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THE EFFECT OF MOBILE PHONE SHORT MESSAGE SERVICE (SMS) ON DRUG ADHERENCE AMONG ADULT HYPERTENSIVE PATIENTS ATTENDING THE GENERAL OUT-PATIENT DEPARTMENT OF JOS UNIVERSITY TEACHING, JOS
ABSTRACT
Introduction: Non-adherence to medication in hypertension is a major problem worldwide. Adherence to medications among adult hypertensive patients ranges between 50% to 72% in the developed countries and 23% to 65% in most African countries including Nigeria. At the beginning of this study the drug adherence rate in both study groups was only 27%. This is below the World Health’s organisation recommended drug adherence rate of 80-85% for chronic diseases like hypertension and this has led to poor blood pressure control and complications of hypertension.
Objectives: To determine the effect of mobile phone short message service (SMS) on drug adherence among adult hypertensive patients with a view to recommending such intervention to achieve optimum blood pressure control.
Study Design/Setting: A randomized controlled trial involving 78 adult hypertensive patients aged 18 years and above on antihypertensive drugs attending the General Out-patient Department of Jos University Teaching Hospital, Jos.
Methods: Subjects were randomly allocated to the control and the intervention groups. The intervention offered was weekly SMS reminders over a 12 weeks period. Data collected from the subjects include socio-demographic data, medical and drug history. Drug adherence rate was measured using the modified Morisky adherence scale (MMAS) questionnaire that was self-administered. Focused physical examination was done including blood pressure. Subjects were followed up monthly over 12 weeks during which measurements were repeated.
Results: There was a higher mean change in Morisky score at the end of 12 weeks in the intervention group of -3.31 versus -0.98 in the control group. This was statistically significant
(t-test=12.67, p<0.001). At the end of 12 weeks, there was a higher drug adherence rate in the intervention group of 88.9% following weekly SMS reminders and drug adherence counselling compared to 54.1% in the control group that had only drug adherence counselling. This difference in drug adherence rate between the two groups was statistically significant (χ2=5.9932, p=0.015).
There was also a higher mean reduction in systolic blood pressure of -22.99mmHg and diastolic blood pressure of -19.09mmHg in the intervention group compared to -7.26mmHg systolic blood pressure and -5.29mmHg diastolic blood pressure in the control group. The mean SBP reduction between the two groups was statistically significant (t-test=8.85, p=<0.001) and the mean DBP reduction between the two groups was also statistically significant (t=9.17, p=<0.001).
There was no statistical significant difference in the proportion of missed hospital appointments between the intervention and control group at the end of 12 weeks; 7.7% versus 17.9% respectively (χ2=1.84, p=0.18). However, the intervention group had less proportion of study participants with missed hospital appointments at the end 12 weeks following weekly SMS reminders.
All data was analysed by Epi info version 3.5.1 2011 (Centre for Disease control and Prevention, Atlanta Georgia, USA).
Conclusion: Weekly SMS reminders along with drug adherence counselling led to significant improved drug adherence rate and mean reduction in blood pressure among adult hypertensive patients attending General Out-patient Department of Jos University Teaching Hospital. There were also a less proportion of subjects with missed hospital appointments following the intervention at the end of 12 weeks.
SMS technology proved to be an important tool in improving the clinical outcome of hypertensive patients in this study.
