Configuración de virtudes

4.4.3.1 Diabetes management

The change of diabetes management of 48 (12.5%) participants from diet-controlled to pharmacological agents in the preceding three months indicates a need for better glycaemic control for these participants. . This is the usual progressive management for T2DM because, as time passes and diabetes advances, there is loss of β-cell function and, therefore, a greater need for pharmacological agents to deal with the resulting hyperglycaemia. Although 25% were advised about their diet, none of the participants were on a prescribed diet. This is a reflection of services available for those living with diabetes in PNG. From personal knowledge, since a 2001 report ²⁶, there are still insufficient resources, such as nutritional and dietetic services, and specialist endocrinologists to support diabetes management in the country. The reason for the availability of a limited range of hypoglycaemics (glibenclamide, metformin and insulin) through the public health care system during the time of the study is because the list of medicines purchased is based on the WHO Model List of Essential Medicines. The use of essential medicines only is to ensure affordable medicines are widely available.

189

Participants were requested to report management of their T2DM when they were initially diagnosed with the disease. The reduction in the number of patients on insulin over time may have been partly due to changing from inpatient services to outpatient services. Some of these participants may have received insulin while in hospital at the time of initial diagnosis but may have been discharged on oral hypoglycaemic medications. It is also possible that T2DM patients who require insulin may not be able to use insulin for reasons such as the storage requirements of this medication. Usage of insulin in PNG is limited by its requirement for refrigeration. As seen in this study, about 20% of the participants lived in rural areas and 20% lived in peri-urban areas. In rural PNG, only a few homes have portable electricity generators but electricity is produced mostly for smaller appliances and lighting purposes only. Some peri-urban areas may not have consistent electricity supplies and, in particular, may not have refrigerators.

4.4.3.2 Medication adherence

Adherence to medications is of paramount importance because there are strong correlations between medication adherence, patient outcomes and treatment costs.

27-30

The type of medication adherence investigated by the present study was omission of doses, which is the most common type of non-adherence. ³¹ This may be intentional or non-intentional. A high proportion of participants (59.6%) reported omitting at least some of their doses. This is consistent with the trends that have been reported elsewhere. ^32-36

The only significant factor which affected adherence to medication regimens was age. Those aged 60 years or older were more likely to be adherent to their diabetes medications. Younger people tend to have other priorities in their lives and lead busier lives than the elderly, because of employment and other social activities.

This may partly explain why the younger age group was less adherent to their hypoglycaemic medications than the older age group in the present study.

190

Older people also may have been more adherent within this study population because the study setting has a medication supply policy that exempts those aged 60 years or older from medication fees. Furthermore, in a society like PNG’s where extended family usually live together in a single household, care of the elderly may have led to better adherence by those aged 60 years and older. This finding, that older people are more adherent, is consistent with other studies showing that better hypoglycaemic medication adherence is associated with increased age. 34, 37, 38 A Scottish study, however, reported that younger people were more adherent in taking their hypoglycaemic medications, compared to their older counterparts.³⁹

There is evidence that strong psychosocial support improves medication adherence.⁴⁰ Participants in this study were living in a society where extended families usually live in the one house. Family ties are strong and, usually, younger family members care for their elder relatives within the family home. With the advantage of strong psychosocial support in PNG, patients and their family carers may have better opportunity to develop good routines in medication behaviour, as it has been shown that developing such routines usually leads to higher levels of adherence.⁴⁰

The most common reasons cited by participants for omitting doses were patient- and health care system-related. The most common patient-related reason for omitting doses cited by participants was that they simply forgot to take their medications. The next most common patient-related factor was participants not refilling their medications, despite having prescriptions. This group of participants did not elaborate further on their reasons for not doing so.

All participants who had problems with access to the diabetes clinic reported that they were waiting for their next medical review to pick up their new prescriptions.

This led to them not continuing their medications as required. The contributing factors to this were: increase in the number of patients attending the clinic, scheduling of appointments, the number of clinic days and hours per week, cancellation/rescheduling of clinic times, shortage of staff at the clinic and closure of the clinic from the beginning of December to the end of January every year.

Scheduling of review dates for each individual patient depends on availability of an appointment time. Even if a doctor wants to see a patient one month later, for

191

example, the next available appointment may not be until two weeks after that. This may lead to a patient missing out on their medications for two weeks, because the doctor will usually prescribe only one month’s supply of medication based on the understanding that the patient will be seen again after a month. Despite the increase in the number of people diagnosed with diabetes, this clinic was still only open for three hours per week. To make matters worse, shortages in staff (both nursing and medical) often led to cancellation of appointments or scaling down of the clinic’s operations. (personal observation)

Cost of medications is a crucial issue in medication adherence, especially for those who have been diagnosed with chronic diseases like T2DM, because therapy is ongoing (life-long). A further cost burden is often incurred due to the complications associated with diabetes. Most patients in PNG do not have private medical insurance but all patients benefit from subsidised medications through the public health system. Despite minimal medicine costs, many patients still cannot afford medications. There are also associated costs, such as consultation fees and the cost of transport to the clinic. Almost 20% of the participants in this study lived in rural villages where the cost of transport is even more than the cost of medicines.

Apart from transport costs, those who live in the rural areas have to find temporary accommodation in the city where the diabetes clinic is situated. Studies elsewhere have shown that the cost of medications contributes to reduced adherence.36, 41, 42

Similarly, the inconvenience of travel and the cost of travel also play a role.

There are three main policies which affect access to hypoglycaemic medications in PNG. Hypoglycaemic medications are only available in hospitals, which makes access more expensive for those living in rural villages. Another policy involves pharmacy fee exemptions. Patients with chronic diseases like cardiovascular diseases and asthma are exempted from paying for their disease-related medications but the same concession is not available, in general, for patients with diabetes. The exception is that patients who are 60 years and older are exempted from the costs of all medical problems. This policy may need revising to improve adherence to hypoglycaemic medications. The third policy concerns the total quantities dispensed per patient. Pharmacy departments usually only dispense one month’s supply, even if the prescriber makes a request for three month’s supply, for

192

example. Patients are then required to travel to the hospital pharmacy more often for their monthly refills.

4.4.4 Physical measurements