Sunday, 23 April 2017

Ethiopian patients’ perceptions of anti-diabetic medications: implications for diabetes education

. 2017; 10: 14.
Published online 2017 Apr 8. doi:  10.1186/s40545-017-0101-2
PMCID: PMC5385044

1School of Pharmacy, College of Health Sciences (CHS), Addis Ababa University (AAU), Addis Ababa, Ethiopia
2School of Medicine, CHS, AAU, Addis Ababa, Ethiopia
3Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
Bruck Messele Habte, Phone: (+251)-91-1626356, te.ude.uaa@elessem.kcurb.
corresponding authorCorresponding author.



The purpose of this study is to explore medication-related perceptions of adult patients with type 2 diabetes attending treatment in public hospitals of urban centers in central Ethiopia.


Qualitative in-depth interviews were held with 39 participants selected to represent a range of treatment experiences and socio-demographic characteristics who were attending their treatment in 3 public hospitals. Interviews continued until key themes were saturated. The interview and analysis was guided by Horne’s necessity-concerns model.


The findings revealed medication-related perceptions some of which were similar to those of Western patients and others that seem to be informed by local socio-cultural contexts. Participants’ perceptions focused on the necessity of and concerns about their anti-diabetic medications, giving more emphasis to the latter. Concerns were expressed about both perceived and experienced adverse effects, inconveniences in handling the medications and access. It was evident that some of these concerns were exaggerated but could nevertheless negatively affect adherence to prescribed medications including resistance to initiate insulin with potential impact on health outcomes.


Understanding patients’ perceptions of their medications is critical for developing a diabetes education program that considers local contexts and beliefs to enhance adherence. Education programs should consider patients’ concerns about medication adverse effects and reasons for use so as to improve their adherence and health outcomes.
Keywords: Patients’ perceptions, Anti-diabetic medications, Qualitative interview, Necessity-concerns model, Ethiopia


Diabetes mellitus, especially type 2 (hereafter referred to as diabetes) is increasingly becoming an important public health problem in sub-Saharan Africa including Ethiopia with a prevalence estimate of 5.1%, and higher rates reported from the urban centers []. Ethiopian studies indicate that the majority of patients have poor health status including blood glucose levels well above recommended levels with a high proportion also having experienced micro- and macro-vascular diabetes-related complications []. One of the studies also reported uncontrolled diabetes leading to hospital admissions in a high proportion of surveyed patients []. A similar study reported that direct hospital costs for patients with diabetes was significantly higher compared to controls and that substantial a part of the cost was related to treatment for diabetes-related complications [].
Among the mainstay of diabetes therapy are the anti-diabetic agents which greatly contribute to the control of blood glucose levels and associated micro- and macrovascular complications. The success of these agents, and other components of the treatment regimen, depends among other things on patients’ adherence to their recommended regimen so as to prevent acute complications and reduce long term complications []. However, adherence to medication regimens has been found to be a major challenge for patients with diabetes. Lower adherence to recommended medication regimens has been reported to have a negative impact on health outcomes and health services utilization such as emergency department visits, hospitalization and doctors’ visits [].
The review paper by Capoccia et al. (2016) found that lower medication adherence was related to concerns about medication side effects and doubts about their necessity. This study also highlighted the influence of cultural variations in medication-related beliefs among different ethnic groups on adherence. These findings and others suggest the need for patient-centered approaches that consider patient preferences and address their specific medication-related concerns []. A number of approaches to improve adherence to anti-diabetic medications are reported including educational and pharmacy-driven interventions [, , ]. The most effective approaches appear to be those that provide proactive care, and where visits are coordinated among a team of healthcare providers, in either community or institutional settings. Furthermore, interventions should be based on the principles of patient-centered care that require patients’ active involvement in their self-management [, ]. The different interventions are based on studies of medication adherence to diabetes and influencing factors that have mostly been conducted in Western nations or minority groups living in Western countries. There is a dearth of literature from developing countries like Ethiopia which are facing an increasing burden from diabetes.
Among the widely reported conceptual models to assess patients’ medication related perceptions is the necessity-concerns framework which posits that patients’ treatment perceptions, especially those with respect to beliefs about necessity and concerns, will play an influential role when patients come face to face with decisions to take medications [, ]. Patients’ perceptions are likely different from that of their healthcare providers, and are thought to be based on their perceptions of the evidence about the benefits and risks [].
The ‘necessity’ part of the Necessity-Concerns framework deals with the perceptions of personal need that patients may have for the medicines which may also be influenced by their beliefs about the efficacy of the medicines [, ]. The ‘concerns’ part deals with both concrete and abstract concerns related to medication-taking. The concrete experiences have to do with unpleasant symptoms such as side-effects and disruptions of daily life, while abstract concerns have to do with worries that regular use could lead to dependence or long term effects [, ]. In cases when the perceived necessity is strong and the perceived concerns are weak, patients tend to follow recommendations to adhere while strong perceived concerns and weaker necessity may lead to them not to adhere to treatments. Treatment perceptions may also lead to unintentional non-adherence if, for instance, patients who consider their medicine to be unimportant for their condition forget to take it. Apart from necessity and concerns perceptions, culture has also been reported to influence adherence to medications. It is also noteworthy that patients may not adhere due to reasons related to unintentional non-adherence(i.e., due to lack of resources) [].
There are a limited number of articles focusing on adherence to anti-diabetic treatment in developing countries like Ethiopia. The few studies from Ethiopia report unacceptably low levels of adherence to recommended medications. The common factors cited for the low levels of adherence include: being on non-insulin drug regimen []; consulting traditional healers []; lack of financial resources []; perceived side effects []; experience of depressive symptoms []; complexity of medication regimens [] and concerns about medications’ safety []. All of these were reported in quantitative studies and provide limited insight into patients’ perspectives of their medications which may be used to design patient-centered interventions to encourage adherence.
The aim of this study was to conduct a theory-guided, exploratory study using qualitative methods to elicit medication-related beliefs of type 2 diabetes patients who are following treatment in Addis Ababa (the largest urban center of Ethiopia) and Butajira (a town in Central Ethiopia that serves as center for the demographic surveillance site of Addis Ababa University) []. The Necessity-Concerns conceptual framework that has been widely used to study chronic patients was selected as the conceptual framework [].