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1.  Prevalence and Determinants of Diabetic Retinopathy in Al Hasa Region of Saudi Arabia: Primary Health Care Centre Based Cross-Sectional Survey, 2007–2009 
Purpose:
To evaluate the prevalence of diabetic retinopathy (DR) in the urban and rural areas of Al Hasa region of Saudi Arabia and to determine risk factors related to DR.
Materials and Methods:
This study was conducted on patient attending primary health care centers between July 2007 and June 2009. A retrospective chart review was conducted on subjects with diabetes mellitus greater than 18 years old. Ophthalmologists examined DR status through dilated pupils by using direct, indirect, and slit lamp bio-microscopy. Frequencies, percentage, and their 95% confidence intervals (CIs) were calculated. Odd’s ratio was used to associate DR with possible risk factors. A P value less than 0.05 was considered statistically significant.
Results:
The prevalence of DR among 473 diabetic subjects was 30% (95% CI: 25.80–34.20). The odd ratios (ORs) of DR among diabetic residing in an urban area was significantly higher than diabetics residing in rural areas [OR = 1.94 (95% CI of OR 0.82–2.89)]. DR was associated to the duration of diabetes (adjusted OR = 1.70), uncontrolled blood sugar level (adjusted OR = 1.96), hyperlipidemia (adjusted OR = 2.04), and hypercholesterolemia (adjusted OR = 2.80).
Conclusions:
DR appears to be a public health problem in the Al Hasa district of Saudi Arabia, and a planned approach is required to avoid severe visual impairment in patients with diabetes mellitus. Primary prevention and early detection could be implemented through primary health centers and non-ophthalmologists.
doi:10.4103/0974-9233.65502
PMCID: PMC2934719  PMID: 20844683
Diabetes Mellitus; Diabetic Retinopathy; Prevention of Blindness; Primary Health Care Centers
2.  Compliance to Anti-Diabetic Drugs: Observations from the Diabetic Clinic of a Medical College in Kolkata, India 
Background: The poor glycaemic control among the patients with type 2 diabetes constitutes a major public health problem and a major risk factor for the development of diabetes complications.
Aim of the Study: To study the compliance rate of the patients with type 2 diabetes to the prescribed medications, to find out its correlation with different socio-demographic factors and other patient characteristics and to find out the reasons behind the non-compliance, if any.
Settings and Design: This cross sectional study was conducted on the patients with type 2 diabetes, who Attended the Diabetic Clinic of a Medical College in Kolkata, India.
Methods and Material: The patients of type 2 diabetes who attended the diabetes clinic between April to August 2012 were recruited in the study by systematic random sampling and they were interviewed by using the help of a structured interview schedule. The patients who reported taking less than 80% of their prescribed anti-diabetes medicines in the preceding week and had HbA1C of < 7% were considered to be non-compliant.
Statistical Analysis Used: The data was analyzed by using the SPSS software. The Chi-square test was used to assess the association of the compliance with the different study variables. A binary logistic regression analysis helped in identifying the factors which contributed to the non-compliance.
Results: The compliance rate to the anti-diabetic drugs was found to be 57.7%. A univariate analysis showed that it decreased significantly with increasing age and that it was also significantly lower among males, illiterates, those with a poor per capita monthly income and those who had a longer duration of diabetes. It varied significantly with the type of drugs, being lowest with an oral drug and insulin combination (43.4%). No knowledge on the complications of diabetes was significantly associated with a lower compliance. The binary logistic regression also helped in identifying these as the significant contributory factors. The common reasons behind the non-compliance were forgetfulness (44.7%) and financial constraints (32.7%).
Conclusion: It can be concluded that the compliance to anti-diabetic drugs was quite poor among the participants. Increasing age, the male sex, illiteracy, a low monthly income and a longer duration of diabetes were significantly associated with the non compliance. A more concerning fact was the significant association of the non-compliance with the types of drug regimens and a lack of knowledge on the complications of diabetes, which emphasized the role of a repeated patient education regarding the basic aspects of diabetes.
doi:10.7860/JCDR/2013/5352.2876
PMCID: PMC3644439  PMID: 23730641
Type 2 diabetes; Anti-Diabetic drugs; Compliance
3.  Socio-demographic Determinants of Compliance among Type 2 Diabetic Patients in Abha, Saudi Arabia 
Background and Objectives: Saudi Arabia has one of the highest prevalence of diabetes. This study was conducted with the following objectives: (1) To study the socio-demographic profile of diabetic patients in Abha. (2) To find the socio-demographic determinants of compliance among diabetic patients in Abha.
Material and Methods: A self administered questionnaire which had detailed the socio-demographic features and various aspects of compliance was used on a random sample of registered diabetics at two primary health care centres of Abha.
Results: Most of the patients (70.4 percent) were between 40-60 years age. Most of the patients were men (about 60 percent) and Saudis. Majority of patients did not have a university education. Young patients (age<40) were more compliant with all aspects of management, except medication (23.8 percent). Women were significantly more compliant with exercise (49.7 percent), while men were significantly more compliant with follow up (81.1 percent). Saudi patients were significantly compliant with medication (79.2 percent), while non Saudis were compliant with exercise (62.9 percent). All single patients were diet compliant. Smokers were significantly less compliant with exercise. Patients with normal BMI were significantly more compliant with diet and exercise.
Conclusion: Patients were found to be generally less compliant towards the regimen. Socio-demographic factors which were significantly associated with non compliance were age, gender, nationality, educational status, marital status, smoking status and BMI.
doi:10.7860/JCDR/2013/6986.3708
PMCID: PMC3919358  PMID: 24551644
Diabetes; Socio-demographic; Compliance; Saudi Arabia
4.  Impact of an education program on patient anxiety, depression, glycemic control, and adherence to self-care and medication in Type 2 diabetes 
Background:
Diabetes mellitus (DM) requires continuous medical care, patients’ self-management, education, and adherence to prescribed medication to reduce the risk of long-term complications. The aim of this study was to assess the benefits of an education program on diabetes, patient self-management, adherence to medication, anxiety, depression and glycemic control in type 2 diabetics in Saudi Arabia.
Materials and Methods:
This was a prospective study, conducted among 104 diabetic patients at a major tertiary hospital in Riyadh, Saudi Arabia, between May 2011 and October 2012. Education materials given to diabetic patients included pamphlets/handouts written in Arabic, the national language. Special videotapes about DM were made and distributed to all participants. In addition, specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged. Patients were interviewed using a structured interview schedule both during the baseline, and after 6 months of the program. The interview schedule included, socio-demographics, clinical characteristics, diabetes self-management, adherence to medication, anxiety, and depression. Glycemic control was considered poor, if hemoglobin A1c (HbA1c) was ≥ 7%.
Results:
The mean age of the study population was 57.3 ± 14.4 years. Seventy one were males (68.3%) and 33 (31.7%) were females. After six months of the diabetes education program, there were significant improvements in patients’ dietary plan (P = 0.0001), physical exercise (P = 0.0001), self-monitoring of blood glucose (SMBG) (P = 0.0001), HbA1c (P = 0.04), adherence to medication (P = 0.007), and depression (P = 0.03).
