Medication adherence and its associated factors among diabetic patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia
Ali et al. BMC Res Notes
Medication adherence and its associated factors among diabetic patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia
Muhammed Ali 0
Tigestu Alemu 0
Oumer Sada 0
0 Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University , Addis Ababa , Ethiopia
Objective: Diabetes is a global problem with devastating human, social and economic impact. Anti-diabetic medications play a major role in the glycemic control of patients with diabetes. However, inadequate adherence compromises safety and treatment effectiveness, leading to increased mortality and morbidity. The aim of this study was to assess adherence to anti-diabetic medications and associated factors among patient with diabetes mellitus receiving care at Zewditu Memorial Hospital. Results: Among the total of 146 diabetic patients (mean age 46.5 ± 14.7), the level of adherence to anti diabetic medication was 54.8% (80) whilst 45.2% (66) of the participants were non adherent. Multiple logistic regression showed that knowledge of medication (AOR = 4.905, 95% CI 1.64-14.62, medication availability (AOR = 0.175, 95% CI 0.031-0.987) and education level (AOR = 13.65, 95% CI 1.45-128.456) were reasons for non-adherence.
Addis Ababa; Adherence; Anti diabetic medication; Diabetes; Zewditu Memorial Hospital
Diabetes mellitus (DM) is probably one of the oldest
diseases known to man. It is defined as a “metabolic
disorder caused by different factors characterized by a chronic
high level of blood sugar with disturbances to
carbohydrate, fat, and protein metabolism resulting from defects
in insulin secretion, insulin action, or both. It is a
complex, chronic diseases requiring continuous medical care
with multifactorial risk-reduction strategies beyond
glycemic control [
The 2014 report stated that the global prevalence of
diabetes among adults was 422 million, compared to 108
million in 1980. This prevalence is nearly doubled since
1980, rising from 4.7 to 8.5% in the adult population. By
2030 this would have risen to 552 million [
According to IDF 2003, diabetes is a global problem
with devastating human, social and economic impact.
Globally DM is the fifth leading cause of death by disease
]. Every 7 s, diabetes causes the death of an individual
worldwide, and in 2014 alone, 4.9 million deaths were
attributed to diabetes with 80% of deaths related to
diabetes reported from low- and middle-income countries
]. According to WHO, diabetes was once considered a
rare disease in sub-Saharan Africa. But in 2010, over 12
million people in sub-Saharan Africa are estimated to
have diabetes, and 330,000 people died from
diabetesrelated conditions. Over the next 20 years, it is predicted
that sub-Saharan Africa will have the highest growth
in the number of people with diabetes of any region in
the world—the 2010 estimated number is predicted to
almost double in 20 years, reaching 23.9 million by 2030
Ethiopia is estimated to have around 1.5 million people
with diabetes. According to WHO data published in 2011
DM dates in Ethiopia reached 21,550 or 2.62% of total
deaths. The age adjusted death rate is 61.96 per 100,000
of population ranks Ethiopia number 28 in the world and
it is the 7th leading cause of death in Ethiopia [
A latest WHO report indicates that because the
magnitude of non-adherence and the scope of its
sequelae are so alarming, more health benefits
worldwide could be achieved by improving
adherence to available medications than by developing new
treatment approaches. Studies revealed that
compliance to chronic medications in high income countries
is 50%. In low income countries, the prevalence is
even lower [
]. Poor compliance complicates the
challenges of improving health in developing countries,
and leads to waste and underutilization of already
limited resources. Compliance studies are peculiar to
every community and culture.
Adherence to medication is influenced by several
factors such as lack of information, complexity of regimen,
concomitant disease, and perceptions of benefit, side
effects, medication cost, long duration and emotional
wellbeing. Personality and cultural factors may influence
adherence-compliance rates. Institutional factors such as
the availability of medication at the hospital pharmacy,
cost of medications, prescription patterns and
accessibility also affects adherence. Again the personal beliefs,
knowledge on disease and medication, forgetfulness and
financial burden also reduce adherence level. These
factors are interrelated.
This study was aimed to assess level of adherence and
identify factors that are particular to diabetic patients
who receive care at Zewditu Memorial Hospital.
