O riginal Article

Factors contributing to non-compliance among diabetics

attending primary health centers in the Al Hasa district
of Saudi Arabia
Ataur R. Khan, Zaki N. Al-Abdul Lateef1, Mohammad A. Al Aithan2, Montaser A. Bu-Khamseen2,
Ibrahim Al Ibrahim3, Shabbir A. Khan3
Department of Community Ophthalmology, Al Omran Primary Health Care Center, Al Hasa, 1PHC Affairs, Health Directorate,
Al Hasa, 2Faculty of Family Medicine, College of Medicine, King Faisal University, Al Hasa, 3King Fahad Hospital, Al Hasa,
Saudi Arabia

Address for correspondence: Dr. Ataur R. Khan, Department of Ophthalmology, Omran Health Center, Al Omran, Al Hasa, 31982, Saudi Arabia.
E-mail: tanyaata@yahoo.com

Purpose: The purpose of the study was to measure the rate of non-compliance and the factors contributing to
non-compliance among the diabetic patients in the Al Hasa region of Saudi Arabia. Materials and Methods:
A cross-sectional survey was conducted in the Al Hasa region during the period of June 2010 to June 2011.
Random sampling was carried out for the selection of 535 diabetic patients from three chronic disease centers
in different parts of Al Hasa. The data were collected by means of interviewing questionnaires and file records.
Any patient who had been prescribed optimum treatment and was properly advised on diet and exercise for
his / her diabetes, but did not follow the medical advice, with Hb1AC of more than 7% at the time of interview,
was considered as non-compliant. Results: The overall prevalence of therapeutic non-compliance of the
ABSTRACT

participants was 67.9% (n = 318, 95% CI 63.59 – 72.02%). The non-compliance of males (69.34%) was higher
than females (65.45%, P = .003). The non-compliance among the urban participants was significantly higher
than (71.04 vs. 60.15%, P = .023) in the rural participants. There was a statistically significant difference in the
prevalence rate of non-compliance among the participants with different levels of education. Factors found
to be significantly associated with non-compliance on bi-variate analysis were: female gender (OR = 1.90,
CI =1.32-4.57),level of education (Illiteracy) (OR = 5.27, CI = 4.63 – 7.19), urban population (OR =5.22, CI=
3.65 – 8.22), irregularity of the follow-up (OR = 8.41, CI = 4.90 – 11.92), non-adherence to drug prescription
(OR = 4.55 , CI = 3.54 – 5.56), non-adherence to exercise regimen (OR = 5.55, CI = 4.2 6 – 6.), insulin (OR =
1.29, CI = .71 – 1.87), and insulin with oral Metformin (OR = 1.20, CI = .65 – 1.75). Conclusion: The findings
indicate that there is a high rate of non-compliance among the diabetes patients in the Al Hasa region of
Saudi Arabia and there is a definite need for improvement in the healthcare system, health education, and
training of diabetic patients.
Key words: Diabetes, Hb1AC, noncompliance

INTRODUCTION keeping appointments with the physicians) coincides with

the healthcare provider’s recommendations for health and
Compliance in healthcare is defined as the extent to medical advice. [1] Non-compliant patients are those whose
which a patient’s behavior (in terms of taking medication, health-seeking or maintenance behaviors lack congruence
executing the lifestyle changes, undergoing medical tests or with the recommendations prescribed by a healthcare
provider.[2]
Access this article online
Quick Response Code:
Website: Patient non-compliance is a serious healthcare concern
www.jfcmonline.com that poses a great challenge to the successful delivery
of healthcare. This is widespread and has been reported
DOI:
from all over the world. [3] According to a study by the
10.4103/2230-8229.94008 New England Health Care Institute, one-third to one-
half of the American patients are non-compliant.[3]Patient