Conclusions:
Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan, physical exercise, SMBG, adherence to medication, HbA1c and depression.
doi:10.4103/2230-8229.114766
PMCID: PMC3748651  PMID: 23983558
Anxiety; depression; diabetes education; diabetes self-management; Saudi Arabia
5.  Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia 
Background
The prevalence of childhood bronchial asthma in Saudi Arabia has increased in less than a decade from 8% to 23%. Innovations in the management of asthma led to the development of evidence based clinical practice guidelines and protocols to improve the patients’ outcomes. The objectives of this study are to examine the compliance of the healthcare providers in the Pediatrics Emergency Department, in King Khalid University Hospital, with the recommendations of the Pediatrics Asthma Management Protocol (PAMP), and to explore the reasons behind non-adherence.
Methods
This study is designed in 2 parts, a patients’ chart review and a focus group interview. The medical records of all the children who presented to the Pediatric Emergency Department (PED) and were diagnosed as asthmatic, during the period from the 1st of January 2009 to the 31st of March 2009, were reviewed to investigate the compliance of healthcare providers (physicians and nurses) with 8 recommendations of the PAMP which are considered to be frequently encountered evidence-practice gaps, and these are 1) documentation of asthma severity grading by the treating physician and nurse 2) limiting the prescription of Ipratropium for children with severe asthma 3) administration of Salbutamol through an inhaler and a spacer 4) documentation of parental education 5) prescription of systemic corticosteroids to all cases of acute asthma 6) limiting chest x-ray requisition for children with suspected chest infection 7) management of all cases of asthma as outpatients, unless diagnosed as severe or life threatening asthma 8) limiting prescription of antibiotics to children with chest infection. The second part of this study is a focus group interview designed to elicit the reasons behind non- adherence to the recommendations detected by the chart review. Two separate focus group interviews were conducted for 10 physicians and 10 nurses. The focus group interviews were tape-recorded and transcribed verbatim. Theory-based content analysis was used to analyze interviews into themes and sub-themes.
Results and discussion
A total of 657 charts were reviewed. The percentage of adherence by the healthcare providers to the 8 previously mentioned recommendations was established. There was non-adherence to the first 5 of the 8 aforementioned recommendations. Analysis of the focus group interview revealed 3 main themes as reasons behind non-compliance to the 5 recommendations mentioned above and those are 1) factors related to the organization, 2) factors related to the asthma management protocol 3) factors related to healthcare providers.
Conclusion
The organizational barriers and the lack of an implementation strategy for the protocol, in addition to the attitude and beliefs of the healthcare providers, are the main factors behind non-compliance to the PAMP recommendations.
doi:10.1186/1472-6963-12-226
PMCID: PMC3464177  PMID: 22846162
6.  Prognostic value of physicians' assessment of compliance regarding all-cause mortality in patients with type 2 diabetes: primary care follow-up study 
BMC Family Practice  2006;7:42.
Background
Whether the primary care physician's assessment of patient compliance is a valuable prognostic marker to identify patients who are at increased risk of death, or merely reflects measurement of various treatment parameters such as HbA1C or other laboratory markers is unclear. The objective of this prospective cohort study was to investigate the prognostic value of the physicians' assessment of patient compliance and other factors with respect to all-cause mortality during a one year follow-up period.
Methods
A prospective cohort study was conducted among 1014 patients with type 2 diabetes aged 40 and over (mean age 69 years, SD 10.4, 45% male) who were under medical treatment in 11 participating practices of family physicians and internists working in primary care in a defined region in South Germany between April and June 2000. Baseline data were gathered from patients and physicians by standardized questionnaire. The physician's assessment of patient compliance was assessed by means of a 4-point Likert scale (very good, rather good, rather bad, very bad). In addition, we carried out a survey among physicians by means of a questionnaire to find out which aspects for the assessment of patient compliance were of importance to make this assessment. Active follow-up of patients was conducted after one year to determine mortality.
Results
During the one year follow-up 48 (4.7%) of the 1014 patients died. Among other factors such as patient type (patients presenting at office, nursing home or visited patients), gender, age and a history of macrovascular disease, the physician's assessment of patient compliance was an important predictor of all-cause mortality. Patients whose compliance was assessed by the physician as "very bad" (6%) were significantly more likely to die during follow-up (OR = 2.67, 95% CI 1.02–6.97) after multivariable adjustment compared to patients whose compliance was assessed as "rather good" (45%) or "very good" (18%). The HbA1C-value and the cholesterol level at baseline showed no statistically significant association with all-cause mortality. According to our survey for most of the physicians self-acceptance of disease, treatment adherence, patient's interest in physician's explanations, attendance at appointments, a good self-management, and a good physician-patient relationship were key elements in the assessment of patient compliance.
Conclusion
The primary care physician's assessment of patient compliance is a valuable prognostic marker for mortality among patients with type 2 diabetes. Identification of patients in need of improved compliance may help to target preventive measures.
doi:10.1186/1471-2296-7-42
PMCID: PMC1533834  PMID: 16824234
7.  Impact of health education on compliance among patients of chronic diseases in Al Qassim, Saudi Arabia 
Objective:
The aim of this study is to assess the impact of health education on diet, smoking and exercise among patients with chronic diseases (coronary artery disease, hypertension and type 2 diabetes mellitus) in Al Qassim Region in Saudi Arabia.
Methods:
We used data from a clustered experimental study in selected primary health care (PHC) centers in Al-Qassim. The study was conducted during January to October 2009 to assess the impact of an enhanced health education program on smoking, diet and exercise. The intervention comprised refresher training of PHC centers’ staff to improve communication skills and use of health education materials. Special health education sessions in the PHC centers were also organized with the help of medical students from Qassim University. Target population included patients of chronic diseases as well as patients visiting for other complaints. Baseline and end-line surveys were conducted to assess the impact of health education program on the prevalence of smoking, unhealthy diet and physical inactivity. The sample size was estimated to detect the impact of health education on these risk factors. Data were analyzed using SPSS (version 11.5) to conduct multivariate analysis to assess the impact of health education among chronic disease patients.
Results:
At baseline, chronic disease patients had generally healthier diet and did more exercise than patients of other diseases. Among chronic disease patients, significant improvements in smoking, diet and exercise habits were observed at end-line survey compared to baseline. These changes persisted after controlling for age, sex, marital status and education.
Conclusion:
We conclude that health education for patients visiting the PHC centers for follow-up of chronic diseases will significantly improve compliance to doctor’s advice regarding smoking, diet and exercise.
PMCID: PMC3068830  PMID: 21475552
health education; lifestyle chronic diseases
8.  Implementation of the world health organization hand hygiene improvement strategy in critical care units 
Background
To determine hand hygiene compliance before and after an intervention campaign in critical care units, this study was carried out in the Intensive care unit (ICU), Neonatal intensive care unit (NICU), Burns unit (BU) and the Kidney unit of the King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia. The observation using the WHO hand hygiene protocol took place in four phases with phase I, between April 24-May 06 2010 and phase II from May 29-June 09 2010. An educational intervention took place between the Phases I and II. Follow-up Phases III and IV were from 01–15 October 2010 and 15–30 March 2011 respectively.
