Clinical Epidemiology and Global Health 8 (2020) 1089–1093

Contents lists available at ScienceDirect

Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Factors influencing adherence to anti-diabetes medications among type 2 T

diabetes patients attending tertiary care hospitals in Mangaluru
Rekha Thapara,b, Ramesh Hollaa,b, Nithin Kumara,b,∗, Shodhan Aithalc,d, Sahana Karkerac,d,
Chaitra Raoc,d, Nikhita Pujaric,d, Ayshath Zahidac,d, Bhaskaran Unnikrishnana,b,
Prasanna Mithraa,b, Darshan K. Swamyc,d, Vaman Kulkarnia,b, Darshan Bhagawana,b,
Avinash Kumara,b
a
Department of Community Medicine, Kasturba Medical College, Mangalore, India
b
Faculty of Health Sciences, Manipal Academy of Higher Education, Manipal, India
c
Kasturba Medical College, Mangalore, India
d
Manipal Academy of Higher Education, Manipal, India

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Poor adherence is generally associated with bad outcomes of the disease especially in Non-com-
Medication adherence municable disease like diabetes.
Non-communicable disease Objectives: To study the level of adherence and factors associated with adherence to anti-diabetes medication
Blood glucose among patients with diabetes.
Multivariate analysis
Method: ology: In this cross-sectional study, 124 diabetes patients attending medicine OPDs at hospitals af-
Cross-sectional study
filiated to Kasturba medical college, Mangaluru were assessed regarding their adherence to anti-diabetes
medications using the Morisky 8-Item Medication Adherence scale. Univariate and multivariate analysis was
done to determine the factors associated with good adherence.
Results: The mean age of the patient was 59.8 ± 11.2 years. The median duration of diabetes was 7 (3–12)
years. In our study 43.5% (n = 54) of the participants had low adherence to anti diabetes medications. On
Univariate analysis, absence of side effects, and regular blood glucose monitoring were found to be significantly
associated with good adherence (P < 0.05). However, on multivariate analysis, absence of side effects was
found to be significantly associated with good adherence (P < 0.05).
Conclusion: Absence of side effects is the factor independently associated with good adherence. The interven-
tions planned to combat the problem of non-adherence to medications should be targeted towards reducing the
side effects of medication.

1. Introduction
In the past few years, the rise in the number of people living with
diabetes and its associated complications has been posing an un-
precedented burden on the healthcare system throughout the world.
According to the International Diabetes Federation (IDF), there are 463
million people living with diabetes, with a prevalence of 9.3% in people
aged 20–79 years.1 The health care system in low - and middle-income
countries which accounts for 79% of adults living with diabetes have
been overstrained.1 India is one among the top three countries with a
largest number of adults with diabetes and is predicted to remain so till
2030.1,2
The WHO defines adherence to medication as ‘'the extent to which a
patient's behaviour of taking medication, is in line with that re-
commended by his physician”.3 Non-Adherence to medications has al-
ways been a challenging aspect of controlling Non-Communicable
Disease (NCD). It leads to a decrease in the therapeutic effect of the
drug, which results in multiple visits to the hospital due to non-

∗
Corresponding author. Department of Community Medicine, Kasturba Medical College, Mangalore, India.
E-mail addresses: rekha.thapar@manipal.edu (R. Thapar), ramesh.holla@manipal.edu (R. Holla), nithin.gatty@manipal.edu (N. Kumar),
shodhanaithal@gmail.com (S. Aithal), snassv94@gmail.com (S. Karkera), chaitrar753@gmail.com (C. Rao), nikitampujari@gmail.com (N. Pujari),
ayshath7zahida@gmail.com (A. Zahida), unnikrishnan.b@manipal.edu (B. Unnikrishnan), prasanna.mithra@manipal.edu (P. Mithra),
darshankswamy@gmail.com (D.K. Swamy), vaman.kulkarni@manipal.edu (V. Kulkarni), darshan.bb@manipal.edu (D. Bhagawan),
avinash.kumar@manipal.edu (A. Kumar).

