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 Table of Contents  
Year : 2013  |  Volume : 26  |  Issue : 1  |  Page : 54-57

Compliance of diabetic patients with the prescribed clinical regimen

1 Preventive Medicine Department, Gharbia Governorate, Menoufiya University, Shebin Elkoum, Egypt
2 Department of Public Health, Faculty of Medicine, Menoufiya University, Shebin Elkoum, Egypt
3 National Liver Institute, Menoufiya University, Shebin Elkoum, Egypt

Date of Submission22-Feb-2013
Date of Acceptance14-Apr-2013
Date of Web Publication26-Jun-2014

Correspondence Address:
Ayman A. Attyia
MBBCh, Department of Health Affairs, Musana District, Sultanate of Oman, PO Box 3, 314 Musanah, Oman

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Source of Support: None, Conflict of Interest: None

DOI: 10.7123/01.MMJ.0000431238.74393.f8

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This study aimed at studying the prevalence of noncompliance among diabetic patients in Gharbia governorate in Egypt as well its causes, its effect on glycemic control, and factors affecting it.


There is growing evidence suggesting that because of the alarmingly low rates of compliance, increasing the effectiveness of compliance interventions may have a great impact on the health of the population. Promotion of therapeutic compliance is considered an integral component of patient care. It has been shown that despite effective methods of treatment, many diabetic patients fail to achieve satisfactory glycemic control, which leads to accelerated development of complications and increased mortality.

Patients and methods

A total of 339 diabetic patients who fulfilled the inclusion criteria were recruited in the present study. Compliance to treatment was evaluated during patients’ visits to health units in Gharbia governorate. Medication compliance was assessed during a personal interview with each patient using a multiple-choice questionnaire. Blood samples were obtained for measurement of glycated hemoglobin (HbA1c).


In the study population, the compliance rates were observed to be suboptimal. The most important social factors that significantly affected compliance rates included age, income, and educational level. Among the factors that significantly affected compliance rates were duration of treatment, presence of diseases other than diabetes, and the number of prescribed drugs. Another factor that played an important role was diabetes care costs. The most common reasons for low rates of compliance were forgetfulness and high cost of treatment.


An improvement in the compliance level may be achieved through improvement of patients’ economic levels as well as reduction in the cost of medication. The number of drugs and doses should be reduced as much as possible through continuous research involving doctors and pharmaceutical companies.

Keywords: clinical regimen, compliance, diabetes mellitus

How to cite this article:
Attyia AA, El Bahnasy RE, Abu Salem ME, Al-Batanony MA, Ahamed AR. Compliance of diabetic patients with the prescribed clinical regimen. Menoufia Med J 2013;26:54-7

How to cite this URL:
Attyia AA, El Bahnasy RE, Abu Salem ME, Al-Batanony MA, Ahamed AR. Compliance of diabetic patients with the prescribed clinical regimen. Menoufia Med J [serial online] 2013 [cited 2023 Mar 22];26:54-7. Available from: http://www.mmj.eg.net/text.asp?2013/26/1/54/135427

  Introduction Top

Diabetes mellitus is one of the most common noncommunicable diseases and is one of the major public health challenges faced at present by the world. There has been a rapid increase in the incidence of diabetes mellitus. Much of this increase occurs in developing countries and results from aging, an unhealthy diet, obesity, and a sedentary lifestyle. Despite the advances in understanding the disease and its management, the morbidity and mortality rate continues to rise 1.

Individuals with poor management of diabetes are at a greater risk of developing long-term microvascular and macrovascular complications that lead to damage of end organs such as kidney, heart, brain, and eyes and affect direct and indirect healthcare costs and overall quality of life 2.

Optimal glucose control can be achieved through strict compliance to medications, diet, and lifestyle modifications, which in turn minimize long-term complications 1.

Medication compliance is defined as the extent to which an individual’s medication use behavior coincides with medical advice, and persistence as the duration of time from initiation to discontinuation of therapy 3.

