Assessing the Influential Factors Associated with Medication Non-Adherence and Self-Care Practices Among Type 2 Diabetes Mellitus Patients in Tripoli, Libya
Assessing the Influential Factors Associated with Medication Non-Adherence and Self-Care Practices Among Type 2 Diabetes Mellitus Patients in Tripoli, Libya
Diabetes mellitus (DM) is a serious global issue and a
public health care concern rapidly expanding worldwide (1). It has
the highest psychological and behavioural demands of
all chronic illnesses (2). There is no indication that the prevalence of
DM will reverse as it continues to rise globally (3). DM prevalence in the
Middle East and North Africa (MENA) area; which Libya is part of, had the
highest regional prevalence rate of 12.2% and 16.2% in 2019 and 2021;
respectively (4, 5). During 1990 and 2019, the region witnessed an increase in
the average mortality rate of 0.2% (24.8 to 25.2) (6). Most mortalities (24.5%)
from diabetes in working-age adults occur in the MENA Region. The MENA area
will have 136 million diabetics by 2045 and an estimated growth of 86 %, which
is the second-highest rate in the world (5). Although it has been estimated
that the prevalence of DM in Libya might reach 14.1%, the exact prevalence is
unclear (7). According to survey findings by Beshyah, the incidence of
non-communicable illnesses like DM is frighteningly high (16.4%) (8). By 2045, DM
cases will reach 762.500 in Libya, up from 442.500 in 2017, in which adults had
a diabetes prevalence of 11.2% (9).
Although adherence to medication therapy is a well-known
issue in clinical practice, medication adherence of DM patients reportedly
varies, and non-adherence is a significant obstacle in providing diabetic care
and treatment delivery (10). Over $100 billion is estimated to be spent yearly
on managing the consequences of inadequate medication adherence (11). Patients
who do not adhere to their drug therapy might do so on purpose or accidentally
(i.e., intentional or unintentional non-adherence) (12). However, a medicine
should be taken as directed to attain its intended effectiveness (13).
Poor medication adherence is a significant contributor to
uncontrolled hyperglycaemia (14). Acute and chronic DM complications can result
from inadequate and poorly controlled hyperglycaemia. Several of these
complications are permanent and can cause impairment and failure to many body
organs, particularly the nerves, eyes, and kidneys, if they are not managed ().
Chronic diabetes complications are the main reason for the high hospitalization
rate of DM patients in Libya, despite the fact that effective treatments and
medications that lower glycaemia levels are available nationwide ().
Declarations
Acknowledgment
The author would like to acknowledge Ahmed Abo-hajar, Atia Zidan, and Muhammad Eswaisi, who helped in the questionnaire distribution and data collection, and all of the patients who participated in this study.
Conflict of Interest
The author declares no conflicting interest.
Data Availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethics Statement
Ethical approval was obtained from the ethical committee at the Biotechnology Research Centre and given a reference number of BEC-BTRC 33-2020.
Studies have investigated and identified possible
influential factors and reasons for non-adherence to medication across a broad
spectrum of illnesses, including DM. Numerous types of research have revealed
inadequate and poor levels of DM patients' adherence to medication (17, 18) and
self-care practice (19, 20). Due to differences in study size and methods, the
association of different factors to adherence is conflicting.
For T2DM patients to adhere to therapy better, they must
have good knowledge and a better understanding of the disease since having
enough knowledge about DM promotes excellent self-care practices, the knowledge
of T2DM patients and their awareness of the disease is directly influenced by
their social and demographic characteristics (21). These characteristics are
important determinants and influential factors that can impact how successfully
a patient comprehends and adheres to their medication and self-care practice
(22). Age (23-27), gender (28, 29), education (27, 29, 30), and occupation (25, 28)
are some of the commonly cited social-demographic factors. The WHO has
identified four additional factors and social-demographic variables that are
likely to contribute to non-adherence. These include; patient-related,
condition-related, therapy-related, and healthcare /system-related factors (31).
Patient-related factors frequently cited include forgetting to take
medication/s (26, 28, 32-35), stopping taking medication/s either when feeling
well (36) or felling worse (23), and lack of finance (33, 35, 37-40). Condition-related
factors have also been reported as the duration of having the disease (24, 30),
associated comorbidities (41, 42), and taking other medications (25). Therapy-related
factors such as side effects (26, 36, 37, 40, 41, 43) and medication cost (24, 36, 44)
were commonly associated with non-adherence.
Given the absence of research that identifies influential
factors that may explain non-adherence behaviour among T2DM patients in Libya,
there is a need to determine the adherence status of T2DM patients to both
antidiabetic medication and self-care practices, as well as the possible factors
that can contribute to non-adherence of these patients to these two
facets of therapy in the country. This study performs a much-needed
service by filling in that knowledge gap. The finding of this study will be
beneficial for Libya's healthcare system and will make an essential
contribution to non-adherence knowledge in Africa.
Material and Methods
Ethics Approval and Consent to Participate
Ethical approval was obtained from the ethical committee at
the Biotechnology Research Centre and given a reference number of BEC-BTRC
33-2020. All participant patients received voluntary informed consent and were
assured that their information was kept confidential since their names were not
requested. The participants were also informed that their participation was
strictly voluntary and that they were free to refuse to participate in the
study at any time without any consequences.
