Issues Affecting Medication-Taking Behavior of People with Type 2 Diabetes in Indonesia: A Qualitative Study

Best fit framework synthesis of qualitative studies on factors associated with medication nonadherence in people with type 2 diabetes using the COM-B model

This review aimed to synthesize factors associated with medication nonadherence among people with type 2 diabetes (PwT2D), using the Capability, Opportunity, Motivation and Behaviour (COM-B) model as the a priori model. Studies published between January 2014 and April 2024 were searched on five databases. Studies were included if they recruited PwT2D aged >18 years, investigated factors associated with adherence to oral and/or nonoral medications for diabetes, used qualitative research methods, were conducted in a community setting, were in English language and had accessible full-text articles. Best fit framework synthesis was undertaken, which led to the development of a hypothesized COM-B variant model specific to medication nonadherence among PwT2D. Study quality was assessed using published criteria to evaluate whether the study was adequately reported. Twenty-two studies were included. Factors were mapped onto the COM-B model: physical capability (e.g., difficulty injecting insulin independently), psychological capability (e.g., understanding about diabetes), physical opportunity (e.g., cost of medication), social opportunity (e.g., quality of communication and relationship with healthcare providers), automatic motivation (e.g., habit formation) and reflective motivation (e.g., perceived necessity and effectiveness of medications). Reflective motivation had the most themes, while physical capability only had one theme. Personality was a theme that could not be mapped onto the model. Interactions between some COM-B components (e.g., capability and motivation) were observed. This theoretically grounded synthesis may facilitate future intervention development by formulating a programme theory and identifying behaviour change techniques to address the identified factors.

Relationship between social capital and medication adherence among frail and pre-frail older people: a cross-sectional study from China

BACKGROUND

The number of frail older people is increasing. To alleviate poor health and improve quality of life, pre-frail and frail older people need to adhere to their medication. Yet, studies examining the connection between social capital (including six dimensions) and medication adherence are currently scarce. Therefore, this study aims to examine their relationship in older individuals with pre-frailty and frailty, respectively.

METHODS

Information concerning the socio-demographics, frailty, social capital, and medication adherence of 4218 participants was collected through a structured questionnaire during November and December 2020. This study employed descriptive analysis and binary logistic regression to fit their relationship.

RESULTS

Among the pre-frail respondents, those with lower social participation (AOR 0.55 [95% CI 0.44-0.69]) had less risk of inadequate medication adherence; while lower social connection (AOR 1.91 [95% CI 1.54-2.36]), lower trust (AOR 2.80 [95% CI 2.25-3.47]), lower cohesion (AOR 2.04 [95% CI 1.65-2.53]), and lower reciprocity (AOR 2.32 [95% CI 1.87-2.88]) were all related to higher odds of inadequate medication adherence. Also, lower social participation (AOR 0.54 [95% CI 0.40-0.74]) was linked to less risk of inadequate medication adherence, while lower trust (AOR 1.89 [95% CI 1.41-2.54]), lower cohesion (AOR 1.68 [95% CI 1.24-2.26]), and lower reciprocity (AOR 1.52 [95% CI 1.14-2.04]) were all found to have a greater odds of inadequate medication adherence in frail respondents.

CONCLUSION

By enhancing the relationship between social capital and medication adherence in this challenging community and offering educational programs that promote medication adherence from the perspective of social capital, our findings emphasize the relevance of social capital in improving medication adherence in later life, especially for frail and pre-frail older adults.

Impact of Syringe and Needle Reuse on the Clinical Outcomes of Patients With Type 2 Diabetes: A 12-Week Randomized Clinical Trial

OBJECTIVE

To evaluate the clinical and laboratory outcomes of patients with type 2 diabetes by comparing the no reuse or reuse of syringes and needles for insulin injection.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes who had reused syringes and needles at least three times were randomly instructed either to not reuse or to reuse insulin syringes and needles five times. The primary outcomes assessed were glycemic control, pain scores, and skin complications (ecchymosis, lipohypertrophy, nodules, infection) at baseline and 4, 8, and 12 weeks after the intervention. Secondary outcomes included treatment adherence, quality of life, microbiological contamination of syringes and needles, needle quality, and insulin injection technique.

RESULTS

Among the 71 participants (mean ± SD age 59.7 ± 8.8 years), 59% were women with a median duration of diabetes of 18 years (interquartile range 10-25 years) and a mean BMI of 31.7 ± 6.7 kg/m2. The group that reused syringes and needles experienced an increase in lipohypertrophy/nodules (0.16 ± 0.08, P = 0.040) but did not experience worsening pain or glycemic control, even when the syringes and needles were inserted into the skin with great effort. There was no difference in the total number of skin complications, quality of life, or microbiological contamination. Both groups improved treatment adherence, with a greater increase in the reuse group.

CONCLUSIONS

The reuse of syringes and needles is associated with a modest increase in lipohypertrophy/nodules but does not have a short-term impact on glycemic control in patients with type 2 diabetes.

Expert Opinion on Addressing the Gap in Injection Technique and Needle Reuse for People with Diabetes in Indonesia

The use of insulin for patients with diabetes mellitus in Indonesia appears to be under expectation; moreover, there are gaps in knowledge regarding the proper injection technique and pen needle reuse by both healthcare professionals (HCPs) and patients. To address these issues, a scientific expert meeting was held with the participation of endocrinologists and public health specialist from many different organizations in Indonesia to identify the challenges and problem related to injection technique, high pen needle reuse rate, and the need of all stakeholders. The experts agreed that it is necessary to ensure physicians to start the initiation phase as early as indicated, continue optimizing its dosage to reach targeted blood sugar based on guideline, and involve all relevant stakeholders to improve insulin distribution and patient access in every primary care facility in order to optimize the use of insulin or other injectable diabetes medications in Indonesia. Additionally, the experts believed that education on proper injection technique and improved reuse rate of pen needle is necessary. To date, Indonesian Diabetes Educators Association (IDEA/PEDI) has established guideline on injection technique. There are also recommendations on injection technique and needle reuse from Indonesian Society of Endocrinology (PERKENI) and Forum for Injection Technique & Therapy: Expert Recommendations (FITTER); however, this guideline/recommendation should be disseminated more widely among HCPs. In addition, cost-effectiveness studies based on local data are needed to propose and convince the Payors and other stakeholders. This article can be used as a guidance for HCPs and policymakers to improve current practice on injection technique, pen needle reuse, needle prescription and reimbursement policy in Indonesia and elsewhere.