For patients with diabetes mellitus, medication use ‘behavior’ includes taking oral hypoglycemic agents and/or insulin injections, following diets, blood glucose monitoring, and making several lifestyle changes 4.

After extensive research, it was concluded that medication noncompliance is due to many factors including beliefs about the medication, complex regimens that are difficult to manage, side effects, lack of adequate knowledge about medication and treatment goals, and costs associated with medications 5.

There are several types of noncompliance. Therapeutic or medication noncompliance includes failure to have prescription medications dispensed or renewed, omission of doses, and premature discontinuation of the drug regimen. A second type of noncompliance is dietary/exercise noncompliance in which the patient fails to follow the diet and exercise recommendations. A third type is the appointment noncompliance in which the patient fails to show up at the clinics for the scheduled checkup 6.

The consequences of medication noncompliance may not only be dangerous for the patient’s health but also dramatically increase the financial costs of public health services 7.

Several methods are used to measure therapeutic compliance. Indirect methods, such as self-reports and interviews with the patient, are the simplest and most common methods for measuring medication compliance 8.

The pill counts method is also used to assess medication compliance by measuring the difference between the number of doses initially dispensed and the number remaining in the container 9.

The achievement of treatment goals might also be used to assess medication compliance, especially when the drug therapy is associated with a successful outcome such as normal blood glucose levels. Computerized compliance monitors such as the Medication Event Monitoring System (MEMS) are the most recent and reliable methods. The system consists of a microprocessor placed in the cap of the medication container; every time the patient removes the cap, the time and date are recorded 10.

Direct methods of measuring therapeutic compliance such as measuring drug concentrations or levels of biological markers in the patient’s biological fluids could also be used 11.

Because of the high prevalence of diabetes in our community and because of the effect of compliance on the control of blood glucose level, we conducted this research in Egypt to overcome the prevailing diabetes mellitus problem.

  Patients and methods Top

Patient characteristics

From the beginning of April 2011 to the end of March 2012, a total 339 patients were recruited in the present study. These patients were randomly selected from the primary healthcare and health insurance units in Gharbia governorate, Egypt. No patient was repeated. Patients were ensured of the confidentiality of personal information.

All patients attending the above-mentioned units were invited to participate in the study. Patients with mental illnesses were excluded from participation in the study.

Assessment of medication compliance

Compliance was assessed during a personal interview with each patient using a structured questionnaire addressing the following aspects:

  1. Sociodemographic criteria including age, sex, educational level, and income.
  2. Data concerning compliance to drugs, its effect, and its determinants; this was assessed using questions of the Measure Treatment Adherence scale developed by Delgado and Lima. This method is used frequently to measure patient compliance with drug treatment. The Measure Treatment Adherence scale is a variation of the Morisky–Green test, which was used to assess patient behavior patterns associated with the use of medicines 12. All questions were read out to the participant, and the answers were recorded. Patients achieving a result of more than 75% were included in the good compliance group. Patients achieving a result less than 50% were included in the poor compliance group. Patients achieving a result between 50 and 75% were included in the fair compliance group.
  3. Blood samples were also obtained from each patient for measurement of glycated hemoglobin (HbA1c).

Data management and statistical analysis

This phase included the following:

  1. Coding of collected data and data entry into the computer.
  2. Statistical analysis of the collected data: The collected data were entered into the computer using the statistical package for social sciences (SPSS) program for statistical analysis, version 11 (SPSS Inc., Chicago, Illinois, USA). Two types of statistical analyses were performed: descriptive statistics [e.g. number, percentage, mean

    , and SD] and analytical statistics (e.g. Student’s t-test, a test of significance used for comparison of quantitative variables between two groups and the χ2-test, a test used to study the association between qualitative variables). A P-value of less than 0.05 was considered statistically significant.

