Evaluation of Factors Influencing Medication Adherence in Patients with Epilepsy in Rural Communities of Kaduna State, Nigeria ()
1. Introduction
Epilepsy is the most common serious neurological disorder and is one of the world’s most prevalent noncommunicable diseases. It is estimated that the condition affects approximately 50 million people, around 40 million of them living in developing countries [1,2]. The incidence of epilepsy in low-income countries may be as high as 190 per 100,000 people [3]. Consequently, in the context of the large and rapidly increasing populations in these countries, epilepsy is a significant health and socioeconomic burden requiring urgent attention [4]. Against this background, the World Health Organization’s (WHO) aim of easing the burden of mental and neurological illnesses that affect 400 million people [5] worldwide is timely. About 90% of people with epilepsy in developing countries are not receiving appropriate treatment. Consequently, people with epilepsy continue to be stigmatized and have a lower quality of life than people with other chronic illnesses [6]. However, bridging the treatment gap and reducing the burden of epilepsy is not straightforward and faces many constraints. Cultural attitudes, lack of prioritization, poor health system infrastructure, and inadequate supplies of antiepileptic drugs all conspire to hinder appropriate treatment as epilepsy is perceived as an ancestral spirits/possession by evil spirits by most Africans. Nevertheless, there have been successful attempts to provide treatment, which have shown the importance of community-based approaches and also indicate that provision for sustained intervention over the long term is necessary in any treatment programme. Adherence to medication is the backbone to effectiveness of a therapy. In the absence of a definitive curative therapy, antiepileptic therapy is a key intervention aimed at prolonging and improving the quality of life of epileptic patients suffering from a disease known for its stigmatization with many cultural misconceptions. The aim of the study is to assess the level of knowledge of epilepsy, and factors influencing adherence to antiepileptic therapy among patients in rural communities attending outpatient clinic in Ahmadu Bello University Teaching Hospital, Zaria and Jicon Hospital, Kaduna, northern Nigeria.
2. Materials and Methodology
2.1. Study Design
This is a cross-sectional study that utilized intervieweradministered, structured questionnaires to obtain information from a sample of 272 patients with epilepsy attending Ahmadu Bello University Teaching Hospital/ Jicon Hospital Kaduna, who had been on antiepileptic drug (AED) for at least one year. Systematic random sampling technique was used to select the patients. Information was obtained on their knowledge of epilepsy and antiepileptic therapy regimen adherence to AED and factors influencing adherence to AED regimen.
2.2. Study Population
All patients with epilepsy (PWE) registered in the Antiepileptic Clinic of Ahmadu Bello University/Jicon Hospital Kaduna who had been on treatment for a minimum of one (1) year prior to the onset of the study constituted the study population. Patients included in this study were adults with confirmed diagnosis of epilepsy who were registered with Ahmadu Bello University Teaching Hospital/Jicon Hospital Kaduna and had commenced treatment with the centre for a minimum of one (1) year. They included those patients that had been on antiepileptic drugs in some rural centres but transferred to the Ahmadu Bello University Teaching Hospital/Jicon Hospital Kaduna for the continuation and supply of drugs.
The exclusion criteria included patients below the age of 14 years, new patients with less than 3 months of medication and mentally ill patients because they could not comprehend the importance of adherence and might even not take the medication at all.
2.3. Sampling Size Determination
A recent review of adherence to antiepileptic drugs (AEDs) reported figures ranging from 28% - 82% and most of the studies sharing rates between 50% and 80%. Therefore 80% was used as p-value at a precision of 5% with 95% confidence limit at 0.05 level of significance [7].
The sample size of 272 was divided equally among the 4 clinic days in a month. The systematic random sampling strategy was used to select patients on each clinic day until the required number of patients was obtained. The 4 clinic days was also randomly selected. The table of random numbers was used to locate the starting point and the sampling interval was calculated based on the average attendance.
