|Year : 2016 | Volume
| Issue : 2 | Page : 169-174
Diabetes treatment satisfaction, medication adherence, and glycemic control among ambulatory type 2 diabetic nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria
Iloh Gabriel Uche Pascal1, Amadi Agwu Nkwa2
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State; Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
2 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
|Date of Web Publication||20-Dec-2016|
Iloh Gabriel Uche Pascal
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Background: Diabetic treatment satisfaction, medication adherence, and glycemic control are widely recognized as the cornerstones for successful management of diabetes and proxy indicators of quality of care. However, in Nigeria, nothing is known on the role of diabetic treatment satisfaction on medication adherence and blood glucose control. Aim: The study was aimed at determining the role of diabetes treatment satisfaction in medication adherence and glycemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Southeast Nigeria. Materials and Methods: This was a descriptive study that was carried out on 120 type 2 diabetic Nigerians who were on treatment for at least 3 months at the primary care clinic of a tertiary hospital in Nigeria. Diabetes treatment satisfaction and medication adherence were assessed in the previous 30 days using pretested, interviewer-administered questionnaire on self-reported satisfaction and adherence to therapy, respectively. Glycemic control was assessed in the previous 1 month. A patient was defined to have goal glycemic control if the fasting blood glucose at the end of the study, visit was between 70 and 130 mg/dL. Results: Diabetic treatment satisfaction, medication adherence, and glycemic control rates were 85.8%, 72.5%, and 61.7%, respectively. Diabetic treatment satisfaction was significantly associated with medication adherence (P = 0.025) and glycemic control (P = 0.04). Conclusion: Diabetic treatment satisfaction was significantly associated with medication adherence and glycemic control. However, treatment satisfaction did not translate marginally to higher medication and glycemic control. Diabetic treatment satisfaction should be integrated into a standard care package for diabetic patients in primary care settings.
Keywords: Adult Nigerians, diabetic treatment satisfaction, glycemic control, medication adherence, primary care
|How to cite this article:|
Pascal IG, Nkwa AA. Diabetes treatment satisfaction, medication adherence, and glycemic control among ambulatory type 2 diabetic nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria. Arch Med Health Sci 2016;4:169-74
|How to cite this URL:|
Pascal IG, Nkwa AA. Diabetes treatment satisfaction, medication adherence, and glycemic control among ambulatory type 2 diabetic nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria. Arch Med Health Sci [serial online] 2016 [cited 2017 Jul 27];4:169-74. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/169/196215
| Introduction|| |
Diabetes mellitus is one of the most common noncommunicable diseases in any given human environment and the most common endocrine-related disease in any given society., It is a chronic disease that constitutes a significant health and socioeconomic challenges for the patients, patient families, health system, and the nation.,, In 2015, International Diabetes Federation estimated that 441 million adult population had diabetes mellitus with projected rise to 926 million by 2040 with low- and middle-income countries being home to 80%–90% of diabetic cases. The perturbing trends of diabetes mellitus in socioeconomically and technologically developing nations have been attributed to dramatic changes in nutritional, lifestyle, and epidemiological transitions.,
Diabetes mellitus is characterized by microvascular and macrovascular complications which are related to the level of glycemic control. Good glycemic control delays onset of microvascular complications of retinopathy, neuropathy, and nephropathy and has beneficial effects on macrovascular complications, especially when good glycemic control is achieved early and maintained prospectively.,, It has been established that medication adherence and good glycemic control lead to a decrease in morbidity and mortality among diabetic patients resulting in satisfaction with care and improvement in health-related quality of care., In accord with national and international guidelines on the management of diabetes mellitus, treat-to-target blood glucose ranges have been recommended by the International Diabetes Federation and American Diabetes Association. The American Diabetes Association defines good glycemic control as fasting blood glucose of 70–130 mg/dL or hemoglobin A1c (HbA1c) of 5%–7%. However, good glycemic control with medication requires adherence with prescribed medications  and recommended lifestyles.
