|Year : 2018 | Volume
| Issue : 2 | Page : 71-77
Family support, medication adherence andglycaemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Eastern Nigeria
Gabriel Uche Pascal Iloh1, Agwu Nkwa Amadi2
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State; Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
2 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
|Date of Submission||12-Dec-2016|
|Date of Acceptance||11-Jun-2018|
|Date of Web Publication||13-Aug-2018|
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Aim: The study was aimed at determining the role of family support in medication adherence and glycemic control among ambulatory Type 2 diabetic patients in a primary care clinic in Nigeria. Materials and Methods: A clinic-based descriptive study was done on 120 Type 2 diabetic Nigerians who were on treatment for at least 3 months at the primary care clinic in Nigeria. Family support and medication adherence were assessed in the previous 3 months and 1 month preceding the study using multi-dimensional Scale of Perceived Social Support and interviewer-administered questionnaire on self-administered and reported therapy (SAT), respectively. Glycemic control was assessed in the previous 1 month. Results: The age of the participants ranged from 27 to 81 years, and there were 37.5% males and 62.5% females with sex ratio of 1:1.7. Family support, medication adherence, and glycemic control rates were 77.5%, 72.5%, and 61.7%, respectively. Family support was significantly associated with elderly age (0.041), medication adherence (P = 0.038), and glycemic control (P = 0.027). The most significant demographic predictor of family support was elderly age (odds ratio = 4.30 [2.06–5.15]; P = 0.015). The elderly patients with Type 2 diabetes were four times more likely to have family support compared to their counterparts who were <60 years. Conclusion: This study has shown the level of family support, medication adherence, and glycemic control among patients with Type 2 diabetes. Family support was significantly associated with elderly age, medication adherence, and glycemic control. Interventions to improve medication adherence and glycemic control should consider measures to enhance family support and this could be used to plan diabetes-oriented management decisions.
Keywords: Adult Nigerians, family support, glycemic control, medication adherence, primary care
|How to cite this article:|
Iloh GU, Amadi AN. Family support, medication adherence andglycaemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Eastern Nigeria. J Health Res Rev 2018;5:71-7
|How to cite this URL:|
Iloh GU, Amadi AN. Family support, medication adherence andglycaemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Eastern Nigeria. J Health Res Rev [serial online] 2018 [cited 2018 Sep 24];5:71-7. Available from: http://www.jhrr.org/text.asp?2018/5/2/71/238861
| Introduction|| |
Diabetes mellitus is a family health problem in both developed , and developing countries  of the world. Diabetes mellitus is one of the most demanding chronic medical conditions that affect the functional status, well-being, and wellness of the victims and impact significantly on their health-related quality of life. It is a sociopsychologically demanding metabolic disease that requires long-term complex care involving family members, friends, and significant others.
Research studies have demonstrated that several factors such as family-, clinician-and environmental-related variables influence medication adherence, and blood glucose control among patient with diabetes mellitus., Among the family-related factors are family support for diabetic care.,, Family support in patients with diabetes has revolutionized ambulatory care, whereas patients support for medication adherence and diverse diabetic care are evaluated with respect to family members, friends, and significant others who are expected to provide necessary support for diabetic care., Family support is conceptually defined as the perception of support from members of the family and includes support provided by immediate family members, extended family members, relatives, and friends. Family support is therefore directly associated with the degree to which diabetic patient perceives how his or her needs in diabetic care are fulfilled by family members and is linked with cognitive evaluation and emotional reactions to the components of care services such as medication adherence and glycemic control.,,,
Several family support tools have been used to evaluate the perception of family support in clinical and epidemiological studies.,,,,, Different scales have been used across and within various global populations and the perceived family support focused on peculiarities that characterized interpersonal relationships and communication in the family specifically and the society in general.,,,,, Family support tools which can be used in medical practice have been documented in biomedical literature with each of the tool having different psychometric properties in terms of strengths and weaknesses: there exist Multidimensional Scale of Perceived Social Support (MSPSS) which measures variability in three major sources of support from family, friends, and significant others; PSS from family (PSS-Fa) and from friends (PSS-Fr); Chinese family support scale; Julkunen family support scale, Duke-UNC Functional Social Support questionnaire, and Thai family support scale for elderly parents.
