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  • 1. FACTORS AFFECTING COMPLIANCE OF TYPE 2 DIABETIC EMPLOYEES IN A SELECTED OCCUPATIONAL SETTING
  • 2. Background of the Study and Statement of the Problem
  • 3. Estimates suggest that, in the year 2000, 171 million people of all ages worldwide had their blood glucose levels in the diabetes range. (Vijayakumar, Arun, & Kutty, 2009) Over the next 30 years the global prevalence of diabetes mellitus is projected to increase by over 100 percent. This will raise the global burden of diabetes mellitus to 366 million by the year 2030 (Wild et al, 2004).
  • 4. In the Philippines, the situation couldn’t be more paralleled. According to a survey conducted by the Philippine Cardiovascular Outcome Study regarding diabetes here in the country, 1 out of every 5 adult Filipinos is diabetic (Pazzibugan, 2008). It also shows that three out of five adults are at risk of developing diabetes if they won’t change their lifestyle.
  • 5. Moreover, as the prevalence of diabetes increases, the proportion of young people with diabetes also increases. The rapidly increasing prevalence of Type 2 Diabetes in the youth is highlighted by studies in the Asian populations in native lands and in migrant countries (Ramachandra et al, 2012).
  • 6. Since diabetes is a chronic disease, it may directly or indirectly affect the individual’s health status and job performance regardless of the type of work. The increased prevalence among younger individuals suggests that diabetes will become more common in the working-age population. Consequently, employment and work productivity of individuals with diabetes are important issues for patients, families, employers, and policy makers (Tunceli et al, 2005).  
  • 7. Several studies have found negative associations between diabetes and employment outcomes (Ng, Jacobs, & Johnson, 2001). Diabetes can affect employment in a number of ways. First, diabetes complications may prevent working entirely or increase absenteeism for those who work (Julius, Gross, & Hanefeld, 1993). Second, productivity while at work may also be impaired (Lavigne et al, 2003).
  • 8. Third, individuals with diabetes may face employment discrimination. In some cases, especially because of the risk of hypoglycemia, employers may restrict access to the jobs designated as safety sensitive (Kraut et al, 2001) or discriminate against individuals with diabetes because of their concerns about low productivity (Matsushima et al, 1993).
  • 9. Diabetic Lifestyle for it to be successful must include changing diet, increasing physical activity, improving the living environment, and at most points compliance to medical and pharmacologic therapies. Pharmacologic therapy is needed to achieve certain desired outcomes for the patient. These desired outcomes are part of the overall objective for diabetes management.
  • 10. However, despite all the best intentions and efforts on the part of the healthcare professionals, those outcomes might not be achievable if the patients are non- compliant (Jin et al, 2008). Several studies were conducted in order to know the possible impact of therapeutic non- compliance in different countries. In general, an estimated compliance rate for long-term therapies was between 40% to 50% while the short-term therapies were between 70% to 80% (DiMatteo, 1995).
  • 11. The above example illustrates the need to know the contributing factors that affect drug compliance among diabetic patients and the extent of the problem, in order to address the issue of therapeutic non- compliance. This could serve as enlightenment for the diabetic employees about the factors that can affect their compliance in their regimen.
  • 12. Moreover, there is a lack of available study concerning factors that affects drug compliance of diabetic patients in the workplace. The results that can be obtained from this study can add-up to the knowledge that would improve better care management among Health care providers and can contribute to the body of existing data about the topic for education and research. In addition, this could help employers in the future planning and implementation of health policies in the workplace.
  • 13. The main objective of this study is to identify factors that affect drug compliance of type II diabetic patients in an occupational setting, specifically in a manufacturing and bottling company situated in Canlubang Laguna, Philippines. Specifically, it aims to determine the association of drug compliance between the profile of the respondents and their health status.
  • 14. Moreover, this study aims to determine if the identified factors such as Psychological; Social; Health Care Provider and Medical System; and Disease and Treatment affects drug compliance of diabetic patients in an occupational setting.
  • 15. However, this study would only focus on employees diagnosed to have type 2 diabetes; working in a manufacturing/bottling company. Furthermore, the focus of the study is those diabetic employees that are currently taking oral anti-diabetic agents without taking insulin preparations and was diagnosed with the disease for not less than three years.
  • 16. The limitation of the study is that it would focus more on the pharmacologic adherence and not on other diabetic managements such as diet and exercise modifications. In addition, this study would not conduct any laboratory or diagnostic procedures relative to diabetic assessment such as Fasting Blood Sugar and HbA1c.   This study is deemed to be conducted for eight (months) duration.
  • 17. Review of Literature
  • 18. Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels (World Health Organization, 2011).
  • 19. I. Diabetes: Basic Facts Type 1 diabetes (previously known as insulin- dependent, juvenile or childhood-onset) is characterized by deficient insulin production and requires daily administration of insulin. The cause of type 1 diabetes is not known and it is not preventable with current knowledge. Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly.