Findings
1,975 hand hygiene opportunities comprising of 409 in Phase I, 406 in Phase II, 620 in Phase III and 540 Phase IV were observed. Compliance rate was 67% pre-intervention, 81% in phase II, declining to 59% and 65% in phases III and IV. Increased compliance in the ICU from 39% in Phase I to 81% in Phase IV (p < 0.05) was sustained throughout the study. Highest compliance rates were recorded among nurses in all phases. The improved compliance for physicians observed in the post-intervention phase was lost in follow-up phases. Missed opportunities for hand hygiene were before patient contact, after touching patient’s surrounding and before aseptic techniques. Team-work and leadership were identified as enhancing factors for compliance.
Conclusion
The WHO hand hygiene strategy combined with health education, continuous evaluation and team approach resulted in increased compliance but this was not sustained in certain critical care areas.
doi:10.1186/2047-2994-2-15
PMCID: PMC3673893  PMID: 23673017
Hand hygiene; Critical care; Infection control; WHO strategy
9.  ERECTILE DYSFUNCTION AMONG DIABETIC PATIENTS IN SAUDI ARABIA: A HOSPITAL-BASED PRIMARY CARE STUDY 
Objectives:
The aim of the present study was to estimate the prevalence of erectile dysfunction in men with diabetes mellitus attending a primary care clinic in King Khalid University Hospital, Riyadh, Saudi Arabia.
Methods:
A cross sectional study was carried out on men with diabetes mellitus followed in a primary care clinic of King Khalid University Hospital in Riyadh, Saudi Arabia, from 13 November 2005 to 13 June 2006. A total of 186 diabetic patients were interviewed. Data collection forms were completed by a member of the medical staff, a family medicine consultant, during the consultation of diabetic patients in the primary care clinic. Erectile dysfunction was categorized as absent erectile dysfunction (normal function), partial erectile dysfunction, and complete erectile dysfunction. The data was analyzed using the Statistical Package of Social Science (SPSS) version 11.5. A p-value of less than 0.05 was considered statistically significant.
Results:
A total of 186 men with diabetes mellitus were interviewed during the study period. The majority of diabetic patients (95%) had type 2 diabetes. Most of the patients (68.8%) were on oral hypoglycemic agents, 24.7% on insulin injection, and 6.5% on diet only. The present study showed that 11.2% of the diabetic patients were suffering from complete and severe erectile dysfunction, while 64% of the patients complained of partial erectile dysfunction which was affecting their marital relationship. The cardiovascular risk factors in the 186 diabetic patients were hypertension 34.9%, smoking 13.4%, obesity 40%, and dyslipidemia 16.6%.
Conclusions:
Complete (severe) and partial erectile dysfunction was quite common among adult diabetic patients in a hospital-based primary care setting in Saudi Arabia. It is important for primary care physicians to diagnose erectile dysfunction in diabetic patients, and to counsel them early, as most patients are hesitant to discuss their concern during a consultation. Further studies are recommended to evaluate the effect of other risk factors on erectile dysfunction in diabetic patients.
PMCID: PMC3410114  PMID: 23012139
Erectile dysfunction; diabetes; primary care
10.  Determinants of misconceptions about diabetes among Saudi diabetic patients attending diabetes clinic at a tertiary care hospital in Eastern Saudi Arabia 
Objective:
To identify the determinants of misconceptions about diabetes in patients registered with a diabetes clinic at a tertiary care hospital in Eastern Saudi Arabia.
Materials and Methods:
This cross-sectional survey was carried out at a diabetes clinic of a tertiary care hospital in Eastern Saudi Arabia, from January to December 2012. A total of 200 diabetic patients were interviewed using a questionnaire comprising 36 popular misconceptions. The total misconception score was calculated and categorized into low (0-12), moderate (13-24) and high (25-36) scores. The association of misconception score with various potential determinants was calculated using Chi-square test. Step-wise logistic regression was applied to the variables showing significant association with the misconception score in order to identify the determinants of misconceptions.
Results:
The mean age was 39.62 ± 16.7 and 112 (56%) subjects were females. Type 1 diabetics were 78 (39%), while 122 (61%) had Type 2 diabetes. Insulin was being used by 105 (52.5%), 124 (62%) were self-monitoring blood glucose and 112 (56%) were using diet control. Formal education on diabetes awareness had been received by 167 (83.5%) before the interview. The mean misconception score was 10.29 ± 4.92 with 115 (57.5%) subjects had low misconception scores (<12/36). On the Chi-square test, female gender, rural area of residence, little or no education, <5 or >15 years since diagnosis, no self-monitoring, no dietary control and no diabetes education were all significantly (P < 0.05) associated with higher misconception scores. Step-wise logistic regression suggested that diabetes education, gender, education and time since diagnosis were significant (P < 0.05) predictors of misconception scores.
Conclusions:
The strongest determinants of misconceptions about diabetes in our study population were female gender, rural area of residence, illiteracy or little education, <5 or >15 years since diagnosis, no self-monitoring, no diet control and no education about diabetes.
doi:10.4103/2230-8229.134764
PMCID: PMC4073566  PMID: 24987277
Diabetes; determinants; misconceptions; myths; Saudi Arabia
11.  Junctures to the therapeutic goal of diabetes mellitus: Experience in a tertiary care hospital of Kolkata 
Journal of Mid-Life Health  2011;2(1):31-36.
Introduction:
The World Health Organization has declared India as the “diabetic capital” of the world. In controlling of such chronic, mostly asymptomatic disease, patients’ role can’t be overemphasized.
Aims:
To assess the level of compliance to anti-diabetic therapies and to ascertain the determinants of non-compliance, if any.
Materials and Methods:
A cross-sectional observational study was conducted for 3 months in a diabetic clinic of R G Kar Medical College and Hospital, Kolkata. Data were collected by interviewing the patients, examining their prescriptions and laboratory reports and anthropometry after obtaining informed consent.
Results:
Blood report at the point of data collection revealed controlled glucose homeostasis in 38.93% patients but evaluation of past 3 months report showed only 24.3% had control over hyperglycemia. Glycemic control was seen to be positively related to short duration of disease, compliance to therapies, and high knowledge about diabetes. Compliance to therapies found in 32.22% of study subjects was in turn associated with short duration of disease. House-wives showed poor compliance; insulin treatment with or without oral-anti-diabetic agent showed better compliance. Knowledge of diabetes was significantly high among higher educated; poor among women, house-wives, and rural people.
Conclusion:
Patient-providers collaboration is to be developed through a patient-centered care model based on the mutual responsibility of both so that each patient is considered in the mesh of his/her other goals of life and helped to promote empowerment to take informed decision for behavioral change conducive to control the disease.
doi:10.4103/0976-7800.83271
PMCID: PMC3156499  PMID: 21897737
Adherence; compliance; diabetic-knowledge; glycemic control
12.  Factors associated with non-adherence to insulin in patients with type 1 diabetes 
Objectives: To find out the various factors associated with non-adherence to diet, physical activity and insulin among patients with type 1 diabetes. (T1DM).
