However, 91.9% were highly adherent to the medication advice.

It is a melancholic reality that majority of our study population was unclear about the true nature of their disease process and pros and cons of therapeutic adherence/non-adherence. Strom et al [17] and Kvarnstrom et al [18], in Danish and Finnish studies respectively, gathered that the physicians frequently do not communicate to the patients about the basic information of the treatment plans. The patients may be left with concerns about adverse effects with lack of comprehension of their own disease. Koch et al, on the basis of a study in Netherlands, concluded that complete and accurate information plays an important role in the behaviour of patients, especially in control and management of disease [19]. In a study by van Delmen et al, the participating GPs agreed that the communication about adherence should be tailor made by not thoughtlessly applying guidelines but by paying attention to patients’ needs [20]. Peschin et al, while speaking at the “9th Power of Partnering (POP) Conference” advocated that improvement of health literacy and simplifying the terminology will help patients to better comprehend the complexity of their disease [21]. It is evident that, in our study, comprehensive information about the medications and lifestyle modifications was either not given to the patients or if given, not adequately picked by them.

The studies conducted in Canada [22], United States [23], Spain[24], Finland[18], Singapore[25] and Ghana[26] have the common inference that poor adherence to medication regimes ,in diabetics, results in significantly worse clinical outcomes including inadequate glycemic control, increased use of healthcare resources, increased out-patient care, hospitalization and re-hospitalization, higher medical costs and markedly huge mortality rates.

The National Council on Patient Information and Education United States (NCPIE), in 2007, published a report “Enhancing Prescription Medication Adherence: A National Action Plan” to make recommendations for improving medication adherence, the emphasis was given on “Educate before you Medicate” [27]. Needless to say that, for the success of such a programme, the central position of the patient must be recognized. Ibn Sina (980-1037 CE), the author of “Kitab al-Qanun fi-al-Tibb” justifiably graded “The First Text Book of Medicine on Earth” [28] has discussed this aspect in detail. While enumerating “Seven Doctrines of Preservation of Health”, he highlighted key role of the individual in the form of “Mudawa Salookia” (Behaviour Modification) [29]. And this is what we must prioritize in a joint team approach to resolve the issue of improving therapeutic adherence.

The consequences of non-adherence are more pronounced in elderly, the fast-growing sector of global population. Estimates range from 40% to 75% [30]. The more serious issue lies in taking more of the drug, in the mistaken belief that by doing so the recovery would be speeded up. Conversely forgetfulness leads to under-utilization or over-utilization of the regimen. As a result they are exposed to both under-adherence and over-adherence.

Recourse to diverse care-providers (homeopaths, herbal medicine, natural healers, faith healers etc) because of low trust in the efficacy of prescription medication, for additional/alternate advice is our cultural issue. The affordability is also an important element. Atinga et al., [26] while enumerating factors influencing long term medication non-adherence among diabetics and hypertensives, in Ghana, identified that perception of inefficacy of the prescription medications turned to return to herbal medicines and spiritual healing because of their easy accessibility, perceived efficacy and affordability.

Complexity of the regimen (number and frequency) has an important bearing on the adherence [31]. In a systematic review of the association between dose regimen and medication compliance, Claxton et al concluded that the prescribed number of doses/per day is inversely related to compliance. Simpler less frequent dosing regime resulted in better compliance across a variety of therapeutic classes [32].

The “Federal Study of Adherence to Medications in the Elderly (FAME)”, aimed to determine the effect of a pharmacy intervention programme on medication adherence and persistence identified the ways to improve adherence [33].

We need to highlight that a significant contributing factor in therapeutic non-adherence, in our study, was the cost of medication. It has been found that even in developed countries like Australia ‘the out of pocket costs of medications’ adversely affect the adherence in chronic diseases.[34].Needless to reiterate that economic problem is the main challenge in our set up where every expense on medical treatment is ‘out of pocket’. Sir Frederick Grant Banting, in his Nobel Lecture on September 15, 1925, admitted “Insulin is not a cure for diabetes, it is treatment”. The same is true of the modern anti-hyperglycaemic oral pills. Diagnosis of a chronic bothersome and incommodious disease like diabetes comes to the family as a strong blow. How can we expect optimal therapeutic adherence in view of the high cost of medication, for an unlimited period, in a middle class family with already over-stretched monthly budget?