https://doi.org/10.1016/j.cegh.2020.03.025
Received 2 November 2019; Received in revised form 14 March 2020; Accepted 19 March 2020
Available online 21 March 2020
2213-3984/ © 2020 INDIACLEN. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
R. Thapar, et al. Clinical Epidemiology and Global Health 8 (2020) 1089–1093

improvement of health, overburdening the health system and high Table 1

health care expenditure on the part of the patient.4 This decrease in Baseline characteristics of the participants (N = 124).
therapeutic effect or lack of response to the therapy could be mis- Variables n (%)
interpreted by the physician as therapeutic ineffectiveness rather than
non-adherence to medication and prompt the physician to increase the Age group (yrs)
< 45 14 (11.3)
dose or change the regimen which could be detrimental to the patient.5
46–55 33 (26.6)
Many advances have been made in treatment and monitoring of 56–65 39 (31.5)
diabetes progression. However, ensuring patient adherence to therapy > 65 38 (30.6)
is a major challenge for doctors. Good adherence to anti-diabetes Gender
medications results in less hospital admission due to complication of Male 68 (54.8)
Female 56 (45.2)
diabetes.6 Due to poor adherence, it is not possible to avoid the medical
Marital status
complications of the disease which can surely be delayed, if not totally Married 107 (86.3)
prevented, if adequate control of blood sugar level is maintained. Poor Widow 13 (10.5)
compliance is generally associated with unfavourable outcomes like Unmarried 04 (03.2)
Socioeconomic status
uncontrolled blood sugar and diabetes related complications.7 This re-
Lower 45 (36.3)
sults in the patient having to spend copious amounts of money on Lower/Upper lower 55 (44.4)
hospitalization and chronic illness care.8 Middle/Lower middle 17 (13.7)
There is paucity of literature regarding adherence to diabetes Upper middle 07 (05.6)
medication from Southern part of India where Diabetes is on the rise. Family History of diabetes
Yes 43 (34.7)
This cross-sectional study was conducted to assess the level of ad-
No 81 (65.3)
herence to anti-diabetes medications and to study the factors influen- Presence of comorbidities
cing adherence among diabetes patients in coastal South India. Yes 72 (58.1)
No 52 (41.9)
2. Materials and methods Presence of diabetic complications
Yes 51 (41.1)
No 73 (58.9)
One twenty-four patients with diabetes attending the Medicine Out Smoker
Patient Department at the hospitals affiliated to Kasturba Medical Yes 25 (20.2)
College, Mangaluru were assessed regarding their adherence to anti- No 99 (79.8)
Alcohol consumption
diabetes medications. All the participants were above 18 years of age
Yes 16 (12.9)
and on anti-diabetes treatment for more than 6 months. The sample size No 108 (87.1)
was calculated considering the adherence to anti-diabetes medication Experience of side effects
as 47%,9 along with a relative precision of 20%, 95% confidence in- Yes 48 (38.7)
terval and a non-response error of 10%. No 76 (61.3)

