AN INVESTIGATION OF COMPLIANCE IN TYPE II DIABETIC PATIENTS ATTENDING CLINIC AT CHURCH OF SCOTLAND HOSPITAL

Thirty Type 11 diabetic patients attending a clinic at a rura! hospital were interviewed^ using structured interviews and clinic records. The patients' clinic cards were also used to obtain the required information. The stuifywas conducted to identi^ the factors that lead to non compliance with the recommended treatment regimen, to establish whether diabetic patients are able to keep appointments and to identify factors that influence patients from keeping appointments. Factors that led to non compliance were financial problems andforgetfulness. Most clients were unemployed while others were pensioners and could not afford the expensive means o f transport to the clinic. Additional issues were rough terrain and roads which depended on good weather. The most common complication found in the study was hypertension, which when combined with minor ailments, led to clients taking multiple medications. OPSOMMING Onderhoude is gevoer met 30 Tipe 11 diabeetpasiente wat die kliniek by die Church o f Scotland Hospital bywoon. Daar is van gestruktureerde onderhoude enJdiniese rekords gebruik gemaak. Die pasiente se kliniekkaarte is ook gebruik om inligting te verkry. Die studie is ondemeem om: die faktore te identifiseer wat lei tot nie-navolging (noncompliance) van die aanbevole behandeling; vas te stel o f diabetiesepasiSnte afsprake kan nakom; faktore te identifiseer watpasiinte daarvan weerom afsprake na te kom. Faktore wat gelei het tot nie-navolging (non-complience) in Tipe 11 diabeetpasiente wat die kliniek by die Church o f Scotland bygewoon het, was: • finansiele probleme en • vergeetagtigheid. Die meeste pasiente was werldoos en sommige was pensioentrekkers wat nie die duur vervoerkoste kon bekostig nie. Bykomendefaktore was topografie enpaaie wat van die weer afhanklik is. Hipertensie was die mees algemene kompUkasie wat in die studie gevind is. Saam met ander geringe ongesteldhede het dit daartoe gelei dat pasiente veelvudige medikasie geneem het. Veelvuldinge medikasie het weer daartoe dat pasiente nie vooegeskrewe behandeling geneem het soos verlang nie, as gevolg van newe-effekte soos deur die pasiente beskryf.


INTRODUCTION
This study was conducted at a clinic run by the Church of Scotland Hospital in the Msmga area of KwaZulu -Natal.It is a community hospital giving a comprehensive service to approximately 250 000 people living in this rural area The land is nigged with difficult terrain and poor mfrastructure; secondary roads become unpossible to access in rainy weather The nearest large town to the hospital is Pietermaritzburg.190km away to the north-east PROBLEM STATEMENT.
Various ^^ecialised services are run by the hospital, including diabetic and hypertensive clinics.Special diabetic clinics are directed towards maintaining diabetic patients in a healthy and an idependent way as possible.
R obert (1 9 9 3 ,4 2 5 ) states th at " ...the prevalence of diabetes, particularly of the non-insulin dependent variety, is reaching near-epidemic proportions in many parts of the world, including parts of South Africa".In South Aihca, the number of diabetics has been estimated at about 700,000, taking into account the known prevalence of non-insulin dependent diabetes mellitus (NIDDM orType II).Several studies show that only about half of the already diagnosed diabetics currently are clinic attenders.(Robertson 1989) NIDDM is by far the most common form of diabetes and usually has its onset in the later adult years.Mortality rates among patients with NIDDM are approximately twice as high as in the n o n -d ia b e tic population.Atherosclerotic vascular disease accounts for 60% of deaths with important causes being cerebro-vascular disease and myocardial mfarction.(Peden & McPherson 1990).
It has been observed in this rural hospital that the majority of diabetic patients who get admitted have a history of having been on oral treatment but end up with complications Uke foot infection, amputation arteriosclerosis and other problems associated with diabetes.This leads to the assumption that non-comphance with treatment is the main reason.(Hentmen & Kyngas 1992, Branon & Feista 1988, Cargill, 1992).

