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Original Research Article

Adherence to Medications among Diabetic Patients

Attending University of Ilorin Teaching Hospital, Nigeria
Edwina C Bosah*1, Mohammed J Saka1, Idayat A Durotoye2, Adewumi O Oyabambi3,
Ahmed T Sanni4 and Abdullahi N Adamu5
1

Department of Epidemiology and Community Health, 2Department of Haematology, 3Department of Physiology, 4Department of
Medical Microbiology and Parasitology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
5
Department of Internal Medicine, Endocrinology unit, University of Ilorin Teaching Hospital, Ilorin, Nigeria
*For correspondence: Email: eddiebabe20@yahoo.com

International Journal of Health Research March 2014; 7(1): 1-25

Abstract
Purpose: To assess patients knowledge of diabetes and its treatment as well as adherence to medications
among diabetic patients in University of Ilorin Teaching Hospital (UITH), Ilorin, Kwara State.
Methods: This was a descriptive cross sectional study involving diabetic patients within 18 to 70 years of age.
Randomly sampled 260 diabetic patients were recruited from outpatients department in the hospital and
interviewed. Adherence was measured on a 3 point scale using a variation of the Morisky-Green Test.
Results: The level of adherence of patients to their anti-diabetic medications was 91%. Only 33.46% of them
had good knowledge of the disease and its treatment. Age of patients was found to have a significant influence
on the level of adherence to their anti-diabetic medications (p=0.04). The main reason for their non-adherence
to their anti-diabetic medications was forgetfulness (66.67%).
Conclusion: Although majority of the patients adhered to their anti-diabetic medications, the patients
knowledge of diabetes and it treatment was low. The need to create better awareness about diabetes to the
public and education of health professionals in this respect is vital.
Keywords: Adherence, anti-diabetic medications, diabetes mellitus, Ilorin
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Int J Health Res, March 2014; 7(1):

Bosah et al

Introduction
Worldwide, diabetes is a major public health
problem and the number of people suffering from
the disease is estimated to reach 330 million by
2030 [1]. There is a high clinical and economic
burden from the disease [2]: people with diabetes
have a two to four times higher risk of
cardiovascular diseases compared to the general
population and increased incidence of
retinopathy, peripheral nerve damage and renal
problems. The global increase in the prevalence
of diabetes is attributed to the huge population
growth, aging, urbanization, increase in obesity
and lack of physical activity.
In both developed and developing countries, nonadherence to medication among diabetic patients
remains a significant concern for physicians,
health care providers, and patients partly because
of its adverse consequences on therapeutic
outcomes [3]. Adherence to a medication regimen
here refers to the extent to which patients take
medications as prescribed by their physician.
There are many different methods for assessing
adherence to medications which are often
categorized as either direct or indirect, none of
which is considered a gold standard as each of
them has its own advantages and disadvantages
[4, 5]. The direct methods of measuring
adherence include directly observed therapy,
measurement of concentrations of a drug or its
metabolite in blood or urine, and detection or
measurement in blood of a biologic marker added
to the drug formulation [4, 5]. Indirect methods
of measuring adherence include patient
questionnaires, patient self-reports, pill counts,
rate of prescription fills, assessment of patients
clinical response, electronic medication monitors,
patients diaries and measurement of physiologic
markers [4, 5]. Although considered to be more
robust than indirect methods, direct methods have
limitations. For instance, they are susceptible to
distortion by patients (hiding pills in the mouth
and then discarding them), variations in
metabolism that can affect serum levels,
burdensome to the health care provider, and high

Knowledge of diabetes and Adherence to Medication

cost. Most of the indirect methods of assessing

adherence including questionnaires, diaries and
self-reports are usually susceptible to distortion
by the patients.
In Nigeria, some studies have been carried out on
knowledge and adherence relating to diabetes. In
2011, a study conducted in Benin City revealed
that those with no formal education had a higher
knowledge of diabetes when compared to their
counterparts that had higher level of formal
education [6]. Another research conducted by
Adisa and colleagues in Ibadan revealed that the
level of adherence to medications among the
diabetic patients was 60.2% [7]. An earlier report
has revealed that non-adherence behaviours
among ambulatory patients with type-2 diabetes
occur mostly due to omission and forgetfulness of
doses of medication [8]. These studies are in the
southern part of the country with religious and
cultural differences from the northern part of the
country. This study was therefore carried out in a
tertiary hospital in Ilorin, Kwara State. Ilorin is
located in north central part of Nigeria which has
not been evaluated in terms of patients adherence
to anti-diabetic medications. The objectives of
this study therefore, were to assess the patients
knowledge of diabetes and its treatment, and to
determine the level of adherence to medications
and factors influencing patients adherence to antidiabetic medications.