Study area and period
Prospective cross sectional study was conducted at
chronic follow up unit of Zewditu Memorial Hospital. It
is a general hospital in central Addis Ababa. The hospital
deals also with palliative care, HIV counseling and
testing, and post-exposure prophylaxis (PEP) service. There
are different clinics for follow-up of patients with chronic
illness at the hospital. The study was conducted from
February 20, 2017 to April 20, 2017.
Study participants and sample size determination
The study participants were all patients with
diabetes, aged at least 18 years, attending the diabetic clinic,
which have been on anti-diabetic medication for greater
than 6 months and gave informed consent to
participate in the study. We excluded those who were very ill
and those who were newly diagnosed with diabetes and
on medication for less than 6 month from the study. A
total of 146 participants were included by using single
proportion formula and using p value of 0.89 from
previous study and correction formula. The first patient was
selected randomly and every 7th patient was included in
the study. The dependent variable was adherence to anti
Data collection procedures
Trained data collectors used pretested structured
questionnaires to collect information on: patient
demographics and variables used to assess patient adherence. And
the data was cleared and checked every day for
completeness and consistency. The level of adherence assessment
was measured by Morisky Medication Adherence Scale-8
Adherence The extent to which a person’s behavior—
taking medication, following a diet, and/or executing
lifestyle changes—corresponds with agreed
recommendations from a health care provider.
Adherent Patients who score 0 based on Morisky
Medication Adherence Scale-8 (MMAS-8).
Non adherent Patients who score 1–8 based on Morisky
Medication Adherence Scale-8 (MMAS-8).
Data management and analysis
The collected data were sorted, coded and entered into
SPSS version 20 software for analysis. Descriptive statics
was generated to summarize patient socio-demographic
data; bivariate analysis was implemented to identify
associated factors. The crude odds ratio (COR), adjusted odds
ratio (AOR) and 95% confidence interval (CI) were
performed to determine factors associated with anti-diabetic
medications adherence and a p value of 0.05 or less was
considered statistically significant.
Approval request paper cleared by ethical review
committee from Addis Ababa University, College of health science,
and school of pharmacy was submitted to Zewditu
Memorial Hospital to undertake the study. Written informed
consent was obtained from study participants.
Confidentiality was maintained throughout the study process.
Socio‑demographic characteristics of participants
A total of 146 diabetics aged 18–79 were recruited. All
the participants had been on diabetic medication for
6 months and above. The mean age of the participant
was 46.5 years (± 14.6) with a range of (18–79 years). The
majority of the participants were above 50 years. About
23.3% (34) of the participants aged 51–60 years and
17.8% (26/146) were older than 60 years. Female
participants formed the majority.
There were 54.1% (79) females and 45.9% (67) males.
Most of participants were married. The married
participants were 69.2% (101). For educational level, 34.9%
(51) of the participant reported primary education
as their highest form of education. However, 223.3%
(34) reported that they have had no formal education.
Sixty-five (44.5%) participants were unemployed and 44
(30.1%) were self-employed. Table 1 shows socio
demographic characteristics of the participant.
Clinical characteristics of participants
Type 2 diabetics the commonest type of diabetics, 54%
(80) participant had been diagnosed with type 2
diabetics. However 25.3% (37) of the participants did not know
type of diabetics. The mean number of medication
prescribed was 1.51 (± 0.816).
More than 20% (35) of the respondents did not have all
their diabetic medication available at the hospital
pharmacy. About 71.2% (104) reported that all their diabetic
medication was covered by health insurance. Majority of
the participant, 97.3% (142) reported that there was not
any difficulty in getting their prescribed medication.
Regarding the service rendered, a larger proportion
74.7% (110) of the participants reported that they were
satisfied with it.
Participants knowledge of diabetes and medication
About 96.6% (141) reported they knew the name of their
medication. However 93.8% (137) reported that they do
not know any side effect of their diabetic medication.
Majority of the participants had knowledge on diabetes
mellitus, types, and sign of hypoglycemia and cause
comorbid disease. However 10.3% (15) reported that
diabetics can be cured (Fig. 1).
Determining the level of adherence
The level of adherence was assessed using eight
itemMorisky Medication Adherence Scale (MMAS-8).
