INTRODUCTION:

Prolanis is a promotive and preventive strategy carried out by BPJS Health. One of the target diseases addressed in this program is diabetes mellitus and hypertension. Both of these diseases have a fairly high incidence rate in Indonesia. The incidence of diabetes mellitus reached 8.8% (415 million) in 2015 and has the 3rd largest mortality impact in Indonesia (6.7%), after stroke (21.1%) and coronary heart disease (12.9%). The prevalence of hypertension in Indonesia has reached 31.7% of which 5.3% have complications to other diseases and have an impact on death number 5 in Indonesia¹.

The increase generally occurs in the elderly so that it requires a special program to inhibit and prevent complications². The prevalence of hypertension in Kendari city occupies the second position out of 10 lists of diseases in Southeast Sulawesi. Data from the National Health Service in 2016 showed that the incidence of hypertension is always increasing. A Kendari City Health Service survey in 2016 found that the number of hypertension sufferers was 11,024 people. Meanwhile, in cases of diabetes mellitus, especially in the city of Kendari, there were 3030 patients suffering from diabetes mellitus in 2020. The aim of treatment for these two diseases is to prevent and increase the success of therapy. Several factors for the success of therapy are influenced by patient adherence in taking medication. Patients with hypertension and diabetes mellitus who are not compliant in undergoing therapy will cause complications to other serious illnesses which will later have an impact on the patient's quality of life^3,22.

Several previous studies have shown that there is a significant relationship between medication adherence and quality of life, both in patients with hypertension and diabetes mellitus. Patients diabetic with this disease are often desperate with a long therapy program, so that patient compliance can affect the success of the treatment.^4,5. This shows that adherence to taking medication is an important thing to pay attention to for patients and health workers in health facilities. Someone who has a high level of medication adherence will have a good quality of life. Meanwhile someone with low adherence has a poor quality of life⁶. This also happens for the chronic disease group. Several studies show that patients with a history of hypertension and diabetes mellitus have low levels of medication adherence followed by poor quality of life scores^7,8.

Adherence with taking medication can be said to be the main focus in treatment because it can not only support the success of therapy but also have an impact on quality of life. By knowing the level of adherence with taking medication, health workers can provide better health services with this data information. Likewise, by measuring quality of life, patients will be better able to control themselves, their emotions and their souls while undergoing therapy. It is hoped that this approach will be able to provide an overview of the treatment of hypertension and diabetes in educating and providing therapy for patients. Patient medication adherence is highly emphasized to optimize treatment so as to improve quality of life.

MATERIALS AND METHODS:

Materials:

The subjects in this study were prolanis patients consisting of Hypertension and Diabetes Mellitus patients at the First Health Facility in Kendari City that met predetermined criteria and exclusions. The instruments used were the Morisky Medication Adherence Scale (MMAS-8) instrument to measure medication adherence and the euroqol-5 Dimention-5 Life (EQ-5D-5L) instrument; Visual Analog Scale (VAS).

Research Path:

Field observations at several health facilities in Kendari City were carried out by going to the community health center. The choice of community health center is because the community health center is the first health facility for the community. Field observations were carried out at the Wua-Wua Community Health Center, Poasia Health Center, Lepo-lepo Health Center and Mokoau Health Center. Field observations were carried out to review the population/sample of hypertension and diabetes prolanis patients in each health center. The research obtained an ethical clearance letter that would be submitted at the Faculty of Public Health, Halu Oleo University (UHO). This study used a questionnaire as an instrument. The quality of life of prolanis patients was measured using the EQ-5D-5L and VAS questionnaires, while the level of medication adherence was measured using the MMAS-8 questionnaire.

The method for taking research samples was by using the total sampling method, paying attention to the inclusion and exclusion criteria that had been previously determined. Patients who were respondents in this study were those who were members of the prolanis group, participated in prolanis group activities in each health center, had history of hypertension or diabetes mellitus or both. The number of respondents selected looked at the existence of the population of prolanis patients in each community health center. Sampling time is 1 month. Previously, patients were asked to fill out an informed consent form as proof of their willingness to participate in the study. Data collection was carried out by direct interviews using the EQ5D-5L and VAS questionnaires for research quality of life (HRQoL) data and the MMAS-8 questionnaire for data on medication adherence levels.