TABLE OF CONTENTS
Declaration……………………………………………………………………………………………………………i
Certification………………………………………………………………………………………………………….ii
Dedication………………………………………………………………………………………………………..iii
Acknowledgement…………………………………………………………………………………………………iv
Table of Contents ………………………………………………………………………………………………….v
List of Tables ……………………………………………………………………………………………………….ix
List of Figures ………………………………………………………………………………………………………x
List of Abbreviations …………………………………………………………………………………………….xi
Abstract ………………………………………………………………………………………………………………xiv
Chapter One
1.0 Introduction……………………………………………………………………………..1
1.1 Background ………………………………………………………………………………………………………1
1.2 Statement of the Problem……….. ……………………………………………………………………….5
1.3 Justification of the study………………………………………………………………….9
1.4 Aim and Objectives……………………………………………………………………..10
1.4.1 Aim…………………………………………………………………………………..10
1.4.2 Objectives…………………………………………………………………………….10
Chapter Two
2.0 Literature Review……………………………………………………………………………………………..12
2.1 Hypertension …………………………………………………………………………………………………….12
2.1.1 Brief History of Hypertension ………………………………………………………………………….12
2.1.2 Definition and classification of Hypertension…..……………………………………12
2.1.3 Epidemiology …………………………………………………………………………………………………19
2.1.4 Pathophysiology………………………………………………………………………………………………26
2.1.6 Complications…………………………………………………………………………………………………31
2.1.7 Management of Hypertension….. …………………………………………………………………….34
2.2 Drug Adherence…………………………………………………………………………………………………45
2.2.1 Overview………………………………………………………………………………………………………..45
2.2.2 Definition of Adherence ………………………………………………………………………………….45
2.2.3 Measures of drug Adherence…………………………………………………………………………….46
2.2.4 Drug Adherence in Management of Hypertension………………………………………………50
2.2.4.1 Non-Adherence to HypertensionTreatment………………………………………………………50
2.2.5 Interventions to improve drug Adherence …………………………………………………………..55
2.2.6 SMS and Drug Adherence ………………………………………………………………………………..58
2.2.6.1 Definition of SMS …………………………………………………………………………………………58
2.2.6.2 Role of SMS in Drug Adherence……………………………………………………………………..58
2.2.7 SMS and Hospital Missed Appointments…………………………………………………………….63 Chapter Three
3.0 Methodology ……………………………………………………………………………………………………..68
3.1 Study Design ……………………………………………………………………………………………………..68
3.2 Study Area………………………………………………………………………………………………………….68
3.3 Study Population………………………………………………………………………………………………….69
3.4 Study Hypothesis ………………………………………………………………………………………………..69
3.5 Sample size determination…………………………………………………………………………………….69
3.6 Eligibility …………………………………………………………………………………………………………..70
3.6.1 Inclusion Criteria……………………………………………………………………………………………..70
3.6.2 Exclusion Criteria…………………………………………………………………………………………….70
3.7 Recruitment, Allocation and Randomization………………………………………………………….71
3.8 Instruments of data collection…………………………………………………………..72
3.9 Data collection……………………………………………………………………………………………………72
3.10 Period and duration of Study…………………………………………………………..75
3.11 Data Analysis……………………………………………………………………………………………………75
3.12 Ethical consideration…………………………………………………………………….76
Chapter Four
4.0 Results ……………………………………………………………………………………………………………..77
4.1 Subjects flow through the study …………………………………………………………………………..77
4.2 Baseline characteristics of the study groups…………………………………………………………..79
4.3 Baseline medical history of the study groups………………………………………………………….82
4.4. Baseline clinical characteristics of the study groups……………………………………………….86
4.5 Drug Adherence of the study groups……………………………………………………..87
4.5.1 Pre-intervention drug Adherence of the study groups…………………………………87
4.5.2 Post-intervention drug Adherence of the study groups…………………………………88
4.6 Blood Pressure of the study groups………………………………………………………91
4.6.1 Baseline blood pressure of both groups……………………………………………………91
4.6.2 Post-intervention blood pressure of both groups……………………………………………93
4.7 Proportion of missed hospital appointments in the study groups………………………….96
Chapter Five
5.0 Discussion…………………………………………………………………………………………………………99
5.1 Socio-demographic characteristics of the study groups……………………………….100
5.2 Medical history of the study participants……………………………………………….101
5.3 Drug Adherence of the study groups……………………………………………………………..102
5.4 Blood pressure of the study groups………………………………………………………105
5.5 Proportion of missed hospital appointments in the study groups………………………107
5.6 Strengths of the study …………………………………………………………………108
5.7 Limitations of the study……………………………………………………………….109
5.8 Conclusion………………………………………………………………………………110
5.9 Recommendation………………………………………………………………………111
References…………………………………………………………………………………..113
Appendices…………………………………………………………………………….131-140
CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Chronic diseases are now the major cause of death and disability worldwide, responsible for 59% of deaths and 46% of the global burden of disease.1 The number of persons with chronic illness is growing at an astonishing rate because of the rapid aging of the population and the greater longevity of persons with many chronic conditions.2 Diabetes, an important component of the non-communicable diseases, is undoubtedly a rising problem globally.2
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycaemia due to disturbances of carbohydrate, fat, and protein metabolism that are associated with absolute or relative deficiencies in insulin secretion.3 The number of people with diabetes is increasing due to population growth, aging, urbanization, and increasing prevalence of obesity and physical inactivity.4 The dramatic worldwide increase in the prevalence of type 2 diabetes is posing a massive health problem in both developed and developing countries.5 Interestingly, in developed countries, lower socioeconomic groups are most affected, while, in developing countries, the reverse applies.6 The magnitude of the healthcare problem of type 2 diabetes results not just from the disease itself but also from its association with obesity and
cardiovascular risk factors, particularly dyslipidaemia and hypertension.7
