Psychosocial care in diabetes
Type 2 diabetes patients’ and providers’ differing perspectives on medication nonadherence: A qualitative meta-synthesis
This qualitative meta-synthesis examines the differences between patient and provider understandings of barriers to medication adherence for type 2 diabetes patients and highlights key discrepancies.
Summary points
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- Non-adherence to medication regimens results in increased morbidity and mortality, reduced quality of life and higher healthcare costs.
- Studies on the topic of barriers to medication adherence conducted in Canada, the USA, Europe, Australia and New Zealand in patients with type 2 diabetes and published from the 1st of January 2002 to the 10th of August 2013 were identified.
- This analysis included 86 studies that involved 2797 patients with type 2 diabetes, 40 caregivers and 356 clinicians.
- Seven categories of barriers and facilitators were identified: Emotional experiences as positive and negative motivators to adherence; intentional non-compliance; patient-provider relationship and communication; information and knowledge; medication administration; social and cultural beliefs; financial issues.
- Positive emotions and social support can improve the ability to follow through with self-care. Negative emotions can raise adherence if patients become motivated by fear of symptoms returning, early death or potential complications, or they can lower adherence if patients become trapped in a “vicious circle of low motivation.”
- Most commonly, intentional non-compliance is motivated by the desire to avoid adverse effects, but can also result from the denial or incorrect beliefs about diabetes and medication. Healthcare providers attribute this behavior to cultural and financial motives, depression or poor cognitive ability, however, they fail to recognize avoiding adverse effects as a reason.
- In the area of patient-provider relationship and communication, patients identify health care professionals’ support, collaboration and effective communication strategies as facilitators of adherence; while adherence is impeded by impractical or burdensome recommendations, perceived lack of support, cultural insensitivity and barriers to access. Providers recognize that a collaborative model of care has a positive impact; factors that can have a negative impact include poorly devised treatment regimens and incorrect assumptions about patient knowledge and understanding, among others.
- Administration requirements can constitute a barrier to adherence for patients due to fears associated with injectable medications or for those on complex treatment regimens. Providers recognize administration requirements as a barrier to adherence in patients with physical or cognitive impairments, comorbid conditions or those with fears related to treatments.
- Patients’ social and cultural health beliefs may affect medication adherence, as well as their relationships with physicians. Providers identify aversion to insulin, fatalistic attitudes, the perception that fat is healthier and a desire to please the physician as health beliefs that can negatively impact adherence.
- Patients identify various medical costs as barriers to adherence. Providers understand the financial barriers that patients may face, but commonly do not identify this issue as a barrier to adherence.
- In general, healthcare providers tend to focus on clinical issues, while patients describe a much wider range of problems with medication adherence, including personal, social and practical challenges.
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Brundisini F et al. BMC Health Serv Res 2015; 15: 516. doi: 10.1186/s12913-015-1174-8
Good cop, bad cop: Quality of parental involvement in type 1 diabetes management in youth
This review synthesizes the recent research on the effects of the involvement of caregivers (mostly mothers and fathers) in the disease management of youths with type 1 diabetes, with a focus on biopsychosocial outcomes.
Summary points
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- Parental involvement in diabetes management tasks can have different effects depending on the nature of intervention, whether it is the mother or the father who is involved and its appropriateness for the child’s age and level of maturity.
- An indirect association has been demonstrated between general parental monitoring and diabetes outcomes through lower levels of externalizing behaviors, while a direct association with glycemic control through restriction of adolescents’ behavior has also been shown.
- Diabetes-specific monitoring has been shown to directly correlate with better diabetes self-care, less family conflict and lower HbA1c levels.
- A collaborative approach between caregivers and youths to diabetes management supports the development of youths and enhances their ability to self-manage, resulting in better outcomes.
- Low-quality parental involvement is characterized by controlling, critical and restrictive behaviors; it is associated with lower adherence and suboptimal glycemic control, as well as lower health-related quality of life and greater family conflict.
- Single parenthood and minority race/ethnicity are associated with poorer outcomes in youths with type 1 diabetes.
- The relationship between parental involvement and distress is complex and bidirectional; promoting a balance of responsibility between both parents (in two-parent households) and/or other family members may help reduce parental distress.
- The child’s behavior may affect the type, amount and quality of involvement.
- Authors conclude that in the recent literature on the subject of parental involvement in diabetes management, a shift in focus has occurred from the amount of involvement to the type and quality.
- To improve the quality of parental involvement in diabetes management of children with type 1 diabetes, the authors recommend gradually shifting responsibility to children in accordance with contextual factors and work collaboratively in order to achieve best outcomes.
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Young MT et al. Curr Diab Rep 2014; 14: 546. doi: 10.1007/s11892-014-0546-5
A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes
This review article includes discussions of barriers to adherence in adolescents with type 1 diabetes, interventions aiming to improve adherence, the role of providers and provides suggestions on future areas of research.
Summary points
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- Across the lifetime of a patient with type 1 diabetes, adolescence is characterized by the worst glycemic control and, therefore, represents a critical opportunity to avoid multiorgan complications later in life.
- Adherence can be defined as “the degree to which patients follow the recommendations of their health professionals.”
- In adolescents with type 1 diabetes, barriers to adherence can be psychosocial (family and parental care, peer support, presence of mood, anxiety and eating disorders), institutional (poor communication with healthcare providers, cost of treatment) or they can be associated with complex and burdensome treatment regimens.
- A number of interventions aiming to improve adherence have been proposed in the recent literature, including motivational interviewing and text message-based approaches, approaches targeting diabetes adherence behaviors in the presence of peers and addressing health care utilization costs; the effectiveness of these approaches varies.
- The role of healthcare providers in improving adherence has received relatively little attention; providers can improve adherence in several ways, such as by scheduling regular follow-up visits and improving communication between physicians, patients and caregivers.
- The authors describe a number of suggestions for future research that include using consistent terminology to define adherence, a greater focus on the role of healthcare providers and investigating specific regimen-associated barriers to adherence.
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Datye KA et al. Curr Diab Rep 2015; 15: 51. doi: 10.1007/s11892-015-0621-6