ABSTRACT

This study investigated the effects of financial constraints and socioeconomic factors on medication adherence among diabetic patients attending the University of Benin Teaching Hospital (UBTH). A cross-sectional survey research design was adopted to examine the extent to which economic and social conditions influence patients’ compliance with prescribed medication regimens. Data were collected from 333 respondents selected from the diabetic clinic at UBTH using a structured questionnaire. The collected data were analysed with the Statistical Package for the Social Sciences (SPSS), version 27. Descriptive statistics were employed to present respondents’ demographic characteristics and levels of medication adherence, while the one-sample t-test was used to examine the research hypotheses. The findings revealed that financial constraints significantly affected patients’ ability to adhere to their prescribed treatment regimens. A considerable number of respondents experienced difficulties purchasing their medications due to limited income and competing financial responsibilities. The study also established a significant association between income level and medication adherence, with respondents in higher income categories demonstrating better adherence patterns. Furthermore, socioeconomic characteristics, particularly educational attainment and employment status, were found to influence medication compliance, as individuals with higher educational qualifications and stable employment were more likely to understand and follow prescribed treatment instructions. The study concluded that financial limitations and socioeconomic inequalities constitute significant barriers to medication adherence among diabetic patients. It therefore recommended the introduction of subsidised healthcare services, the expansion of health insurance coverage, improved public health education, and economic empowerment initiatives to enhance medication adherence and improve diabetes management outcomes. Addressing these underlying socioeconomic challenges is essential for preventing diabetes-related complications and improving the quality of life of affected individuals. The findings contribute to a broader understanding of the influence of economic and social conditions on chronic disease management in Nigeria and provide relevant insights for healthcare professionals and policymakers (Fasanu et al., 2024; Oguoma et al., 2025; NHIA, 2025; Sapkota et al., 2024).

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Diabetes mellitus is a chronic metabolic condition characterised by elevated blood glucose levels, commonly referred to as hyperglycaemia, resulting from inadequate insulin production, ineffective insulin utilisation by the body, or a combination of both factors (International Diabetes Federation [IDF], 2024). The condition is generally classified into Type 1 and Type 2 diabetes, with Type 2 diabetes accounting for more than 90% of cases worldwide. Over the years, diabetes mellitus has developed from a relatively uncommon medical condition into a major global public health challenge. According to the International Diabetes Federation, approximately 537 million adults were living with diabetes in 2021, and the global figure is expected to increase to 783 million by 2045 if existing trends continue (IDF, 2024).

The impact of diabetes is particularly severe in low- and middle-income countries (LMICs), including Nigeria. These countries frequently experience weaknesses in their healthcare systems, inadequate diagnostic facilities, and limited availability of essential medicines, thereby creating difficulties in the effective management of the disease (Oguoma et al., 2025). In Nigeria, the increasing prevalence of diabetes has been associated with urbanisation, reduced physical activity, unhealthy dietary practices, and rising levels of obesity (Fasanu et al., 2024). Although awareness of diabetes has improved, many individuals are still diagnosed at advanced stages of the disease, sometimes after complications have developed. Consequently, early diagnosis and consistent treatment, particularly through appropriate pharmacological interventions, are necessary to minimise the long-term consequences of the condition.

The effective management of diabetes requires a comprehensive approach involving lifestyle adjustments, including healthy eating and regular physical activity, routine blood glucose monitoring, periodic medical assessments, and consistent adherence to prescribed medications (American Diabetes Association [ADA], 2025). Medication adherence plays a fundamental role in preventing acute complications, such as hyperglycaemia and hypoglycaemia, as well as long-term conditions including diabetic neuropathy, nephropathy, retinopathy, and cardiovascular diseases (Lam & Fresco, 2025). Nevertheless, maintaining satisfactory medication adherence remains a major challenge for diabetic patients across both developed and developing countries.

In Nigeria, financial difficulties further complicate the achievement of adequate medication adherence. In contrast to many high-income countries, where health insurance arrangements frequently provide financial coverage for the treatment of chronic conditions, a large proportion of Nigerians are responsible for paying directly for their healthcare services. These expenses include medication costs, laboratory investigations, and hospital consultations (National Health Insurance Authority [NHIA], 2025). The country's healthcare financing structure is heavily dependent on out-of-pocket (OOP) payments, which reportedly constitute more than 76% of total healthcare expenditure (NHIA, 2025). Such a financing arrangement places considerable pressure on individuals living with chronic diseases, including diabetes, because their treatment requires continuous medical attention and regular expenditure.

