Influence Between Compliance to Therapy and Psychological Burden of Diabetes Mellitus among Patients

 Influence Between Compliance to Therapy and Psychological Burden of Diabetes Mellitus among Patients

Behavioural changes and adherence to therapeutic regimes are essential for improving the prognosis of chronic illness. Generally, chronic conditions can be defined as illness or diseases that have a prolonged course that do not resolve spontaneously, and for which complete cures are rare. (Makenna, Taylor, Marks, 1998). The specific condition may be as a result of illness, genetic factors, or injury. It may be a consequence of conditions or unhealthy behaviours that began during childhood or young adulthood.

Chronic illness and disability affect people of all ages – the young, the middle – aged, and the very old and chronic condition is a global issue that affects both and poor nations (Mascie – taylor and Karim, 2003). In developed countries with effective records such as the United States, chronic diseases account for 7 to 10 leading causes of death. In 1995, an estimated 99 million people in the United States had chronic conditions and it has been projected that by the year 2050, about 167 million people will be affected (Robert Wood Johnson Foundation (RWJF), 2001).

People with disorders such as diabetes, hypertension, obesity and cardiac and respiratory disorders are described as people with chronic conditions (Juarbe, 1998: Malcenna et al; 1998; United States Department of Health and Human services (USDHHS), 2005) Wing, Goldstein, Action, et al, 2001).

Chronic disease is associated with 70% health care costs in the united states (CDC, 2004), many people with chronic disorders including the elderly and people who are working may be unable to afford the high costs of care often associated with chronic illness (Mold, Fryer and Thomas 2004).

Diabetes mellitus as a chronic illness leads to psychological, emotional and cognitive crisis to the diagnosed patient. (Brunner and Suddarth, 2007) this response to the patient occurs immediately after the diagnosis and to recur if symptoms worsen or recur after a period of remission. (American psychiatric Association, 2000). Such mental disorders that are associated with a response to diagnosed condition among the population include anxiety, depression and substance abuse.

Keeping chronic conditions under control requires persistence adherence to therapeutic regimens. Failing to adhere to treatment plan or do so consistently increases the risks of developing complications and accelerating the disease process.

In this study, a review of the influence between compliance to therapy and psychological burden of diabetes mellitus among client in Federal medical centre Abakaliki is the major focus.


Over the last 30 years, diabetes has changed from being considered a relatively mild ailment associated with aging to one of the major contemporary causes of premature mortality and morbidity worldwide. (Diabetes Research and Clinical practice 2008), Meanwhile World Health Organization 2003, estimated that the burden of unsatisfactory treatment outcomes in people with diabetes is on the increase due to lack of treatment adherence (Global burden of diabetes 1995 – 2025, World Health Organization).

In Federal Medical Centre (F.M.C) Abakaliki, My clinical experiences shows  that patient with  chronic conditions while receiving treatment in hospital most often developed complications showing that little information is available on treatment adherence. Therefore, this work seeks to investigate the psychological burden of diabetes mellitus as a determinant to treatment adherence among the patients


The purposes of this study include:

1. To determine the compliance to therapy by the subject

2. To determine the psychological burden of diabetes mellitus on subjects.

3. To determine the influence of personal characteristics of subject on compliance to therapy.

4. To determine the influence of personal characteristics of subject on psychological burden of mellitus.


This study will provide insight into the problem of non compliance among diabetic patients in Federal Medical centre and also reveal the influence of psychological burden on treatment. The findings of this study when forwarded to medical journal will enlighten those calling for people diagnosed with diabetes on the importance of diagnosing and alleviating the psychological burden of the disease with a view to increase treatment adherence.


The study will involve psychological burden of diabetic patients/ clients, sleep, mood, anxiety and withdrawal and compliance to therapy in Federal Medical Centre Abakaliki that visit the clinic for medical check up.

The main limitation of the study has been time and money visiting the hospital on the clinical days required a lot of money and much time was spent in gaining the respondents cooperation to assist in the data collection.

