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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 23-30

Family functionality, medication adherence, and blood glucose control among ambulatory type 2 diabetic patients in a primary care clinic in Nigeria


1 Department of Family Medicine; Nutrition and Dietetics, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
3 Department of Nutrition and Dietetics, Federal Medical Centre, Umuahia, Abia State, Nigeria

Date of Web Publication1-Mar-2018

Correspondence Address:
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_29_17

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  Abstract 


BACKGROUND: Family functionality is a patient-oriented medical outcome of care that is emerging in scientific literature. It is a family-related factor that influences medication adherence and glycemic control, yet it is not easily recognized by clinicians.
AIM: The study was aimed at determining the role of family functionality on medication adherence and glycemic control among ambulatory type 2 diabetic patients in a primary care clinic in Nigerian.
MATERIALS AND METHODS: A clinic-based descriptive study was carried out on 120 type 2 diabetic Nigerians who were on treatment for at least 3 months at the primary care clinic in Nigeria. Family functionality and medication adherence were assessed in the previous 3 months and 1 month preceding the study using General Functioning Subscale of the Family Assessment Device and interviewer-administered questionnaire on self-reported adherence to therapy, respectively. Glycemic control was assessed in the previous 1 month.
RESULTS: The age of the study participants ranged from 27 to 81 years and there were 37.5% males and 62.5% females. Healthy family function, medication adherence, and glycemic control rates were 90.8%, 72.5%, and 61.7%, respectively. Family functionality was significantly associated with household family (P = 0.048), medication adherence (P = 0.031), and glycemic control (P = 0.022). The most significant demographic predictor of family functionality was household family (odds ratio = 5.19 (3.31–7.01); P = 0.029). The type 2 diabetic patients in household families were five times more likely to have functional families compared to their counterparts who were from nonhousehold families.
CONCLUSION: Family functionality was significantly associated with household family, medication adherence, and glycemic control. Assessment of family functionality should be part of reason for encounter during consultation with diabetic patients in order to unravel family factors that can positively or negatively influence medication adherence and glycemic control.

Keywords: Adult Nigerians, family functionality, glycemic control, medication adherence, primary care


How to cite this article:
Iloh GU, Collins PI, Amadi AN. Family functionality, medication adherence, and blood glucose control among ambulatory type 2 diabetic patients in a primary care clinic in Nigeria. Int J Health Allied Sci 2018;7:23-30

How to cite this URL:
Iloh GU, Collins PI, Amadi AN. Family functionality, medication adherence, and blood glucose control among ambulatory type 2 diabetic patients in a primary care clinic in Nigeria. Int J Health Allied Sci [serial online] 2018 [cited 2018 Sep 19];7:23-30. Available from: http://www.ijhas.in/text.asp?2018/7/1/23/226257




  Introduction Top


Diabetes mellitus is one of the ancient diseases known to humans.[1] It is a lifelong health condition that requires self-care and affects the functional status, well-being, and wellness of the victims and impacts significantly on their health-related quality of life.[2],[3] As a chronic metabolic disease requiring complex care, optimal care of diabetes entails functioning family system involving family members, friends, and significant others.[4],[5]

The burden of diabetes mellitus has been reported to vary between different populations and is relentlessly increasing globally affecting economically affluent nations and gradually creeping and afflicting developing nations such as Nigeria.[1],[2],[3] Globally, 415 million (1 in 11) adults have diabetes mellitus and by 2040 the burden will rise to 642 million (1 in 10).[3] In Africa, 14.2 million adults are living with diabetes mellitus while Nigeria has 1.6 million.[3] In 2013, an estimated 382 million adults had diabetes mellitus with predicted rise to 592 million in 2035 compared to the world prevalence of 366 million in 2011 and predicted increase to 540 million in 2035 with predilection for developing countries.[3]