Methods
The study was a cross-sectional study carried out
among
diabetic
patients
attending
the
Endocrinology unit of the Department of
Medicine and Family Medicine of the University
of Ilorin Teaching Hospital, Ilorin between April
and June 2013. The minimum sample size was
determined by Fishers formula for population
less than 10,000 [9].
A total 260 subjects were selected using
multistage sampling technique. Inform consent
was obtained and only patients who consented
were recruited for the study. Ethical approval was
Int J Health Res, March 2014; 7(1):

Bosah et al

Knowledge of diabetes and Adherence to Medication

obtained from the Ethical and Review Committee

(ERC) of University of Ilorin Teaching Hospital
(UITH) with assigned number NHREC/02/05 /
2010.

Sciences (SPSS) version 16. Pearsons Chi

Square was used to test association in the cross
tabulated variables. Level of statistical
significance was predetermined at a p-value of
0.05.

In an interview using a structured questionnaire,

adherence to medication and knowledge of
diabetes and its treatment were evaluated. The
questionnaire was divided into three sections. The
first section obtained information on sociodemographic variables such as age, sex, place of
residence, ethnicity, religion and educational
level, marital status and occupation. The second
section obtained information about respondents
knowledge of diabetes including opinion,
knowledge about symptoms of the disease to
know if it can be treated medically or not,
information about anti diabetic medications, the
source of their information, and knowledge about
the type of anti diabetic medication used. The
third section obtained information about the
respondents
adherence
to
anti-diabetic
medications. In this section, patients were made
to identify the drugs they are taking, they were
asked to recall the time at which they took their
pills, number of times per day they took their
medications and the number of pills they took per
day and per dose. Patients were also asked to
recall the number of doses they missed within the
past seven days preceding the interview and to
verify with the remaining pills they will be
having left. If no missing of pill was their
answer, they were asked how long ago it has been
since a dose was missed. However, if they missed
their pills, they were asked the reasons for
missing. They were also asked about identified
side effects of pills they are using. Adherence was
evaluated using a variation of the Morisky Green
Test that have the advantage of making
alternative to answers in the Likert scale possible
[13].

Results

The study was carried out every Wednesday (with

the exclusion of public holidays) before the usual
clinic time of 1:00 pm. The interviewers were
research assistants recruited and trained for this
purpose. Non-English speaking patients were
interviewed using the Yoruba translation of the
English questionnaire which was the language all
the patients understood. The data obtained were
analyzed using Statistical Package for Social

Table 2: Patients knowledge about diabetes and its

treatment (n=260)

The response rate for the study was 100%. As

shown in Table 1, the ages of the clients ranged
from 18 to 70 years with a mean of 65 36.17
years. Majority of them (60%) were females.
Most of the patients (66.5%) did not have
adequate knowledge of diabetes (Table 2).
Table 1: Socio demographic data of clients
Socio demographic
characteristics (n=260)
Age group (years)
15 30
31 45
46 60
61 75
Sex
Male
Female
Marital status
Single
Married
Widowed
Level of education
None
Primary
Secondary
Tertiary
Occupation
Businessman/woman
Student
Housewife
Unemployed
Unskilled labourer
Skilled labourer
Others

Level of knowledge
Poor
Fair
Good

Frequency (%)
26 (10.0)
70 (26.9)
112 (43.1)
52 (20.0)
104 (40.0)
156 (60.0)
25 (9.6)
222 (85.4)
13 (5.0)
31 (11.9)
50 (19.2)
98 (37.7)
81 (31.2)
98 (37.7)
13 (5.0)
42 (16.2)
6 (2.3)
8 (3.1)
92 (35.4)
1 (0.4)

Frequency (%)
127 (48.85)
46 (17.69)
87 (33.46)

Many of the patients (99.2%) claimed to have

heard the information about diabetes from health
workers. As many as 91% of them adhered to
Int J Health Res, March 2014; 7(1):

