Anuradhapura Teaching Hospital: Diabetes Mellitus Compliance Study

This report presents a study on knowledge related to poor compliance for Diabetes Mellitus (DM) among patients with Type 2 diabetes mellitus at Anuradhapura Teaching Hospital. The research aims to determine the level of knowledge regarding diabetes diet, drug regimens, and exercises among these patients. The introduction highlights the global prevalence of diabetes, the importance of self-management, and the challenges of non-compliance with treatment. Background information emphasizes the impact of poor knowledge and awareness on self-management behaviors and outcomes. The study's justification underscores the need for assessing knowledge gaps to improve diabetes care and prevent complications. The literature review synthesizes findings from various studies, revealing the influence of knowledge on compliance with medication, exercise, and dietary control. The review also identifies barriers to compliance, such as environmental factors and lack of awareness about diabetes and its complications. The report concludes by emphasizing the significance of diabetes self-management education and its potential to improve patient outcomes. The study seeks to contribute to the understanding of poor compliance and provide a basis for future research in Sri Lanka, ultimately benefiting patients, their families, and the community.

1. Introduction
Diabetes mellitus is a complex, chronic non- communicable disease, which is becoming a
rapidly escalating epidemic in the developing and developed countries throughout the world,
due to the increasing prevalence of obesity and growing older population(Gunathilake et,al
2017).A high prevalence of diabetes and its microvascular and macrovascular complications constitute a
significant burden on healthcare systems. Self-management through patient education contributes to
reduce the burden of uncontrolled diabetes (Cooray et,al. 2017 ). This has become a major problem in
low and middle socioeconomic countries where it has a significant influence on productivity and the
overall economic output that leads to a considerable burden on health care and welfare system (Cooray
et,al 2017). Problems associated with DM can be minimized by early diagnosis and proper management.
The primary aim of management of DM is to delay the macro and microvascular complications by
achieving optimal glycemic control. This involves lifestyle modification, including regular exercise,
healthy diet and weight loss, and drug therapy (Herath et,al 2017 ). According to the World Health
Organization, non-compliance with long-term medication for chronic illnesses like diabetes is a
common problem that leads to compromised health benefits and serious economic consequences
in terms of wasted time, money and uncured disease ( Bartels D. 2004).
Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a
healthy diet and exercise regimen, followed by early medication that generally includes one or
more oral hypoglycemic agents and later may include an injectable treatment. To prevent the
complications associated with type 2 diabetes, therapy frequently also includes medications for
control of blood pressure, dyslipidemia and other disorders, since patients often have more than
three or four chronic conditions (Luis-Emilio García-Pérez 2013 )As a result, hyperglycemia and

long-term complications increase morbidity and premature mortality, and lead to increased costs
to health services.( Luis-Emilio García-Pérez 2013) Diabetes requires constant attention to diet,
exercise, glucose monitoring, and medication to achieve good glycemic control. Self-
management and proper compliance for treatment regimen is highlighted recently in the long-
term management of diabetes (Gunathilake et,al 2017)
Background
Diabetes mellitus (DM) is a leading cause of death in industrialized and developing
countries. Alsairafi Z.K,et.al .2016). Bailey C.J. said that, in 2011, all studies done in UK,
affirm that, a significant proportion of type 2 diabetes patients exhibit poor compliance that will
contribute to less than desired control. A Study was done in Chennai in 2007, shows that
knowledge of complication was poor among diabetic population. In Egypt, health awareness of
patients with diabetes is an important determinant of health behavior, and the study has found
that a majority of diabetic patients (90.0%) had poor knowledge about the disease, 83.7% had
poor knowledge about the complications associated with diabetes and 96.3% had poor awareness
of how to control the disease. (Kamel NM, et. Al) The Iraqi diabetic patients have inadequate
self-management behaviors. Diabetes self-management behaviors are necessary to ensure
optimum glycemic control, but the main barrier to self-management practices was the lack of
knowledge. Mikhae E. M.et. al,2018).
Knowledge and lack of health awareness about the proper management of the disease, and its
seriousness, were reported in several Middle East countries. For example, one study in Libia,
reported that patients had poor knowledge about the effects of diabetes on the eye and kidney.
(Roaeid R.B, 2007). According to Basker J., et.al , 1n 2016, poor adherence in diabetic patients

