|Year : 2021 | Volume
| Issue : 4 | Page : 180-186
Adherence of chronic disease care during COVID-19 pandemic: Results from eastern India
Surama Manjari Behera1, Somen Kumar Pradhan2, Sanghamitra Pati1, Priyamadhaba Behera2, Srikanta Kanungo1, Binod Kumar Patro2
1 Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar, Odisha, India
2 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||21-Jun-2021|
|Date of Acceptance||20-Nov-2021|
|Date of Web Publication||31-Dec-2021|
Dr. Binod Kumar Patro
Department of Community Medicine and Family Medicine, 3rd Floor, Academic Building, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
Background: With the advent of the COVID-19 pandemic, prevention and control of noncommunicable diseases (NCDs) have become even more critical as NCDs are major risk factors for patients with COVID-19. Therefore, this study was planned with the following objectives: (i) To assess adherence with chronic disease care among patients with NCDs. (ii) To determine the factors associated with adherence with chronic disease care among patients with NCDs during COVID-19 nationwide lockdown.
Materials and Methods: This was a hospital-based cross-sectional study conducted in the NCD prevention clinic of All India Institute of Medical Sciences, Bhubaneswar, during July 2020–August 2020. A total of 210 patients were studied. Patients were interviewed both at the clinic and telephonically; those who had scheduled visits did not make it. Out of 210 patients, 105 participants were interviewed face to face in the hospital in the NCD prevention clinic. The other 105 patients were interviewed telephonically who did not attend the clinic during follow-up.
Results: All the participants (210) had diabetes mellitus, and 44.8% of participants had accompanying hypertension. One-fourth of participants could not follow the dietary practices advised by the doctor during the lockdown. Similarly, 42% of participants could not maintain moderate-intensity physical activity (30 min) during the lockdown period. The period prevalence of nonadherence to prescribed drugs/medicines in our sample was 45.71% (95% confidence intervals [CI] 38.84–52.71). Participants with more than one NCDs had a 52% less chance to stop the drugs/medications during the national lockdown period than participants with one NCD (adjusted odds ratio 0.48, 95% CI 0.27–0.83).
Conclusions: The continuum of chronic disease care of NCD patients has been affected by COVID-19 nationwide lockdown. Appropriate planning and provision of chronic disease care are essential during the lockdown and similar situations.
Keywords: Adherence, chronic disease care, India, lockdown, non-communicable disease
|How to cite this article:|
Behera SM, Pradhan SK, Pati S, Behera P, Kanungo S, Patro BK. Adherence of chronic disease care during COVID-19 pandemic: Results from eastern India. Int J Non-Commun Dis 2021;6:180-6
|How to cite this URL:|
Behera SM, Pradhan SK, Pati S, Behera P, Kanungo S, Patro BK. Adherence of chronic disease care during COVID-19 pandemic: Results from eastern India. Int J Non-Commun Dis [serial online] 2021 [cited 2022 Nov 30];6:180-6. Available from: https://www.ijncd.org/text.asp?2021/6/4/180/334614
| Introduction|| |
The global burden of chronic noncommunicable diseases (NCDs) constitutes a major public health problem that undermines social and economic development throughout the world. Chronic disease is defined by the World Health Organization as being of long duration, generally slow in progression and not passed from person to person. Despite advances in treatment effectiveness, research shows that patients with chronic diseases frequently do not get the care they want or need. Because of this, the Chronic Care Model (CCM) was designed by Wagner et al. to restructure health care through interactions between health systems and communities. These six interrelated elements are; organization of health care, self-management support, decision support, delivery system design, clinical information systems, and community resources and policies.
Self-care is considered the cornerstone of the chronic disease care model. It is defined as actions taken by individuals to care for themselves within their environmental conditions. For persons with a chronic disease like type 2 diabetes mellitus (T2DM), self-care involves a series of behaviors that encompass diet, exercise, medication-taking (insulin or oral hypoglycemic agents), foot care, self-monitoring blood glucose and blood pressure, etc.
With the advent of the COVID-19 pandemic, NCDs' prevention and control have become even more important as NCDs are major risk factors for patients with COVID-19. On March 24, 2020, the Government of India imposed a nationwide lockdown till May 31, 2020, to buy time to prepare for a potential surge in cases as the pandemic was being forecasted to peak in the coming weeks. Various restrictive measures such as civil confinement, social distancing, and travel restrictions were introduced to reduce the spread of infection. On the other hand, they have impacted the general population's ability to maintain self-care and access to health services for various health conditions, including NCDs. This has led to a simultaneous disruption in NCDs' self-care management because of compromised functioning of the multiple elements of CCM, as mentioned earlier. However, the impact of this disruption, as well as its consequences, is still unknown. Therefore, there is a need to assess the impact of the COVID-19 pandemic and subsequent lockdown on chronic disease care among NCDs patients. Hence, we planned this study to assess the adherence with chronic disease care and factors affecting it among patients with NCDs during COVID-19 nationwide lockdown.
