Research Proposal

Principal Investigator: Dr. Ala` Ahmad Shannaq

Institutions: Tokyo Medical and Dental University, Japan

Title:

Non-adherence and its contributing factors for patient's in

the outpatient setting with anti-diabetic medications in public
hospitals.

:Summary
Rational
Because of recent media attention on epidemics in developing countries,
there is an assumption that relatively low-income levels lead to conditions
that promote communicable diseases and allow easily preventable
diseases to persist. However, in Jordan, it is economic growth that has
contributed to a public health crisis, but in chronic, not communicable,
disease. Communicable disease rates in Jordan are low even in
comparison with many developed countries. [1] High vaccination rates
have reduced and eliminated many easily preventable diseases. [2]
However, chronic disease rates have been steadily rising. As a result, the
leading cause of mortality in Jordan is chronic disease. [3] In part, Jordan
has been a victim of its own success. Increased prosperity has brought
electricity, tap water, television and transportation into the home, leading
to a decrease in physical activity. [4] Mechanized agriculture has made
food cheap and abundant. Diets that are oftentimes low in fruits and
vegetables and high in fats and starches have exacerbated the problem.
[5] Obesity, defined as having a body mass index (BMI) over 30, has a
prevalence of nearly 50%. [6] Even improved health care has exacerbated
the problem; as people live longer, the likelihood of chronic disease
increases. [7] For these reasons, chronic disease rates are predicted to
continue on an upward trend. [8] The growth in diabetes rates, oftentimes
thought of as a rich country disease, has been particularly alarming.
From 2002 to 2004, the reported rate of diagnosed diabetes climbed from
6.3% to 7.4%. [9] Current total estimates range from 16% to 30%
depending on the age range and defined glucose levels. [10] The
prevalence of diabetes in Jordan constitutes not only the highest in the
region, but also one of the highest in the world.[11] A Finnish study
estimated that Type 2 diabetes, most commonly known as adult onset, can
be prevented in 58% of cases; [12] a startling statistic indicating the need
for action.
The population explosion and resulting demographic transition currently
underway in Jordan contribute to the sense of urgency surrounding
diabetes. High natural population growth rates mean that a large portion
of the population is young, signaling a future crisis should the cultural
issues identified above not be addressed. According to the Population
Reference Bureaus mid- 2007 statistics, 37% of Jordans total 5.7 million
Dr. Ala Ahmad Shannaq
Research Proposal
1 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan

population is comprised of <15 year olds [13] Confounding matters is the

presence of over 2 million Palestinian and Iraqi refugees.

Objectives
The objective of this study is to measure the relation between nonadherence among diabetic patients attending the diabetic clinic in
Jordanian Public Hospitals and certain proposed factors.

Methods
This descriptive cross-sectional study is to be conducted among
patients with DM attending the DM clinic of public Referral Hospitals.
One out of every three patients will be selected to collect their data
and in particular their adherence to medication using a structured
survey. The analysis will be through SPSS-16.

Background
The occurrence of DM is growing rapidly worldwide and it is becoming
epidemic.

Non-adherence, poverty, lack of knowledge, and poor

follow-ups are the main factors observed in poor glycemic control. Nonadherence to prescribed medication plan is a major problem worldwide.
In previous studies, it was found that adherence to diabetes treatment
generally to be suboptimal ranging (23%77%) [14]
There is a need to regularly check the reasons for non-adherence
among patients with diabetes in clinical practice. This is very important
in developing countries in particular, such as Jordan, where poor
economy and lack of proper awareness lead to the increased
occurrence of medication non-adherence. In resource-limited countries
like Jordan, poor economy and lack of awareness lead to the increased
occurrence of medication non-adherence. To the best of our knowledge,
evidence-based research that evaluates medication adherence among
patients with diabetes in Jordanian public hospitals.
Additionally, the following points is to be considered:
1. Extensive studies are usually done in developed countries,
accordingly, some important factors that are restricted to a
country like Jordan are not taken into consideration.
2. Few studies on anti-diabetic medication adherence have been
reported from Jordan.

Dr. Ala Ahmad Shannaq

Research Proposal
2 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan

3. The sample size used in some of the studies is relatively small

and the method of sampling in some cases were not indicative
enough.
Therefore, the main purpose of this study is to bridge the gap in
knowledge of the non-adherence and its contributing factors and their
association with diabetic patients in public hospitals in Jordan.

Objectives
General Objective:
The objective of this study is to measure the relation between nonadherence among diabetic patients attending the diabetic clinic in
Jordanian Public Hospitals and certain proposed factors.
Specific Objective:
The specific objectives are as follows:

1. To assess adherence
patients with diabetes;

to

medication

among

ambulatory

2. To identify the probable reasons for non-adherence with a view

to develop intervention to improve adherence;
3. To determine the relationship between non-adherence and
various socio-demographic and other drug and patient related
factors

4. To describe the prevalence of different perceived problems of

respondents with disease or the medication and on the
healthcare system;
5. To provide the baseline data for future study.