26 Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1 | 26-32
 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

non-compliance is not only limited to the failure to take MATERIALS AND METHODS
medication , but also the failure to make lifestyle changes,
undergo tests or keep appointments with physicians. The A cross-sectional study was conducted at three chronic
non-compliant patients especially with chronic diseases are disease clinics, representing the different geographical areas
more prone to encountering serious difficulties.[4] of Al Hasa, between June 2010 and June 2011. The three
chronic disease clinics were selected randomly from the
The rate of non-compliance in patients with chronic lists of chronic disease clinics in the Al Hasa region. The
diseases in developed countries, on long-term treatment, study population included registered diabetic patients who
is on the order of 50%This could be even higher in were attending these clinics and were getting medication on
developing countries (WHO)[5] One study showed that a regular basis. Subjects with at least a one-year history of
while diabetic and cardiac patients who take medication diabetes, and who were on a fixed drug therapy for the last
correctly have a 7% death rate; for those who are non- six months, were selected for this study. The assumption
compliant the death rate is 12%. In another study, the rate for sample size determination was 65% prevalence of
of non-compliance ranged between 16.7 and 80% among non-compliance (as observed by a study in Saudi Arabia),
the patients suffering from tuberculosis, hypertension, a 95% confidence level with a deviation of ± 4% from
asthma, diabetes, epilepsy, and congestive cardiac failure. [6] true prevalence. The study population included all the
diabetic patients attending the chronic disease clinics of
A compliance study conducted in Saudi Arabia for those all three health sectors of Al Hasa with about 25100 cases.
on short-term medication found 67.8% compliance. To calculate the representative sample, we used Epi Info
However, compliance of patients tend to decrease with (version 6; November, 1993). With the assumption that
time being lower in patients on long-term medication than the non-compliance of patients with diabetes could be
in those on short-term medication. [7]Another study done between 65 and 69% , to achieve the confidence level of
in Saudi Arabia found an overall 65.8% non-compliance 95% we needed 535 persons with diabetes. A systematic
in patients suffering from hypertension. [8] The non- random sampling was done to select every third diabetic
compliance to long-term therapy severely compromises patient from the appointment list of the selected chronic
the effectiveness of treatment and adversely affects the disease clinics. The patients who had an appointment, but
patient's condition .[9] did not attend the clinics on the day of the appointment
were approached to complete questionnaires . The study
Non-compliance can be due to factors that are patient- sample was as per the population proportion to the size
centered , therapy-related , or healthcare system – (PPS) of the diabetic cases in Al Hasa; Mobarraz and
related .[10] The patient-centered factors can be demographic Faisaliya with 224 and 177 patients, respectively, belonged
(age, gender, educational level, and marital status) to the urban area, while Omran with 134 patients belonged
and psychological (patients’ beliefs and motivation to the rural area.
towards the therapy, negative attitude , patient-prescriber
relationship,understanding of health issues , and patient's The data collected comprised age, sex, marital status,
knowledge).[2]The therapy-related factors include route educational level, presence of other chronic diseases,
of medication, duration of treatment, complexity of duration of the DM, number of drugs taken for DM,
treatment, and the side effects of the medicines. The factors disease control status, regularity of taking the medication,
associated with the healthcare system include availability, and regularity of follow-up. A trained nurse conducted
accessibility, and the physician. an interview using structured questionnaires. The
questionnaire included questions relating to their non-
Diabetes Mellitus (DM), the most common endocrine compliance behaviors, the extent of information they
disease in the world, is a major global public health issue. [11] had about the medicine they were getting from a general
There has been an 8% increase in the prevalence of DM practitioner, and difficulty to comply with the treatment. A
in Saudi Arabia in the last 10 years and at present 25% of five-point Likert type scale was used to measure the degree
the Saudi population is diabetic. [12] of response to most of the questions .However, in some,
close- ended (yes or no) question types were used. The
To the best of our knowledge, there is little or no questionnaires were prepared with the help of the head
information on the magnitude of non-compliance of the of the diabetic clinic of the Al Hasa region.
diabetic patients in the Al Hasa region of Saudi Arabia. The
current study was undertaken to estimate the magnitude of The therapeutic outcome was considered in assessing
the problem of non-compliance and explore the factors the compliance of the patient. A patient who had been
contributing to non-compliance of the diabetic patients prescribed optimum treatment and had been given proper
of Al Hasa. advice on diet and exercise for his / her diabetes, but who

Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1 27

 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

did not follow the medical advice, and had Hb1AC of Table 1: Demographic characteristics of the
more than 7%, at the time of interview, was considered study sample
as non-compliant. Non-compliance was further assessed
Percentage No.
using the patients' self-report on how they had been taking
Gender
their medication in the week preceding the interview and Male 41.2 193
their regular attendance at the clinic . Patients were asked Female 58.8 275
to recall if they had missed any doses of medication on a Geographic distribution
Rural 28.4 133
day-to-day basis over a period of one week. The number Urban 71.6 335
of tablets or injections missed was calculated based Duration of diabetes
on the prescribed dose. Patients who reported taking 1-5 years 20.3 95
6-10 years 29.9 140
less than 80% of their prescribed diabetes medicines 11-15 years 24.4 114
were considered as failing to adhere to the treatment. 16-20 years 18.8 88
Those patients who missed even a single appointment >20 years 6.6 31
Educational level
were considered as non-adherent to the chronic disease Illiterate 64.7 303
clinic appointment.[9] Non-compliance to exercise and Primary 23.9 112
diet was assessed by the questionnaire as to whether the Secondary 9.6 45
respondents followed the GP’s advice on diet and exercise College degree 1.7 8
Marital status
(taking a 20-minute walk a day at least) or not. SPSS 13 Married 72 337
versions were used for all statistical calculations. The Never married 16.2 76
results were expressed as mean values ± SD. For non- Divorced 0.9 4
Widow 10.9 51
parametrical distributions, the chi square test was used. A Associated chronic disease
P value of < 0.05 was considered significant. None 54.1 253
Hypertension 42.9 201
Asthma 0.9 4
CHD 2. 10
RESULTS

A total of 468 patients participated in this study, while 67 Regarding the information received from the general
refused, giving a response rate of 87.47%. Two-thirds of physician, most of the patients reported that they had
the participants were from the urban area. The average age got enough information on ‘how to take the medicine’
of the participants was 58 years (SD ± 11.64) and more (91%), ‘how long it would take to act’, (68.6%), and ‘how
than half of them were females (58.8%). The majority of long the medicine should be taken’ (69%), but this was
the participants were uneducated (64.7%, n = 303). Most not true with the information regarding the side effects.
were married (84.4%, n = 395).The median duration of Sixty-one percent of the participants did not receive
diabetes was 10 years (range four years – thirty-two years). any information on the side effects of the medicine
The sociodemographic characteristics of the participants and 64% did not know what to do if there were any
are summarized in Table 1. side effects from the medicine. Most of the participants
(96%, n = 448) agreed that the attending physicians
Regarding the regularity of follow-up in the clinic only completely understood their health problem on the day
7.9% (n = 37) of the participants had not missed any of appointment, and 90% (n = 421) were comfortable
appointment in the last one year, while almost half of them with the multiple drug prescriptions.
(49.4%)had missed an appointment once or twice, and
41% (n = 191) more than twice. More than 50% (n = 249) The overall prevalence of therapeutic non-compliance,
of the participants did not attend the clinic on the day of that is, Hb1Ac level of more than 7 with the optimum
interview; 42.9% (n = 94) of them mentioned unavailability treatment among the participants was 67.9 % (n = 318,
of transport as the excuse for non- attendance, and 95% CI 63.59 – 72.02%). The non-compliance of the males
15.5% (n = 34) said they had forgotten , while 28.7% (69.34%) was higher than that of the females (65.45%,
(n = 63) of them considered it unnecessary as they were P = .003). The non-compliance in the urban participants
taking medicine from other sources. More than half of was significantly higher than (71.04 vs. 60.15%, P = .023)
the participants (57.5%, n = 289) did not adhere to the in the rural participants. There was a statistically significant
anti-diabetic medication as advised by the GP. The same difference in the prevalence rate of non-compliance among
obtained in the advice on exercise, where 62.6% (n = 293) the participants of different educational levels. It was
did not follow the instructions given by the GP. However, highest among the illiterates (72.6%, P = .001), falling as
the instructions on diet were followed by 64.7% (n = 303) the level of education rose. It was , 61.60% among those
of the participants. with primary school education , 47.61% among those with

