Bruce SP, Acheampong F, Kretchy I.

Adherence to oral anti-diabetic drugs among patients attending a Ghanaian

teaching hospital. Pharmacy Practice 2015 Jan-Mar;13(1):533.

Original Research
Adherence to oral anti-diabetic drugs among
patients attending a Ghanaian teaching hospital
Suliasnaia P. BRUCE, Franklin ACHEAMPONG, Irene KRETCHY.
Received (first version): 9-Nov-2014 Accepted: 29-Jan-2015

*
ABSTRACT INTRODUCTION
Background: The burden of diabetes mellitus, especially
Type-2, continues to increase across the world. Medication adherence is gaining recognition among
Medication adherence is considered an integral clinicians, healthcare systems, and governments
component in its management. Poor glycemic controls due because of the increasing concerns of the high
to medication nonadherence accelerates the development prevalence rate of non-adherence and its
of long-term complications which consequently leads to associated adverse outcomes and higher costs of
increased hospitalization and mortality. care.
Objective: This study examined the level of adherence to
oral antidiabetic drugs among patients who visited the The prevalence of diabetes for all age-group
teaching hospital and explored the probable contributory worldwide was estimated to be 2.8% in 2000 and
factors to non-adherence. expected to rise to 4.4% by 2030.1 The cost of
Methods: A cross-sectional descriptive study using
systematic sampling to collect quantitative data was
managing diabetes as well as the associated
undertaken. Questionnaires were administered to out- complications has a significant impact on the
patients of the medical department of a teaching hospital healthcare systems of many countries. In US for
in Ghana. Logistic regression was performed with example, the direct cost incurred in the
statistical significance determined at p<0.05. management of diabetes include USD31 billion for
Results: A total of 200 diabetic patients participated in the general medical cost, USD27 billion for the
study. Using the Morisky Medication Adherence scale, the provision of care in the direct treatment of the
level of adherence determined was 38.5%. There were disease and also USD58 billion for the treatment of
significant correlations between level of adherence and
educational level [(OR)=1.508; (CI 0.805- 2.825),
diabetes-related complications.2
P=0.019), and mode of payment [(OR)=1.631; (CI 0.997- The World Health Organization in their medication
2.669), P=0.05).
adherence report has quoted the statement by
Conclusion: Adherence in diabetic patients was low
among respondents and this can be improved through
Haynes et al.3 that “increasing the effectiveness of
education, counseling and reinforcement of self-care. adherence interventions may have a far greater
There were several possible factors that contributed to the impact on the health of the population than any
low adherence rate which could benefit from further improvement in specific medical treatments”. The
studies. treatment of chronic illnesses like diabetes
commonly includes the long-term use of
Keywords: Medication Adherence; Diabetes Mellitus, pharmacotherapy. Although these medications are
Type 2; Risk Factors; Logistic Models; Ghana
effective in combating the disease, their full benefits
are often not realized because approximately 50%
of patients do not take their medications as
prescribed.4 A patient’s ability to follow treatment
plans to achieve results is frequently compromised.
Factors contributing to poor medication adherence
are myriad5 and include those that are related to
patients (e.g., suboptimal health literacy and lack of
involvement in the treatment decision–making
process), those that are related to physicians (e.g.,
prescription of complex drug regimens,
communication barriers, ineffective communication
of information about adverse effects, and provision
of care by multiple physicians), and those that are
related to health care systems (e.g., office visit time
limitations, limited access to care, and lack of health
information technology). Because barriers to
* medication adherence are complex and varied,
Suliasnaia Patricia BRUCE. MSc, BPharm. Clinical solutions to improve adherence must be
Pharmacist, Pharmacy Department, Korle Bu Teaching
multifactorial.
Hospital. Accra (Ghana). [email protected]
Franklin ACHEAMPONG. MSc, MBA, BPharm. Principal Adherence has been defined as the active,
Clinical Pharmacist, Emergency Department, Korle Bu voluntary, and collaborative involvement of the
Teaching Hospital. Accra (Ghana).
[email protected]
patient in a mutually acceptable course of behavior
Irene KRETCHY, MPhil, BPharm. Lecturer, School of to produce a therapeutic result.6
Pharmacy, University of Ghana. Legon, Accra (Ghana).
[email protected]

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 Bruce SP, Acheampong F, Kretchy I. Adherence to oral anti-diabetic drugs among patients attending a Ghanaian
teaching hospital. Pharmacy Practice 2015 Jan-Mar;13(1):533.