  Results Top

Of the 339 respondents, 238 (70.2%) were men and 101 (29.8%) were women. Among the respondents, 38 (11.2%) had received postsecondary education, 114 (33.6%) had received secondary education, and 187 (55.2%) had received primary or no formal education. A total of 112 (33.0%) respondents perceived their economic standard as being below their needs, 191 (56.4%) perceived it as being enough for their needs, and 36 (10.6) perceived it as being more than their needs (the social characteristics of the selected group of patients and their demographic data as well as the effect of these two parameters on the compliance level are summarized in [Table 1]. Among the respondents, 81 (23.9%) were found to have good compliance, 131 (38.6) had a fair compliance, and 127 (37.5) had poor compliance [Table 2]. The present study found many reasons for noncompliance, such as forgetfulness (22.4%), high cost of treatment (13.9%), and side effects of treatment (9.1%) [Table 3].
Table 1: Relationship between the compliance level and sociodemographic criteria among the studied group (n=339)

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Table 2: Degree of drug compliance among the studied group

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Table 3: Common reasons of noncompliance among the studied group (n=339)

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Compliance was found to have a positive effect on the blood glucose level: 50.6% of patients of the good compliance group achieved a blood glucose level within the target, whereas only 15% of patients of the poor compliance group achieved target levels [Table 4].
Table 4: Relationship between the compliance level and HbA1c levels among the studied group

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  Discussion Top

The compliance level among diabetic patients is suboptimal. Diabetic patients are in general noncompliant to their treatment, and only a small number of diabetic patients were found compliant with all aspects of diabetic care 13. In this study, the percentage of patients with a good compliance level was 23.9%. Studies assessing compliance to diabetes treatment have found that the prevalence ranges from 23 to 77% 14.

Sociodemographic variables appear to influence the degree of compliance to medication 15. This study has shown that compliance is affected by the patient’s sociodemographic status. There is a significant relationship between age and the rate of compliance 16.

This study showed that age is important determinant of compliance in the studied group; the younger the patient, the better was the compliance level. There was no relationship between sex and compliance. This result agrees with that of Senior et al. 17, who found no relationship between sex and compliance.

In this study, highly educated patients showed higher levels of compliance compared with other patients. Illiterate patients do not appreciate the effect of drug compliance on the therapeutic outcome; in addition, more educated people tend to appreciate and understand the consequences of noncompliance. Thus, the degree of compliance increases with an increasing level of education among patients 16.

This study also showed that multiple causes are responsible for a poor compliance, the most common being forgetfulness. Forgetfulness is among the commonly cited reasons for noncompliance 18.

In addition, a high cost of treatment is among the common causes of a poor compliance. Financial variables, especially the direct and indirect costs associated with a prescribed regimen and restricted access to therapy, were found to influence patient compliance 19.

This study also showed that side effects are an important cause of noncompliance. Patients who experienced side effects with antidiabetic drugs were more likely not to comply with treatment 20. Side effects and the unpleasant taste of some oral hypoglycemic medications were part of the factors contributing to medication noncompliance 21.

Compliance to drugs has shown significant effects on control of blood glucose levels; 50.6% of patients who achieved blood glucose levels within the target range were from the good compliance group. Poor compliance to medication seems to be a significant barrier to attainment of positive clinical or therapeutic outcomes among diabetic patients in both developed and developing countries 19 [Figure 1].
Figure 1: Prevalence of drug compliance among the studied group. It has shown that patients who achieved HbA1c within the target were 24.5%, whereas those with HbA1c levels higher than the target were 75.5%.

