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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 4  |  Page : 348-352  

Assessment of compliance to treatment of hypertension and diabetes among previously diagnosed patients in urban slums of Belapur, Navi Mumbai, India


1 Junior Resident, Department of Community Medicine, MGM Medical College, Navi Mumbai, Maharashtra, India
2 Professor, Department of Community Medicine, MGM Medical College, Navi Mumbai, Maharashtra, India
3 Associate Professor, Department of Community Medicine, MGM Medical College, Navi Mumbai, Maharashtra, India

Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Sneha Pratap Kotian
Department of Community Medicine, MGM Medical College, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_422_18

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   Abstract 


Background: Nonadherence to treatment is a challenge in managing the increasing burden of chronic noncommunicable diseases in India. The issue is not limited only to people having limited access to health-care services, but for a variety of reasons, a typical pattern of nonadherence is being seen. Objective: The objective was to assess the compliance and to find out the reasons of noncompliance to treatment of diabetes/hypertension among previously diagnosed patients from urban slums. Methods: This is a community-based, cross-sectional study conducted during October 2017–February 2018 in urban slums of Belapur, Navi Mumbai, selecting all cases of diabetes and hypertension diagnosed for >1 year by house-to-house survey, covering a population of 4125. A structured and pretested questionnaire including sociodemographic details, treatment details, and compliance pattern was administered. Results: The study included 208 individuals, of which 164 were under treatment for hypertension and 85 for diabetes. All the patients revealed discontinuation of medication for a significant period at some point since diagnosis. The most common reasons of noncompliance were lack of money (50.58% patients with diabetes, 73.78% patients with hypertension) and difficulty to remember to take daily medication due to work or forgetfulness (49.41% patients with diabetes, 26.21% patients with hypertension). Only 56.5% of patients with diabetes and 64.6% of patients with hypertension were aware that discontinuation of treatment can cause complications, whereas 95.3% of patients with diabetes and 99.4% of patients with hypertension feel that remembering medication at work is difficult. Conclusions: As the nonadherence is too high, there is an urgent need of attention to this aspect, and remedial measures such as proper counseling to the patient, involvement of family members, and use of low-cost drugs for treatment should be sought.

Keywords: Diabetes, hypertension, medication adherence


How to cite this article:
Kotian SP, Waingankar P, Mahadik VJ. Assessment of compliance to treatment of hypertension and diabetes among previously diagnosed patients in urban slums of Belapur, Navi Mumbai, India. Indian J Public Health 2019;63:348-52

How to cite this URL:
Kotian SP, Waingankar P, Mahadik VJ. Assessment of compliance to treatment of hypertension and diabetes among previously diagnosed patients in urban slums of Belapur, Navi Mumbai, India. Indian J Public Health [serial online] 2019 [cited 2020 Jan 23];63:348-52. Available from: http://www.ijph.in/text.asp?2019/63/4/348/273366




   Introduction Top


The health sector is experiencing a rapid transition with the rising burden of chronic noncommunicable diseases among the adult population in both developed and developing countries. Globally, hypertension and diabetes are the core contributors to the burden of noncommunicable diseases and are often coexistent. They pose a major public health problem to the population due to their long-term treatment adherence as well as the risk of various complications. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014. Diabetes prevalence has been rising more rapidly in middle- and low-income countries.[1] Worldwide, increased blood pressure is estimated to cause 7.5 million deaths, about 12.8% of the total of all deaths. This accounts for 57 million disability-adjusted life years (DALYs) or 3.7% of total DALYs.[2]

Medication nonadherence is a growing concern to health-care systems, doctors, and other stakeholders because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care.[3] Adherence is a basic determinant of the effectiveness of treatment because poor adherence attenuates optimum clinical benefit and paves the way for complications.[4] Improving medication adherence is, therefore, of utmost significance, which has been revealed in many studies, suggesting that interventions can improve medication adherence. One such significant aspect of the strategies to improve medication adherence is to understand its magnitude.[5] Once this is known, steps can then be taken to curtail the problem through relevant strategies.

Diabetes is known for its various long-term complications. Special steps can be taken to prevent them at early stages by few self-care practices which are easy to do as well as free of cost. The adherence to lifestyle modification is a vital element in the management of diabetes, which could vary from person to person.[6]

Urban slum dwellers live in poor socioenvironmental conditions and have limited access to health-care services. Studies on urban slums have mainly emphasized on communicable diseases and very few on noncommunicable diseases. With this background, the current study was aimed to assess the compliance to treatment of diabetes and hypertension among previously diagnosed patients in urban slums of Belapur, Navi Mumbai. The study intended to highlight the magnitude of compliance to treatment, which will aid the policymakers to devise strategies which will cater to the needs of the people living in the urban slums.