Study Setting and Study Participants
A descriptive cross-sectional study in a single health
facility using a pre-tested questionnaire was carried out on T2DM who sought
care at the National Centre for Diabetes and Endocrinology (NCDE) in Tripoli/
Libya. The NCDE provides outpatients with diabetes follow-up, medications, and
laboratory testing despite operating as a referral clinic. The study was
conducted for eight months (Starting June 2019) to investigate the reasons and
factors influencing the non-adherence behaviour of these patients to their
diabetic treatment. The study included patients of both genders attending the
NCDE who are diagnosed with T2DM, aged ≥25 years old, with a fasting blood
glucose level > 126 mg/dl and are being treated for at least six months with
oral anti-hyperglycaemic (OAH) medication with/or without insulin. All these
patients agreed to participate of their free will. A nurse participated in
looking over the patient file to make sure that the type 1 diabetes was
excluded from the study. The study also excluded patients who were recently
diagnosed with diabetes (≤ 6 months). Being newly diagnosed can be confusing
and overwhelming, and because patients may have trouble adjusting to life with
DM, they were excluded. Patients who could not speak either Arabic or English
were ruled out. The study also excluded patients who were very sick, unable,
and unwilling to participate in the survey.
Sample Size Determination
The sample size for this study was calculated using the
formula mentioned in Naing et al. review (45):
n=d2Z2P(1−P)
Equation 1
N = the estimated sample size of
patients, Z = confidence level of which 95% is conventional, Z = 1.96, and P =
the expected prevalence and the population assumed to be non-adherent to diabetic
treatment. According to Mesquida et al., 50-60% of diabetic patients show poor
medication adherence (46). The mean of this percentage will be the target
population, i.e., P = 0.55, 1-P is the probability of diabetic adherent
patients (1-P = 45%), and d is the precision and accepted margin of error (5%,
d = 0.05).
The outcome of the sample size formula is the required
sample group for this study (i.e., 380 patients).
Data Collection and Sampling Technique
A self-report, pre-tested questionnaire was used to collected
the data. It consisted mainly of closed-ended questions with few open-ended
questions. These questions were collected from previous and similar literature
(41, 47, 48). The questionnaire contained four main sections. The first section had
six questions regarding the socio-demographic characteristics of the
participants, such as; age, gender, marital status, education level, employment,
and family income. The second section contained six questions regarding
participants’ medical conditions; duration of having diabetes, medications
prescribed, duration of taking diabetes medication/s, frequency of drug intake,
dosage regimen, and what associated chronic disease/s they have besides T2DM. Since
no golden standard is available for medication adherence assessment (49),
adherence to diabetic medication was determined by asking patients to recall if
they missed any doses of medication as least once in the past seven days (50).
Using a dichotomous response scale (i.e., yes/no), the third section contained
four adherence indicators that were used to evaluate medication adherence and
diabetic self-care practices of the patients. They include taking prescribed
medication as recommended, maintaining and not having difficulty following
recommended dietary restrictions, performing exercise regularly and monitoring
blood glucose levels regularly. Since outdoor exercise is uncommon for Libyan
women, regular exercise was defined as doing all the household routines by oneself
as cooking, cleaning, and washing. The last section was also a dichotomous
scale (i.e., yes/no), which contained twelve reasons and influential factors
causing non-adherence to medication, taking other medications, having
associated chronic disease, forgetting to take prescribed antidiabetic
medication, being aware of the consequences of skipping doses and not adhering
to medication as recommended, stop taking prescribed antidiabetic medication
without physician recommendation, stop taking it when feeling well and symptoms
under control, stop taking it when not feeling well and symptoms not under
control, taking alternative treatment instead of medication, medication price,
monitoring blood glucose level is cumbersome, sleep disturbance because of frequent
urination, and experiencing side effects from antidiabetic medicines. Three
final year B. Pharm. students from the Faculty of the Pharmacy / University of
Tripoli helped to distribute and collect the questionnaires from the patients
at the NCDE. Using a convenient sampling method, a nurse working at the clinic
was asked to help select patients who were willing to participate and met the
study's inclusion criteria. Patients who only met the requirements were given
the questionnaire. The study's objective was clarified to the selected patient
on the explanatory letter attached to the questionnaire. The nurse was asked to
fill out the questionnaire for illiterate patients, and the rest of the
participants completed the questionnaire themselves. The students went through
all sections to ensure no missing data in the collected questionnaires. Data's
completeness was checked regularly until the required sample size was ordered.
Operational Definition of Adherence to Antidiabetic
Medication
This study's operational definition of adherence was 100 %
adherence to the recommended medical prescription. Missing a single dose out of
more than one prescribed dose was considered non-adherent. Patients who did not
miss a dose in the previous seven days were considered adherent. These patients
were given a score of “1”.
Data Management and Quality Assurance
Before distributing the questionnaire, it was first prepared
in English. It was then translated into the local Arabic language by the
principal investigator, using iterative translation to enhance the quality of
the translation (51). Five T2DM patients at the NCDE were asked if the
questions were clear, simple to understand, and not ambiguous. All five
patients confirmed that the questions' meanings were interpreted the same as
intended (52). These patients were not included in the study. The internal
consistency of the questionnaire was pilot-tested on 30 patients. A default
sample size of 30 participants is advised in pre-tests of questionnaires (53).
Because the questions are a dichotomous response scale (yes/no),
Kuder–Richardson 20 test (KR-20) was used to assess the reliability using
Microsoft Excel 2016. The KR-20 obtained (0.806) was above the accepted limit of
0.70, which indicates reliability (54). To manage the data obtained and ensure
its quality, the principal investigator monitored the data collection process
throughout the study.
Data Analysis
Data collected in this study were coded, entered using
double data entry to ensure completeness and was analyzed using Statistical
Packages for Social Sciences (SPSS) version 26 (SPSS Inc., Chicago, IL, USA).
