Academic Sciences International Journal of Pharmacy and Pharmaceutical Sciences

ISSN- 0975-1491 Vol 6, Suppl 2, 2014

Research Article

MEDICATION ADHERENCE TO ANTIDIABETIC THERAPY IN PATIENTS WITH TYPE 2

DIABETES MELLITUS

MANJUSHA SAJITH*1, MADHU PANKAJ2, ATMATAM PAWAR3, AMIT MODI4, RONAK SUMARIYA4
1Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, 2Department of Medicine, Bharati
Medical College, Bharati Vidyapeeth Deemed University, 3Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, 4Poona
College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune. Email: manjusaji1@yahoo.com
Received: 10 Dec 2013, Revised and Accepted: 09 Feb 2014

ABSTRACT
Objective: The study is to evaluate self-reported medication adherence and to identify factors linked with poor adherence in patients with type 2
diabetes mellitus.
Methods: The prospective study was conducted over a period of six months in the department of Medicine, Bharati Hospital. A total of 105 type 2
diabetics patients who fulfilled the inclusion criteria were recruited in the study. Adherence to treatment has been assessed during a personal
interview with each patient using questionnaire. Medication adherence was assessed by using Morisky medication adherence scale (MMAS).
Results: The adherence levels were 40.95%, 37.14% and 21.90% for high, medium and poor adherence, respectively. The correlation between
patients’ socio-demographic and adherence rate to anti diabetic therapy indicated that higher prevalence of adherence among men (43.33%), the
elderly (46.81%), those with primary education (47.06%) and the unemployed patients (41.46%). We found a better percentage of adherences in
combination therapy with 43.90%. The most common reasons for non-adherence to taking medication(s) as prescribed were inadequate knowledge
about therapy (81.90%), financial problem (61.90%), patients feeling better (33.33%) and feeling worse (33.33%). Moreover, the factors for non
adherence to appointment keeping were identified as travel a lot and busy schedule of work with 33.33%, and 13.33%, respectively.
Conclusion: In conclusion, this study revealed a moderate level of adherence among the participants. Efforts are needed to increase the medication
adherence of these patients so they can realize the full benefits of prescribed therapies
Keywords: Anti-diabetic medication, Medication adherence, Glycaemia control, Type 2 diabetes mellitus.

INTRODUCTION modifications that in turn minimizes long-term complications [11,

Diabetes mellitus refers to a group of common metabolic disorders
that share the phenotype of hyperglycaemia.
The prevalence of diabetes mellitus is growing rapidly worldwide
and is reaching epidemic proportions. It is estimated that there are
currently 285 million people with diabetes worldwide and this
number is set to increase to 438 million by the year 2030 [1]. India
leads the world with largest number of diabetes subjects earning the
dubious distinction of being term the “Diabetes Capital of the world”
[2]. The prevalence of diabetics in Indian adults was found to be
2.4% in rural and 4‐11.6% in urban dwellers [3]. India is presently
estimated to have 41 million individuals affected by this deadly
disease, with every fifth diabetic in the world being an Indian [4].
A key dimension of healthcare quality is adherence to prescribed
medications. According to the World Health Organization, non-
adherence to the medical regimen consist a major clinical problem in
the management of patients with chronic illness [5]. Rates of non
adherence with any medication treatment may vary from 15% to
93%, with an average estimated rate of 50% [6].
Adherence with medication usage is defined as the proportion of
prescribed doses of medication actually taken by a patient over a
specified period of time [7]. Compliance, a synonymous term which
was commonly used in the past, implies a passive role and simply
following the demands of a prescriber and non-compliance has been
regarded as associated with deviant or irrational behaviour [8].
Non-adherence or non-compliance, poverty, lack of knowledge and
poor follow ups are the main factors observed in poor glycaemic
control [9]. Individuals with poor management of diabetes are at a
greater risk of developing long-term micro and macro-vascular
complications that lead to the damage of end organs such as kidneys,
heart, brain and eyes, affects the direct and indirect health care costs
and overall quality of life [10]. Optimal glucose control can be
achieved through strict adherence to medications, diet and life style
12].
Poor adherence to medication regimens is common, contributing to
substantial worsening of disease, death and increased health-care
costs. Hence, practitioners should always look for poor adherence
and can enhance adherence by emphasizing the value of a patient’s
regimen, making the regimen simple and customizing the regimen to
the patient’s lifestyle. Therefore, the purpose of this study is to
identify Drug Utilization pattern, Medication Adherence and reasons
associated with Non-adherence to anti-diabetic therapy which will
help the Physicians in making decisions to reduce the same, helps in
achieving glycemic targets of type 2 diabetes mellitus patients. It will
undoubtedly benefit the physicians to understand the patient’s
response to the treatment provided which may help for a strict and
successful management of this chronic illness in the future.
MATERIALS AND METHODS
A prospective observational study was carried out for the duration
of six months among the patients who were admitted in Bharati
hospital. All the patients above 18 years of age of either sex, patients
taking diabetes medication(s) were included in the study. Pregnant
women and surgical reference were excluded from the study.
For data collection and documentation Patient profile form was
designed which includes information on patients demographic
details (e.g. Patient’s Name, Age, Sex, educational status,
employment, date of admission and date of discharge), presenting
complaints, provisional/confirmed diagnosis, social history, past
medical/medication history, current medications, discharge
medications, laboratory test reports.
Adherence to treatment has been assessed during a personal
interview with each patient using questionnaire. Medication
adherence to diabetes medicines was determined using a modified
version of the four items, self-reported Morisky medication
adherence scale [41]. Each item is in a yes/no format with a
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Int J Pharm Pharm Sci, Vol 6, Suppl 2, 564-570

