Adherence To Diabetes Mellitus Treatments In Family Health Strategy Units^*

Adherencia Al Tratamiento De La Diabetes Mellitus En Unidades De Estrategia De La Salud De La Familia

Abstracts

This cross-sectional study aimed to analyze the adherence to drug and non-drug treatments in 17 Family Health Strategy units. A total of 423 patients with type 2 diabetes mellitus were selected through stratified random sampling in Family Health Strategy units of a city in the state of Minas Gerais, Brazil, in 2010. The results showed that the prevalence rate of adherence to drug therapy was higher than 60% in the 17 units investigated; in relation to physical activity, adherence was higher than 60% in 58.8% units; and for the diet plan, there was no adherence in 52.9% units. Therefore, we concluded that adherence to drug therapy in most units was high and the practice of physical activity was heterogeneous, and in relation to diet adherence, it was low in all units. We recommend strengthening of institutional guidelines and educational strategies, in line with SUS guidelines, so that, professionals may face the challenges imposed by the lack of adherence.



Diabetes mellitus
; Medication adherence
; Family health
; Health evaluation
; Primary Health Cared


Estudio transversal, cuyo objetivo fue analizar la adherencia al tratamiento farmacológico y no farmacológico en 17 unidades de Estrategia Salud de la Familia (ESF). Participaron 423 pacientes con diabetes mellitus tipo 2 seleccionados mediante muestreo aleatorio estratificado en unidades de ESF de un municipio de Minas Gerais en el año 2010. Los resultados mostraron que la tasa de prevalencia de la adherencia al tratamiento farmacológico fue superior a 60% en las 17 unidades investigadas; en relación a la actividad física, ésta fue superior a 60% en el 58,8% de las unidades; y para el plan de alimentación, no tuvo efecto en 52,9% de las unidades. Se concluye que: la adherencia al tratamiento farmacológico fue alta en la mayoría de las unidades, la práctica de actividad física fue heterogénea y la adherencia a la dieta fue baja en todas las unidades. Se recomienda el fortalecimiento de las normas institucionales y estrategias educativas en consonancia con las directrices del SUS para hacer frente a los desafíos impuestos por la falta de adherencia.

Diabetes mellitus
; Complimiento de la medicación
; Salud de la Familia
; Evaluación en salud
; Atención Primaria de Salud



Estudo transversal que teve como objetivo analisar a adesão ao tratamento medicamentoso e não medicamentoso em 17 unidades da Estratégia Saúde da Família (ESF). Participaram 423 pacientes com diabetes mellitus tipo 2 selecionados por meio de amostragem aleatória estratificada, nas unidades da ESF de um município do interior de Minas Gerais, em 2010. Os resultados mostraram que a adesão ao tratamento medicamentoso foi superior a 60% nas 17 unidades investigadas; em relação à atividade física foi superior a 60% em 58,8% das unidades; entretanto, para o plano alimentar, foi nula em 52,9% das unidades. Conclui-se que a adesão ao tratamento medicamentoso foi alta na maioria das unidades; a prática de atividade física foi heterogênea e, em relação ao plano alimentar foi baixa em todas as unidades. Recomenda-se o fortalecimento das diretrizes institucionais e estratégias educativas, em consonância com as diretrizes do SUS, para o enfrentamento dos desafios impostos pela falta de adesão.


Diabetes mellitus 
; Adesão à medicação 
; Saúde da família 
; Avaliação em saúde
; Atenção Primária à Saúde


Introduction

Adherence is defined as the measure to which a person’s behavior – taking medication, following a diet plan or adopting changes in lifestyle, meets the recommendations suggested by a health professional(¹).


In the control of diabetes mellitus (DM), the lack of adherence to treatment is a challenge often faced by the professionals of health institutions in clinical practice(²-³). Thus, intervention strategies aimed at minimizing this situation in diabetes care must be sought.


Factors involved in adherence include: accessibility and availability of drugs in health services, demographic data from users, acceptability of the medication, loss of sense of control over one’s body, friends and family attitudes, social isolation, relationship between user and health professional, therapeutic regimen, chronicity, absence of symptoms, time to diagnosis, knowledge and understanding of the disease and treatment(-¹⁰).


When considering the current policy of the Brazil’s Ministry of Health, from the Family Health Strategy (FHS), the conditions for the reorientation of health care model, replacing the traditional model of care were created.


Health actions implemented by Family Health teams have allowed increasing new relationships between health professionals, families and communities, guided by the establishment of connection and creating bonds of commitment and responsibility among health professionals and the public, which facilitates the identification and care of community health problems, such as lack of adherence to treatment in DM(¹¹). However, there is still lack of evaluation studies that allow us to know the outcomes self-related by the health care model in relation to the percentages of adherence to drug and non-drug treatments in the Family Health Units (FHS)(¹²).