Research Questions

1.  Does patient with diabetes mellitus adhere or comply to medical advice.

2. Does the diagnosis of the condition bring about psychological burden (depression) on the patient?

3. Could person characteristics of the subject influence compliance to therapy

4. Could personal characteristics of the subjects influence the psychological burden of diabetes mellitus?

Operational Definition of Terms

1. Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels that result from defect in insulin secretion action or both

2. Adherence (Compliance) to treatment is defined as the extent to which a person’s behaviour coincides with health related advice.

3. Psychological burden. This means the problem encountered by patients by cognitive appraisal and reappraisal of the diagnosis of diabetes mellitus.



Medical compliance is defined as the extent to which a patient acts in accordance with the prescribed interval, dose, and dosing regimen (Najah 2005, Waleed Sweileh et al.., 2001). In other words, patient’s compliance to medical management of diabetes mellitus refers to the characteristics of the behaviour that define the extent to which a patient follows a medical treatment for diabetes mellitus.

According to Hughes 2007, compliance is a primary term and adherence is a synonym of compliance, therefore could be used interchangeably.

However, World Health Organizaion (2003) promoted the term adherence for use in chronic disorders with the following definitions. The extent to which a person’s behaviours in terms of taking medication, following diets or executing lifestyle changes corresponds with agreed recommendation from health care provider. Adherence (Compliance) connotes the willingness on the patient’s part to follow the physicians or nurses recommendation.

Diabetes is a prime risk factor for cardiovascular disease controlling other risk factors which may give rise to secondary conditions, as well as diabetes itself is one of the facets of diabetes management.  Diabetes can be very complicated and the health care providers need to have as much information as possible to help the patient establish an effective management plan. Meanwhile, the patient as an integral part of the diabetes mellitus management team has to be properly educated on the disease process.

Lack of adherence is a common problem in every practice and every patient drop out of care prematurely, patient adherence to medication is one of the greatest obstacles that physicians face when treating a patient with diabetes mellitus (Israel leman 2005, Marie Brown 2010). Diabetic regimen may contain aspects that are difficult to comply with. In diabetes management lifestyle changes are required, treatment may be complex and inconvenient and preventive instead is symptom reduction or cure is frequently the main goal. (Archives of medical Research, 2005).

NON COMPLIANCE: Lack of adherence to treatment regimen by a patient is known as non compliance. Non compliance has been reported to lead to an increase in healthcare resource utilization and expenditure due to development of complications by patients with diabetes mellitus. (American Diabetes Association 2003). In particular, non compliance may lead to worsened glycaemic control which in turn may result in increased healthcare utilization and cost (e.g due to hospitalizations, temporary or permanent disability because of diabetic retinopathy or amputations caused by diabetic neuropathy (Menzin 2001, Wagner, 2001).

There are several types of non compliance which include

1. Therapeutic or medication noncompliance which include; failure to have the prescription dispensed or renewed, omission of doses errors of dosage, incorrect administration, error in time and frequency of administration and premature discontinuation of the drug regimen.

2. Dietary non compliance: non adherence to dietary recommendation or when the patient fails to follow the diet recommendations.

3. Appointment non compliance; is a non compliance in which the patient fails to show up at the clinics for scheduled check up. (Waleed, Ola Aker and Saed Hamooz, 2005). Waleed (2005) also opined that the rate of adherence could be analysed based on the above mentioned types of non compliance.

4. Exercise noncompliance; is a non compliance in which the patient fails to carry out the recommended exercise that can help in glucose control.

Psychological Burden

The emotional burden of diabetes is often greatly undiagnosed and can manifest itself as depression, eating disorders, anxiety, needle phobia and severe mental health conditions; these negatively impact on self care which leads to poorer glycaemic control and long term complications for the patient (Jackie 2011).