Categorical and numerical variables were tabulated and expressed as frequencies
and percentages. Binary logistic regression was used to assess the association
between medication adherence and each independent explanatory variable as
socio-demographic parameters, duration of diabetes, diabetic treatment,
comorbid conditions, other medications taken with diabetic treatment, and the
different factors influencing non-adherence (i.e., between dependent and
independent variables). Furthermore, multivariate logistic regression was performed
to further analyze all independent variables with a p-value of less than
0.25 at a 95% confidence interval (CI) in the binary logistic regression
analysis. Using the model of the Hosmer–Lemeshow goodness of fit test in
multivariable logistic regression, the adjusted odds ratios (AORs) at 95% CI were
estimated to identify non-adherence associated factors, and the association was
considered statistically significant when the p-value is equal to 0.05
or less.
Table 1. Socio-demographic characteristics and adherence association of the participants.
The socio-demographic parameters of the 380 participants are shown in Table 1. Out of the total participants, more than a quarter of the patients, 105 (27.6%), aged between 51- 60 years, more than half 227 (59.7%), were males, and the majority, 322 (84.7%), were married. Regarding education status, 216 (56.8%) of the participants have an education degree, either university or another degree, and 54(14.2 %) of the subjects had no formal education. Regarding occupation, 228(60 %) of the patients were employed, and 136(35.8%) had per capita monthly income of less than 500 L.D.
Participants' Medication Adherence Status
The adherence to diabetic medication among the study
participants was 67.1 %. These patients did not miss a single dose of
medication in the past seven days. Whereas; 125 (32.9%) of the participants were
non-adherent and did miss to take the prescribed medication at least once.
Adherence Indicators to Diabetic Self-care Practices
The T2DM participant patients were assessed for their
diabetic self-care practices. 221 (58.2%) of the patients were not careless and
took their prescribed medication as recommended by their physician, 180(47.4%)
maintained and did not find difficulty in following recommended dietary
restrictions, 169(44.5%) performed exercise regularly, and 283(74.5%)
monitoring their blood glucose level regularly (See Table 2).
Participants' Clinical and Medication Characteristics
The clinical and medication-related characteristics of the participants are shown in Table 3. One-third of the participants, 132(34.7%), have had diabetes for more than ten years, 129(33.9%) have been taking diabetic medication for less than 5 years, 153(40.3%) were taking OHA with insulin, 168(44.2%) were taking two dose unit per day, and 227(59.7%) of the patients were taking their medication twice a day. Of the patients taking OHA, 59(15.5%) were on monotherapy, while 131(34.5%) were on combination therapy. Metformin alone was taken by 53 (13.9%) of the patients. The most frequently prescribed combination therapy was a dual OHA containing metformin and glimepiride 57 (15%), followed by metformin and glibenclamide 26 (6.8 %). Triple OHA was also prescribed, in which 13 (3.4%) of the patient were taking a combination therapy of metformin, sitagliptin, and glimepiride. More than a third of the patients, 153(40.3%), took OHA with insulin. Metformin was the most typical combined OAH medication with insulin 138 (36.3%). 145(38.2%) of the patients have associated comorbidities. Hypertension 67(17.6%) was the most frequent among the participants, followed by heart disease 22(5.8%). Whereas; 21(5.5%) of the patients had hypertension and heart disease.
Binary Logistic Regression Association to Adherence
In the crude binary logistic analysis, patients aged between 71-80 years were 77% less to adhere to the prescribed anti-diabetic medications than those aged 25 -30 years (Crude OR [COR] [95% CI] =0.231 [0.054-0.991]). Participants who had a university education were 2.49 times more adhered to medication than those who were illiterate ([COR] [95% CI] =02.497[1.285-4.854]). See Table 1.
Table 2. Adherence indicators and diabetic self-care practices of the participants.
Adherent Indicators
Frequency (%) (n=380)
Non-adherent (n=125)(%)
Adherent (n=255)(%)
COR [95% CI]
p-value
Taking prescribed medication as recommended and not being careless
No
159(41.8%)
87(69.6)
72(28.2)
1.00
Yes
221(58.2%)
38(30.4)
183(71.8)
5.819[3.642-9.298]
0.000*
Maintaining and not finding difficulty in following recommended
dietary restrictions.
As seen in Table 2, patients who maintain and follow recommended dietary restriction ([COR] [95% CI] =1.902 [1.226-2.950]) and regularly monitor their glucose level ([COR] [95% CI] =1.952[1.213-3.141]) are two times more likely to be adherent to their antidiabetic medication. Whereas; those who perform regular exercise ([COR] [95% CI] =2.848[1.795-4.517]) are three times more likely to be adherent.
Patients having DM for five years or more were 57% less likely to adhere to medication than patients who have had diabetes for less than five years ([COR] [95% CI] =0.430[0.245-0.755] and 0.426[0.244-0.743] respectively). Participants who are taking OHA with Insulin are 65% less adherent to their medications than patients who are on single OHA ([COR] [95% CI] =0.355[0.182-0.690]). T2DM patients who have comorbidities such as hypertension, heart disease, or both and asthma are 67%, 73%, 65%, and 79% less likely to adhere to medication than respondents who have no associated comorbidities ([COR] [95% CI] = 0.330[0.188-0.580], 0.267[0.110-0.650], 0.352[0.142-0.872] and 0.213[0.073-0.626]); respectively. Details are in Table 3.