OBJECTIVES OF THE STUDY.
The objectives of the study were; Enabling factors such as time, money, equipment, skills, available services play an important part in behaviour e.g. a patient may have a leg amputated or may be old.He wants to go to the clinic for more supplies of tablets but may be luuible to do so.He may have no money for transport (Hubley 1988,134-138) A person may in ten d to change the behaviour but is unable to do so because of enabling factors such as tim e, money, ' ■ material resourses, skills and services accessible to him.Holme & Tiuibridge (1991) suggest that the term attitude should be used for a person's judgement of a behaviour as good or bad and worth carrying out or not The judgement will depend on the beliefs he has about the consequences of perfonning the action.If he believes that performing the action will lead to mainly good outcomes then his attitude will be favourable e g compliance can be attauied if the Type II diabetic patient believes that adherance to treatment will enable him to lead a normally vaned and full life A person will be influenced by various persons m his or h a social network.Some people will want the person to perform the bdiaviour, others will not.The term subjective norm is used for the overall perceived social pressure.
The beliefs of a person coiKeming the wishes of people significant to her will aflect her performance of that action or bdiaviour.The overall social pressure will depend on a person's perceptions of the w i^es of the persons who have the most influence, i.e. are most significant in his or her network.
For example the diabetic patient may beUeve that her friends and health workers wish her to use traditional medicine for her diabetes.She is likely to conform to wishes of those most signiflcant or important to her.
According to Hubley (1988) the person may be influenced by her or his motha, father, husband, wife or others as stated a)x)ve to perform the behaviour or not which is being refered to as social pressure created by the signiflcant others.The theoretical framewori: refers to the above as subjective norms.
LITERATURE REVIEW .

Compliance
Branon & Feista (1988) stated that in order for medical advice to beneficially affect the health of the patient, two contingencies must be met.
• First the advice must be accurate.
• Secondly it must be followed.
Both conditions are essential.
Ill-founded advice, if strictly followed, may introduce new health problems, leadmg to disastrous outcomes for the comphant patient Yet excellent advice, based on the most complete and current medical knowledge, is essentially worthless if unheeded Branon & Feista (1988)  • they do not have sufficient education.
• there is a lack of adequate follow up from health personnel.
• they are not given an individualised diet, but rather a standard "handout" without any explanation.
• cultural and socio-economic factors are not considered by health persormel when advice is given.
• they are not self-m o tiv ated or self-disciplined Alcohol abuse holds several dangers for the diabetic patient because sym ptoms of ex cessiv e a lco h o l in ta k e and o f hypoglycaemia can be easily confused d ^n d in g on the severity of each entity.
Excessive alcohol intake may result in the skipping o f m eals.R ecovery from hypoglycaemia may be delayed due to alcohol induced mhibition of gluconeogenesis.In some patients on chlopropimide alcohol may cause an unpleasant flushing sensation, sometimes accompanied by severe vomitmg • Alcohol intake ^ould be reduced and the client to be advised not to drmk on an empty stomach.(Omar, Christopher, Motala, Jailal and Seedat 1987).

EXERCISE
Exercise is probably beneficial to people with diabetes, in improving uisuhn sensitivity.It is regarded as an unportant part of life by many people, particularly the young Unfortunately, exercise can cause problems of blood glucose control in inadequately controlled diabetic patients using insulin.(Hobne and Tunbridge 1991)

D U BET IC FOOT.
Hohne and Tunteidge (1991) mentioned that the foot problem in diabetic patients causes more in-patient bed occupancy than all other medical problems put together.Amputation causes major disability and quite often both limbs may need to be amputated.These authors believed that foot problems are largely preventable by giving suitable, repetitive education and ^vice.Keen and Jarret (1982) stated that poor hygiene and poorly controlled diabetes are the most important contributing causes of foot problems.