have been educational; with the presupposition that knowledge in south Asia. Malaysian
Diabetes patients knowledge regarding diabetes might affect patients’ compliance to their
treatment regimen.(Harith K.H.et al., 2011) According to world health organization, the
compliance to long-term therapy for chronic illnesses in developed countries averages 50% in
2003. In developing countries, the rates are even lower. It is undeniable that many patients
experience difficulty in following treatment recommendations. Patient dissatisfaction is a major
factor contributing to medicine misuse and non- adherence (World Health Organization, 2003.)
Diabetes mellitus (DM) is a rapidly growing health concern in Sri Lanka. Despite
understanding the importance of dietary control and physical activity in the management of
diabetes, adherence to practices were poor, mainly due to lack of clarity of information
provided(Ranasinghe P. et al.2015) The majority of patients with diabetes can significantly
reduce the chances of developing long-term complications by improving self-care activities.
Despite this fact, compliance or adherence to these activities has been found to be low, in both
India and Sri Lanka (Shrivastava S.R.B.L.et al.2013). Most of the vascular complications can be
prevented with good glycaemic control and to achieve this, compliance to medication is
essential. Similar to most of the other chronic diseases, drug compliance has been poor among
patients with diabetes. (Gunathilake G. et al.2017) Despite having good health care fascilties,
awareness and knowledge of diabetes mellitus are inadequate among patient of Colombo suburb
Jayawickrama W., Perera K 2016)
According to Herath H.M.M.in ,2017even though the majority (77%) had moderate or above
moderate knowledge on diabetes in southern province, their attitudes towards diabetes was poor
(88%). It appears that the higher knowledge on diabetes did not translate into good practices as
over 50% of study subjects did not involve with any preventive measures. Patients’ knowledge

about their illness is considered important in controlling diabetes and preventing complications.
Although overall knowledge about diabetes among our patients was adequate there were critical
gaps in knowledge. In particular, knowledge about the management of diabetes and diabetic
complications was poor. (D.P. Perera,1 R.E.E. De Silva, W.L.S.P. Perera,2013)
Justification and significant
Diabetes self-management education is a cornerstone of diabetes care. The management of
diabetes mellitus (DM) largely depends on patients' ability to self-care in their daily lives, and
therefore, patient education is always considered an essential element of DM management.
Studies have consistently shown that improved glycemic control reduces the rate of
complications and evidence suggests that (Shrivastava et al., 2015). Improvement of the disease
awareness is the key to reduce the disease burden by early diagnosis and appropriate treatment
and effective management of diabetes that will minimize disease related complications of these
patients ( Rowley W.R et al., 2012). (Islam et al., 2015). Even though knowledge with regard to
risk factors of type-2 diabetes mellitus was observed to be better among the patients, they were
significantly lagging in terms of self-care practices in the same domains.(Katulanda et al., 2011)
Many studies reported that patients had poor knowledge about the effects of diabetes on the
eye and kidney. It has been found that patients lack the awareness about the symptoms of
hypoglycemia and its treatment. Self-monitoring of blood glucose levels and responding to hypo-
and hyperglycemic episodes are an integral part of the management of diabetes by insulin. Only
a small proportion of patients have been found regularly to monitor their blood glucose levels.
Reasons included not understanding its importance, not knowing how to do it, or lacking the
desire to do so(Elliott et al.) (Alsairafi et al., 2014). Assessment of the level of knowledge on
diabetes among persons with diabetes can assist in targeting public health efforts to reduce

