IMPACT ASSESSMENT OF PHARMACEUTICAL CARE INTERVENTION ON NEWLY DIAGNOSED DIABETES MELLITUS PATIENTS IN A TERTIARY CARE HOSPITAL OF A SUB METROPOLITAN CITY OF WESTERN NEPAL by DINESH KUMAR UPADHYAY Thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy October 2013
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IMPACT ASSESSMENT OF PHARMACEUTICAL CARE INTERVENTION ON
NEWLY DIAGNOSED DIABETES MELLITUS PATIENTS IN A TERTIARY
CARE HOSPITAL OF A SUB METROPOLITAN CITY OF WESTERN NEPAL
by
DINESH KUMAR UPADHYAY
Thesis submitted in fulfilment of the requirements for thedegree of Doctor of Philosophy
October 2013
ii
DEDICATION
I DEDICATE THE PRESENT STUDY TO THOSE
PEOPLE WHO HAVE LOST THEIR LOVED ONES
DUE TO DIABETES
iii
ACKNOWLEDGEMENTS
In recognition of my doctoral research I am in debt to my GOD, the almighty, the most
gracious, the most merciful, my constant guide, friend and source of strength who gave
me courage, will, determination, and wisdom to complete this ardent task. I thank HIM
for giving me the most wonderful supportive family members; the opportunity to work
with some of the most highly qualified and respected professionals, the most excellent
working environment, and the best of friends.
I would like to express my sincere gratitude and bottomless appreciation to my
beloved supervisor Dr. Mohamed Izham Mohamed Ibrahim, Professor of Social and
Administrative Pharmacy and Associate Dean for Research and Graduate Studies
Affairs, College of Pharmacy, Qatar University, Doha Qatar (who was formerly
Professor of Social and Administrative Pharmacy and Deputy Dean of Research and
Postgraduate Studies at the School of Pharmaceutical Sciences, Universiti Sains
Malaysia, Penang, Malaysia) for supervising me to carry out this research work as well
as fulfilling the role of a teacher, guide, counsellor, advisor, and a mentor. His constant
and steady support, which often goes beyond academics, helped me a lot in learning the
research methodology and conducting the research in a better way. As a human being I
perceived him a very clever, intelligent and an embodiment of patience. This work
would not have been possible without his guidance and encouragement throughout the
study. I belief, I was very fortunate being his student and got the opportunity to learn
about the real meaning of research.
I am profoundly grateful to my clinical supervisor Dr. Vijay M. Alurkar,
Professor and Head, Department of Medicine, Manipal College of Medical Sciences and
iv
Manipal Teaching Hospital, Pokhara, Nepal for his excellent guidance during my course
of data collection in the hospital. I am also thankful to him for giving me opportunity to
deal the diabetes patients, counsel, and educate them regarding their disease under his
close supervision. My heartfelt thanks to Professor Dr. Pranaya Mishra, who was
formerly Associate Professor at the Department of Pharmacology, Manipal College of
Medical Sciences (MCOMS), Pokhara, Nepal and presently working as Professor and
Course Director at Department of Pharmacology, Saba University School of Medicine,
Saba, Netherlands-Antilles for co-supervising me in conducting this research work and
helping me in translation of questionnaire and different educational materials into
Nepali. His task-oriented approach, constructive comments and ‘one work at a time’
strategy helped me very much throughout my research.
My sincere thanks to Dr. Archana Saha, Professor and Head, Department of
Pharmacology for her administrative support and help in conducting the study and
permitting me leave whenever required. I acknowledge the services of Dr. Brij Mohan
Nagpal, Deans of the MCOMS for permitting me to execute the study in the hospital. I
am also thankful to all the members of Ethics and Research Committee, Manipal
College of Medical Sciences for approving the research study and permitted me to
conduct the study in the hospital. I also acknowledge the direct and indirect contribution
of my pharmacy staffs in conducting my research work in the hospital. My sincere thank
goes to all the medical and paramedical staffs of Manipal Teaching Hospital for their
contribution in my work. My sincere thank goes to Mr. Ghanshyam Adhikari for his
assistance to me in drafting the Nepali version of questionnaire and other study tools. I
would like to acknowledge the sincere contribution of all the members who were
involved in Linguistic Validation process of ADDQoL questionnaire.
v
I would also like to express my sincere appreciation to Dr. Azmi Ahmad Hassali
Associate Professor, Department of Social and Administrative Pharmacy and Deputy
Dean, Student Affairs & Networking, School of Pharmaceutical Sciences, and Dr. Asrul
Akmal Shafie, Associate Professor and Chairperson, Department of Social and
Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains
Malaysia, Penang, Malaysia for their encouragement and support time to time whenever
I needed during my course of thesis writing. I never felt that I am away from my home
because of their friendly and caring nature and always kept me enthusiastic.
