Medication Management Program: Adherence, Disease-related Knowledge, Health-related Quality of Life, and Glycemic Control for Type 2 Diabetes Mellitus

Saeed Ur Rashid Nazir, BPharm, MPhil, MBA, PhD; Mohamed Azmi Hassali, BPharm, MPharm, PhD;  Fahad Saleem, BPharm, MPhil, MBA, PhD; Naheed Haque, BPharm, MPharm, PhD

 


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ABSTRACT

Context • Escalation in rates of diabetes in Pakistan is posing threats to the economy and to the people’s quality of life due to poor glycemic control and very high rates of complications. Cost of care is very high, and many barriers to quality care exist. Most often patients are unable to afford the high cost of treatment. Patients’ knowledge about diabetes is associated with better medication adherence and better glycemic control.

Objective • The current study intended to evaluate the effects of an educational intervention in a pharmacist led, medication management program (MTM) tailored for patients with type 2 diabetes (T2DM).

Design • The research team conducted a nonclinical, randomized controlled trial.

Setting • The study took place at District Headquarters and Teaching Hospital, a public-sector hospital (Sargodha, Pakistan).

Participants • Participants were 392 individuals with T2DM.

Intervention Participants were randomly assigned to one of 2 groups—intervention and control—with 196 patients in each. The intervention group, instead of receiving standard care, received pharmaceutical care through the Medication Therapy Management program, whereas the control group received standard care.

Outcome Measures • At baseline and 3 mo post ntervention, the study assessed participants’ diabetes-related knowledge, medication adherence, and health-related quality of life (HRQoL) using the 14-item Michigan Diabetes Knowledge Test, the 8-item Morisky Medication Adherence Scale, and the European Quality of Life scales, respectively. To determine glycemic control, participants’ baseline HbA1c levels were taken from their medical records, and the final HbA1c result was obtained postintervention.

Results • For the intervention and control groups at baseline, diabetes-related knowledge was average, at 7.99 ± 2.65 and 8.03 ± 2.49, respectively; medication adherence was low, at 4.54 ± 1.69 and 4.41 ± 1.84, respectively; and glycemic control was poor, at 9.47 ± 1.57 and 9.41 ± 1.57, respectively. After the educational intervention, the intervention group had increased its diabetes-related knowledge, medication adherence, and HRQoL scores, with the results being 10.55 ± 2.56, 5.24 ± 1.48, and 0.6115 ± 0.286, respectively. The group’s glycemic control has also improved to 8.97 ± 1.362. A statistically significant difference between the groups had occurred, with P < .001. The control group’s scores had remained approximately the same for medication adherence, HRQoL, and glycemic control, and little difference had occurred as compared with the group’s baseline analysis.

Conclusion • The study found that the educational program increased the intervention group’s level of diabetes-related knowledge, and improved its adherence to medication and its glycemic control, all due to its improved HRQoL. Patients’ beliefs about the effects of long-term use of medicines were also addressed by the MTM program. The program was successful because it decreased participants’ HbA1c values, which is a positive indicator of successful T2DM therapy. (Altern Ther Health Med. 2020;26(S2):4-10.)

 

Saeed Ur Rashid Nazir, BPharm, MPhil, MBA, PhD, is an assistant professor, College of Pharmacy, University of Sargodha, Sargodha, Pakistan. Mohamed Azmi Hassali, BPharm, MPharm, PhD, is a professor, School of Pharmaceutical Sciences, University Sains Malaysia, Penang, Malaysia. Fahad Saleem, BPharm, MPhil, MBA, PhD, is an associate professor, Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan. Naheed Haque, BPharm, MPharm, PhD, is an associate professor, Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan.

 


Corresponding author: Saeed Ur Rashid Nazir, BPharm, MPhil, MBA, PhD
E-mail address: [email protected]


 

INTRODUCTION

Diabetes mellitus (DM) is one of the most common non communicable diseases globally and is a serious, complicated, and overwhelming disease affecting people of all ages and ethnic groups. In 2014, it was estimated that 422 million people worldwide had DM, corresponding to a global prevalence of 8.5%.1 Type 2 diabetes mellitus (T2DM) accounts for the majority of these cases, and 80% of people with DM live in low- and middle-income countries.2-3 In South Asia, the majority of people live at or below the poverty line and lack access to health care services. They live in countries without national welfare programs and provision of health insurance to the poorer members of their populations. These individuals cannot afford to pay for health care services and often are diagnosed with diabetes late, resulting in acute and chronic complications.4