OBESITY
Obesity ismore common in patients with Type II diabetes.Day (1992) staled that there is a high correlation between the degree of obesity in a population and the prevalence of diabetes mellitus.Genetic p rc d i^sitio n and obesity can lead to NIDDM or genetic p ie d i^sitio n may lead to obesity.

NEPHROPATHY
Holme and Tunbridge (1991)stated that causes o f nephropathy include vascular insuficiency and high blood sugar levels which lead to metabolic disturbances within the nephron itself.
There is a need for early identication of this potentially fatal complication.

Sandler (1989) stated that clinical diagnosis of diabetic nephropathy relies on detection of persistent proteinuria
Van Zyl Sm it (1 9 9 1 ) m entioned that controlling an elevated blood pressure is the single most effective way of retarding the rate of renal function loss in diabetic nephropathy and should be aggressively pcrsued in all patients.

METHODOLOGY
This is a descriptive study which used a structured mterview tool.The stiuly was designed to take into account the expenences of Type n diabetic patients attending the diabetic clinic at a Church O f Scotland Hospital.Clinic records were used to elicit the information which could not be gathaed by using the structured interview tool.

SAMPLE
The population consisted o f all Type II diabetic patients attending a climc at the Church O f Scotland Hospital.A convenience sample of thirty (30) diabetic patients were selected from all those patients who were Type II diabetic patients and who attended this clinic.The clients were attending the clinic on a weekly basis on Thursdays.
INSTRUMENT AND DATA COLLECTION.
The structured interview tool was used to interview clients in the clinic on Thursdays.Clinic records and patients' cards were also used to aquire information wliich could not be sqjplied by the clients.
The permission to undertake this study was obtained from the relevant authorities of the Department of Health KwaZulu, and from the medical superintendent of the Church Of Scotland Ho^ital.
Consent for participation in the study was obtained from each patient prior to the interview.
Each patient was infcHmed verbally that the interview was vohmtary, and that even after the interview had begun, the client was free to refuse to answer any question and/or to terminate the interview at any point The clients were told that answers to the questions will not be supplied to anyone else, and that no report of this study will ever identify the clients in any way.
Clients were informed that they would receive no dircct benefit from their pmticipatioa

CONSTRUCT VALIDITY.
According to Polit and Hungler (1991) construct validity is done to assess v^ether there is adequate measuring o f abstract concepts under investigation.Lobiodo-Wood and Haber (1990,40) stated that constrct validity attempts to validate a body of theory underlying the measurement.Bellack and Hersan (1984,40) furtha explained that there is no prescription for determining construct validity.It is established by showing that a measure is related in a systematic way to the focus of interest In order to meet the above mentioned measures in this study the definition of concepts was done to guide the data collection Basmg the mterview tool on the literabire also contributed to validity.
According to Best and Khan (1993,203) reliability is the degree of consistency that the instrum ent or procedure demonstrates.W hatever it is m easuring, it does so consistently.
This was achieved by using the structured interview tool, clinic records and patients' cards.When used repeatedly these three processes produced similar results.

ANALYSIS AND FINDINGS.
The results were presented in relation to the structured interview tool as it tried to elicit the factors influencing compliance with the recommmended treatment and diet The results were also interpreted according to the concq>tual fnunewoik of the Basnef model which considers the enabling factors, subjective norms, beliefs and attitude of people.
Age The aged person may intend to con^ly with treatment regimes but due to disabling factors might be unable to do so.Hubley (1988,134) mdicated that ailments of the aged, such as partial blindness or painful knees, may contribute to non-compliance.

INCOME LEVEL.
Level of income of the clients has an impact on compliance with diet and treatments.Thirty percent of the clients stated that financii problems contributed to their inability to follow their prescribed diets and treatments.
Silvis (1992), Peden and McPherson (1990) and Holme (1989) indicated that a reduction in energy intake produces an early fall in blood glucose concentration and an improvement in symptoms caused by hyperglycaemia.