At tertiary healthcare institutions such as the University of Benin Teaching Hospital (UBTH), Benin City, many diabetic patients come from economically disadvantaged backgrounds. For these individuals, meeting the financial requirements of routine healthcare can be difficult, sometimes resulting in medication rationing, missed doses, and, in extreme circumstances, the discontinuation of treatment (Oguoma et al., 2025). Patients may also encounter difficult choices between providing for essential household needs and purchasing medications required for their continued survival and well-being (Uloko et al., 2024). Such circumstances can negatively affect individual health outcomes and increase pressure on the national healthcare system through avoidable complications and hospital admissions.

Previous empirical investigations have demonstrated the adverse relationship between financial hardship and treatment adherence. A qualitative investigation by Adeloye et al. (2024) found that some diabetic patients reduced their medication intake or discontinued treatment because of the high cost of medicines and inadequate social support services. Similarly, Fasanu et al. (2024) reported that financial limitations contributed significantly to delayed hospital attendance and inconsistent use of prescribed medications among patients receiving treatment for diabetes. Research conducted in northern Nigeria also indicated that patients' ability to afford prescribed medications influenced physicians' therapeutic decisions and patients' compliance with treatment recommendations (Uloko et al., 2024). These findings demonstrate the importance of socioeconomic conditions in determining the effectiveness of diabetes management.

Beyond the availability of prescribed medications, their affordability remains a major concern. In Nigeria, oral glucose-lowering medications and insulin preparations are often expensive for individuals who do not benefit from adequate healthcare subsidies. Furthermore, the limited availability of functional health insurance coverage, particularly among people working in the informal sector, means that many patients are required to finance their treatment through personal resources (NHIA, 2025). Consequently, the financial burden associated with medication purchases may contribute to inadequate blood glucose control, an increased likelihood of complications, and a reduced quality of life among diabetic patients (Sapkota et al., 2024).

As a major referral institution serving patients from different parts of southern Nigeria, the University of Benin Teaching Hospital receives individuals with varying socioeconomic backgrounds and healthcare needs. Some diabetic patients present with advanced disease conditions following delays in diagnosis and treatment, which may be associated with difficulties accessing continuous and affordable healthcare services (Oguoma et al., 2025). The cost of diabetes management extends beyond purchasing medications to include transportation expenses, laboratory investigations, consultation fees, and other related healthcare costs. Consequently, some patients may reduce their prescribed insulin doses to make their supplies last longer or miss scheduled medical appointments because of financial difficulties. These practices can undermine treatment effectiveness and expose patients to further health complications (Lam & Fresco, 2025).

Despite the significant implications of financial difficulties for medication adherence, there remains a need for more institution-specific research examining this relationship within tertiary healthcare facilities such as UBTH. Much of the existing literature discusses general factors responsible for medication non-adherence without giving sufficient attention to the specific economic challenges experienced by patients within particular healthcare settings. A focused investigation into the influence of financial constraints on medication adherence among diabetic patients attending UBTH could therefore provide useful evidence for improving healthcare delivery and patient management.

An understanding of the relationship between financial hardship and medication non-adherence is also important for developing appropriate intervention strategies. Possible measures include the introduction of hospital-based medication subsidy programmes, the expansion of community health insurance schemes, and the provision of essential medicines at reduced costs or without charge to financially disadvantaged patients (ADA, 2025). In addition, patient counselling and health education programmes can improve individuals' understanding of the importance of taking prescribed medications correctly and attending scheduled clinical appointments, even when they experience financial difficulties (Adeloye et al., 2024).

Furthermore, identifying the specific financial challenges encountered by diabetic patients can assist healthcare professionals and policymakers in developing interventions that respond more effectively to patients' circumstances. Creating a supportive healthcare environment that reduces financial barriers may improve treatment adherence, minimise preventable complications, and decrease the long-term economic burden of diabetes on individuals, healthcare institutions, and society.

