Journal of Family Medicine and Primary Care

: 2018  |  Volume : 7  |  Issue : 2  |  Page : 475--476

A comment on “lacunae in noncommunicable disease control program: Need to focus on adherence issues”

Saurav Basu 
 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Correspondence Address:
Dr. Saurav Basu
Department of Community Medicine, Maulana Azad Medical College, New Delhi

How to cite this article:
Basu S. A comment on “lacunae in noncommunicable disease control program: Need to focus on adherence issues”.J Family Med Prim Care 2018;7:475-476

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Basu S. A comment on “lacunae in noncommunicable disease control program: Need to focus on adherence issues”. J Family Med Prim Care [serial online] 2018 [cited 2020 Jul 4 ];7:475-476
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Dear Editor,

The article by Singh et al. evaluated medical adherence in diabetes and hypertension patients in a clinic setting in the Punjab state.[1] The strength of the study is that it is one of the few studies which reports medication adherence findings among noncommunicable disease (NCD) patients from a small, nonmetropolitan city of India. Nevertheless, I would like to highlight a few methodological concerns regarding the study which can be clarified on by the authors.

Reporting of medication adherence – The Singh et al. study assesses medication adherence jointly for two different disease conditions such as diabetes and hypertension. Furthermore, it does not stratify patients as diabetic, hypertensive, or comorbid which is a limitation of their study since it precludes assessment of the extent of adherence for the individual disease conditions. Such an approach should also be avoided since the factors influencing medication adherence in diabetes can differ from other NCD conditions such as hypertension, thyroid disorders, and chronic obstructive pulmonary disease. Poor adherence to antihypertensive medication in diabetes-hypertension comorbidity has also been previously reported.[2] This could be due to increasing complexity of regimen resulting from a higher pill burden [3] or patient perceived accentuated side effects from a regimen containing both antihypertensives and antidiabetic medications [2]Sample size calculation – The Singh et al. study calculated the sample size based on reported adherence of 40%, but no previous study has been cited by the authors. Appropriate calculation of sample size for a prevalence study for measuring adherence in a population should preferably identify self-reported adherence from a previous study which uses a similar method for assessment of medication adherenceAssessing medication adherence – Several validated methods exist for measuring medication adherence in diabetes patients.[4] In the Singh et al. study, nonadherence was defined as missing a dose of any of the prescribed antidiabetic or antihypertensive medications in the previous 7 days. The high cutoff is required for optimum clinical outcomes in diseases such as HIV-AIDS and tuberculosis (≥95% and ≥90% adherence rate, respectively) but should be set lower at ≥80% for diabetes.

Unintentional type of nonadherence resulting from lack of drug stocks in patients over a significant period of time should also be assessed in resource-constrained health settings, especially in low-income patients, using the proportion of days covered method. Although the provision of free of cost medications in the study setting as reported in the Singh et al. study is likely to reduce unintentional nonadherence, it does not eliminate it. The study by Basu et al. in government hospitals of Delhi observed that more than one-fourth of the nonadherent diabetic patients reported skipping doses due to running out of antidiabetic medication stocks despite provision of free medication.[5] This usually occurs among patients of low socioeconomic status who may be unable to obtain medicine refills due to the high opportunity cost in terms of their lost daily wages and expenditure on transport.

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1Singh T, Bhatnagar N, Moond GS. Lacunae in noncommunicable disease control program: Need to focus on adherence issues! J Family Med Prim Care 2017;6:610-5.
2Kilonzo SB, Gunda DW, Bakshi FA, Kalokola F, Mayala HA, Dadi H, et al. Control of hypertension among diabetic patients in a referral hospital in Tanzania: A cross-sectional study. Ethiop J Health Sci 2017;27:473-80.
3Odegard PS, Gray SL. Barriers to medication adherence in poorly controlled diabetes mellitus. Diabetes Educ 2008;34:692-7.
4Lehmann A, Aslani P, Ahmed R, Celio J, Gauchet A, Bedouch P, et al. Assessing medication adherence: Options to consider. Int J Clin Pharm 2014;36:55-69.
5Basu S, Khobragade M, Kumar A, Raut DK. Medical adherence and its predictors in diabetes mellitus patients attending government hospitals in the Indian capital, Delhi, 2013: A cross sectional study. Int J Diabetes Dev Ctries 2015;35 Suppl 2:95.