Humans are social beings whose health is strongly influenced by socio-family environmental factors, especially family interactions, communication, relationships, and functionality.[6],[7],[8] Family has long been recognized as a natural unit of care in the society and its dynamism facilitates care process such as medication adherence among diabetic patients.[9],[10],[11],[12] Family is defined in the context of the index patient as a group of individuals connected to a patient biologically, legally, or by choice from whom the patient reasonably expects a measure of support in the form of food, shelter, finance, and emotional nurturing, sharing a past, a present, and a future including all who contribute to the family culture.[13] Research studies have demonstrated that diabetes mellitus is a family disease [3],[4],[10],[12],[14] and that the health problems of the family are interlocking. In order to achieve positive effects of the family on diabetic care outcome, the family should be functional in meeting the demands of care for diabetic family members.[15],[16] Numerous family factors have been reported to influence the management of diabetes mellitus in ambulatory settings.[4],[5],[9],[10],[12],[15],[17] Among these factors is the level of family functioning. Family function is conceptually defined as the perception of behavior of family members in relation to day-to-day diabetes care decisions and their psycho-physical interactions.[15] Family function is, therefore, directly associated with the degree to which diabetic patient perceives how his or her needs in daily diabetic care are fulfilled by family members and is linked with cognitive-affective evaluation and physical interactions to the components of care services such as medication adherence and glycemic control.[5],[18],[19] There is clinical and epidemiological evidence that family function can have either beneficial or harmful effects on diabetic outcome, and socio-physical climate of the family has been linked with medication adherence and blood glucose control.[4],[5],[9],[15],[16],[19]

Several tools have been designed for the evaluation of family function at the point of care, with each of the tool having varying degrees of complexities and psychometric properties.[8],[20],[21],[22] Different scales have been used across and within various global populations and the perceived family functionality focused on peculiarities that characterized interpersonal interactions, relationships, and communication. There exist McMaster Model of Family Functioning (MMFF)-Family Assessment Device (FAD);[20] Global Assessment of Relational Functioning;[21] Family Adaptability and Cohesion Evaluation Scale;[8] Family APGAR;[22] Family Functioning Index;[8] Family Functioning Questionnaire;[8] and Family Environment Scale.[8]

Globally, family functionality is a family health issue that is increasingly been recognized because of its association with a wide range of diabetic treatment outcomes.[11],[12],[15],[17],[18],[23],[24],[25],[26] In Nigeria, Africa, there is a dearth of research on the role of family functioning on medication adherence and glycemic control among diabetic patients. Evaluation of the gap in the knowledge on family functioning of diabetic Nigerians is quintessential in unraveling the effects of healthy and unhealthy family functioning on medication adherence and glycemic control. It is based on this premise that the authors were motivated to determine the role of family functioning on medication adherence and blood glucose control among ambulatory type 2 diabetic Nigerians in a primary care clinic situated in a resource-constrained environment of Nigeria.


  Materials and Methods Top


This was a clinic-based descriptive study conducted on 120 adult type 2 diabetic Nigerians from April 2011 to December 2011 at a primary care clinic in Nigeria.

The study was carried out in a federal tertiary hospital in Nigeria located in a metropolitan capital city of a state in South-East Nigeria. The state is endowed with luxuriant agricultural and mineral resources with a supply of professional, skilled, semi-skilled, and unskilled workforce. Until recently, the capital city has witnessed an upsurge in the number of hotels, junk food restaurants and eateries, banks, markets, schools, and industries, in addition to the changing demographic geography and nutritional and social lifestyles.

The department of family medicine serves as a primary care clinic within the tertiary hospital setting of the hospital. All adult patients excluding those who need emergency health-care services, pediatric patients, and antenatal women are first seen at the department of family medicine where diagnoses are made. Patients who need primary care are managed and followed up in the clinic while those who need other specialists care are referred to the respective core specialist clinics for further management.

The inclusion criteria were adult diabetic Nigerians aged ≥18 years who gave informed consent, had been on outpatient treatment for diabetes mellitus for at least 3 months in the family medicine clinic, and had recorded at least two clinic visits (recruitment visit and end of study visit). This was to ensure that the study population was familiar with prescribed oral hypoglycemic medications. The exclusion criteria included critically ill patients, diabetic patients living alone, and diabetic patients who were on insulin therapy.

Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies [27] using the following formula: n = Z2pq/d2 and nf = n/1 + n/N where n = desired sample size when population is more than 10,000; nf = desired sample size when population is <10,000; Z = standard normal deviate set at 1.96 which corresponds to 95% confidence limit; P = authors assumed that 50% (0.50) would have functional family, adhered to medication, and have controlled blood glucose; and d = desired level of precision set at 0.05. The following finite population correction formula nf = n/1 + n/N was employed for studying population <10,000 using an estimated population size of 170 adult diabetic patients based on the previous 9 months' diabetic patients' attendance records at the family medicine clinic. Among these 170 adult diabetic patients, other diabetic patients referred to and being followed up in diabetic clinic and other outpatient clinics of the medical center were excluded. This gave a sample estimate of 117 patients. However, the selected sample of 120 diabetic patients was used for the study.