Bosah et al

Knowledge of diabetes and Adherence to Medication

their medication (Table 3). Age had a significant

influence on their level of adherence (p < 0.05)
unlike education, occupation and monthly income
of the patients. The major factors affecting the
adherence were forgetfulness (66.7%), busy
schedule (16.7%) and better feeling of the
patients (16.7%).
Table 3: Patients adherence
medications (n=260)
Level of adherence
High
Intermediate
Low

to

anti

diabetic

Frequency (%)
206 (79.2)
32 (12.3)
22 (8.5)

Discussion
This study revealed that majority (91.0%) of the
study population adhered to their anti-diabetic
medication but less than half (33.5%) of them had
adequate knowledge of their disease condition.
Adherence to medication was only significantly
affected by age (p<0.050) and the main reason for
non-adherence was forgetfulness (66.7%).
From the result of this study, the poor level of
knowledge of patients that attended the clinics
could be a reflection of the low level of literacy
of the patients as 11.9% of them have no formal
education. This is contrary the study conducted in
Benin City which revealed that those without
formal education had a higher knowledge about
diabetes compared to their counterparts that had
higher level of formal education [6]. Since many
of the patients claimed to have been informed
about the disease by the health workers, it does
appear that the knowledge of the disease passed
to the patients was inadequate and their further
education is vital.
In the hospital evaluated, medications were
provided to the patients by the pharmacists unless
the medication prescribed is not available in the
hospital, in which case the patient is referred to a
community pharmacy to fill/refill his/her
prescription. Compared to earlier adherence
levels of less than 61% reported previously [7,
11], it does appear that the counseling of the
diabetic patients by the pharmacists before

medications are supplied in the facility studied is

effective.
The association of age with the patients level of
adherence in this study has been reported in a
Japanese study [10]. However, unlike the
Japanese study where adherence decreased among
middle aged patients, we observed increase in
adherence to the medications with age. Although
education had no influence on the patients level
of adherence to their anti-diabetic medications in
this study, other studies revealed that adherence
improves with the level of education of clients
[11, 12].
This finding is line with similar studies which
revealed that forgetfulness was the major singular
reason why medications were missed and it has
been implicated as one of the major reasons why
doses of medications are missed in patients with
type 2 diabetes [8]. Another study also identified
that busy work schedules [8] especially for
patients in the working population as one of the
reasons why some patients do not take their antidiabetic medications as prescribed.
The data presented is limited by the sample size
and the population studied. Since data were not
collected from other hospitals in the parts of the
country where this study was carried out, the
interpretation may be limited to the facility.

Conclusion
This study revealed a high level of adherence to
anti-diabetic medications and poor knowledge of
diabetes among the patients. This calls for better
education of diabetic patients and the health
professionals in Nigeria as a whole as diabetes is
now one of the leading non-communicable
diseases in the world of major concern.

Acknowledgements
The authors appreciate the study participants,
management and staff of University of Ilorin
Teaching Hospital (UITH) particularly the
departments of family and internal medicine for
their supports in the data collection process.
Int J Health Res, March 2014; 7(1):

Bosah et al

Knowledge of diabetes and Adherence to Medication

Funding

Munger MA, VanTassel BW, LaFleur J. Medication

nonadherence: An unrecognized cardiovascular Risk factor.
MedGenMed 2007; 9(3):58.
The Centers for Disease Control and Prevention. National
diabetes fact sheet: National estimates and general
information on diabetes in the United States. Revised edition.
Atlanta, GA, US Department of Health and Human Services,
Centers for Disease Control and Prevention, 1998.
King H. WHO and the International Diabetes Federation:
Regional Partners. Bulletin WHO. 1999; 77:954.
Odili VU, Isiboge PD, Eregie A. Patients knowledge of
diabetes mellitus in a Nigerian city. Trop J Pharm Res 2011;
10(5); 637 - 642.
Adisa R, Fakeye TO, Fasanmade A. Medication adherence
among ambulatory patients with type 2 diabetes in a tertiary
healthcare setting in southwest Nigeria. Pharm Practice
(Internet). 2011; 9(2):72-81.

This work did not receive any special grant from

any funding agency in the public, commercial or
non-governmental organization. It was solely
funded by members of the team.

Conflict of interest
No conflict of interest associated with this work.

Authors contribution
We declare that this work was done by the
authors named in this article and all liabilities
pertaining to claims relating to the content of this
article will be borne by the authors. ECB and
IAD conceived and designed the work, AOO
participated in data collection, STA analysed the
data while MJS and ANA supervised the work.
ECB wrote the manuscript and all authors read
and approved it for publication.

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