GRDS International Conferences

1. Presented By: Dr Nithin Kumar
Associate Professor
Department of Community Medicine
Kasturba Medical College
Mangalore[Manipal University]
Effect of Distress on Adherence to Anti diabetic
Medications among Type 2 Diabetic Patients Attending
Tertiary Care Hospitals in Mangalore

2.  INTRODUCTION
• WHO defines adherence as “the extent to which a person's behaviour
taking medication, following a diet , and /or executing lifestyle changes
corresponds with agreed recommendations from a health care provider”.
• According to WHO there are 5 factors influencing patient
adherence:
1. Socioeconomic factors
2. Health system and health care team related
3. Therapy related for patient
4. Condition or disease related and
5. Patient related

3. • Poor adherence is generally associated with bad outcomes of the
disease
• Diabetes Distress, Depression, and Subclinical Depression are
all psychologic disorders which are known to affect patients with
diabetes
• Very limited studies are trying to find out association of distress
with
adherence to anti-diabetic medication

4.  OBJECTIVES
• To assess the level of adherence towards anti diabetic medication
among patients with type 2 diabetes mellitus
• To assess the level of distress and its effect on adherence among
diabetic patients
• To study the influence of patient related factors, medication related
factors and health system related factors to adherence to anti-diabetic
medications

5.  MATERIALS AND METHODS
 Study setting:
- Kasturba Medical College Hospital, Attavar, and
- Peripheral outreach clinics belonging to the Department of
Community Medicine, Kasturba Medical College Mangalore.
 Study design: Cross-sectional study
 Study type: Analytical study
 Study duration: 1st
January 2015 to 31st
January 2015
 Study subjects: All type 2 diabetic patients on anti-diabetic therapy for
more than 6 months

6. • Sample size: 124
• Sample size calculation:
The sample size was calculated taking level of adherence to anti diabetic
medication as 47% based on previous study. Taking 20% relative precision
and 95% confidence interval, the sample size was calculated to be 113.
Adding 10% as non-response error, the final sample size is 124.

7.  Data Collection Methodology:
Institutional ethics committee approval was obtained.
• Study tool: Pretested semi structured questionnaire consisting of
the following sections
Section A - Socio demographic information of the patients
Section B - Diagnosis treatment details and advice given
Section C - Factors related to health
Section D- Diabetes Distress Scale
Section E - Morisky 8-Item Medication Adherence Questionnaire

8.  DATA ANALYSIS:
• The collected data was analysed using SPSS ver 11.5.
• Descriptive statistics (Mean, Standard Deviation) and proportions.
• We undertook both unadjusted and adjusted logistic regression to assess the
various ( Patient related, Medication related and Health system related)
factors favoring adherence to anti-diabetic medication among patients.
• Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) are
reported.

9. TABLE 1: Baseline characteristics of the participants
Variables n(%)
Age group (yrs)
<45 14(11.3)
46-55 33(26.6)
56-65 39(31.5)
>65 38(30.6)
Gender
Male 68(54.8)
Female 56(45.2)
Marital status
Married 107(86.3)
Widow 012(09.7)
Unmarried 004(03.2)
Divorced 001(0.8)
N=124
Median age =
60(50-68)yrs

10. Variables n(%)
Lower socioeconomic status 100 (80.6)
Family History of diabetes 43 (34.7)
Presence of comorbidities 72 (58.1)
Presence of diabetic complications 51 (41.1)
Smoker 25 (20.2)
Alcohol consumption 16 (12.9)
Experience of side effects 48 (38.7)
Table 1 continued:
N=124

11. 72(58.1)
Fig 1: Level of distress among diabetic patients

12. Fig 2: Level of adherence to anti diabetic
medications among diabetic patients

13. Table 2: Univariate analysis showing the Patient related factors
associated with adherence to anti-diabetic medication [N=124]