Pakistan is a South Asian country with a population of approximately 150 million; 69% of the population are rural, spread over an area of 800 000 km2. Diabetes prevalence in Pakistan is high; 12% of people older than 25 years suffer from the condition, and 10% have impaired glucose tolerance (IGT).5 According to the World Health Organization (WHO), Pakistan is currently eighth in the prevalence of DM and will become fourth by the year 2025, with more than 15 million individuals suffering from the disease.6

T2DM is a pandemic disease and is one of the main threats to human health. A chronic and growing health problem worldwide, it requires continuous medical care and patient education to prevent microvascular and macrovascular complications. The risk of heart disease and stroke is 2 to
4 times higher among people with DM than those not suffering from it.7 The International Diabetes Federation (IDF) estimates that close to one-fifth of all adults with diabetes in the world live in the South East Asia region.8

The middle-aged population in Pakistan generally is overweight or obese, lacks physical activity, eats unhealthy food, and has poor eating habits, which exposes individuals to a high risk of T2DM.9 T2DM demands a lifetime of careful behavior and personal care because it is a disease with serious short- and long-term consequences for the afflicted.10 Both microvascular and macrovascular complications are associated with T2DM,11-13 and the risk of death from a cardiac or cerebrovascular event is also significantly elevated when compared with people without T2DM. Several studies have shown that at 1 year after myocardial infarction (MI), 41% of people with diabetes are at high risk of mortality; that is 2 times the risk of people without diabetes.14 At 5 years post-MI, mortality is 72% higher than that of people without diabetes.

T2DM causes 2 death in 10, and 2 amputation every 30 seconds worldwide.15-16 Escalation in rates of diabetes in Pakistan is posing threats to the economy and to the people’s quality of life due to poor glycemic control and very high rates of complications.17-18 Cost of care is very high, and resource constraints in the society, lack of medical reimbursements, and insufficient allocations to a health budget are barriers to quality care. Most often a patient is unable to afford the high cost of treatment.19-20

Institutions specializing in diabetes care are limited in number and are concentrated in the big cities. No support personnel and very few dietitians and pharmacists are available. Family physicians have little time for counselling; the average time spent with a person with diabetes as of 2009 was 8.5 minutes.21 Al-Qazaz et al22 found that patients’ knowledge about diabetes is associated with better medication adherence and better glycemic control. However, in the literature, no studies have provided evidence about the effectiveness of an intervention through a medication therapy management program for patients with T2DM in Pakistan.

The current study intended to evaluate the effects of an educational intervention in a pharmacist-led, medication management program (MTM) tailored for patients with T2DM.

 

Methods

Participants

The research team conducted a nonclinical, randomized controlled trial (RCT). The study took place at District Headquarters and Teaching Hospital, a public-sector hospital (Sargodha, Pakistan). It is a teaching hospital and provides medical services to most of the population of that region. Participants were recruited into the study through multiple methods: self-referrals and referrals by local, diabetes health care professionals; by community pharmacists at the time of dispensing diabetes-related medications; and by primary care physicians’ offices.

Prospective participants were included in the study if they (1) were adults; (2) had a confirmed diagnosis of T2DM; and (3) were able to read and write Urdu, the official language of Pakistan. Prospective participants were excluded from the study if they (1) were pregnant women, (2) were patients with type 1 diabetes mellitus, (3) had severe diabetic complications, (4) had a psychiatric disorder, or (5) were immigrants from other countries.

The study was conducted according to guidelines provided by the National Bioethics Committee in Pakistan.23 Permission to conduct the study was obtained from the medical superintendent of the hospital (Letter No .DHSGD-2905/2014). Prior to data collection, the research team explained the nature and objectives of the study to the patients who had agreed to participate. All participants were assured of confidentiality and were asked to sign an informed consent form prior to the data-collection process.

 

Procedures

Following baseline assessment, the patients were randomly assigned by the toss of a coin to one of 2 groups, intervention or control, with an allocation ratio of 1:1. In the toss, heads indicated assignment to the intervention group, and tails indicated the control group.

At baseline, participants provided demographic and disease-related information. At baseline and 3 months postintervention, the study assessed participants’ (1) diabetes-related knowledge, using the Michigan Diabetes Knowledge Test (MDKT-U)24; (2) medication adherence, using the Morisky Medication Adherence Scale (MMAS-U)25; and (2) health-related quality of life (HRQoL), using the European Quality of Life scale (EQ-5D and EQ-VAS).26 Participants self-administered pre validated Urdu versions those scales. To determine glycemic control, participants’ baseline HbA1c levels were taken from their medical records, and the final HbA1c result was obtained post intervention.