My special thank goes to Professor Clare Bradley, Health Psychology Research,
Department of Psychology, Royal Holloway, University of London, Engham, Surrey,
UK for her continuous support and guidance in conducting Linguistic Validation of
Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire into Nepali
language and permitted me to use ADDQoL questionnaire in my research study. I would
like to thank all my friends and well-wishers for giving me moral support and inputs
during my entire journey of research study. I am also grateful for the services and
support I received from non-academic staffs in the Discipline of Social and
Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains
Malaysia, Penang, Malaysia. I am very thankful to Eli Lilly Company for providing the
free sample of insulin pen (Brand: Humapen) for diabetes patients whenever needed. I
offer my heartfelt thanks to all the diabetes patients who actively participated in the
study and shared their valuable time and information. This project was not possible
without their support and contribution. Last but not least, I am thankful to my parents,
brothers and sisters for whom no words can express my gratitude for the constant
encouragement, moral support and prayers.
vi
TABLE OF CONTENTS
Title Page
DEDICATION Ii
ACKNOWLEDGEMENTS iii
TABLE OF CONTENTS vi
LIST OF TABLES xvii
LIST OF FIGURES xxi
LIST OF APPENDICES xxiii
ABBREVIATIONS xxiv
ABSTRAK xxvi
ABSTRACT xxix
CHAPTER 1 – GENERAL INTRODUCTION
1.1 Introduction 1
1.1.1 Background of diabetes mellitus 1
1.2 Epidemiology of diabetes mellitus 4
1.2.1 Global scenario of diabetes mellitus 4
1.2.2 Prevalence of diabetes mellitus in Nepal 5
1.3 Impact of diabetes mellitus and its complications 6
1.4 Concept of pharmaceutical care vs. Medication therapeuticmanagement 8
1.5 Concept of pharmaceutical care in Nepal 11
1.6 Pharmaceutical care and its importance in diabetes mellitusmanagement 12
1.7 Problem statement 13
1.8 Rationale of the study and its importance 15
1.9 Contribution of the study findings 17
vii
1.10 Study objectives 18
1.10.1 General objective 18
1.10.2 Specific objectives 18
1.11 Thesis overview 20
CHAPTER 2 - LITERATURE REVIEW AND RESEARCHCONCEPTUAL FRAMEWORK
2.1 Definition of diabetes mellitus 22
2.2 Classification of diabetes mellitus 22
2.3 Clinical presentation of diabetes mellitus 24
2.4 Diagnosis of diabetes mellitus 24
2.5 Complications of diabetes mellitus 25
2.6 Management of diabetes mellitus 27
2.6.1 Non-pharmacological treatment 27
2.6.2 Pharmacological treatment 28
2.7 Literature review related to knowledge, attitude and practice ofdiabetes mellitus patients 29
2.7.1 Studies from the developed countries 30
2.7.2 Studies from the developing countries 33
2.8 Literature review related to health-related quality of life of diabetesmellitus patients 40
2.8.1 Studies from the developed countries 41
2.8.2 Studies from the developing countries 44
2.9 Literature review related to medication adherence and metaboliccontrol (i.e. glycaemic and blood pressure control ) of diabetesmellitus patients
47
2.9.1 Concept of medication adherence 47
2.9.2 Methods to measure medication adherence 50
2.9.3 Studies from the developed countries 53
viii
2.9.4 Studies from the developing countries 55
2.10 Literature review related to direct healthcare costs of diabetesmellitus patients 57
2.10.1 Studies from the developed countries 57
2.10.2 Studies from the developing countries 58
2.11 Literature review related to diabetes mellitus patients’ satisfactionto provided healthcare services 59
2.11.1 Studies from the developed countries 60
2.11.2 Studies from the developing countries 61
2.12 Conceptual framework of the research study 63
2.13 Research questions 65
2.14 Research hypotheses 65
2.15 Conclusion 66
CHAPTER 3 – GENERAL METHODOLOGY
3.1 Study design 69
3.2 Study location and time frame 74
3.3 Ethical approval from hospital for undertaking the study 75
3.4 Consent from study patients 75
