MEDICATION ADHERANCE AND ITS ASSOCIATED FACTORS AMONG DIABETES PATIENTS HAVING FOLLOW UP IN DIABETIC CLINIC AT HAWASSA UNIVERSITY COMPRENSIVE SPECIALIZED HOSPITAL.

Objective :-To assess the magnitude of medication adherence and its associated factors among diabetic patient in diabetic (DM) clinic, Southern Ethiopia, 2019. Result: The magnitude of medication adherence among Diabetes was found to be 58.8%. The independent predictors were social support AOR 95%CI 3.2(1.28, 4.93), dietary regimen AOR 95% CI 2.45(1.37, 4.35) and duration of illness AOR 95% CI 1.52 (1.32, 2.12). Health information provision for the patients as well as for the community through different means of communication should be essential to increase the medication adherence and social support to bring the good clinical outcome.


Introduction Background
Diabetes mellitus (DM) is a group of metabolic disorders of carbohydrates, lipids, and proteins characterized by high blood glucose level. DM occurs due to absence of insulin secretion or decreased insulin secretion [1]. About 415 million people worldwide, or 8.8% of adults aged 20-79 years, were estimated to have diabetes in 2015. From this, about 75% of them live in low and middle-income countries. If these trends continue, by 2040, some 642 million people (or one in ten adults) will have diabetes. The largest increases will take place in the regions where economies are moving from low-income to middle-income levels [2]. In 2015 in sub-Saharan Africa, the International Diabetes Federation (IDF) estimates that there were about 14.2 million people lived with diabetes; it is projected that in 2040 this number will increase to 34.2 million people [3]. Medication adherence is defined by world health organization as the extent to which person's behavior relates with the agreed recommendation from health care providers [4]. Adherence has been also defined as the "active, voluntary, and collaborative involvement of the patient to certain recommended regimen to brought a therapeutic result" [5].
Worldwide, adherence to medication for diabetes varies in a wide range of variation. So, Poor adherence to treatment of DM is a worldwide problem to decrease the magnitude of adherence. As the world health organization (WHO) statement about 50% of a patient diagnosed with DM were fully compliant with their treatment regimen, in developing country the rate are even lower. It is true that many patient faces in striking recommended treatment regimen [ 6].Anti-diabetic medications are prescribed for DM patients to brought glycaemic control, therefore non-adherence to drugs can alter blood glucose level resulting in complications [7]. Poor adherence result in remarkably high rates of morbidity and mortality due to metabolic control, especially poor glycemic control [8]. The studies indicated that there were different factors related to adherence to medication. These were patients, conditions, socioeconomic status, the health system and therapy.
Therefore, interventions which focus on improving medication adherence should aim this entire factor [9]. Adhering to their medication is still difficult in type II diabetic patients. In Ethiopia, particularly in the study area, little is known about the adherence status of medication among DM patients and its associated factors. Therefore, the aim of this study was to assess the adherence status and associated factors among diabetes.

General objective
To assess the magnitude of medication adherence and its associated factors with poor adherence among diabetic patient having follow up in diabetic clinic, Hawassa, Southern Ethiopia,2019.

Specific objectives
To determine magnitude of medication adherence among diabetic patients attending medication at Hawassa, Southern Ethiopia, 2019.
To identify associated factors of medication adherence with poor adherence among diabetes at Hawassa, Southern Ethiopia, 2019.

Study area
The study was conducted in Hawassa Compressive Specialized Hospital at Hawassa town which is the capital city of Southern nation nationality and peoples region (SNNPR) region in Ethiopia and it is 273 km far from Addis Ababa. Currently Hawassa University Compressive Specialized Hospital (HUCSH) is providing health service for over 18 million people in and around SNNPR. The Hospital had 461 diabetes patients attending the clinic for follow up.

Study design
Facility based cross-sectional study design was employed.

Source population
Was all diabetes out patients who was visiting the diabetes clinic in HUCSH during the study period.

Study population
Sampled DM patient who was randomly selected during the study period

Study Unit
Were individual diabetic patient who participated in the study.

Inclusion and Exclusion Criteria Inclusion Criteria:
All sampled diabetes mellitus patient whose age was 18 and above which can give informed consent was included.

Exclusion Criteria
Were sampled diabetic patient who were mentally ill and seriously ill during data collection.

Sample Size Determination
Sample size was determined using single population proportion formula.

Sampling Technique
In Hawassa university comprehensive specialized Hospital 461 patients were registered in the DM registration book and then made into sampling frame, prepared from the list of patients who had been appointed for follow up during the study period. The 210 patients were selected by systematic random sampling. Then sampling interval were calculated by = (/Tsz).  denotes total number of diabetic patients who had follow up during appointment day which is in the study period was 461 and the Tsz is total sample size. So, every 2 nd patient was selected from sampling frame and the sampled DM outpatients were interviewed at exit of the service provision.

Operational definition
Adherent-Those patients who scored equal or greater than 6 from the morisky medication adherence scale (MMAS).
Non-adherent-Those patient who scored less than 6 from the (MMAS).