Methods: This cross sectional study was conducted among T1DM subjects attending the Baqai Institute of Diabetology & Endocrinology (BIDE) and Diabetic Association of Pakistan (DAP), from July 2011 to June 2012.Clinical characteristics, anthropometric measurements, knowledge regarding type 1 diabetes along with adherence to dietary advice, physical activity and insulin were noted on a predesigned questionnaire and score was assigned to each question. Patients were categorized as adherent or non-adherent on the basis of scores obtained. Statistical Package for Social Sciences (SPSS) for windows version 17.0 was used to analyze the data.
Results: A total of 194 patients (Male 94, Female 100), with mean age of 17.9± 6.4 years, mean duration of diabetes 5.37±4.96 years (38.1% >5 yrs, 61.9% <5 yrs) were included in the study. One hundred and fourteen (58.5%) patients were non adherent to dietary advice, 82(42.3%) non adherent to physical activity while 88.1% respondents were non adherent to their prescribed insulin regimen. Factors associated with non-compliance were family type, occupation & educational level of respondent’s parents, duration of T1DM, family history of diabetes, frequency of visits to diabetic clinic, knowledge regarding diabetes, lack of family support and fear of hypoglycemia.
Conclusion: Non adherence to prescribed treatment regimen in patient with TIDM is quite high. There is need to design strategies to help patients and their family members understand their treatment regimen in order to improve their adherence.
PMCID: PMC3998985  PMID: 24772118
Non-adherence; Patients with type 1 diabetes
13.  The Role of Educational Level in Glycemic Control among Patients with Type II Diabetes Mellitus 
Objectives
To evaluate the impact of the educational level on glycemic control among patients with type II diabetes mellitus.
Methods
A disproportional systematic stratified sample of 384 patients, based on educational level, was selected from patients of type II diabetes attending the Primary Care Clinic of King Khalid University Hospital, over a period of 6 months in 2012–2013. A questionnaire sought information about socio-demographic factors, clinical characteristics, awareness of diabetic complications and self-care management behaviors. Weight and height were measured. Poor glycemic control was defined as HbA1c ≥7%.
Result
The rate of patients who had poor glycemic control is 67.7%. The educational level had no impact on glycemic control, but the patients of high educational level had better awareness of the complications and a high rate of adherence to diet. About 70.5% of patients were aware of two or more diabetic complications. The factors associated with poor control included increased duration of diabetes, use of insulin and oral hypoglycemic agents combination, being obese or overweight, poor adherence to diet, poor adherence to exercise and poor compliance with follow up. This study found a high rate of poor adherence to diet (68%) and poor adherence to exercise (79.4%).
Conclusion
The proportion of patients with poor glycemic control was high in this study. This study showed that educational level may not be a good predictor of better therapeutic compliance. In-spite of the significant importance of appropriate diet and exercise in the control of diabetes, there was a high rate of poor adherence to diet and to exercise, especially among females. Educational programs that emphasize adherence to treatment regimens as a whole, especially to diet, to exercise and to regular follow up are of greater benefit in glycemic control as compared to compliance of medications alone.
PMCID: PMC4166990  PMID: 25246885
Primary care clinic; diabetes mellitus type 2; educational level; awareness of diabetic complications; glycemic control
14.  Vitamin D Deficiency in Patients with Type-2 Diabetes Mellitus in Southern Region of Saudi Arabia 
Mædica  2013;8(3):231-236.
ABSTRACT
Introduction: Type-2 diabetes mellitus and Vitamin D deficiency are both common in Saudi Arabian population. New roles of vitamin D have emerged recently especially in the prevention of cardiovascular disease, cancer and insulin resistance.
Objective: To estimate 25-OH vitamin D deficiency in patients with type-2 diabetes mellitus in comparison to normal age-matched non-diabetic control population. Methods: A Randomized Case-Control study was done in three tertiary care hospitals in Southern Region, Saudi Arabia from June 2010 to June 2012 and 345 patients were selected; 172 in the diabetic group and 173 in the non-diabetic group. Biochemical workup and 25-OH vitamin D levels were done.
Results: The mean serum 25-OH vitamin D levels in the diabetic group were 15.7 + 7.5 ng/mL as compared healthy non-diabetic group having 11.1 + 5.9 ng/mL and a total of 340 patients (98.5%) from both groups were found to be deficient in 25-OH vitamin D which is the highest reported so far in Saudi Arabia.
Conclusion: The population in our study was generally deficient in 25-OH vitamin D irrespective of diabetes mellitus indicating a greater need for vitamin D supplementation.
PMCID: PMC3869110  PMID: 24371490
vitamin D deficiency; Saudi Arabia; sunlight exposure; diabetes mellitus
15.  GPs' perspectives of type 2 diabetes patients' adherence to treatment: A qualitative analysis of barriers and solutions 
BMC Family Practice  2005;6:20.
Background
The problem of poor compliance/adherence to prescribed treatments is very complex. Health professionals are rarely being asked how they handle the patient's (poor) therapy compliance/adherence. In this study, we examine explicitly the physicians' expectations of their diabetes patients' compliance/adherence. The objectives of our study were: (1) to elicit problems physicians encounter with type 2 diabetes patients' adherence to treatment recommendations; (2) to search for solutions and (3) to discover escape mechanisms in case of frustration.
Methods
In a descriptive qualitative study, we explored the thoughts and feelings of general practitioners (GPs) on patients' compliance/adherence. Forty interested GPs could be recruited for focus group participation. Five open ended questions were derived on the one hand from a similar qualitative study on compliance/adherence in patients living with type 2 diabetes and on the other hand from the results of a comprehensive review of recent literature on compliance/adherence. A well-trained diabetes nurse guided the GPs through the focus group sessions while an observer was attentive for non-verbal communication and interactions between participants. All focus groups were audio taped and transcribed for content analysis. Two researchers independently performed the initial coding. A first draft with results was sent to all participants for agreement on content and comprehensiveness.
Results
General practitioners experience problems with the patient's deficient knowledge and the fact they minimize the consequences of having and living with diabetes. It appears that great confidence in modern medical science does not stimulate many changes in life style. Doctors tend to be frustrated because their patients do not achieve the common Evidence Based Medicine (EBM) objectives, i.e. on health behavior and metabolic control. Relevant solutions, derived from qualitative studies, for better compliance/adherence seem to be communication, tailored and shared care. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase compliance/adherence. It was recognized that the GP's efforts do not always meet the patients' health expectations. This initiates GPs' frustration and leads to a paternalistic attitude, which may induce anxiety in the patient. GPs often assume that the best methods to increase compliance/adherence are shocking the patients, putting pressure on them and threatening to refer them to hospital.
Conclusion
GPs identified a number of problems with compliance/adherence and suggested solutions to improve it. GPs need communication skills to cope with patients' expectations and evidence based goals in a tailored approach to diabetes care.
doi:10.1186/1471-2296-6-20
PMCID: PMC1156882  PMID: 15890071
16.  DIETARY MISCONCEPTIONS AMONG DIABETIC PATIENTS IN MAKKA CITY, SAUDI ARABIA 
Objectives:
To assess the prevalence of some dietary misconceptions among primary health care center-registered diabetic patients in Makka City, Saudi Arabia.