3.5 Study population and sample size 75
3.5.1 Inclusion criteria 77
3.5.2 Exclusion criteria 77
3.6 Development of study tools and design of the questionnaire 78
3.6.1 Consent form 78
3.6.2 Socio-demography form 78
3.6.3 Lab investigation documentation form 79
3.6.4 Direct healthcare costs documentation form 79
ix
3.6.5 Medication documentation form 79
3.6.6 Diabetes information booklet 80
3.6.7 Diabetes complication chart 80
3.6.8 Diabetic food chart 80
3.6.9 Medication envelope 81
3.6.10 Insulin pen and insulin syringe 81
3.6.11 Glucometer 81
3.6.12 Diabetic kit 82
3.6.12 (a) Glass tubings 82
3.6.12 (b) Chart of human anatomy with circulatory system 83
3.6.12.(c) Daily medication calendar 83
3.6.12.(d) Calendar of antidiabetic medicines 84
3.6.13 Formulation of Knowledge, Attitude and Practice````````questionnaire 84
3.6.13 (a) Scoring method for Knowledge, Attitude and``````````````````Practice questionnaire 86
3.6.13 (b) Validation of Knowledge, Attitude and Practice`````````````````` questionnaire 87
3.6.14 Formulation of Diabetes Patient Satisfaction questionnaire 87
3.6.14 (a) Scoring method for Diabetes Patient Satisfactionquestionnaire 88
3.6.14 (b) Validation of Diabetes Patient Satisfactionquestionnaire 88
3.6.15 Adaptation of Audit of Diabetes-Dependent Quality of Lifequestionnaire 89
3.6.15 (a) Scoring method for the Audit of Diabetes-Dependent````````````````` Quality of Life questionnaire 90
3.6.15 (b) Description of Linguistic Validation process for `` Audit of Diabetes-Dependent Quality of Life ` ` ``` questionnaire
91
x
3.7 Data collection and description of pharmaceutical care interventionamong diabetes mellitus patients 94
3.7.1 Intervention phase 95
3.7.2 Reinforcement phase 102
3.8 Data management and analysis 102
3.8.1 Sources of data 102
3.8.2 Data analysis 103
3.9 Statistical analysis 104
3.10 Pilot study 105
CHAPTER 4 - IMPACT ASSESSMENT OF PHARMACEUTICALCARE INTERVENTION ON THE KNOWLEDGE, ATTITUDE ANDPRACTICE OF NEWLY DIAGNOSED DIABETES MELLITUSPATIENTS IN A TERTIARY CARE HOSPITAL
4.1 Introduction 108
4.2 Study objectives 109
4.2.1 General objective 109
4.2.2 Specific objectives 110
4.3 Methodology 110
4.3.1 Study design 110
4.3.2 Study location and duration of the study 111
4.3.3 Study population and sample selection 111
4.3.4 Instrument used to assess knowledge, attitude and practice ofdiabetes mellitus patients 111
4.3.5 Educational intervention of diabetes patients throughpharmaceutical care 112
4.3.6 Method of data collection 112
4.3.7 Data analysis 112
4.4 Results 113
xi
4.4.1 Socio-demographic characteristics of study patients 113
4.4.2 Patients’ knowledge about diabetes and its management atbaseline and follow-ups 117
4.4.3 Patients’ knowledge scores about diabetes and itsmanagement at baseline and follow-ups 121
4.4.4 Patients’ attitude about diabetes management and its effect onpatients’ sexual life at baseline and follow-ups 123
4.4.5 Patients’ attitude scores about diabetes and its management atbaseline and follow-ups 127
4.4.6 Patients’ practice about diabetes management at baseline andfollow-ups 129
4.4.7 Patients’ practice scores about diabetes management atbaseline and follow-ups 133
4.4.8 KAP scores of control group, test 1 group and Test 2 grouppatients at baseline and follow-ups 135
4.4.9 Correlation of baseline knowledge, attitude and practice andKAP scores with patients’ age and monthly income 137
4.4.10 Gender-wise comparison of baseline knowledge, attitude,practice and KAP scores 138
4.4.11 Comparison of baseline knowledge, attitude, practice andKAP scores with patients’ education 138
4.4.12 Comparison of baseline knowledge, attitude, practice andKAP scores with patients’ occupation 140
4.4.13 Comparison of patients’ knowledge, attitude, practice andKAP scores at baseline, 3-months, 6-months, 9-months and12-months follow-ups within the test groups (Test 1 groupand Test 2 group)
142
4.4.14 Comparison of knowledge, attitude, practice and KAP scoresbetween Test 1 group and Test 2 group 145