Robbert Michael (2003) carried out a study on stress coping and psychological sequelae of diabetes and reveals that childhood diabetes places an enormous cognitive, affective and behavioural burden on children, adolescents and their families. He further argued that since children are at risk of psychopathology, they must cope with the array of stresses in order to guarantee improved metabolic control through improved treatment adherence.

In a study by Peyrot and associates (2002), investigators found that almost 70% of clinicians responding to the Diabetes Attitudes Wishes and Needs (DAWN) survey reported that Psychological problems (including stress and depression) affected treatment adherence in their diabetic patients.

Similarly, Williams and Wilkins 2009, revealed that patient with emotional burden were physically less active, were more likely to smoke tobacco, had less healthy eating habit and adhered less to diabetic treatment.

In the DAWN Survey, almost 50% of patients reported specific psychological problems and poor psychological well – being, but only 10% indicated that they received treatment for those problems. Another report estimated that only 250% of patients with type 2 diabetes mellitus received adequate treatment for it (Rubin 2004). Effective treatment of distress and depression could lead to improved glycaemic control directly (Rubin and Peyrot 2002)

Factors Influencing Adherence To Therapy

Patients with diabetes mellitus do not completely adhere to medical advice, however, several investigators revealed that adherence to diabetes treatment guidelines are influenced by the; level of Education, perception of treatment benefits, regimen complexity, perceived adverse effects, medication costs and emotional well- being.

2.1 EDUCATIONAL BARRIER; Of the factors that may affect treatment adherence, the most common is patients comprehension of the treatment regimen, Schillinger and coworkers (2003) studied 408 English-speaking and Spanish- speaking patients in public hospitals and found that > 50% of both groups had limited health literacy, defined as comprehension of common medical terms or concepts and for dosings (e.g take this medication 4 times a day).

A higher educational background and increased diabetes related knowledge are associated with better adherence and adjustment to any treatment program. Waleed and Colleagues, 2005 studied 321 patients with diabetes mellitus and the contigency test results showed that illiterate patients do not appreciate the importance of drug compliance on therapeutic outcome and led to a higher percentage of non compliance.


Perception of Treatment Benefit.


Effective – provider – patient communication can help clinicians address other factors that influence treatment adherence, including patients perception of the potential benefits of adherence. A study by Grant and Associates (2003) emphasized that patients are more likely to adhere to treatment they perceive as helpful in alleviating their symptoms as those they do not.

Regimen Complexity

Many Patients with diabetes mellitus are prescribed complex treatment regimens to help them achieve glycemic goals, several retrospective database studies have shown that rates of adherence to polytherapy regimens were  10% to 20% lower than those for monotherapy regimen (Dailey G 2001, Melikian C 2002, Donnan 2002).

Rubin (2005) used electronic monitoring to compare adherence to medication dosed once, twice or thrice daily. To determine whether agents were taken at the prescribed times, the monitoring system tracked not only how often the medication was taken but also precisely when. The adherence rate for once daily dosing was 79%: those for 2 and 3 times daily dosing decreased to 66% and 38%, respectively.

Furthermore, medications were taken at prescribed times in 77 % cases of once daily dosing; the rate fell to 41% and 5% respectively for dosing 2 and 3 times daily.


Percieved Adverse Effects


                Adverse effects (AEs) (ie hypoglycemia weight gain) as well as agent tolerability, drug–drug interactions and complicated drug regimens lead some patients to use medicines prescribed for the treatment of diabetes mellitus.

In a study by Boccuzzi and Colleagues (2001), after 12 months of metformin therapy 60% of patient were still adherent to their medication regimen, whereas 12 – month persistent rates for sulfonylureas, repaglinide, and alpha – glucosidase inhibitors were lower 56%, 46% and 31% respectively.

In a similar study of 128 patients using  3 medications concurrently, 21% were not perfectly adherent to their regimens. (Grant RW, 2003).