Methods:
A sample of 1039 primary health care center- registered diabetic patients was interviewed using a structured questionnaire on diabetic diet -related misconceptions. A scoring system was used to document the frequency of misconceptions. The relationship of the misconceptions to socio-demographic and diabetes-related variables was assessed using chi-squared tests.
Results:
Most patients (68.7%) had a high diet misconception score. More than half of the sample had the misconception that carbohydrates were to be completely eliminated from the diet, and only dried bread and bitter foods were to be consumed. Data included the belief in the consumption of honey and dates; the omission of snacks; belief in the carcinogenicity of the sugar substitutes; and obesity as a sign of good health. The score was significantly higher among males (p<0.01), patients older than 35 years (p<0.02), and among patients whose level of education was low (p<0.01).
Conclusion:
It is important to note that the rate of diet-related misconceptions among diabetics in Makka city is high. The study pointed to the target fraction of diabetic patients among whom these misconceptions prevailed. There is a need for constant motivation and appropriate education at frequent intervals to encourage better knowledge of the disease so that there is compliance to treatment.
PMCID: PMC3430184  PMID: 23008671
Misconceptions; diabetes; diet; Saudi Arabia
17.  Is there any relationship between medication compliance and affective temperaments in patients with type 2 diabetes? 
Background
Type 2 diabetes mellitus (DM) is the most common type of diabetes.The number of patients with this disease is expected torise in future. Given the increasing prevalence of diabetes, there is an urgent need for the treatment of diabetes and the associated complications. Glycemic control largely depends on compliance with medication therapies. In fact, the most common problem in patients with diabetes is lack of medication compliance. This study aimed to determine the relationship between affectivetemperaments and medication compliance in patients with type 2 diabetes.
Methods
In this cross-sectional research, the study population consisted of all patients referring to the endocrinology clinic of Ayatollah Taleghani Hospital of Tehran in 2010 and 2011. Two hundreds and seven patients were selected, using available sampling method. In this study, we used Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto questionnaire (TEMPS-A), a single-item scale of medication compliance, Beck Depression Inventory-II (BDI-II), and a researcher-made questionnaire to assess the patients’ demographic information. All participants completed the questionnaires related to affective temperaments, medication compliance, depression and demographic information. The obtained data were recorded on the prepared sheets.
Results
Of 207 patients, 79 (38.2%) and 128 (61.8%) subjects were male and female, respectively. The mean and standard deviation of demographic data were calculated. In total, 13.5%, 19.3%, and 8.2%of the participants had mild, moderate, and severe depression, respectively. In this study, as the single-item rating scale indicated, medication compliance and non-compliance were reported in 75.4% and 24.6% of the patients, respectively. Among the demographic characteristics and clinical variables, frequency of patient referral and glycated hemoglobin level were predictors of medication compliance. Also, among affective temperaments, irritable temperament was a predictor of medication compliance.
Conclusions
The obtained findings emphasize the importance of psychological factors such as personality characteristics in medication compliance of patients with diabetes. In case a patient obtains high scores in irritable temperament (which indicate poor medication compliance), he/she should follow special training programs to improve his/her medication compliance.
doi:10.1186/s40200-014-0096-z
PMCID: PMC4180133  PMID: 25276668
Medication compliance; Affective temperaments; Type 2 diabetes
18.  Association of Lifecourse Socioeconomic Status with Chronic Inflammation and Type 2 Diabetes Risk: The Whitehall II Prospective Cohort Study 
PLoS Medicine  2013;10(7):e1001479.
Silvia Stringhini and colleagues followed a group of British civil servants over 18 years to look for links between socioeconomic status and health.
Please see later in the article for the Editors' Summary
Background
Socioeconomic adversity in early life has been hypothesized to “program” a vulnerable phenotype with exaggerated inflammatory responses, so increasing the risk of developing type 2 diabetes in adulthood. The aim of this study is to test this hypothesis by assessing the extent to which the association between lifecourse socioeconomic status and type 2 diabetes incidence is explained by chronic inflammation.
Methods and Findings
We use data from the British Whitehall II study, a prospective occupational cohort of adults established in 1985. The inflammatory markers C-reactive protein and interleukin-6 were measured repeatedly and type 2 diabetes incidence (new cases) was monitored over an 18-year follow-up (from 1991–1993 until 2007–2009). Our analytical sample consisted of 6,387 non-diabetic participants (1,818 women), of whom 731 (207 women) developed type 2 diabetes over the follow-up. Cumulative exposure to low socioeconomic status from childhood to middle age was associated with an increased risk of developing type 2 diabetes in adulthood (hazard ratio [HR] = 1.96, 95% confidence interval: 1.48–2.58 for low cumulative lifecourse socioeconomic score and HR = 1.55, 95% confidence interval: 1.26–1.91 for low-low socioeconomic trajectory). 25% of the excess risk associated with cumulative socioeconomic adversity across the lifecourse and 32% of the excess risk associated with low-low socioeconomic trajectory was attributable to chronically elevated inflammation (95% confidence intervals 16%–58%).
Conclusions
In the present study, chronic inflammation explained a substantial part of the association between lifecourse socioeconomic disadvantage and type 2 diabetes. Further studies should be performed to confirm these findings in population-based samples, as the Whitehall II cohort is not representative of the general population, and to examine the extent to which social inequalities attributable to chronic inflammation are reversible.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Worldwide, more than 350 million people have diabetes, a metabolic disorder characterized by high amounts of glucose (sugar) in the blood. Blood sugar levels are normally controlled by insulin, a hormone released by the pancreas after meals (digestion of food produces glucose). In people with type 2 diabetes (the commonest form of diabetes) blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing sugar from the blood become insulin resistant. Type 2 diabetes, which was previously called adult-onset diabetes, can be controlled with diet and exercise, and with drugs that help the pancreas make more insulin or that make cells more sensitive to insulin. However, as the disease progresses, the pancreatic beta cells, which make insulin, become impaired and patients may eventually need insulin injections. Long-term complications, which include an increased risk of heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.
Why Was This Study Done?
Socioeconomic adversity in childhood seems to increase the risk of developing type 2 diabetes but why? One possibility is that chronic inflammation mediates the association between socioeconomic adversity and type 2 diabetes. Inflammation, which is the body's normal response to injury and disease, affects insulin signaling and increases beta-cell death, and markers of inflammation such as raised blood levels of C-reactive protein and interleukin 6 are associated with future diabetes risk. Notably, socioeconomic adversity in early life leads to exaggerated inflammatory responses later in life and people exposed to social adversity in adulthood show greater levels of inflammation than people with a higher socioeconomic status. In this prospective cohort study (an investigation that records the baseline characteristics of a group of people and then follows them to see who develops specific conditions), the researchers test the hypothesis that chronically increased inflammatory activity in individuals exposed to socioeconomic adversity over their lifetime may partly mediate the association between socioeconomic status over the lifecourse and future type 2 diabetes risk.
