poor controlled blood glucose with Hemoglobin A1C (HbA1C) of ≥7% is indicated to have low MA. All characteristics were collected to identify factors that are potentially associated with low MA. The univariate analysis tests were used to analyze factors that potentially associate with low MA. Multiple logistic regression analysis was performed in the factors to find their relationship with low MA.

RESULTS

The study obtained 143 patients with a female dominance (67.8%) and mean ± standard deviation (SD) age of 59.53 ± 9.251 years. Approximately 75.5% of the patients had low MA (HbA1C ≥ 7). Univariate analysis found that duration of T2DM significantly (P = 0.047) related to MA, where patients with T2DM of less than or equal to 5 years tended to have low MA. Logistic regression showed that patients with T2DM less than or equal to 5 years (P = 0.015, odds ratio = 1.206, 95% confidence interval = 1.216-8.014) were associated with low MA.

CONCLUSION

Patients with the duration of T2DM less than or equal to 5 years surprisingly were susceptible to have low MA. Low MA was not affected by polytherapy.

The determinants of out-of-pocket health-care expenses for diabetes mellitus patients in India: An examination of a tertiary care government hospital in Delhi

OBJECTIVE

To assess the determinants of out-of-pocket (OOP) expenses on diabetes-related treatment incurred in patients attending outpatient clinics in a tertiary care hospital in Delhi, India.

STUDY DESIGN

A cross-sectional analysis of baseline data from a quasi-experimental study was conducted over 8 months in 2016 in a major tertiary care hospital in Delhi.

METHODS

The study included 375 diabetes patients up to 65 years of age on treatment for at least a year without significant complications. Data were collected through a patient interview schedule.

RESULTS

Of the previous six scheduled appointments, at least two missed appointments were seen in 267 (71.2%) patients. The average patient's OOP expenditure on diabetes-related medicines was ₹63.5 a month, a similar amount was spent on traveling to and from health facilities. Sixty-four (17.1%) patients took antidiabetic medication for <85% of the days in the previous 3 months.

CONCLUSION

There exists a high burden of missed clinic appointments among diabetes patients in tertiary care government health settings in India. This appears to be related to the high cost in terms of both time and money involved in attending appointments for the modest benefit of a dispensation of a 15-day drug refill. Health policy measures focused on strengthening medication coverage need to explore the balance of costs and benefits when determining the frequency of clinical appointments in these settings.

Behaviour model for diabetic ulcer prevention

Purpose

Diabetic ulcers are one of the complications that often occur in patients with DM. The aim is to develop a behaviour model for diabetic ulcer prevention by integrating Lawrance Green Theory and the Theory of Planned Behaviour.

Methods

An explanative observational design was used with a cross-sectional approach. The population consisted of DM patients who had underwent treatment at the internal medicine clinic of Sidoarjo District Hospital. The sample size of 133 respondents was obtained through purposive sampling. The data analysis used Partial Least Square.

Results

Predisposing factors (knowledge), supporting factors (availability of health facilities and accessibility of health resources) and driving factors (the role of health workers and family support) significantly influence the main factors (attitudes toward behaviour, subjective norms and perceptions of self-control) with a statistical T value>1.96. The main factor influences intention (T = 48.650) and intention influences behaviour (T = 4.891).

Conclusion

Intention is influenced by the attitudes toward behaviour, subjective norms and self-control perceptions. Good intentions can increase the preventive behaviour related to diabetic ulcers. Increasing the diabetic ulcer prevention behaviour can be done by providing regular education to both the patients and their families about diabetic ulcers and their prevention through the appropriate management of DM, lifestyle modification and regular foot care that requires active involvement from the family and health care workers.

Medication adherence and glycemic control among diabetes patients in developing countries

The potential interconnectedness of medication adherence, glycemic control, and clinical inertia in resource-constrained settings of the developing world needs further evaluation.

Diabetes self-care in primary health facilities in India - challenges and the way forward

India has approximately 73 million people living with diabetes and another 37 million with prediabetes while nearly 47% of the diabetes cases are undiagnosed. The high burden of poor glycemic control and early onset of complications with associated economic costs indicates a high prevalence of poor self-management practices. It is well-established that achieving patient-centered primary care consistent with a chronic care model ensures optimum diabetes self-management support and improves long-term clinical and health outcomes in diabetes patients. The public sector primary care system in India provides services free of cost to beneficiaries but lacks patient-centered care that undermines diabetes self-management education and support. Furthermore, factors like poor patient knowledge of diabetes, suboptimal medication adherence, persistent clinical inertia, lack of data for monitoring and evaluation through clinical audit worsens the standards of diabetes care in primary care settings of India. There is a need for government initiatives to be directed towards the provision of comprehensive outpatient care that is inclusive of uninterrupted supply of drugs, provision of essential laboratory investigators, training and availability of qualified diabetes educators and availability of specialist support when required. Furthermore, the integration of depression screening and smoking cessation services at the primary care level is warranted.

Factors influencing diabetes self-care practice among type 2 diabetes patients attending diabetic care follow up at an Ethiopian General Hospital, 2018

INTRODUCTION

Diabetes mellitus is a global public health emergency in the twenty-first century. Diabetes patients who had to adhere to good self-care recommendation can prevent the complication associated with diabetes mellitus. Self-care management of diabetes mellitus in Sub-Saharan Africa was poor including Ethiopia. The aim of this study was to assess factors influencing diabetes self-care practice among type 2 diabetes patients at Debre Tabor General Hospital, Northwest Ethiopia diabetes clinic follow up unit.