maximum possible score of four equating very poor adherence and 0
considered as good adherence.
RESULTS
A total of 105 diabetes mellitus patients were enrolled in the study,
out of which 57.14% were males and 42.86% were females. The
prevalence of Diabetes Mellitus in our study set up was 7.95%. Most
patients belonged to the middle age group 41-60 years (48.57%)
followed by Elderly group > 60 years (44.76%). 32.38% patients had
a primary education and the occupation section of the respondents
indicates that 39.05% patients were unemployed. Socio-
demographic and clinical characteristics of the participants are
summarized in TABLE1.
The assessment of the patients’ responses to the 4-item modified
Morisky adherence predictor scale showed that 43 (40.95%) of the
patients had good adherence with prescribed medications, whereas
37.14% had medium adherence and 21.90 % had low adherence
(Table 2).

Table 1: Socio-demographic characteristics of diabetic patients

Respondent’s characteristics No. of patients Percentage (%)
Gender
Male 60 57.14
Female 45 42.86
Age (years)
Young group (18–40) 7 6.67
Middle-age group (41–60) 51 48.57
Elderly group (>60) 47 44.76
Educational status
Primary 34 32.38
Secondary 30 28.57
Tertiary 20 19.05
Illiterate 21 20.00
Employment status
Employed 40 38.09
Unemployed 41 39.05
Disabled 3 2.86
Retired 21 20.00
Place of residence
City 70 66.67
Village 35 33.33
Social habits
Smoker 14 13.33
Alcoholic 7 6.67
Both 8 7.62
None 76 72.38
Clinical characteristics of diabetic patients
Disease related parameters No. of patients Percentage (%)
a) Duration of disease since diagnosis (years)
<5
6-10 46 43.81
> 10 30 28.57
29 27.62
b) Family history of diabetes
Yes 25 23.81
No 80 76.19
c) HbA1c (%)
Yes 50 47.62
No 55 52.38
4.5-6.3 6 12.00
6.4-8.0 15 30.00
8.0-9.0 5 10.00
9.0-14.0 24 48.00
e) Co-morbidities
Hypertension 24 22.86
Hypertension+ Ischemic heart disease 11 10.48
Hypertension + Coronary artery disease 1 0.95
Chronic renal failure 1 0.95
Ischemic heart disease 1 0.95
Others 50 47.62
No 17 16.19

Table 2: Summary of patient’s responses to the modified Morisky adherence predictor scale (n=105)
Question Yes No
Response (score coding) Number Percentage Number Percentage
(%) (%)
Do you ever forget to take your Medicine(s)? 43 40.95 62 59.05
Do you sometimes not being careful in taking your medicine (s)? 39 37.14 66 62.86
When you feel better, do you sometimes stop taking your medicine(s)? 35 33.33 70 66.67

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Int J Pharm Pharm Sci, Vol 6, Suppl 2, 564-570