A pretested semi-structured questionnaire consisting of four sections

was used to collect the relevant information: Section A - Socio-demo-
proportion (n = 68, 54.8%) of the participants were males and below
graphic information of the participants, Section B – Diagnosis and
the age of 60 years (n = 65, 52.4%). The median duration of diabetes
treatment details, Section C- Factors related to health, Section D -
was 7 years (IQR - 3–12). Family history of diabetes was present among
Morisky 8-Item Medication Adherence Questionnaire.10,11 The socio-
34.7% (n = 43) of the participants, and hypertension was the most
economic status of the patient was assessed using modified Kuppus-
common co-morbidity (n = 72, 58.1%). Among the 41.1% (n = 51)
wamy scale.12
patients who had diabetes related complications, the most common
Approval was obtained from the Institutional Ethics Committee of
complication observed was retinopathy (n = 29, 23.4%) (Table 1).
Kasturba Medical college, Mangaluru (Manipal Academy of Higher
In our study, the self-reported prevalence of adherence to diabetes
Education) prior to the commencement of the study. Permission was
medication was 87.9% (n = 109). Among the participants who re-
also obtained from the respective authorities of the hospital. The pa-
ported to have not taken their diabetes medication regularly (12.1%,
tients were approached in the OPD and were briefed about the objec-
n = 15), forgetfulness (40%, n = 6) was the most commonly cited
tives of the study in the vernacular language. After obtaining a written
reason. Using the Morisky adherence scale, 43.5% (n = 54) of our study
informed consent the participants were interviewed.
participants were found to have low adherence to anti diabetes medi-
cations, followed by 29% (n = 36) and 27.4% (n = 34) who had
2.1. Statistical analysis
moderate adherence and high adherence respectively (Fig. 1). For
comparison and further analysis, participants with high and moderate
Data collected was analysed using SPSS (Statistical Package for
level of adherence were grouped together into a single category of
Social Sciences) version 16 and expressed using mean (Standard
having good adherence (n = 70, 56.5%) and participants with low
Deviation), median (Inter quartile Range) and proportions. Univariate
adherence as having poor adherence (n = 54, 43.5%).
and multivariate analysis was carried out to assess the factors (Patient
Patient related factors associated with adherence to anti-diabetes
related, Medication related and Health system related) influencing ad-
medication is shown in Table 2. Good adherence to anti-diabetes
herence to anti-diabetes medication among patients and a P value less
medication was seen to be higher among the participants aged 60 years
than 0.05 was considered to be statistically significant. Only the factors
or less, female gender, married, belonging to middle socio economic
found to be significant on univariate analysis were considered for
status, and participants who did not smoke and drink alcohol. However,
multivariate analysis. Unadjusted and adjusted odds ratios (ORs) and
none of these factors were found to be statistically associated with good
corresponding 95% confidence intervals (CIs) were also reported.
adherence behaviour. (P > 0.05).
Table 3 depicts the comparison of health system and medication
3. Results
related factors with adherence to anti-diabetes medication. Regular
monitoring of blood glucose level and absence of side effects was found
This cross-sectional study was conducted among 124 patients with
to be statistically associated with good adherence behaviour.
diabetes to assess their adherence to anti-diabetes medication. The
(P < 0.05).
mean age of the participant was 59.8 ± 11.2 years. A higher

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R. Thapar, et al. Clinical Epidemiology and Global Health 8 (2020) 1089–1093

Fig. 1. Level of adherence to anti diabetes medications among the study participants (N = 124).

Table 2 Table 3
Univariate analysis showing the patient related factors determining adherence Univariate analysis showing the Health system related factors and Medication
to anti-diabetic medication (N = 124). related factors determining adherence to anti-diabetic medication (n = 124).
Variables Adherence Unadjusted OR (95%C.I) P Variables Adherence Unadjusted OR P value
Value (95%C.I)
Good (n = 70) Poor (n = 54) Good (n = 70) Poor (n = 54)

Age group (yrs) Distance from hospital (km)