  • 20. Type 2 diabetes (formerly called non-insulin- dependent or adult-onset) results from the body’s ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity. Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, once complications have already arisen. Until recently, this type of diabetes was seen only in adults but it is now also occurring in children.
  • 21. Gestational diabetes is hyperglycemia with onset or first recognition during pregnancy. Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather than reported symptoms.
  • 22. Impaired glucose tolerance (IGT) and impaired fasting glycemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes,although this is not inevitable (World Health Organization, 2011).
  • 23. II. Components of Diabetes Treatment Treatment for diabetes mellitus involves restoring blood glucose to or near normal levels in all patients. The American Diabetes Association (ADA) recommends a treatment target for diabetes that includes a glycosylated hemoglobin (HbA1c) level <7% and optimal blood glucose levels obtained before meals should be in the range of 70– 130 mg/dl, while levels taken 1–2 hours after beginning a meal should be lower than 180 mg/dl.
  • 24. In order to achieve maximum treatment gains, patient involvement and cooperation is a must. Self-management of diabetes involves frequent self-monitoring of blood glucose, along with dietary modifications, exercise, education, and medication administration.
  • 25. Self-care management is necessary to improve one’s health and reduce the risk of having diabetes-related complications. Failure to control blood glucose adequately can have immediate and long-term effect. To avoid complication and maintain acceptable blood glucose level, one must follow a self-care regimen that includes right diet, exercising, blood glucose monitoring, and medication.
  • 26. A. Dietary modifications and Exercise Dietary modifications and exercise initiation are essential components of diabetes self-management. The American Diabetes Association recommends 1550- 1650 calories per day that include breakfast, lunch, dinner, and two snacks. Calories are spaced throughout the day between meals and snacks.
  • 27. Recommendations includes having a moderate intake of carbohydrates (45-50% of Calories)reduction in saturated fats and trans fat; having less than 200 mg per day of cholesterol; keeping sodium to less than 1500 mg per day and increase in fiber intake of more than 25mg.
  • 28. In a randomized lifestyle intervention trial conducted by Kang et. al in 2010, results showed that continuous lifestyle intervention for two years is more effective at improving risk factors than one year intervention. In this study, the intervention program consists of motivating the participant to correct imbalances in their lifestyle voluntarily by providing practical advice through dietary modification and increasing their physical activity.
  • 29. Dietary recommendations of 1400-2200 calories per day was followed and about 200-300 kcal/day were burnt through brisk walking of 10-30 min a day and other endurance exercises (Kang et.al, 2010).
  • 30. B. Blood glucose monitoring Another important component of diabetes self-management is the monitoring of glycemic status. Results of blood glucose are used to assess the efficacy of therapy as well as to provide information regarding necessary adjustments to nutritional therapy and medication.
  • 31. The A1C or HbA1c (Glycated hemoglobin) test measures an individual’s average blood glucose control for the past 2 to 3 months. It can be done twice a year for patients with controlled blood glucose level and more frequent for those who are unable to cope with the normal blood glucose level. It recommends the goal of therapy as an HbA1c of <7%, and recommends that treatment be reevaluated when HbA1c exceeds 8% (American Diabetes Association).
  • 32. C. Medication Modifications to diet and exercise are an initial and conservative treatment for type 2 DM, but many patients require pharmacologic intervention to maintain glycemic control. Only type 2 diabetic patients can use pills or oral antidiabetic medication in managing their blood glucose because the pancreatic beta cells aren’t functioning at a minimum level in type 1 diabetes(Nursing Pharmacology made Incredibly Easy, 2005). These pills work best when used with meal planning and exercise (American Diabetes Association).
  • 33. As stated in the Merck Manual of Medical Information (2003), there are several types of Antidiabetic medication. Sulfonylureas (for example, glyburide) and meglitinides (for example, repaglinide) stimulate the pancreas to produce more insulin (insulin secretagogues). Biguanides (for example, metformin) and thiazolidinediones (for example, rosiglitazone) do not affect the release of insulin but increase the body's response to it (insulin sensitizers). Doctors may prescribe one of these drugs alone or with a sulfonylurea drug.
  • 34. Another class of drug is the glucosidase inhibitors, such as acarbose, which work by delaying absorption of glucose in the intestine. The drugs are sometimes taken only once a day, in the morning, although some people need two or three doses. More than one type of oral drug may be used if one is not adequate. If oral antihyperglycemic drugs cannot control blood sugar levels well enough, insulin injections alone or in combination with the oral drugs may be needed.
  • 35. III. Prevalence: International and Local Diabetes mellitus is a serious and increasing global health problem (Detaille et. al, 2005). Projected increase in the global prevalence of type 2 diabetes suggests that its treatment and prevention could become one of the major health challenges of the 21st century (Oberlinner & Neumann, 2007).
  • 36. In The United States, diabetes is becoming a serious threat with significant increases projected. This increase will drain healthcare and financial resources and government and community services, and will negatively impact quality of life. In 2004, an estimated 3.4 million people died from consequences of high blood sugar and more than 80% of diabetes deaths occur in low- and middle- income countries (World Health Organization, 2011).
