ABSTRACT
Background: Diabetic management rarely targets family support as a means of promoting diabetes self-care behaviour among adults.
Objectives: The purpose of this study was to assess the effect of family support on medication adherence and glycemic control of type 2 diabetic out-patient in a tertiary hospital in south-eastern Nigeria.
Methods: This was a prospective cross-sectional survey conducted on type 2 diabetes out-patients attending that were Endocrinology clinic at the University of Nigeria Teaching Hospital (UNTH) between October 2013 and April 2014. The Modified Diabetes Family Behavioural Checklist (MDFBC-13) was used to assess family support (patient reported) while for medication adherence; the MMAS-8 (Morisky medication Adherence Scale) was used and Fasting blood glucose readings were obtained from patients case files. Data was analyzed using Microsoft Excel and Statistical Package for Social Sciences (SPSS) window version 16.0. Statistical significance for analysis was defined as p value less than 0.05.
Results: A total of250 patients participated in the study. Family support correlated with educational status (p= 0.007) but not with adherence or glycemic. Medication adherence was generally poor as 1.6% of the patients were adherent. Patients who were moderately (medium) adherent and those with low adherents were 5.2% and 93.2% respectively. Adherence was correlated with marital status (r= 0.170) and it was statistically significant (p= 0.007). glycemic control was poor because no difference was observed between the final mean FBG and the initial mean FBG. No statistically significance was found between FBG percentage change and demographic characteristic (age, gender, level of education, marital status).
Conclusion: Family support had negative influence on medication adherence and glycemic control.
  CHAPTER ONE
INTRODUCTION AND LITERATURE REVIEW
1.1 Background to the study          Â
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin secretion, insulin action or both [1]. The disease is highly prevalent, afflicting approximately 150 million people worldwide [2], and this number is expected to rise to 300 million in the year 2025 [3]. This increase will occur in developing countries and will result from population ageing, unhealthy diet, obesity and a sedentary lifestyle [4]. In developed countries, such as the United States, diabetes has been reported as the seventh leading cause of death [5], and the leading cause of lower extremity amputation, end-stage renal disease and blindness among persons aged 18-65 years [6-9]. Recent estimates indicate there were 171 million people in the world with diabetes in the year 2000 and this is projected to increase to 366 million by 2030 [10]. This increase in prevalence is expected to be more in the Middle Eastern crescent, Sub-Saharan Africa and India [10]. In Africa, the estimated prevalence of diabetes is 1% in rural areas, up to 7% in urban sub-Sahara Africa, and between 8-13% in more developed areas such as South Africa and in population of Indian origin [11]. The prevalence in Nigeria varies from 0.65% in rural Mangu (North) to 11% in urban Lagos (South) [12] and data from the World Health Organization (WHO) suggests that Nigeria has the greatest number of people living with diabetes in Africa [10]. Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires multi-factorial risk reduction strategies beyond glycemic control [13]. The family is the natural and fundamental unit of society [14]. Most people are born into a family, live much of their lives within a family, and consider it to be a high priority in their value system. A healthy lifestyle is usually developed, maintained, or changed within the family context. The presence of a chronic disease is a source of stress for the family, especially if the stress requires changes that interfere with the family’s roles and tasks [15]. When the family is dealing with an acute disease, the changes are usually brief and transitory. In the case of diabetes, a chronic disease, changes are long term and may create tension and conflicts in the family [16] [17]. Family members may provide practical help, for example, they might assist with blood glucose testing or by identifying the signs of an oncoming hypoglycaemia. The family may also act as a psychological resource, encouraging people with diabetes to view themselves as healthy and normal [18]. Interventions rarely target family support as a means of promoting diabetes self-care behaviours among adults. Most diabetes intervention trials examine the effect of individual education on glyceamic control, without engaging or educating family members or accounting for family member support as a process outcome [19].
1.2Â Â Â Statement of the problem
Most theories of health behaviour change required for diabetes self-care performance include a social support component [20-22], and family members are considered a significant source of social support for adults with diabetes [23,24]. Family members can have a positive and/or negative impact on the health of people with diabetes, interfere with or facilitate self-care activities (e.g., by buying groceries or refilling a prescription), and contribute to or buffer the deleterious effects of stress on glycemic control [25]. The issue which arise for this study, was, what effect or role does family support have on medication adherence and glycemic control of type 2 diabetic out-patient?
1.3Â Â Significance of the Study
It would be interesting to study the effect of family support on medication adherence and glycemic control of type 2 diabetes out-patients. This study would give insight and understanding on the importance and role of family support in the management of type 2 diabetes, which is, of great value to health care provider and family members providing diabetes care. It would educate the diabetic patient on the importance of medication adherence and glycemic control and how, family support plays a role in diabetic management either, positively or negatively. It would also educate the public on the importance of positive support to diabetic patients to improve the diabetic management in Nigeria. Policy can be implemented to improve patients’ medication adherence and glycemic control, such as reducing or subsidising cost of anti-diabetic drugs and glucose meter apparatus, providing free or reduced cost medical clinics and health care provider.
1.4 Overview of Diabetes
1.4.1 Definition
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. The effects of diabetes mellitus include long-term damage, dysfunction and failure of various organs. Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss. In its most severe forms, ketoacidosis or a non-ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death. Often symptoms are not severe, or may be absent, and consequently hyperglycemia sufficient to cause pathological and functional changes may be present for a long time before the diagnosis is made. The long-term effects of diabetes mellitus include progressive development of the specific complications of retinopathy with potential blindness, nephropathy that may lead to renal failure, and/or neuropathy with risk of foot ulcers, amputation, Charcot joints, and features of autonomic dysfunction, including sexual dysfunction. People with diabetes are at increased risk of cardiovascular, peripheral vascular and cerebrovascular disease. Several pathogenetic processes are involved in the development of diabetes. These include processes which destroy the beta cells of the pancreas with consequent insulin deficiency, and others that result in resistance to insulin action. The abnormalities of carbohydrate, fat and protein metabolism are due to deficient action of insulin on target tissues resulting from insensitivity or lack of insulin [26].
1.4.2 Etiology
Both genetic and environmental factors are relevant in the development of type 1 diabetes, but the exact relationship between the two is still unknown. There is strong immunological component to type 1 and a clear association with many organ-specific autoimmune diseases. Type 2 diabetes also has a strong genetic predisposition. Identical twins have a concordance rate approaching 100%, suggesting the relative importance of inheritance over environment. If a parent has type 2, the risk of a child eventually developing type 2 is 5-10 % compared with 1-2% for type 1. Type 2 diabetes occurs because of the progressive development of insulin resistance and β- cell dysfunction, the latter leading to an inability of the pancreas to produce enough insulin to overcome the insulin resistance. About 85% of people with type 2 diabetes are obese. This highlights the clear association between type 2 and obesity, with obesity causing insulin resistance. In particular, central obesity, where adipose tissue is deposited intra-abdominally rather than subcutaneously, is associated with the highest risk [27]. Other theories proposed include: the production of defective insulin which will not function effectively; the production of an insulin antagonist which may compete for insulin receptors; the formation of anti-insulin antibodies which immunologically inactivate insulin [28].