Of these > 70% were perfectly adherent to all but 1 agent. Adverse effects (AEs) were the most common reason for lack of adherence. However, patients should be asked about AEs and their treatment should be adjusted accordingly.

Medication Cost

Medication costs affect adherence. In a U.S suivey of adults with  diabetes mellitus receiving blood glucose- lowering therapy, 11% indicated that they had limited their medication in the past year due to cost, with 7% having cutback in the past month (Piette JD 2004). Similarly, Breitscheidel and Associates 2010 reported that some patients justify their non compliance to economic reasons.

Furthermore, Clinicians do not seem to be doing everything possible to prevent cost as a barrier to adherence, about 70% of patients indicated that their providers had not raised the issue of medication cost and only 10% reported being given information on sources of low cost medications or financial assistance programs. A similar proportion of patients (10%) reported that their providers had prescribed fewer medications to decrease out- of – pocket expenses.

Emotional Well – Being

Although some barriers such as stress and depression have direct effects on metabolic outcomes, anxiety, sleeplessness, and other psychosocial barriers constitute the major emotional burden among patient diagnosed with chronic condition (Brunner and Suddarth 2007). Attitude of reluctance to accept diabetes and difficulties to introduce the behavioural changes in daily life contribute and complicate the adjustment to any treatment program. Low self- efficacy and low levels of family and social support are strongly and consistently related to low levels of diabetes self- management. Emotional dysfunction associated with diabetes and psychosocial stress are commonly linked with poorer metabolic control, more frequent hospitalizations and eventually the development of long term complications (Glasgow 2001).

Lack of social and family support has been associated with poor achievements of treatment goals. Families may provide valuable reinforcement and emotional support and may play a key role in adherence to diabetes regimen. Older adults in particular after rely on supportive relations for transportation, mealtime companionship and medications compliance (Brunner & Suddarths 2007). Rather that focusing only on individual management, health professionals should consider the family as an integral part of the treatment (Isreal Lerman, 2005).

Theoretical /Conceptual Framework

Diabetes is a chronic disease in the sense that it cannot be curved through it can be controlled, due to the nature of the disease, diabetes mellitus can be greatly influenced by self care; adequate control of the disease requires much of the patients self knowledge skills, determination and will power.

Orem’s self care model is one % the theoretical approach in the management of client with diabetes.

Orems Self Care Model

Dorothea Orem’s model of nursing is based on the beliefs that health care is each individuals own responsibility. The model is aimed at helping client direct and carry out activities that either help maintain or improve their health. The central clement of this model is basically the client who is a biological, psychological and a social being with the capacity of self care, which involves a set of learned behaviour, to sustain life, maintain or restore functioning and brings about a condition of will being (Mensing 2003).

The nurse assists the client with self care when there is deficit in his or her ability to perform. The individual is  regarded as healthy, when he or she is able to live fully when he or she is able to live fully within a particular, physical, biological and social environment, achieving a higher level of functioning that distinguishes the person from lower forms of life.

In Orem’s model self – care is categorized into three;

1. Universal Self Care: which includes those elements commonly found in everyday life that support and encourage normal human growth, development and functioning. A healthy person according to Orem’s is one who carry out the universal self care activities in order to maintain a state of health.  To some degree, all those elements are necessary activities in maintaining health through self care (Mensing 2005)

2. Development Self Care:- This comes into play with either special expressions of universal self care requisites derived from a condition or associated with an event (Olabisi, 2008) examples are adjusting to body changes and lifestyle

3. Such as Facial Lines or New Job.

3.1 Health Deviation Self Care: Health deviation self care includes those activities carried out by individuals who have diseases, injuries physiologic or psychosocial stree or other health concerns.  Activities such as secking health care at an emergency room or clinic, entering a dry rehabilitation unit or going to hospital for medical and nursing services fall in this category.

Orem’s further specified the situations when nursing is needed to assist the individual in the provision of self care and the method of nursing care system required whether it is wholly compensatory, partially compensatory or supportive – educative.

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