Research studies have demonstrated that variables that influence medication adherence and blood glucose control among diabetic patients are multifactorial ranging from patient-related, health professional-related, and health facility-related factors.,,, Among the patient-related factors is diabetic treatment satisfaction., Patient satisfaction studies have been used as a tool for quality of care assessment and are conceptually defined as the patient's judgment on the quality and goodness of care., Patient satisfaction is, therefore, directly associated with the degree of satisfaction with expected care and is linked with cognitive evaluation and emotional reactions to the components of care services such medication adherence and glycemic control.,,
Several methods for assessing satisfaction with care have been described in biomedical literature with majority of the patient satisfaction study tools emanating from developed countries. However, there is no universally accepted tool for measuring satisfaction with care that can be used across and within all the regions of the world or all disease entities. There exist general satisfaction tools such as satisfaction with outpatient services  and patient survey of quality of care  and specific instruments such as Diabetes Treatment Satisfaction Questionnaire. The Diabetes Treatment Satisfaction Questionnaire status version which had undergone change version  and modifications  in different ethnolinguistic settings may not be appropriate for Nigerian diabetics due to content analysis of its Likert scale response items.,, Similarly, various questionnaire methods of measuring medication adherence have been reported by researchers in different parts of the world, but there is no gold standard for precise measurement of medication adherence, but different questionnaire instrument for assessing medication at the point of care has been described such as Morisky Adherence Scale (MAS-4), modified Morisky Medication Adherence Scale-8, modified Morisky Adherence Predictor Scale, Brief Medication Questionnaire, and Medication Adherence Rating Scale among others.
Diabetes treatment satisfaction, medication adherence, and glycemic control are reportedly variable from one region of the world to another. However, in a resource-limited environment such as Nigeria, diabetes treatment satisfaction, medication adherence, and glycemic control probably may be lower than that reported in advanced nations of the world. In Nigerian Africans, diabetes treatment satisfaction remains a significant challenge particularly at primary care settings and is likely to affect adherence with medication and invariably blood glucose control. It is based on this premise that the authors were motivated to determine the role of diabetes treatment satisfaction in medication adherence and glycemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria.
| Materials and Methods|| |
This was a clinic-based descriptive study conducted on 120 adult type 2 diabetic Nigerians from April 2011 to December 2011 at the Department of Family Medicine of the Federal Medical Centre (FMC), Umuahia, Nigeria.
Umuahia is the capital of Abia State, Southeast Nigeria. Abia State is endowed with abundant mineral and agricultural resources with supply of professional, skilled, semi-skilled, and unskilled workforce. Economic and social activities are low compared to industrial and commercial cities such as Onitsha, Port Harcourt, and Lagos in Nigeria. Until recently, the capital city and its environ have witnessed an upsurge in the number of banks, hotels, schools, markets, industries, junk food restaurants, in addition to the changing dietary and social lifestyles. The Department of Family Medicine serves as a primary care clinic within the tertiary hospital setting of the medical center. 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 three clinic visits (recruitment visit, penultimate visit before the end of study, and end of the study visit). This was to ensure that the study population was familiar with prescribed oral hypoglycemic medications. The exclusion criteria included critically ill patients and diabetic patients who were on insulin medication.
Sample size estimation was determined using the formula  for estimating minimum sample size for descriptive studies and had been explained in previous publication by the authors. A sample size of 120 adult 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 instrument consisted of sections on sociodemographic data, information on medication adherence, diabetes treatment satisfaction, and blood glucose control in the previous 1 month.
Medication adherence was assessed by the use of pretested, interviewer-administered questionnaire on 30 days self-administered and reported therapy. 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: (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-times, sometimes, rarely, and never). (iv) How many dose(s) of your antidiabetic drugs have you missed in the previous 1 month? (v) How many of your previous blood glucose medication is 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 ,,,,, as follows all-times = 4 points, most-times = 3 points, sometimes = 2 points, rarely = 1 point, and never = 0 point.
Diabetes treatment satisfaction was studied using questionnaire tool that was designed by the authors to suit Nigerian environment through review of relevant literature on outpatient treatment satisfaction ,,,,, and diabetes treatment satisfaction.,,,,,,,, The specific domains of treatment satisfaction examined were satisfaction with current treatment, convenience of treatment, flexibility of treatment, and continuity with present treatment. Satisfaction with each of the specific domains of treatment was given an ordinal score in a six-point Likert scale of extremely satisfied = 5 points, very satisfied = 4 points, satisfied = 3 points, dissatisfied = 2 points, very dissatisfied = 1 point, and extremely dissatisfied = 0.
Pretesting of the diabetic treatment satisfaction and medication adherence section of the study instrument was done at the Family Medicine Clinic of the FMC, Umuahia. Five diabetic patients were haphazardly used for the pretesting of the diabetic treatment satisfaction and medication adherence questionnaires 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 questions were interpreted with the same meaning as intended.
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.
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, whereas those that scored 0–3 points and missed a day dose of antidiabetic medications meant nonadherence. 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. Overall satisfaction referred to those who scored at least 3 points in all the domains examined, whereas specific satisfaction to the subscales of items of satisfaction referred to those that scored at least 3 points in specific domain. Overall dissatisfaction referred to those who scored 0–2 points in all the domains examined, whereas specific dissatisfaction to the subscales of items of satisfaction referred to those that scored 0–2 points in specific domain.