Based on the prevalence of T2DM in Pakistan, 392 patients with T2DM of the hospital were recruited for the current study.

 

Intervention

Before the commencement of the patient education program, a patient module in Urdu was developed to improve patients’ knowledge and awareness regarding T2DM, medication adherence and HRQoL by the research team. The module was composed of the following components:

 

  1. A detailed view of T2DM, its etiology, symptoms, diagnosis, treatment, prevention, and management.
  2. Introduction to medication adherence, consequences of nonadherence, factors affecting medication adherence and strategies to overcome nonadherence.
  3. Introduction to HRQoL, factors affecting HRQoL, and HRQoL and its importance in treatment outcome assessment.

 

The module was subjected for face and content validity. Two independent diabetologists were invited to review the module. The module was declared as a valid instrument for counseling and training purposes after a series of discussions with the experts previously mentioned. All objections and questions raised by the experts were presented and answered in the final assessment session prior to the initiation of the intervention. The patients were provided with the module on the first visit to the pharmacist providing the intervention.

The pharmaceutical care provided to the IG by hospital pharmacist during visit consisted approximately of
15 minutes and the follow-up visits (approximately 10 min). The intervention was conducted with each patient twice in a month (or based upon their appointment schedule). At each visit, the hospital pharmacist conducted a thorough interview of the patient, identified problems leading to poor medication adherence, and provided patient education (T2DM education, lifestyle education and counseling, medication education and counseling tips to enhance knowledge towards T2DM, medication adherence, and HRQoL). The pharmacists followed the following procedure during counseling sessions:

 

  1. Ice-breaking session.
  2. Introducing to/off the patient.
  3. Interviewing the patient to recognize major problems regarding T2DM.
  4. Inquiring the patient about current and past medication history.
  5. Counseling to the patient for his/her disease condition and drug use problems.
  6. Delivering the patient health education towards T2DM, medication adherence, and HRQoL.
  7. Informing the importance of health education for the patients.
  8. Answering any queries posted by the patients.

 

The intervention group, instead of receiving standard care, received pharmaceutical care through the medication therapy management program, whereas the control group received standard care.

The pharmacist on the research team provided pharmaceutical care to the intervention group for approximately 15 minutes on their first visit and for approximately 10 minutes on follow-up visits. The physician on the research team acted as an observer. The participants in the intervention group were scheduled to meet with the pharmacist every 2 weeks for 12 weeks. At each visit, the pharmacist conducted a thorough interview of the participant, identified problems leading to his or her poor medication adherence, and provided disease-related education to him or her, diabetes-related information, lifestyle education, and medication counselling tips to enhance knowledge about T2DM, medication adherence, and HRQoL. Printed educational material about diabetes, in Urdu, was also given to the intervention group. All participants in the intervention group received the same educational input. The control group was provided no educational sessions during the study.

 

Outcome Measures

Michigan Diabetes Knowledge Test. The MDKT-U was used for the assessment of diabetes-related knowledge. The MDKT was scored as 0 for incorrect response and 1 for a correct response. Therefore, the knowledge scores ranged from 0 to14. The range of knowledge score was categorized in 3 different ways (poor knowledge <7, average knowledge 7–11, and good knowledge >11).

Morisky Medication Adherence Scale. Medication adherence was assessed using the MMAS-U. The scale consists of 8 questions, with the first 7 items having a dichotomous answer (yes/no) that indicates adherent or nonadherent behavior. For item 8, a patient can choose an answer on a 5-point Likert scale, expressing how often happens that a patient does not take their medications. MMAS-8 scores can range from 0 to 8 points with higher points showing high adherence and vice versa.

European Quality of Life Scale. This scale measures HRQoL. EQ-5D is a generic instrument for the measurement of health outcomes. It provides a descriptive profile and a single index value for health status. EQ-5D is composed of 2 portions. The first part also known as EQ-5D descriptive contains 5 dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) among each of which can take 1 of 3 responses (no problems/some or moderate problems/extreme problems) within a particular EQ-5D dimension. The second part is known as EQ-VAS (visual analogue scale). which consists of a 20-cm health thermometer with 2 distinct end points, the best imaginable health state (score of 100), and the worst imaginable health state (score of 0).