4.4.15 Comparison of knowledge, attitude, practice and KAP scoresbetween Control group and Test 1 group 147
4.4.16 Comparison of knowledge, attitude, practice and KAP scoresbetween Control group and Test 2 group 149
xii
4.4.17 Relationship between knowledge and attitude (K-A),knowledge and practice (K-P), and attitude and practice (A-P) scores
151
4.5 Discussion 153
4.5.1 Patients’ knowledge, attitude and practice about diabetes andits management 154
4.5.1 (a) General knowledge about diabetes mellitus 156
4.5.1 (b) Knowledge about diabetes complications and its `` `````````preventive measures 159
4.5.1 (c) Patients’ attitude about diabetes and its management 162
4.5.1 (d) Patients’ practice about diabetes and its management 164
4.6 Conclusion 166
CHAPTER 5 - IMPACT ASSESSMENT OF PHARMACEUTICALCARE INTERVENTION ON HEALTH-RELATED QUALITY OFLIFE OF NEWLY DIAGNOSED DIABETES MELLITUS PATIENTSIN A TERTIARY CARE HOSPITAL
5.1 Introduction 167
5.2 Study objectives 168
5.2.1 General objective 168
5.2.2 Specific objectives 169
5.3 Methodology 169
5.3.1 Study design 170
5.3.2 Study site and duration of the study 170
5.3.3 Study population and sample selection 170
5.3.4 Instrument used to assess patients’ health-related quality of```````life 170
5.3.5 Pharmaceutical care intervention of diabetes mellitus patients 171
5.3.6 Method of data collection 171
5.3.7 Data analysis 171
xiii
5.4 Results 172
5.4.1 General quality of life scores of the control group and testgroups (Test 1 group and Test 2 group) DM patients atbaseline and follow-ups
172
5.4.2 Impact scores, Importance scores and Weighted impact scores```````of control group and test groups (Test 1 group and Test 2```````group) DM patients at baseline and follow-ups
174
5.4.3 Average weighted impact scores (AWIS) of control group andtest groups (Test 1 group and Test 2 group) DM patients atbaseline and follow-ups
184
5.4.4 Association of patients’ baseline average weighted impactscores (AWIS) with patients’ age and monthly income 186
5.4.5 Comparison between patients’ gender and patients’ baselineaverage weighted impact scores (AWIS) 186
5.4.6 Comparison between patients’ education and patients’baseline average weighted impact scores (AWIS) 187
5.4.7 Comparison of patients’ average weighted impact scores(AWIS) at baseline, 3-months, 6-months, 9-months and 12-months follow-ups within test groups (Test 1 group and Test2 group)
188
5.4.8 Comparison of patients’ average weighted impact scores(AWIS) between Test 1 group and Test 2 group 190
5.4.9 Comparison of patients’ average weighted impact scores(AWIS) between Control group and Test 2 group 191
5.4.10 Comparison of patients’ average weighted impact scores(AWIS) between Control group and Test 1 group 192
5.5 Discussion 193
5.6 Conclusion 200
CHAPTER 6 - IMPACT ASSESSMENT OF PHARMACEUTICALCARE INTERVENTION ON MEDICATION ADHERENCE ANDCLINICAL OUTCOMES, DIRECT HEALTHCARE COSTS ANDSATISFACTION OF NEWLY DIAGNOSED DIABETES MELLITUSPATIENTS IN A TERTIARY CARE HOSPITAL
6.1 Introduction 202
xiv
6.2 PART- 1: Impact of pharmacist-provided pharmaceutical care `````````intervention on medication adherence and clinical`````outcomes (i.e. glycaemic and blood pressure control) of`````newly diagnosed diabetes mellitus patients
206
6.2.1 General objective 206
6.2.2 Specific objectives 206
6.2.3 Methodology 207
6.2.3 (a) Medication counselling of diabetes mellitus patients 207
6.2.3 (b) Measurement of medication adherence by pill counts```````````method 209
6.2.3 (c) Method of data collection 212
6.2.3 (d) Data analysis 212
6.2.4 Results 212
6.2.4 (a) Patients’ medication adherence and clinical outcomes,and patients’ conversion rate at baseline and follow-ups
212
6.2.4 (b) Association of patients’ baseline medicationadherence with patients’ age and monthly income 217
6.2.4 (c) Comparison of patients’ baseline medicationadherence with patients’ gender, education andoccupation
217
