ABSTRACT
Objective: This study was carried to evaluate the beliefs about medicines, adherence and self care management knowledge among type 2 diabetes mellitus patients in a teaching hospital in south eastern Nigeria.
Method: A questionnaire consisting of standardized survey instruments (DSCK–30, MMAS, BMQ and factors affecting knowledge acquisition and barriers to adherence) were used for this study. The questionnaire was interviewer assisted and administered to a cross section of 480 randomly selected ambulatory adult patients (18 years and above) who were attending the endocrinology clinic in the teaching hospital used for this study. Data was presented in frequency tables. Bivariate analysis was used to test the correlations among variables. Chi – square test was used to test for independence of variables.
Results: 413 participated in the study. The bivariate analysis showed a correlation between patients knowledge of diabetes and adherence (0.776, P = 0.000). Chi Square tests showed an association between occupation and monthly income with the categorical adherence of the patients. No association was found between age, gender, family history, duration of diabetes with categorical adherence for this study. The overall adherence of the patients on the Morisky Medication Adherence Scale (MMAS) was 6.2. Most of the respondents reported side effects (75.3%), forgetfulness (79%), cost of medications (84%), polypharmacy/pillburden (72.4%) and depression 77.0% as major barriers to adherence to their medications. Most of the respondents reported lack of time on the part of the patients, lack of time on the part of the health care professionals and access to health care as major barriers to acquiring diabetes care knowledge.
Conclusion: There are many factors that lead to medication non- adherence and acquisition of diabetes self care knowledge. Cost of medications, forgetfulness, polypharmacy, depression and side effects were the major factors reported in this study. A lot of work should be done in this area to improve patients’ adherence to medications for better prognostic outcomes.
CHAPTER ONE
INTRODUCTION
1.0 Introduction
Diabetes is a group of metabolic diseases1 in which a person has high blood sugar, either because the body does not produce enough insulin, or cells do not respond to the insulin that is produced.2 This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydyspsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes mellitus (DM): Type 1 DM results from the body’s failure to produce insulin and presently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as “insulin-dependent diabetes mellitus” (IDDM) or “Juvenile diabetes”. Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred to as non-insulin dependent diabetes mellitus (NIDDM) or “adult onset diabetes”. The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 Diabetes mellitus.
All forms of diabetes are treatable since the discovery of insulin in 1921, and type 2 diabetes may be controlled with oral medications. Both types 1 and 2 are chronic conditions that cannot be cured but can be adequately managed as to allow the patients lead normal lives. Pancreas transplants have been tried with limited success in types 1 DM; gastric bye pass surgery has been performed in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hyperglycemia, diabetic ketoacidosis, or non-ketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and diabetic retinopathy (retinal damage). Adequate treatment of diabetes is thus important, as well as blood pressure control and life style modifications such as smoking cessation and maintaining a healthy body weight.
1.1 Epidemiology of Diabetes Mellitus Worldwide
Diabetes mellitus is one of the leading health problems in Africa, where an estimated 12.1 million people, or 3.2% of the adult population, are now estimated to have the disease and, alarmingly, only 15% of people with the disease are diagnosed.3 In most cases, the diagnosis is made when the person presents to the clinic with a complication which is either acute or chronic. More daunting figures major preventive actions are taken, the number of people with diabetes is expected to double in the next 20 years to 23.9million in 2030.4 In 2012 alone, more than 330,000 people were expected to die from diabetes – related causes in the African Region, accounting for approximately 6% of all deaths in the 20 – 79 age group. More daunting still are reports that a child diagnosed with type 1 diabetes in sub-Saharan Africa has a life expectancy which varies between 7 months and 7 years, depending on the country, compared to 60 years in Western Europe.5 Despite these worrying figures, diabetes is not yet included as a priority in the global development agenda; consequently donors and international organizations are yet to pledge support to help developing countries address the emerging problems of diabetes as is being done with malaria, HIV/AIDS and tuberculosis.
Globally, as of 2012, an estimated 346 million people have type 2 diabetes.6 Diabetes mellitus occurs throughout the world, but (especially type 2) in the developed countries. The greatest increase in prevalence is expected to occur in Asia and Africa, where most patients will probably be found by 20307; the increase in incidence in developing countries follows the trend of urbanization and lifestyle changes, perhaps most importantly the “Western style” diet. This has suggested an environmental (i.e. dietary) effect, but there is little understanding of the mechanism(s) at present, though there is much speculation, some of it most compelling presented.7
In the United States, incidences of diabetes mellitus have been increasing substantially. In 2010, nearly 26 million people had diabetes in the United States, of which seven million people remain undiagnosed. Another 57 million people are estimated to have pre-diabetes. 8, 9
The Center for Disease Control (CDC) has termed the change an epidemic. The National Diabetes Information clearing house estimates diabetes costs $132 billion in the United States alone every year.10 About 5 – 10% of diabetes mellitus cases in North America are types 1, with the rest being type 2. The fraction of type 1 in other parts of the world differs. Most of these differences are not currently understood. The American Diabetes Association (ADA) cites the 2003 assessment of the National Centre for Chronic Disease Prevention and Health Promotion (Centre for Disease Control and Prevention) that one in three Americans born after year 2000 will develop diabetes in their lifetime.11,12According to ADA, about 18.3% (8.6million) of Americans age 60 and older have diabetes.13 Diabetes mellitus prevalence increases with age, and the numbers of older persons with diabetes are expected to grow as the elderly population increases in number. The National Health and Nutrition Examination Survey (NHANES III) demonstrated, in the population over 65 years old, 18% – 20% to have diabetes, with 40% having either diabetes or its precursor form of impaired glucose tolerance.14
1.2 Epidemiology of diabetes mellitus in Nigeria.
Diabetes is associated with considerable morbidity and mortality. In Nigeria, where health care services and accessibility are poor, DM is associated with a high disease burden.15Diabetes is also a major risk factor for cardiovascular diseases, stroke, and kidney failure.15
People with diabetes have shown to have higher mortality rates than people without it, although mortality rates depend on the location and the specific group reported.15 In Africa, DM probably has the highest morbidity and mortality rates of all chronic non-infective diseases.15 In Nigeria, communicable diseases remain the priority condition for the Ministry of Health. The importance of non communicable diseases as a significant contribution to disease burden in Nigeria is highly underscored. Most of the reports on morbidity and mortality rates of diabetes in Nigeria were made in the 1960s and 1970s and therefore may not reflect the current situation. A recent study in a tertiary hospital in Nigeria showed that DM admissions accounted for 15% of all medical admissions and 22% of all medical deaths.15 These facts demonstrate a worsening condition for DM-related admissions and deaths in Nigeria. An earlier study by Ogbera et al reported cumulative DM admission rates and death rates of 10% and 7.6% respectively. These figures were obtained from a 10 year survey from 1990 – 2000. These findings were not surprising because there had been projected worldwide increase in the prevalence of DM, especially in developing countries15 with this projected increase in prevalence rates in DM, the morbidity and mortality rates are expected to assume an upward trend especially in regions of the world where healthcare services are sub-optimal for the rapidly expanding populations.