  • 37. In the Philippines, a survey conducted by the Philippine Cardiovascular Outcome Study on Diabetes Mellitus in 2007 showed that “3 out of 5 adults are already diabetic or on the verge of diabetes unless they change their lifestyles.” This result is very alarming and needs to be addressed. Meanwhile, no data on the prevalence of diabetes among Filipino children have been made.
  • 38. With this in mind, effects of Diabetes overall could not be denied. The disease in itself brought with it challenges not only to the patient but to his family and the society. The medical care costs associated with diabetes create a considerable economic burden for patients, family, and society. Productivity losses from diabetes have been estimated to be almost half of the medical cost. As the prevalence of diabetes has increased, so too have the associated economic burdens (Tuncelli et. al, 2005).
  • 39. IV. Diabetes and Workplace This challenge has been extended to the occupational setting as well- becoming an, “increasingly prevalent and burdensome disease in working populations” (Oberlinner & Neumann, 2007).
  • 40. For some, diabetes in the workplace seems to have a negative connotation to those who have it. It was a common practice to restrict individuals with diabetes from certain jobs or classes of employment solely because of the diagnosis of the diabetes or the use of insulin, without regard to an individual’s abilities or circumstances (American Diabetes Association, 2009).
  • 41. For the lucky others, employers accommodate employees with diabetes and may even produce some changes to accommodate the diabetic needs. Many of the accommodations that employees with diabetes need on a day-to-day basis are those that allow them to manage their diabetes in the workplace as they would elsewhere. There are usually simple accommodations that can be provided without any cost to the employer, and should cause little or no disruption in the workplace (American Diabetes Association, 2009).
  • 42. V. Diabetes and Compliance
  • 43. A. Differentiating Adherence versus Compliance The increasing prevalence and chronic nature of diabetes implies that continuity of care and self-management should be an important factor on the management of this disease (Detaille, 2005).
  • 44. However, with all the accommodations and all said and done, Diabetes and its course still largely depends on the individual and his/her therapeutic compliance. Hence, therapeutic compliance in any setting – “has been a topic of clinical concern since 1970s due to the widespread nature of non- compliance therapy” (Jin & Sklar, 2008).
  • 45. Generally speaking, it was estimated that the compliance rate of long-term medication therapies was between 40% and 50% while the rate of compliance for short-term therapy is between 70% and 80% based on the studies by Jin et al in 2008. Moreover, Jin et al added that More than 20 studies published in the past few years found that compliance with oral medication for type 2 diabetes mellitus ranged from 65% to 85%.
  • 46. With the growing prevalence of Diabetes in the workplace setting, it is therefore important to assess the factors that might affect non compliance among employees. To address this issue, it is of first and utmost importance to have a clear and acceptable definition of compliance. In healthcare, the most commonly used definition of compliance is patient’s behaviors (in terms of taking medication, following diets, or executing lifestyle changes) coincide with the health care providers’ recommendations for health and advice.
  • 47. Thus, therapeutic non-compliance occurs when an individual’s health seeking or maintenance behavior lacks congruence with the recommendations as prescribed by healthcare provider (Jin & Sklar, 2008).
  • 48. A few debates have been made on whether non-compliance is the proper word to use to describe this phenomenon. Some years ago, diabetes educators argued that the term “adherence” be used preferentially instead of “compliance” and the tem “non- adherence” be substituted for “non- compliance”. The rationale for this proposal was that the term “non compliance” implies a series of negative value judgments about the patients as people. Instead, the term “non-adherence” was thought to imply description of a failure to follow medical prescription without bias toward the patient as a person.
  • 49. In addition, specific studies have noted that non-adherence may entail various components that may relate to flaws in the process of care and that do not entail a failure on the part of the patient (Leichter, 2005). Although there are slight differences between these terms, in clinical practice, these terms are used interchangeably (Jin & Sklar, 2008).Furthermore, much of the medical community has never adopted this concept, and in many other areas of clinical practice, the term “non-compliance” remains the standard (Leichter, 2005).
  • 50. B. Compliance about Self-Care Management Majority of patients with diabetes can significantly reduce the chances of developing long-term complications by improving self-care activities. Despite this fact, compliance or adherence to these activities has been found to be low in some studies (Wabe et. al, 2011). Several studies conducted and showed many contributing factors that affects compliance in diabetic patients.
  • 51. 1. Factors Related to Compliance To improve patient compliance, it is very important to understand why noncompliance occurs. A substantial literature has documented a number of factors related to diabetes regimen compliance problems. It is helpful to consider demographic, psychological, and social factors, as well as health care provider, medical system, and disease- and treatment-related factors (Khan et. al, 2012; Jin et. al, 2008; Wabe et.al, 201, Delamater et.al, 2006).
  • 52. a. Demographic factors Demographic factors such as age, gender, ethnicity, level of education, and socio-economic status are associated with medication compliance (Patel et. al, 2010,Verghari et. al, 2010, Kaylango et. al, 2008).