The ethical clearance was obtained from the Ethics Committee of the hospital. Consent was also obtained from the patients.
The results generated were analyzed using software Statistical Package for Social Sciences (SPSS) version 13.0, Inc. Chicago, IL, USA, for the calculation of percentages for categorical variables. Percentages and frequencies were compared by Chi-square test. The level of statistical significance was set at P < 0.05.
| Results|| |
Of the 120 diabetic patients studied, 103 (85.8%) were satisfied with the diabetic treatment received whereas 17 (14.2%) were not satisfied. More so, 87 (72.5%) diabetic patients were adherent with antidiabetic medication whereas 33 (27.5%) of them were not adherent with medication. Furthermore, 74 (61.7%) patients had good glycemic control whereas 46 (38.3%) of them were uncontrolled [Table 1].
|Table 1: Diabetic treatment satisfaction, medication adherence, and blood glucose control among the study participants|
Click here to view
Of the 103 diabetic patients that were satisfied with treatment, 80 (77.7%) of them were adherent with medication whereas 23 (22.3%) were nonadherent with medication. The difference was statistically significant (χ2= 11.65; P = 0.025) [Table 2].
|Table 2: Association between overall diabetic treatment satisfaction and medication adherence|
Click here to view
Of the 103 diabetic patients that were satisfied with treatment, 69 (67.0%) of them had good glycemic control whereas 34 (33.0%) had poor glycemic control. The difference was statistically significant (χ2= 8.33; P = 0.04) [Table 3].
|Table 3: Association between overall diabetic treatment satisfaction and blood glucose control|
Click here to view
| Discussion|| |
This study has shown that 85.8% of the diabetic patients were satisfied with their treatment and that diabetic patient satisfaction with treatment was significantly associated with medication adherence and glycemic control. Although the overall treatment satisfaction was high, it was skewed toward the lower end of satisfaction subscales. The finding of this study is in tandem with the reports that satisfied diabetic patients had better medication adherence and glycemic control than their dissatisfied counterparts.,, The implication of this finding is that physician attending to dissatisfied diabetic patient may attribute the lack of response to medication as therapeutic failure rather than dissatisfaction with treatment. Dissatisfaction with treatment could constitute a risk factor for nonadherence with medication, and dissatisfied patient may take recourse to complementary and alternative medications, healer and doctor shopping.,,, It is, therefore, pertinent to improve treatment satisfaction among the diabetic patients as this has been shown to enhance coping mechanism, treatment-seeking behavior, illness behavior, medication adherence, blood glucose control, and overall quality of life of diabetic patients., The primary care physicians involved in the treatment of diabetes should be aware of these subtleties as this can affect continued relationship with the medical practitioner and recommendation of the practitioner to other diabetic patients.
This study has shown that diabetic treatment satisfaction was significantly associated with medication adherence. Adherent patients had higher satisfaction scores than nonadherent patients thus corroborating the reports that improving satisfaction with treatment could enhance medication adherence.,,, It is, therefore, not enough to prescribe antidiabetic medications during clinical encounter with diabetic patients, but regular evaluation of satisfaction with treatment should be a component of care package for diabetic patients in primary care settings. Primary care clinicians managing diabetic patients should inquire for treatment satisfaction at every patient encounter because adherence to prescribed antidiabetic medications is crucial for achieving metabolic control. Being aware of these determinants of medication adherence and evaluating them during subsequent patient visits can affect the quality and quantity of care delivered to these diabetic patients.
This study has demonstrated the association between diabetic treatment satisfaction and blood glucose control. The finding is in consonance with the reports that if diabetic patients are satisfied with their treatment, glycemic outcome will expectedly improve.,, This could be a reflection of improved well-being and wellness associated with good glycemic control amid other contributing factors.,, The goal of diabetic treatment is to achieve good glycemic control, prevent acute complications, and reduce the risk of long-term diabetic-related complications., Diabetic patients that are dissatisfied with treatment do not only have poor blood glucose control but also have broader socioeconomic and medical consequences caused by uncontrolled diabetic medical condition.,, Achieving and sustaining treatment satisfaction and good glycemic control will enable diabetic Nigerians benefit from satisfying life reportedly enjoyed by their counterparts in developed countries. Efforts are, therefore, needed to improve on diabetic treatment satisfaction of adult Nigerian diabetics as well as providing patient-oriented care that will promote treatment satisfaction. This will help in the attainment of positive therapeutic outcomes such as good glycemic control and will enable diabetic Nigerians realize the full benefits of antidiabetic therapy.
