- Email: [email protected]
Adherence to treatment and social support in patients with non-insulin dependent diabetes mellitus
Adherence to Treatment and Social Support in Patients With Non-Insulin Dependent Diabetes Mellitus Ma. Eugenia Garay-Sevilla, Laura E. Nava, Juan M. Malacara, Raquel Huerta, ]orge Diaz de Ledn, Aurora Mena, and Martha E. Fajardo
ABSTRACT We carried out a cross-sectional study to investigate factors associated with adherence to diet and medication in non-insulin-dependent diabetes mellitus (NIDDM) patients. A total of 200 patients not seeking treatment from clubs for diabetics from two hospitals in Leon, Mexico, accepted inclusion. Patients interviewed had a mean age of 58.8 (53.3-56.4, 95% C.I.) years. We evaluated adherence to diet and medication, knowledge on diabetes, social support, family’s structure and functioning (with a modified McMaster model), metabolic control, and complications. Stepwise multiple regression procedure showed that adherence to diet was associated with years since diagnosis @ = 0.003) and with social support fp = 0.007). Adherence to medication was associated with social support (p = 0.002), and the age of the spouse (p = 0.016).
INTRODUCTION dherence to treatment is referred to as the characteristics of the behavior that define the extent to which a patient follows a medical treatment .I For non-insulin-dependent diabetes mellitus (NIDDM), Harris et a12r3 found that
A
Instituto de Investigaciones Medicas. Universidad juato, Ledn, Guanajuato, Mexico. Address reprint requests to: Dr. Juan M. MaIacara, Investigaciones Medicas, Universidad de Guanajuato, 929, Le6n Guanajuato, Mexico. ~oumal of Diabetes and Its Complications 1995; 9:82-f% 0 Elsevier Science Inc., 1995 655 Avenue of the Americas, New York, NY 10010
de GuanaInstituto de 20 de Enero
Adherence to medication was lower in patients from families with rigid control than in the group with Laissez-faire type of control fp = 0.010) or the group with flexible control @ = 0.002). Social support was lower in the group with chaotic control than that in the group with flexible control (p < 0.001). Compliance to diet was associated with peripheral neuropathy and plasma creatinine, and adherence to medication with plasma glucose and peripheral neuropathy. We concluded that (1) adherence to treatment in NIDDM patients is associated with social support; (2) some aspects related to the family, such as the age of the spouse and the control of behavior, were also associated with compliance to treatment; and (3) it is important for the practicing physicians, and for institutional programs, to consider factors associated with adherence to treatment. (Journal of Diabetes and Its Complications 9;2:81-86, 1995.)
compliance to a prescribed diet and exercise was associated with the benefit perceived, and adherence to medication was correlated with the cost perceived. According to Brobrow et al.,4 adherence is associated with less aggressiveness, and open frank discussion about diabetes. Studies carried out for NIDDM5 show that supporting behavior correlated with blood glucose and diet adherence, but the frequency of nonsupporting behavior did not correlate with adherence. Glasgow et al5 investigated factors associated with social environment, and they found that family support was the strongest and most consistent predictor
SSDI
1056~8727/95/$9.50 1056-8727(94)00021-H
82
GARAY-SEVILLA
ET Al..
1 Diab Camp 1995; 9:81-8h
of adherence to treatment in patients with NIDDM. A study in women with gestational diabetes showed significant correlation between diet compliance and social support. Insulin compliance was related to social support but not with minor or major stressorsh In diabetic patients, nonadherence for diet ranged from 35% to 75%,‘,* for the technique of administration of insulin is about 80%,’ and 9390 for thtr combination of proper insulin, foot care, and diet or urine testing regimens.* Some patients justify their nonadherence to treatment on basis of economic factors, interpersonal problems with their spouses and families,9*10and other factors. The interaction of the family structure and function with adherence to treatment in NIDDM patients is insufficiently studied. Family functioning is a set of patterns of interactions among members of a family.” During the course of a chronic disease such as diabetes mellitus, adverse interactions may impose an excessive load on the capability for adaptation of the family. It may have an effect on the course of the disease. Under such circumstances, a family function may change to a rigid control, that may threaten its stability. ‘* Several investigators have proposed that the family system has a role on the initiation, selection of symptoms, clinical course, use of clinical facilities, and the compliance to medical treatment in diverse chronic diseases.12-” This study was done to investigate the adherence to diet and medication in NIDDM patients, and its associations with social support, metabolic control, complications, knowledge on diabetes, and family’s structures and functioning.