What Did the Researchers Do and Find?
To assess the extent to which chronic inflammation explains the association between lifecourse socioeconomic status and type 2 diabetes incidence (new cases), the researchers used data from the Whitehall II study, a prospective occupational cohort study initiated in 1985 to investigate the mechanisms underlying previously observed socioeconomic inequalities in disease. Whitehall II enrolled more than 10,000 London-based government employees ranging from clerical/support staff to administrative officials and monitored inflammatory marker levels and type 2 diabetes incidence in the study participants from 1991–1993 until 2007–2009. Of 6,387 participants who were not diabetic in 1991–1993, 731 developed diabetes during the 18-year follow-up. Compared to participants with the highest cumulative lifecourse socioeconomic score (calculated using information on father's occupational position and the participant's educational attainment and occupational position), participants with the lowest score had almost double the risk of developing diabetes during follow-up. Low lifetime socioeconomic status trajectories (being socially downwardly mobile or starting and ending with a low socioeconomic status) were also associated with an increased risk of developing diabetes in adulthood. A quarter of the excess risk associated with cumulative socioeconomic adversity and nearly a third of the excess risk associated with low socioeconomic trajectory was attributable to chronically increased inflammation.
What Do These Findings Mean?
These findings show a robust association between adverse socioeconomic circumstances over the lifecourse of the Whitehall II study participants and the risk of type 2 diabetes and suggest that chronic inflammation explains up to a third of this association. The accuracy of these findings may be affected by the measures of socioeconomic status used in the study. Moreover, because the study participants were from an occupational cohort, these findings need to be confirmed in a general population. Studies are also needed to examine the extent to which social inequalities in diabetes risk that are attributable to chronic inflammation are reversible. Importantly, if future studies confirm and extend the findings reported here, it might be possible to reduce the social inequalities in type 2 diabetes by promoting interventions designed to reduce inflammation, including weight management, physical activity, and smoking cessation programs and the use of anti-inflammatory drugs, among socially disadvantaged groups.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001479.
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health-care professionals, and the general public, including information on diabetes prevention (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes; it includes peoples stories about diabetes
The nonprofit Diabetes UK also provides detailed information about diabetes for patients and carers, including information on healthy lifestyles for people with diabetes, and has a further selection of stories from people with diabetes; the nonprofit Healthtalkonline has interviews with people about their experiences of diabetes
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
Information about the Whitehall II study is available
doi:10.1371/journal.pmed.1001479
PMCID: PMC3699448  PMID: 23843750
19.  Transmission and evolution of the Middle East respiratory syndrome coronavirus in Saudi Arabia: a descriptive genomic study 
Lancet  2013;382(9909):1993-2002.
Summary
Background
Since June, 2012, Middle East respiratory syndrome coronavirus (MERS-CoV) has, worldwide, caused 104 infections in people including 49 deaths, with 82 cases and 41 deaths reported from Saudi Arabia. In addition to confirming diagnosis, we generated the MERS-CoV genomic sequences obtained directly from patient samples to provide important information on MERS-CoV transmission, evolution, and origin.
Methods
Full genome deep sequencing was done on nucleic acid extracted directly from PCR-confirmed clinical samples. Viral genomes were obtained from 21 MERS cases of which 13 had 100%, four 85–95%, and four 30–50% genome coverage. Phylogenetic analysis of the 21 sequences, combined with nine published MERS-CoV genomes, was done.
Findings
Three distinct MERS-CoV genotypes were identified in Riyadh. Phylogeographic analyses suggest the MERS-CoV zoonotic reservoir is geographically disperse. Selection analysis of the MERS-CoV genomes reveals the expected accumulation of genetic diversity including changes in the S protein. The genetic diversity in the Al-Hasa cluster suggests that the hospital outbreak might have had more than one virus introduction.
Interpretation
We present the largest number of MERS-CoV genomes (21) described so far. MERS-CoV full genome sequences provide greater detail in tracking transmission. Multiple introductions of MERS-CoV are identified and suggest lower R0 values. Transmission within Saudi Arabia is consistent with either movement of an animal reservoir, animal products, or movement of infected people. Further definition of the exposures responsible for the sporadic introductions of MERS-CoV into human populations is urgently needed.
Funding
Saudi Arabian Ministry of Health, Wellcome Trust, European Community, and National Institute of Health Research University College London Hospitals Biomedical Research Centre.
doi:10.1016/S0140-6736(13)61887-5
PMCID: PMC3898949  PMID: 24055451
20.  Treatment Compliance among Patients with Hypertension and Type 2 Diabetes Mellitus in a Coastal Population of Southern India 
Background:
Hypertension and diabetes are major risk factors for cardiovascular and cerebrovascular disease. Adherence is a primary determinant of the effectiveness of treatment because poor adherence attenuates optimum clinical benefit and paves the way for complications.
Methods:
The cross-sectional community-based survey was carried out among men and women aged 30 years and above in the field practice area of a medical college to assess treatment compliance with respect to hypertension and type 2 diabetes mellitus. The study comprised of 426 subjects, already diagnosed with hypertension (287) and type 2 diabetes mellitus (139). During house visits, data were collected by personal face-to-face interview using a pre-tested structured questionnaire. Compliance was determined by indirect methods, which included self-reporting and interviews with the patients.
Results:
Compliance to hypertension treatment was found to be 82.2%, while 83.6% of individuals with type 2 diabetes mellitus were on regular medication. Among the individuals on regular medication, 88 (37.3%) of them had controlled blood pressure. Although the compliance was good, blood pressure control was not optimal. Adherence was better among females as compared with males. Literacy status and socio-economic background were not found to be associated with treatment compliance. High cost of treatment for hypertension (39.3%) and diabetes (30.4%) and asymptomatic nature of the disease were the most common reasons cited for not taking regular medications.
Conclusions:
Adherence to hypertension and diabetes treatment was good. High cost of medications and asymptomatic nature of the disease were the reasons identified among the non-adherent patients.
PMCID: PMC4258676  PMID: 25489447
Adherence; hypertension; treatment compliance; type 2 diabetes mellitus
21.  Muscle-Strengthening and Conditioning Activities and Risk of Type 2 Diabetes: A Prospective Study in Two Cohorts of US Women 
PLoS Medicine  2014;11(1):e1001587.
Anders Grøntved and colleagues examined whether women who perform muscle-strengthening and conditioning activities have an associated reduced risk of type 2 diabetes mellitus.
Please see later in the article for the Editors' Summary
Background
It is well established that aerobic physical activity can lower the risk of type 2 diabetes (T2D), but whether muscle-strengthening activities are beneficial for the prevention of T2D is unclear. This study examined the association of muscle-strengthening activities with the risk of T2D in women.