Sometimes if you feel worse when you take your medication(s), do you stop taking 35 33.33 70 66.67
them?
Distribution of scores Total Percentage (%)
0 43 40.95
1 16 15.24
2 23 21.90
3 20 19.05
4 3 2.86
Percentage Category
0 43 (%)
1-2 39
3-4 23 40.95 High adherence
37.14 Medium adherence
21.90 Low adherence

Table 3: A correlation between patients’ socio-demographic characteristics and

Variables No. of Patients High Adherence Medium Adherence Low
(%) N (%) N (%) Adherence
N (%)
Gender
Male 60 (57.14) 26 (43.33) 19 (31.67) 15 (25.00)
Female 45 (42.86) 17 (37.78) 20 (44.44) 8 (17.78)
Age (years)
Young group (18–40) 7 (6.67) 3 (42.86) 2 (28.57) 2 (28.57)
Middle-age group (41–60) 51 (48.57) 17 (33.33) 25 (49.0) 9 (17.65)
Elderly group (>60) 47 (44.76) 22 (46.81) 12 (25.53) 13 (27.66)
Educational status
Primary 34 (32.38) 16 (47.06) 9 (26.47) 9 (26.47)
Secondary 30 (28.57) 10 (33.33) 16 (53.33) 4 (13.33)
Tertiary 20 (19.05) 6 (30.00) 8 (40.00) 6 (30.00)
Illiterate 21 (20.00) 10 (47.62) 6 (28.57) 5 (23.81)
Employment status
Employed 40 (38.09) 12 (30.00) 17 (42.50) 11 (27.50)
Unemployed 41 (39.05) 17 (41.46) 14 (34.15) 10 (24.39)
Disabled 3 (2.86) - 3 (2.86) -
Retired 21 (20.00) 13 (61.90) 5 (23.81) 3 (14.28)
Family Support
Present 37 (35.24) 17 (45.94) 13 (35.13) 7 (18.92)
Absent 68 (64.76) 24 (35.29) 27 (39.70) 17 (25.00)
Place of residence
City 70 (66.67) 26 (37.14) 28 (40.00) 16 (22.86)
Village 35 (33.33) 15 (42.86) 12 (34.28) 8 (22.86)

Fig. 1a: Drug adherence Fig. 1b: Dietary adherence

45.00% 3.81%
Adherence rate(%)

40.95% 37.14%
40.00%
35.00%
30.00% 21.90%
25.00%
20.00%
15.00% Yes=4
10.00% No=101
5.00%
0.00% 96.19%
High Medium Low
Drug adherence

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Fig. 1c: Exercise adherence Fig. 1d: Appointment adherence

1.90%

Yes=36
32.29%
Yes=36 Yes=2
No=69 No=103
No=69
65.71% 98.10%

Fig 1

50.00%
45.45%
45.00% 40.54% 43.90%

40.00% 40.54%

35.00% 34.15%
% of Adherence rate

31.82%
30.00%

25.00% 21.95% 22.73% High

18.92%
20.00% Medium

15.00% Low

10.00%

5.00%

0.00%
Monotherapy=37 Combination=41 Fixed dose=22

Types of therapy

Fig. 2: Adherence by types of therapy

Table 4: Factors affecting rate of medication adherence in Type 2 diabetic patients.

Causes Number of patients Percentage (%)
Non adherence to taking anti-diabetic medications as prescribed
Social and Economic
a. Costs of medication too expensive 36 34.29
b. lack of financial resources 65 61.90
Therapy- related factors
a. Complexity of medication regimen 20 19.05
b. Number of medications/Too much medications 27 25.71
c. Frequency of dosing / Increasing number of dosing times 19 18.10
d. Side effects 1 0.95
e. Long duration of treatment period 61 58.10
Patient-related factors
a. Lack of knowledge about the disease 33 31.43
b. Inadequate knowledge regarding therapy 86 81.90
c. Forgetfulness 17 16.19
d. Decision to omit 20 19.04
e. Being busy/ busy schedule of Work 12 11.42
f. Forget fullness + Being busy 2 1.90
g. When felt better 35 33.33
h. When felt worse/bad 35 33.33