Given these challenges, we ask: what is the adherence to drug and non-drug treatments to control diabetes in FHS units in a city in the state of Minas Gerais, Brazil?


Based on this, the present study aimed to identify adherence to drug and non-drug treatments in 17 FHS units from a city in Minas Gerais, Brazil. It is expected to contribute to the redirection of the actions implemented in diabetes care in the primary care network services.


Method

This is a quantitative, cross-sectional, descriptive, observational study conducted from February to December of 2010 in the city of Passos, Minas Gerais, Brazil. The study population consisted of 1,406 individuals with type 2 DM (T2DM) registered in 17 FHS units that corresponds to SUS (Unified Health System) network for Primary Care service in the referred city. It is worth noting that the FHS program coverage in the city is more than 70% of the total population, which justifies the choice of this population.


The study included patients aged over 18 years old, diagnosed with T2DM, with a drug therapy prescription to control the disease, cognitive and hearing abilities preserved, monitored to referred FHS. Women with gestational diabetes and patients who used insulin were excluded.


The sample was calculated using the formula for cross-sectional studies of infinite population, based on a conservative adherence prevalence of 50%, which allowed the best possible quantitative number of participants. The calculation of sample size resulted in 421 people with T2DM. When considering a possible loss of sample due to denials, hospitalizations, dropouts, misinformation and/or not availability, a 20% increase was made, totaling 505 individuals.


The sample was probabilistic, type random stratified, based on the percentage of people with T2DM who were registered in each of the 17 FHS. A total of 505 patients were selected, of whom 14 were not found at home, 12 refused to participate in the study, six have denied the diagnosis of T2DM, 25 were excluded because they used insulin, 11 have moved from their address, five did not use pharmacological therapy for T2DM, three had visual and hearing impairment and five died, totaling 82 (16.2%) sample loss. Thus, the sample consisted of 423 patients with T2DM, who met the inclusion criteria.


To collect data for the study, four instruments were used: 1) a questionnaire containing sociodemographic variables (gender, age, education and household income), clinical (time of diagnosis, comorbidities, chronic complications), metabolic control (Body Mass Index - BMI, waist circumference - WC, blood pressure - BP and laboratory tests); 2) Measure Treatment Adherence - MTA: instrument used to assess the patient’s behavior in relation to everyday use of prescription drugs, which consists of seven items on a Likert six-point scale from 1 (always) to 6 (never)(¹³); 3) Self-administered food-frequency questionnaire (FFQ) assesses consumption of ten food groups according to the number of times, and unit size consumed portions(¹⁴); and 4) International Physical Activity Questionnaire (IPAQ), short version: consisting of eight questions that assess the level of habitual physical activity, from information about the frequency and duration of physical activity, as well as the time spent in the sitting position(¹⁵).


Data collection was conducted by field researchers, previously selected and trained. Sociodemographic, clinical, MTA, FFQ and IPAQ were obtained through structured interviews conducted in patients’ homes. The average duration of each interview was 40 minutes. Data from BP, weight, height, WC and laboratory tests were collected in the 17 FHS units, after prior notice and guidance on fasting. To obtain the values of BP, weight, height and WC, the standard procedures in the literature were used(¹⁶-¹⁷). Patients on medication to control blood pressure and diabetes, received special recommendations. The study was conducted from February to December 2010.


For data analysis, we followed the criteria proposed by SBD (2011) for BP, weight, height, WC and laboratory tests. BP >130/85 mmHg was considered high. In relation to body weight, we considered BMI ≥30 an indicator of obesity. For the WC, we considered values >102cm for men and 88cm for women. Altered values of total cholesterol >200mg/dl, glycated hemoglobin A1c (HbA1c) >7, triglycerides >150mg/dl, lipoprotein cholesterol of high density (HDL-C) >100mg/dl and lipoprotein cholesterol of low density (LDL-C) <45mg/dl were considered.


In the questionnaire MTA, patients were considered adherent and non-adherent who obtained values ≥ 5 points and < 5, respectively. Patients were considered as treatment non-adherence values obtained 1 to 4, relating the answers always,very often,often and sometimes. To characterize treatment adherence, we considered the values 5 and 6, corresponding to the responses rarely and never(¹⁸).


Data obtained through the FFQ were entered into the Dietsys software version 4.0(¹⁹) and, through this software, we obtained the average of the total caloric value (TCV) consumed by each individual, amount of fiber and cholesterol in mg, along with the percentage of carbohydrates, protein, total and saturated fat compared to TCV. The calculation of TCV and macronutrients was carried from the coding responses on the frequency of consumption of each food in the FFQ.