Methodology
Study Design
A proposed cross-sectional study is to be conducted at the
ambulatory diabetic clinic of public hospitals in Jordan.
Study Setting/ Data Collection
Study the samples of all diabetic patients receiving anti-diabetic
medication in the ambulatory diabetic clinic during the study period,
in five Jordanian Public Hospitals in deferent cities in Jordan.

Dr. Ala Ahmad Shannaq

Research Proposal
3 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan

Data analysis will be conducted in Japan, Tokyo Medical and Dental

University

Study Population
Source population is diabetic patients being treated at five public
Hospitals in Jordan, there is no available formal statistics from the
Ministry of Health (MOH). But the expected number from the
Medical records from the 5 hospitals will be more than 5000 diabetic
patients.
Sample Size
The sample size will be calculated using single population proportion
formula as follows:

Where n = is desired sample size for population, Z = is standard

normal duration usually, and P = means that we use positive
prevalence estimated, to maximize sample size. W = degree of
accuracy desired

Sampling Method
A systematic random sampling technique will as used.
Inclusion criteria
Include ambulatory patients who
1. Are on anti-diabetic medications for more than six months;
2. Consented to participating in the study;
3. Will attend the diabetic clinic during the study period.

Exclusion Criteria
Exclusion criteria are as follows:
1. Unconscious patients;
2. Patient age less than 18 years;
3. Very ill patients.

Data Collection Method

Before data collection to conduct this study ethical approval will be
obtained from Ministry of Health (MOH) and the letter will submitted
to the five public hospitals to the beginning of undertaking the study
in the area. All the study participants will be informed about the
purpose of the study; their right to refuse is maintained. Ethical
Dr. Ala Ahmad Shannaq
Research Proposal
4 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan

conduct is maintained during data collection and throughout the

research process. Verbal consent will be obtained from each patient
before the interview. Patients will be assured of their anonymity. The
confidentiality of the data obtained will be assured and the name
and address of the patient will be omitted from the questioner.
The study involves cross-sectional surveys of consecutive diabetic
patients who visit the DM clinic during the study period.
The questionnaire, will be the instrument of the study, this tool
consists of information about the socio-demographic characteristics
of the respondents, the pattern of drug adherence, and factors
contributing to non-adherence. It also consists of information related
to drugs prescribed, dose, frequency, and Patients' mean fasting
plasma glucose reading at the last clinic visit. Each questionnaire
containing 25 questions that took an average of 5 to 10 minutes to
fill. It will be designed to have two sections; the first section
elucidated the socio-demographic characteristics of diabetic
patients while the second section contained questions that assess
the adherence patterns and the likely reasons for patients' nonadherence to prescribed medications.

References
1. World Health Organization, Global Health Atlas,
http://www.who.int/GlobalAtlas/
2. World Health Organization, WHO vaccine preventable diseases:
monitoring system, 2007 summary,
http://whqlibdoc.who.int/hq/2007/WHO_IVB_2007_eng.pdf,
3. Meyasser Zindah, et al., Obesity and Diabetes in Jordan, Findings
From the Behavioral Risk Factor Surveillance System, 2004,
Preventing Chronic Disease Public Health Research, Practice and
Policy 5, no. 1. Academic Search via Search Tools,
http://searchtools.lib.umich.edu
4. K. Ajlouni, H. Jaddou, H. and A. Batieha, Obesity in Jordan,
International Journal of Obesity, no. 22 (1998): 627. Academic
Search via Search Tools, http://searchtools.lib.umich.edu.
5. Ibid
6. Ibid
7. Laeth S. Nasir and Arwa K. Nasir, Introducing Arabic language
patient education materials in Jordan, Patient Education and
Counseling, no. 60 (2006): 144. Academic Search via Search Tools,
http://searchtools.lib.umich.edu.
8. Centers for Disease Control and Prevention, Assessing Risk Factors
for Chronic Disease Jordan, 2004,
http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5523a3.htm
9. Centers for Disease Control and Prevention, Assessing Risk Factors
for Chronic Disease Jordan,
Dr. Ala Ahmad Shannaq
Research Proposal
5 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan

2004,http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5523a3.ht
m
10.Estimate provided by National Center for Diabetes, Endocrinology
and Genetic Diseases.
11.K. Ajlouni, et. al. Diabetes and impaired glucose tolerance in
Jordan: prevalence and associated risk factors, Journal of Internal
Medicine October 1998; 244: 4, pg. 320.
12.J. Tuomilehto J, et al., Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose
tolerance, N Engl J Med 2001; 344: 1343.
13.Population Reference Bureau: Statistic on Jordan.
http://www.prb.org/Countries/Jordan.aspx

Dr. Ala Ahmad Shannaq

Research Proposal
6 | Page
Non-adherence and contributing factors for patient's in the outpatient
setting with anti-diabetic medications in public hospital.
Tokyo Medical and Dental University, Japan