28 Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1

 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

secondary school education , and 45.83% in those educated therapy only. With regard to a multiple oral drug regime,
beyond high school. Patients who were regular on follow- non-compliance was more among patients who were
up had a significantly higher compliance rate than those on Metformin and Glibenclamide (66.66% Vs 61.29%,
who were irregular (46.88% for those who never missed P = .003) than those who were on Metformin and
an appointment, 35.53% for those who had missed an Gliclazide [Table 2]. Physician related factors are
appointment once or twice in a year, 26.40%for those who described in Table 3.
had missed the appointment more than twice in a year and
18.19% for those who never attended the clinic, P = .039). Factors found to be significantly associated with non-
The non-compliance was higher among the patients who compliance on bivariate analysis were: Male gender (OR =
did not follow the exercise regime than those who followed 1.90, CI =1.32-4.57), education level ( literacy) (OR = 5.27,
it (66.66% vs. 54.67%, P = .012). However, this did not CI = 4.63–7.19),urban population (OR = 5.22, CI = 3.65-
hold for instructions on diet where non-compliance was 8.22), irregularity of follow up (OR = 8.41, CI = 4.90-11.92),
statistically insignificant [Table 2]. non- adherence to drug prescription (OR = 4.55 , CI = 3.54-
5.56), non -adherence to instruction on exercise (OR = 5.55,
The non-compliance was least (48%, P = .003) with the CI = 4.2 66.86), insulin (OR = 1.29, CI = .71-1.87), insulin
single drug regimen (Metformin) while it was highest with oral antidiabetic (OR = 1.20, CI = .65-1.75).
(79.31%, P = .003) among patients who were on combined
oral and insulin treatment. The non-compliance was also Age, marital status, duration of diabetes, associated chronic
higher (79.03%, P = .003) in patients who were on insulin disease, and attendance on the day of appointment were

Table 2: Patients’ related factors associated with non compliance

Compliance % Non compliance % P
Geographic
Rural 39.85 60.15 .023
Urban 28.96 71.04
Gender
Male 28.49 71.50 .035
Female 34.54 64.46
Marital status
Married 33.53 66.47 .862
Never married 26.31 73.69
Divorced 25 75
Widow 51.61 48.39
Attendance on the day of appointment
Attended 31.48 68.52 .774
Not attended 32.72 67.28
Forgot the appointment 28.57 71.43 .000
Non availability of transport 23.7 76.3
Did not think it necessary as he is taking medicine from other source 41.58 58.42
Education
Illiterate 27.4 72.6 .001
Primary school 38.4 61.60
Secondary school 52.39 47.61
College graduate 0 100
Follow up in the clinic
Never missed an appointment 46.88 53.12 .039
Missed the appointment once or twice 35.53 64.47 .039
Missed the appointment more than twice 26.40 73.60 .039
Never attended the clinic 18.19(2) 81.81 (9) .039
Diet instruction
Patients who followed the diet instruction 64.66 64.78 .003
Patients who did not follow the diet instruction 35.34 35.22 .981
Exercise instruction
Patients who followed the exercise instructiuon 45.33 33.34 .012
Patients who did not follow the exercise instruction 54.67 66.66
Drug regimen
Metformin only 51.72 48.28 0.003
Glibenclamide only 38.09 61.90 0.003
Glazide only 21.43 78.57 0.003
Metformin+Glibenclamide 33.33 66.67 0.003
Metformin+Glaz 38.70 61.30 0.003
Insulin+Glazide or glibenclamide 20.98 79.02 0.003
Insulin Only 20.96 79.04 0.003

Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1 29

 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

Table 3: Physician’s related factors Kong,[17] Mexico,[18] and Saudi Arabia,[19] where it was found
to be 28.9, 51.4, 59, 61, and 65% (average), respectively,
Information received by the patient Compliant Non
% compliant and lower than in India,[20] where it was found to be 75%.
% However, in the Uganda study, the median duration of
Information to the patient diabetes was four years (range one month to 38 years);
How to use the ant diabetic medicine P=.023 in the Palestine study non-compliance was divided in
Adequate 32.11 67.89
Little or none 25 75
two categories (51.4% poor compliance and 6.5% non-
How long the medicines take to act P=.008 compliance). In the Saudi study, the research was conducted
Adequate 33.87 66.13 at only one PHC and the non-compliance was divided into
Little or none 25.49 74.51 different categories, such as, non-compliance to drugs (20%
Whether the medicine has any P=.008
untoward side effects’’
P = 0.03; OR = 14.93; 95% CI = 2.862 – 2.516), non-
Adequate 40.20 59.8 compliance to lifestyle modification (60%, P = 0.010), and
Little or none 27.63 72.36 non-compliance to appointments (25%, P = 0.01; OR =
What should do if you experience P=.009 3.16; 95% CI = 1.41 – 0.80). In our study, we measured the
the side effects’’
Adequate 40.25 59.74 therapeutic non-compliance of the study population, which
Little or none 28.02 71.98 consisted of compliance with medication, appointments,
Interaction with the patient and lifestyle changes.
The physician completely P=.449
understands your health problem
when you saw him on the day of There was a significant rural–urban difference in the
appointment non-compliance rate among the diabetic patients in our
Agree 31.02 68.98 study. The non-compliance in the urban population was
Disagree 31.91 68.09
significantly higher than the rural population (71.04 vs.
You feel comfortable when your
physician prescribe multiple P=.449 60.15%, P = .023). The same finding has been documented
medicines for your diabetes in the Palestine study where the non-compliance among
Agree 31.99 68.01 urban diabetic patients was higher than among the rural
Disagree 31.91 68.09
patients (8.2 vs. 6.2%, P =.003). [16 ] This difference may be
due to various lifestyles. Urban residents tend to be more
not significantly associated with non-compliance. However, sedentary with relatively poor dietary habits as compared
non-compliance was significantly higher among the patients to the rural population .
who did not attend the clinic on the day of appointment,
because of unavailability of transport, than those who In our study, females were significantly more compliant
forgot the appointment day, and those who thought it (34.55 vs. 30.66%, P = .003). This was true of other
unnecessary as they were taking medicine from other researches conducted in various parts of the world.[21,22]
sources (78.3, 76.3, and 58.42%, respectively, P = .000). However, some studies have suggested the contrary,
Patient–doctor interaction factors, such as, the patients' indicating that males were more compliant.[15] In addition,
perception of the physician’s understanding of their health there are a few studies which found no relationship between
problems and the patients’ ease with the prescription of gender and non-compliance.[23,24] This difference may be
multiple drugs, were not significantly associated with the due to geographical variation in their education, and social
compliance rate. factors.

DISCUSSION In our study ,higher educational levels of patients

were found to be significantly associated with a higher
The concept of detection and management of diabetes compliance rate of the patients,. Several studies have
mellitus at a primary health care center is strongly justified found the same results,[22] while some studies have found
and widely practiced in Saudi Arabia. However, the no such association.[23] A study conducted in the UK has
control of diabetes is crucially dependent on the diabetic shown that patients with a lower level of education have
patient's compliance to medical advice.[13] Measuring the better compliance.[24,25] It may be presumed that patients
compliance of diabetic patients is a complex issue.[14] Our with a lower educational level may have more trust in
study explored therapeutic compliance and the factors the physician’s advice. However, these results show that
contributing to the non-compliance of diabetic patients education may not be a good predictor of therapeutic
in the Al Hasa region of Saudi Arabia. compliance.