There have been reports of the role of family support on medication adherence and blood glucose control in various global populations.,,,, These studies have demonstrated variable effects of family support on diabetic outcome. In Nigerian Africa, the family network has been described as sociocentric and is characterized by close-knit relationship which constitutes basic sources of necessary support for diabetes care. However, not much is reported about the role of family support on adherence with medication and blood glucose control among diabetic Nigerians. Given the research evidence of the consequences of poor family support on diabetic outcome ,, and growing burden of diabetes mellitus in Nigeria, operational research in this area is needed to determine the magnitude of the problem to institute interventions that are family care driven. It is based on this premise that researchers were prompted to determine the role of family support on medication adherence and glycemic control among ambulatory Type 2 diabetic Nigerians in a primary care clinic of a tertiary hospital situated in underresourced environment of Eastern Nigeria.
| Materials and Methods|| |
This was a descriptive clinic-based study conducted on 120 adult Type 2 diabetic Nigerians from April 2011 to December 2011 at the primary care clinic of a tertiary hospital in Nigeria.
All adult patients excluding those who need emergency healthcare services, pediatric patients, and antenatal women are first seen at the primary care clinic where diagnoses are made. Patients who need primary care are managed and followed up in the clinic while those who need other specialists care are referred to the respective core specialist clinics for further management.
The inclusion criteria were adult diabetic Nigerians who were aged 18 years and more that gave informed consent for the study. The participants must have been on outpatient treatment for diabetes mellitus for a minimum of 3 months in the Department of Family Medicine and had recorded at least three clinic visits (recruitment visit, penultimate visit before the end of study, and end of study visit). The 3 months outpatient treatment was to make sure that the study participants were conversant with prescribed antidiabetic medications. Critically ill patients, patients with diabetes living alone, and patients with diabetes who were on insulin therapy were excluded from the study.
Sample size determination was estimated using the formula  for determining the least sample size for descriptive studies and had been explained in detail in the previous publication by the authors. Sample size of 120 adult patients with diabetes was used for the study.
The eligible patients for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 120 was achieved.
The study tool consisted of sections on sociodemographic data, information on medication adherence, family support, and glycemic control.
Medication adherence was assessed by the use of pretested, interviewer-administered questionnaire on 30 days self-administered and reported therapy (SAT). Patients were seen at the recruitment visit and at the end of the study visit. At the end of study visit, the adherence section of the data collection tool was administered. The details of the information collected had been explained in specific details in the previous study by the authors. Grading of adherence was done using an ordinal scoring of 0–4 points designed by the researchers from literature review ,,,,, as follows: all-times = 4 points, most times = 3 points, sometimes = 2 points, rarely = 1 point, and never = 0 point.
Family support was assessed in the previous 3 months using a 12-item MSPSS from family, friends, and significant others. Each item is scored 1–7 as follows: very strongly disagree = 1; strongly disagree = 2; mildly disagree = 3; neutral = 4; mildly agree = 5; strongly agree = 6; and very strongly agree = 7. The score ranged from 12 to 84 with scores 12–48 = low PSS; 49–68 = moderate PSS; and 69–84 = high PSS. The family support scale was reclassified by the authors for statistical analysis into family support with scores of 49–84 and no family support with scores <49. The moderate and high PSS were categorized as family support while low PSS included low PSS. This categorization recognized the influence of family on diabetic care in sociocentric and household family settings in Nigeria.,
Pretesting of the family support tool and medication adherence section of the study instrument was done at the primary care clinic of the hospital. Five patients with diabetes were haphazardly used for the pretesting of the family support tool and medication adherence questionnaire which lasted for 1 day. The pretesting was done to assess the applicability of the questionnaire tools. All the patients used for the pretesting of the questionnaire instrument gave valid and reliable responses confirming the clarity and applicability of the questionnaire tools and questions were interpreted with the same meaning as intended.
The fasting plasma glucose at baseline was recorded at the recruitment visit for each patient and subsequently at the end of study visit.
A patient was said to adhere to treatment when he/she had a score of 4 points (took all the prescribed doses of oral hypoglycemic medication(s) all-times) in the previous 30 days by the end of the study visit while those that scored 0–3 points and missed a day dose of anti-diabetic medications meant nonadherence. A goal blood glucose control was defined as fasting plasma glucose at the end of study visit of 70 and 130 mg/dL. Family support referred to the perception of support from immediate family members, extended family members, and friends.
The ethical approval for this study was provided by the Ethical Committee of Federal Medical Centre Umuahia (Queen Elizabeth Hospital), Nigeria, with reference number FMC/QEH/G.596/Vol. 3 dated June 18, 2010. Consent was also obtained from the patients.