6.2.4 (d) Comparison of patients’ medication adherence andclinical outcomes at baseline, 3-months, 6-months, 9-months and 12-months follow-ups within test groups(Test 1 group and Test 2 group)
219
6.2.4 (e) Comparison of patients’ medication adherence andclinical outcomes between T1G and T2G, CG andT1G, and CG and T2G
223
6.3 PART- 2: Impact of pharmacist-provided pharmaceutical careintervention on direct healthcare costs of newly diagnosed diabetesmellitus patients
225
6.3.1 General objective 225
6.3.2 Specific objectives 225
6.3.3 Methodology 226
xv
6.3.3 (a) Estimation of direct medical and non-medical costs ofdiabetes mellitus patients 226
6.3.3 (b) Method of data collection 228
6.3.3 (c) Data analysis 228
6.3.4 Results 229
6.3.4 (a) Geometric changes in direct medical and non-medical`````````````````costs of Control group, Test 1 group and Test 2 group`````````````````patients at baseline, 3-months, 6-months, 9-months`````````````````and 12-months follow-ups
229
6.3.4 (b) Direct healthcare costs (direct medical + non-medical`````````````````costs) of control group, Test 1 group and Test 2 group`````````````````patients at baseline and follow-ups
233
6.3.4 (c) Comparison of direct healthcare costs of patients at ``` ` ```` baseline, 3-months, 6-months, 9-months and 12-`````````````````months follow-ups within test groups (Test 1 group```````````````` and Test 2 group)
236
6.3.4 (d) Comparison of direct healthcare costs between test`````````````````groups (Test 1 group and Test 2 group), and control`````````````````group and test groups patients
238
6.4 PART- 3: Impact of pharmacist-provided pharmaceutical careintervention on satisfaction of newly diagnosed diabetes mellituspatients
241
6.4.1 General objective 241
6.4.2 Specific objectives 241
6.4.3 Methodology 241
6.4.3 (a) Instruments used to evaluate patients’ satisfaction 242
6.4.3 (b) Method of data collection 242
6.4.3 (c) Data analysis 242
6.4.4 Results 243
6.4.4 (a) Patients’ satisfaction with pharmacist andpharmaceutical care intervention at baseline andfollow-ups
243
6.4.4 (b) Patients’ satisfaction scores at baseline, 3-months, 6-months, 9-months and 12-months follow-ups 249
xvi
6.4.4 (c) Association of patients’ baseline satisfaction scoreswith patients’ age and monthly income 251
6.4.4 (d) Comparison of patients’ baseline satisfaction scoreswith patients’ gender and education 251
6.4.4 (e) Comparison of patients’ satisfaction scores atbaseline, 3-months, 6-months, 9-months and 12-months follow-ups within test groups (Test 1 groupand Test 2 group)
252
6.4.4 (f) Comparison of patients’ satisfaction scores betweenTest 1 group and Test 2 group 254
6.4.4 (g) Comparison of patients’ satisfaction scores betweenControl group and Test 2 group 255
6.4.4 (h) Comparison of patients’ satisfaction scores betweenControl group and Test 1 group 256
6.5 Discussion 257
6.5.1 Patients’ medication adherence and clinical outcomes 258
6.5.2 Direct healthcare costs of diabetes mellitus patients 268
6.5.3 Patients’ satisfaction with pharmacist and provided care 272
6.6 Conclusion 277
CHAPTER 7 - THESIS CONCLUSION
7.1 Summary of the study 280
7.2 Limitations of the study 281
7.3 Recommendations 283
7.4 Future research 284
7.5 Conclusion 285
REFERENCES 289
APPENDICES 320
xvii
LIST OF TABLES
Table No Title Page
3.1 Distribution chart of intervention and reinforcementprogramme in Control group, Test 1 group and Test 2 groupdiabetes mellitus patients
95
4.1 Socio-demographic characteristics of study patients 114
4.2 Patients’ knowledge about diabetes and its management atbaseline and follow-ups 119
4.3 Patients’ knowledge scores about diabetes and itsmanagement at baseline and follow-ups 122
4.4 Patients’ attitude about diabetes management and its effecton patients’ sexual life at baseline and follow-ups 124
4.5 Patients’ attitude scores about diabetes and its managementat baseline and follow-ups 128
4.6 Patients’ practice about diabetes management at baselineand follow-ups 130