Methods and Findings
We prospectively followed up 99,316 middle-aged and older women for 8 years from the Nurses' Health Study ([NHS] aged 53–81 years, 2000–2008) and Nurses' Health Study II ([NHSII] aged 36–55 years, 2001–2009), who were free of diabetes, cancer, and cardiovascular diseases at baseline. Participants reported weekly time spent on resistance exercise, lower intensity muscular conditioning exercises (yoga, stretching, toning), and aerobic moderate and vigorous physical activity (MVPA) at baseline and in 2004/2005. Cox regression with adjustment for major determinants for T2D was carried out to examine the influence of these types of activities on T2D risk. During 705,869 person years of follow-up, 3,491 incident T2D cases were documented. In multivariable adjusted models including aerobic MVPA, the pooled relative risk (RR) for T2D for women performing 1–29, 30–59, 60–150, and >150 min/week of total muscle-strengthening and conditioning activities was 0.83, 0.93, 0.75, and 0.60 compared to women reporting no muscle-strengthening and conditioning activities (p<0.001 for trend). Furthermore, resistance exercise and lower intensity muscular conditioning exercises were each independently associated with lower risk of T2D in pooled analyses. Women who engaged in at least 150 min/week of aerobic MVPA and at least 60 min/week of muscle-strengthening activities had substantial risk reduction compared with inactive women (pooled RR = 0.33 [95% CI 0.29–0.38]). Limitations to the study include that muscle-strengthening and conditioning activity and other types of physical activity were assessed by a self-administered questionnaire and that the study population consisted of registered nurses with mostly European ancestry.
Conclusions
Our study suggests that engagement in muscle-strengthening and conditioning activities (resistance exercise, yoga, stretching, toning) is associated with a lower risk of T2D. Engagement in both aerobic MVPA and muscle-strengthening type activity is associated with a substantial reduction in the risk of T2D in middle-aged and older women.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Worldwide, more than 370 million people have diabetes mellitus, a disorder characterized by poor glycemic control—dangerously high amounts of glucose (sugar) in the blood. Blood sugar levels are normally controlled by insulin, a hormone released by the pancreas. In people with type 2 diabetes (the commonest form of diabetes), blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing excess sugar from the blood become less responsive to insulin. Type 2 diabetes, which was previously known as adult-onset diabetes, can often initially be controlled with diet and exercise, and with antidiabetic drugs such as metformin and sulfonylureas. However, as the disease progresses, the pancreatic beta cells, which make insulin, become impaired and patients may eventually need insulin injections. Long-term complications of diabetes, which include an increased risk of cardiovascular problems such as heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.
Why Was This Study Done?
Type 2 diabetes is becoming increasingly common worldwide so better preventative strategies are essential. It is well-established that regular aerobic exercise—physical activity in which the breathing and heart rate increase noticeably such as jogging, brisk walking, and swimming—lowers the risk of type 2 diabetes. The World Health Organization currently recommends that adults should do at least 150 min/week of moderate-to-vigorous aerobic physical activity to reduce the risk of diabetes and other non-communicable diseases. It also recommends that adults should undertake muscle-strengthening and conditioning activities such as weight training and yoga on two or more days a week. However, although studies have shown that muscle-strengthening activity improves glycemic control in people who already have diabetes, it is unclear whether this form of exercise prevents diabetes. In this prospective cohort study (a study in which disease development is followed up over time in a group of people whose characteristics are recorded at baseline), the researchers investigated the association of muscle-strengthening activities with the risk of type 2 diabetes in women.
What Did the Researchers Do and Find?
The researchers followed up nearly 100,000 women enrolled in the Nurses' Health Study (NHS) and the Nurses' Health Study II (NHSII), two prospective US investigations into risk factors for chronic diseases in women, for 8 years. The women provided information on weekly participation in muscle-strengthening exercise (for example, weight training), lower intensity muscle-conditioning exercises (for example, yoga and toning), and aerobic moderate and vigorous physical activity (aerobic MVPA) at baseline and 4 years later. During the study 3,491 women developed diabetes. After allowing for major risk factors for type 2 diabetes (for example, diet and a family history of diabetes) and for aerobic MVPA, compared to women who did no muscle-strengthening or conditioning exercise, the risk of developing type 2 diabetes among women declined with increasing participation in muscle-strengthening and conditioning activity. Notably, women who did more than 150 min/week of these types of exercise had 40% lower risk of developing diabetes as women who did not exercise in this way at all. Muscle-strengthening and muscle-conditioning exercise were both independently associated with reduced diabetes risk, and women who engaged in at least 150 min/week of aerobic MVPA and at least 60 min/week of muscle-strengthening exercise were a third as likely to develop diabetes as inactive women.
What Do These Findings Mean?
These findings show that, among the women enrolled in NHS and NHSII, engagement in muscle-strengthening and conditioning activities lowered the risk of type 2 diabetes independent of aerobic MVPA. That is, non-aerobic exercise provided protection against diabetes in women who did no aerobic exercise. Importantly, they also show that doing both aerobic exercise and muscle-strengthening exercise substantially reduced the risk of type 2 diabetes. Because nearly all the participants in NHS and NHSII were of European ancestry, these results may not be generalizable to women of other ethnic backgrounds. Moreover, the accuracy of these findings may be limited by the use of self-administered questionnaires to determine how much exercise the women undertook. Nevertheless, these findings support the inclusion of muscle-strengthening and conditioning exercises in strategies designed to prevent type 2 diabetes in women, a conclusion that is consistent with current guidelines for physical activity among adults.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001587.
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health-care professionals and the general public, including information on diabetes prevention (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes and explains the benefits of regular physical activity
The World Health Organization provides information about diabetes and about physical activity and health (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages
The US Centers for Disease Control and Prevention provides information on physical activity for different age groups; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories
More information about the Nurses Health Study and the Nurses Health Study II is available
The UK charity Healthtalkonline has interviews with people about their experiences of diabetes
MedlinePlus provides links to further resources and advice about diabetes and about physical exercise and fitness (in English and Spanish)
doi:10.1371/journal.pmed.1001587
PMCID: PMC3891575  PMID: 24453948
22.  Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee 
STUDY OBJECTIVES—To understand reasons for compliance and non-compliance with a home based exercise regimen by patients with osteoarthritis of the knee.
DESIGN—A qualitative study, nested within a randomised controlled trial, examining the effectiveness of physiotherapy in reducing pain and increasing mobility in knee osteoarthritis. In the intervention arm, participants undertook a series of simple exercises and repositioning of the kneecap using tape. In depth interviews were conducted with a subset of participants in the intervention arm using open ended questions, guided by a topic schedule, to encourage patients to describe their experiences and reflect on why they did or did not comply with the physiotherapy. Interviews were audiotaped, fully transcribed and analysed thematically according to the method of constant comparison. A model explaining factors influencing compliance was developed.
SETTING—Patients were interviewed at home. The study was nested within a pragmatic randomised controlled trial.
PARTICIPANTS—Twenty participants in the intervention arm of the randomised trial were interviewed three months after they had completed the physiotherapy programme. Eight were interviewed again one year later.
MAIN RESULTS—Initial compliance was high because of loyalty to the physiotherapist. Reasoning underpinning continued compliance was more complex, involving willingness and ability to accommodate exercises within everyday life, the perceived severity of symptoms, attitudes towards arthritis and comorbidity and previous experiences of osteoarthritis. A necessary precondition for continued compliance was the perception that the physiotherapy was effective in ameliorating unpleasant symptoms.
