The neglected side of diabetes

Poor adherence to diabetes medications and treatment has been reported to be a prime reason for the increasing morbidity due to diabetes in Kerala, where diabetes affects nearly one in five persons in rural areas.

A recent cross-sectional survey conducted among known diabetes patients in rural Kerala reported that the levels of non-adherence to medication is as high as 74 per cent — underlining the need for immediate interventions to improve patient awareness about the disease.

The study, conducted by researchers at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, appears in the latest issue of Asia-Pacific Journal of Public Health. In a State which has one of the highest levels of diabetes prevalence at 20.6 per cent and has reported the highest proportion of out-of-pocket spending on health in the country at 90 per cent, poor adherence to treatment of a systemic disease such as diabetes could have catastrophic effects on the health system’s resources as well as individual family budgets, it is pointed out.

The community-based study was conducted among 346 diabetes patients in rural Thiruvananthapuram, specifically from 24 wards from the panchayats of Kadakkavoor, Chirayinkeezhu, Sreekaryam, Kudappanakkunnu, Vembayam, Karakulam, Balaramapuram, and Vizhinjam.

The prevalence of diabetes in Thiruvananthapuram district is estimated to be 16 per cent. Most of the patients in the sample had co-morbid diseases, mainly hypertension (77.5 per cent). Majority of them were on a combination therapy and the most commonly used medication was metformin, followed by glibenclamide. The researchers reported that patients using oral hypoglycaemic agents (OHAs), those with irregular blood sugar monitoring, those who received limited instructions from doctors, those who resorted only to symptomatic management, and those who did not have a family member’s help to remember to take medications were more likely to have poor adherence to treatment.

Diabetes management instructions from doctors are an important modifiable factor associated with treatment adherence. Detailed, individual instructions from doctors may improve adherence rates, especially since diabetes patients are known to require constant motivation and intensive patient education. However, the high patient load and staff shortage in public sector hospitals often result in inadequate patient-physician interaction. Hence, counselling for both patients as well as doctors may be necessary to improve treatment adherence, the study pointed out.

Adherence might improve if patients are made aware of the rationale behind the management of diabetes and the importance of taking their medications regularly regardless of symptoms. The study’s findings thus underline the importance of patient’s awareness of his disease and his habits of self management in achieving adequate glycemic control (proper blood sugar levels) and thus minimising the complications of diabetes. Another finding was that the family played a big role in encouraging drug adherence. Patients whose family ensured that they took medication on time had better drug adherence.

Lower socio-economic status is another factor to be taken into account. Those with lower per capita expenditure were more likely to report poor adherence.

The study also reported that adherence rates were higher for insulin use than for OHAs. Those taking oral drugs were likely to discontinue their treatment unlike those using insulin. Patients who did not monitor their blood glucose levels regularly were nearly five times more likely to be poorly adherent to treatment, it was found.

The study has pointed to the urgent need for better efforts to improve drug adherence in the case of chronic non-communicable diseases, as the complications of diseases such as diabetes can lead to increased morbidities as well as increased cost of treatment. More effective interventions are needed so that patients have a better understanding of the disease and are self-motivated to comply with their doctors’ instructions.