The objectives of the study were to assess the compliance to treatment of diabetes/hypertension/both among previously diagnosed patients and to find out the reasons of noncompliance to the treatment of hypertension and diabetes in urban slum population.


   Materials and Methods Top


This is a community-based, cross-sectional, observational study conducted during October 2017–February 2018 in the three urban slums of Belapur, Navi Mumbai, namely, Ramabai Nagar, Sambhaji Nagar, and Durgamata Nagar, comprising the population of approximately 4125 which are part of field practice area of Urban Health Training Centre (UHTC) of the Department of Community Medicine, MGM Medical College, Kamothe, Navi Mumbai.

There was no sampling done as the total population was small, and all the residents of the designated area who were already diagnosed as suffering from diabetes mellitus (Type 2) or hypertension or both for a period of >1 year (before October 1, 2016) and consented to participate in the study were included in the study.

A house-to-house survey was conducted to identify all eligible individuals, and data were collected using a predesigned, pretested, semi-structured pro forma to obtain the information on various study variables. All the efforts were made to keep the dropouts to minimum.

The study questionnaire revealed demographic data, details of duration of illness and treatment, frequency of investigations, and reasons of noncompliance. All interactions with the participants were done in the language which they could understand the best.

Patient compliance to medications was measured by recall method and recording number of missed doses over 2 weeks prior to the date of interview. The operational definition for pharmacological management was as follows: pharmacological compliance was defined as the failure to take more than two doses of medication over a period of the last 14 days. As we did not get any standard definition for compliance, experts were consulted, and this definition was used.

Blood pressure of all the study patients was recorded with Omron Digital BP Recorder (OMRON Healthcare India, main company headquarters- Gurgaon, Haryana). Existing evidence of blood sugar levels over the period since the diagnosis of diabetes was checked to verify the level of compliance and similarly for hypertension, the patient's case papers/investigation reports/any evidence of complications and hospital admissions were scrutinized.

All the study patients were referred to specialists visiting UHTC at Belapur for free treatment review, and the new cases which were suspected or detected incidentally during the house-to-house visits were also referred as an ethical consideration.

Data was compiled, tabulated, and analyzed using Microsoft Excel, EpiInfo 7 (Epi Info™, http://wwwn.cdc.gov/epiinfo/ ) and Statistical Package for Social Sciences version 24.0, IBM Corp- Released 2016 (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp).


   Results Top


A total of 706 houses, 240 in Durgamata Nagar, 236 in Ramabai Nagar, and 230 in Sambhaji Nagar, from the urban slums of Belapur were surveyed. Thirty houses were found locked and twenty of these were not inhabited, whereas in the remaining ten houses, the occupants had gone to their native place since long.

Out of the total population of 4125, 223 individuals were found to be diagnosed as either hypertensive or diabetic or both. Nine patients were excluded as they were diagnosed for <a year, whereas six patients did not give consent for personal reasons.

All the remaining 208 individuals were included in the study. Out of the total 208 patients, 123 (59.13%) were suffering only from hypertension, 44 (21.15%) were suffering only from diabetes, whereas 41 (19.71%) were suffering from both diabetes and hypertension. The study group comprised of 85 (40.86%) patients with diabetes and 164 (78.84%) patients with hypertension.

The study population comprised 97 (46.6%) males and 111 (53.4%) females. The mean age of the study population was 54.3 years (standard deviation [SD] 12.6), while the median was 53 years [Table 1]. The median family size was 6 (mean 5.8, SD 2.0). Out of 208 participants, 197 (94.7%, 104 females and 92 males) were Hindus and 11 (5.3%, 7 females and 5 males) were Muslims, in this predominantly Hindu community. A total of 168 patients (80.7%) were married, 34 (16.3%) were widowed, and 4 (1.9%) were separated, while 2 (0.9%) were unmarried. A total of 190 (91.3%) patients had never gone to school, 15 (7.2%) had received primary education, and 3 (1.4%) had completed middle school education.
Table 1: Age and sex distribution of patients with diabetes and hypertension

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Out of the total study population, 78 (37.5%) were unemployed, 116 (55.7%) were unskilled workers, 3 (1.5%) were semi-skilled workers, 8 (3.8%) were skilled workers, and 3 (1.5%) were in small-scale business. Majority of the individuals, i.e., 184 (88%) belonged to socioeconomic Class III or IV (middle and lower middle) as per the B. G. Prasad Classification, updated for the year 2017.[7]