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i. Others (pain due to injection, Hypoglycemia etc.)
Non-adherence to appointment keeping
Causes
Forgetfulness
Travel a lot
Long clinic wait time
No response
Nature/busy schedule of work
Figure 2 reveals the fact of percentages of adherence rate and
number of drugs used in T2DM patients with respect to
Monotherapy, Combination therapy and Fixed dose therapy. Several
factors were found to have significant effects on the rate of
medication adherence (Table 4). Among 105 patients, 32.38%
patients had good blood glucose control and 67.62% patients had no
Table 5: Association between adherence with medication and plasma glucose control
Parameters No. of patients
105
Medication adherence pattern
Good adherence 43
Medium adherence 39
Low adherence 23
Total 105
DISCUSSION
Diabetes mellitus is one of the major non communicable diseases
which are growing very fast in this modern era. Diabetes and
associated complications pose a major healthcare burden worldwide
and present major challenge to patients, health care systems and
national economies. Males predominated in the study population
which is in agreement with the results of various other studies in
India [13] and United States [14]. The reason for this might be that
smoking, alcoholic habits and other lifestyle changes are seen more
commonly in males and these factors have hallucinating effect on
health including glycemic control. The higher prevalence in younger
age group may be due to the lifestyle of the younger population and
also the stress factor which unmasks diabetes causing blood sugar to
rise [15]. The level of education and place of residence are important
determinants of how quickly a diagnosis will be made. The
performance paid work, level of education and economic status can
have a positive and negative impact on the quality of life of diabetes
patients, as a result, on the level of metabolic control. Satisfaction
with treatment and quality of life are positively associated with
employment and a higher income. People with lower education level
and unemployment persons, have, in general, a lower satisfaction
with life and are less satisfied with diabetes treatment, as well as
having worse metabolic control [16]. Educational status in our study
was found more in primary education with higher prevalence rate of
32.38%. In the employment status the unemployed patients had
more prevalence with 39.05% than employed with 38.09%;
compared with French study there was no significant difference
found [38]. The uses of alcohol and cigarette smoking were not
significantly reported in our study [15].
The duration of diabetes plays an important role in management of
diabetes. This study showed that most of the patients (43.81 %) had
a diabetic history of 1-5 years [17]. Patients with a long duration of
diabetes are at a higher risk of developing complications [17].
76.19% patients were with no family history of diabetes [18].
Achieving good glycaemic control in diabetic subjects has proven a
real challenge to healthcare providers. Studies have documented
that self-care among T2DM subjects improved glycaemic control and
reduced complications [19, 20]. In the present study, only 23 (53.49
%) of the subjects had good glycaemic control, which is different
from various studies [21]. A total 88 (83.81%) patients suffered
from co-morbid condition. Hypertension accounted for 27.27% of
the total complications which is lower than the study reported in
Int J Pharm Pharm Sci, Vol 6, Suppl 2, 564-570
14 13.33
Number of patients Percentage (%)
17 16.50
35 33.98
16 15.53
21 20.39
14 13.59
blood glucose control. Of the 31 patients who had goal blood glucose
control, 53.49% were high adherent, 20.51 % were medium
adherent and 13.04 % were low adherent. The blood glucose control
rate was significantly higher in those that high adhere to anti-
diabetic medication when compared with non-adhering (medium
and poor adherence) patient (TABLE 5).
Plasma glucose status
Controlled (%) Uncontrolled (%)
34 (32.38) 71 (67.62)
No. % No. %
23 53.49 20 46.51
8 20.51 31 79.49
3 13.04 20 86.96
34 32.38 71 67.62
Nepal (Hypertension accounted for 70.62% of the total
complication) [22]. Our study findings are also similar to the study
conducted in Texas medical centre that hypertension is more
common complication affecting 20-60% of people with diabetes
[23].
The 4-item modified Morisky adherence predictor scale used to