≤60 37 (56.9) 28 (43.1) 1.04 (0.51–2.12) 0.912 ≤2 28 (62.2) 17 (37.8) 1.45 (0.69–3.06) 0.329
> 60 33 (55.9) 26 (44.1) 1 >2 42 (53.2) 37 (46.8) 1
Gender Cost of drugs
Male 36 (52.9) 32 (47.1) 1 Free 36 (63.2) 21 (36.8) 1.66 (0.81–3.42) 0.173
Female 34 (60.7) 22 (39.3) 1.37 (0.67–2.81) 0.386 Paid 34 (50.7) 33 (49.3) 1
Marital status Frequency of blood glucose monitoring
Married 62 (57.9) 45 (42.1) 1.55 (0.56–4.32) 0.403 Regular 58 (61.7) 36 (38.3) 2.41 (1.03–5.60) 0.040
Single 08 (47.0) 09 (53.0) 1 Occasional 12 (40.0) 18 (60.0) 1
Socioeconomic status Means of conveyance
Middle 17 (70.8) 07 (29.1) 2.15 (0.82–5.64) 0.119 Walking 22 (71.0) 09 (29.0) 2.29 (0.95–5.50) 0.063
Lower 53 (53.0) 47 (47.0) 1 UseTransport 48 (51.6) 45 (48.4) 1
Family history of diabetes Number of anti-diabetic medications taken
Yes 21 (48.8) 22 (51.2) 1 ≤2 39 (52.0) 36 (48.0) 1
No 49 (60.5) 32 (39.5) 1.60 (0.76–3.38) 0.221 >2 31 (63.3) 18 (36.7) 1.59 (0.76–3.32) 0.223
Presence of comorbidities Side effects experienced
Yes 41 (56.9) 31 (43.1) 1.05 (0.51–2.15) 0.897 Yes 21 (43.8) 27 (56.2) 1
No 29 (55.7) 23 (44.3) 1 No 49 (64.5) 27 (35.5) 2.33 (1.11–4.88) 0.020
Smoker Insulin injection taken
Yes 11 (44.0) 14 (56.0) 1 Yes 20 (57.1) 15 (42.9) 1.04 (0.47–2.29) 0.922
No 59 (59.6) 40 (40.4) 1.87 (0.77–4.55) 0.171 No 50 (56.2) 39 (43.8) 1
Alcohol consumption Duration of diabetes(years)
Yes 07 (43.7) 09 (56.3) 1 <5 25 (54.3) 21 (45.7) 1
No 63 (58.3) 45 (41.7) 1.80 (0.62–5.19) 0.289 >5 45 (57.7) 33 (42.3) 1.14 (0.55–2.38) 0.720
Diabetic complications present
Yes 27 (52.9) 24 (47.1) 1
No 43 (58.9) 30 (41.1) 1.27 (0.61–2.62) 0.516
On univariate analysis, absence of side effects and regular blood
Fasting Blood Glucose Level
glucose monitoring were found to be significantly associated with good ≤126 14 (66.7) 07 (33.3) 1.67 (0.63–4.75) 0.319
adherence behaviour among diabetes patients. However, on multi- > 126 56 (54.4) 47 (45.6)
variate analysis, absence of side effects (OR 2.18, CI 1.02–4.61,
P < 0.05) was found to be the single most factor influencing good
adherence behaviour among the study participants. (Table 4). Table 4
Factors associated with adherence to anti-diabetic medication.
4. Discussion Factors UNADJUSTED P value ADJUSTED P value
OR (95% CI) OR (95%CI)
Non-adherence to anti-diabetes medication is a major public health
Absence of Side effects 2.33 (1.11–4.88) 0.020 2.18 0.042
problem leading to increase in the incidence of diabetes related com-
(1.02–4.61)
plications and hospitalization due to the disease. The rise in prevalence Regular blood 2.41 (1.03–5.60) 0.040 2.21 0.069
of poor adherence has led to it being termed an “invisible epidemic”.3 monitoring (0.94–5.22)
Our study aimed at determining the level of adherence to anti-diabetes
medications and identifying the factors influencing good adherence
behaviour among patients with diabetes. In our study, 43.5% of the
participants were found to have low adherence to anti-diabetes