Table 1. Demographics and relevant characteristics of the numbered 1 to 5, and the first number picked then
respondents (N=200) became the first patient. Beginning from the first
Respondents patient picked as the starting point on the
Characteristics (N=200) th
attendance register for the day every 5 person was
n %
selected till the total number of patients required for
Gender
the sample was selected.
Female 105 52.5
Male 95 47.5 The study setting was a 2000 bed tertiary care
Age(years) facility with an average daily out-patient attendance
<30 12 6.0
of 1500 and an average admission rate of about
30-39 44 22.0
40-49 52 26.0 250 patients per day. Type 2 diagnosed patients
50-59 54 27.0 between the ages of 18 and 75 who visited the
>59 38 19.0 medical out-patient department of the hospital were
Highest level of education included in the study.
No formal education 34 17.0
Primary 53 26.5 Data were collected from May to June, 2011 using a
Secondary 65 32.5 self-administered questionnaire. The questionnaire
Tertiary 48 24.0 consisted of respondents’ demographics such as
Occupational status gender, age, levels of education, occupation, marital
Unemployed 48 24.0 status, monthly income and mode of payment of
Trader/artisan 83 41.5 diabetic drugs. It also included questions to test
Professional 62 31.0 their knowledge and beliefs of diabetes mellitus and
Others 7 3.5
the use of oral anti-diabetic drugs. The
Mode of payment
Self-paying 51 25.5 questionnaire was translated into local languages
Health insurance 129 64.5 such as Ga, Twi and Ewe and back into English to
Family and friends 18 9.0 ensure uniformity without altering the questions to
NGO 1 0.5 be communicated to the respondents.
Average monthly income(USD)*
< 25 59 29.5 Adherence level was determined with the Morisky
9
25-50 48 24.0 Medication Adherence Scale (MMAS). This is a 4-
51-75 25 12.5 item inventory used in assessing both unintentional
>75 68 34.0 and intentional non-adherence behaviors.
* USD calculated based on 1USD=GHc2 Adherence in this study was defined as a “NO”
response (or a score of 1) to each of the questions
In the premiere teaching hospital in Ghana, on the scale. Four then became the excellent
diabetes accounted for 6.8% of all adult admissions adherence score. However, in this study, binary
and also accounted for 7.8% of all adult death.7 In variables using categorization of 3 or greater versus
2009, diabetes mellitus also ranked first in the top <3 representing adherent and non-adherent
ten admissions of the hospital. Patients obtain their patients respectively was used. This was based on
oral antidiabetic drugs either via the National Health acceptable adherence rate of 75% as the cut-off
Insurance scheme or by purchasing their own point for adherence.8
medications. Knowing the level of adherence
among oral antidiabetic drug users and identifying Retrieved copies of the questionnaire were entered
the probable factors contributing to their medication into SPSS version 16 for descriptive statistics and
adherence have implications for designing inferential statistics. Factor analysis of the 4
strategies to improve adherence. This study questions of the MMAS was undertaken to
therefore sought to determine the level of determine the direction of their measurement.
adherence to antidiabetic drugs by type-2 diabetic Logistic regression was performed with statistical
patients and explore the contributory factors to non- significance determined at p<0.05. Approval was
adherence. obtained from the Internal Research Ethics Review
Board of the Public Health Unit of the Hospital.

METHODS
RESULTS
This was a cross-sectional descriptive study using
systematic sampling to collect quantitative data. A total of 200 questionnaires were retrieved,
Patients attending diabetic clinic at the Medical out- crosschecked for accuracy and entered for analysis.
patient department of the of the Korle-bu Teaching This represented a response rate of 89.3%. Many of
Hospital are normally given appointment dates and the respondents (27.1%) were aged 50–59 years.
to which they are expected to come for review. Females were more than males and over a third 65
Therefore participants were identified using the list (32.8%) had at least secondary education.
of all the patients attending the clinic on the different Respondents’ demographic characteristics are
clinic days during the study period. The sample size presented in Table 1.
was calculated using the precision method. This About 47.5% of the respondent had been diagnosed
was based on the assumption of a minimum of type-2 diabetes for between 5-10 years, 31% for
estimated adherence rate of 25%8 at a 95% less than 5 years, 18% for more than 10years and
confidence interval with 80% statistical power to only 3% did not know. Retinopathy (66.5%) and foot
obtain a sample size of 224. The first patient was ulcers (73%) were the commonest knowledge of
randomly selected through a ballot of a set of balls diabetes complications among the respondents.