Reasons for Medication Non-adherence
Details of the factors contributing to non-adherence that
were assessed in this study are presented in Table 4. More than a third of the
participants, 145(38.2%), have associated chronic disease, 154(40.5) are taking
other medications besides their diabetic medicine, and 273(71.8%) respond that
they forget to take prescribed antidiabetic drugs. Nearly a quarter of the participants,
77 (20.3%), stopped taking their prescribed anti-diabetic medication without
physician recommendation, 60 (15.8%) stopped taking it when they were feeling
well, and 66 (17.4 %) stopped taking their medication when not feeling well and
symptoms not under control. 50 (13.2%) of the participants admitted taking
alternative treatment instead of the prescribed anti-diabetic medication, and
359 (94.5%) said they would take medication more regularly if it were provided
for free or affordable. Monitoring blood glucose levels is cumbersome for 153 (40.3%)
participants, and 177 (46.6%) are disturbed at night during sleep because of
frequent urination. Side effects from the anti-diabetic medication were
experienced by 104 (27.4%) of the patients, and 29 (7.6%) were unaware of the
consequences of not adhering to medication as recommended and the consequences of
skipping doses. All of these factors in the binary logistic analysis were
associated with medication non-adherence except stopping prescribed
antidiabetic medication when not feeling well, taking medication more regularly
if provided at an accessible or affordable price, and monitoring glucose level
is cumbersome. Participants who answered yes to the influential factors are
(50.9%-87.6%) less likely to adhere to medication than participants answering
‘no’.
Factors Associated with Medication Non-adherence
Factors that were found to have a statistically significant association with non-adherence in the multivariable logistic regression analysis, as illustrated in Table 5, are; the type of medications being prescribed ([AOR] [95% CI] = 0.214[0.073-0.632]), carelessness ([AOR] [95% CI] = 2.880 [1.387- 5.983]), forgetfulness ( [AOR] [95% CI] =0.199 [0.070- 0.570], feeling well ( [AOR] [95% CI] = 0.153[0.058- 0.402]), medications side effects ( [AOR] [95% CI]=0.382 [0.181- 0.809]) and unawareness ([AOR] [95% CI] = 0.146 [0.037- 0.581]).
Table 4. Factors and reasons contributing to non-adherence behaviour among T2DM participants.
Factors
/ reasons influencing non-adherence
Total
Frequency (%) (n=380)
Non-adherent
(n=125)(%)
Adherent
(n=255)(%)
COR
[95% CI]
p-value
Associated
chronic disease
No
235(61.8)
57(45.6)
178(69.8)
1.00
Yes
145(38.2)
68(54.4)
77(30.2)
0.363
[0.233-0.564]
<0.001
Taking
other medications
No
226(59.5)
51(40.8)
175(68.6)
1.00
Yes
154(40.5)
74(59.2)
80(31.4)
0.315
[0.202-0.491]
< 0.001
Forget to
take prescribed antidiabetic medication.
No
107(28.2%)
9(7.2)
98(38.4)
1.00
Yes
273(71.8%)
116(92.8)
157(61.6)
0.124
[0.060- 0.256]
< 0.001
Stop
taking prescribed medication without a physician's recommendation.
T2DM patients who were prescribed OHA and insulin, forget to
take prescribed antidiabetic medication, stop taking prescribed anti-diabetic
medication when feeling well and symptoms under control, who experience side
effects from antidiabetic medicines, and those who are not aware of the
consequences of not adhering to medication as recommended and the consequences
skipping doses are 79 %, 80%, 84%, 62% and 85% less likely to be adherent to
their diabetic treatment; respectively. Being careless and not taking
prescribed medication as recommended is 2.8 times non-adherent to therapy.
Discussion
To the author’s knowledge, the influential factors causing
poor adherence to diabetic medication and self-care practices among T2DM
patients have not been reported before in Libya. For this reason, T2DM patients
attending the NCDE in Tripoli, Libya, were assessed in this study for their
medication adherence, self-care activities, and the influential factors
associated with the non-adherence of these patients to these two
facets of therapy in the country. Few studies on adherence to anti-diabetic
medication among T2DM patients in Libya were identified (55-57). Two of these
studies took place in Benghazi Diabetes Centre and targeted both T1 and 2 DM
patients at different periods. The first aimed to assess patients’ practices
and knowledge (55). The other study also assessed patients’ ability in addition
to factors that improve adherence to the condition's treatment and management
(56). A most recent study, which took place in Tripoli at the NCDE, assessed
the influence of illness perceptions on medication adherence among T2DM
patients (57). Each of these research utilized a different adherence measure.
Still, none of these studies have focused on the influential factors causing
poor adherence to diabetic medication and self-care practices in the country.
The status of adherence to anti-diabetic medication reported
by this study was unsatisfactory 67.1% but reasonable when compared to other
developing African countries such as Egypt (38.9%) (58), Sudan (45%) (59), Ethiopia
(95.7%) (47) and Nigeria (86.8%) (60). Patients may also have difficulty
remembering their medication-taking regimens. This was minimized by asking the
participants to recall events over a short period which was from the preceding
week. Similar findings of adherence level were reported in the previously
mentioned Libyan studies. The prevalence of low medication adherence which was
measured using the eight-item Morisky medication adherence scale, was 36.1%
according to Ashus et al., (57). Whereas; 27.1% of diabetics reported by Roaeid
et al. not take their medications regularly (55). A much higher percentage of
low adherence levels was reported by Elkharam et al., which assessed adherence
using HbA1c and showed that 63.2% of diabetic patients had poor glycaemic
control (56). All these findings highlighted the low adherence levels among the
diabetic Libyan population.
According to this study, males were found to have a higher
prevalence of T2DM than females in the Libyan population. This outcome was
consistent with earlier studies conducted in other nations, where T2DM
prevalence was lower in females than males (61). The distribution of body fat
varies by gender. Females tend to have more subcutaneous and peripheral fat,
which increases their insulin sensitivity and helps protect them from T2DM. In
contrast, males are linked to insulin resistance because they have a more
significant proportion of visceral and hepatic fat. Laziness in the lifestyle
of the male gender is another contributing factor to developing T2DM (61).