4.7 Patients’ practice scores about diabetes management atbaseline and follow-ups 134
4.8 KAP scores of Control group, Test 1 group and Test 2 grouppatients at baseline and follow-ups 136
4.9 Correlation of baseline knowledge, attitude and practice andKAP scores with patients’ age and monthly income 137
4.10 Comparison of baseline knowledge, attitude, practice andKAP scores with patients’ gender 138
4.11 Comparison of baseline knowledge, attitude, practice andKAP scores with patients’ education 139
4.12 Comparison of baseline knowledge, attitude, practice andKAP scores with patients’ occupation 141
4.13 Comparison of patients’ knowledge, attitude, practice andKAP scores at baseline, 3-months, 6-months, 9-months and12-months follow-ups within test groups (Test 1 group andTest 2 group)
144
xviii
4.14 Comparison of knowledge, attitude, practice and KAPscores between Test 1 group and Test 2 group
146
4.15 Comparison of knowledge, attitude, practice and KAP scorebetween Control group and Test 1 group 148
4.16 Comparison of knowledge, attitude, practice and KAP scorebetween Control group and Test 2 group 150
4.17 Correlation between K-A, K-P and A-P scores of patients 152
5.1 General quality of life scores of control group and testgroups (Test 1 group and Test 2 group) diabetes mellituspatients at baseline and follow-ups
173
5.2 Impact scores, Importance scores and Weighted impactscores of Control group, Test 1 group and Test 2 grouppatients at baseline
176
5.2 (a) Impact scores, Importance scores and Weighted impactscores of Control group patients at 3-months, 6-months, 9-months and 12-months follow-ups
178
5.2 (b) Impact scores, Importance scores and Weighted impactscores of Test 1 group patients at 3-months, 6-months, 9-months and 12-months follow-ups
180
5.2 (c) Impact scores, Importance scores and Weighted impactscores of Test 2 group patients at 3-months, 6-months, 9-months and 12-months follow-ups
182
5.3 Average weight impact scores (AWIS) of control group andtest groups (Test 1 group and Test 2 group) patients atbaseline and follow-ups
185
5.4 Association of patients’ baseline average weighted impactscores (AWIS) with patients’ age and monthly income 186
5.5 Comparison between patients’ gender and patients’ baselineaverage weighted impact scores (AWIS) 187
5.6 Comparison between patients’ education and patients’baseline average weighted impact scores (AWIS) 187
5.7 Comparison of patients’ average weighted impact scores(AWIS) at baseline, 3-month, 6-month, 9-month and 12-month follow-ups within test groups (Test 1 group and Test2 group)
188
xix
5.8 Comparison of patients’ average weighted impact scores(AWIS) between Test 1 group and Test 2 group 190
5.9 Comparison of patients’ average weighted impact scores(AWIS) between Control group and Test 2 group 191
5.10 Comparison of patients’ average weighted impact scoresbetween Control group and Test 1 group 192
6.1 Conversion rate of diabetes mellitus patients at baseline andfollow-ups 216
6.2 Association of patients’ baseline medication adherence withpatients’ age and monthly income 217
6.3 Comparison of patients’ baseline medication adherence withpatients’ gender, education and occupation 218
6.4 Comparison of patients’ medication adherence and clinicaloutcomes at baseline, 3-months, 6-months, 9-months and12-months follow-ups within test groups (Test 1 group andTest 2 group)
220
6.5 Geometric changes in direct medical and non-medical costsof Control group, Test 1 group and Test 2 group patients atbaseline and follow-ups
231
6.6 Total direct healthcare cost (direct medical and non-medicalcosts) of control group and test groups patients at baseline,3-months, 6- months, 9-months and 12-months follow-ups
235
6.7 Direct healthcare costs comparison of patients at baseline, 3-months, 6-months, 9-months and 12-months follow-upswithin test groups (Test 1 group and Test 2 group)
237
6.8 Differences in direct healthcare costs of patients in both thetest groups over time 238