HbA1c. Glycated hemoglobin is a form of hemoglobin that is covalently bound to glucose. It is measured primarily to determine the 3-month average blood sugar level and is used as a diagnostic test for DM and as an assessment test for glycemic control in people with diabetes.

 

Statistical Analysis

The Kolmogorov-Smirnov test was used to establish the nature of the data, and nonparametric statistical tests were used accordingly. Descriptive statistics were used to describe participants’ demographic and disease-related information. Percentages and frequencies were used for the categorical variables, whereas mean and standard deviations (SDs) were calculated for the normally distributed continuous variables. Inferential statistics were applied to assess the intervention’s effects. The χ2 test was applied to test differences between categorical variables. The Mann-Whitney test was used to compare significance between groups. The within-group comparison was calculated using the Wilcoxon signed rank test. A statistical value of P < .05 was taken as significant. The collected data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software, version 21.0 (SPSS, Armonk, NY, USA).

 

Results

Of the 451 prospective participants, 392 Patients with T2DM participated in the study: 196 in the intervention group and 196 in the control group. At baseline, the intervention and control groups were comparable with respect to age, gender, education, occupation, monthly income, geographical location. and duration of disease (Table 1). For the intervention and control groups at baseline, diabetes-related knowledge was average, at 7.99 ± 2.65 and 8.03 ± 2.49, respectively; medication adherence was low, at 4.54 ± 1.69 and 4.41 ± 1.84, respectively; and glycemic control was poor, at 9.47 ± 1.57 and 9.41 ± 1.57, respectively. In addition, participants of both groups reported poor HRQoL, 0.4775 ± 0.335 for intervention group and 0.4779 ± 0.341 for control group. The VAS also reported poor HRQoL, 65.38 ± 14.19 for intervention group and 65.70 ± 15.19 for control group.

Table 2 compares the intervention and control groups post intervention. Of the 392 original participants, 325 (82.91%) completed the study, 161 (82.15%) in the intervention group, and 164 (83.67%) in the control group. The reasons for withdrawal were conflict with a job, an inability to attend follow-up visits, and family-related difficulties. After intervention, the intervention group’s scores were significantly better for diabetes-related knowledge, medication adherence, glycemic control, and HRQoL scores than the control group’s (P < .001). After the educational intervention, the intervention group had increased its mean diabetes-related-knowledge to 10.55 ± 2.56; medication adherence, at 5.24 ± 1.48; and HRQoL, at 0.6115 ± 0.286. The group’s glycemic control had also improved to 8.97 ± 1.362. The control group’s scores had remained approximately the same for medication adherence, HRQoL, glycemic control, and little difference was observed as compared with the group’s baseline analysis. A small decline was observed when diabetes-related knowledge (7.53 ± 2.27) was compared with the baseline analysis (8.03 ± 2.49) in the control group.

Table 3 compares the differences between baseline and post intervention for the intervention group.


Table 1. Baseline Characteristics of Participants

 

Characteristics All Participants

N = 392

N (%)

Intervention

Group

n = 196

n (%)