Participants who had score of 0 were classified to adherent. The
minimum score was 0 and the maximum score 4. Based
on this classification 54.8% (80) of the participants were
adherent whilst 45.2% (66) of the participants were non
Factor affecting adherence
On bivariate analysis Medication availability, complexity
of regimen, satisfaction and Education level were found
to be significantly associated. On the other hand,
multiple logistic regression showed that knowledge of
medication (AOR = 4.905, 95% CI 1.64–14.62, medication
availability (AOR = 0.175, 95% CI 0.031–0.987) and
Education level (AOR = 13.65, 95% CI 1.45–128.456) were
reasons for non-adherence (Table 2).
Currently, there is no single measure accepted as the
gold standard to measure medication adherence since all
commonly employed methods have drawbacks. In this
study, from the available methods, a self-reported 8-item
Morisky Medication Adherence Scale was used to assess
A systematic review on the adherence to medication
among diabetic patients showed that the average
compliance to the oral hypoglycemic agents ranged from 36 to
The magnitude of adherence level in this study was
54.8%. In contrast to this finding, two studies in Ethiopia
showed that the patients self-reported adherence rate to
anti-diabetic medication was 72.2 and 68.8% [
difference may be attributed to, methodological
variations and ways of measurement for adherence level.
Health care providers should be cognizant of
knowledge of patients on diabetes and how this may affect
long-term efforts to successful management of diabetes
mellitus. Emphasis on awareness creation about diabetes
and its management is important to achieve positive
diabetes outcomes. It was revealed in this study that patients
who had no knowledge about diabetes were five times
more likely to be non-adherent as compared to patients
who had knowledge on diabetes. Other studies are also
consistent with this finding.
Regarding educational level, it was found to be
significantly associated with the level of adherence to the
treatment regimen. From different studies education
has been identified as major socioeconomic
determinant of adherence to anti-diabetic medication. Low
educational level has been associated with higher
rates of non-adherence. This was supported by
previous researches done in UAE [
]. Being illiterate 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.
Availability of medications was one of the variables
that found to be significantly associated with the
adherence status of the respondents. Findings of this study
collaborated with other studies indicated an
association between medication adherence and medication
]. Unavailability of medications in the
health institution has negative impact on patient
adherence, especially when it is accompanied by low
economic status. Because the patient cannot afford to bay
medication from the private sectors, where medications
are usually costly.
Concerning institutional factors, number of
medication prescribed was independently associated with
non-adherence. Participants who had complex
regimen were more likely to have poor adherence. This
finding is similar to study done in Jimma University
Specialized Hospital [
]. This can be explained by
the perception that participants who had more
medications perceived themselves as severely ill and hope
less to cure from chronic disease. Another
independently associated factor was patient satisfaction. This
indicates that patients satisfied by service rendered in
the hospital were adherent to their prescribed
medication. Better relationship between health professionals
and clients improve satisfaction. Findings from a study
in Nigeria found an association between poor patient
provider communication, lack of trust in the provider
and adherence [
p value of 0.05 or less was considered statistically significant (in italics)
COR [95% CI]
AOR [95% CI]
In general, level of adherence to prescribed
medications was poor among diabetic patients in diabetic clinic
of ZMH. Knowledge of medication, medication
availability and education level were found to be factors
contributory for medication non-adherence, all of which are
modifiable factors. A lot should be done to maximize the
medication adherence of these patients so that they can
recognize the full importance of prescribed therapies.
The study is single centered and it may limit its
MMAS-8: Adherence Scale-8; DM: diabetes mellitus.
MA conceives, conducted the study and collected the data. OS and TA
advised, analyzed and interpreted the data, drafted the manuscript, revised it
critically and submitted it. All authors read and approved the final manuscript.
Our deepest gratitude goes to all who has support to this study.
The authors declare that they have no competing interests.
Availability of data and materials
The data that support the findings of this study are available from the
Consent for publication
Not applicable (the manuscript does not contain any individual person’s data
in any form).
Ethics approval and consent to participate
Ethical approval and clearances was obtained from Institutional Review Board
(IRB), school of pharmacy, Addis Ababa University. Written and oral consent
was obtained from patients.
This study was not funded.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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