Barriers to Compliance
May 23, 2018
Challenges in Managing Diabetes
“Where should I go?” asked Alice. “That depends on where you want to end up”, replied the Cheshire Cat. This witticism from Lewis Carroll, mathematician turned writer, of the famous book, Alice in Wonderland, quite aptly sums up what the patient should expect by complying with the regimen when he/she has diabetes.
Diabetes is chronic in nature, due to which, non-compliance can prove to be a major barrier to effective treatment, besides leading to poor health outcomes. According to WHO, the non-adherence rates for chronic illness regimens and for lifestyle changes is close to 50%. Non-compliance with the diabetes regimen can lead to increase in symptoms, disability, complications, (especially nerve damage and kidney), and even mortality.
Although the doctor and prescribed treatment play an important role in diabetes management, without the patient’s participation, it is like “two people working towards different goals.” Patients often feel a sense of permanence and powerlessness due to the demands of diabetes and the multidimensional care required to keep their sugar under control. Compliance with a diabetes regimen encompasses four factors, viz. healthy diet, exercise, regular medication and blood glucose monitoring. Lifestyle changes that have to be made to keep the blood sugar in check can be challenging and frustrating for some.
Despite widespread awareness and education regarding diabetes, non–compliance continues to be a matter of concern due to several reasons:
Social support plays an important role in diabetes management. Family members and spouses could be more understanding and less critical when the patient is not complying and find out the reasons for their non-cooperation. Being authoritative makes the patient more resistant and defiant and leads to social isolation.
Cultural and religious factors:
Attitudes and health beliefs are often influenced by culture and religion. People have faith in indigenous medicine due to its therapeutic value, and the high recommendation by elders in the family whose advice they do not want to reject. Food habits in general as well as fasting and feasting during festival times are also governed by the same factors.
Psychological problems such as depression, anxiety and eating disorders aggravate metabolic control. Apart from these, even high stress levels and maladaptive coping strategies lead to non-compliance. Hence, identification of the above mentioned problems, addressing the issue, as well as stress management techniques, will lead to better adherence.
Personal qualities of patients such as forgetfulness (about taking medication), low will power, lack of discipline and low motivation levels affect compliance. Sometimes, patients adopt a passive, defeatist role as they feel no obvious ‘benefits’ by complying. Quite often, the treatment regimen does not make sense to them; this is especially true in the case of insulin, which they feel will lead to ‘insulin addiction’ and, like a drug, is best avoided.
Low socioeconomic status, financial constraints and low education levels leads to poor adherence.
There is a general misunderstanding about the chronic nature of the disease as diabetes is mainly asymptomatic. Patients do not feel the need for adherence to the treatment regimen until it is too late. Deterioration in health and symptoms are seen as a separate issue unrelated to diabetes. Hence, they look only for alleviation of symptoms at the time. Traditional medicines are preferred as people are convinced that they come without side effects. Practitioner should be informed regarding alternate treatments, to avoid adverse drug interactions.
Last, but not least, age also plays an important role with regard to compliance. Young people may not comply with their regimen, as they do not feel ‘unhealthy’ and because they do not want to change their present lifestyle or seem different from their friends. On the other end of the spectrum, old people may also not comply due to failing memory, physical handicaps and lack of social support. Young and old people are likely to comply if supported by their family and friends.
These psychosocial issues should be taken into consideration as they are barriers to good metabolic control, and better quality of life. From an individual point of view, the patient will probably benefit from four factors, viz. readiness to change, self-motivation, a sense of personal choice and use of problem–solving techniques for positive health outcomes when it comes to diabetes management