Non-compliance with medication was higher in our study Irregularity of follow-up was an important factor in
than the earlier finding in Uganda,[15] Palestine,[16] Hong non-compliance in our study. The most important

30 Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1

 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

causes of non-compliance with clinic appointmenst CONCLUSION

were the non -availability of transport, followed by
forgetfulness. Forgetfulness has been widely published The result of this study showed that the rate of
as an important cause of irregularity of follow-up[26,27] noncompliance of diabetic patients in the Al Hasa
It is worth mentioning here that the rural as well as the region was high. The main reasons for this were non-
urban areas of the Al Hasa region lack good transport adherence to the anti-diabetic treatment, the appointment
facilities. Besides, owing to socio-cultural factors females schedule, and the exercise and diet regimen. The level of
cannot go out on their own to a health care center. education also played an important role in adherence to
medical advice. The majority of patients who could not
Patient physician relationship in our study has emerged see the doctor on the day of appointment mentioned
as an important factor affecting patients’ compliance. unavailability of transport and forgetfulness as the main
Compliance was fairly high among those patients who reasons. This reveals that there is the need to establish
had adequate information on the dose, duration of some sort of system by which contact can be made with
action, and side effects of the anti-diabetic medicines. those patients who have difficulty in attending clinics and
Those patients who did not get adequate information medication delivered to them on time. The PHC should
on what to do in the event of their missing a dose , or if have dietitian or diabetic counsellor who will give sustained
they experienced any side effects of the medicine, were encouragement and a one-to-one guidance on diet and
more non-compliant. Those patients who agreed that the exercise. Physician–patient relationship as well as patient’s
physician completely understood their health problem knowledge of diabetes should be improved through proper
when they saw them on the day of appointment were educational and training programs.
also more compliant. Numerous researches involving
various diseases have evaluated the effect of the patient–
physician relationship on patients’ compliance, and ACKNOWLEDGMENT
has found it to be another strong factor in favour of
My special thanks go to Dr. Hussain Ahmad Al Mehdi (Technical
patient compliance.[27-29] Compliance to treatment advice
Director, PHC Directorate), Dr Mohammad Neil (Technical
was good when the physicians were supportive, supplied consultant, PHC Directorate), Dr. Salah Abdul Aziz Mirghani
vital information, and listened patiently to patients.[30] (Technical consultant, PHC affairs), Mosaad Abdul Hadi Zayed
(Technical Director, A Hofuf Sector), Dr. Waleed Swelleh
The increased rate of therapeutic non-compliance (Assoc. Prof, Clinical Pharmacology, Palestine), Dr. Reyazuddin
in our study resulting from the multi-drug regimen Ahmad (General Practitioner), Dr. Yusuf Al Omerehal (technical
(Metformin + Sulfonylurea) and insulin injection director, Omran Sector), Yusuf al Najjar (Technical Supervisor,
was consistent with the previous study, which found Omran sector), Dr. Khadim (Chronic Disease Specialist, Al
that only 13% of the diabetic patients who were on Faisaliyah Health Care Centre), Dr. Zakaullah Khan Afghan
Metformin + Sulfonylurea adhered to the regimen, (Resident Cardiology), Dr. Nadira Ansari (Resident, Gynecology),
as compared to those on a single drug regimen with Dr. Shakil Ur Rahman (GP) and Ibrahim Al Hizzi (Director
Metformin (31%). [31] The high non-compliance rate Omran PHC) for their active support of my research.
among the patients taking insulin agrees with other
I am grateful to Staff Nurse Sheham Ali Nasruddin (Faisaliya),
studies in which researchers found 29 [32]and 37% [33]
Fatima Sultan (Omran), Hafifa A hadi Zainab Al Marzook
adherence to the medication in the study population. (Omran) and Wassel Yusuf who have taken great pain in helping
Non-adherence to insulin therapy in our study could me in Arabic to English translation and for data entry on paper
be attributed to a wrong technique in injecting insulin as well as in the computer.
or unavailability of someone at home to administer
the injection.[34]The results of the dietary and exercise
compliance in our study showed that patients were REFERENCES
more compliant to dietary directions than instructions
1. Partridge AH, Avorn J, Wang PS, Winer EP. Adherence to therapy
on exercise (64.66 vs. 45.33%). However, the rate of with oral antineoplastic agents. J Natl Cancer Inst 2002;94:652-61.
compliance to diet was better than in the study done 2. Jing J, Sklar GE, Min Sen Oh V, Chuen LiS. Factors affecting
in Alexandria, Egypt, where it was found to be 58.8% therapeutic compliance: A review from the patient’s perspective.
Ther Clin Risk Manag 2008;4:269-86.
However, the rate of compliance to the exercise regime 3. Zieger A. Does Better Packaging Equal Better Patient Compliance?
was poorer than in the Egyptian study (51.7%).[21] This [Online] [Last cited on 2010 Nov 20] Available from: http:// www.
difference in results may be due to the "easier-to-follow" pharmamanufacturing.com/articles/2005/312.html [Last accessed on
2011 Aug 01].
diet instructions, especially for females who seem to be
4. OtCm. Assisting therapy compliance, on compliance.2011. [online]
more sedentary in Saudi Arabia than in Egypt, because [Last cited on 2011 Apr 02] Available from: http://www.dsm.com/le/
of cultural constraints. en_US/otcm/htmlsolution_therapy_effectiveness.htm. [Last accessed

Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1 31

 Khan, et al.: Noncompliance and its factors among the diabetes of Al-Hasa, Saudi Arabia

on 2011 Aug 01]. rural primary health care units in Alexandria. J Fam Community
5. WHO: A report; Chronic Diseases - Poor compliance of Patients with Med 2010;17:121-8.
drug treatment[online] [Last cited on 2010 Oct 02]Available from: 22. Ghods AJ. Nasrollahzadeh D. Noncompliance with
http://www.bio-medicine.org/medicine-news/In-Chronic-Diseases- Immunosuppressive Medications after Renal Transplantation.
--Poor-compliance-of-Patients-with-drug-treatment--2097-1/. [Last Tissue Antigens 2002;60:553.
accessed on 2011 Aug 01]. 23. Spikmans FJ, Brug J, Doven MM, Kruizenga HM, Hofsteenge GH,
6. Loghman Adham-M. Medication noncompliance in patients with van Bokhorst-van der Schueren MA. Why do diabetic patients
chronic disease: Issues in dialysis and renal transplantation. Am J not attend appointments with their dietitian? J Human Nutr Diet
Manag Care 2003;9:155-71. 2003;16:151-8.
7. Al-Shammari SA, Khoja T, Al-Yamani MJ. Compliance with 24. Kyngas H, Lahdenpera T. Compliance of patients with hypertension
short-term antibiotic therapy among patients attending primary and associated factors. J Ad Nurs 1999;29:832-9.
health center in Riyadh, Saudi Arabia. J Royal Soc Promot Health 25. Senior V, Marteau TM, Weinman J. Self-reported adherence
1995;115:231-4. to cholesterol-lowering medication in patients with familial
8. Al-Sowielem LS, Elzubier AG. Compliance and knowledge of hypercholesterolaemia: The role of illness perceptions. J Cardiovasc
hypertensive patients attending PHC centers in Al-Khobar, Saudi Drugs Ther 2004;18:475-81.
Arabia. East Mediterr Health J 1998;4:301-7. 26. Lee VW, Leung PY. Glycemic control and medication compliance in
9. Abula T, Worku A. Patient noncompliance with drug regimens diabetic patients in a pharmacist-managed clinic in Hong Kong. Am
for chronic diseases in northeast Ethiopia. Ethiop J Health Dev J Health Syst Pharm 2003;60:2593-6.
2001;15:185-92. 27. Hernández-Ronquillo L, Téllez-Zenteno JF, Garduño-Espinosa J,
10. Lewis A. Non-compliance: A $100bn problem. Remington Rep González-Acevez E. Factors associated with therapy noncompliance
1997;5:14-5. [Last cited on 2010 Nov 20] Available from: qu.edu.qa in type-2 diabetes patients. Salud Publica Mex 2003;45:191-7.
/ pharmacy / documents / MEMS_Seminar_29Sep09-Semin. [Last 28. Cummings KM, Kirscht JP, Binder LR, Godley AJ. Determinants of
accessed on 2011 Aug 01]. drug treatment maintenance among hypertensive persons in inner
11. Anukote CC. Epidemiology studies of diabetes mellitus in Saudi city Detroit. Public Health Rep 1982;97:99-106.
Arabia –Part 1-screening of 3158 males in King Saud University. J R 29. Kim YS, Sunwoo S, Lee HR, Lee KM, Park YW, Shin HC, et al.
Soc Health 1990;110:201-3. Determinants of non-compliance with lipid-lowering therapy
12. Al-Khaldi YM, Khan MY, Khairallah SH. Audit of referral of diabetic in hyperlipidemic patients. Pharmacoepidemiol Drug Saf
patients. Saudi Med J 2002;23:177-81. 2002;11:593-600.