  • 53. Factors such as sex and educational level appeared to be associated in non- adherence rate in Mulago Hospital, Uganda while age, marital status, and occupation of the respondent were not significantly associated with non-adherence (Kaylango et.al, 2008).
  • 54. In 2010, Patel and colleagues studied 3,169 patients with type 2 DM in North Carolina. A retrospective cohort study was done and consists of patients aged 18-44 years, 45- 64years, and 65+ years who were newly starting medication from July 2001- June 2002. In order to determine the medication adherence of the patients, the researchers utilized medication possession ratio using prescription refill patterns. Result showed that a better medication adherence is associated with increased age.
  • 55. In an experimental study conducted across mainland U.S. and Hawaii, 2,155 adults with impaired glucose tolerance participated and were randomly assigned to either metformin or matched placebo treatment arm, Walker et.al (2006) reported that age, gender and ethnicity is associated with medication adherence. The middle-aged and older age-groups (aged 45–59 and ≥60 years) had significantly greater adherence in both metformin and placebo groups than younger participants (aged 25–44 years).
  • 56. The metformin group, as expected, had lower adherence than the placebo group in each age category, presumably because of its gastrointestinal side effects. Women were significantly less adherent than men in the metformin group only (68 vs. 74%, P= 0.01). Among ethnicity/racial groups, there were significant differences in rates of adherence, with Caucasians having the highest rates of adherence in both arms.
  • 57. In a Mexican cross-sectional study, educational level was associated with treatment adherence (Martinez et.al 2008). Similar result showed with Khan’s group in 2012, but in the research made by Park’s group in Korea (2010), they did not detect this association.
  • 58. Some studies have found an association between socio-economic status and adherence. Leichter (2005) states that there are multiple issues that contribute to whether a diabetic patient adheres to the prescribed treatment – cost is one. A study on Cost-related Nonadherence to medications among patients with diabetes and chronic pain by Kurlander et al supports this statement.
  • 59. Patients’ income was significantly associated with adherence behavior. Compared with higher income patients, lower-income patients were three times as likely to cut back on both medication types (13.1%) and selectively on chronic pain medications (2.4%) but only slightly more likely to cut back on their diabetes medications (14.6%) (Kurlander et. al, 2009).
  • 60. b. Psychological factors Psychological factors are also linked with regimen compliance. Appropriate health beliefs, such as perceived seriousness of diabetes, vulnerability to complications, and the efficacy of treatment, can predict better adherence, (Skinner et. al, 2001; Guthrie et. al, 2003, Park et. al, 2010).
  • 61. Patients adhere well when the treatment regimen makes sense to them, when it seems effective, when they believe the benefits exceed the costs, when they feel they have the ability to succeed at the regimen, and when their environment supports regimen- related behaviors(Guthrie et. al, 2003).
  • 62. c. Social factors The presence of family members and the quality of relationship with the diabetic patient play an important role in managing their health. Studies have shown that low levels of conflict, high levels of cohesion and organization, and good communication patterns are associated with better regimen adherence (Delamater et. al, 2001).
  • 63. This study is also supported by the results obtained by Garay-Sevilla et. al. In their paper, they claimed that adherence to medication and diet in NIDDM patients are strongly associated with social support from spouse and family members.
  • 64. d. Health care provider and medical system factors Physicians and nurse practitioners working in teams can improve both diabetes patient care and clinical outcomes. Nurses who provide support to their diabetic patients increase the chance of improving their health status through counseling and health education (Kang et.al 2010). Another study showed that having regular, frequent contact with patients by telephone promoted regimen adherence and achieved improvements in A1c compared with print intervention.
  • 65. It was also noted that greater intensity of the intervention (6 calls) was associated with greater improvement in A1C (Walker et. al, 2011). In January 2012, a recent study revealed that telephone coach­ing is effective low­cost method to improve self­ management of diabetes among residents in three rural Washington counties (Maclean et.al, 2012).
  • 66. Aside from obtaining support from the health care providers, the quality of patient­physician relationship is an important key determinant in therapeutic adherence. (Delamater, 2006 & Khan et. al, 2012). Research has demonstrated that patients who are satisfied with their relationship with their health care providers have better adherence to diabetes regimens.
  • 67. e. Disease- and treatment-related factors Studies have generally shown that adherence is influenced by the acute or chronic health status, varied symptoms, complexity of medication and lifestyle changes (Delamater, 2006).
  • 68. According to Khan et. al (2012), there is a high rate of non­compliance to anti­ diabetic treatment and regimen. Factors associated with non­compliance are related to appointment schedule, exercise and diet regimen. Two main reasons why majority of patients could not make it on the said appointment are due to unavailability of transport and forgetfulness.
  • 69. It was also reported that Patient­physician relationship emerged as an important factor in compliance. Patients who have adequate information about the medication in terms of dose, duration of action and side effects have fairly high compliance rate compared to those who doesn’t understand the information instructed by the doctor.