Treatment protocols for T2DM patients include
pharmacological and non-pharmacological measures (27). These patients rely on
insulin and OAH that should be taken on schedule in addition to a healthy diet,
frequent blood sugar testing, and regular exercise to achieve satisfactory control
of blood glucose levels (62). Medication adherence and self-care practices are
the most crucial aspects of diabetes control (63). Because
patients alone are responsible for 98% of the self-care activities, adherence
to these two facets of therapy is difficult, demanding, and
challenging (64). Adherence to anti-hyperglycaemic medication, diet, and exercise is,
therefore, essential and must be maintained to sustain blood glucose levels and
minimize complications over the long term (65). When comparing patients who
don't follow these non-pharmacological routines in the binary logistic analysis,
self-care adherent practices are up to three times more medication adherence.
It is a matter of need for cognitive training programs and behavioural therapy
on lifestyle modifications, dietary restrictions, physical work out, diabetic
foot care, and regular ophthalmology examinations. All these therapy measures
have shown to enhance patients’ life expectancy and quality (48).
This study revealed that non-adherence was a statistically
significant association with patients who were prescribed OHA and insulin. Such
patients are 79 % less likely to be adherent to their medication ([AOR] [95%
CI] = 0.214[0.073-0.632]). More than a third of the participants, 153(40.3%),
were using combination therapy. This may be due to the Libyan market's high
cost of insulin injections. Contrary to this study’s finding, glibenclamide
monotherapy was administered to 74.3% of the patients (40). Combination therapy
is aligned with the indicated strict management of blood glucose levels, and
such patients may have felt better and stopped taking medication accordingly.
This may explain why 60 (15.8%) stop taking their prescribed antidiabetic
medication when feeling well, and their symptoms are under control and are less
likely to be adherent. A tailored treatment strategy and individualized blood
glucose target for each patient may be essential. It is of equal importance and
necessary to develop approaches to educating patients about their medication
regimens. This will assist in reducing the already enormous disease burden associated
with non-adherence and diabetic complications.
In coincide with similar studies (21, 26, 28, 32-35); that
indicated that forgetfulness and being unaware of the consequences of not
adhering to medication as recommended and the consequences of skipping doses
were significantly associated with medication non-adherence, this current study
revealed that almost three-quarters of the patients 273(71.8%) forget to take
their prescribed antidiabetic medication and 159(41.8%) were being careless and
not taking prescribed medication as recommended. Since 228(60%) of the patients
are employed, and the majority are of working age, they may become distracted
at work and forget to take their prescriptions. Furthermore, one-third of the
research population comprises patients aged 60 and beyond, which may account
for forgetfulness. As people age, their cognitive ability drops. This pertains
to individuals aging with multi-comorbidities and taking multi-medications.
Measures must be developed to lessen forgetfulness and unawareness. These
factors may result from the patient not receiving the ongoing assistance they
require after the prescribed medication. Patients unaware of their disease must
have regular meetings with diabetes educators to raise their awareness, and of
equal importance is to keep the period between consultations
with health professionals as minimal as possible.
T2DM patients who experience side effects from anti-diabetic
medication were found in this current study to be 62% less likely to be
adherent to their medication and showed a statistically significant
association. In the same way, Manobharathi et al. and several other studies
have stated that side effects of drugs as one of the critical associated
factors for non-adherence (26, 36, 37, 40, 41, 43). Anti-diabetic medications may
not have been the only cause of the side effects seen during treatment. Since
more than a third of the study population have comorbidities, medications such
as antibiotics, antihypertensive, angiotensin receptor blockers, β -blockers,
calcium channel blockers, and vitamins may have contributed. These adverse
effects may be mistakenly thought to result from anti-diabetic medications (61).
Associated comorbidities were found to be insignificantly
associated with medication adherence in this study. This finding differs from a
Saudi Arabia study which revealed that patients with no comorbid disorders had
a significant association with good adherence (66). Patients with chronic
illnesses, in general, and DM in particular, may struggle to adhere to the
prescribed therapy due to cumbersome and inconvenient dosing regimens caused by
multi-medication and the concern of consuming too many medicines. Due to the
multi-medications administered to T2DM patients with associated comorbidities,
poor adherence appears to hinder achieving a satisfactory clinical outcome in
such patients substantially. The associated comorbidities of these patients
will determine how many medications they will take and are dependent mainly on
their disease severity. Such patients are, therefore, challenging and present a
problem to healthcare practitioners since they may have difficulty
adhering to all prescribed medications belonging to numerous different
pharmacological classes. In this study, Hypertension 67(17.6%) and heart
disease 22(5.8%) were the most associated comorbidities among the patients
studied.
The cost of medications, low monthly income, and unemployment
are deterrent factors affecting patients’ medication adherence. Although these
economic factors were found to be insignificant similar to research from South
India finding (67), medication non-adherence is potential because these
patients may be unable to purchase most of their medications, resulting in
missed doses. However, this can cause sub-optimal drug levels if the
medications are not taken regularly and timely. Only 21 (5.5%) of respondents
answered no when asked if they would take their prescription more frequently if
it were free or inexpensive, which may account for the lack of a significant
association. This may be since after and during the covid-19 break out. The
Libyan healthcare system had suffered a clear scarcity of medications and
pharmaceutical products previously offered to the general population free of
charge in all public healthcare systems. Therefore, chronic disease medications
should be available at medical facilities so that patients who cannot afford
them can easily obtain them.
In further assessing the factors that affect medication
adherence, it was found that some diabetic patients, 50 (13%), shifted to
alternative treatment, cupping (bloodletting), and herbal medication instead of
their antidiabetic medications. The Libyan nation commonly uses alternative
therapies, especially herbal medicine, in their culture. Libya has a rich
source of medical plants (68). A study by Ashur et al. showed that
seventy-seven different traditional medicine products were utilized by 28.9% of
diabetes patients, with herbs being the most frequently used (69). Another study
by Gupta et al. revealed that numerous herbs could cause drug-herbal
interaction when taken with anti-diabetic medication. Such interaction could
alert the pharmacokinetic and pharmacodynamics features of such medications and
also can have both risks and benefits to diabetic patients (70).