| Materials and Methods|| |
This is a hospital-based cross-sectional study conducted at the NCD prevention clinic under Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS) Bhubaneswar. The study was undertaken from June 2020 to August 2020 after the nationwide lockdown was lifted on May 31, 2020. The study population involved all the subjects who had attended the NCD prevention clinic to diagnose and treat chronic diseases like type 2 diabetes, hypertension, dyslipidemia, hypothyroidism, chronic kidney disease, and osteoarthritis before lockdown (during the period from January 1, 2020, to March 23, 2020). Patients with any diagnosed mental disorder or patients who are seriously ill and unable to comprehend were excluded from the study. With 50% adherence to chronic disease care, 10% absolute precision, 95% confidence interval (CI) and 10% expected nonresponse rate, the sample size came out to be 105. Pretesting was done among ten patients at NCD preventive clinic to finalize the study tool. Out of the patients registered at the NCD clinic, only a few patients came to the clinic for consultation during the unlocking. The daily patient footfall remained low (approximately 30%) compared to the pre-lockdown period. Therefore, we decided to include half of the patients from the clinic and the other half patients who did not attend the clinic through consecutive sampling. A total of 210 participants were interviewed. Out of them, 105 participants in the NCD clinic were interviewed face to face, and 105 patients, those not attending the clinic, were interviewed telephonically.
A single researcher conducted all the interviews, and a standard patient information sheet was used to reduce variability in communicating the study objectives to the patients. After explaining the study objectives and procedure, subjects found eligible were enrolled and written informed consent (for face-to-face interview)/informed verbal consent (for telephonic interview) was taken. An interviewer-administered semi-structured questionnaire was used to collect the details on the participants' sociodemographic data, clinical outcomes, and chronic-care practices. In this study, nonadherence has been defined as at least a single day of interruption in chronic disease medication during the lockdown period. All the study participants were explained that their identity would remain confidential. We removed all the direct personal identifiers from the datasheet to maintain confidentiality.
Data were entered in Kobo Toolbox, and data analysis was done in SPSS 21.0 (https://www.ibm.com/support/pages/how-cite-ibm-spss-statistics-or-earlier-versions-spss)., The results were reported as a proportion with a 95% CI, and a P < 0.05 was considered statistically significant. Mean (standard deviation [SD]) was reported for continuous measurements. Univariate and multivariable analyses were done to examine sociodemographic and clinical factors with chronic disease care variables. The strength of association was measured as odds ratios. The variables for which P < 0.25 on univariate analysis were included in multivariate analysis. General stepwise logistic regression was undertaken with the probability of entry and removal as 0.05 and 0.10, respectively.
| Results|| |
The mean (SD) age of participants was 52.9 (8.4) years, with most of them (38.6%) in the age group 50–59 years. Out of 210 participants, 135 (64.3%) were men, and 75 (35.7%) were women. Out of all of the participants, 7.6% were illiterate. Illiteracy was more (20.0%) among women as compared to men (0.7%). Among the literate participants, the majority had an education of high school certificate (25.7%). Among the people who were engaged in various occupations, most women were homemakers 61 (81.3%) and 53 (39.3%) men were self-employed/businessmen. More than half of the participants were living in extended families (54.8%). One-fourth of participants (25.7%) had a family with more than or equal to five family members; others had a family with one to five family members. More than half of the participants (55.2%) were from the general category, 30.0% belong to other backward categories, and 7.6% and 7.1% were in scheduled caste and scheduled tribe, respectively. Approximately one-third of participants (32.0%) were below the poverty line. Fifty-seven percent of the participants had no health insurance [Table 1].
|Table 1: Distribution of participants by sociodemographic variables (n=210)|
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In our study, all participants had T2DM. Approximately half, i.e., 94 (44.8%) participants had hypertension, 25 (11.9%) participants had dyslipidemia, 10 (4.8%) participants had hypothyroidism, 9 (4.3%) participants had osteoarthritis, and 6 (2.9%) participants had chronic kidney disease in addition to T2DM. Half of the participants (50.5%) had a single NCDs. Approximately one-third of participants (36.7%) had two NCDs, and 27 (12.9%) participants had three or more NCDs. The majority of the participants, i.e., 97 (46.2%), had chronic disease history of 2–5 years, followed by 6–10 years (34.3%) [Table 2].
|Table 2: Distribution of participants according to clinical profile (n=210)|
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Out of 210 participants, 175 (83.34%) reported a delay of more than 1 month. The median (interquartile range) duration for the delay in seeking follow-up care was 56.0 (34.0) days. On the other hand, telemedicine facility was started by both state government and central institutes to facilitate the health services during this national lockdown period. However, only 7 (3.00%) participants availed themselves the telemedicine services during this lockdown period.
A total of 25 (24.76%) participants could not follow the dietary practices advised by the doctor during the lockdown. Similarly, 42% of participants could not maintain moderate-intensity physical activity (30 min/day) during the lockdown period. Only one-fourth of participants (24%) could do yoga and meditation during the lockdown period. Among all participants, 6% of patients reported a history of alcohol consumption during the lockdown period. The prevalence of smokeless tobacco use was 29% compared to smoked tobacco (10%) among NCD patients during the lockdown period.