The mean age of onset or rather detection of diabetes was 50 years (SD 9.7), while the median was 58.5 years. The mean age of detection of hypertension was 48.3 years (SD 10.5), while the median was 52 years. The mean duration of treatment of diabetes since detection was 8.6 years (median 7.0, SD 5.7, range: 2–27, Q3 13), whereas for hypertension, it was 6.4 years (median 4.5, SD 5.2, range: 2–27, Q3 8.0). All the patients revealed that they had discontinued treatment at some point of time since detection and none were having any documentation at the time of detection of illness. It was found that 63% of the population availed government health-care facilities, whereas 37% of the population seeked private health-care facilities. They were also asked regarding the unavailability of drugs due to shortage in supply as a hindrance to compliance for which a negative response was obtained from all the patients.

All the patients mentioned that they are following the prescribed treatment currently. However, when asked that if they have missed taking medication on any 2 days in the past 2 weeks, it was found that 160 (97.5%) patients with hypertension and 82 (96.5%) patients with diabetes had missed the medication. When inquired about taking medicine a day before interviewing, it was found that only 35 (41.2%) patients with diabetes and 44 (26.8%) patients with hypertension had taken all their medicines the previous day.

Among patients with hypertension, only 28 (17.1%) had systolic blood pressure levels of 130 mmHg or below and only 42 (25.6%) had diastolic blood pressure levels of 80 mmHg or below on the day of interviewing, the goal to be achieved as per the American Heart Association hypertension guidelines.[8] None of the patients with diabetes had checked their blood sugar levels in the last 3 months.

Seventy-eight (91.8%) patients with diabetes and 155 (94.5%) patients with hypertension agree that the treatment prescribed to them currently is appropriate and should be followed. However, the treatment behavior differs [Table 2].
Table 2: Treatment behavior of patients with diabetes and hypertension

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The most common reasons of noncompliance were lack of money (50.58% of patients with diabetes and 73.78% of patients with hypertension) and difficulty to remember to take daily medication due to work or forgetfulness (49.41% of patients with diabetes and 26.21% of patients with hypertension).

All the patients felt that family plays an important role in reminding to take medication on time and overall treatment compliance.


   Discussion Top


Many studies do not comment on the age of onset as it is rather age at detection in case of hypertension and diabetes as these noncommunicable diseases are known to remain asymptomatic for significant duration. In this study, the mean age at detection of diabetes was 50 years and for hypertension, it was 48.3 years. The study showed a slightly earlier onset of the disease in comparison to other studies. In a similar study done in urban slums of Hyderabad,[9] the mean age of hypertension was 54.5 years (SD ± 11.03). Similar observations were found in a study at Karachi,[10] Pakistan, where the mean age was 54 years. The Chennai Urban Rural Epidemiology Study [11] investigation in Chennai done in 2006 demonstrated a temporal shift in the age at diagnosis to a younger group when compared to the National Urban Diabetes Study [12] study published earlier.

Health awareness is the most important pillar in disease prevention. The educational status of the present study population was very poor, with 91.3% being illiterate and 7.2% having only primary education. In a similar study done in the urban slums of Hyderabad,[9] it was found that majority (64.9%) were illiterates. Most of the study participants (55.7%) were in socioeconomic Class IV, in this study based on B.G. Prasad Classification updated for 2017. In a similar study done in the urban slum community of Mumbai,[13] majority of the participants (550 [50.5%]) belonged to upper lower socioeconomic classes using Kuppuswamy's socioeconomic status scale modified for 2007. Socioeconomic status is also a known major factor contributing to compliance to treatment.

The most common reasons of noncompliance were difficulty to remember to take daily medication due to work or forgetfulness (100% of patients with diabetes and 99.4% of patients with hypertension) and lack of money (50.6% of patients with diabetes and 73.8% of patients with hypertension). In the similar way, in a study conducted at Thiruvananthapuram, South India,[14] the major factors associated with noncompliance were found to be the asymptomatic course of hypertension and the nonavailability of free-of-cost drugs from the local health center. The relatively asymptomatic course of the disease and lack of adequate knowledge about hypertension and diabetes predispose the patients to nonadherence to the drug regimen and restricting them to the intake of medications for symptomatic benefit only. In a study conducted in South India, the reasons quoted by patients for not being compliant were that they forget to take medications (63%), side effects (22%), and the rest (15%) were not collecting medications from the center due to reasons such as going out of station and inability to come to the center to collect medications.[15]

