Study participants were mostly middle-aged clients (mean age: 58.3, SD = 10.7), had been living with diabetes for almost a decade (mean since diagnosis: 8.8 years, SD = 5.7) and generally overweight (mean BMI: 26.5, SD = 4.7). A larger percentage of study participants were married (n = 88, 55.0%), self-employed (n = 84, 52.5%) or had a minimum of senior high school education (n = 80, 50.0%) (Table 1). According to clinic records, most participants under review were being managed for type 2 diabetes (n = 150, 93.8%) (Table 2).
Medication compliance was measured on an a modified MMAS with three outcomes: low (a score of > 2), medium (a score of 1 or 2) and high (a score of 0) medication compliance based on a set of seven questions. Low (n = 39, 24.4%) and medium (n = 121, 75.6%) compliance was observed for participants based on the MMAS. None of the participants reported high medication compliance (Table 3).
Factors associated with noncompliance to anti-diabetic medication
Qualitative responses from patients suggested that the observed compliance to medication could be as a result of entrenched religious misconceptions regarding health and superstition. Psychosocial factors related to stress, fate, perception of health, compliance fatigue, socioeconomic factors and barriers to health-seeking behaviour were also among reasons given for non-compliance. Social support, however, for patients was reported to be adequate.
Barriers related to religious beliefs and practices
Belief in faith healing
Religion is an integral aspect of social life in Ghana. All participants interviewed held on to some form of religious worldview. A number of study participants cited potential conflict between medical care and superstitious beliefs regarding their condition.
“I have been attending prayer meetings and all night services at church; I believe that in God’s own time, I will have my miracle” (Patient T2-147, Diabetic for 4 years).
“My medication has been prescribed to be taken after meals. When I’m fasting, I don’t take my medicines because of potentially unpleasant side effects” (Patient T2-003, Diabetic for 10 years).
The impact of diabetes and accompanying side effects from medications affect patients both socially and psychologically. Psychosocial factors such as resignation to fate, fear of medication side effects, perception of health, compliance fatigue and stress and preference for complementary and alternative medicine were cited as reasons for non-compliance among participants.
Resignation to fate
A common trend in responses recorded during interactions with participants seem to suggest that some of them have become apathetic and resigned to fate. Often, the trigger was a misunderstanding of clinical protocols for management of chronic conditions. Furthermore, it was clear some form of education had been given by healthcare workers to encourage patients to continue taking their medications but participants were left disillusioned instead of feeling motivated.
“I have been counselled by the doctors, nurses and other healthcare staff that this condition will stay with me for the rest of my life so sometimes when I forget to take my medicines, it does not bother me; whatever will be will be” (Patient T2-009, Diabetic for 7 years).
Some participants could not hide their morbid feelings about their condition. For these, the subsequent coping strategy that emanated from such sentiments was a determinant of non-compliance to prescribed medication:
“As for me, I know that I have this disease until the day I die and there’s nothing I can do about it. I’m just living my life the best way I can” (Patient T2-017, Diabetic for 9 years).
Fear of medication side-effects
Another important determinant of non-compliance was the dread of unpleasant pharmocological effects. Participants were aware of the glucose-lowering effects of the drugs and were occasionally anxious enough to abstain from taking their medication.
“I am a driver… I often skip my medications when I have to drive long distances especially in the mornings because they make me drowsy” (Patient T2-017, Diabetic for 9 years).
Some however feared the perceived effects that could arise from other known and unknown side effects of Metformin
“I skip my medications because … as a sexually active man, the inability to perform well in bed scares me…” (Patient T2-024, Diabetic for 16 years).
Compliance fatigue and stress
Patients who were on combination of oral hypoglycaemic drugs and/or drugs for complications often complained of difficulties with medication compliance. The difficulty was largely to do with the effort needed to remember doses and stick to regimen and requirements for food intake. Over time, this leads to fatigue and stressful computations which threaten the sustainability of a compliant lifestyle in long-term diabetics. Here are some extracts from the in-depth interviews:
“Every day, I have to swallow these pills in order to stay alive. I find this rather tiring and boring to be doing the same things over and over” (Patient T2-053, Diabetic for 18 years).
My medicines for hypertension make me urinate a lot” (Patient T2-130, Diabetic for 4 years)
Preference for herbal medication
Preference for traditional medicine was also a conributing factor to non-compliance among patients as they perceived traditional medicine to be safer and easier to consume than the medicines prescribed by their doctors.
“Sometimes, I prefer herbal concoctions to the pills. Herbal medicine is more natural and safer than the orthodox medicines” (Patient T2-039, Diabetic for 5 years).
Perception of health
Both favourable and poor perception of health were attributable for non-compliance:
“After taking my medicines for a while, I realised I was feeling better so I thought to myself that there is no need to keep taking them” (Patient T2-008, Diabetic for 7 years).
“I have stomach ulcer, and sometimes I experience pain after taking these medicines” (Patient T2-018, Daibetic for 5 years).
Majority of patients interviewed were of low to medium economic status and that was also a contributing factor to non-compliance. Reasons given for non-compliance included medicines running out before next review date, inability to acquire medicines in the local neighborhoods as well as financial constraints when commuting to and from the hospital or clinic site.
“Some of my medications… for cholesterol, are not covered by the NHIS. I am unable to follow my prescription when run out of my supply,” (Patient T2-011, diabetic for 5 years).
Barriers to health-seeking behaviour
A number of reasons given for failure to seek care on time and medication compliance could be classified as health-system related.
A negative perception of clinic protocols persists among a handful of clients. This perception undermines healthcare-seeking behaviour, and may ultimately result in avoidance of medications until complications set-in. For example, patients are required to visit the hospital reception to pick up their folders before going in to see the doctor:
“On clinic days, there is always a long queue where we have to pick up our folders...” (Patient T2-017, Diabetic for 9 years).
Perception of preferential treatment of clients
Another negative perception has to do with disruptions in consultating room schedules. Some patients complained about long-waiting times and a preferential treatment culture where relatives of hospital staff are not made to join patient queues making other patients more anxious. This can be a threat to honouring appointments for review.
“Sometimes, the doctors attend to other patients who are not in queue because they are friends or close relatives of health staff. That is not fair” (Patient T2-017, Diabetic for 9 years).