Type 2 diabetes is the predominant form of diabetes in sub-Saharan Africa, accounting for over 90% of cases. As 50% of cases of type 2 diabetes are currently undiagnosed, enhanced
detection and diagnosis are critical.7
Diabetes presents a major challenge to the health care industry now and in the foreseeable future. However, strategies for the improved management of diabetes and its associated conditions are available. Compelling evidence indicates that controlling glycaemic levels as well as hypertension and dyslipidaemia in diabetes patients cost-effectively reduces the risk of related morbidity and mortality and improves their quality of life.8
The epidemic of type 2 diabetes and the recognition that achieving specific glycaemic goals can substantially reduce morbidity have made the effective treatment of hyperglycaemia a top priority.9
Diabetes is a complex chronic disorder with major short- and long-term health implications. Diabetes care hinges on the daily commitment of the person with diabetes to self-management, balancing appropriate lifestyle choices and pharmacologic therapy. Improving clinical outcomes in diabetes requires patients to undertake and sustain a complex array of self-care behaviours, including taking medications, monitoring blood glucose levels, following a diet, engaging in regular exercise, and caring for their feet. These and other skilled behaviours to promote health and prevent complications are often called “self-management.” How best to evaluate and support patients’ diabetes self-management is a critically important question.10
Improving diabetic self-management is critical in improving glycaemic control. Multiple studies have found that diabetes self-management education (DSME) is associated with improved diabetes knowledge, improved self-care behaviour and improved clinical outcomes such as lower HbA1c, improved quality of life, healthy coping, and lower costs. Patients’ behaviour alone does not determine glycaemic control but these studies have shown significant association between self-management and glycaemic control. However; the studies are crosssectional and so it might be that patients with better glycaemic control assess their self- management as better.
Medical care then must assure that persons with chronic illness have the confidence and skills to manage their condition; the most appropriate treatments to assure optimal disease control and prevention of complications; a mutually understood care plan; and careful, continuous follow-up.1
Decades ago, pioneers such as John Runyon recognized that the effective management of chronic illness requires a new kind of practice designed expressly to help patients meet the challenges of chronic disease.2 More recently, stronger evidence suggests that busy practices can redesign their care and do much better than “care as usual.” For example, a Cochrane Collaboration review carefully examined the more rigorously tested interventions to improve primary care for diabetes. Among the forty-one studies examined, many showed increases in recommended care processes such as the prevalence of eye or foot examinations and a few improved health and disease-control outcomes. Also a few randomized controlled trials revealed that the group receiving the experimental program achieved average improvements in blood glucose control (reduction in HbA1c of 1 percent or more) that, if sustained over time, would result in a 21 percent reduction in mortality, a 14 percent reduction in myocardial infarction, and a 37 percent reduction in microvascular complications.2
Today’s medical system is optimized for the delivery of acute, episodic care by individual physicians, yet the primary burden on the system is from chronic illnesses that are not effectively managed under the current healthcare system.12 Evidence-based guidelines from the American Diabetes Association (ADA) describe a care pattern that, if followed, would greatly reduce the impact of diabetes and its complications, yet repeated studies in a variety of settings continue to show suboptimal processes or outcomes of care.13 The Chronic Care Model (CCM) was designed by Wagner and colleagues to build on the interrelationships between six evidence- based elements that lead to improved clinical quality. It aims to facilitate productive interactions between “informed and activated patients” and “prepared, proactive practice teams” For example, for patients to engage in proactive care (delivery system design), practices need to be able to view all of the patients in their panels (clinical information systems) who need certain guideline-based treatments (decision support), and patients must agree to any changes in their care and integrate them into their lives (self-management support). Increasing access to effective programming in the community through linkages with the relevant agencies is a cost-effective way to obtain important services such as nutrition counseling or peer-support groups (integration of community resources). For all these to occur chronic illness improvement should be represented in the organization’s goals (healthcare organization
redesign).2,14
Implementation of the CCM from the patient perspective can be assessed using the Patient Assessment of Chronic Illness Care (PACIC) survey. It focuses on the receipt of patientcentred care and self-management behaviours. It is a 20-item patient report instrument that assesses patient’s receipt of clinical services and actions consistent with the CCM.15
Studies done in Nigeria have shown that the morbidity and mortality associated with diabetes is high due to suboptimal management and noncompliance with global standards.16 Though these studies were cross-sectional and might not reflect the actual magnitude of the disease. Studies have also shown the need for restructuring of the healthcare delivery systems in Nigeria in order to adopt more appropriate and effective preventive treatment strategies in the management of diabetes in Nigeria.