Control
Group
n = 196n (%)
P Value
Age (y)
30-40 69 (17.6) 31 (15.8) 38 (19.4) .520
41-50 131 (33.4) 69 (35.2) 62 (31.2)
51-60 137 (34.9) 65 (33.2) 72 (36.7)
61-70 55 (14.0) 31 (15.8) 24 (12.2)
Gender
Male 222 (59.6) 113 (57.7) 109 (55.6) .478
Female 170 (43.3) 83 (42.3) 87 (44.4)
Marital Status
Married 353 (90.0) 174 (88.8) 179 (91.3) .294
Unmarried 18 (4.5) 8 (4.1) 10 (5.1)
Widow 21 (5.3) 14 (7.1) 7 (3.6)
Education
Illiterate 52 (13.26) 26 (13.3) 26 (13.3) .749
Primary 37 (9.44 18 (9.2) 19 (9.7)
Middle 17 (4.34) 11 (5.6) 06 (3.1)
Matriculation 83 (21.17) 48 (24.5) 35 (17.9)
Intermediate 73 (18.62) 28 (14.3) 45 (23.0)
Graduate 75 (19.13 37 (18.9) 38 (19.4)
Masters 55 (14.03) 28 (14.3) 27 (13.8)
Occupation
Private Job 63 (16.0) 31 (15.8) 32 (16.3) .327
Government Job 76 (19.3) 37 (18.9) 39 (19.9)
Businessman 80 (20.4) 41 (20.9) 39 (19.9)
Housewife/Homemaker 137 (34.9) 69 (35.2) 68 (34.7)
Retired 36 (9.1) 18 (9.2) 18 (9.2)
Monthly Incomea
0 124 (31.6) 64 (32.7) 60 (30.6) .556
5000-10 000 11 (2.8) 02 (1.0) 09 (4.6)
10 000-15 000 31 (7.91) 12 (6.1) 19 (9.7)
>15 000 226 (57.6) 118 (60.2) 108 (55.1)
Location
Urban 282 (71.9) 143 (73.0) 139 (70.9) .227
Rural 110 (28.0) 53 (27.0) 57 (29.1)
Duration of Disease (y)
<1 39 (9.9) 23 (11.7) 16 (8.2) .490
1-3 110 (28.0) 52 (26.5) 58 (29.6)
3-5 83 (21.1) 37 (18.9) 46 (23.5)
>5 160 (40.8) 84 (42.9) 76 (38.8)
Baseline Knowledge Score, m ± SD 8.02 ± 2.58 7.99 ± 2.65 8.03 ± 2.49 .612
Baseline Adherence Score, m ± SD 4.43 ± 1.78 4.54 ± 1.69 4.41 ± 1.84 .789
Baseline EQ-5D Score, m ± SD 0.4715 ± 0.336 0.4775 ± 0.335 0.4779 ± 0.341 .908
Baseline EQ-VAS Score, m ± SD 64.77 ± 6.566 65.38 ± 14.19 65.70 ± 15.19 .644
Baseline HbA1c Values, m ± SD 9.44 ± 1.58 9.47 ± 1.57 9.41 ± 1.57 .773

 

a1 Pakistan rupee = 0.0098 USD

 

Abbreviations: EQ-5D and EQ-VAS, European Quality of Life scale; glycemic control, HbA1c; m, mean; SD, standard deviation.


Table 2. Postintervention Analysis Between the Intervention Group and the Control Group

 

Characteristics Intervention Group

n = 161

n (%)

Control
Group
n = 164n (%)
P Value
Agea (y)
30-40 28 (17.4) 32 (19.5) .634
41-50 61 (37.9) 57 (34.8)
51-60 53 (32.9) 59 (36.0)
61-70 19 (11.8) 16 (9.8)
Gendera
Male 95 (59.0) 91 (55.5) .585
Female 66 (41.0) 73 (44.5)
Marital Statusa
Married 141 (87.6) 148 (90.2) .474
Unmarried 08 (5.0) 10 (6.1)
Widow 12 (7.5) 06 (3.7)
Educationa
Illiterate 18 (11.2) 22 (13.4) .259
Primary 16 (9.9) 16 (9.8)
Middle 09 (5.6) 06 (3.7)
Matriculation 41 (25.5) 30 (18.3)
Intermediate 22 (13.7) 35 (21.3)
Graduate 32 (19.9) 31 (18.9)
Masters 23 (14.3) 24 (14.6)
Occupationa
Private Job 25 (15.5) 27 (16.5) .289
Government Job 34 (21.1) 35 (21.3)
Businessman 37 (23.0) 33 (20.1)
Housewife/Homemaker 54 (33.5) 56 (34.1)
Retired 11 (6.8) 13 (7.9)
Monthly Incomec
0 51 (31.7) 48 (29.3) .658
5000-10 000 00 (0.0) 07 (4.3)
10 000-15 000 09 (5.6) 18 (11.0)
>15 000 101 (62.7) 91 (55.5)
Locationa
Urban 116 (72) 117 (71.3) .114
Rural 45 (28) 47 (28.7)
Duration of Diseasea (y)
<1 19 (11.8) 14 (8.5) .556
1-3 43 (26.7) 44 (26.8)
3-5 35 (21.7) 44 (26.8)
>5 64 (39.8) 62 (37.8)
Knowledge Score, m ± SDb 10.55 ± 2.56 7.53 ± 2.27 <.001
Adherence Score, m ± SDb 5.24 ± 1.48 4.3 ± 1.6 <.001
EQ-5D Score, m ± SDb 0.6115 ± 0.286 0.49 ± 0.31 <.001
EQ-VAS Score, m ± SDb 68.3 ± 14.0 64.2 ± 14.6 <.001
HbA1c Values, m ± SDb 8.97 ± 1.362 9.3 ± 1.3 .009

 

aχ2 test.

bMann-Whitney test.

c1 Pakistan rupee = 0.0098 USD

 

Abbreviations: EQ-5D and EQ-VAS, European Quality of Life scale; HbA1c, glycemic control; m, mean; SD, standard deviation.