The eligible patients for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 120 was achieved.

The study tool consisted of sections on sociodemographic data, information on medication adherence, blood glucose control, and family functionality.

Medication adherence was assessed by the use of a pretested, interviewer-administered questionnaire on 30 days' self-administered and reported therapy.[28] Patients were seen at the recruitment visit and at the end of the study visit. At the end of the study visit, the adherence section of the data collection tool was administered. The information collected at the end of the study visit included the following: (i) How many times per day do you take your blood glucose medication?, (ii) How many tablets do you take specific to your diabetic condition?, (iii) How often do you take your blood glucose medication (all times, most of the times, sometimes, rarely, and never), (iv) How many dose(s) of your antidiabetic drugs have you missed in the previous 1 month?, and (v) How many of your previous blood glucose medications are remaining after the previous 1 month visit? Adherence was graded using an ordinal scoring system of 0–4 points developed by the authors from the review of literature [28],[29],[30],[31],[32] as follows: all times = 4 points, most of the times = 3 points, sometimes = 2 points, rarely = 1 point, and never = 0 point.

Family functionality was assessed in the previous 3 months using a 12-item General Functional subscale of MMFF-FAD.[20] The 12-item questionnaire tool consists of six positively worded items and six negatively worded items. Each item is scored on a 4-point Likert scale (1–4) as follows: strongly agree = 1; agree = 2; disagree = 3; and strongly disagree = 4. Higher scores indicate worse levels of family functioning or problematic functioning. The final score was obtained by summing up the item scores and then divided by 12. In General Functioning subscale, the final score of ≤2.0 means healthy family functioning while a score of >2.0 indicates unhealthy family functioning.

Pretesting of the family function tool and medication adherence section of the study instrument was done at the family medicine clinic of the hospital. Five diabetic patients were haphazardly used for the pretesting of the family function tool and Medication Adherence Questionnaire which lasted for 1 day. The pretesting was done to assess the applicability of the questionnaire tools. All the patients used for the pretesting of the questionnaire instrument gave valid and reliable responses, confirming the clarity and applicability of the questionnaire tools, and the questions were interpreted with the same meaning as intended. The questionnaire was administered by the principal author and two resident medical doctors who were trained and recruited for the study.

The baseline fasting blood glucose was recorded at the time of recruitment for each patient (recruitment visit) and subsequently at the end of the study visit.[28]

An adherent patient was defined as one who had a score of 4 points (took all the prescribed doses of antidiabetic medication(s) all times) in the previous 30 days by the end of the study visit while those who scored 0–3 points and missed a day dose of antidiabetic medications means nonadherence.[28] A patient was defined to have goal blood glucose control if his or her fasting blood glucose at the end of the study visit was between 70 and 130 mg/dL.[28] Family functionality referred to the perception of behavior of family members in relation to day-to-day diabetic care decisions and their physical and psychological interactions. Household family referred to a number of persons eating from the same pot.[13]

The ethical clearance was obtained from the ethics committee of the hospital. Informed written consent was also obtained from the patients.

The results generated were analyzed using software Statistical Package for the Social Sciences version 13.0 (SPSS, Inc., Chicago, IL, USA) for the calculation of percentages for categorical variables. Bivariate Chi-square analysis was used to test for the significance of associations between categorical variables. Logistic regression analyses were performed where appropriate. In logistic regression analysis, the dependent (outcome) variable was the family function score and the independent variables were age, sex, marital status, types of marriage, family size, household family structure, medication adherence, and blood glucose control. In all cases, P < 0.05 was considered statistically significant. Odds ratio (OR), which is an indicator of degree of association of family function with a predictor demographic variable, was estimated at 95% confidence limit.


