NON-ADHERENCE TO ORAL HYPOGLYCAEMIC AGENT AMONG TYPE 2 DIABETES PATIENTS

Paulus, J. B. H. (20570) Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak

Introduction
Oral hypoglycaemic agent (OHA) is a crucial part of life-long type 2 diabetes treatment. Yet, nonadherence to OHA is a worldwide problem (Adisa, Alutundu, & Fakeye, 2009). As the problem facilitates development of diabetes complications and raises healthcare expenditures (Rohana et al., 2007), optimising type 2 diabetes patients adherence to OHA becomes imperative (Song, Lee, & Shim, 2010). Culturally tailored diabetes education programme is essential to improve type 2 diabetics adherence to OHA (Song et al., 2007). To do so, healthcare professionals must determine the barriers to self-regulated health management activities among patients (Song et al., 2010). Hence, this study was conducted to determine and understand those barriers. Studies in other countries found that socio-demographic factors, personality and psychosocial factors, knowledge and beliefs about diabetes, relationship between patient and health care provider, and treatment complexity influence type 2 diabetics adherence to OHA (Peyrot, McMurry, & Kruger, 1999; Vermiere et al., 2007; Adisa, Alutundu, & Fakeye, 2009). This research mainly questions what are the factors that cause non-adherence to OHA among type 2 diabetics?. This study aims to investigate how type 2 diabetics perceive and behave towards diabetes and OHA as well as the obstacles that they experienced in adhering to OHA. Furthermore, this study would generate knowledge for understanding why non-adherence to OHA occurs. The findings could be useful as reference to design future interventional programmes to promote continuous adherence to OHA among type 2 diabetes patients with diverse lifestyles and beliefs about their disease and treatment.

Discussion
Non-adherence to OHA is divided into intentional and non-intentional. In this study, the Health Belief Model (Fertman & Allensworth, 2010) was used to describe the reasons behind intentional omission of OHA. Based on the model, adherence to OHA is influenced by perceived barriers and self-efficacy in adhering to OHA, perceived benefits of adhering to OHA, and perceived severity of diabetes. The findings imply that patients might omit OHA when they perceive that the barriers to adherence are greater than the benefits as implied by Yam who felt inconvenient to get OHA refill at pharmacy due to transportation difficulty. Besides that, patients like Phil might omit OHA when they have low self-efficacy due to stress. Low self-efficacy might also contribute to omission of OHA when engaging in social activity as implied by Jen who felt uncomfortable to take OHA in the presence of her peers. Moreover, low self-efficacy to adhere to OHA might also be influenced by inadequate knowledge about diabetes (Vermiere et al., 2007) due to inability to understand the information conveyed by healthcare professional. Other than that, Phil connoted that patients may not adhere to OHA if they do not perceive its benefit to their health. Furthermore, Lee implied that patients might find it advisable to omit OHA when they perceive that the threat of its side effect is greater than its benefit. In addition, patients might also omit OHA when they do not perceive the severity of their diabetes disease as implied by Jos. On the other hand, unintentional non-adherence to OHA in this study occurred in the form of forgetfulness. Forgetfulness to take OHA could be influenced by busy working schedule (Adisa et al., 2009) as implied by Lee. Besides that, scarceness of OHA could also happen in rural hospital due to medicine under-stocking (Kagashe & Massawe, 2012). This leads to delay in getting OHA refill as experienced by Sal.

Figure 3: Themes and sub-themes that emerged from interviews

Findings
This study found six themes that describe the factors associated with type 2 diabetes patients non-adherence to OHA (Figure 4). Interpreting the meaning of the themes would help healthcare professionals to understand the reason behind non-adherence to OHA from patients perspective.
Figure 4: Themes, findings, and interpretation of findings that describe the factors associated with type 2 diabetes patients nonadherence to OHA

Method
This study employed a qualitative descriptive design to reveal and understand why non-adherence to OHA occurs among type 2 diabetics living in both rural and urban area. After obtaining ethical clearance from the Ethical Review Board of the Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, convenient sampling was done to select potential participants according to designated criteria (Table 1).
Table 1: Inclusion and exclusion criteria for this study Inclusion criteria Type 2 diabetes patients aged 30 to 79 years old Prescribed with single or multiple OHA, with or without other types of oral medication Has been on OHA prescription for one or more years Claimed to have experience difficulty adhering to OHA Exclusion criteria Type 1 diabetics Patients with gestational diabetes User of insulin or other types of self-administered injections Patients with cognitive or communication barrier

Conclusion
This study produces knowledge about the causes of non-adherence to OHA from patients point of view. Being theoretically generalisable, the findings of this study could guide healthcare professionals in understanding patients barriers to adhering to OHA and become a basis for healthcare professionals in assessing patients health beliefs. In turn, this could help in tailoring interventions to improve adherence to OHA among patients with different backgrounds and beliefs about diabetes and its treatment. However, this study involves only small groups of participants from two different regions, so the findings are not empirically generalisable for type 2 diabetes patients in other regions. Subsequently, this study implies that it is important for healthcare professionals to consider patients health beliefs in treating diabetes. Therefore a qualitative, ethnographic study is recommended for future research to gain knowledge about the social meaning of diabetes among larger groups of people in order to obtain findings with greater generalisability.