1.2 Statement of the Problem

Diabetes mellitus is a lifelong medical condition that requires continuous management through regular medication use, appropriate lifestyle practices, and consistent attendance at clinical appointments. Despite improvements in diabetes treatment and management, inadequate medication adherence remains a significant obstacle to achieving favourable health outcomes, particularly in low- and middle-income countries such as Nigeria (Lam & Fresco, 2025). Among the various factors responsible for poor adherence, financial constraints represent a major challenge that can prevent patients from obtaining and using their prescribed medications consistently (Fasanu et al., 2024; Uloko et al., 2024).

The high level of out-of-pocket healthcare expenditure in Nigeria places considerable financial responsibility on patients and their families. Many individuals have limited access to effective health insurance coverage and therefore depend largely on their personal income to meet medical expenses (NHIA, 2025). This situation is particularly challenging for people living with diabetes because the condition requires continuous access to medications, routine diagnostic investigations, and regular hospital consultations. At tertiary healthcare facilities such as the University of Benin Teaching Hospital (UBTH), patients may experience difficulties balancing essential household expenses with the financial demands of purchasing prescribed medications (Oguoma et al., 2025). Consequently, some patients adopt inappropriate medication practices, including skipping doses, reducing prescribed quantities, or independently altering their treatment schedules. Such behaviours may increase the likelihood of diabetes-related complications, including neuropathy, retinopathy, and cardiovascular diseases (Sapkota et al., 2024; IDF, 2024).

Several studies have investigated the general challenges associated with medication adherence among diabetic patients in Nigeria and other developing countries. For example, Adeloye et al. (2024) identified an association between low socioeconomic status and medication non-adherence among individuals managing diabetes and hypertension. Similarly, Uloko et al. (2024) established a relationship between poverty and treatment discontinuation among diabetic patients in northern Nigeria. However, these studies have generally examined financial difficulties alongside other barriers to adherence, with limited emphasis on the economic dimension as a major determinant of patients' treatment behaviour. Furthermore, relatively few investigations have specifically examined this issue within tertiary healthcare institutions such as UBTH, which provide specialised services to patients from diverse socioeconomic backgrounds.

In addition, existing research has not sufficiently explored patients' individual experiences and the specific financial obligations associated with diabetes management. Expenses relating to transportation, medication purchases, laboratory investigations, and hospital visits are important considerations in understanding how financial limitations affect patients' ability to follow prescribed treatment plans (Adeloye et al., 2024; Oguoma et al., 2025). The limited attention given to these practical experiences creates a gap in the available evidence and may restrict the development of appropriate, institution-specific interventions and policies aimed at reducing financial barriers to treatment adherence.

Consequently, there is a need to examine the extent to which financial constraints influence medication adherence among diabetic patients attending the University of Benin Teaching Hospital. Investigating this relationship will provide relevant information for improving patient-centred healthcare services, supporting evidence-based policy decisions, and reducing the burden of diabetes-related complications and premature mortality in Nigeria.

1.3 Objectives of the Study

The main objective of this study is to examine the effect of financial constraints on medication adherence among diabetic patients attending the clinic at the University of Benin Teaching Hospital (UBTH), Benin City.

The specific objectives are to:

1. Assess the level of medication adherence among diabetic patients attending the clinic at UBTH.
2. Determine the extent to which financial constraints affect medication adherence among these patients.
3. Examine the influence of other socioeconomic characteristics, particularly income level, employment status, and educational attainment, on medication adherence among diabetic patients.

1.4 Research Questions and Hypotheses

Research Questions

The study is designed to provide answers to the following research questions:

1. What is the level of medication adherence among diabetic patients attending the clinic at UBTH?
2. To what extent do financial constraints influence medication adherence among these patients?
3. What other socioeconomic factors are associated with medication adherence among diabetic patients attending UBTH?

Research Hypotheses

The following null hypotheses are formulated to guide the investigation:

1. There is no statistically significant relationship between financial constraints and medication adherence among diabetic patients attending UBTH.
2. There is no statistically significant association between income level and medication adherence among diabetic patients.
3. Socioeconomic characteristics, particularly employment status and educational attainment, have no statistically significant influence on medication adherence among diabetic patients.

1.5 Significance of the Study

This study is important to various stakeholders within the healthcare sector, particularly those involved in the management of chronic diseases in resource-constrained settings such as Nigeria. Its findings are expected to provide useful information on the financial and socioeconomic conditions that may prevent diabetic patients from adhering to prescribed treatment regimens.