Data Analysis:

The medication adherence level questionnaire consists of 8 questions. Score = 8 including high adherence category; score 6 - <8 is in the medium category; a score >6 is included in the low adherence category. The patient's quality of life questionnaire describes one's condition which is categorized into 5 levels. Self-assessment by the patient on the EQ-VAS (Visual analog scale) ranges from 0 (worst health) to 100 (best health). These results are converted with the Indonesian EQ-5D-5L value set to obtain an index value (Utility)⁹. Analysis of the relationship between the level of medication adherence and the quality of life of prolanis patients was analyzed using the bivariate-spearman rank test.

RESULTS:

1. Characteristics of Prolanis Patients:

In this study, the number of prolanis patients who met the inclusion criteria was 121 patients taken from 4 locations of First Level Health Facilities in Kendari City. The four research locations were Mokoau Health Center, Wua-wua Health Center, Lepo-lepo Health Center and Poasia Health Center. The results of the study showed that the average age of prolanis patients was 60 years, female. The majority of prolanis patients are female (83.5%). The reason more women suffer from hypertension or diabetes mellitus is because of the role of hormones in the body with its fluctuating changes. This is one of the factors that trigger more women to develop hypertension or diabetes mellitus¹⁰. Prolanis patients> 60 years are more than patients with an age range of 40-60 years. The educational level of prolanis patients in this study was at the high school level, followed by the undergraduate level (27.3%). A person's level of education is one of the factors that can affect adherence to taking medication. Prolanis patients who have higher education will probably have more knowledge than prolanis patients with low education. Education will affect awareness for prolanis patients to continue to maintain their health.

The job categories in this study consisted of 5 categories, namely housewives, civil servants, entrepreneurs, farmers and retirees. The results showed that the majority of prolanis patients in 4 health centers had the status of housewives (58.7%). The results showed that 46.3% of prolanis patients in the 4 health centers in this study had a history of diseases other than hypertension and diabetes mellitus, while the rest did not (53.7%). Prolanis patients with a history of other diseases are said to have a complex condition compared to others. The history of other diseases includes cholesterol, gout, gastrointestinal disease and heart disease. The results showed that most prolanis patients had long suffered from hypertension or diabetes mellitus, as many as 70.2% of prolanis patients had suffered from the disease <5 years, while the rest >5 years (29.8%). Most of the drugs consumed by prolanis patients with a diagnosis of hypertension in this study were amlodipine (84.2%), followed by candesartan and captopril.

The use of amlodipine in this study varied in dose and frequency of administration. Meanwhile, for diabetes mellitus, prolanis patients mostly use metformin and glimepiride. Characteristics of prolanis patients at first-level health facilities in Kendari city are shown in table 1.

Table 1. Characteristics of Prolanis Patients at First Level Health Facilities in Kendari City

Characteristic

Frequency

(n=121)

Percentage (%)

Age

Average

40-60 year

>61 year

60 year

47.1

52.9

Gender

Female

Male

101

83.5

16.5

Last Education

Unfinished of Elementary school

Junior High School

Senior High School

Scholar

17.4

21.5

33.9

27.3

Occupation

Housewife

Civil Servant

Self-employed

Farmer

Retiree

58.7

15.7

12.4

2.5

10.7

Marital Status

Married

Unmarried

Widower/Widow

113

93.3

6.6

History of Other Diseases

Have

Do not have

46.3

53.7

Illness Duration

≤5 Year

>5 Year

70.2

29.8

Type of HT Drug

Amlodipine

Candesartan

Captopril

102

84.2

4.13

0.8

Type of DM Drug

Glimepiride

Metformin

9.9

12.3

2. Description of Medication Adherence of Prolanis Patients:

Medication adherence in this study was measured using the MMAS-8 instrument. The results of the validation test on the MMAS-8 instrument showed valid and reliable results (Crombach alpha value; 0.652). The results showed that prolanis patients at first-level health facilities in Kendari city were non-compliant (66.1%) in taking medication. The level of adherence to taking medication in prolanis patients is in the adherent (15.7%) and medium (18.2%) categories.

Table 2. Medication Adherence of Prolanis Patients in First Level Health Facilities in Kendari City

Adherence Category	Number (n=121)	Percentage (%)
Adherent	19	15,7
Medium	22	18,2
Non-adherent	80	66,1

In this study data collection was carried out by direct interviews in order to prevent biased filling of the questionnaire. The results showed that prolanis patients, both hypertensive and diabetic patients, had non-adherent behavior in taking medication. This can be seen from the number of respondents who often forget to take medication (63.6%), patients stop taking medication because they feel their condition has improved (52.8%). As many as 29.7% of patients did not comply because they deliberately did not take medication in the last 2 weeks, when traveling patients do not bring their medicines for supplies (43.8%). Occasionally (28%) and sometimes (23.14%) patients had difficulty remembering to take medication. The distribution of respondents' answers to the MMAS-8 instrument is shown in table 3.