  • 70. Complex medication regimens are a significant barrier to medication adherence. The use of multiple medications is often required and beneficial in helping patients with diabetes achieve optimal blood glucose, blood pressure, and lipid control and manage other diabetes­related complications and comorbidities. It is not uncommon for a patient with diabetes to be appropriately prescribed five or more medications.
  • 71. Furthermore, studies with diabetic patients indicate better adherence to simpler regimens than to more complex ones. Delamater et. al, (2001) reported that among the factors associated with medication adherence, adherence with a simple prescription is higher than that for a more complex prescription. This remains true with the study of Park et. al (2010) where in adherence with medication of 1 antidiabetic drug per day was higher than with more than 2 drugs.
  • 72. Significance of the Study
  • 73. For the Diabetic Patients in Occupational Setting The results of this study can serve as awareness for the Diabetic Patients in Occupational setting for them to become aware of the common factors that might affect their compliance with the diabetic therapy regimen. This in turn can serve as the beginning of possible changes in their therapeutic compliance and self­ knowledge.
  • 74. For the Occupational Health Professionals The factors identified by this study can serve as a guide to Occupational Health Professionals in dealing with Diabetic Clients and individualizing their management towards a successful medical therapy.
  • 75. For the Health Community The findings of this research can further add to the knowledge of individual patient care. Furthermore, the knowledge obtained from this research can revolutionize assessment of the factors in determining patient compliance in diabetic management, and probably in any medical management that involves a patient.
  • 76. For the researchers Other researchers can use the results in making similar investigations. This study will serve as a springboard for them to begin inquiry. Furthermore, this could open the interest of researchers, especially health researchers, to focus their attention in other aspects of care management that is outside the clinical area.
  • 77. For the employers This research can serve as enlightenment to employers, hiring or currently hiring diabetic patients. Furthermore, the factors identified by this research can help employers better improve the planning and implementation of certain health policies within their organization especially in those employees with lifestyle­related diseases such as diabetes.
  • 78. In general, the study serves as an additional input to the body of knowledge that will broaden our perception about diabetes and its management.
  • 79. Objectives of the Study
  • 80. General Objective The main objective of this study is to identify factors that affect drug compliance in a type 2 diabetic patient in a selected occupational setting.
  • 81. Specific Objectives 1. To determine the association of drug compliance among diabetic patients in terms of: Age, Gender, Marital Status, Educational Background, Economic Status, Familial History of DM, and Health Status. 2. To assess whether the patients are compliant or non­compliant in taking their medications. 3. To determine the complexity of drug medication taken by diabetic patients.
  • 82. Conceptual Framework
  • 83.   FIGURE 1. Factors Related Variables Affecting Drug Compliance of Diabetic Patients TYPE II DIABETIC PATIENT PERSONAL PROFILE • Age • Gender • Civil Status • Educational Attainment • Economic Status • Health Status • Complexity of Pharmacological regimen • Psychological Factors • Social Factors • Health Care Provider/Medical System Factors • Disease and Treatment- related Factors • DRUG COMPLIANCE Compliant or Non-compliant
  • 84. Fig. 1 shows the relationship of patient’s personal profile and Health status that may influence drug compliance. The patient’s personal profile, health status and drug compliance are presented and described. It is assumed that drug compliance is affected by variations on the personal profile and health status. Patient can be compliant or non­compliant. On the other hand, it is assumed that being compliant or non­compliant can affect the health status of the patient and in the same manner changes in the health status affects compliance.
  • 85. Materials and Methods
  • 86. Research Design
  • 87. This study will use the descriptive method. This method seeks to know the characteristics of the phenomenon and categorize into some descriptive terms. This method tends not to penetrate the data in any interpretative depth (Sandelowski, 2000). More specifically, this study is a Descriptive­ Correlational study because it will attempt to describe the relationship between the independent and dependent variables identified in the study.
  • 88. Study Population
  • 89. This study will focus on Diabetic Patients in an Occupational Heath Setting, particularly in a bottling and manufacturing company located in Industrial Estate in Canlubang which is a major industrial zone located in the province of Laguna, Philippines.
  • 90. The site consists of 425 employees, 320 males and 105 females working in different plant departments such as Sales, Supply Chain, Finance, Human Resources, Logistics and Center of Excellence within the 20­55 years old bracket. All of which will be screened based on the criteria set by the researchers for possible inclusion in the study.
  • 91. Sampling Design
  • 92. Purposive sampling will be utilized for this study. Purposive sampling or judgmental is based on the belief that researcher’s knowledge about the population can be used to hand­ pick sample members (Polit & Beck, Sampling Designs, 2003).
  • 93. In order to attain homogeneity among the respondents and to control extraneous variables, the following criteria were the basis in selecting the respondents.