  Results Top


The age of the study participants ranged from 27 years to 81 years, with a mean age of 36.8 ± 5.4 years. There were 45 (37.5%) males and 75 (62.5%) females, with male-to-female ratio of 1:1.7. Other demographic characteristics of the study participants are shown in [Table 1].
Table 1: Demographic profile of the study participants

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[Table 2] shows that of the 120 diabetic patients who participated in the study, 109 (90.8%) had functional (healthy) family while 11 (9.2%) had dysfunctional (unhealthy) family functioning. On adherence to antidiabetic medications, 87 (72.5%) diabetic patients were adherent to medications while 33 (27.5%) of them were not adherent to medications, while on blood glucose control, 74 (61.7%) diabetic patients had their blood glucose controlled while 46 (38.3%) of them were uncontrolled.
Table 2: Family functionality, medication adherence, and glycemic control among the study participants

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[Table 3] shows that of the 120 diabetic patients, 82 (94.3%) of them who had functional (healthy) family functioning were adherent to antidiabetic medications while 5 (5.7%) of them who had dysfunctional (unhealthy) family were adherent to medications. The difference was statistically significant (χ2 = 9.304; P = 0.031). Similarly, of the 120 diabetic patients, 70 (94.6%) of them who had functional (healthy) family functioning had controlled blood glucose while 4 (5.4%) of them who had dysfunctional (unhealthy) family had controlled blood glucose. The difference was statistically significant (χ2 = 12.633; P = 0.022).
Table 3: Association between family functionality and medication adherence and family functionality and blood glucose control among the study participants

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Of the 120 diabetic patients who participated in the study, 101 (92.7%) of the study patients from household family had functional (healthy) family functioning while eight (7.3%) of them from nonhousehold family had functional (healthy) family functioning. Bivariate Chi-square analysis of the demographic variables as related to family functionality showed that household family structure was statistically significant (χ2 = 7.02; P = 0.048) while other demographic factors were not statistically significant [Table 4].
Table 4: Association between demographic variables and family functionality of the study participants

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On logistic regression analysis of demographic factors as related to family functionality, household family (OR = 5.19 [3.31–7.01]; P = 0.029), medication adherence (OR = 3.62 [2.77–5.31]; P = 0.041), and controlled blood glucose (OR = 2.01 [1.95–3.09]; P = 0.038) were statistically significant while other variables were not statistically significant [Table 5]. The most significant demographic predictor of family functionality was household family. A significantly higher proportion of type 2 diabetic patients from household family (92.7%) had functional family compared to their counterparts from nonhousehold family (7.3%). The type 2 diabetic patients in household family were five times more likely to have functional family compared to their counterparts who were from nonhousehold family (OR = 5.19 [3.31–7.01]; P = 0.029).
Table 5: Logistic regression analysis of demographic variables, medication adherence, and glycemic control as related to family functionality

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  Discussion Top


One hundred and nine (90.8%) study participants had healthy family functioning and family functioning was significantly associated with medication adherence and blood glucose control. Although not every patient with healthy family function adhered to medication with good glycemic control, their chances are higher when compared with those with unhealthy family function. The finding of this study is in consonance with the reports that healthy family functioning has beneficial effects on the care of diabetic patients while unhealthy family function has adverse effects on diabetic care and could affect adherence to medication, glycemic control, and other diverse diabetic care.[5],[9],[10],[11],[12],[15],[19],[24] Although evaluation of family functioning among diabetic patients is easy to be done in clinical practice, identification of potentially modifiable risk factors that are associated with dysfunctional family among the diabetic patients is of high clinical value during physician–patient encounter.[4],[5],[18],[17] The implication of this finding is that physicians attending to diabetic patients with dysfunctional family may attribute lack of response to prescribed antidiabetic medications as therapeutic failure when it is rather due to the absence of healthy family functioning. Absence of healthy family functioning for diabetic care can be used as a surrogate predictor of how well a diabetic patient would be able to cope with his or her disease and maintain long-term health and wellness states. Family functionality in the care of diabetic patients is therefore a suitable, innovative, and therapeutic tool in ambulatory care that provides appropriate psychosocial support necessary for improvement on medication adherence and blood glucose control.[23] The family members of the diabetic family should therefore be made aware of this subtlety and made to actively participate in the care of diabetic family member, especially in resource-poor environment where there are limited options for optimal diabetic care and healthy living.