Eight type 2 diabetes patients were selected as respondents (Table 2), four each from the rural Beaufort District (Figure 1) and the urban Kuching City (Figure 2), to allow collection of diverse data, generate theoretically generalisable finding, and compare the findings between both areas.
Table 2: Respondents demographic and medication regime details Name Age Gender Ethnicity (year) 55 63 48 33 40 55 48 71 Male Male Female Female Female Male Male Male Lundayeh Dusun Bisaya Dusun Chinese Chinese Chinese Chinese Occupation Origin Current oral medication regime OHA Rubber-tapper Farmer None (housewife) None (housewife) Clerk Wedding planner School bus driver Retired technician Beaufort Beaufort Beaufort Beaufort Kuching Kuching Kuching Kuching Metformin Metformin Metformin Metformin Metformin Metformin Gliclazide and metformin Metformin Others None Hydrochlorothiazide and captopril Hydrochlorothiazide None None Captopril None None Duration taking OHA (year) 1 5 9 1 2 2 1 11

Reference
Adisa, R., Alutundu, M. B., & Fakeye, T. O. (2009). Factors contributing to nonadherence to oral hypoglycemic medications among ambulatory type 2 diabetes patients in Southwestern Nigeria. Pharmacy Practice, 7(3), 163-169. doi: 10.4321/S1886-36552009000300006 Department of Statistics Malaysia (2010). Basic population characteristics by administrative districts. Retrieved from http://www.statistics.gov.my/portal/download_Population/files/BPD/ad_2010.pdf Fertman, C. I. & Allensworth, D. D. (2010). Health promotion programs: from theory to practice. California: John Wiley & Sons Google (2012). Google Maps. Retrieved April 16, 2012, from http://maps.google.com.my/ Kagashe, G. A., & Massawe, T. (2012). Medicine stock out and inventory management problems in public hospitals in Tanzania: a case for Dar Es Salaam region hospitals. International Journal of Pharmacy, 2(2), 252-259. Retrieved from http://www.pharmascholars.com/admin1/files/22004.pdf Rohana, D., Wan Norlida, W. I., Nor Azwany, Y., Mazlan, A., Zawiyah, D., Che Kamaludin, C. A., Che Ghani, C. S. (2007). Economic evaluation of type 2 diabetes management at the Malaysian Ministry of Health primary care clinics, in Machang, Kelantan. Malaysian Journal of Public Health Medicine, 7(1), 5-13. Retrieved from http://www.pppkam.org.my/mjphm/journals/Volume%207%20(1)%20:%202007/5-13.pdf Song, M., Lee, M., & Shim, B. (2010). Barriers to and facilitators of self-management adherence in Korean older adults with type 2 diabetes. International Journal of Older People Nursing, 5(3), 211218. doi: 10.1111/j.1748-3743.2009.00189.x Vermiere, E., Hearnshaw, H., Ratsep, A., Levasseur, G., Petek, D., van Dam, H., et al. (2007). Obstacles to adherence in living with type-2 diabetes: an international qualitative study using meta-ethnography (EUROBSTACLE). Primary Care Diabetes, 1(1), 25-33. doi:10.1016/j.pcd.2006.07.002

Jos Phil Sal Yam Jen Lee Jong Leong

Consent for participation was obtained from all participants. In-depth, unstructured individual interviews were conducted to obtain ample data regarding respondents personal experience in adhering to OHA. Researcher functioned as both interviewer and moderator who probed respondents to express desired data. The topics covered in interview were mainly about what is diabetes and what respondents think regarding adhering to OHA. Each interview was recorded using voice recorder with respondents permission. Respondents physical reactions during interviews were noted to assist in interpreting the personal meaning of their statements. Theoretical data saturation was achieved after seven respondents were interviewed. All recorded interviews were transcribed. Each transcript was stored in the format of Microsoft Word Document. Data were analysed thematically. Transcripts were iteratively read and interpreted. Interesting data were then extracted. Inductive coding was done on significant data extracts. Codes with common patterns were attributed to significant sub-themes. Then, the sub-themes were examined to generate main themes. Finally all corresponding codes, sub-themes, and themes were reviewed for relevance and coherence. This resulted in six main themes that describe the factors associated with non-adherence to OHA (Figure 3): demographic factor, psychosocial factor, beliefs about disease and its treatment, communication between patient and health care provider, complexity of medication regime, and side effects of OHA.