diabetes related complications (Gil &Amp; Jacob, 2010) .
In Sri Lanka, even though the majority of patients had some knowledge on diabetes, that
knowledge on diabetes did not translate into good practices as over 50% of them did not involve
with any preventive measures(Herath et al.,2017).However there are lack of literature to show
the proper compliance to diabetes management in Sri Lanka. Thus it is important to assess the
knowledge regarding poor compliance for diabetes treatment regimen. This study will help to
enhance the knowledge of patients related to poor compliance specifically, and ultimate benefit
will go to the their family and the community. And also the study will be a basic literature for
future researches in Sri Lanka,
1.4 Problem statement
Knowledge related to poor compliance for Diabetes Mellitus (DM), among patients with
Type 2 diabetes mellitus at Anuradhapura Teaching Hospital.
1.5Purpose of the study
To determine the knowledge related to poor compliance for Diabetes Mellitus (DM), among
patients with Type 2 diabetes mellitus at Anuradhapura Teaching Hospital.
1.To identify the level of knowledge regarding diabetes diet, among type 2 DM patients.
2.To identify the level of knowledge regarding drugs among type 2 DM patients.
3. To assess the knowledge of and exercises among type 2 DM patients.
2.Literature review
Literature review is an account of what has been published on a topic by accredited scholars
and researchers. More often it is a part of the introduction to an essay, research report, or thesis.

(Taylor, 2017 p.1). It presents the theoretical framework for the study. In writing the literature
review, the purpose is to convey to the reader what knowledge and ideas have been established
on a topic (Ingrid, 2008 p.8)
Several research studies contribute to explore the knowledge of Diabetes Mellitus among
patients with Diabetes Mellitus and in here we are discussing the research articles for finding the
patients’ compliance for the diet, treatment regimen, and exercises.
When considering about the global situation, a study done by Memon A R et.al in Saudi
Arabia in 2015 has identified that patients’ awareness towards their disease and medication is
directly proportional to patients’ compliance to medication, exercise and dietary control, which
in turn are crucial for the management of diabetes and prevention of its long term complications.
These finding strongly suggest that awareness programs towards disease and medication for
diabetic patients should be adequately arranged for better management of diabetes in the
community. Furthermore, a study done in South Africa in 2001 by Gladys Nthangeni et.al
revealed that the majority of black, type 2 diabetic patients studied showed poor glycemic
control. Additionally, many had dyslipidemia, were obese and/or had an elevated blood pressure.
Although it is difficult to determine the extent to which dietary compliance contributed to this,
the factors were identified as contributors are lack of knowledge regarding the disease;
inadequate and inaccurate dietary counseling; and poor compliance with dietary advice given.
According to a pilot study done by Siti Maisharah and Mohd Baidi Bahari in Malasia in 2009
it showed that in the sense of exercise, more than half of patients with diabetes mellitus had
exercised for less than 3 times per week, as recommended, and claimed that they were not active
in exercising. Patients’ belief and knowledge towards exercising were not the possible barriers to

exercise compliance. This can be explained as patient had the right belief and adequate
knowledge regarding exercise requirements for them. The barriers to exercise compliance as
determined in this study were the environmental factors, such as time constraint to exercise or
having not enough time to exercise, busy with daily works, as well as no companion to exercise.
Other barriers such as laziness to exercise, poor health condition, and tired were also reported in
this pilot study. They also conducted another pilot study in 2011 in the same setting to identify
the pattern of diet in diabetic patients, and to determine the possible barriers influencing
compliance towards diet, and recognized that in term of the barriers to comply with dietary
intake recommendation, belief and knowledge of dietary intake were not the possible barriers, as
patient had the right belief and knowledge regarding dietary intake. Environmental factors as
festivals, ceremonies and social gathering also reported to be a barrier influencing diet
compliance in diabetic patients.
According to the cross sectional study of Tewahido et.al.(2017) the importance of proper
self-care practices for effective management of diabetes is not adequately emphasized in diabetes
care centers and patients lack sufficient knowledge for proper self-care. Furthermore Seid et.al
(2015) said, according to their cross sectional quantitative study on knowledge, practice and
barriers of foot care among diabetic patients in Ethiopia, the knowledge of them is average in
both diabetic & non diabetic people specially in middle age where as Zeyana S.et al said in 2013,
by their cross sectional study in Oman, have identified that Omani Patients seemed aware and,
displayed satisfactory diabetic knowledge except adherence to regular exercises.
Several studies have been done to explore whether there is enough knowledge and
compliance for diabetes mellitus among both diabetic and non-diabetic persons. Especially in the
developing countries, various studies related to the knowledge, attitude and practice of diabetes