The utilization of a self-report
questionnaire has limitations as an estimate of patients medication adherence
levels. Although a cost-effective, reliable, and a method that helps health
care providers to identify patients who are more likely to have poor adherence;
it’s not the real medication-taking behaviour. Self-reports might be subjective
and may overestimate patient’s adherence status when compared to other methods.
Social desirability is another disadvantage of self-reporting questionnaires. The
possibility of meaning loss during translation cannot be neglected. Another
methodological limitation of the study is convenience sampling, which has the
potential to produce samples that are either under or over-represented in the
research population. The obtained results do not represent medication adherence
of diabetic patients in the entire city or country because it was a cross-sectional
survey conducted in a single diabetes centre. The findings' generalizability
may have been improved with a multicentre investigation. Selection bias is
another study limitation because, typically, patients who visit NCDE are often
more concerned about their health and were the selected participants. Because the study assessed
adherence by just using a questionnaire and did not consider the consequence
of non-adherence, future researchers need to narrow these gaps by
using different analysis methods. For example, analysis of patient’s medication
record, pill counts, and medication use control in addition to using a
questionnaire. These methods would greatly improve the value of
clinical analysis and allow further evaluation of the
impact of non-adherence to anti-diabetic medication.
Conclusion
Non-adherence to recommended medication and self-care
practices exists among T2DM patients in Libya and is unsatisfactory but
reasonable compared to other developing countries. Influential factors contributing
to non-adherence behaviour are the type of prescribed medications,
carelessness, unawareness, forgetfulness, stopping taking prescribed
antidiabetic medication when feeling well and symptoms under control, and
medication side effects. Monitoring T2DM individuals' medication adherence
levels and self-care practices through regular follow-up and providing these
patients with the necessary education is vital. This will make it easier for
medical practitioners to recognize patients who don't take their medications as
prescribed, aid in creating effective programs, and facilitate the
establishment of successful measures to encourage medication adherence and
self-care practices and eventually prevent diabetic complications. If the
patient does not follow the specified treatment plan, all attempts, time, and
funds spent on diagnosing, prescribing, and educating them on their condition
will be squandered.
Influential factors causing poor adherence to antidiabetic medications and self-care practices among type 2 diabetes mellitus (T2DM) patients have not been reported before in Libya. To assess such factors that contribute to non-adherence, a single health facility, cross-sectional descriptive study was carried out on T2DM patients attending the NCDE in Tripoli/ Libya; using a pre-tested questionnaire. Crude odds ratios in the binary logistic regression were used to describe the associations between medication adherence and various independent factors using SPSS version 26. Adjusted odds ratios with their corresponding 95% confidence intervals were further generated in the multivariable analysis, to determine variables which were independently associated with medication adherence and were considered significant at a p-value of <0.05. Of the 380 study participants, only 225(67.1%) were adherent. 159(41.8%) were non-adherence to physician recommendations and were careless when taking their medication, 200(52.6%) found difficulty maintaining recommended dietary restrictions, 211(55.5%) and 97(25.5%) didn’t adhere to regular exercise or blood glucose monitoring; respectively. Factors significant association with non-adherence were; medication being taken; especially patients who were prescribed OHA and insulin ([AOR] [95% CI] = 0.214[0.073-0.632]), being careless and not taking prescribed medication as recommended ([AOR] [95% CI] = 2.880 [1.387- 5.983]), forgetfulness ([AOR] [95% CI] =0.199 [0.070- 0.570], stop taking prescribed antidiabetic medication when feeling well ( [AOR] [95% CI] = 0.153[0.058- 0.402], medications side effects ( [AOR] [95% CI]=0.382 [0.181- 0.809] and unawareness of the consequences of not adhering to medication as recommended and the consequences skipping doses ([AOR] [95% CI] = 0.146 [0.037- 0.581]). Adherence to recommended medication and self-care practices in Libya is unsatisfactory. Diabetes education, awareness programs, and regular monitoring of T2DM individuals’ medication adherence and self-care practices are vitally required.
Guariguata L, et al. Global estimates of diabetes prevalence for
2013 and projections for 2035. Diabetes Res Clin Pract. 2014; 103(2):
137–149.
Ciechanowski PS, et al. The patient-provider relationship:
attachment theory and adherence to treatment in diabetes. Am J Psychiatry.2001;158(1):29-35.
El-Kebbi IM, et al. Epidemiology of type 2 diabetes in the Middle
East and North Africa: Challenges and call for action. World J Diabetes
2021; 12(9): 1401-1425.
World health organization. [Internet], (16 September 2022). Fact
sheets on Diabetes. [Internet]. https://www.who.int/news-room/fact-sheets/detail/diabetes.
International Diabetes Federation. Middle East and North Africa
diabetes report 2000 -2045. IDF Diabetes Atlas, 10th edn. Brussels, Belgium:
2021. https://www.diabetesatlas.org
Moradinazar M, et al. Epidemiological status of type 2 diabetes
mellitus in the Middle East and North Africa, 1990–2019. East Mediterr
Health J. 2022;28(7):478–488.
El-Shareif HJ. Quality of care for type 2 diabetes mellitus in
Tripoli Medical Center: A retrospective study of 628 patients. Clin Diabetol.
2017; 6(6): 204-210.
Beshyah SA. Non-communicable diseases and diabetes care guidelines:
Epidemiology and call for collective action. Ibnosina J Med BS.
2010;2(3):142-8.
Elmiladi SA. Presentation and character for adult patients with
diabetes in Libya. Mediterr J Pharm Pharm Sci. 2022; 2(1): 83-90.