For the FFQ, we considered adherent patients who attended at least three of the six nutritional recommendations established by the Brazilian Diabetes Society (SBD)(²⁰), ie, consumption of total carbohydrates, dietary fiber and fractioning of meals. We chose these three recommendations because of the direct relationship to glycemic control of patients with DM.


For the analysis of IPAQ, first, patients were classified into four categories: sedentary, insufficiently active, moderately active and very active. Physical activity was described in: type of activity according to IPAQ – walking, moderate activity and vigorous activity, and total physical activity in MET. Physical inactivity was assessed by the daily and weekly sitting time, measured in minutes/day and minutes/week, classified into quartiles. To define the level of physical activity, the metabolic equivalent (MET) derivative time in minutes/week in specific activities was considered, which was estimated from the compendium of Ainsworth(21) and combined the frequency with which the activities were performed. In this study were considered adherent patients who were classified in moderately active and very active categories and non-adherent those included in the inactive and insufficiently active categories.


For data analysis of body mass index (BMI) and waist circumference, laboratory tests and blood pressure, we followed the recommendations of the World Health Organization (WHO)(²²) and SBD(²⁰), respectively. To organize the data, a database was created in SAS® 9.0 statistical software, performing double entry. For each FHS unit a number was assigned (FHS 1, FHS 2... FHS 17). Data were analyzed using descriptive statistics. For data presentation the absolute and percentages values were used. The project was approved by the Ethics Committee on Human Research of the School of Nursing of Ribeirão Preto, University of São Paulo (protocol no. 0990/2009).


Results

From the 423 (100%) patients, the mean age was 62.4 (SD=11.8) years with a predominance of females (66.7%); in relation to education, the mean in number of years of study was 4.3 (SD=3.6), the average family income was U$ 886.95 (SD=2744.4) dollars. Most patients (58.4%) had less than ten years of diagnosis time, with an average of 9 years (SD=6.6). The main comorbidities related to DM2 were: hypertension (81.3%) and dyslipidemia (32.4%). Regarding chronic complications, the highlights were: retinopathy (37.8%) and heart disease (20.3%). Patients obese were 18.9%, 76.1% and 73.7% had elevated waist circumference number and blood pressure, respectively. With the exception of total cholesterol (48.9%), all other laboratory parameters were altered in the majority of the sample: HbA1c (75.2%), triglycerides (60.3%), HDL-C (65.6%) and LDL-C (68.7 %).


Table 1 shows the numbers of patients examined in each FHS unit. It is noteworthy that, from the sample, the majority of patients were registered in the FHS 2 (8.0%), followed by FHS 5 (7.8%) and FHS 9 (7.8%). The lowest sample (2.8%) was from the FHS 1.


Table 1
Number and percentage of patients with DM2, registered at the FHS, according to the FHS they belong to - Passos, MG, Brazil 2010

FHS	N	%
1	12	2.8
2	34	8.0
3	25	5.9
4	32	7.6
5	33	7.8
6	24	5.7
7	15	3.5
8	25	5.9
9	33	7.8
10	20	4.7
11	19	4.5
12	22	5.2
13	23	5.4
14	24	5.7
15	30	7.1
16	27	6.4
17	25	5.9
Total	423	100.0

• ^Note:
  (N = 423)

The results showed that 84.4% of patients had adherence to drug therapy, 58.6% for physical activity and only 3.1% to the diet plan. Analysing simultaneously the three elements investigated, we note that only six (1.4%) patients had total adherence to the treatments for T2DM, 49.4% had adherence to two treatment plans, so 47.7 % combined drug therapy and physical activity and 43 (6.2 %) had adherence to one or none of the treatments for DM2, respectively.


Table 2 shows the number and percentage distribution of patients in each FHS adhering to drug therapy, diet plan and physical activity in relation to the total number of patients investigated in each unit. It is observed that adherence to medication was greater than 60% in all units investigated, highlighting the FHS 5, which had the highest percentage (93.9%).