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 Bruce SP, Acheampong F, Kretchy I. Adherence to oral anti-diabetic drugs among patients attending a Ghanaian
teaching hospital. Pharmacy Practice 2015 Jan-Mar;13(1):533.

Table 2. Correlation matrix for 4-items on MMAS

Do you stop taking
If you feel worse do Careless at times Do you ever forget
your medicines
you stop taking about taking my to take your
when you feel
your medicines medicines medicines
better
If you feel worse do you stop taking
1.00
your medicines
Do you stop taking your medicines
0.77 1.00
when you feel better
Careless at times about taking my
0.85 0.81 1.00
medicines
Do you ever forget to take your
0.71 0.87 0.64 1.00
medicines
The others included nephropathy (28%), neuropathy backgrounds were unable to read effectively or
(35%), erectile dysfunction (31%), and 5.5% did not understand the instruction provided by the health
know. professionals and as such were not able to take
their medications optimally. Drug therapy in
The majority of the respondent (79%) took diabetes is increasingly becoming more complex
Metformin as part of their regimen, and then and as such patients need to understand the
glibenclamide (57.5%), tolbutamide (16%), regimen prescribed by their health providers to aid
pioglitazone (10%) and rosiglitazone (1%). The adherence and good health outcomes.
correlation analysis between the 4 questions of the
MMAS showed strong correlation among them (see Occupational status was not associated with level of
Table 2). adherence. This was also similar to studies from
Uganda14 and Malaysia15 where the nature of work
The level of adherence among respondents based of diabetes patients did not have any association
on excellent adherence where respondents had a with adherence to oral antidiabetic drugs. The ability
perfect score of 4 was 11%. Moreover with an to obtain medications by health insurance scheme
acceptable score of 75%, 38.5% of the respondents holders contributed to adherence. Regular income
were adherent (Table 3). earners who did not use health insurance in
There were significant correlations between level of acquiring their medications could make regular
adherence and educational level [(OR)=1.508; purchases.
(95%CI 0.805 - 2.825), P=0.019), and mode of There was an inverse but significant correlation
payment [(OR)=1.631; (95%CI 0.997 - 2.669), between the total number of oral anti-diabetic drugs
P=0.05).Details of logistic regression analysis are taken daily and adherence. Adherence rates
provided in Table 4. decrease as the pill burden increases as with the
16,17
study by Dailey et al. An earlier work had also
DISCUSSION concluded that patients became more adherent
when they received fixed-dose combination therapy
Adherence to oral anti-diabetic drugs measured in which reduced pill burden instead of the
this study at a cutoff point of 75% or higher was combination therapies.18
38.5%. The adherence rate was similar to a study
conducted in Egypt in which the adherence rate was Although duration since diagnosis19 had been
38.9%10 and Mexico with an adherence rate of shown to be associated with increased adherence,
41%.11 However this was lower compared with 60% this study found otherwise. For example, a study
in a similar study conducted in Southwestern conducted in Mexico showed that newly diagnosed
Nigeria12 and 78.3% in Brazilian study.13 Although patients had poorer adherence to their
these reported rates of adherence vary with respect medications.20 In chronic diseases such as type 2
to the previous studies, these serve to confirm the diabetes mellitus, the attitude of patients in denying
problem of non-optimal adherence among the the disease is reduced as patients accept treatment
majority of patients with chronic medical conditions. after years of suffering from the disease.

