Social Support and Medication Adherence Among People with Type 2 Diabetes Mellitus in Central Karnataka, India

Background: Social support is crucial to improving the health of people with type 2 diabetes mellitus through medication adherence. Objectives: 1. To assess the social support and medication adherence among people with Type 2 diabetes mellitus. 2. To study the factors associated with social support and medication adherence among people with Type 2 diabetes mellitus. Methodology: This community-based study was undertaken among 150 people with type 2 diabetes mellitus. Social support was assessed using standard, validated Multidimensional Scale of Perceived Social Support. Medication adherence was assessed using standard, validated 8-item Morisky adherence scale. Results: Mean age of study participants was 57.42±11.07 years. In the present study 87 (58%) had high social support followed by moderate support 63 (42%). In the present study majority of study participants 83 (55%) had moderate medication adherence followed by low medication adherence 67 (45%). Conclusions: Social support plays an important role in promoting medication adherence among diabetes patients.


INTRODUCTION
Diabetes mellitus, a chronic metabolic condition, is a major public health concern around the world.According to the International Diabetes Federation (IDF), there were approximately 463 million people with type 2 diabetes mellitus in 2019, with the number expected to rise to 700 million by 2045.As of 2019, it was estimated that around 77 million adults aged 20-79 years had diabetes in India, making it one of the countries with the highest number of people affected by diabetes. 1This number is expected to rise in the coming years due to various factors such as urbanization, sedentary lifestyles, unhealthy diets, and genetic predisposition. 2It is crucial to raise awareness, promote early detection, and encourage healthy lifestyle practices to effectively manage and prevent diabetes in India. 3fective management including healthy lifestyle management, medication adherence, and regular follow-up is critical for avoiding complications such as cardiovascular disease, renal failure, retinopathy, and neuropathy. 4,5cial support refers to the assistance, encouragement, and understanding that individuals receive from their social networks, such as family, friends, or support groups. 6Medication adherence is the extent to which people take their prescribed medications. 710] Considering the multifaceted nature of diabetes management, it is crucial for healthcare professionals to help people with diabetes mellitus develop and maintain a strong social support system.Engaging in support groups, seeking out online communities, involving family and friends in diabetes education, and connecting with healthcare professionals can all contribute to a holistic approach to diabetes care. 11us, through this study we aim to assess the social support and medication adherence among people with type 2 diabetes mellitus in central Karnataka, India.
The objectives of this study were to assess the social support and medication adherence among people with Type 2 diabetes mellitus and also to study the factors associated with social support and medication adherence among them.

METHODOLOGY
It was community based cross sectional study conducted for the duration of 6 months from 1 st June to 30 th November 2022.There is total 8 slums with of population of 16,599 with households of 3405 under urban field practice area of tertiary care teaching hospital, Central Karnataka.Among 8 slums, four slums were selected randomly.Total 1625 households were visited.Among the households visited, 183 known cases of type 2 diabetes were found.Permanent residents of selected urban slums who were living with type 2 diabetes mellitus and on treatment for at least one year were recruited for the study through the house-to-house visits.Those who were not able to contact even after 3 visits and refused to be the part of the study were excluded.Out 183 people with type 2 diabetes, 150 people with type 2 Diabetes mellitus satisfying inclusion and exclusion criteria were recruited for the study.
After getting clearance from institution's ethical review board (Reference no: JJMMC/IEC_16-2022 dated 20 th May 2022) and informed written consent from study participants, data was collected using predesigned, pretested, semi-structured questionnaire consisting of information on sociodemographic characteristics, duration of diabetes, family history of diabetes, glycaemic status (Glycated Haemoglobin <6.5% is considered as normal and ≥ 6.5% as high 12 ) and health insurance and also the participants were examined for body mass index.Body mass index (BMI) was calculated using formula: BMI = weight (kg)/height (mt)2 and it was categorized as per WHO criteria for Asia Pacific population 13 .BMI <18.5 was categorized as underweight, 18.5-22.9as normal range, 23-24.9 as overweight, 25-29.9 as obese I and ≥30 as obese II.Using WHO proposed methods, weight was measured with an accuracy of 0.1 kg by using weighing machine and anthropometry rod was used for measuring height with an accuracy of 0.1 cm.Social support was assessed using standard, validated Multidimensional Scale of Perceived Social Support (Zimet, Dahlem, Zimet & Farley, 1988)  14 .This is a brief tool that can be used to assess any individual' sense of support from three different sources: family, friend and a significant other.This instrument consists of 12 questions.The responses were categorised using a 5-point Likert scale (0 = strongly disagree, 5 = strongly agree).The scale was categorised into low support (score of 1 to 2.9), moderate support (score of 3-5) and high adherence (score of 5.1 to 7).
Medication adherence was assessed using standard, validated 8-item Morisky adherence scale. 15This is a beneficial resource for addressing adherence issues among patients.The scale includes elements of forgetfulness, symptom severity, situational and emotional aspects of medication adherence.Patient is considered more adherent if the score is higher on the scale.Responses were categorised as yes/no for each item and a 5-point Likert response for the last item.The scale was categorised into low adherence (score of <6), medium adherence (score of 6-<8) and high adherence (score of 8).
Both the questionnaires were translated to local Kannada language and back translated.Content va-lidity was done by subject and language experts.Internal consistency was calculated by Cronbach's alpha.It was found to be 0.78 for Multidimensional Scale of Perceived Social Support and 0.82 for 8-item Morisky adherence scale.
Data was entered in Microsoft excel 2019 and analysed using IBM SPSS v26.0 software.Data was presented in the form of descriptive statistics (means, proportions and percentage).Chi square test was applied to know association of factors with social support and medication adherence.P value less than 0.05 was considered statistically significant.