13. Federal Bureau of Prisons, Clinical Practice Guidelines Management 30. Lawson VL, Lyne PA, Harvey JN, Bundy CE. Understanding why
of diabetes, 2010 [online] [Last cited on 2011 June 02] Available from: people with type 1 diabetes do not attend for specialist advice: A
http://www.bop.gov/news/PDFs/diabetes.pdf. [Last accessed on qualitative analysis of the views of people with insulin-dependent
2011 Aug 01]. diabetes who do not attend diabetes clinic. J Health Psychol
14. Khattab MS, Abolfotouh MA, Khan MY, Humaidi MA, AlKaldi YM. 2005;10:409-23.
Compliance and control of diabetes in a family practice setting, 31. Donnan PT, MacDonald TM, Morris AD. Adherence to prescribed
Saudi Arabia. East Mediterr Health J 1999;5:755-65. oral hypoglycemic medication in a population of patients with Type
15. Kalyango JN, Owino E, Nambuya AP. Non-adherence to diabetes 2 diabetes: A retrospective cohort study. Diabetic Med 2002;19:279-84.
treatment at Mulago Hospital in Uganda: Prevalence and associated 32. Donnelly LA, Morris AD, Evans JM; DARTS / MEMO collaboration.
factors.Afr Health Sci 2008;8:67-73. Adherence to insulin and its association with Glycemic control in
16. Sweileh W, Aker O, Hamooz S. Rate of Compliance among Patients patients with type 2 diabetes. QJM 2007;100:345-50.
with Diabetes Mellitus and Hypertension. An-Najah Univ J Res 33. Rajagopalan R, Joyce A, Smith D, Ollendorf D, Murray FT.
2005;19:1-12. Medication compliance in type 2 diabetes patients: Retrospective
17. Lee VW, Leung PY. Glycemic Control and Medication Compliance data analysis. Value Health 2003;6:328.
in Diabetic Patients in a Pharmacist-Managed Clinic in Hong Kong. 34. Khan AR, Lateef ZN, Khamseen MA, Al- Aithan MA, Khan SA,
Am J Health-Syst Pharm 2004;60:2593-5. Ibrahim IAl. Knowledge, attitude and practice of ministry of health
18. Hernández-Ronquillo L, Téllez-Zenteno JF, Garduño-Espinosa J, primary health care physicians in the management of type 2 diabetes
González-Acevez E. Factors associated with therapy noncompliance mellitus: A cross-sectional study in the Al Hasa District of Saudi
in type-2 diabetes patients. Salud Publica Mex 2003;45:191-7. Arabia, 2010. Niger J Clin Pract 2011;14:52-9.
19. Khattab MS, Abolfotouh MA, Khan MY, Humaidi MA, AlKaldi
YM. Compliance and control of diabetes in a family practice setting,
Saudi Arabia. East Mediterr Health J 1999;5:755-65. How to cite this article: Khan AR, Al-Abdul Lateef ZN, Al Aithan
20. Shobhana R, Begum R, Snehalatha C, Vijay V, Ramachandran A. MA, Bu-Khamseen MA, Al Ibrahim I, Khan SA. Factors contributing
Patients' adherence to diabetes treatment. J Assoc Physicians India to non-compliance among diabetics attending primary health
1999;47:1173-5. centers in the Al Hasa district of Saudi Arabia. J Fam Community
21. Ibrahim NK, Attia SG, Sallam SA, Fetohy EM, El-Sewi F. Physicians’ Med 2012;19:26-32.
therapeutic practice and compliance of diabetic patients attending Source of Support: Nil, Conflict of Interest: Nil

32 Journal of Family and Community Medicine | April 2012 | Vol 19 | Issue 1