6.9 Comparison of direct healthcare costs between test groups(Test 1 group and Test 2 group) and control group and testgroups patients
240
6.10 Patients’ satisfaction with pharmacist and pharmaceuticalcare intervention at baseline and follow-ups 245
xx
6.11 Patients’ satisfaction scores at baseline, 3-months, 6-months,9-months and 12-months follow-ups 250
6.12 Association of patients’ baseline satisfaction scores withpatients’ age and monthly income 251
6.13 Comparison of baseline patients’ satisfaction scores withpatients’ gender and education 252
6.14 Comparison of patients’ satisfaction scores at baseline, 3-months, 6-months, 9-months and 12-months follow-upswithin test groups (Test 1 group and Test 2 group) 253
6.15 Comparison of patients’ satisfaction scores between Test 1group and Test 2 group 255
6.16 Comparison of patients’ satisfaction scores between Controlgroup and Test 2 group 256
6.17 Comparison of patients’ satisfaction scores between Controlgroup and Test 1 group
257
xxi
LIST OF FIGURES
Figure No Title Page
1.1 Vision of the overall research 19
2.1 Conceptual framework representing problems encounteredin diabetes management and the provided means ofintervention for better patient outcome
64
3.1 Flow chart of study design 72
3.2 Flow chart of pharmaceutical care intervention 73
3.3 Location of Kaski district in the map of Nepal 74
4.1 Comparison of mean knowledge scores of Control group,Test 1 group and Test 2 group DM patients at baseline, 3-months, 6-months, 9-months, and 12-months follow-ups
122
4.2 Comparison of mean attitude scores of Control group, Test1 group and Test 2 group DM patients at baseline, 3-months, 6- months, 9-months and 12-months follow-ups
128
4.3 Comparison of mean practice scores of Control group, Test1 group and Test 2 group DM patients at baseline, 3-months, 6-months, 9-months and 12-months follow-ups
134
4.4 Comparison of overall mean KAP scores of Control group,Test 1 group and Test 2 group DM patients at baseline, 3-months, 6-months, 9-months and 12-months follow-ups
136
5.1 Average weight impact scores (AWIS) of control groupand test groups (Test 1 group and Test 2 group) DMpatients at baseline and follow-ups
185
6.1 Medication adherence of Control group, Test 1 group andTest 2 group DM patients at baseline and follow-ups 215
6.2 Fasting blood glucose (FBG) of Control group, Test 1group and Test 2 group DM patients at baseline andfollow-ups
215
6.3 Post prandial blood glucose (PPBG) of Control group, Test1 group and Test 2 group DM patients at baseline andfollow-ups
215
6.4 Glycated haemoglobin (HbA1c) of Control group, Test 1 215
xxii
group and Test 2 group DM patients at baseline andfollow-ups
6.5 Systolic blood pressure (SBP) of Control group, Test 1group and Test 2 group DM patients at baseline andfollow-ups
216
6.6 Diastolic blood pressure (DBP) of Control group, Test 1group and Test 2 group DM patients at baseline andfollow-ups
216
6.7 Direct healthcare costs (in Nepali rupees) of control groupand test groups DM patients at baseline, 3-months, 6-months, 9-months and 12-months follow-ups
234
6.8 Comparison of mean satisfaction scores of Control group,Test 1 group and Test 2 group DM patients at baseline, 3-months, 6-months, 9-months and 12-month follow-ups
250
xxiii
LIST OF APPENDICES
Appendix No Title Page1 Informed consent 320
2 Socio-demography form 322
3 Lab investigation form 324
4 Direct healthcare costs documentation form 325
5 Medication documentation form 327
6 Diabetes information booklet 328
7 Diabetes complication chart 329
8 Diabetic food chart 330
9 Medication envelope 331
10 Insulin pen and insulin syringe 332
11 Glucometer 333
12 Diabetic kit 334
12 (a) Glass tubings 334
12 (b) Chart of human anatomy with circulatory system 334
12 (c) Daily medication calendar 335
12 (d) Calendar of antidiabetic medicines 336
13 Knowledge, Attitude and Practice Questionnaire related todiabetes and its management 337