RESULTS
A total of 150 people living with type 2 diabetes mellitus on medication on at least one year were recruited for the study.Among them 46 % of the study participants were in the age group of 60 years and above followed by 45 to 59years (43%).Mean age of study participants was 57.42±11.07years.In the present study 55% were females and 45% were males.In our study 55% were from urban areas, 43% were illiterate, and 47% were educated up to high school.In our study 71% were currently working and 11% were homemakers.Majority of participants were belonging to class IV and V according to modified B G Prasad socio-economic classification (59%) and 33% had health insurance.Majority of participants were having Diabetes mellitus since 1 to 4 years with mean duration of diabetes 11.07±4.90years. .In present study 53% were obese, 13% were alcoholic and 27% participants had family history of Diabetes mellitus.In the present study 91% had achieved normal HBa1C level.(Table 1) In the current study high adherence was not reported among any of the study participants.In the present study moderate adherence was observed in age group of 45 to 59 years 38 (46%), in males 37 (55%), among study participants from rural areas 44 (53%), studied up to high school 40 (48%) ,currently working 60 (72%) , belonging class IV socio economic status 29 (35%) , among married 66 (99%), who had diabetes of duration 1 to 4 years 42 (51%), obese 46 (55%), who didn't have any habits 63 (76%) ,who had family history of diabetes 64 (77%), who had normal HBA1C level 73 (88%).Who don't have health insurance 55 (66%).None of these factors were statistically associated with adherence to medication (Table 2) In the present study low social support was not reported among any of the study participants In the present study high social support was seen in the age group 45 to 59years 40 (46%), in males 45 (52%) , among study participants from rural areas 44 (51%), study participants studied up to high school 42 (48%), currently working 65 (75%), belonging class IV socio economic status 30 (34%), married 85 (98%),who had diabetes of duration 1 to 4 years 47 (54%), obese 46 (53%) ,who didn't have any habits 62 (71%), who don't have family history of diabetes 65 (75%), who had normal HBA1C level 75 (86%),who don't have any health insurance 53 (61%).Out of all these factors sex, occupation, health insurance and glycaemic status were statistically associated social support (Table 3).In the present study majority of study participants 87 (58%) had high social support followed by moderate support 63 (42%).None of the study participants had low social support.In the present study majority of study participants 83 (55%) had moderate medication adherence followed by low medication adherence 67 (45%).None of the participants had high medication adherence.
Among study participants with high social support 55 (66%) of them had moderate medication adherence.Among study participants with low medication adherence 35 (52%) had moderate social support.The association between total perceived social support and medication adherence was found to be statistically significant (X 2 =5.21 P= 0.02) (Table 4)  In the present study majority of study participants 87 (58%) had high social support followed by moderate support 63 (42%).None of the study participants had low social support.In the present study majority of study participants 83 (55%) had moderate medication adherence followed by low medication adherence 67 (45%).None of the participants had high medication adherence.
Among study participants with high social support 55 (66%) of them had moderate medication adher-ence.Among study participants with low medication adherence 35 (52%) had moderate social support.The association between total perceived social support and medication adherence was found to be statistically significant (X 2 =5.21 P= 0.02) (Table 4) 1 Association of social support with medication adherence The scatter diagram shows how the individual's social support can change medication adherence.There is clear increase in mediation adherence following higher social support.