Table 2
Numerical and percentage distribution of patients in each FHS adhering to drug treatment, Diet plan and physical activity in relation to the total number of patients investigated in each FHS - Passos, MG, Brazil 2010

FHS	Adherence to treatment
	Drug therapy (MTA)	Diet plan (FFQ)	Physical activity (IPAQ)
	n (%)	n (%)	n (%)
1	8 (66.7)	_	12 (100.0)
2	27 (79.4)	1 (2.9)	16 (47.1)
3	23 (92.0)	_	7 (28.0)
4	23 (71.9)	1 (3.1)	20 (62.5)
5	31 (93.9)	_	15 (45.4)
6	21 (87.5)	_	11 (45.8)
7	14 (93.3)	_	5 (33.3)
8	20 (80.0)	2 (8.0)	6 (24.0)
9	28 (84.8)	2 (6.1)	26 (78.8)
10	16 (80.0)	1 (5.0)	15 (75.0)
11	16 (84.2)	1 (5.3)	15 (78.9)
12	18 (81.8)	2 (9.1)	11 (50.0)
13	18 (78.3)	_	14 (60.9)
14	22 (91.7)	_	15 (62.5)
15	26 (86.7)	_	25 (83.3)
16	24 (88.9)	_	19 (70.4)
17	22 (88.0)	3 (12.0)	16 (64.0)

• ^Note:
  (N = 423)

In relation to their diet plan, more than half, or 52.9% of FHS patients were non-adherent to treatment. In the FHS where there was adherecence, the highest percentage was 12%, observed in the FHS 17.


In this variable, we also observed variability in the results depending on the unit, but with smaller amplitude of variation of adherence: 2.9% to 12%. Regarding physical activity, adherence ranged from 24 to 100%, having highlighted the FHS 1. This was the largest variability observed between FHS units. It is noteworthy that 58.8% of the units showed adherence to physical activity greater than 60% . 


Table 3 shows the numerical and percentage distribution of total patients registered in the FHS that adhered to drug therapy, the diet plan and physical activity. It is observed that, from the 423 patients studied, 357 showed adherence to drug therapy, 13 to diet plan and 248 to physical activity. Of those with adherence to drug therapy for the control of diabetes, 8.7% were from FHS 5. As to diet, the majority (23.0%) was registered in the FHS 17. Regarding physical activity, 10.5 and 10.1% came from FHS 9 and 15, respectively.


Table 3
Numerical and percentage distribution of total patients registered in the FHS that adhered to drug therapy, diet plan and physical activity. Passos, MG, Brazil 2010

FHS	Adherence to treatment
	Drug therapy (MTA)	Diet plan (FFQ)	Physical activity (IPAQ)
	n (%)	n (%)	n (%)
1	8 (2.2)	_	12 (4.9)
2	27 (7.6)	1 (7.7)	16 (6.5)
3	23 (6.4)	_	7 (2.8)
4	23 (6.4)	1 (7.7)	20 (8.1)
5	31 (8.7)	_	15 (6.0)
6	21 (5.9)	_	11 (4.4)
7	14 (4.0)	_	5 (2.0)
8	20 (5.6)	2 (15.4)	6 (2.4)
9	28 (7.8)	2 (15.4)	26 (10.5)
10	16 (4.5)	1 (7.7)	15 (6.0)
11	16 (4.5)	1 (7.7)	15 (6.0)
12	18 (5.0)	2 (15.4)	11 (4.4)
13	18 (5.0)	_	14 (5.7)
14	22 (6.2)	_	15 (6.0)
15	26 (7.3)	_	25 (10.1)
16	24 (6.7)	_	19 (7.7)
17	22 (6.2)	3 (23.0)	16 (6.5)
Total	357 (100)	13 (100)	248 (100)

• ^Note:
  (N = 357)

Discussion

More than half of the nursing diagnoses that appeared in the nursing consultations analyzed had correspondence with the diagnoses contained in the Nomenclature of Nursing Diagnosis and Interventions adopted in the basic network of Curitiba, which was based on the ICNP® Beta 2 version, published in 2002.


The others were mapped to ICNP® Version 1.0, published in 2005, due to the fact they were not included in said nomenclature, which does not contain the totality of infant health nursing diagnoses. Moreover, the ICNP® version 1.0 introduces focus terms of practice and more specific judgments that were not contained in the Beta 2 version, which was used to build the Nomenclature of Curitiba.


The analysis of these results was performed considering the 43 diagnoses of deviation from normalcy and the 13 diagnoses of normalcy. Interestingly, both in situations of normalcy and in those of abnormality, 77 (96.0%) of the 80 infant health nursing consultations analyzed in this study were concerned to assess and record the condition of infant growth, in accordance with the standard of reference recommended by the Ministry of Health (MOH).


The diagnosis of development was cited in 60 consultations, corresponding to 75% of cases. This finding is important, because it shows that the nurses in the clinic studied complied with the recommendation of the MOH to meet one of the established basic actions, which is to monitor the growth and development of children under five years of age seen in all basic network health services.