Implications of the study
Diabetes treatment satisfaction, medication adherence, and blood glucose control are of phenomenal relevance in the management of diabetic patients in a resource-constrained setting of Nigeria. As the case detection rates of type 2 diabetes mellitus increase in adult Nigerians achieving treatment satisfaction, medication adherence, and glycemic control to target has constituted an important management challenge in the subregion. This study, therefore, brings to the fore the need for improved diabetes management through periodic evaluation of treatment satisfaction as well as strengthening the standard of diabetic care aimed at enhancing medication adherence and good glycemic control.
Limitations of the study
The limitations of this study are recognized by the researchers and were described in the previous study by the authors. 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 ,, 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 insight into the magnitude of the glycemic control among the study population. Furthermore, the limitations imposed by the self-reported measure of adherence and satisfaction with treatment for the study are recognized by the authors. In addition, the sample size for the study was relatively small, but this was the number of patients seen within the duration of the study.
| Conclusion|| |
Diabetic treatment satisfaction was significantly associated with medication adherence and glycemic control. However, treatment satisfaction did not translate to marginally higher medication and glycemic control. There is a need to sustain and improve on the current diabetic treatment satisfaction while efforts should be made to address the areas of dissatisfaction with treatment to make the diabetic clinic patient friendly.
Future research studies
Future research directions are required to explore the aspects of diabetic treatment that leads to dissatisfaction with treatment. This will provide valuable clinical data for intervention purposes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
International Diabetes Federation. IDF Diabetes Atlas. 7th
ed. Brussels, Belgium: International Diabetes Federation; 2015.
Ogbera AO, Ekpebegh C. Diabetes mellitus in Nigeria: The past, present and future. World J Diabetes 2014;5:905-11.
Iloh GU, Amadi AN, Ebirim CI. Type 2 diabetes mellitus in ambulatory adult Nigerians: Prevalence and associated family biosocial factors in a primary care clinic in Eastern Nigeria: A cross-sectional study. Br J Med Med Res 2015;9:1-12.
Adetunji AA, Ladipo NM, Irabor AE. Perceived family support and blood glucose control in type 2 diabetes. Diabetes International 2007;15:18-19.
Ginter E, Simko V. Type 2 diabetes mellitus, pandemic in 21st
century. Adv Exp Med Biol 2012;771:42-50.
Ginter E, Simko V. Global prevalence and future of diabetes mellitus. Adv Exp Med Biol 2012;771:35-41.
Uloko AE, Ofoegbu EN, Chinenye S, Fasanmade OA, Fasanmade AA, Ogbera AO, et al.
Profile of Nigerians with diabetes mellitus – Diabcare Nigeria study group (2008): Results of a multicenter study. Indian J Endocrinol Metab 2012;16:558-64.
Redekop WK, Koopmanschap MA, Stolk RP, Rutten GE, Wolffenbuttel BH, Niessen LW. Health-related quality of life and treatment satisfaction in Dutch patients with type 2 diabetes. Diabetes Care 2002;25:458-63.
Barnett AH, Bowen-Jones D, Burden AC, Janes JM, Sinclair A, Small M, et al
. Multicentre study to assess quality of life and glycaemic control of type 2 diabetic patients treated with insulin compared with oral hypoglycaemic agents. Pract Diabetes Int 1996;13:179-83.
Narayan KM, Gregg EW, Fagot-Campagna A, Gary TL, Saaddine JB, Parker C, et al.
Relationship between quality of diabetes care and patient satisfaction. J Natl Med Assoc 2003;95:64-70.
Franciosi M, Pellegrini F, De Berardis G, Belfiglio M, Cavaliere D, Di Nardo B, et al.
The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: An urgent need for better educational strategies. Diabetes Care 2001;24:1870-7.
American Diabetes Association. Standards of medical care in diabetes-2006. Diabetes Care 2006;29 Suppl 1:S4-42.
Pascal IG, Ofoedu JN, Uchenna NP, Nkwa AA, Uchamma GU. Blood glucose control and medication adherence among adult type 2 diabetic Nigerians attending a primary care clinic in under-resourced environment of Eastern Nigeria. N Am J Med Sci 2012;4:310-5.
Iloh GU, Okafor GO, Amadi AN, Ebirim CI. A cross-sectional study of adherence to lifestyle modifications among ambulatory type 2 diabetic Nigerians in a resource-poor setting of a primary care clinic in Eastern Nigeria. Int J Trop Dis Health 2015;8:113-23.
Pringle M, Stewart-Evans C, Coupland C, Williams I, Allison S, Sterland J. Influences on control in diabetes mellitus: Patient, doctor, practice, or delivery of care? BMJ 1993;306:630-4.