Approximately half of the participants self-reported that they have stopped taking medications during the lockdown period for various durations. The period prevalence of nonadherence to prescribed medication in our sample was 45.71% (95% CI 38.84–52.71). The median (range) duration for not taking drugs/medicines was 15.0 (89.0) days. Participants with more than one NCDs had a 52% less chance to stop the medications during the national lockdown period than participants with one NCDs (adjusted odds ratio [AOR] 0.48, 95% CI 0.27–0.83]. Age, gender, type of family, education, occupation, income, presence of health insurance, and chronic disease duration were not significantly associated with nonadherence to prescribed drugs/medicines among NCD patients [Table 3].
|Table 3: Associated factors for adherence to prescribed drugs/medicines among patients of noncommunicable disease during COVID-19 nationwide lockdown|
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| Discussion|| |
India's nationwide “lockdown” from March 25, 2020 to May 31, 2020, has been one of the most stringent containment measures implemented by the government. The interventions have helped prevent the worst-case scenario for COVID19 in India but could not avoid the spike in the number of cases in the later stage. The lockdown provided the time for the health system' preparedness and state to tackle the COVID19 disease. However, the lockdown has also been criticized for the disruption in non-COVID health care services. For chronic diseases, the continuum of care is vital to their control and prevention of acute or chronic complications. During this nationwide lockdown period, the continuum of care for chronic disease has been disrupted due to various reasons such as suspension of outpatient services, lack of transportation facility, and engagement of health workforce in COVID19 management and response.
Our study also found that self-care was also affected during this lockdown period. One-fourth of participants could not follow the dietary practices advised by the doctor; 42% of participants could not maintain moderate-intensity physical activity (30 min) during the lockdown period. These results are almost in agreement with a similar study undertaken by Alshareef et al. in Saudi Arabia. Social distancing measures were stringent during this period, which may have hampered the outdoor activities and exercise by social groups together. On the other hand, alcohol consumption (6%) and smoked tobacco (10%) were low among NCD patients during the lockdown period. These may be attributed to shops' closure and the ban on sales of these items during the national lockdown period in India. The lesser consumption of alcohol in our study was by another study by Cransac-Meet et al. However, the difference in tobacco consumption may be due to different study settings.
The coronavirus pandemic has presented additional challenges to medication adherence, especially for patients with NCDs. Our study found that 45.71% of patients had stopped drugs/medication, which was much higher than a similar study done by Sankar et al. in Kerla, India (10%). This nonadherence with drugs/medicine may be due to the lack of medicine or lack of physician consultation leading to inadequate knowledge on the further line of management. This is backed by a previous study demonstrating that diabetes management was severely hampered in 89.47% during the COVID-19 pandemic in India. Participants with more than one NCD had a 52% less chance to stop the medications during the national lockdown period than participants with one NCDs (AOR 0.48, 95% CI 0.27–0.83). Patients with more than one NCD may be more concerned and aware regarding their treatment because of their knowledge of poor outcomes in the absence of control of the disease.
The 56 days of median delay in seeking follow-up care can be associated with strict lockdown measures and fear of getting hospital-acquired COVID-19 infection on visiting a health facility. Although the government promoted telemedicine during the pandemic, surprisingly, only seven patients (3%) had availed of telemedicine services during the lockdown period. This is comparatively lesser than findings from the study done by Abdul et al. Lack of experience and knowledge about telemedicine services, their practical use, and trust may be the possible reasons for the same. Therefore, it is time to renew the focus on the utilization of telemedicine in the context of the chronic disease continuum of care. The utilization of telemedicine needs to be promoted. The mass media may play a pivotal role in creating awareness among people about telemedicine services.
Among the strengths of this study and clinical variables, we have also tried to focus on social and family factors. Our study included two types of previously registered NCD patients, i.e., those who visited the NCD prevention clinic after lockdown and those who couldn't visit the same. Among limitations, the generalizability of the study is confined to a tertiary care hospital only. The results may be different in community settings. We could not study the disease's control status during lockdown because the data were available only for very few patients.
| Conclusions|| |
Appropriate planning and provision of chronic disease care are essential during the lockdown and similar situations. During the lockdown-like situation, NCD patients should be encouraged to adhere to their treatment and continue self-care practices such as physical activity, dietary practices, yoga, and limited substance use. Awareness should be created in mass media to utilize the telemedicine services available, and the health system should try to make these services more user-friendly. Nearby primary health-care facilities can also play a pivotal role in ensuring the chronic disease care continuum among this pandemic.
Undoubtedly, the chronic disease continuum of care is vital to patient well-being and crucial to prevent NCDs' acute and chronic complications. However, in the current scenario of the COVID-19 pandemic, its role is even more significant in improving public health outcomes among NCD patients.
Ethical approval statement
The ethical approval was obtained from the institutional ethics committee of AIIMS, Bhubaneswar, with reference no. T/IM-NF/CM&FM/20/35.
Financial support and sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]