The results generated were analyzed using software Statistical Package for Social Sciences (SPSS) version 13.0, Inc., Chicago, IL, USA for the calculation of percentages for categorical variables. Bivariate analyses involving Chi-square test was used to test for the significance of associations between categorical variables. Logistic regression analyses were performed where appropriate. In all cases, P < 0.05 was considered statistically significant. Odds ratio (OR) which is an indicator of degree of association of family support with a predictor demographic variable was estimated at 95% confidence limit.
| Results|| |
The age of the study subjects ranged from 27 to 81 years with average age of 36.8 ± 5.4 years. The study participants were made up of 45 (37.5%) males and 75 (62.5%) females with sex ratio of 1:1.7. Other demographic profile of the study individuals are shown in [Table 1].
Of the 120 patients with diabetes studied, 93 (77.5%) had family support while 27 (22.5%) had no family support. On adherence to antidiabetic medications, 87 (72.5%) of the patients with diabetes were adherent with medications while 33 (27.5%) of them were not adherent with medications while on glycemic control 74 (61.7%) of the patients had their blood glucose controlled while 46 (38.3%) of them were uncontrolled [Table 2].
|Table 2: Family support, medication adherence, and glycemic control among the study individuals|
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Of the 93 patients with diabetes who had family support, 71 (81.6%) of them were adherent with antidiabetic medications while 22 (66.7%) were nonadherent with medications. The difference was statistically significant (χ2 = 9.30; P = 0.038) [Table 3].
|Table 3: Association between family support and medication adherence among the study participants|
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Of the 93 patients with diabetes who had family support 66 (89.2%) of them had controlled blood glucose while 27 (58.7%) had uncontrolled blood glucose. The difference was statistically significant (χ2 = 13.15; P = 0.027) [Table 4].
|Table 4: Association between family support and glycemic control among the study participants|
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Bivariate Chi-square analysis of the demographic factors as related to family support showed that elderly age was statistically significant (χ2 = 5.67; P = 0.041) while other demographic variables were not statistically significant [Table 5].
|Table 5: Association between demographic factors and family support of the study participants|
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However, on logistic regression analysis of demographic factors as related to family support, age (OR = 4.30; confidential interval [CI] = 2.06–5.15; P = 0.015) and type of household family (OR = 2.80; CI = 1.17–6.11; P = 0.033) were statistically significant while other demographic factors were not statistically significant [Table 6]. The most significant demographic predictor of family support was elderly age. A significantly higher proportion of elderly patients with Type 2 diabetes (54.8%) had family support compared to their counterparts aged <60 years (45.2%). The elderly patients with Type 2 diabetes were four times more likely to have family support compared to patients with Type 2 diabetes aged <60 years. (OR = 4.30; CI = 2.06–5.15; P = 0.015).
|Table 6: Logistic regression analysis of demographic factors as related to family support|
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| Discussion|| |
This study has shown that 77.5% of the patients with diabetes had family support, and family support was significantly associated with medication adherence and glycemic control. Although not every patient with good family support adhered to medication with good glycemic control, their chances are higher when compared with those with no family support. The finding of this study is in tandem with the reports that patients with diabetes with family support had better medication adherence and glycemic control than those without family support.,, The implication of this finding is that clinicians attending to patients with diabetes with no family support may attribute inadequate response to medication as treatment failure rather than absence of family support. The absence of family support for diabetic care could constitute a risk factor for medication nonadherence and could be a surrogate marker of patients who generally are less likely to adhere to medication.,, It is, therefore, quintessential to inquire about family support during clinical encounter with ambulatory patients with diabetes as this has been shown to enhance coping mechanism, medication adherence, glycemic control, and overall quality of life of patients with diabetes.,,, Family support in the management of diabetes is, therefore, a suitable innovative practice in ambulatory care that provides appropriate psychosocial support necessary for optimal diabetic care. The family members of the diabetic family should therefore be aware of this subtlety and made to actively participate in the care of diabetic family member. More attention should be given to factors that promote family support among ambulatory Type 2 patients with diabetes especially in resource-poor environment where there are limited options for optimal diabetic care and healthy living.
Family support was significantly associated with elderly age. The elderly patients with Type 2 diabetes mellitus have higher family support when compared with other age groups. The higher family support among the elderly patients with diabetes in this study could be due to sociocultural and behavioral reasons.,, In this part of the world, with functional sociocentric and household family structure, elderly patients with diabetes tend to depend on their family members for diabetic care resources. This dependence on family members leads to the supervision and monitoring of treatment by the family members. In such families with older diabetic family member(s), the elderly father maintains the traditional role as the head of the family and primary bread winner if he is involved in primary or secondary occupation and the mother who is essentially the primary home maker. The older diabetic patient by virtue of being a mother or father could have children, grandchildren, and significant others who ensured that medications are taken and other diabetic prescriptions are observed. In addition, the presence of older person in the family promotes family togetherness, cohesion, and psychological well-being and family members are eager to improve the quality of life and prolong the lifespan of their elderly diabetic family members or parents. More so, functional family discussion, especially that between the elderly diabetic persons and other family members of the household, is critically important in ensuring optimal diabetic care particularly adherence to medication.