In a study conducted at Hyderabad,[9] out of 376 study participants in urban slums, 232 (61.7%) were highly adherent to their antihypertensive medications. In the study by Rao et al.[16] in urban slums of Hyderabad, 60.6% of participants were considered adherent to the prescribed medication. A study by Bhandari (2015)[17] in urban slums of Kolkata showed treatment adherence of 73% (95% confidence interval: 68%–78%). In a study conducted in coastal population in South India,[4] compliance to hypertension treatment was found at 82.2%, whereas 83.6% of individuals with Type 2 diabetes mellitus were on regular medication. In the study by Thomas et al. (2011)[18] in Bengaluru, it was stated that 50.3% were adherent to antihypertensive medication.

In this study, it was found that all the patients with diabetes and hypertension had discontinued their treatment at some point since detection. It was also found that 160 (97.5%) patients with hypertension and 82 (96.5%) patients with diabetes had missed taking medication on any 2 days in the past 2 weeks. When inquired about taking medicine a day before interviewing, it was found that only 35 (41.2%) patients with diabetes and 44 (26.8%) patients with hypertension had taken all their medicines the previous day. In a study done in Palestine,[19] it was reported that 24% of the participants did not take their medications on at least one occasion in the 2 weeks before the interview and 91.4% had taken all their medications on the day before the interview. In a study done in rural Maharashtra,[20] it was found that 29.5% of patients with diabetes and 23.3% of patients with hypertension never discontinued the treatment since started.

It was also found that 56.5% of the patients with diabetes and 64.6% of the patients with hypertension were not aware about the complications associated with diabetes and hypertension. These factors are also responsible for very high levels of nonadherence to treatment. This is in contrast to a study conducted in South India,[15] in which around 79% of the patients were aware about at least one of the complications of diabetes. In a study conducted at Loni in Maharashtra,[21] only 58% of the patients taking one pill a day with regular checkups maintained satisfactory compliance to medication for a period of 12 months. The lowest level of compliance was seen in patients taking three pills a day, with 28.3% in patients with regular follow-ups and 3.7% in those visiting irregularly, which in turn suggested that the number of pills was directly proportional to compliance level observed. It was also found that the percentage of dropouts from the therapy increased proportionately with the increase in the number of pills per day. In a study by Akgol et al., the causes for treatment noncompliance were demonstrated as lack of access to the treatment (treatment costs, far location of medical center, busy work of the physician, and not arranging an appointment) and absence of disturbing complaints.[22] Studies conducted in Spain between 1975 and 2011 were reviewed which revealed that treatment compliance was detected as 74.8% and 25.62% as noncompliant to treatment.[23] These studies report increase in compliance because of single-dose form of combined treatments.[24]

In this study, it was found that 56.5% of the patients with diabetes and 64.6% of the patients with hypertension were ignorant about the fact that medications would delay and prevent the complications associated with diabetes and hypertension. This could be a major contributing factor to irregular compliance to treatment and discontinuation of treatment due to symptomatic relief. It was also noted that all the patients felt that families have role in facilitating the intake of medicines. This study has a limitation that the compliance was tested based on the self-report (recall bias).


   Conclusions Top


The study findings reflect that patients fail to see hypertension and diabetes as a chronic condition requiring long-term adherence to treatment and do not have sufficient motivation for the same. In lower socioeconomic strata, the medication price considering the lifelong nature of treatment is also an issue. The asymptomatic course of the diseases and lack of health awareness are the major factors associated with nonadherence.

The policies for health programs focused on the prevention and control of hypertension and diabetes need to address these issues. The incorporation of tool for active involvement of family members for case holding and improvement in treatment compliance rates is needed. The promotion of low-cost alternative drugs and making them reach to target population will help in preventing the morbidity arising out of complications caused by noncompliance to treatment.

The barriers associated with medication adherence should further be explored among urban slum dwellers and dealt with to achieve the desired clinical outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Diabetes Factsheet. World Health Organization; 2016. https://www.who.int/news-room/fact-sheets/detail/diabetes. [Last accessed on 2017 Oct 06].  Back to cited text no. 1
    
2.
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19.
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21.
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22.
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23.
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Erdine S. Compliance with the treatment of hypertension: The potential of combination therapy. J Clin Hypertens (Greenwich) 2010;12:40-6.  Back to cited text no. 24
    



 
 
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