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  References Top

1.Rickles NM, Brown TA, McGivney MS, Snyder ME, White KA.Adherence: a review of education, research, practice and policy in the United States.J Pharm Pract2010;8:1–17.  Back to cited text no. 1
2.Maddigan SL, Feeny DH, Johnson JA.Health-related quality of life deficits associated with diabetes and comorbidities in a Canadian National Population Health Survey.Qual Life Res2005;14:1311–1320.  Back to cited text no. 2
3.Cramer JA, Roy A, Burrell A, Fairchild CJ, Fuldeore MJ, Ollendorf DA, et al..Medication compliance and persistence: terminology and definitions.Value Health2008;11:44–47.  Back to cited text no. 3
4.Odegard PS, Capoccia K.Medication taking and diabetes: a systematic review of the literature.Diabetes Educ2007;33:1014–1029.  Back to cited text no. 4
5.Osterberg L, Blaschke T.Adherence to medication.N Engl J Med2005;353:487–497.  Back to cited text no. 5
6.Hughes D, Manns B, Clark WF, Forwell L.Patient compliance with drug therapy for diabetic nephropathy.CMAJ2000;162:1553–1554.  Back to cited text no. 6
7.Muszbek N, Brixner D, Benedict A, Keskinaslan A, Khan ZM.The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review.Int J Clin Pract2008;62:338–351.  Back to cited text no. 7
8.Girerd X, Hanon O, Anagnostopoulos K, Ciupek C, Mourad JJ, Consoli S.Assessment of compliance to antihypertensive treatment using a self-administered questionnaire: development and use in a hypertension clinic.Presse Med2001;30:1044–1048.  Back to cited text no. 8
9.Rudd P, Byyny RL, Zachary V, LoVerde ME, Mitchell WD, Titus C, et al..Pill count measures of compliance in a drug trial: variability and suitability.Am J Hypertens1988;1Pt 1309–312.  Back to cited text no. 9
10.Hedtke PA.Can wireless technology enable new diabetes management tools?J Diabetes Sci Technol2008;2:127–130.  Back to cited text no. 10
11.Liu H, Kaplan AH, Wenger NS.Measuring patient adherence.Ann Intern Med2002;137:72–73.  Back to cited text no. 11
12.Lopes N, Zanini AC, Casella Filho A, Chagas ACP.Metabolic syndrome patient compliance with drug treatment.Clinics2008;63:573–580.  Back to cited text no. 12
13.Kurtz SM.Adherence to diabetes regimens: empirical status and clinical applications.Diabetes Educ1990;16:50–59.  Back to cited text no. 13
14.Kalyango JN, Owino E, Nambuya AP.Non-adherence to diabetes treatment at Mulago Hospital in Uganda: prevalence and associated factors.Afr Health Sci2008;8:67–73.  Back to cited text no. 14
15.Linda CC.Health education and health promotion.Brunner and Suddarth’s textbook of medical-surgical nursing2004:10th ed..Hagerstown, USA:Lippincott Williams & Wilkins;46–47.  Back to cited text no. 15
16.Sweileh W.Effect of polypharmacy and frequency of drug dosing on rate of compliance among diabetic and hypertensive patients: A survey study in palestine.An-Najah Univ J Res2003;17:155–165.  Back to cited text no. 16
17.Senior V, Marteau TM, Weinman J.Self-reported adherence to cholesterol-lowering medication in patients with familial hypercholesterolaemia: the role of illness perceptions.Cardiovasc Drugs Ther2004;18:475–481.  Back to cited text no. 17
18.Ary DV, Toobert D, Wilson W, Glasgow RE.Patient perspective on factors contributing to nonadherence to diabetes regimen.Diabetes Care1986;9:168–172.  Back to cited text no. 18
19.Adisa R, Alutundu MB, Fakeye TO.Factors contributing to nonadherence to oral hypoglycemic medications among ambulatory type 2 diabetes patients in southwestern Nigeria.Pharm Pract2009;7:163–169.  Back to cited text no. 19
20.Grant RW, Devita NG, Singer DE, Meigs JB.Polypharmacy and medication adherence in patients with type 2 diabetes.Diabetes Care2003;26:1408–1412.  Back to cited text no. 20
21.Ostrop NJ, Hallett KA, Gill MJ.Long-term patient adherence to antiretroviral therapy.Ann Pharmacother2000;34:703–709.  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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