“The big talent is persistence”. Octavia E. Butler
It is always extremely difficult to ascertain why human behaviour does not correspond with agreed recommendations from a healthcare provider, whether it is in following diet, exercise, lifestyle changes or taking medications. In diabetes, approximately half are not able to do so, resulting in poor control of diabetes. This has far reaching consequences - increased heart attacks, stroke, amputations, kidney and eye problems, along with economic implications. The ability of physicians to recognize non adherence is poor, and interventions to improve adherence have had mixed results.
A number of reasons have been suggested and it is probably combinations of these factors that are responsible. Majority of diabetics are on multiple medications and complex regimes due to many coexisting conditions. Some are forgetful, or miss doses due to being preoccupied with other more pressing activities. Some are unable to tolerate or have side effects like hypoglycemia and weight gain. Sometimes people with high blood glucose levels have difficulty in reading labels and this should be kept in mind.
The perception of benefits of treatment can also have a significant effect on adherence. People have their own assumptions about their risks of complications and side effects, which leads to reduced adherence to treatment. There is also a considerable resistance to injectable medications. Some of the reasons are injection phobia, negative impact on work, permanent need for insulin, inconvenience, not believing insulin was necessary, hypoglycemia, less flexibility and feeling of failure. People adhere well when the treatment regimen makes sense to them, when it seems effective, when they believe the benefits exceed the inconvenience, when they feel they have the ability to succeed at the regimen, and when their environment supports regimen-related behaviours.
A very oft reported problem is that communication between the patient and the provider is not adequate and this barrier leads to misunderstandings. As diabetes is a long journey, adherence is influenced by the changing situations in a person`s life. Various life`s events influence human behaviour, either good or bad, may result is deviation from set practices and result in poor adherence.
Though numerous methods have been tried, there is not one simple solution. The first and foremost is to win the confidence of patients by improved two way communication with a non-judgemental approach. Reduced treatment complexity, regimen coordination with daily life (eg, meals, waking, bedtime, brushing teeth, etc), fixed-dose combinations and decreased frequency of administration of medications are important. Weight gain and hypoglycaemia are important issues, which must be discussed in details and pre-emptive advice must be given.
Diabetes is associated with multiple psychological problems, some of which may not be clinically apparent. This has a bearing on adherence. Social support influences the ability to adjust to and live with illness and patient adherence. Assistance and support from friends and family have been implicated in promoting patient adherence by encouraging optimism and self-esteem, buffering the stresses of being ill, reducing patient depression, improving sick role behaviour and giving practical assistance. The presence of close others may result in the direct or indirect control of behaviour and facilitating adherence. However, a non-supportive relationship maybe toxic and have an opposite effect.
A collaborative approach to care augments adherence. People who have difficulty maintaining adequate adherence need more intensive strategies than do patients who have less difficulty with adherence, a more forgiving medication regimen, or both. A useful approach could be to create a social strategy with involvement of medical, lifestyle and mental health experts to empathise, motivate and provide continuous guidance. Regular monitoring of blood sugar levels using cloud services and forthwith action which is pragmatic and with person involvement bolsters confidence. Importantly, people should have help and guidance at hand and should have people to speak to. This can be done remotely using video link, text messaging and chat using mobile health. As travel takes up a lot of time and is inconvenient, this can be done from a place of choice of both the provider and the patient.
Other new technologies such as reminders through mobiles and pillboxes may be needed to help patients who have the most difficulty meeting the goals of a regimen. Medication apps represent a possible strategy that can be recommended to non-adherent patients and incorporate into their practice. It is important to make the person believe that whatever strategy is used, people with good diabetes self-care behaviours can attain excellent control.