The findings showed that there was a positive Patients who receive information about their
significant association between the level of disease and medication from healthcare providers
education and adherence. This was consistent with are more adherent21,22 but like in a previous study
other studies.
10,13
Educated patients are more likely this was not the case.10
to know the consequences of diabetes and the Limitations
complications associated with diabetes and as such
tend to adhere to their medications. This study was conducted in a tertiary setting where
most diabetic patients across the country with
In addition, patients with no/low educational

Table 3. Respondents’ beliefs and motivation for adherence

Positive response
Item
n (%)
Do you feel that your diabetes and complication is getting worse? 72 (36)
Does complication pose severe problem to your health 162 (81)
Does medication effectively reduce your blood sugar level 175 (87.5)
Are you reminded to take drugs as scheduled by family members and friends? 91 (45.5)
Are you sure you will be able to follow all the advice given to you by your health professional? 177 (88.5)

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 Bruce SP, Acheampong F, Kretchy I. Adherence to oral anti-diabetic drugs among patients attending a Ghanaian
teaching hospital. Pharmacy Practice 2015 Jan-Mar;13(1):533.

Table 4. Logistic regression analysis

Variable Odd ratio 95% Confidence interval p-value
Age 0.826 (0.605 - 1.127) 0.229
Highest level of education 1.508 (0.805 - 2.825) 0.019
Occupation 0.274 (0.119 - 0.633) 0.002
Level of income 1.516 (0.982 - 2.340) 0.060
Mode of payment 1.631 (0.997 - 2.669) 0.050
Number of drugs taken per day 1.241 (1.005 - 1.532) 0.045
Duration since diagnosis 1.174 (0.721 - 1.910) 0.915
uncontrolled sugar levels and complications are ADHERENCIA A ANTIDIABÉTICOS ORALES
referred for management. Participants’ frequent ENTRE PACIENTES QUE VISITAN UN
interactions with physicians may affect their HOSPITAL UNIVERSITARIO EN GANA
attitudes and perceptions about medication
adherence during the study period. Another RESUMEN
important limitation is that patients could be giving Antecedentes: La carga de la diabetes mellitus,
wrong estimates of their adherence levels when especialmente de la tipo 2, continúa creciendo en todo el
using a self-reporting method. Also the number of mundo. La adherencia a la medicación se considera un
componente integral de su manejo. El mal control de la
factors contributing to adherence explored in this glicemia debido a la no adherencia a la medicación
study might not have been comprehensive. acelera el desarrollo de complicaciones a largo plazo lo
que lleva consecuentemente a aumento de hospitalización
y mortalidad.
CONCLUSIONS Objetivo: Este estudio examinó los niveles de adherencia
Adherence in diabetic patients was low among a los antidiabéticos orales entre pacientes que visitaron el
respondents and this can be improved through hospital universitario y exploró los factores
probablemente contribuyentes a la no adherencia.
education, counseling and reinforcement of self- Métodos: Se realizó un estudio transversal descriptivo
care. It is also recommended that prescribing usando una muestra sistemática para recoger datos
regimen with fixed-dose combinations which tend to cualitativos. Se administraron cuestionarios a pacientes
reduce both the frequency of intake as well as the ambulatorios del departamento médico de un hospital
pill burden can contribute to adherence. universitario de Gana. Se realizó una regresión logística
con significación estadística en p<0,05.
Resultados: Un total de 200 pacientes diabéticos
ACKNOWLEDGEMENT participaron en el estudio. Usando la escala de adherencia
de medicación de Morisky, el nivel de adherencias
We are grateful to patients who participated in the determinado fue del 38,5%. Hubo correlación
study. Special thanks go to the Director of significativa entre el nivel de adherencia y el nivel
Pharmacy-Korle Bu Teaching Hospital, Mrs E. educativo [(OR)=1,508; (95%CI 0,805 – 2,825),
Bruce for her administrative support. P=0,019), y el modo de pago [(OR)=1,631; (95%CI
0,997 - 2,669), P=0,05).
Conclusión: La adherencia en pacientes diabéticos fue
CONFLICT OF INTEREST baja entre los respondentes y esto puede mejorarse
mediante educación, consejo y refuerzo de los auto-
Authors have no conflict of interest to declare with cuidados. Había varios posibles factores que
this work. contribuyeron a la baja adherencia que podrían
Funding: Self funded beneficiarse de estudios posteriores.

Palabras clave: Cumplimiento de la Medicación;

Diabetes Mellitus Tipo 2; Factores de Riesgo; Modelos
Logísticos; Gana

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