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medications. Studies from India and other parts of the world have re-
ported poor adherence behaviour to anti diabetes medication ranging
from 16% to 73.6%.9,13–26 This variation in adherence level could be
due to absence of a standard, universally accepted definition for ad-
herence and the use of different adherence questionnaires leading to
variation in the level of adherence to anti-diabetes medications.
Self-reported adherence to medication was high among our study
participants compared to the adherence as assessed by Morisky ad-
herence scale, which was also reported from a study in Nigeria.18 The
most common reason cited by majority of our participants for not
taking medications regularly was forgetfulness. Forgetfulness was also
reported as one of the reasons for non-adherence to medications in
many studies conducted in different parts of India and other coun-
tries.5,13,14,17,18,24–26 Forgetfulness can manifest in a number of ways –
in most geriatric patients, it could be because they forgot to take their
medicines or refill their prescription. Many of the patients might also
avoid taking medicines because they don't realize the importance of
being compliant to medication. Among all the patient related factors for
non-adherence, forgetfulness is one that requires an active involvement
of the patient and family members which can be reinforced by the
physician who can advise and educate the patient about diabetes and
the importance of compliance to medication. High cost of medicines,
unavailability of drugs, poor income, unawareness regarding im-
portance of medications and busy work schedule were the other reasons
for not adhering to medications.5,13,14,17,18,24–26
In our study, absence of side effects and frequent blood monitoring
for glucose level were the factors found to be associated with good
adherence to anti-diabetes medication. After multivariate analysis, ab-
sence of side effects emerged out to be the single most important factor
found to be significantly predicting good adherence behaviour. Similar
findings were obtained in the study conducted in Ethiopia.20 Side ef-
fects were experienced by 38.7% of our participants, which was higher
compared to studies from Tanzania and South India.19,21 Side effects to
medications was reported as a reason for non-adherence in studies
conducted elsewhere.13–16,19–21,24,26,27 Hypoglycemia, dyspepsia and
weight gain were some of the side effects experienced by participants in
our study. Some of the side-effects reported by participants from other
study included symptoms related to hypoglycemia, gastrointestinal
symptoms15,19,20 and weight gain20.
Regular monitoring of blood glucose level was associated with good
adherence behaviour in our study. This was in concurrence with a study
conducted in Egypt16 where irregular monitoring of blood glucose level
was associated with non-adherence to medication.
Studies across the globe have shown an assortment of factors asso-
ciated with good adherence behaviour to diabetes medications like,
duration of diabetes < 5 years,7,13,17 higher education level,14,17,18,20
higher socio-economic status,20,26,27 female gender,27 co-habitation
status,22 residing in an urban area,14 and single drug regimen.18,25
However, none of these factors were found to be significantly associated
with good adherence behaviour in our study.
It is evident from our study as well as studies from different parts of
the world that the problem of non-adherence is universal and multi-
factorial. Its impact may be more evident in countries with limited
resources where poor adherence might lead to early and more severe
complications which will in turn pose a financial liability on the patient
as well as overburden the heath system.
5. Conclusion
Our study revealed absence of side effect as the single most im-
portant factor in predicting good adherence. But the problem of ad-
herence to anti-diabetes medication is a multifactorial one.
Interventions have to be targeted towards reducing side effects to in-
crease good adherence behaviour among patients suffering from dia-
betes. Patients need to be educated and made aware regarding the
disease and the importance of being adherent to the medications in
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Clinical Epidemiology and Global Health 8 (2020) 1089–1093
order to check the progression of the disease and prevent complica-
tions. The health care providers need to educate the patients regarding
the possible side effects of the medications, ensure and motivate them
to be adherent to medications.
Limitations
The results of our study cannot be generalized as the sample size
was low. The Morisky 8-item adherence questionnaire which was used
in our study to assess the adherence has not been validated in Indian
population.
Recommendations
Patients should be made aware by means of health education re-
garding chronicity of the disease, need for strict blood glucose control,
and effect of poor adherence to anti-diabetes medications leading to
complications. We would recommend further such studies in different
study settings in the Indian subcontinent, so that we can generalize our
conclusion to the entire nation. Qualitative studies to recognise the
factors predicting non-adherence must be encouraged. Since the most
common reason stated for poor adherence by participants was for-
getfulness, usage of phone reminders, medication calendars, and pill
boxes may be beneficial. We advise prescription of Drug regimen with
minimal side effects. Physicians are advised to monitor the side effects
during every follow-up along with determining adherence to medica-
tions, and rectify if there is any other cause for poor adherence. Self-
help groups can be beneficial as the patients can discuss among them-
selves the reason for poor adherence and solve it. National programme
on prevention and control of diabetes, cardiovascular disease and
stroke (NPCDCS) should recognise the threat posed by non-adherence
to anti-diabetes medication and include it as one of the modifiable risk
factors for preventing complications of diabetes.
Funding statement
No funds were obtained for the study.
Details of ethical approval
Ethics Committee approval was obtained from the Institutional
Ethics Committee of Kasturba Medical College, Mangaluru (affiliated to
Manipal Academy of Higher Education), India prior to the commence-
ment of the study.
Declaration of competing interest
We would like to declare no conflict of interest.
Acknowledgements
I am grateful to the study participants who voluntarily took part in
the study. I also acknowledge the support provided by the Department
of Medicine, Department of Community Medicine, and Kasturba
Medical College, Mangaluru and Manipal Academy of Higher Education
for encouraging research and its publication in international journals of
repute.
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