Nicolucci A, Cucinotta D, Squatrito S, Lapolla A, Musacchio N, Leotta S, et al.
Clinical and socio-economic correlates of quality of life and treatment satisfaction in patients with type 2 diabetes. Nutr Metab Cardiovasc Dis 2009;19:45-53.
Biderman A, Noff E, Harris SB, Friedman N, Levy A. Treatment satisfaction of diabetic patients: What are the contributing factors? Fam Pract 2009;26:102-8.
Iloh GU, Ofoedu JN, Njoku PU, Odu FU, Ifedigbo CV, Iwuamanam KD. Evaluation of patients' satisfaction with quality of care provided at the National Health Insurance Scheme clinic of a tertiary hospital in South-Eastern Nigeria. Niger J Clin Pract 2012;15:469-74.
Iloh G, Ofoedu J, Njoku P, Okafor G, Amadi A, Godswill-Uko E. Satisfaction with quality of care received by patients without national health insurance attending a primary care clinic in a resource-poor environment of a tertiary hospital in Eastern Nigeria in the era of scaling up the Nigerian formal sector health insurance scheme. Ann Med Health Sci Res 2013;3:31-7.
Chatterjee JS. From compliance to concordance in diabetes. J Med Ethics 2006;32:507-10.
Lavsa SM, Holzworth A, Ansani NT. Selection of a validated scale for measuring medication adherence. J Am Pharm Assoc 2011;51:90-4.
Keegan O, Mcgee HA. A Guide to Hospital Outpatient Satisfaction Surveys. Practical Recommendations and the Satisfaction with Outpatient Services (SWOPS) Questionnaire. Dublin: Royal College of Surgeons in Ireland; 2003.
Woodward CA, Ostbye T, Craighead J, Gold G, Wenghofer EF. Patient satisfaction as an indicator of quality care in independent health facilities: Developing and assessing a tool to enhance public accountability. Am J Med Qual 2000;15:94-105.
Bradley C. Diabetes treatment satisfaction questionnaire. Change version for use alongside status version provides appropriate solution where ceiling effects occur. Diabetes Care 1999;22:530-2.
Ishii H, Bradley C, Riazi A, Barendse S, Yamamoto T. The Japanese version of the Diabetes Treatment Satisfaction Questionnaire (DTSQ): Translation and clinical evaluation. J Clin Exp Med 2000;192:809-14.
Pouwer F, Snoek FJ, Heine RJ. Ceiling effect reduces the validity of the Diabetes Treatment Satisfaction Questionnaire. Diabetes Care 1998;21:2039.
Petterson T, Lee P, Hollis S, Young B, Newton P, Dornan T. Well-being and treatment satisfaction in older people with diabetes. Diabetes Care 1998;21:930-5.
Ware JE Jr., Hays RD. Methods for measuring patient satisfaction with specific medical encounters. Med Care 1988;26:393-402.
Araoye MO. Sample size determination. Research methodology with statistics for health and social sciences. Ilorin: Nathadex Publishers; 2004. p. 115-21.
Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;10:348-54.
Jimmy B, Jose J. Patient medication adherence: Measures in daily practice. Oman Med J 2011;26:155-9.
Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care 2004;27:1218-24.
Al-Aujan S, Al-Aqeel S, Al-Harbi A, Al-Abdulltif E. Patients' satisfaction with diabetes medications in one hospital, Saudi Arabia. Patient Prefer Adherence 2012;6:735-40.
Lliffe S, Wilcock J, Manthorpe J, Moriarty J, Cornes M, Clough R, et al.
Can clinicians benefit from patient satisfaction surveys? Evaluating the NSF for Older People, 2005-2006. J R Soc Med 2008;101:598-604.
Nwankwo CH, Nandy B, Nwankwo BO. Factors influencing diabetes management outcome among patients attending government health facilities in South East Nigeria. Int J Trop Med 2010;5:28-36.
Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: The role of disease and medication beliefs. J Behav Med 2009;32:278-84.
Gåfvels C, Wändell PE. Coping strategies in men and women with type 2 diabetes in Swedish primary care. Diabetes Res Clin Pract 2006;71:280-9.
Adebisi SA, Oghagbon EK, Akande TM, Olarinoye JK. Glycated haemoglobin and glycaemic control of diabetics in Ilorin. Niger J Clin Pract 2009;12:87-91.
Gadzama AA, Nyandaiti Y, Mshelia DS. Role of a diagnostic laboratory in the management of diabetes mellitus. Niger J Clin Pract 2008;11:67-71.
[Table 1], [Table 2], [Table 3]