Cramer JA. A systematic
review of adherence with medications for diabetes. Diabetes Care
2004;27(5):1218-24.
Schuz B, et al. Medication
beliefs predict medication adherence in older adults with multiple illnesses. J
Psychosom Res 2011;70(2):179–87.
de Vries, ST, et al.
Medication beliefs, treatment complexity, and non-adherence to different drug
classes in patients with type 2 diabetes. J Psychosom Res. 2014;
76(2):134-138.
Khan AR, et al. Factors
contributing to non-compliance among diabetics attending primary health centers
in the Al Hasa district of Saudi Arabia. J Fam Community Med.
2012;19(1):26-32.
American Diabetes Association. Diagnosis and classification of
diabetes mellitus. Diabetes Care 2012;35(supplement -1): S64 – s71.
Alshwikh HE, Hander F. Reasons for admission of individual with
diabetes to the Tripoli Medical Center in 2015. Diabetes Metab Syndr:
Clinical Research & Reviews 2019; 13:2571-2578.
Aminde LN, et al. Adherence
to antidiabetic medication and factors associated with non-adherence among
patients with type-2 diabetes mellitus in two regional hospitals in Cameroon. BMC
Endocr Disord. 2019;19(1): 35.
Elsous A, et al. Medications
adherence and associated factors among patients with type 2 diabetes mellitus
in the Gaza Strip, Palestine. Frontiers in Endocrinology. 2017; 8:100
–9.
Mogre V, et al. Adherence to and factors
associated with self-care behaviours in type 2 diabetes patients in Ghana. BMC
Endoc Disord. 2017; 17:20–8.
Kassahun T, et al. Diabetes
related knowledge, self-care behaviours and adherence to medications among
diabetic patients in Southwest Ethiopia: A cross-sectional survey. BMC Endoc
Disord. 2016; 16:28–39.
Fatema K, et al. Knowledge attitude and practice regarding diabetes
mellitus among nondiabetic and diabetic study participants in Bangladesh. BMC
Pub Health. 2017;17: 364-74.
Nurumal MS, et al. A review on knowledge of
diabetes and practice of medication adherence among people living with diabetes
mellitus. Int J Care Scho. 2020;3(1): 45-54.
Abate TW. Medication non‑adherence
and associated factors among diabetes patients in Felege Hiwot Referral
Hospital, Bahir Dar city administration, Northwest Ethiopia. BMC Res Notes.
2019; 12:175.
Garcı´a-Pe´rez LE, et
al. Adherence to Therapies in Patients
with Type 2 Diabetes. Diabetes Ther. 2013; 4:175–194.
Tsehay T, et al. Assessment
of antidiabetic medication adherence and its determinants among ambulatory
patients with type 2 diabetes at Tikur Anbessa Specialized Hospital, Addis
Ababa, Ethiopia. J Pharm Alternative Med.2016;11:19-24.
Siraj J, et al. Patients’
adherence to antidiabetic medications and associated factors in Mizan-Tepi
University Teaching Hospital: A cross-sectional study. Inquiry. 2021;
58: 1–8.
Afaya AR. et al,. Medication adherence and self-care behaviors
among patients with type 2 diabetes mellitus in Ghana. PLOS ONE. 2020:
15(8):1-14.
Adisa R, et al. Factors
contributing to non-adherence to oral hypoglycemic medications among ambulatory
type 2 diabetes patients in Southwestern Nigeria. Pharm Pract.
2009;7(3):163-169.
Khan AR, et al. Factors
contributing to non-compliance among diabetics attending primary health centers
in the Al Hasa district of Saudi Arabia. J Fam Community Med. 2012;
19:26-32.
Abebaw M, et al. Adherence
and Associated Factors towards Antidiabetic Medication among Type II Diabetic
Patients on Follow-Up at University of Gondar Hospital, Northwest Ethiopia. Adv
Nurs. 2016; 2016: 1-7.
Pourhabibi N, et al. Determinants of poor treatment adherence among
patients with type 2 diabetes and limited health literacy: A scoping review. J
Diabetes Res. 2022; 2980250: 1-10.
Demoz GT, et al. Andrew
Collier Predictors of poor adherence to antidiabetic therapy in patients with
type 2 diabetes: a cross‑sectional study insight from
Ethiopia. Diabetol Metab Syndr. 2020; 12:62-70.
Gelaw BK, et al.
Non-adherence and contributing factors among ambulatory patients with
antidiabetic medications in Adama Referral Hospital. J Diabetes Res. 2014; 2014:1-9.
Ahmadipour H, et al.
Secondary prevention by enhancing adherence in diabetic patients. Int J Prev
Med. 2010;1(1):50-55.
Medi RK, et al. Medication
adherence and determinants of non-adherence among south Indian diabetes
patients. J Soci Health Diabetes 2015; 3(1):48-51.
Rwegerera, GM. Adherence to
antidiabetic drugs among patients with Type 2 diabetes mellitus at Muhimbili
National Hospital, Dares Salaam, Tanzania-A cross-sectional study. Pan Afr
Med J. 2014; 17:252. doi:10.11604/pamj.2014.17.252.2972.
Yusuff, KB, et al. Adherence
to antidiabetic drug therapy and self-management practices among type-2
diabetics in Nigeria. Int J Clin Pharm.
2008; 30(6): 876-88.
Pascal IG, et al. Blood
glucose control and medication adherence among adult type 2 diabetic Nigerians
attending a primary care clinic in under-resourced environment of eastern
Nigeria. North Am J Med Sci. 2012; 4:310-5.
Adisa R, et al. Medication
adherence among ambulatory patients with type 2 diabetes in a tertiary
healthcare setting in southwestern Nigeria. Pharm Pract.
2011;9(2):72-81.