AGE AT TIM E OF DLVGNOSIS
Twenty-seven percent o f patients were diagnosed wiien they were between 4 1 -5 0 years of age.Fifty-seven percent of cUents were diagnosed between 51 -60 years of age.Sixteen percent of clients were diagnosed between 6 1 -7 0 years of age.
These fmdings confumed what Holme and Tumbridge (1991) stated that NE)DM is by far the most commmon fomi of diabetes and usually has its onset after the age of 40.
REASONS FOR TRANSPORT PROBLEMS.
The reasons that were given by the cUents included roads w hich w ere w eather dependent.The study showed that during the rainy days few clients attended the clinic.This caused clients to attend clinic wdien they had nin out of medication.

COST FACTOR
Fifty seven percent of clients considered the cost of travelling to the clinic as too much Some were unemployed and had no money while pensioners got their money on alternate months.s M ULTIPLE M EDICATION.
Multiple medication could cause patients to omit prescribed treatments Some clients stated that multiple medication caused toxic effects such as vomiting, nausea, headache and dizziness T his caused clien ts to discontinue theu^ treatments before consulting the health practitioners Accordmg to Caigill (1992) the complex health problems of older people and their prescnption regimes can potentiate the harmful cfTects of a medication regime and non-compUance According to the conceptual framework developed attitudes and beliefs lead to a person performing or not performing the desired tehaviour Negative attitudes towards m ultiple m edication led to clients not complying with the prescribed treatment and diet COMPLLVNCE.
Thirty-percent of chets indicated that more than six tablets were left in their packages because they forgot to take tablets sometimes.The reasons given for this were • foigetfutaess.

EATING PATTERNS.
All clients were taking breakfast, lunch and sifljper and very few were taking snacks during the morning, afternoon or evening Although forty percent of the clients stated that diet was the topic most emphasized in the clinic, many cUents were not taking snacks.
Twenty percent of the cUents stated that failure to foUow their diet was due to lack of self discipline e.g.taking tea with sugar instead of with sweetners even if they were available A LCOHOL USE.
Thirty-three percent of the cUents were taking alcohol.AU were unaware of the dangers of alcohol.Omar, Christopher, Motala, Jailal and Seedat (1987) stated that recover)' from hypoglycaemia may be delayed due to alcoholinduced inhibition of gluconeogenesis ADDITIONAL FACTORS.
W hilst conducting the research it was observed that clients waited for a long time to be attended to in the clinic The clinic day is once per week on Thursdays, from 07hoo-14h00; there was one registered nurse to see the clients, and one doctor to see the clients Time spent with the clerk was thirt\' mmutes to one hour.Time spent with the registered nurse was approximatetly forty minutes to one hour, time spent with the doctor was ten to fifteen minutes and time spent while waiting for the laboratorv results ranged from one to two hours.
The total amount of time spent in the clmic was approxunatcly three hours and forty mmutes RECOM M ENDATIONS AND CONCLUSION.
1 The clinic booking system needs to be revised to avoid long waiting penods Snacks should be provided m orda to meet the nutntional needs of the diabetic patients, who spent up to four hours at the clinic 2 There is a need for ui-service education for health professionals who manage the diabetic patients, to improve the education of patients.The inadequacy of nuises was shown when respondants ' indicated that they were never given health education on topics such as shaking out their shoes before wearing them.
The education of diabetics needs to be planned and implemented according to their needs.Frequent evaluation of the effectiveness of teaching should be implemented.
3. Nutrition and dietary advice should be included in health education of the cUents.A follow up, by means of home visits, should be done in order to give appropriate advice based on available resouces in the patient's home surroundings.
4. FamiUes, friends, reUgious groups, womens' clubs and other social groups could be actively involved in the teaching and counseUing of the diabetic pateints.Friends also play an important role in the prevention of self destructive behaviours such as alcohol consumption and smoking.
The study revealed that diabetic care in a poverty stncken population is a challenge as people are faced with many social and economic problems.
2 To establish whether diabetic patients are able to keep appomtments with the clinic 3 To identify factors that mfluence and prevent patients from keeping appointments with the clmic THEORETICA L FRAM EW ORK This study is based on the