DISCUSSION
The mean age of the study participants in this study was 57.42±11.07years and similar finding was observed in the study conducted by Linni Gu et al 16 (57.23±11.43).This finding is higher than studies conducted by Okwuosa JC et al 17 in the diabetic clinic of the Federal Medical Centre, Asaba was 51.9 ± 6.1 years, the study conducted by Ufuoma et al 18 19 .This discrepancy in observation may be due to difference in the age group of the population in these studies as majority of study participants in the present were middle aged and elderly.
In the current study majority of study participants were females (55%).Almost Similar findings were observed.In the study conducted by Okwuosa JC et al 17 (60%), Onodugo et al 22 (62.2%) and Anthony et al 23 (66.9%) in rural communities of Abuja.This finding may be because of more availability of elderly females at the time of data collection as it was a community-based study.
In the present study most of study participants (99%) were married and it is higher than study conducted by Okwuosa JC et al 17 (62.7 %).In the current study Majority of study participants were literate (60%) and similar finding was observed in the study conducted by Okwuosa JC et al 17 .
In the present study we found statistically significant association between total perceived social support and medication adherence (x2 p).The higher the social support the higher the medication adherence was observed.Similar findings were reported by of Okwuosa JC et al 17 and Hamidreza KTet al 24, Arulmozhi S et al 25 , Linni Gu et al 16 .
In the present study majority of study participants (58%) had high social support and similar finding was observed in the study conducted by Ojewale et al 26 (59.9%) and this finding is higher than study conducted by Okumagba PO 27 (21.9%).In the present study majority of study participants were females, married, newly diagnosed, with no hobbits which may be the reason for the hogher social support.This study finding is lower than the study conducted by Ayonote Uzoramaka Angela et al 28 and Iloh & Amadi 29 (77.5%).This difference in observation was due to the study setting, the present study was community-based study compare to previous studies 28,29 which have been conducted in hospitals.
In the present study none of the study participants had high medication adherence but similar dtusies conducted reported high adherence by Ayonote Uzoramaka Angela et al 28 (50%), Jeby Jose Olickal 30 (29%) and lower than Dadhich J et al 31 (66%).This difference in observation was due to the study setting, the present study was community-based study compare to previous studies 26,28,29 which have been conducted in hospitals.
In the present study we found that factors like age, sex, residence, education, occupation, socioeconomic status, marital status, duration of diabetes, habits, body mass index, family history, glycaemic status and health insurance had no statistically significant association with Medication Adherence and similar finding was observed in the study conducted by Linni Gu et al 16 .Factors like sex, occupation, health insurance and glycaemic status were statistically associated social support.

CONCLUSION
Social support plays an important role in promoting medication adherence among diabetes patients.This

RECOMMENDATIONS
Social support improves treatment outcomes and reduces unpleasant impact of diabetes mellitus.Health care professionals should stress on the importance of role of family, friends or social support groups in the management of diabetes mellitus.For people with type 2 diabetes mellitus with poor medication adherenece routine monitoring of perceived social support is needed.
role of family and friends in the management of type 2 diabetes mellitus which necessitates the establishment of supportive environment and modification of behaviour in promoting patients' medication adherence, healthy diet and other self -care practices.

Table 2 :
Factors associated with Adherence to medication

Table 3 :
Factors associated with social support *Reference, 95% Confidence Interval

Table 4
Chi square value 5.21, P value 0.02