Table 3. Distribution of Adherence Questions Based on Prolanis Patient Answers

Question	Yes (%)	No (%)
Forget to take medicine	63.6	36.3
Deliberately not taking medicine in last 2 weeks	29.7	70.8
Stop drinking medicine due to condition worsened	23.1	76.8
Not bringing medicine when traveling	43.8	56.1
Did you take medicine yesterday?	70.2	29.7
Stop drinking medicine due to better condition	52.8	47.1
Feeling uncomfortable when driniking medicine	29.7	70.2
Level of difficulty when taking the medicine Never Occasionally Sometimes Usually Always/ often	42.9 28.0 23.14 5.78 0

3. Description of the Quality of Life of Prolanis Patients:

The measurement of quality of life in this study used the EQ-5D-5L and VAS instruments. Instrument validation refers to Hamida's research (2019)⁹. The quality of life of prolanis patients is categorized into low, medium and good quality of life. The results of data analysis show that the quality of life of prolanis patients in first-level health facilities in the city of Kendari is in the good category (61.6%) for the EQ-5D-5L instrument measurements. Meanwhile for VAS, the quality of life category is also classified as good (54.9). The average utility value of quality of life in this study was 0.745, the highest utility value was 1.0 while the lowest utility was 0.10.

Table 4. Level of Quality of Life of Prolanis Patients in First Level Health Facilities in Kendari City

QoL (EQ-5D-5L) Category	Number (N=121)	%	QoL (VAS) Category	Number (N=121)	%
Low	23	16	Low	6	4.2
Medium	10	6,9	Medium	36	25.0
Good	88	61,6	Good	79	54.9

Most of the patient domain responses are still at level 1. This level indicates the absence of problems caused by the ability to walk, self-care, daily routine activities, pain and anxiety. In the self-care domain, prolanis patients have no difficulty in self-care (64.6%). This result is the highest percentage of domains among other domains (Table 5). Patients with a low quality of life showed problems in the domains of gait (19%) and pain (19%). Patients with a good quality of life show problems in the pain and anxiety domains. These two domains are the most problematic for prolanis patients (Table 6).

4. Analysis of the relationship between the level of medication adherence and the quality of life of prolanis patients

Table 7 shows that medication adherence affects the quality of life of prolanis patients. These results are shown based on statistical analysis of the p-value (0.000). Prolanis patients with a good level of adherence had a good quality of life (14.9%).

Table 5. Comparison of EQ-5D-5L Domain Responses in Prolanis Patients at Each Level

Domain	Respond Percentage (%)
Domain	Level 1	Level 2	Level 3	Level 4	Level 5
Mobility (MO)	55.6	15.3	10.4	2.8	-
Self-Care (SC)	64.6	11.8	6.3	1.4	-
Usual activities (UA)	56.9	13.2	9	2.1	2.8
Pain/ Discomfort (PD)	22.9	38.9	18.1	4.2	-
Anxiety/ Depression (AD)	50	20.8	9.0	4.2	-

Table 6. Quality of Life and Comparison of Responses for Each Problem Domain of Prolanis Patients

QoL Category	Response of each problematic domain (%)
QoL Category	MO	SC	UA	PD	AD
Low	19.0	18.2	17.4	19.0	16.5
Medium	6.6	4.1	5.0	7.5	2.5
Good	8.3	0.8	9.9	46.3	21.5

Table 7. Relationship between the level of medication adherence and the quality of life of Prolanis patients at first-level health facilities in Kendari City

Variable	Category	Low Quality of life		Medium Quality of life		Good Quality of Life		p-value
Variable	Category	n	%	n	%	n	%	0.000*
Adherence	Adherent	0	0,0	1	0.8	18	14.9
	Medium	0	0,0	2	1.7	20	16.5
	Non-adherent	23	19.0	7	5.8	50	41.3

DISCUSSION:

The results of this study indicate that the majority of prolanis patients are female with an age range of >60 years. Increasing age allegedly makes the level of adherence lower¹¹. This could be due to anatomical and physiological factors in the body which have begun to decline and trigger aging. In several studies it has been said that the prevalence of chronic diseases is more common in women than men. Women have greater risk factors for developing chronic diseases, including hypertension or diabetes¹². In this study, the educational level of most patients was in high school (33.9%) with the status of most being housewives (58.7%). Education has little effect on a person's adherence to taking medication²¹. This is related in terms of the level of adherence and self-awareness to improve the level of health and quality of life. Previous research (Pramesti, 2020) showed that diabetes mellitus patients with poor levels of drinking adherence and quality of life mostly come from those with low levels of education¹³. A high level of knowledge is associated with a low level of medication adherence¹⁴

Adherence with taking medication can be influenced by factors such as socio-economic factors, the doctor's relationship with the patient or service system, the patient's disease condition, therapy and the patient himself. Based on the research results, it is known that prolanis patients have a low level of drinking adherence (66.1%). Young man, worked and high sosialeconomic have a low level adherence because forgetfulness, afraid of dependency, misunderstood instructions¹⁵. The results of interviews in the field, the reasons for prolanis patient non-adherence varied. Some of them did not adhere to taking medication with reasons of forgetfulness, fear of drug side effects and relying more on the use of herbal medicines that were mixed and made at home. The results of this research are in line with research (Harris, et.all 2023) which shows low medication adherence in a group of hypertension patients¹⁶. Adherence with taking medication is one of the important things to do in order to achieve treatment and prevention targets effectively¹⁴. Non-adherence can also be caused by a lack of knowledge regarding taking medication or a lack of motivation and low self-confidence in undergoing treatment⁹. Besides the patients’ attitude, health facility and means have also affected significantly²⁰. The results of measuring medication adherence in prolanis patients will be very useful for staff at health facilities to provide support for successful therapy for prolanis patients. The results of this study serve as a means of information, education and counseling for ongoing therapy. In research (Archana, 2017) medication adherence increased after providing counseling¹⁷

In addition to medication adherence, the focus in this study is quality of life. Adherence in taking medication can support the improvement of the patient's quality of life. The results of the study showed that the quality of life of prolanis patients was in the good category. The description of the quality of life of prolanis patients consists of five measurement dimensions, namely the walking ability domain, self-care domain, daily routine activities domain, pain and anxiety domain. The measurement results with the EQ-5D-5L instrument show that the most problematic domain is the pain domain (61.2%) followed by anxiety (34%). This result is in line with research (Nurhamida, 2019), which obtained similar results⁸. According to the results of interviews with patients, the pain caused is relatively mild but usually unbearable and slightly interferes with daily activities. The feeling of anxiety is caused by the paradigm that hypertension and diabetes will always end in death. Patients feel anxious if they have to take medication for life. Other research showed the quality of life of hypertensive patients is influenced by low physical and mental domains¹⁸

Prolanis patients with low quality of life have problems in almost all domains, weather in walking ability, self-care, usual activities and discomfort. However, prolanis patients with good quality of life have problems in the pain and anxiety domains. The results of statistical analysis using the Spearman rank test obtained the p-value is 0.000*. These results indicate that there is a significant relationship between the level of medication adherence and the quality of life of prolanis patients. These results are in line with the research by Emy (2020)⁵ and Printinasari (2023)¹⁹ which concluded that there is a close relationship between medication adherence and the quality of life of patients with hypertension and diabetes mellitus.

CONCLUSION:

Based on the research results that have been obtained, the level of adherence with taking medication for prolanis patients in first-level health facilities in the city of Kendari is in the non-adherent category (66.1%), other prolanis patients have medium levels of adherence (18.2%) and good adherence (15.7%). Quality of life measurements with the EQ-5D-5L-VAS show the good quality of life category. The results of the Spearman rank statistical test show that there is a significant relationship between the level of adherence to taking medication and the quality of life of prolanis patients p value (0.000*)

CONFLICT OF INTEREST:

There is no conflict of interest in this research.

ACKNOWLEDGMENTS:

Acknowledgments to the Ministry of Education and Culture (Kemdikbudristek) for supporting funding for this research.

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Received on 05.09.2023 Revised on 13.05.2024

Accepted on 18.10.2024 Published on 28.01.2025

Available online from February 27, 2025

Research J. Pharmacy and Technology. 2025;18(2):551-556.

DOI: 10.52711/0974-360X.2025.00082

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.