Table 3. Differences Between Baseline and Postintervention for the Intervention Group

 

Variable Baseline

Mean (Median)

Postintervention

Mean (Median)

P Value
Knowledge Score 7.91 (8.00) 10.55 (11.00) <.001
Adherence Score 4.53 (4.75) 5.26 (5.00) <.001
EQ-5D Score 0.47 (0.62) 0.61 (0.69) <.001
EQ-VAS Score 65.33 (70.00) 68.37 (70.0) <.001
HbA1c Values 9.45 (9.00) 8.98 (8.70) <.001

 

Abbreviations: EQ-5D and EQ-VAS, European Quality of Life scale; HbA1c, glycemic control.


 

Discussion

Human behavior plays a central role in the maintenance of health and the prevention of disease. Growing evidence suggests that programs that can effectively change individual health behavior require a multifaceted approach to help people adopt, change, and maintain behavior.27

Interventions are effective in modifying beliefs and attitudes and can result in population-wide behavioral change.28 Such interventions generate opportunities for patients to understand their conditions better and to clarify the misapprehensions that they have of disease and its treatment.29 Educating patients about the disease and the medications used can improve disease-related knowledge, change attitudes toward the disease, provide practice toward management, and improve patients’ HRQoL.30 One study has shown that inadequate knowledge is one of the leading influences on adherence behavior.31 Therefore, intervening educationally through medication therapy management may make patients more aware of their disease, increase their adherence to a therapeutic regimen, and improve HRQoL.

The current intervention consisted of an educational program focused on improving diabetes-related knowledge and making patients aware of the importance of medication adherence. The results showed a significant increase in the level of diabetes-related knowledge for the intervention group between baseline and post intervention. The mean score on diabetes-related knowledge increased for that group to 10.55 ± 2.56.

The research team expected this increase in diabetes-related knowledge to cause a change in participants’ attitudes toward medications, resulting in improved adherence. Previous studies have shown that diabetes-related knowledge can be essential in effective diabetes self-care.32

Certain features should be considered before health education is designed and offered to patients, such as cultural, linguistic, and literacy needs, and diabetes education must be flexible enough to suit individual needs. In Pakistan, more than half the population (66%) lives in rural areas.33 Poverty—compounded by illiteracy, the low status of women, and inadequate water and sanitation facilities—has had a deep effect on health indicators.34

Cultural beliefs and practices often lead to self-care or home remedies in rural areas and consultation with traditional healers.34 Alternative therapies have regularly been used by people in Pakistan, who have faith in spiritual healers, clergymen, hakeems, homeopaths, or even unethical practitioners.34 The urban population of Pakistan used to hold such convictions, yet with modernization, most urban dwellers presently focus on pharmaceutically based treatments. Just moderate movement on the same course would be welcome among the rural population of Pakistan.

Nevertheless, medical practitioners must address existing beliefs and ideas in the configuration and execution of an educational program. Educational interventions can lead to a greater acceptance of the biomedical concept of illness and medicines, which is of extraordinary significance in managing chronic conditions.

In the current study, statistical analyses of participants’ attitudes and beliefs toward medication use and adherence before and after the educational intervention uncovered a positive movement for the intervention group, as illustrated in Table 3. Optimal pharmaceutical care can be achieved through patients’ education about self-management. That education can improve their knowledge and understanding of their conditions, coping behavior, and adherence to treatment. Previous studies have clearly highlighted the fact that educational interventions can lead to the modification of patients’ attitudes toward treatment and can enhance adherence to the therapeutic regimen.35-37

Most of the current study’s patients indicated that it is imperative that individual MTM service visits are not limited in number and will be available in the course of an extended period to maximize the interventional effects. Furthermore, participants stressed that such programs should be initiated at the community level. The study’s respondents also stated that they had had the opportunity to articulate their feelings, fears, and thoughts with the pharmacists, which was not possible during their visits to physicians. Another study found that improving patient information and education increased adherence by 13%.38. In developing nations, various interventions have been used for treatment and management of diseases. These interventions are often analyzed within a particular period and long-term effects are frequently disregarded, and no concept exists of evaluation postintervention. Therefore, the current research team suggests that continuing medical education (CME) should be provided even after an intervention so that patients can retain maximum knowledge.