Healthcare Providers: The findings will provide healthcare professionals with a better understanding of how patients' financial circumstances and socioeconomic backgrounds affect their ability to comply with prescribed diabetes treatment. Although clinical interventions are essential in managing diabetes, non-clinical factors, particularly the affordability and accessibility of medications, can significantly influence treatment outcomes. By identifying the financial challenges associated with medication non-adherence, healthcare providers may be better positioned to adopt patient-centred approaches that consider the economic circumstances of individuals when developing treatment plans (ADA, 2025).

Policymakers: The study will also be beneficial to policymakers responsible for healthcare planning and financing. In Nigeria, a substantial proportion of healthcare expenses is paid directly by patients through out-of-pocket expenditure. The findings may therefore provide useful evidence for developing policies and programmes aimed at reducing the financial burden of chronic disease management. Such interventions may include expanding health insurance coverage to accommodate long-term treatment needs, introducing medication subsidy schemes for low-income patients, and improving the pricing and availability of essential medicines required for diabetes management (NHIA, 2025).

Patients and Their Families: The research may increase awareness among diabetic patients and their families regarding the importance of consistent medication use and the possible consequences of treatment interruption. By explaining how financial difficulties contribute to medication non-adherence, the study may encourage households to make informed decisions about budgeting and prioritising essential healthcare expenses. Its findings may also strengthen patients' awareness of available support systems, including government interventions, non-governmental assistance, and community-based health financing programmes (Oguoma et al., 2025).

Researchers and Academicians: The study will contribute to the existing body of academic knowledge concerning the relationship between financial hardship and medication adherence among individuals living with chronic diseases in sub-Saharan Africa. Although several international studies have examined medication adherence, there remains a need for more context-specific evidence, particularly within tertiary healthcare institutions such as the University of Benin Teaching Hospital. The findings may therefore serve as a useful reference for future researchers investigating the relationship between socioeconomic circumstances and chronic disease management (Sapkota et al., 2024).

The Healthcare System and Society: More broadly, the study is expected to provide information that may support improvements in diabetes care and public health interventions. Addressing financial barriers to medication adherence could contribute to better treatment outcomes, fewer preventable complications, reduced healthcare expenditure, and improved quality of life among diabetic patients.

1.6 Scope of the Study

This study is restricted to diabetic patients attending the diabetes clinic at the University of Benin Teaching Hospital (UBTH), Benin City, Edo State. It focuses primarily on examining the influence of financial constraints on medication adherence among the selected patients. The investigation also considers relevant socioeconomic characteristics, including income level, educational attainment, and employment status, which may affect patients' ability to comply with prescribed treatment regimens. The study does not extend to individuals managing other chronic illnesses or patients receiving treatment at healthcare institutions outside UBTH.

1.7 Operational Definition of Terms

Medication Adherence: The degree to which a patient follows the medication instructions provided by a healthcare professional. This involves taking the prescribed medicines according to the recommended dosage, timing, and frequency (Lam & Fresco, 2025).

Financial Constraints: Economic limitations or difficulties experienced by individuals in meeting their financial obligations, particularly expenses associated with healthcare services, medication purchases, transportation, and hospital bills (NHIA, 2025).

Diabetic Patients: Individuals who have received a medical diagnosis of diabetes mellitus and are currently accessing treatment and related healthcare services at the diabetes clinic of UBTH.

Socioeconomic Factors: Social and economic characteristics, including income level, educational attainment, and employment status, that influence an individual's socioeconomic position and may affect health-related decisions and behaviours (Adeloye et al., 2024).

University of Benin Teaching Hospital (UBTH): A federal tertiary healthcare institution located in Benin City, Edo State, Nigeria, which provides specialised medical services, including the diagnosis, treatment, and management of diabetes mellitus.

Chronic Illness: A medical condition that persists over an extended period and requires continuous medical attention, treatment, and management. Diabetes mellitus is an example of such a condition (IDF, 2024).

Out-of-Pocket Expenditure: Payments made directly by individuals or households to healthcare providers for medical services, medications, and other healthcare-related expenses without receiving reimbursement through health insurance arrangements (NHIA, 2025).

Medication Rationing: A practice in which patients reduce their prescribed medication doses, skip doses, or extend the duration of their medication supplies because they cannot afford to purchase the required quantities regularly. This behaviour is often associated with financial difficulties (Uloko et al., 2024).

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