Data collection methods and tool
The initial English version of the questionnaire was translated into Amharic.
Then it was back translated in English independently by language experts to maintain the equivalence of the test questionnaire in Amharic. The questionnaires have 4 parts. Socio demographic information, morisky medication adherence scale-8 and behavioural factors and clinical factors were gathered from patients recorded data and own word.

Quality control
To assure the quality of the study finding, training of the data collectors (5) and supervisor (2), conducting pre-test had done. In addition to this, checking, editing and clearing the data at data collection site plus monitoring data collectors by principal investigators and supervisor was carried out.

Data processing and Analyzing
After checking collected data, the responses was cleaned, edited, coded and entered into the computer using Epi-data 3.1 version and exported to SPSS version 20.0. The data was checked for missed value before analysis. The descriptive analysis including frequency and cross tabs was done. Binary logistic regression was carried to assess the association of dependent variable with independent variables. Finally forward stepwise logistic regression model with all independent variables having p value <0.25 was fitted and adjusted odds ratio was calculated to identify independent predictors of poor adherence to medication

Plan for dissemination
It was disseminate to Hawassa University CBE office of college of medicine and health science and to the school of Nursing. It was also disseminated to the HUCSH.

Ethical consideration
The study was conducted after approval of ethical review committee of hawassa university college of medicine and health science. Permission to conduct the study was obtained from authorities at HUCSH. Written informed consent was obtained from each study participant by assuring privacy and confidentiality throughout the data collection period in the Hospital.

Magnitude of Medication adherence
According to this study the magnitude of medication adherence among DM patients were found to be 122 (55.2%).

Clinical characteristic and factors associated with medication adherence
In our study from clinical factors that affect medication adherence among Diabetes; four variables were found to be associated significantly in binary logistic regression. This were type of sugar, type of treatment, duration of illness and level of blood glucose (See table 3

Independent factors of medication adherence
From 19 variables; 8 variables with p < 0.25 were entered into forward logistic regression. Then 3 variables were found to be independently associated .These were social support, dietary regimen and duration of illness.

DISCUSSION
In this study, the magnitude of medication adherence status in our study was 130 (58.8%). It is in line with the study done in 2016 at Zewditu Memorial hospital in Addis Ababa in which 51.3% were adhered to the ant diabetic's medication [11]. This is might be due to uniformly distributed socio demographic characteristic of the respondents. Even though it is in line; continuous provision of health education about the importance of adhering to prescribed medication should be strengthened while the patient visit the hospital for medication follow up. Besides, the diabetes association should strictly discuss with them not to interrupt the recommended medication regimen. But our study result is low when compared to the study done in 2013 at University of Gondar Hospital which is 85.1% [12]. This might be lower educational status of the respondents and MMAS with cut point of 6 were used to determine the magnitude of medication adherence.
Our study reveals that those who were satisfied by their family and friends support had 3 times more likely found to be adhered to medication compared to those who were not satisfied. This study result is in line with the study done from 2015-2016 at Kenyatta national hospital in Kenya [13]. This might be due to those who had motivation and encouragement made them to be well psychologically and enable them strictly to follow recommended medication. Studies also indicate that poor social support has been associated with non adherence to medication [14].
Our study also reveals that those respondents who were adhered to the recommended dietary practice were found to be 2 times more likely adhered to prescribed medication. This study is also supported by studies conducted at Yemen in 2016 [15] which indicated that most of the respondents who were not adhered to diet had found to be not adhered to medication. So, of continuous provision of education about recommended dietary regimen for patients visiting DM clinic will be strengthened.
Duration of illness was also found to be significantly associated with the adherence status of the respondents. In this study; those patients who had been 5 years and above since medically diagnosed with diabetes were more likely to be adherent than those with less than 5 years of duration. This finding is in line with the study done in Urmia, Iran [16] and Nigeria [17]. This could be explained by patients with longer duration of diabetes by increases contacts with health care provider and health professionals are more likely to be given repetitive instruction on medication adherence and become aware of the complications and then adhered to medication. In addition, it could be a reflection of wider social interaction with other diabetic patients on ant diabetic medication adherence.

CONCLUSION
This study reveals that those medication adherence among diabetes patients were found to be low and its independent predictors were social support and dietary regimen and duration of years on follow up RECOMMENDATION Health information provision for the patients as well for the community through different means of communication should be essential to increase the medication adherence and social support to bring the good clinical outcome.

LIMITATION
There might be recall bias to respond medication intake questions. Since this study was cross sectional study, it shows point time occurrence of the adherence among patient.

Declaration Ethics approval and consent to participate
The study was conducted after approval of ethical review committee of hawassa university college of medicine and health science.
Permission to conduct the study was obtained from authorities at HUCSH. Written informed consent was obtained from each study participant by assuring privacy and confidentiality throughout the data collection period in the Hospital. An individual who was unwilling to participate from the beginning or at any part of the interview was allowed to withdraw. There was no risk or hazardous procedures putting the participants at harm.