This study has shown that family support was significantly associated with medication adherence. Adherent patients had higher family support scores than nonadherent patients thus corroborating the reports that enhancing family support among patients with diabetes could improve medication adherence.,, It is therefore not sufficient to prescribe oral hypoglycemic medications during clinical consultation with patients with Type 2 diabetes, but consistent evaluation of family support should be a component of care package for patients with diabetes. Family members have obligations to provide a broad range of support to ensure that antidiabetic medications are taken as prescribed. Family support is, therefore, one of the crucial factors for reducing the risk of medication nonadherence. Patients with diabetes should be evaluated for family support to identify those with no family support so as to institute family-oriented therapy.
This study has demonstrated the association between family support and glycemic control. The finding of this study is in accord with the reports that patients with diabetes who have family support are adherent to treatment, have better glycemic control when compared with those without family support., A high degree of sense of received family support has been linked with better coping, adaptation and enabled the diabetic patient to live on with the disease condition. Family support, therefore, impacts on medication adherence which is one of the leading factors for good glycemic control resulting in substantial improvement of disease condition and decrease use of medical resources like hospital admissions.,, Being aware of this determinant of blood glucose control and evaluating them during subsequent patient visits can affect the quality and quantity of care delivered to these patients with diabetes. The findings of this study provide an evidence of the growing issue of the relevance of family support in the care of patients with diabetes and calls for measures to improve management of diabetes mellitus through strengthening of the family support.
Implications of the study
The role of family support in medication adherence and blood glucose control has been the subject of recent research particularly in developing countries and is widely recognized as patient-oriented outcome of quality of care in diabetic management. This has implications for family life, resource expenditure and other diverse diabetic care. Family dynamics is an integral component of factors that maintain optimum health in the management of diabetes mellitus, especially in ambulatory care environment. Poor glycemic control is not only life-threatening condition to the diabetic patient; however, it also affects their quality of life and that of their family members and friends as a whole. As the diagnosis of diabetes mellitus increases in Nigeria with poor knowledge of the relevance of good glycemic control in the onset and emergence of its complications, there is need to employ a family-oriented approach in its holistic care. This study will sensitize clinicians involved in the care of patients with diabetes to explore family support during clinical encounter especially in resource-poor settings where there are limited options for optimal diabetic care.
Limitations of the study
The limitations imposed by the study are recognized by the authors and had been described in detail in previous study by the authors. The study relied on self-reported measures of adherence and family support by the patients with Type 2 diabetes. The family support tool did not examine objectively the family support that the individual received but rather assessed the sense that the patient had of how much he or she is supported by the person(s) who he or she lived together.
| Conclusion|| |
This study has shown the level of family support, medication adherence, and glycemic control among patients with Type 2 diabetes. Family support was significantly associated with elderly age, medication adherence, and glycemic control. Multifaceted interventional strategies to improve medication adherence and glycemic control should consider measures to enhance the family support of patients with diabetes and this could be used to plan diabetes-oriented management decisions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Knafl K. Family synthesis research: Possibilities and challenges. J Fam Nurs 2015;21:3-10.
Rintala TM, Jaatinen P, Paavilainen E, Astedt-Kurki P. Interrelation between adult persons with diabetes and their family: A systematic review of the literature. J Fam Nurs 2013;19:3-28.
Iloh GU, Collins PI, Amadi AN. Family functionality, medication adherence, and blood glucose control among ambulatory type 2 diabetic patients in a primary care clinic in Nigeria. Int J Health Allied Sci 2018;7:23-30. [Full text]
Dasappa H, Prasad S, Sirisha M, Ratna Prasanna SV, Naik S. Prevalence of self-care practices and assessment of their sociodemographic risk factors among diabetes in the urban slums of Bengaluru. J Fam Med Prim Care 2017;6:218-21.