Family functioning was significantly associated with household family structure. Diabetic patients from household family have higher family functioning when compared with those from nonhousehold family. The higher family functioning among the diabetic patients from household family in this study could be a reflection of socio-centric type of family structure which is functional and predominant in Nigeria in which the family forms the epicenter of care activities and social support for diabetic patients.[2],[10],[13],[14],[33],[34] This is in contrast to egocentric family which is more common in Westernized societies.[13] In Nigeria, a majority of diabetic patients live in household families and maintain traditional ties and roles. However, while it is likely that this traditional socio-centric family structure in Nigeria will prevail in the near future, there are visible signs of changes. More so, functional family discussion, particularly that between the diabetic persons and other members of the household, is critically important in ensuring optimal diabetic care, particularly adherence to medication.[2],[10],[14],[33] Physicians attending to diabetic patients should recognize the relevance of family functioning as an effective channel to improve medication adherence and blood glucose control. By exploring the functionality in the family unit, clinicians are likely to fulfill the patients' obligations in attainment of blood glucose control to the recommended goal. Having a household member with diabetes can also provide opportunity for healthy behavior in nondiabetic household members and will address lack of knowledge on diabetic care.

This study has showcased that healthy family functioning was significantly associated with medication adherence. Adherent patients had lower family function scores than nonadherent patients, thus corroborating the reports that enhancing family function among diabetic patients could improve medication adherence.[9],[12],[15],[19],[24] Unhealthy family functioning could lead to diminished self-care activities such as medication nonadherence.[4],[5] It is, therefore, not enough to prescribe antidiabetic medications during clinical encounter with diabetic patients, but regular evaluation of family functioning should be a component of standard care for diabetic patients. Diabetic patients with family dysfunction should be offered appropriate family-oriented interventions to improve family functionality.

This study has shown the association between family functioning and blood glucose control. The finding of this study is in consonance with the reports that diabetic patients who have healthy family functioning have controlled blood glucose when compared with those with unhealthy family functioning.[4],[5],[9],[10],[11],[12],[15],[19],[24] Healthy family functioning therefore impacts on goal blood glucose control resulting in substantial improvement in diabetes health-related quality of life. Being aware of this determinant of glycemic control and evaluating them during subsequent diabetic patient visits can affect the quality of care delivered to these diabetic patients. This study therefore provides an evidence of the growing issue of the role of family functionality on glycemic control as part of the search for an effective intervention to enhance blood glucose control. This study beckons for holistic care of diabetic patients with relative relevance given to family functionality through strengthening of the family functioning. A functional family not only facilitates glycemic control, but also contributes to the maintenance of family stability and homeostasis in illness, disease, and healthy states.[6],[23]

Study implications

Diabetes mellitus is a multidimensional disease that has implications for family and community health. Diabetic patients with dysfunctional family system are often encountered in primary care settings in the study area, and family dynamics is an integral component of factors that maintain optimum health in the management of diabetes mellitus, especially in ambulatory care environment. Regular evaluation of family function can provide the clinician with additional information on diabetic patients at risk of nonadherence to medication and poor glycemic control. It is therefore relevant to determine the role of family functionality on medication adherence and blood glucose control.

Study limitations

The study has some limitations. First and foremost, the sample for the study was drawn from family medicine clinic of the hospital. Hence, the findings of this study may not be general conclusions regarding diabetic patients attending medical outpatient clinics of the department of internal medicine of the hospital. Second, the limitations of using fasting plasma glucose to assess glycemic control are also recognized by the authors. Admittedly, fasting plasma glucose is predictive of acute glycemia and day-to-day variability of blood glucose and contributes to chronic glycemia. However, local Nigerian studies [28],[35] have shown strong, significant positive correlations of HbA1c and fasting plasma glucose among Nigerian diabetics, implying that fasting plasma glucose could be a good useful surrogate marker for glycemic control. However, this study gave some useful insights into the magnitude of the glycemic control among the study population. Furthermore, the limitations imposed by the self-reported measure of adherence and family functionality for the study are recognized by the authors. Despite these limitations, the study provides valuable data that have relevant implications for family-oriented diabetic care.


  Conclusion Top


Family functionality was comparatively high and significantly associated with household family, medication adherence, and glycemic control. Assessment of family functionality should be part of reason for encounter during clinical consultation with diabetic patients in order to unravel positive and negative family factors that can influence optimal care of diabetes in the family.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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