Pre-tested, structured, and mostly closed-ended questionnaires were used for data collection. It was interviewer administered and data were collected over one month period. The questionnaire was in four parts. The first part obtained information on socio-demographic variables such as age, sex, place of residence, ethnicity, religion and educational level, marital status and occupations. The second part obtained information about respondents’ knowledge on epilepsy i.e. whether any of their relatives was infected, the transmission of the disease, their opinions about the cause, knowledge about signs and symptoms of the disease, to know if it has a cure or not, and how it can be prevented. The third part was about the knowledge of antiepileptic therapy, the source of their information, when to commence the therapy, knowledge about combination therapy, the duration of treatment, the timing of usage of medication, frequency of dosing and identification of drugs. The fourth part was about the level of adherence to antiepileptic drugs. Patients were to identify the drugs they were taking presently (using the samples obtained from the hospital pharmacy). The number of months they have been on treatment was determined, case notes were crosschecked to know whether the dosages and the frequency with the name of the drugs tally, they were asked to recall the number of times per day they were supposed to take the medication, based on the regimen the hospital is using, the number of pills they take per day and per dose. Patients were then asked to recall the number of doses they missed within the past seven days preceding the interview, and to verify it with the sachets of used drugs they brought to the clinic. Then if he or she has missed any dose the reasons for missing were sought for. Respondents were asked about side effects of the drugs they were using. Enquiries about satisfaction and confidentiality of the clinic setting, waiting time in the hospital and if at any time drug was not available were made. Those without problems or complaints were giving monthly visit for follow up. Eight medical personnel previously trained did the interviews ensuring confidentiality and privacy. Pre-testing of the questionnaire was done on 10 patients at JICON Hospital Kaduna. The results of the pilot study were used to modify the contents and wordings of the questionnaire. The quality assurance in terms of validity and accuracy of the data were done after each day of the interview.
2.4. Data Analysis
Data was analyzed using SPSS Version 11, statistical software (SPSS Inc. Chicago, IL). Data was presented in graphs and tables. Absolute numbers and simple percentages were described using measures of central tendency (mean, median) and measures of dispersion (Range, standard Deviation) as appropriate. The Chi-square test was done to assess the strength of association between socio-demographic characteristics and medication adherence on one hand, and between knowledge of epilepsy and adherence on the other. A p-value of 0.05 or less was considered statistical significant.
2.5. Ethical Consideration
An ethical approval was obtained from the authority of the Ahmadu Bello University Teaching Hospital/Jicon Hospital Kaduna and verbal consent from the patients before administering the questionnaire. Confidentiality was ensured in the handling of data.
3. Results
A total of 272 PWE were studied but 2 patients did not meet the requirements during the final analysis. There were 172 female and 98 male, giving a male: female ratio of 1:1.7. The respondent’s ages ranged from 18 to 62 years. The mean age was 35 ± 8.8 years. Most patients (85.9%) were below 45 years of age. Majority of them were married (44.4%), Christians (70%), had some formal education (90.7%), and earn less than N7500 ($59) monthly, (55.1%) (Refer Table 1). The level of knowledge, signs and symptoms of epilepsy was high with 57.8% and 25.9% demonstrating excellent and good knowledge respectively. The level of knowledge on the causes, signs and symptoms of epilepsy was very poor with only 9.3% knowing that it is a brain disorder while 66.7% attributes it to witchcraft, curse from above, 58.5%; evil spirits, 39.6% and micro organisms (germs), 25.9% (Table 2).
The level of knowledge of AED was high with 78.6% (Table 3). The level of adherence to AED was 32.6%. There was significant association between knowledge of AED and adherence to therapy (p = 0.00385) but there was no association between age (p = 0.067), sex (p = 0.182) educational status (p = 0.688), income (p = 0.519) religion (p = 0.69) and place of residence (p = 0.157) with AED adherence. The reasons for non-adherence were as a result of forgetfulness, AED-induced fatigue and being away from home (Figure 2).
Table 4 shows respondents knowledge of the source of information of Antiepileptic therapy (AED) while Table 5 shows respondents’ knowledge of Antiepileptic therapy (AED) when to start treatment after diagnosis.
Out of 144 respondents, 64.8% believe that drugs can cure the disease, 20.8% believe that traditional herbs can cure it while 14.4% believe in mystical ways for the cure (Figure 1).
As shown in Figure 2, out of 182 respondents that missed pills, 74 (40.7%) said it was due to forgetfulness. 47 (25.8%) complain of pill fatigue and being away from home was the reason in 22 (12.1%).
Figure 3 shows factors influencing the distribution of respondent’s perception to efficacy of AED therapy.