CONCLUSIONS—Non-compliance with physiotherapy, as with drug therapies, is common. From the patient's perspective, decisions about whether or not to comply are rational but often cannot be predicted by therapists or researchers. Ultimately, this study suggests that health professionals need to understand reasons for non-compliance if they are to provide supportive care and trialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.


Keywords: compliance; physiotherapy; qualitative research
doi:10.1136/jech.55.2.132
PMCID: PMC1731838  PMID: 11154253
23.  AUDIT OF STRUCTURE, PROCESS, AND OUTCOME OF DIABETIC CARE AT AL ASYAH PRIMARY HEALTH CARE CENTRE, QASSIM REGION, SAUDI ARABIA 
Objective:
To assess the quality of diabetic care in Al-Asyah primary health care (PHC) center, Qassim region, KSA , through an auditing of structure, process, and outcome.
Methodology:
The files of all registered diabetic patients in this PHC center were reviewed. The indicators for structure were evaluated according to the National Quality Assurance protocol and manual of chronic diseases, and those for process were assessed by a modified scoring system. The outcome indicators were evaluated using the recommendations of American Diabetic Association (ADA) 2002.
Result:
Dietician, diabetic educator and Hb A1C, HDL level, LDL level were the most common non available resources. Out of 4628 patients registered in this PHC center, only 159 patients had diabetes. The prevalence of diabetes among registered adults aged 15 years and above was 5.8% and this increased with age. The patients were mostly Saudi (96.2%) and married (75.5%). They included 83 females (52.2%). The mean age was 56 years. Most of the patients were Type 2 (95.6%) and most were diagnosed at the PHC center (94.3%). The mean duration of the diabetes since diagnosis was 6.4 years. All checked process items showed high percentages of coverage (73% and above) except for the examination of the fundus, and the measurement of the triglyceride levels. Results showed that most of the samples were obese or overweight (49.7% and 32.7% respectively). While 21.4% had good diabetic control, 42.8% had poor diabetic control. Patient compliance to appointment was good (98.1%), and 13% of the diabetic patients had at least one reported complication.
Conclusion:
This study proves that some essential resources needed for diabetic care were inadequate. Provision of these resources is essential for the improvement of the quality of health care for diabetic patients. Also, there is a need to improve the referral system and establish an appropriate health education program to encourage patients, their families and the community to follow a more healthy life-style.
PMCID: PMC3410085  PMID: 23012057
Diabetic care; Audit; process; outcome; Qassim; PHC; Al Asyah
24.  Non-compliance with health surveillance is a matter of Biosafety: a survey of latent tuberculosis infection in a highly endemic setting 
BMJ Open  2011;1(1):e000079.
Objective
This study aimed at identifying demographic, socio-economic and tuberculosis (TB) exposure factors associated with non-compliance with the tuberculin skin test, the management and prevention of non-compliance to the test. It was carried out in the context of a survey of latent TB infection among undergraduate students taking healthcare courses in two universities in Salvador, Brazil, a city highly endemic for TB.
Methods
This is a cross-sectional study of 1164 volunteers carried out between October 2004 and June 2008. Bivariate analysis followed by logistic regression was used to measure the association between non-compliance and potential risk factors through non-biased estimates of the adjusted OR for confounding variables. A parallel evaluation of occupational risk perception and of knowledge of Biosafety measures was also conducted.
Results
The non-compliance rate was above 40% even among individuals potentially at higher risk of disease, which included those who had not been vaccinated (OR 3.33; 95% CI 1.50 to 7.93; p=0.0018), those reporting having had contact with TB patients among close relatives or household contacts (p=0.3673), or those whose tuberculin skin test status was shown within the survey to have recently converted (17.3% of those completing the study). In spite of the observed homogeneity in the degree of Biosafety knowledge, and the awareness campaigns developed within the study focussing on TB prevention, the analysis has shown that different groups have different behaviours in relation to the test. Family income was found to have opposite effects in groups studying different courses as well as attending public versus private universities.
Conclusions
Although the data presented may not be directly generalisable to other situations and cultural settings, this study highlights the need to evaluate factors associated with non-compliance with routine testing, as they may affect the efficacy of Biosafety programs.
Article summary
Article focus
The reasons behind non-compliance with health monitoring are rarely investigated, even though high rates of non-compliance have been observed in several studies among groups ranging from the general population to students and healthcare professionals.
Non-compliance with the tuberculin skin test (TST) may affect the efficacy of tuberculosis control programs.
Key messages
Having information on the targeted disease, as well as being at risk of this disease, was found to be insufficient to ensure compliance with routine testing.
Non-compliance with the TST was associated with socio-economic status, gender and career choice, which suggests that cultural and psychological reasons for non-compliance are shared within such groups.
Investigation of the reasons associated with non-compliance among different groups would be a first step to improve the efficacy of Biosafety programs.
Strengths and limitations of this study
This study was conducted only among healthcare students and within the context of a survey for latent TB infection. The risk factors found here to be associated with non-compliance may not be directly generalisable to other situations and cultural settings. This study is limited by the fact that all the information collected was self-reported, except for the frequency of non-compliance and the TST induration measurements. Unlike in other TST surveys, non-compliance due to logistics problems was addressed and minimised.
doi:10.1136/bmjopen-2011-000079
PMCID: PMC3191424  PMID: 22021753
Health monitoring; latent tuberculosis; occupational risk; Biosafety; immunology; tuberculosis; epidemiology; health and safety
25.  Cure or control: complying with biomedical regime of diabetes in Cameroon 
Background
The objective of the study was to explore the cultural aspect of compliance, its underlying principles and how these cultural aspects can be used to improve patient centred care for diabetes in Cameroon.
Methods
We used participant observation to collect data from a rural and an urban health district of Cameroon from June 2001 to June 2003. Patients were studied in their natural settings through daily interactions with them. The analysis was inductive and a continuous process from the early stages of fieldwork.
Results
The ethnography revealed a lack of basic knowledge about diabetes and diabetes risk factors amongst people with diabetes. The issue of compliance was identified as one of the main themes in the process of treating diabetes. Compliance emerged as part of the discourse of healthcare providers in clinics and filtered into the daily discourses of people with diabetes. The clinical encounters offered treatment packages that were socially inappropriate therefore rejected or modified for most of the time by people with diabetes. Compliance to biomedical therapy suffered a setback for four main reasons: dealing with competing regimes of treatment; coming to terms with biomedical treatment of diabetes; the cost of biomedical therapy; and the impact of AIDS on accepting weight loss as a lifestyle measure in prescription packages. People with diabetes had fears about and negative opinions of accepting certain prescriptions that they thought could interfere with their accustomed social image especially that which had to do with bridging their relationship with ancestors and losing weight in the era of HIV/AIDS.
Conclusion
The cultural pressures on patients are responsible for patients' partial acceptance of and adherence to prescriptions. Understanding the self-image of patients and their background cultures are vital ingredients to improve diabetes care in low-income countries of Sub-Sahara Africa like Cameroon.
doi:10.1186/1472-6963-8-43
PMCID: PMC2267458  PMID: 18298835

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