In addition to diabetes-related complications, diabetic episodes and fear of hypoglycemia, changes in lifestyle, and fear of long-term consequences can cause a state of anxiety among patients, which leads to reduced HRQoL. Grandy and Fox39 found that patients with T2DM have a reduced HRQOL. HRQoL in the current study’s diabetic patients was measured as low at baseline. HRQoL increased in the intervention group postintervention (0.6115 ± 0.286, 68.37 ± 14.094). No significant change occurred in HRQoL for the control group.

A previous study had reported that pharmacists’ interventions can have both positive and negative effects on the HRQoL of individuals.40 Another study had demonstrated that patients seen by clinical pharmacists who were diabetes educators, indicated they had an overall excellent HRQoL.41 The current study also provided data that suggest that pharmacists’ interventions can influence diabetes-related outcomes in the community, with improvement in HRQoL for patients with T2DM.

Pakistan faces a severe shortage in terms of professionals and health care facilities. The health services are very expensive, and the most health care costs are paid by the patients themselves. Resource constraints in the society, lack of medical facilities, and insufficient allocation to a health budget are barriers to quality care. Most often patients are unable to afford the high cost of treatment.19-20 A multipronged, national health policy is needed to reduce the burden of disease. Moreover, it is imperative to improve the provision of primary and tertiary health care with a strong monitoring system in place.42

 

Conclusion

The current study found that a pharmacist’s educational program could increase patients’ levels of diabetes-related knowledge, improve adherence to medication, and increase glycemic control and that these increases can result in an improved HRQoL. The current MTM was successful because it managed to decrease participants’ HbA1c values, which is a positive indicator of a successful T2DM therapy.

 

AUTHOR DISCLOSURE STATEMENT

The current research team declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. The team received no financial support for the research, authorship, and/or publication of the study.