assess medication adherence might be associated with some
shortcomings since it is a self-report method; however, there is no
gold standard method for assessing adherence. The assessment of
the patients’ responses to the 4-item modified Morisky adherence
predictor scale [41] showed that 40.95% (n=43) of the patients had
good adherence with prescribed medications, whereas 37.14% had
medium adherence and 21.90 % had low adherence. The finding is
in line with the findings of a study carried out in France, which
revealed the following adherence levels: good adherence 39%,
medium adherence 49%, and poor adherence 12%. The good
adherence recorded in this study is also inconsistent with the
findings of some studies. However, the poor adherence level
revealed by this study is consistent with the finding of a study
carried out in Mulago teaching hospital Uganda that recorded an
overall prevalence of non-adherence of 28.9% [24].
Medication adherence is a key component for patients with
diabetes. Our results have shown that therapeutic adherence was
significantly affected by different patient- centered factors like age,
family support, educational status, employment status, place of
residence. Our study has found a high rate of good adherence in
male with 43.33% than females. The result is similar to that found in
another study among African Americans in which the men scored
higher than women on self care adherence [25]. The effect of gender
on the rate of adherence to medication in other research studies is
contradictory. Female patients were found by some researchers to
have better adherence [26]. In addition, some studies could not find
a relationship between gender and adherence to medication [27].
The effect of the age factor was found in our patient population with
higher rate of drug compliance in elderly patients with 46.81%
whereas in other study elderly age group was found with 68%
adherence rate [28]. In another study, more adherence was found in
younger age group with 51.8% and lesser adherence was found in
elderly and middle age group [27]. Data on age is consistent with the
literature; chronic patients' age affects adherence to drug therapy, as
lower adherence was seen among younger patients [29]. In regard to
schooling, more educated patients were more adherent to therapy.
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Low schooling makes learning more difficult; as diabetes drug
therapy gets more complex; patients are required to have more
complex cognitive skills to be able to understand the prescribed
drug therapy and to adhere to treatment for good glucose control. In
our study, patients with primary education (47.06%) have higher
compliance. Several studies found that patients with higher
educational level might have higher compliance [30]. On the basis of
occupation, the unemployed patients had high medication
adherence rate with 41.46% compared to employed patients
30.00%,whereas the study conducted in Malaysia, the unemployed
patients rate was more with 74.1% and employed ratio was low
[31]. Support provided by family also played a beneficial role in
enhancing adherence, in our study around 45.94% was found while
similar result with 47.7% was found in another study [27]. The
general finding from different research articles showed that patients
who had emotional support and help from family member, or
healthcare providers were more likely to be adherent to the
treatment. [9]. Place of residence is important determinant where
37.14% patients of urban had shown higher rate of adherence
compare to rural area. A study conducted in Egypt was found 41.9%
in urban and 34.4% in rural adherence rate [16]. Aerobic exercise
and restricted food was reported to be part of the recommended
non-drug management of diabetes mellitus disease. Dietary and
exercise self-care behaviours are similar which are the most time-
consuming aspects of the daily regimen and are also the behaviours
requiring the greatest alteration in life-style. In our study, it was
noted that 3.81%, 32.29% and 1.90% respectively of all patients
were belonging to dietary, exercise adherence and to the
appointment for regular follow up. As for noncompliance with
individual measures, the dietary noncompliance was found in this
study (96.19%) which is more than the Canadian study with 73%
[32], the U.S. study with 65% [33], and the Mexican study with 62%
[34]. In our study, good exercise adherence was found to be 32.29%