15. Variables Adherence Unadjusted
OR (95%C.I)
P
value
Good
(n=70)
Poor
(n=54)
Distance from hospital (km)
≤2 28(62.2) 17(37.8)
0.7(0.3-1.5)
0.329
>2 42(53.2) 37(46.8)
Cost of drugs
Free 36(63.2) 21(36.8)
0.6(0.3-1.2) 0.166Paid 34(50.7) 33(49.3)
Frequency of blood glucose monitoring
Regular 58(61.7) 36(38.3)
0.4(0.2-0.9) 0.040Occasional 12(40.0) 18(60.0)
Means of conveyance
Walking 22(71.0) 9(29.0)
0.4(0.2-1.0) 0.063Use Transport 48(51.6) 45(48.4)
Table 3:Univariate analysis showing the Health system related
associated with adherence to anti-diabetic medication [N=124]

16. Variables
Adherence
Unadjusted
OR (95%C.I)
P
value
Good
(n=70)
Poor
(n=54)
Number of anti diabetic medications taken
≤2 39(52.0) 36(48.0)
0.6(0.3-1.3) 0.217
>2 31(63.3) 18(36.7)
Side effects experienced
Yes 21(43.8) 27(56.2)
0.4(0.2-0.8) 0.025No 49(64.5) 27(35.5)
Insulin injection taken
Yes 20(57.1) 15(42.9)
0.9(0.4-2.1) 0.922No 50(56.2) 39(43.8)
Table 4: Univariate analysis showing Medication related factors
associated with adherence to anti diabetic medication [N=124]

17. Variables Adherence
Unadjusted
OR
(95%C.I)
P
value
Good
(n=70)
Poor
(n=54)
Duration of diabetes (yrs)
<5 25(54.3) 21(45.7)
0.6 (0.3-1.3) 0.217
>5 45(57.7) 33(42.3)
Diabetic complications
Yes 27(52.9) 24(47.1)
0.8 (0.4-1.6) 0.510
No 43(58.9) 30(41.1)
Fasting Blood Glucose Level
≤126 56(80.0) 06(11.1)
0.5 (0.2-1.4) 0.188
>126 14 (20.0) 48(88.9)

18. Variables Adherence Unadjusted
OR (95%C.I)
P
Value
Good
(n=70)
Poor
(n=54)
Diabetic distress
Low 67 (95.7) 41 (75.9)
0.1 (0.0-0.5) 0.004High 03 (04.3) 13 (24.1)
Emotional Burden
Low 49 (70.0) 25 (46.3)
0.4 (0.2-0.8) 0.008High 21 (30.0) 29 (53.7)
Regimen distress
Low 69 (98.6) 35 (64.8)
0.0 (0.0-0.2) 0.001High 01 (01.4) 19 (35.2)
Interpersonal
Low 60 (85.7) 41 (75.9)
0.5 (0.2-1.3) 0.168
High 10 (14.2) 13 (24.1)
Table 5: Univariate analysis showing association between diabetic
distress and adherence to anti-diabetic medication [N=124]

19. Factors
UNADJUSTED
OR (95% CI)
P
value
ADJUSTED
OR (95% CI)
P
value
Absence of Side effects
0.4 (0.2-0.9) 0.025 0.4 (0.2-1.0) 0.06
Regular blood
monitoring 0.4 (0.2-0.9) 0.040 0.7 (0.3-2.1) 0.570
Low Diabetic distress
0.1 (0.0-0.5) 0.004 0.6 (0.0-5.9) 0.620
Low Emotional
burden 0.4 (0.2-0.8) 0.008 0.7 (0.3-1.7) 0.442
Low Regimen
distress 0.0 (0.0-0.2) 0.001 0.0 (0.0-0.3) 0.006
Table 6:Factors associated with adherence to antidiabetic medication
[N=124]

20.  CONCLUSION AND RECOMMENDATIONS
• In our study , experiencing any side-effects , non-monitoring of blood
glucose and diabetic distress were found to be significantly associated with
good adherence behaviour Not one factor can be solely held responsible for
influencing non-adherence among patients
• The regimen distress could be minimized by prescribing fixed-dose or
combined preparations.
 Health education and awareness about regular monitoring of blood glucose
levels must be promoted.
 Uninterrupted Government supply of anti diabetic drugs will benefit the
patients