  • 94. 1. Diagnosed Diabetic employees working in a manufacturing/bottling company in Industrial Estate in Canlubang, Laguna. 2. Is currently taking oral anti­diabetic agents for not less than 3 years. 3. Does not receive any insulin preparation. 4. Has given his/her consent to participate in the study. 5. Does not have any mental disability or sensory handicap such as those who are confused or disoriented during the interview, blind or deaf.
  • 95. Variables to be investigated A. Dependent variable The Dependent variable in this study is the Compliance of Diabetic patients in their Pharmacological regimen. Dependent variable is the variable hypothesized to depend on or be caused by another variable (Polit & Beck, 2004).
  • 96. B. Independent variable Independent variable is the variable that is believed to cause or influence the dependent variable (Polit & Beck, 2004). The following Independent variables to be identified in this study are as follows. 1. Personal Profile which includes the following: a. Age b. Gender c. Civil Status d. Educational Attainment e. Economic Status
  • 97. f. Familial History of Diabetes Mellitus 2. Health Status of the Employees based on: a. Familial History of Diabetes b. Length of time with Diabetes Mellitus 3. Complexity of Pharmacological regimen 4. Psychological Factors 5. Social Factors 6. Health Care Provider/Medical System Factors 7. Disease and Treatment-related Factors
  • 98. e. Economic Status f. Familial History of Diabetes Mellitus 2. Health Status of the Employees based on: a. Length of time with Diabetes Mellitus b. Presence of other chronic/lifestyle diseases. 3. Complexity of Pharmacological regimen 4. Number of Medicines Taken per day.
  • 99. Methods of Data Collection
  • 100. The researcher will first prepare letters to be addressed to the human Resources Department or the Plant Manager or any authorized head of the Manufacturing and bottling company in Industrial Estate. Upon approval, the researcher will personally go to the plant clinic to identify the targeted population which is the Diabetic patients. If the site has no plant clinic, the researchers would go on the site and ask employees on who among them are diagnosed diabetic patients. Based on the identified employees, the researchers would decide if the following employees fit the criteria of this research.
  • 101. Upon identification of the respondents that fits the criteria, a survey tool would be given for the employees to answer. An explanation on the purpose of the study will be given as well. After finishing the questionnaire, the researchers collect the questionnaires with an assurance that the answers would be treated with utmost confidentiality.
  • 102. Instrumentation/ Data Collection Tools
  • 103. For this study, the researcher will be using a questionnaire or SAQ (self-administered questionnaire). The questionnaire will address three keys areas: a determination of perceived medication adherence, personal profile and identification of factors affecting compliance.
  • 104. To test the perceived drug compliance of the respondents, the researcher will adapt the Morisky Medication Adherence Questionnaire. It consists of an 8-item questions that determine whether the respondents have low, medium or high adherence rate. The questionnaire will consist of the following sections:
  • 105. a. A cover letter seeking for the respondent’s consent in participating in the study as well as assuring them of anonymity and confidentiality of data and informing them that there is no right or wrong answer; b. A set of questions pertaining to the respondents personal profile and health status and; c. A set of questions related to the different types of factors affecting drug compliance.
  • 106. Data Processing and Data Analysis
  • 107. The researchers will be using SPPS for faster and more accurate results. Through this, the values for the following statistical measures will be obtained. 1. Frequency and Percentage Distribution- these tools will enable the researchers to present summary distributions of data in categories of values expressing the frequency and percentage of occurrence.
  • 108. 2. Mean – the most widely used measure of the central tendency. Mean is a numerical value that in some sense represents the central value of a set of numbers. Mean is the sum of all scores, divided by the number of scores. Weighted mean can be best defined or explained by illustrating its process of calculation.
  • 109. Weighted mean is solved using the following formula: Weighted mean is very useful tool in summarizing the responses of respondents from a survey questionnaire. ∑(XW) Wtd = ––––––– ∑W Where: Wtd is the weighted mean. X is the individual score or value W is the weight ∑(XW) is the sum of the products of X and W. ∑W is the sum of the weights.      
  • 110. 3. Standard deviation- shows how much variation or "dispersion" exists from the average (mean, or expected value). A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data points are spread out over a large range of values.
  • 111. 4. Correlational Coefficient (r) – this tool will be used to test the hypothesis of the study. It measures the extent or strength of relationship between 2 numerical variables based on a correlation coefficient that ranges from 0 to + 1. The closer the value to 1 the stronger the relationship between 2 variables while the closer it is to zero, the more unrelated the variables are.
  • 112. The SPSS package will simplifies further data analysis as it readily determines whether the computed r is significant or not at specified level of significance.