Interventions based on the CCM have not been widely or systematically adopted in primary care practices, however, and few data exist to demonstrate that the incremental incorporation of CCM elements in small, independent primary care practices is associated with better clinical outcomes.12 These studies are limited by the self- reported nature of both clinician use of CCM elements and processes of care measures. But the patient report of services and laboratory ascertainment of physiologic data lends some strength to the associations.
Although quality diabetes care is essential to prevent long-term complications, care often falls below recommended standards regardless of healthcare setting or patient population,
emphasizing the necessity for system change.16
1.2 STATEMENT OF THE PROBLEM
Diabetes is a common chronic disease. It also meets all 3 criteria for a public health disorder
“a high disease burden, changing burden suggesting preventability, and fear that things are unknown and out of control.”17
The United States and the rest of the world are in the midst of a diabetes epidemic.18 The global prevalence of diabetes was 8.3% in 2011 and is still on the increase, particularly in developing countries, where provision and delivery of care is most difficult.4 In Africa, the prevalence is 3.8% and is rapidly on the increase, especially among urban communities. The reason can be attributed principally to the nature of food consumed and lifestyles adopted. According to
Sobnigwe and colleagues, ‘the prevalence of diabetes mellitus and other non-communicable diseases is on the rise in African communities due to the ageing of the population and drastic lifestyle changes and accompanying urbanization and westernization.19
Sub-Saharan Africa is not immune to the process, and is experiencing a triple and in many instances, a quadruple burden of disease, as the traditional infectious diseases such as malaria and tuberculosis have been joined by non-communicable diseases in addition to HIV.6 All this occurs in a region in which over 40% of the population live on less than US$1/day.20 It threatens to overwhelm the healthcare system in the near future. Sadly, the majority of the people with diabetes in developing countries are within the productive age range of 45–64 years (179 million). These are the same individuals who are expected to drive the economic engines of their countries in order to achieve the agreed international development goals. Besides their reduced productivity, diabetes further imposes a high economic burden in terms of healthcare expenditure, lost productivity, and foregone economic growth.21
Diabetes and its complications impose significant economic consequences on individuals, families, health systems and countries.21 The threat is growing, the number of people, families and communities afflicted is increasing. This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries.21 Diabetes takes a staggering toll on the people in Nigeria and the economic burden is heavy.22
In resource-poor countries, shortage of insulin, other drugs, monitoring and laboratory facilities and trained staff all lead to serious shortfalls in diabetes care.23 The rural areas of Africa present particular problems, due to scattered populations, difficulties in access to clinic facilities, poor provision of health care personnel, and shortage of drugs and equipment.24 These factors potentially lead to poor glycaemic control and a high burden of complications.25
Very little research has been carried out concerning care delivery and its problems in such
areas. 24
The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information.2 The physical, social, and economic burden of diabetes mellitus result mostly from the complications of the disease, which occur because of poor compliance to treatment. Studies done in Kano by Lawan and colleagues showed that diabetic patients are being selective on the use of the disease control measures prescribed to them by their physicians.26 However, Physicians commonly ignore this important aspect of diabetic management.
Well-designed interactions between practice team and patient will be needed to complete the important clinical and behavioral work of modern chronic illness care. Evidence suggests that the typical acute problem–oriented visit practiced in the primary care settings, which is similar to that practised in Nigeria is a barrier to such care.4
Type 2 diabetes accounts for 90% of diabetes and people living with type 2 diabetes are more vulnerable to varied forms of both short- and long term complications, which often lead to their premature death. This vulnerability to increased morbidity and mortality is as a result of the commonness of this type of diabetes, its insidious onset, and late recognition, especially in resource-poor developing countries like Nigeria.27 Studies have shown that in Nigeria and many sub Saharan countries, professional adherence to approved guidelines for diabetes care is poor. It also showed that Nigerians are at substantial risk of premature death and complications related to diabetes even while in care.28 A study by Chijioke and collegues in Ilorin showed that contributory factors to the high mortality were ignorance, poor hygiene, infections, lack of foot care and inadequate glycaemic/blood pressure control. This emphasises
the importance of early diagnosis of diabetes and proper management.29
To curb this scourge of diabetes, public health interventions are required to prevent diabetes or delay the onset of its complications.30 This will entail redesigning of the health care structure with emphasis on self- management education. CCM emphasizes self-management training and counselling and patient participation as essential in improving outcome in the management of diabetes.