It is known that infant growth is considered one of the best indicators of health of the child, due to its close dependency on social factors related to: type of food in quantity and quality; occurrences and types of diseases; health care and vaccination; affectionateness of the family with the child; living conditions, especially housing and basic sanitation; and access to health services(¹⁵). Therefore, adequate monitoring of child growth is recognized and recommended as an important health action.


It was also possible to perceive the preoccupation of the nurses to assess and record the vaccination status of the children being seen. The diagnosis of adequate vaccination status and delayed vaccination status were cited in 48 consultations, corresponding to 60.0% of the visits. The result shows the need for nurses to identify, orient and register the vaccination status in all visits performed, in accordance with the recommendation of the Immunization Programs that encourage protection against immunopreventable diseases, aimed at increasing vaccination coverage.


It was further found that in 36 (45.0%) visits, the children were aged equal to or less than six months, a period in which there is a need for assessment of breastfeeding. The diagnosis of early weaning was found in 20 consultations, highlighting the need for encouragement and guidance about breastfeeding in prenatal and infant health consultations, as well as promoting relactation.


Dietary intake of infants appeared in 45 of the analyzed consultations; in 24 of them the infant’s food intake was inadequate and in 21 the feeding was satisfactory. Diagnoses related to food ingestion and exclusive breastfeeding were cited in 62 (77.5%) consultations, as it is important for the promotion of child health that they are recorded in all visits in order to define possible effective nursing interventions.


It is worth mentioning the results regarding the evaluation of cutaneous and mucosal integrity, which, although not considered a basic action by the MOH, was found very frequently in the nursing consultations analyzed. Diagnoses related to this problem appeared 70 times in the 80 well child nursing consultations analyzed, and in 69, deviations from normalcy were identified. Studies have demonstrated the high prevalence of these clinical findings in nursing consultations aimed at monitoring growth and development, which confirms the relevance of identifying cutaneous-mucosal problems in infants, for the determination of early and adequate nursing intervention(¹⁶).


The nursing diagnoses most often found related to aspects of nutrition, growth and development, and vaccination status, which are addressed in the child health programs developed by the Municipal Health Secretary of São Paulo.


One study conducted in Curitiba with respect to the nursing practices executed by professional nurses in primary care showed that nursing consults with children conducted in the period of August to December of 2005 generated 28 nursing diagnoses, with an emphasis on diagnoses of normalcy, which appeared in a higher number than those of deviations in normalcy(¹⁷).


It is worth remembering that nursing diagnoses are indicators of necessary nursing care, and they favor the development of the body of nursing knowledge, to the extent that they generate interventions and the need for research about them(¹⁷). Due to the importance of recognizing nursing care and its respective interventions, we must regard as a routine the description of the nursing diagnoses during nursing consultations(¹⁸).


Classification systems enable visualization of nursing practices, and reflect on daily care, both for the individual as well as for the community(¹⁹).


Conclusion

Adherence to drug therapy was positive in all FHS, showing that the public policy of free distribution of medicines by health care network and the primary care model adopted by the FHS may favor the percentages of adherence to drug therapy. Adherence to physical activity was also positive. This finding is promising because it reveals that this aspect of self-care is being incorporated into the treatment of diabetes. On the other hand, adherence to diet was worrying, which highlights the complexity of adopting new eating habits into adulthood. This factor is a key obstacle to changing habits of life, which was evident in all FHS investigated.


Given the findings in this study, the strengthening of institutional guidelines and educational strategies in line with the guidelines of SUS is recommended, so that adherence to diet, physical activity and drugs for the treatment of diabetes are considered effective indicators of the implementation of the principles of comprehensiveness in longitudinality and integrality in attention to diabetes in the city of this research. Furthermore, it is recommended that future studies, related to strategies aimed at identifying the individual risk for non-adherence, are carried out in order to know their predictor variables.


As limitation of the study, we highlight the need to explore why adherence is higher in some units than in others. Identifying contextual variables involved in this matter could contribute to the qualification of health professionals in the planning of interventions in diabetes. In this direction, we suggest studies to assess the capacity and configuration of the FHS units’ staff in diabetes care, chronic disease complications, sociodemographic characteristics of users of health services, among other variables to better understand the phenomenon investigated.


Knowing adherence to drug and non-drug therapy has clinical relevance for Nursing, since it allows direct clinical decisions regarding the treatment of diabetes in FHS team.


• *
  Extracted from the course conclusion work, "Adequacy of the nursing diagnosis taxonomies in infant health nursing consultations", Undergraduate degree in nursing, Paulista School of Nursing, Universidade Federal de São Paulo (Federal University of São Paulo), 2009.

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Publication Dates

• Publication in this collection
  Apr 2014

History

• Received
  09 Dec 2013
• Accepted
  29 Jan 2014