Adherence to Long-Term Therapies - Evidence for Action
(2003; 211 pages) View the PDF document
Table of Contents
View the documentPreface
View the documentAcknowledgements
View the documentScientific writers
View the documentIntroduction
View the documentTake-home messages
Open this folder and view contentsSection I - Setting the scene
Open this folder and view contentsSection II - Improving adherence rates: guidance for countries
Close this folderSection III - Disease-Specific Reviews
Open this folder and view contentsChapter VII - Asthma
Open this folder and view contentsChapter VIII - Cancer (Palliative care)
Open this folder and view contentsChapter IX - Depression
Close this folderChapter X - Diabetes
View the document1. Introduction
View the document2. Treatment of diabetes
View the document3. Definition of adherence
View the document4. Prevalence of adherence to recommendations for diabetes treatment
View the document5. Correlates of adherence
View the document6. Interventions
View the document7. Methodological and conceptual issues in research on adherence to treatment for diabetes
View the document8. Conclusions
View the document9. References
Open this folder and view contentsChapter XI - Epilepsy
Open this folder and view contentsChapter XII - Human immunodeficiency virus and acquired immunodeficiency syndrome
Open this folder and view contentsChapter XIII - Hypertension
Open this folder and view contentsChapter XIV - Tobacco smoking cessation
Open this folder and view contentsChapter XV - Tuberculosis
Open this folder and view contentsAnnexes
Open this folder and view contentsWhere to find a copy of this book

6. Interventions

Almost any intervention that is designed to improve metabolic control in diabetes or to reduce the probability of acute or chronic complications does so by influencing patient self-care or self-management behaviours. Early efforts focused on patient education (110), but more recently, the importance of psychological and behavioural interventions has been stressed as a result of the growing recognition that knowledge alone is insufficient to produce significant changes in behaviour (111).

Elasy et al. (112) developed a taxonomy for describing educational interventions for patients with diabetes based on a thorough review and analysis of the literature published between 1990 and 1999 which revealed the great diversity of interventions employed to improve self-management of diabetes.

Brown conducted a meta-analysis of studies that had tested interventions to improve self-management of diabetes, and found a recent trend towards combining patient education with behavioural intervention strategies. Combining behavioural techniques with the provision of information was found to be more effective than interventions that provided only information. In general, the literature supports the conclusion that diabetes education results in at least short-term improvements in adherence and metabolic control (113), but more research is needed to learn which interventions work best with different types of patient and for specific behaviours (111,112).

Beyond interventions that focus on individual patients, two other approaches can be used to improve the self-management of diabetes - interventions that target health providers and interventions at the community or systems level. Several studies have reported that physicians and other health care providers deliver less-than-optimal care to patients with diabetes. There have been several corresponding studies of attempts to modify professional behaviours and attitudes in ways that might lead to improved patient outcomes. Kinmonth et al. (114) trained nurses to provide patient-centred diabetes care, and showed that patient satisfaction was improved although metabolic parameters were not. Olivarius et al. (115) in a study of physicians in Denmark used goal-setting, feedback and continuing education and found that the patients of the physicians who had received this intervention had improved metabolic parameters when compared to the patients of the physicians in the control group. In a series of studies, Pichert and colleagues showed that a training programme for nurses and dieticians improved their education and problem-solving skills (116 - 118). Other studies of training for health care providers have not documented any changes in patient behaviour or metabolic control (119).

Systems interventions can change the way in which environmental determinants influence the self-management behaviour of patients with diabetes. Systems interventions can focus on economic determinants, such as changing Medicare policy to pay for medical nutrition therapy (120). Health care delivery systems are also a target for intervention by means of changing programmes, policies or procedures to improve quality of care and outcomes for patients. For example, Hardy et al. (121) used telephone reminders to patients to improve appointment-keeping behaviour.

The chronic care model is a systems approach to improving the quality of care for patients with chronic diseases such as diabetes (122). Feifer (123) conducted a cross-sectional analysis of nine community-based primary care practices and showed that providing system supports to health providers resulted in better care of patients with diabetes. Wagner et al. (124) modified the way in which care was provided to patients with diabetes in primary care clinics and showed that these systemic changes resulted in better achievement of treatment goals, improved metabolic control, more time spent on diabetes education and enhanced patient satisfaction. Wagner et al. (125) intervened using a continuous quality care approach combined with the chronic care model in 23 health care organizations and documented improvements in diabetes care and patient outcomes in many of them.

Clearly, the solution to the problem of poor adherence must involve a combination of approaches that include intensive efforts to modify the behaviour of individuals with diabetes together with intelligent efforts to make changes in the larger environmental systems that shape and modify behaviours (126).

Table 4 Factors affecting adherence to therapy for the control of diabetes and interventions for improving it, listed by the five dimensions and the interventions used to improve adherence


Factors affecting adherence

Interventions to improve adherence

Socioeconomic-related factors

(-) Cost of care (59); patients aged over 25 years (21) (adherence to physical activity); older adolescents (insulin administration) (42); older adolescents (SMBG) (60); male (adherence to diet) (21); female (adherence to physical activity) (21); environmental high-risk situations (72,82,83,85 - 89,92,93,95,98,102,103,105)

(+) Patients aged less than 25 years (21) (adherence to physical activity); younger adolescents (insulin administration) (42); younger adolescents (SMBG) (60); male (adherence to physical activity) (21); female (adherence to diet) (21); social support (21,68); family support (21)

Mobilization of community-based organizations; assessment of social needs (21,68); family preparedness (21)

Health care team/health system-related factors

(-) Poor relationship between patient and physician (79)

Multidisciplinary care; training of health professionals on adherence (114,116); identification of the treatment goals and development of strategies to meet them; continuing education; continuous monitoring and reassessment of treatment (115); systems interventions: health insurance for nutrition therapy (120), telephone reminders to patients (121), chronic care models (122 - 125)

Condition-related factors

(-) Depression (73); duration of disease (21,41)

Education on use of medicines (110,113)

Therapy-related factors

(-) Complexity of treatment (48,50)

(+) Less frequent dose (48); monotherapy with simple dosing schedules (50); frequency of the self-care behaviour (48,50)

Patient self-management (112); simplification of regimens (48,50); education on use of medicines (110,112,113)

Patient-related factors

(-) Depression (75); stress and emotional problems (70 - 72); alcohol abuse (77)

(+) Positive self-esteem (62,63)/self-efficacy (64 - 67,78)

Behavioural and motivational interventions (111,112); assessment of psychological needs (111)


SMBG, Self-monitoring of blood glucose; (+) factors having a positive effect on adherence; (-) factors having a negative effect on adherence.

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