REFERENCES

  1. World Health Organization. Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes. Published 2018. Accessed September 8, 2019.
  2. International Diabetes Federation. Diabetes in Pakistan – 2014. Published 2014. Accessed http://www.idf.org/membership/mena/pakistan
  3. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data. 2006;367(9524):1747-1757.
  4. Danaei G. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. 2011;378(9785):31-40.
  5. Shera A, Rafique G, Khwaja I, Ara J, Baqai S,King H. Pakistan national diabetes survey: Prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province. Diabet Med. 1995;12(12):1116-1121.
  6. Murray CJ and Lopez AD. Evidence-based health policy—Lessons from the global burden of disease study. 1996;274(5288):740-743.
  7. Centers for Disease Control. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.
  8. Sicree R, Shaw J, Zimmet P. Diabetes and impaired glucose tolerance. Diabet Atlas. 2006;2:15-103.
  9. Ansari RM. Effect of physical activity and obesity on type 2 diabetes in a middle-aged population. J Pub Health. 2019;1(1):1-11.
  10. Rodrigues TC, Lima MHM, Nozawa MR. O controle do diabetes mellitus em usuarios de unidade basica de saude, Campinas, SP. Ciencia, Cuidado e Saude. 2008;5(1):41-49.
  11. Gilbert EA. Long-term glycemic control and the rate of progression of early diabetic kidney disease. Kidn Internatl. 1993;44:855-855.
  12. Grundyet EA. Diabetes and cardiovascular disease a statement for health care professionals from the American Heart Association. 1999;100(10):1134-1146.
  13. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Relationship of hyperglycemia to the long-term incidence and progression of diabetic retinopathy. Arch Internal Med. 1994;154(19):2169-2178.
  14. Karlson B, Herlitz J, Hjalmarson A. Prognosis of acute myocardial infarction in diabetic and non‐diabetic patients. Diabet Med.1993;10(5):449-454.
  15. Herlitz J, Bang A, Karlson B. Mortality, place and mode of death and reinfarction during a period of 5 years after acute myocardial infarction in diabetic and non-diabetic patients. 1996;87(5):423-428.
  16. Basit A, Hydrie M ZI, Hakeem R, Ahmedani MY, Masood Q. Frequency of chronic complications of type 2 diabetes. J Coll Phys Surg Pakistan. 2004;14(2):79-83.
  17. Khoharo HK and Qureshi F. Frequency of cardiac autonomic neuropathy in patients with type 2 diabetes mellitus reporting at a teaching hospital of Sindh. J Coll Physicians Surg Pak. 2008;18(12):751-754.
  18. Moin S, Gondal GM, Bano U. Risk of development of chronic kidney disease in patients with type 2 diabetes having metabolic syndrome. J Coll Physicians Surg Pak. 2008;18(8):472-476.
  19. Govender VM, Ghaffar A, Nishtar S. Measuring the economic and social consequences of CVDs and diabetes in India and Pakistan. Biosci Trend. 2007;1(3):121-127.
  20. Khuwaja AK, Khowaja L,Cosgrove P. The economic costs of diabetes in developing countries: Some concerns and recommendations. 2010;53(2):389-390.
  21. Shera A, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. 2002;52:465-470.
  22. Al-Qazaz HK, Sulaiman A, Hassali MA, Shafie AA, Sundram S, Al-Nuri R, Saleem F. Diabetes knowledge, medication adherence and glycemic control among patients with type 2 diabetes. Int J Clin Pharm..2011;33(6):1028-1035.
  23. National Bioethics Committee (NBC) Pakistan. Ethical Research Committee-Guidelines-2010. Published 2004. Accessed http://www.pmrc.org.pk/erc_guidelines.htm
  24. Saleem EA. Translation and validation study of 14-Item Michigan Diabetes Knowledge Test (MDKT): The Urdu version. Value Health. 2011;14(7):A481.
  25. Saleem EA. Translation and validation study of Morisky Medication Adherence Scale (MMAS): The Urdu version for facilitating person-centered health care in Pakistan. Int J Person Cent Med. 2012;2(3):384-390.
  26. Rabin R and Charro FD. EQ-SD: A measure of health status from the EuroQol Group. Ann Med. 2001;33(5):337-343.
  27. Sharby N. Health and behavior, the interplay of biological, behavioral and societal influences. J Phys Ther Ed. 2005;19(2):71.
  28. Saounatsou EA. The influence of the hypertensive patient’s education in compliance with their medication. Pub Health Nurs. 2001;18(6):436-442.
  29. Gao X, Nau D, Rosenbluth S, Scott V, Woodward C. The relationship of disease severity, health beliefs and medication adherence among HIV patients. AIDS Care. 2000;12(4):387-398.
  30. Rajanandh M, Nageswari A, Ilango K. Impact of pharmacist provided patient education on knowledge, attitude, practice and quality of life in asthma patients in a South Indian hospital. J Med Sci. 2014;14(5):254.
  31. Bender BG. Overcoming barriers to nonadherence in asthma treatment. J Allerg Clin Immunol. 2002;109(6):S554-S559.
  32. Garcia AA, Villagomez ET, Brown SA, Kouzekanani K, Hanis CL. The Starr County diabetes education study development of the Spanish-language diabetes knowledge questionnaire. Diabetes Care. 2001;24(1):16-21.
  33. Shaikh BT, Hatcher J. Health-seeking behavior and health service utilization in Pakistan: Challenging the policy makers. J Pub Health. 2005;27(1):49-54.
  34. Nyamongo I. Health care switching behavior of malaria patients in a Kenyan rural community. Soc Sci Med. 2002;54(3):377-386.
  35. Karim M, Mahmood M. Health Systems in Pakistan: A Descriptive Analysis. Karachi, Pakistan: Department of Community Health Sciences, Aga Khan University; 1999.
  36. Horne R. One to be taken as directed: reflections on nonadherence (noncompliance). J Soc Admin Pharm. 1993;10:150-156.
  37. Magadza C, Radloff S, Srinivas S. The effect of an educational intervention on patients’ knowledge about hypertension, beliefs about medicines, and adherence. Res Soc Admin Pharm. 2009;5(4):363-375.
  38. Peters K, Horne R, Kong F, Francomano C, Biesecker B. Living with Marfan syndrome II. Medication adherence and physical activity modification. Clin Genet. 2001;60(4):283-292.
  39. Schedlbauer A, Davies P, Fahey T. Interventions to Improve Adherence to Lipid Lowering Medication. New York, NY: Cochrane Library; 2010.
  40. Grandy S. EQ-5D visual analog scale and utility index values in individuals with diabetes and at risk for diabetes: Findings from the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD). Health Qual Life Outcome. 2008;6:18.
  41. Cote I, Moisan J, Chabot I, Gregoire JP. Health‐related quality of life in hypertension: Impact of a pharmacy intervention program. J Clin Pharm Ther. 2005;30(4):355-362.
  42. Jennings DL, Ragucci KR, Chumney EC, Wessell AM. Impact of clinical pharmacist intervention on diabetes related quality-of-life in an ambulatory care clinic. Pharm Pract. 2019;5(4):169-173.

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