mellitus Type 2 were conducted to explore the specific knowledge on diabetic self-management.
By assessing with the prospective & observational study related to knowledge, additive &
practice among diabetic & non diabetic in India in this Year, Konduru S.S.T. et al say that
diabetic patients have more knowledge regarding diabetic mellitus than non-diabetic subjects.
The same thing has found in 2015 by Mumunkoley et al with their Quantitative cross sectional
study in India.
Another study was done in Pakistan in 2016 by Saeed Ur et.al regarding diabetes related
knowledge, medication adherence and glycemic control of patients with type 2 diabetes.
According to that cross sectional quantitative study, they concluded as there was a negative
association between treatment adherence and diabetes related knowledge. By doing another
quantitative cross sectional study in 2015 Gautam et al., revealed a variation between diabetes
related health knowledge, attitude and practice of patients in Napol. A cross sectional study was
done in Hong Kong in 1999 with a 52 participants of non-insulin dependent diabetes mellitus; a
convenient sample by Chan, et al., to explore the relationship between diabetes knowledge and
compliance among Chinese, they found that there was no association between them and there is a
gap between with the patients were taught and what they were actually doing.
Sriwastava in 2014 said in his cross sectional descriptive quantitative study that conducted to
assess the knowledge and self- care practice, type 2 diabetes patients in Thamilnadu, even though
the knowledge regarding diabetes was better among patients, they were significantly lagging in
terms of self- care practice in some domains.A descriptive study was conducted among patients
with type 2 diabetes in India by Santhanakrishnan et al.(2014) found that the compliance to
pharmacological treatment was 76% and was significantly associated with literacy level of the

patients, but the compliance to physical activity, foot care, annual eye and renal check-up was
low .
When considering the Sri Lankan situation, some research studies give contribution as
guidance for the purposes of this study. In 2013, a cross sectional descriptive study has done by
Perera, et al., with patients attending a primary health care setting in Moratuwa to assess the
knowledge among type 2 diabetes patients and they found that although patients had higher
knowledge, they had higher fasting blood glucose level.According to a study done by
Gunathilake G et al, non-compliance to anti-diabetic medications is high among patients with
diabetes in Sri Lanka reaching to an epidemic nature and sincere effort must be given to identify
the barriers in individual settings and find remedies in order to face this enormous burden of
diabetes in the future. A study was done by Herath, et al., in Galle district to assess the
knowledge, attitude and practice related to diabetes mellitus among the general public recently in
2017. With this quantitative cross sectional study, they found that even though the majority had
moderate or above moderate knowledge on diabetes, there attitude towards diabetes was poor or
they did not translate it in to good practices.
Gunathilake et. al (2017), according to their cross-sectional study said that non-compliance to
anti-diabetic medications is high among patients with diabetes in Sri Lanka. Ranasinghe et al., in
2015 said in their qualitative study that despite understanding the importance of dietary control
and physical activity in the management of diabetes, adherence to practices were poor, mainly
due to lack of clarity of information provided. There were many myths with regard to diet, some
of which have originated from health care professionals.The majority of studies investigating the
relationship between compliance and outcome found that compliance had a positive effect on
outcome. Further research into the problem of poor compliance with cardiovascular and

antidiabetic medication is warranted to increase the number of published studies in this area and
to increase awareness of the problem. By increasing awareness, it may be possible to improve
patient compliance. The availability of different targeted interventions, including behavioural
training and electronic devices designed specifically to improve patient compliance, may also
contribute to improved compliance and persistence, and hence to improved clinical outcomes
(Cramer J. A.et al.,2005).
With the consideration of the overall literature, it can be concluded as most of patients with
Type 2 diabetes have general knowledge but their compliance towards diet, treatment regimen
and exercise is poor not only in Sri Lanka and other regional countries, but also all over the
world. Hence there is a gap of the knowledge related to the compliance.