which is higher than the studies [27] and [34]. We found a better
percentage of adherence in combination therapy with 43.90% and
lower percentage of adherence in monotherapy with 18.92% as
compared to study conducted in Italy [35].
The high costs of medication agreed to by majority of the patients as
the most important reason preventing optimal adherence had been
supported by previous studies where financial constraint was
identified as the major hindrance to medication adherence among
type 2 diabetes populations. In our study, the cost of expensive
medication was found to be 34.29% which is similar, whereas the
other factor for non adherence i.e. complexity of dosage regimen was
found to be 19.05% which is noted significantly higher than the
study performed in South-western Nigeria [36]. India is a resource
limited setting where the majority of the people estimated to live
below poverty levels so the economic access to anti diabetic
medication appeared restricted. In this study, the main external
challenge of adherence is financial problem (61.90%). This is in
agreement with study done in Nigeria [37] in which around 2/3 and
in Ethopia 37.1% of the non-adherence is due to financial difficulty
[38]. Side effect of drug which is considered as a factor for non-
adherence appeared with 0.95% which is significantly lower than
the study carried out in Ethopia [38]. Our results confirm that one of
the most important factors contributing to adherence to OHAs was
the level of patients’ knowledge about the disease, its causes,
principles of drug therapy and complications of drug therapy as well
as patients’ beliefs and motivation about OHAs. Patients who had
low motivation to change behaviours or take medication are
believed to have poor compliance. In present study, 81.90% patient
with inadequate knowledge regarding therapy was found which is
considerably higher than the study conducted in Egypt where he
found with 62.0% [27]. The identified causes of non- adherence to
taking anti-diabetic medications as prescribed were nature of work
/busy schedule of work, when felt worse, when felt better, and
forgetfulness were found to be 11.42%, 33.33%, 33.33% and
16.19% , respectively in our study which are lower than the study
conducted in tertiary care hospital, Nigeria except forgetfulness [18].
Similarly, non-adherence to appointment keeping was caused by
forgetfulness, nature of work and busy schedules, travelling away
from home, long clinic wait time. A study identified busy work
schedules especially for patients in the working population as one of
Int J Pharm Pharm Sci, Vol 6, Suppl 2, 564-570
the reasons why some patients do not take their anti-diabetic
medications as prescribed was found to be 16.19% and forgetfulness
is a widely reported factor that causes non-adherence with
medication or clinic appointments was found to be 13.33% which
are lower than the study conducted in Nigeria [18].
This study has demonstrated that blood glucose control was
significantly higher among patients that adhered with their anti-
diabetic medication compared with their non-adherent
counterparts. The adherence rate of 40.95% in this study is lower
than adherence rate of 72.5% reported in Eastern Nigeria [39] while
60.2% reported in Ibadan, south-west Nigeria in 2009 [36] and
51.3% reported in Ethiopia [38]. The finding of this study has
demonstrated the contribution of adherence factor for blood glucose
control among the study population. Thus, if diabetic patients
adhere with their appropriately prescribed anti-diabetic medication,
glycaemic outcome will be expectedly improved [40]. Clinicians
attending to type 2 diabetic patients should inquire rationally for
medication adherence at every clinical encounter with diabetic
patients. This will prevent the clinician from attributing lack of
response to medications as therapeutic failure rather than
medication adherence problems. This assumption has resulted in the
clinical decision of increasing the dose of the medications, changing
the medication or adding another anti-diabetic drug. The magnitude
of this practice is better imagined than seen and will not favour
attainment of clinically therapeutic outcome among type 2 diabetic
patients.
CONCLUSION
It is concluded that the participants in the area of study were
moderately adherent to their anti-diabetic medications. Various
factors of medication non-adherence were identified and evaluated.
Therefore, we recommend interventions that will address these