Diabetes is a major challenge for the health care system and especially for the primary care provider. There is a dearth of information on the extent to which diabetic patients receive care congruent with the chronic care model (CCM) and evidence-based behavioural counseling.31 While CCM has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.14 The lack of physician training in chronic illness management is an obstacle.14 This might be due to the fact that there is no laid down CCM protocol in most health care settings, though the fact that aspects of CCM are difficult to implement due to the low economic status of most patients and lack of electronic medical records in most primary care settings might be a contributing factor. The public health care system is overburdened and under-resourced, often leading to overcrowded clinics, inadequate number of staff, high patient load, short consultation time and poor record keeping. A huge burden is placed on these public health facilities and may contribute to the quality of care
delivered to chronic disease patients.32
1.3 JUSTIFICATION OF STUDY
The main justification for this study is that the findings may lead to recommendations that would improve the management of diabetes and outcome of care. Although diabetes, especially type 2 DM, is a major cause of morbidity and mortality world-wide, the associated burden is felt more in developing countries like Nigeria because of delays in diagnosis, and late presentation and poor compliance with recommended management guidelines. Interventions based on the CCM have not been widely or systematically adopted in primary care practices in Nigeria. Studies have shown that small primary care practices have been able to incorporate elements of the CCM into their practice style, often without major structural change in the practice. Despite advances in the effectiveness of treatment, research shows that patients frequently do not get the care they want or need.1
Restructuring of the health system is important in order to improve the outcome of care of chronic illnesses like diabetes in Nigeria. A Cochrane review showed that complex interventions that only target providers’ behavior did not change patient outcomes unless accompanied by interventions directed at patients.2 Hence implementation of elements of the CCM involving patient self- management support is a step in redesigning chronic care in resource poor countries Nigeria. Because implementing and maintaining CCM requires on- going advocacy as it requires educational and financial support, and a leadership committed to change.
Family physicians play a key role in chronic disease prevention, identification and management since they are the frontlines and gateway to the healthcare system.33 A survey done by Madaki and collegues in Jos University Teaching Hospital General Out-Patient Department in 2007 showed that 3% of the total number of patients seen are diabetic.34 Hence it is one of the common diseases managed by the family Physician. They are in the best position to deal with chronic disease. Their unique training, based on the principles of Family Medicine, is well suited to this challenge. They are skilled clinicians who remain up to date and capable of incorporating best evidence into clinical regimens as new information emerges.
The doctor-patient relationship is the hallmark of family medicine. As family doctors follow their patients over time, a trusting relationship develops. This relationship is key to engaging the patient in the management of own their disease(s) by incorporating self management plans into their daily lives, an essential element of the Chronic Care Model that encourages high quality chronic disease care.35 Furthermore, family physicians come to understand the illness experience of their patient with chronic disease. Patient engagement in the disease process and management is enhanced when care is provided within the context of the illness experience for any individual patient.
Family physicians focus on prevention, which is the key to preventing diabetes and further complications when already established. They coordinate the team based care which is essential in the management of diabetes. Only family doctors have the dedication to continuity of care that enhances chronic disease management. They see their patients in the office / clinic, at home, hospital, and in long term/chronic care settings.
Elements of the CCM to be implemented in this study will involve patient self- management support, aspects of delivery system design through appropriate referral, and integration of community resources by advocacy to join the local Diabetic association. These are aspects of the CCM that can be incorporated into the health care delivery in resource poor settings like Nigeria. Also, counselling on self-management behaviour modification can be effected in patients irrespective of gender, literacy or financial status. The effect of these interventions on self- management behaviour and glycaemic control of patients in our setting will be evaluated and thus identify areas where changes can be made to improve diabetic care. The outcome of the study could lead to recommendations aimed at improving the outcome of diabetes management in a cost effective manner.
1.4 AIMS AND OBJECTIVES
AIM OF THE STUDY
To determine the effect of the chronic care model on self-management behaviour and glycaemic control among adults 18 years and above with Type 2 Diabetes attending the General out-patient department, Jos university teaching hospital (GOPD), JUTH, Jos , Plateau State with a view to recommending its use in routine care so as to ensure improved diabetes care in patients.
SPECIFIC OBJECTIVES
- To determine the mean change in glycated haemoglobin in subjects allocated to the chronic care model versus usual care.
- To determine the mean change in self-management behaviour in subjects allocated to the chronic care model versus usual care.
- To determine the mean change in Patient Assessment of Chronic Illness Care (PACIC) scores in subjects allocated to the chronic care model versus usual care using the PACIC scale.
THE EFFECT OF MOBILE PHONE SHORT MESSAGE SERVICE (SMS) ON DRUG ADHERENCE AMONG ADULT HYPERTENSIVE PATIENTS ATTENDING THE GENERAL OUT-PATIENT DEPARTMENT OF JOS UNIVERSITY TEACHING, JOS
