Diabetes Self-management Adherence

Lack of adherence to prescribed medical regimens is a commonly acknowledged problem. Adherence rates for oral medication across disease states are typically around 50%, and adherence rates for lifestyle recommendations and other more demanding regimens are even lower.[1] Diabetes is unique among chronic medical conditions because the burden of management falls on the patient. Thus, adherence with medical recommendations is an issue of critical importance.

Correlates of adherence

Psychosocial research efforts have identified a number of correlates of patient adherence that fit into 3 broad categories: patient characteristics, disease characteristics, and regimen characteristics.[2] Patient characteristics include knowledge, attitudes, social support, and family interactions. Disease characteristics include age at disease onset, and illness severity. Regimen characteristics include regimen duration, regimen complexity, and occurrence of negative side effects. In terms of diabetes, the regimen is lifelong, complex and, in many cases, may cause unwanted side effects. Thus, adherence is a particularly difficult challenge for patients with diabetes and for their healthcare providers.

Theories of patient adherence

There are many theories of patient adherence and behavior change, some descriptive and some prescriptive. Although there are numerous adherence theories, the Health Belief Model, the patient empowerment approach, and the Chronic Care Model will be discussed.

The Health Belief Model

The Health Belief Model (HBM) was originally developed in the 1950s to describe people's attitudes toward utilization of preventive services and was later extended to predict adherence to medical recommendations.[3] According to the theory, individuals will be more likely to adhere to medical treatment if they: a) believe themselves to be susceptible to the disease (perceived susceptibility), b) believe that the disease has serious consequences (perceived severity), c) believe that the benefits of the behaviors considered are great, and that the behavior is both feasible and effective (perceived benefits), d) believe that the barriers to the behaviors are few and easy to overcome (perceived barriers), e) believe that they are personally capable of performing the behaviors (perceived self-efficacy), and f) have a cue to motivate action, such as the presence of symptoms (cues to action). The main HBM constructs and their effects on adherence are summarized in Table 1.

Table 1. The Health Belief Model

The Patient Empowerment Approach

The patient empowerment approach was developed specifically to promote behavior change among people with diabetes.[4] Because 98% of diabetes care is the responsibility of the patient, patients and their health-care providers should collaborate to determine the best diabetes self-management plan. The role of the diabetes care team is to provide ongoing expertise, education, and support to the patient. The role of the patient is to use the information provided by the diabetes care team to make informed self-management choices. This approach relies on the principle that patients are more likely to be adherent if behavior changes are personally meaningful and freely chosen. Because this view represents a radical departure from the normal physician-patient interaction, there are a number of barriers to its use. Many patients are not honest with their healthcare team about their true self-care practices for fear of being reprimanded. Physician barriers include the desire to solve patients’ problems rather than allowing patients to solve their own problems, and unwillingness to explore the emotional component of diabetes self-management. Anderson and colleagues [4] have developed a behavior change protocol that is designed for use by physicians. This interview protocol will help patients take responsibility for their diabetes self-care activities, prioritize diabetes-related problems, generate solutions, and develop a behavior change plan that they are committed to. The behavior change protocol is summarized in Table 2.

Table 2. Patient Empowerment Interview Protocol[4]

The Chronic Care Model

The Chronic Care Model (CCM) is a health behavior model comprising a variety of factors related to clinical outcomes. The CCM encompasses 4 different factors--decision support, clinical information systems, self-management education, and delivery system design.[5]

The first factor, decision support, refers to the availability of providers to access evidence-based guidelines to drive their treatment decisions. Information systems refers to the availability of timely and useful individual and population-based clinical data, such as data on patient follow-up care and the proportion of pations who are meeting treatment goals. Self-management education and support is the patient variable that corresponds to decision support. Both physicians and patients need to be informed about diabetes care in order to achieve optimal outcomes. Finally, the delivery system design component refers to the need for a team-based approach to diabetes. This model addresses important aspects of diabetes care that can be modified to improve outcomes.

Adherence with components of diabetes self-care

Because diabetes self-care is a multifaceted endeavor, it is important to examine adherence with each component. Adherence with oral medications is relatively high, even among patients taking multiple medications. Consistent with the HBM, research has shown that patients were more likely to be nonadherent when they believed that the medications were not beneficial to current or future health (low perceived benefits). Unreported side effects (perceived barriers) were also significantly related to nonadherence.[6] Adherence with insulin treatment is also very high, especially among people with type 1 diabetes, as the consequences of nonadherence are great.[7] Adherence rates for lifestyle changes, such as diet and physical activity tend to be lower, as they are much more complex, difficult to implement, require a lifelong commitment, and do not have any immediate benefits. For example, in the lifestyle arm of the Diabetes Prevention Program study, patients received extensive external support for their behavior change, and adherence was approximately 50%.[8]

Strategies to improve adherence in diabetes

Although patient adherence is a difficult issue, there are a number of strategies that can improve adherence.[9] First, the empowerment technique has been demonstrated to improve adherence. Use of extensive behavior change strategies has also been shown to improve adherence.[10] Specifically, helping patients to determine practical ways to overcome barriers to self-management tasks is an effective strategy. In terms of physical activity and weight loss, small but consistent changes are advocated.[11] Changes of this magnitude are more realistic and less likely to lead to decreased motivation in the face of failure.

References

1. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatments. JAMA. 2002;288:2880-2883.
2. Lemanek KL, Kamps JK, Chung NB. Empirically supported treatments in pediatric psychology: regimen adherence. J Ped Psych. 2001;26:253-275.
3. Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q. 1984;11:1-47.
4. Anderson RM, Funnell M, Arnold MS. Using the empowerment approach to help patients change behavior. In: Anderson BJ, Rubin RR, eds. Practical Psychology for Diabetes Clinicians. 2nd ed. Alexandria, VA: American Diabetes Association; 2003:3-12.
5. Siminerio LM Zgibor J, Solano FX. Implementing the Chronic Care Model for improvements in diabetes practice and outcomes in primary care: the University of Pittsburgh Medical Center experience. Clinical Diabetes. 2004;22:54-58.
6. Grant RW, Singer DE, Devita NG, Meigs JB. Polypharmacy and medication adherence in patients with type 2 diabetes. Diabetes Care. 2003;26:1408-1412.
7. Tolijamo M, Hentinen M. Adherence to self-care and glycemic control among people with insulin-dependent diabetes mellitus. Issues Innovations Nurs Pract. 2001;34:780-786.
8. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
9. Anderson RM, Funnell MM, Butler P, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment: results from a randomized control trial. Diabetes Care. 1995;18:943-949.
10. Clement S. Diabetes self-management education. Diabetes Care. 1995;18:1204-1214.
11. Diabetes Prevention Program Research Group. The Diabetes Prevention Program: design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care. 1999;22:623-634.