METHODS

An institutional based cross-sectional survey was conducted on systematically sampled 405 type 2 diabetes patients at Debre Tabor General Hospital diabetes clinic from June 02/2018 to June 30/2018. Bivariate and multivariable logistic regression was fitted to identify independent predictors of diabetes self-care practice. A p value of less than 0.05 was used to declare statistical significance.

RESULTS

A total of 385 type 2 diabetes patients participated with a response rate of 95%, of which 243 (63.1%) study participants had good self-care practice. The mean ± SD age of the respondents and the duration of diagnosed for diabetes mellitus was 52.28 ± 12.45 and 5.09 ± 3.80 years respectively. Type 2 diabetes patients who had a glucometer at home (AOR = 7.82 CI (3.24, 18.87)), getting a diabetes education (AOR = 2.65 CI (1.44, 4.89)), and having social support (AOR = 2.72 CI (1.66, 4.47)) were statistically associated with good self-care practice.

CONCLUSION

Despite, the importance of diabetes self-care practice for the management of diabetes and preventing its complications, a significant number of type 2 diabetes patients had poor diabetes self-care practice. So, to enhance this poor practice of diabetes self-care, provision of diabetes self-care education and counseling on self-monitoring blood glucose should be promote by health care providers during their follow up.

Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.

Vitamin D status, determinants and relationship with biochemical profile in women with Type 2 Diabetes Mellitus in Delhi, India

OBJECTIVE

To determine the burden of vitamin D deficiency and its determinants and to assess the relationship of 25 hydroxycholecalciferol (25-OHD) levels with biochemical parameters linked to health outcomes in women with Type 2 Diabetes Mellitus (T2DM).

MATERIAL AND METHODS

This was a hospital based cross-sectional study in the diabetes out-patient department clinic of a major tertiary care hospital in Delhi, India. Adult women with T2DM on treatment for at least 6 months were included in this study. The women who have been given Vitamin D supplementation during the past 6 months were excluded. We assessed Serum 25-OHD, HbA1c, lipid profile and fasting plasma glucose in the patients through standardized laboratory methods.

RESULTS

One hundred women with T2DM were enrolled of which 22 (22%) had good glycemic control (HbA1c < 7%). Vitamin D deficiency was seen among 77 (77%) and insufficiency among 16 (16%) of the recruited subjects. Younger age group (31-45 years) and illiteracy was significantly associated with vitamin D deficiency (p < 0.05). No association was found between Vitamin D deficiency and HbA1c levels.

CONCLUSION

Vitamin D deficiency is highly prevalent among women with T2DM. Illiteracy and young age were major determinants of vitamin D deficiency indicating they need special attention and Vitamin D supplementation.

Achieving TB elimination in India: The role of latent TB management

The elimination of Tuberculosis (TB) in settings with a high dual burden of active and latent TB is one of the most important public health challenges of the 21st century. India has the highest TB burden in the world and nearly 40% of the population being infected with TB. There also exist large often overlapping socially and medically vulnerable populations like the PLHIV, pediatric TB contacts, children with protein-energy malnutrition, homeless people, workers in silica industry and adults with low BMI. A significantly higher risk of progression into active tubercular disease exists in those with compromised immune or nutritional status. It is uncertain if global TB elimination targets can be achieved in the absence of aggressive LTBI treatment strategies for interrupting the chain of transmission of the disease. India hence needs to accelerate and prioritize capacity building in latent TB research. A research agenda is outlined for generating evidence towards the evolution of critical evidence-based policy for LTBI management under Indian health settings.

Clinical inertia on insulin treatment intensification in type 2 diabetes mellitus patients of a tertiary public diabetes center with limited pharmacologic armamentarium from an upper-middle income country

BACKGROUND

Clinical inertia is related to the difficulty of achieving and maintaining optimal glycemic control. It has been extensively studied the delay of the period to insulin introduction in type 2 diabetes mellitus (T2DM) patients. This study aims to evaluate clinical inertia of insulin treatment intensification in a group of T2DM patients followed at a tertiary public Diabetes Center with limited pharmacologic armamentarium (Metformin, Sulphonylurea and Human Insulin).

METHODS

This is a real life retrospective record based study with T2DM patients. Demographic, clinical and laboratory characteristics were reviewed. Clinical inertia was considered when the patients did not achieve the individualized glycemic goals and there were no changes on insulin daily dose in the period.

RESULTS

We studied 323 T2DM patients on insulin therapy (plus Metformin and or Sulphonylurea) for a period of 2 years. The insulin daily dose did not change in the period and the glycated hemoglobin (A1c) ranged from 8.8 + 1.8% to 8.7 ± 1.7% (basal vs 1st year; ns) and to 8.5 ± 1.8% (basal vs 2nd year; p = 0.035). The clinical inertia prevalence was 65.8% (basal), 61.9% (after 1 year) and 58.2% (after 2 years; basal vs 1st year vs 2nd year; ns). In a subgroup of 100 patients, we also studied the first 2 years after insulin introduction. The insulin daily dose ranged from 0.22 ± 0.12 to 0.32 ± 0.24 IU/kg of body weight/day (basal vs 1st year; p < 0.001) and to 0.39 ± 0.26 IU/kg of body weight/day (basal vs 2nd year; p < 0.05). The A1c ranged from 9.6 + 2.1% to 8.6 + 2% (basal vs 1st year; p < 0.001) and to 8.7 + 1.7% (1st year vs 2nd year; ns). The clinical inertia prevalence was 78.5% (at the moment of insulin therapy introduction), 56.2% (after 1 year; p = 0.001) and 62.2% (after 2 years; ns).

CONCLUSION

Clinical inertia prevalence ranged from 56.2 to 78.5% at different moments of the insulin therapy (first 2 years and long term) of T2DM patients followed at a tertiary public Diabetes Center from an upper-middle income country with limited pharmacologic armamentarium.