Iloh GUP, Collins PI. Hypoglycaemia in a resource-poor Nigerian environment: A cross-sectional study of knowledge of symptoms, causes, and self-management practices among ambulatory type 2 diabetic patients in South-East Nigeria. BLDE Univ J Health Sci 2017;2:29-37. [Full text]
Basu S, Garg S, Sharma N, Singh MM, Grarg S. Adherence to self-care practices. Glycaemic status and influencing factors in diabetes patients in a tertiary care hospital in Delhi. World J Diabetes 2018; 9:72-9.
DiMatteo MR, Haskard-Zolnierek KB, Martin LR. Improving patient adherence: A three-factor model to guide practice. Health Psychol Rev 2012;6:74-91.
Miller TA, Dimatteo MR. Importance of family/social support and impact on adherence to diabetic therapy. Diabetes Metab Syndr Obes 2013;6:421-6.
McEwen MM, Murdaugh C. Partnering with families to refine and expand a diabetes intervention for Mexican Americans. Diabetes Educ 2014;40:488-95.
Mayberry LS, Osborn CY. Family support, medication adherence, and glycemic control among adults with type 2 diabetes. Diabetes Care 2012;35:1239-45.
Fortmann AL, Gallo LC, Philis-Tsimikas A. Glycemic control among Latinos with type 2 diabetes: The role of social-environmental support resources. Health Psychol 2011;30:251-8.
Waari G, Mutai J, Gikunju J. Medication adherence and factors associated with poor adherence among type2 diabetes mellitus patients on follow up at Kenyatta National, Kenya. Pan Afr Med J 2018;29:82.
Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multi-dimentional scale of perceived social support. J Pers Assess 1988;52:30-41.
Procidano ME, Heller K. Measures of perceived social support from friends and from family: Three validation studies. Am J Community Psychol 1983;11:1-24.
Li G, Hu H, Dong Z, Arao T. Development of the Chinese family support scale in a sample of Chinese patients with hypertension. PLoS One 2013;8:e85682.
Tselebis A, Anagnostopoulou T, Bratis D, Moulou A, Maria A, Sikaras C, et al.
The 13 item family support scale: Reliability and validity of the Greek translation in a sample of Greek health care professionals. Asia Pac Fam Med 2011;10:3.
Broadhead WE, Gehlbach SH, de Gruy FV, Kaplan BH. The duke-UNC functional social support questionnaire. Measurement of social support in family medicine patients. Med Care 1988;26:709-23.
Patcharee K, Sang-arun I, Umaporn B, Joanne KS. Development of the Thai family support scale for elderly parents (TFSS-EP). Thai J Nurs Res 2009;13:118-32.
Vaccaro JA, Exebio JC, Zarini GG, Huffman FG. The role of family/friend social support in diabetes self-management for minorities with type 2 diabetes. World J Nutr Health 2014;2:1-9.
Ramkisson S, Pillay BJ, Sibanda W. Social support and coping in adults with type 2 diabetes. Afr J Prm Health Care Fam Med. 2017;9:a1405.
Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care 2018;7:497-500. [Full text]
Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med 2013;35:121-6.
] [Full text]
Pascal IG, Ofoedu JN, Uchenna NP, Nkwa AA, Uchamma GU. Blood glucose control and medication adherence among adult type 2 diabetic Nigerians attending A primary care clinic in under-resourced environment of Eastern Nigeria. N Am J Med Sci 2012;4:310-5.
Lavsa SM, Holzworth A, Ansani NT. Selection of a validated scale for measuring medication adherence. J Am Pharm Assoc (2003) 2011;51:90-4.
Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;10:348-54.
Jimmy B, Jose J. Patient medication adherence: Measures in daily practice. Oman Med J 2011;26:155-9.
Ba-Essa EM, Abdulrhman S, Karkar M, Alsehati B, Alahmad S, Aljobran A,et al
. Closing gaps in diabetes care: From evidence to practice. Saudi J Med Med Sci 2018;6:68-76. [Full text]
Iloh GUP, Amadi AN. Epidemiology of Diabetic Emergencies in the Adult Emergency Department of a Tertiary Hospital in South-Eastern Nigeria International Journal of Tropical Disease and Health 2018; 30:1-10.
Iloh GUP, Amadi COA, Amadi AN. Epidemiology of Cardiovascular Emergencies in the Adult Emergency Department of a Tertiary Hospital in a Resource-constrained Setting of South-Eastern Nigeria. Journal of Advances in Medicine and Medical Research 2018;25:1-10.
Egunjobi AO, Ojo OS, Malomo SO, Sogunle PT. Medication adherence and family support among patients with type 2 diabetes mellitus seen at a primary care clinic in south-west Nigeria. Niger J Fam Pract 2018;9:21-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]