  • 113. Timetable/ Schedule
  • 114. 7 8 9 10 11 12 1 2 3 4 5 1. Literature review 2. Designing materials 3. Learning how to use method 4. Designing questionnaire 5. Finding participants 7. Analyzing data 8. Submission of thesis proposal 9. Fine tune research question and methodology 10. Prepare research tools in detail 11. Make contacts for questionnaires/Running tests 12. Data collection 13. Data analysis 14. Writing up of thesis 15. Thorough proof-reading by an adviser 16. Revision, editing, and printing of thesis 17. Submission of thesis 18. Thesis defense Activities 2012 2013
  • 115. Budgetary Requirements
  • 116. Budget Item Budget Requirement Printing and Publications Advising Services Statistician Reader Transportation Expenses Meal Expenses Php 5,000 Php 20,000 Php 10,000 Php 5,000 Php 7,000 Php 3,000  Total : Php 50,000
  • 117. References
  • 118.  Jin, J., Sklar, G. E., Oh, V. M., & Li, S. C. (2008). Factors affecting therapeutic comliance: A review from the patient's perspective. Callaghan, Australi: Dove Medical Press Limited.  Kaan Tuncelli, C. B., & Lafata, &. J. (2005). The Impact of Diabetes on Employment and Work Productivity.  Kang J., C. S. (2010). Effects of a continuous diabetes lifestyle intervention program in male workers in korea. Diabetes Research and Clinical Practice , 26-33.  Kaylango J., O. E. (2008). Non-adherence to diabetes treatment at Mulago Hospital in Uganda: Prevalence and Associated Factors. African Health Sciences , 67-73.  Khan. (2012). Factors Contributing to Non-Compliance Among Diabetics attending Primary Health Care Centers in the Al Hasa District of Saudi Arabia.  Khan. (2012). Factors Contributing to Non-Compliance among Diabetics attending Primary Health Centers in the Al Hasa District of Saudi Arabia.  Kurlander, J. E., Merr, E. A., & Krein, S. (2009, September 3). Cost-Related Nonadherence to Medications Among Patients With Diabtes and Chronic Pain. Diabetes Care 2009 Vol. 32 no. 12 , 2143-2148.  Leichter, S. B. (2005). Outpatient Care of Diabetes More Efficient: Analyzing Noncompliance. Clinical Diabetes Vol. 23 No. 4 , 187-190.  Maclean L., W. J. (2012). Telephone Coaching to Improve Diabetes Self-Management for Rural Residents. Clinical Diabetes , 13-16.  Martinez Y., P.-A. R.-P. (2008, July 30). Quality of life associated with treatment adherence in patients with type 2 diabetes: A cross-sectional study. BMC Health Services Research.
  • 119.  Nursing Pharmacology Made Incredibly Easy! (2005). lippincott Williams & Wilkins.  Oberlinner, C., & Neumann, S. (2007). Screening for Pre-Diabetes and Diabetes in the workplace. Oxford Journals of Occupational Medicine , 41-45.  Park K., K. J. (2010). Factors that Affect Medication Adherence in Elderly Patients with the Diabetes Mellitus. Korean Diabetes Journal , 55-65.  Patel. (2010). Medication Adherence in Low Income Elderly Type 2 Diabetes Patients: A retrospective Cohort Study.  Pazzibugan, D. (2008, November 11). Diabetes Rising among Filipinos. Philippine Daily Inquirer .  Polit, D. F., & Beck, C. T. (2004). Key Concepts and Terms in Qualitative and Quantitative Research. In D. F. Polit, & C. T. Beck, Nursing Research: Principles and Methods Seventh Edition (pp. 29-31). New York: Lippinocott Williams & Wilkins.  Polit, D. F., & Beck, C. T. (2003). Sampling Designs. In D. F. Polit, & C. T. Beck, Nursing Research, Principles and Methods 7th Edition (pp. 292-295). Lippincott, Williams & Wilkins.  Sandelowski, M. (2000). What happened to qualitative description? In Research in Nursing & Health (pp. 334-340).  Skinner C., H. S. (2001). Personal Models of Diabetes in Relation to Self-Care, Well-Being, and Glycemic Control. Diabetes Care , 828-833.  (2003). The Merck Manual of Medical Information. Merck & Co.,Inc.  Wabe N., A. M. (2011). Medication adherence in diabetes mellitus and self management practices among type-2 diabetics in Ethiopia. North American Journal of Medical Sciences , 418-423.  Walker E., S. C. (2011). Results of a Successful Telephonic Intervention to Improve Diabetes Control in Urban Adults. Diabetes Care , 2-7.
  • 120.  World Diabetes Foundation. (2012, March 15). Diabetes Facts. Retrieved 15 2012, June, from World Diabetes Foundation: http://www.worlddiabetesfoundation.or/composite- 35.htm  (2011, August). Retrieved August 2012, from World Health Organization: http://www.who.int/mediacentre/factsheets/fs312/en/index.html  A., D. (2006). Improving Patient Adherence. Clinical Diabetes , 71-77.  American Diabetes Association. (2009). Diabetes and Employment. Diabetes Care , S80-S84.  Delamater A, J. A. (2001). Psychosocial Therapies in Diabetes. Diabetes Care , 1286- 1292.  Delamater, A. (2006). Improving Patient Adherence. Clinical Diabetes , 71-76.  Detaille, S., Haafkens, J., Hoekstra, J., & Dijk, F. v. (2005). What employees with diabetes meliitus need to cope at wotk: Views of employees and health professionals. Patient Education and Counselling , 183-190.  DiMatteo, M. (1995). Patient Adherence to pharmacotherapy: the importance of effective communication. Formulary .  Fukunaga, L., Uehara, D., & Tom, T. (2011, February 15). PErceptions of Diabetes, BArriers to Disease Management, and Service Needs: A Focus Group Study of Working Adults with Diabetes in Hawaii.  Garay-Sevilla M., N. l. (1995). Adherence to Treatment and Social Support in Non- Insulin Dependent Diabetes Mellitus. Joumal of Diabetes and Its Complications , 81-86.  Guthrie D., B. C.-C. (2003). Psychosocial Issues for Children and Adolescents With Diabetes: Overview and Recommendations. Diabetes Spectrum , 8-12 .