factors of non-adherence in order to improve adherence the more.
Some of such interventions include the physicians and pharmacists
improving on the areas of patient education and medication
counselling, communication between them and patients,
encouraging patients to monitor their blood glucose level regularly,
simplifying drug regimen with decreasing the number of drug taken,
medication selection bearing in mind cost and intolerable side
effects of the medications. Physicians and Pharmacists should also
adopt interventions that are designed to help patients remember to
keep their clinic appointments and to take their anti-diabetic
medications as prescribed.
ACKNOWLEDGEMENT
This study would not have been possible without the guidance and
the help of several individual who in one way or another contributed
and extended their valuable assistance in the preparation and
completion of this study.We extend our immense thanks to our Co-
guide for his guidance and help that provided a good basis for our
project work.We also would like to thank to all the post graduate
students, residents, nurses of Medicine Department, Bharati Hospital
& Research Centre, Bharati Vidyapeeth Deemed University, for
helping us in one way or the other.
REFERENCES
1. R.M. Anjana, M.K. Ali, R. Pradeepa, M. Deepa, M. Datta, R.
Unnikrishnan, et al.The need for obtaining accurate nationwide
estimates of diabetes prevalence in India - Rationale for a
national study on diabetes. Indian J Med Res 2011 April; 133:
369-380.
2. V Mohan, S sandeep. Epidemiology of type 2 diabetes: Indian
scenario. Indian J Med Res 2007 March; 217-230.
3. Munichoodappa C, Jayaram BM. Epidemiology and burden of
type 2 diabetes mellitus, Bangalore Type 2 Diabetes – the
Indian scenario. Micro labs 2002; 13.
4. World Health Organization. Diabetes facts country and regional
data 2010, Available online from:
http://www.who.int/features/factfiles/diabetes/02_en.html
ml.
5. World Health Organization. Adherence to long-term
therapies—evidence for action 2003. Available
569
 Sajith et al.
at:http://www.who.int/chronic_conditions/en/adherence_rep
ort.pdf. 2003.
6. Singh N, Squier C, Sivek C, Wagener M, Nguyen MH, Yu VL.
Determinants of compliance with antiretroviral therapy in
patients with human immunodeficiency virus: prospective
assessment with implications for enhancing compliance. AIDS
Care 1996; 8: 261–269.
7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med
2005; 353:487497.
8. H. Lee M, Keeffe EB. Study of adherence comes to the treatment
of chronic hepatitis B. (editorial). Journal of Hepatology 2011;
54:6–8.
9. Kalyango J, Owino E, Nambuya A. Non-adherence to diabetes
treatment at Mulago Hospital in Uganda: prevalence and
associated factors. Afr. Health Sci 2008; 8: 67–73.
10. Maddigan, S.L, Feeny, D.H., Johnson, J.A. Health related quality
of life deficits associated with diabetes and co morbidities in a
Canadian national population health survey. Qual. Life Res
2005; 14: 1311–1320.
11. Schectman-Joel, M., Nadakarni-Mohan, M., Voss-John D. The
association between diabetes metabolic control and drug
adherence in an indigent population. Diabetes Care 2002; 25:
1015–1021.
12. Rickles N, Brown T, McGivney M, Snyder M, White K. Adherence
A review of education research practice and policy in the
United States. J Pharm Pract. (Internet) 2010; 8: 1–17.
13. Vengurlekar S, Shukla P, Patidar P, Bafna R, Jain S. Prescribing
pattern of antidiabetic drugs in Indore city hospital. Indian J
Pharm Sci 2008; 70:637–40.
14. Willey CJ, Andrade SE, Cohen J, Fuller JC, Gurwitz JH.
Polypharmacy with oral antidiabetic agents: An indicator of
poor glycemic control. Am J Manag Care 2006; 12:435–40.
15. Santhosh YL, Naveen MR. Medication Adherence Behavior in
Chronic Diseases like Asthma and Diabetes Mellitus.
International J of Pharmacy and Pharmaceutical Sciences 2011;
3 (Suppl 3): 238-240.
16. Maria Kurowska, Jerzy S. Tarach, Joanna Malicka, Anna Chitryn,
Anna Dabrowska. The Impact of the level of education and paid
work on HbA1c concentrations in patients with type 1
diabetes- preliminary findings. Lublin- Polonia 2010; 23
(Suppl 2): 74-77.
17. Upadhyay DK, Palaian S, Ravi Shankar P, Mishra P, Sah AK.
Prescribing pattern in diabetic outpatients in a tertiary care
teaching hospital in Nepal. J Cardiovasc Dis Res. 2007; 4:248–
55.
18. Roland Nnaemeka Okoro, Cyprian Kingsley Ngong. Assessment
Of Patient’s Anti-Diabetic Medication Adherence Levels in Non-