Wabe NT, et al. Medication
adherence in diabetes mellitus and self-management practices among type-2
diabetics in Ethiopia. N Am J Med Sci. 2011; 3(9):418-423.
Manobharathi M, et al.
Factors associated with therapeutic non-compliance among type 2 diabetes
mellitus patients in Chidambaram, Tamilnadu, India. Int J Community Med
Public Health. 2017;4(3):787-791.
Alqarni AM, et al. Adherence
to diabetes medication among diabetic patients in the Bisha governorate of
Saudi Arabia – a cross-sectional survey. Patient Prefer Adherence. 2019;
13:63–71.
Badi S, et al. Adherence to
Antidiabetic Medications Among Sudanese Individuals With Type 2 Diabetes
Mellitus: A Cross-Sectional Survey. J Patient Exp. 2020;7(2): 163-168.
Ajibola, SS, Timothy FO. The
influence of national health insurance on medication adherence among outpatient
type 2 diabetics in Southwest Nigeria. J Patient Exp. 2015;
5(2):114-119.
Naing L, et al. Practical
Issues in Calculating the Sample Size for Prevalence Studies. Arch Orofacial
Sci. 2006; 1: 9–14.
Mesquida
M, et al. Primary Care Records of Chronic-Disease Patient Adherence to
Treatment. Int. J. Environ. Res. Public Health. 2021; 18(7): 3710.
Bonger
Z, et al. Adherence to diabetic self-care practices and its associated factors
among patients with type 2 diabetes in Addis Ababa, Ethiopia. Patient
Prefer Adherence. 2018;12: 963–970.
Sharma
T, et al. Poor adherence to treatment: A major challenge in diabetes, J Int
Clin Med. 2014; 15(1): 26-29.
Lehmann
A, et al.. Assessing medication adherence:
options to consider. Int J Clin Pharm. 2014; 36 (1):55-69.
Abula T, Worku A. Patient noncompliance with drug regimens for
chronic diseases in northeast Ethiopia. Ethiop J Health Dev. 2001;
15:185-92.
Forsyth
BH, et al. Methods for translating
survey questionnaires. Paper presented at the 61st Annual Conference of the
American Association for Public Opinion Research, Montréal; 2006.
Pascal
IG, et al. Blood glucose control and medication adherence among adult type 2
diabetic Nigerians attending a primary care clinic in under-resourced
environment of eastern Nigeria. N Am J Med Sci. 2012;4(7):310-5.
Patricia
TV, et al. Sample size for pre-tests of questionnaires. Qual Life Res.
2014;24(1):147-51.
Heale
R, Twycross A. Validity and reliability in quantitative studies. Evid Based Nurs. 2015; 3(8): 66-67.
Roaeid
RB, Kablan AHA. Profile of diabetes health care at Benghazi Diabetes Centre,
Libyan Arab Jamahiriya. East Mediter Health J. 2007; 13(1): 168-76.
Elkharam
WM, et al. Knowledge of and adherence to health advice among adults with
diabetes in Libya. Ibnosina J Med BS. 2013; 5: 143-150.
Ashur
SA, et al. Illness perceptions of Libyans with T2DM and their influence on
medication adherence: a study in a diabetes center in Tripoli. Libyan J Med.
2015, 10: 29797.
Shams
ME, Barakat EA. Measuring the rate of therapeutic adherence among outpatients
with T2DM in Egypt. Saudi Pharm J. 2010; 18 (4): 225-232.
EI-Hadiyah
TM, et al. Factors affecting medication non-adherence in type 2 Sudanese
diabetic patients. Pharmacol Pharm. 2016;7: 141-146.
Awodele O, Osuolale JA. Medication adherence in type 2 diabetes
patients: study of patients in Alimosho General Hospital, Igando, Lagos,
Nigeria. Afr Health Sci. 2015;15(2): 513-522.
Manandhar-Shrestha
JT, et al. Adverse effects of oral hypoglycemic agents and adherence to them
among patients with type 2 diabetes mellitus in Nepal. J Lumbini Medic
College. 2017;5(1):34-40.
Hernandez-Ronquillo
L, et al. Factors associated with therapy noncompliance in type 2 diabetes
patients. Salud Publica de Mexico. 2003;45(3): 191-197.
Nazar
CMJ, et al. Effectiveness of diabetes education and awareness of diabetes
mellitus in combating diabetes in the United Kigdom; a literature review. J
Nephropharmacol. 2016;5(2):110-115.
Jannoo
Z, Mamode Khan NM. Medication adherence and diabetes self-care activities among
patients with type 2 diabetes mellitus. Value Health Reg Issues.
2019;18:30-5.
Barnes
L, et al. Illness beliefs and adherence in diabetes mellitus: a comparison
between Tongan and European patients. The New Zealand Medical Journal.
2004;117(1188):743.
Alqarni AM, et. al.
Adherence to diabetes medication among diabetic patients in the Bisha
governorate of Saudi Arabia – a cross-sectional survey. Patient Preference
and Adherence 2019,13: 63–71.
Divya
S. and Nadig P. Factors contributing to non-adherence to medication among type
2 diabetes mellitus in patients attending Tertiary care hospital in south
India. Asian J Pharmac Clin Res. 2015; 8(2): 274-276.
Abogmaza
A.F, et al. A review on the medicinal and aromatic plants growing in Libya and
their therapeutic properties. Int Res J Sci Tech. 2020; 2(1): 327-334.
Ashur
SA, et al. Use of traditional medicine among type 2 diabetic Libyans. Eastern
Medit Health J. 2017; 23(5):375-82.
Gupta RC. et al. Interactions between
antidiabetic drugs and herbs: an overview of mechanisms of action and clinical
implication. Diabetology and Metabolic Syndrome. 2017; 9:59.