  • 121.  Jin, J., & Sklar, G. E. (2008). Factors Affecting Therapeutic Compliance: A review from the patient's perspective. Therapeutics and Clinical Risk Management . Callaghan, Australia: Dove Medical Press Limited.  Jin, J., Sklar, G. E., Oh, V. M., & Li, S. C. (2008). Factors affecting therapeutic comliance: A review from the patient's perspective. Callaghan, Australi: Dove Medical Press Limited.  Kaan Tuncelli, C. B., & Lafata, &. J. (2005). The Impact of Diabetes on Employment and Work Productivity.  Kang J., C. S. (2010). Effects of a continuous diabetes lifestyle intervention program in male workers in korea. Diabetes Research and Clinical Practice , 26-33.  Kaylango J., O. E. (2008). Non-adherence to diabetes treatment at Mulago Hospital in Uganda: Prevalence and Associated Factors. African Health Sciences , 67-73.  Khan. (2012). Factors Contributing to Non-Compliance Among Diabetics attending Primary Health Care Centers in the Al Hasa District of Saudi Arabia.  Khan. (2012). Factors Contributing to Non-Compliance among Diabetics attending Primary Health Centers in the Al Hasa District of Saudi Arabia.  Kurlander, J. E., Merr, E. A., & Krein, S. (2009, September 3). Cost-Related Nonadherence to Medications Among Patients With Diabtes and Chronic Pain. Diabetes Care 2009 Vol. 32 no. 12 , 2143-2148.  Leichter, S. B. (2005). Outpatient Care of Diabetes More Efficient: Analyzing Noncompliance. Clinical Diabetes Vol. 23 No. 4 , 187-190.  Maclean L., W. J. (2012). Telephone Coaching to Improve Diabetes Self-Management for Rural Residents. Clinical Diabetes , 13-16.
  • 122.  Martinez Y., P.-A. R.-P. (2008, July 30). Quality of life associated with treatment adherence in patients with type 2 diabetes: A cross-sectional study. BMC Health Services Research.  Nursing Pharmacology Made Incredibly Easy! (2005). lippincott Williams & Wilkins.  Oberlinner, C., & Neumann, S. (2007). Screening for Pre-Diabetes and Diabetes in the workplace. Oxford Journals of Occupational Medicine , 41-45.  Park K., K. J. (2010). Factors that Affect Medication Adherence in Elderly Patients with the Diabetes Mellitus. Korean Diabetes Journal , 55-65.  Patel. (2010). Medication Adherence in Low Income Elderly Type 2 Diabetes Patients: A retrospective Cohort Study.  Pazzibugan, D. (2008, November 11). Diabetes Rising among Filipinos. Philippine Daily Inquirer .  Polit, D. F., & Beck, C. T. (2004). Key Concepts and Terms in Qualitative and Quantitative Research. In D. F. Polit, & C. T. Beck, Nursing Research: Principles and Methods Seventh Edition (pp. 29-31). New York: Lippinocott Williams & Wilkins.  Polit, D. F., & Beck, C. T. (2003). Sampling Designs. In D. F. Polit, & C. T. Beck, Nursing Research, Principles and Methods 7th Edition (pp. 292-295). Lippincott, Williams & Wilkins.  Sandelowski, M. (2000). What happened to qualitative description? In Research in Nursing & Health (pp. 334-340).  Skinner C., H. S. (2001). Personal Models of Diabetes in Relation to Self-Care, Well-Being, and Glycemic Control. Diabetes Care , 828-833.  (2003). The Merck Manual of Medical Information. Merck & Co.,Inc.
  • 123.  Wabe N., A. M. (2011). Medication adherence in diabetes mellitus and self-management practices among type-2 diabetics in Ethiopia. North American Journal of Medical Sciences , 418-423.  Walker E., S. C. (2011). Results of a Successful Telephonic Intervention to Improve Diabetes Control in Urban Adults. Diabetes Care , 2-7.  World Diabetes Foundation. (2012, March 15). Diabetes Facts. Retrieved 15 2012, June, from World Diabetes Foundation: http://www.worlddiabetesfoundation.or/composite- 35.htm
  • 124. Appendices