Comorbid Diabetes Mellitus in A Tertiary Health Care Setting in
Nigeria. Pharmacie Globale, International J of Comprehensive
Pharmacy. July 2012; 7(Suppl1):1-9.
19. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD,
Vijay V. Indian Diabetes Prevention Programme (IDPP): the
Indian Diabetes Prevention Programme shows that lifestyle
modification and metformin prevent type 2 diabetes in Asian
Indian subjects with impaired glucose tolerance (IDPP-1)
Diabetologia 2006; 49:289–97.
20. Heisler M, Pietee JD, Spencer M, Kieffer E, Vijan S. The
relationship between knowledge of recent HbA1c values and
diabetes care understanding and self-management. Diabet Care
2005; 28:816-22.
21. Al-Maskari F, El-Sadig M. Prevalence of risk factors for diabetic
foot complications. BMC Fam Pract 2007; 8:59.
22. Upadhyay DK, Palaian S, Ravi Shankar P, Mishra P, Sah AK.
Prescribing pattern in diabetic outpatients in a tertiary care
teaching hospital in Nepal. J Cardiovasc Dis Res 2007; 4:248–
55.
Int J Pharm Pharm Sci, Vol 6, Suppl 2, 564-570
23. Arauz-Pacheco C, Parrott MA, Raskin P. Treatment of
hypertension in adult patients with diabetes. Diabetes Care
2002; 25:134–47.
24. Owino E, Nambuya A. Non-adherence to diabetes treatment at
Mulago Hospital in Uganda: prevalence and associated factors.
Afr. Health Sci 2008; 8: 67–73.
25. Montague MC. Psychosocial and functional outcomes in African
Americans with diabetes mellitus. ABNF J. 2002 Sep 13; 5:103–
109.
26. Lertmaharit S, Kamol-Ratankul P, Sawert H, 2005. Factors
associated with compliance among tuberculosis patients in
Thailand. J. Med. Assoc. Thai. 88: 149–156.
27. Mohamed E.E. Shams, Enaase A.M.E. Barakat. Measuring the
rate of therapeutic adherence among outpatients with T2DM in
Egypt. Saudi Pharmaceutical Journal 2010; 18: 225–232.
28. Sander D. Borgsteede , Marjan J. Westerman ,Irene L. Kok , Jok
C.Meeuse,Theo P. G. M. de Vries ,Jacqueline G. Hugtenburg.
Factors related to high and low levels of drug adherence
accordingto patients with type 2 diabetes. Int J Clin Pharm
2011; 33:779–787.
29. Horne R, Weinman J. Patients' beliefs about prescribed
medicines and their role in adherence to treatment in chronic
physical illness. J Psychosom Res 1999; 47 (Suppl6):555-67.
30. Mi-A Seo1 and Sung-Kil Min2. Development of A Structural Model
Explaining Medication Compliance Of Persons With Schizophrenia.
Yonsei Medical Journal. 2005; 46 (Suppl 3): 331 - 340.
31. S.S. Chua and S.P. Chan. Medication adherence and achievement
of glycaemic
32. Targets in ambulatory type 2 diabetic patients. Journal of
Applied Pharmaceutical Science.2011; 1(Suppl 4): 55-59.
33. Watkins JD, Williams F, Martin DA, Hogan MD, Anderson E. A
study of diabetic patients at home. J Am Public Health 1967;
56:452-459.
34. Cerkoney AB, Hart K. The Relationship between the Health
belief model And Compliance of Persons with Diabetes Mellitus.
Diabetes Care 1980; 3:594-598.
35. Lizbeth Hernández-Ronquillo, José Francisco Téllez-Zenteno,
Juan Garduño-Espinosa, Erick González-Acevez. Salud Publica
Mex 2003; 45:191-197.
36. Giorgio L Colombo, Elisa Rossi,Marisa De Rosa, Danilo
Benedetto, Antonio V Gaddi. Antidiabetic therapy in real
practice: indicators for adherence and treatment cost. Dove-
press journal.Patient Preference and Adherence 2012; 6: 653–
661.
37. Rasaq Adisa, Titilayo.O.Fakaye, Adesoji Fasanmade. Medication
adherence among ambulatory patients with type 2 diabetes in a
tertiary healthcare setting in South-western Nigeria. Pharmacy
Practice (Internet) 2011 Apr-Jun; 9 (Suppl 2):72-81.
38. Yusuff KB, Obe O, Joseph BY. Adherence to antidiabetic drug
therapy and self management practices among type 2 diabetes
in Nigeria. Pharm World Sci 2008; 30 (Suppl 6):876-883.
39. Nasir T Wabe, Mulugeta T Angamo, Sadikalmahdi Hussein.
Medication adherence in diabetes mellitus and self
management practices among type-2 diabetics in Ethiopia.
North American Journal of Medical Sciences Sep 2011; 3 (Suppl
9):418-423.
40. Iloh GU Pascal, John N Ofoedu, Njoku P Uchenna, Amadi A
Nkwa, Godswill-Uko E Uchamma. N AM J Med Sci sep 2009;
3(Suppl 1):426-431.
41. Yelena Rozenfeld, Jacquelyn S. Hunt, Craig Plauschinat, Ken S.
Wong. Oral Anti diabetic Medication Adherence and Glycemic
Control in Managed Care. The American Journal of Managed
Care. Feb 2008; 14 (Suppl 2):71-75.
42. Morisky DE, Green LW, Levine DM. Concurrent and Predictive
Validity of a Self‐Reported Measure of Medication Adherence.
Medical Care 1986; 24 (Suppl 1):67‐74.
570