MATERIAL
AND METHODS
Reauitment of Patients. A cross-sectional study was carried out with patients not seeking treatment from clubs for diabetes from two hospitals. Invitation was done during their weekly meetings, after explaining the purpose of the study. Twenty visits to groups of people with diabetes were done, and an acceptance rate close to 20% was obtained. A total of 200 patients with NIDDM, 19-85 years old, were included in the study. All of them were residents in the urban zone of the city, who showed adequate physical and mental capacity to answer questions about their disease. The details of the questionnaire were explained to the volunteers. Patients answered it through direct questioning by an investigator. The investigators involved in the study did not have institutional ties with the hospital or treating physician. Questionnaire. The questionnaire had 66 items, and included the following: General D&n. Sex, date of birth (for calculation of age), schooling (in years), marital status in two groups:
married or in free union and nonunited (single, widowers, divorced, or separated), years since diagnosis of NIDDM, weight and height to calculate body-mass index (BMI) (weight/height:, kg/m2), and sitting systolic (SBP) and diastolic blood pressures (DBP). Social Support. Social support was evaluated on the basis of the patient’s perception of the backing they received by their relatives and their friends to comply with treatment for diabetes. The Diabetes Social Support Questionnaire, designed for gestational diabetes6 was modified by us for patittnts with NIDDM. The score ranged from 0 to 3). Life Style. Smoking habit, alcoholism (if alcoholic beverages were periodically consumed), and exercise (if done more than once per week) data were collected as yes or no. Structure of the Family. The family structure was classified as: Uniparental if only one parent was living at home, nuclear if both parents did so, and extended if other relatives such as married sons or daughters, grandparents or uncles were living at home. The number of sons and daughters was also collected.
Function of fhe Fuamily. The family functioning was evaluated with the modified McMaster model,” including six aspects: (1) Problem solving in the family was evaluated in seven categories: identification of problems, communication to the appropriate person, development of alternatives, decision taking, action, monitoring the action, and evaluation, with progressively increased scores for these stages. (2) Communication within the family was rated in four categories (clear and direct, clear and indirect, masked and direct, and masked and indirect). (3) The roles assumed b) each member of the family were explored on six aspects: provision of financial support, confidence, counseling, problem solution, spend time in the family, and provides love. For each item, five categories were considered: husband or wife, a son or daughter, parents of the patient, a brother or sister, or other. Higher scores were given if the roles were assumed by the husband or the wife. (4) Affective responsiveness registered for happy situations with five categories (very effusive, effusive, lukewarm, very lukewarm, and indifference); and adverse situations with five categories (very anguish, anguish, tranquil, very tranquil, and indifference) with higher score for full responses. (5) Affective involvement between the couple, a range of involvement with six scores of progressive empathic involvement. (6) Control of behavior in the family had four categories: rigid (if permissions for members of the family were seldom given), flexible (if permissions were frequently obtained), laissez faire (permissions almost always granted), and chaotic (if no permissions
1 Diab Comp
199.5; 9:81-86
were needed). Each aspect was examined choice questions.
ADHERENCE
by multiple
Knowledge on Diabetes. Knowledge was investigated with 13 questions related to the nature of the NIDDM, its associated factors, procedures to monitor metabolic control, the complications of the disease, and the care needed for control of the disease and its complications. Questions were designed as short statements that the patient answered on a Likert’s scale from 1 to 5: Total disagreement, disagreement, indifferent, agreement, and total agreement. The sum of answers was the score of knowledge. The maximum score was 58. Adherence to Treatment. Adherence to treatment was assessed in regards to prescribed diet and to medication. Adherence to diet was investigated with seven questions concerning uniformity of daily intake of food, acceptance and compliance to prescribed diet, and asking the patient’s interest in keeping an appropriate weight. Adherence to medication included three questions about continuity of intake of medication, self-decided changes of doses or its type. Answers ranged from 1 to 4, with increasing scores for better compliance. Validity of Questionnaire. Validity of the questionnaire was tested in a pilot study applied to 20 patients. Correlation matrices of responses to sets of questions were calculated for each aspect; only significant questions were included in the final questionnaire. For social support, four questions were tested, and three had significant results. For knowledge on diabetes, 13 out of 19 questions were significant. For adherence to treatment, 10 out of 11 questions were significant and therefore included in the final questionnaire. Questions related to family function were also tested with a correlation matrix, and only significant factors were included. After validation of the questionnaire, it was applied to the group of patients under study. The time for response was 30-45 min. Metabolic Control of Diabetes and Complications of Diabetes. Metabolic control was evaluated by a fasting blood glucose (enzymatic GOD-PAP method purchased from Lakeside) and a determination of HbA1, (Sigma, St. Louis, MO) (normal values, 5.5%~8.5%). Peripheral neuropathy was evaluated questioning six symptoms in both legs: paresthesia, hyperesthesia, dysesthesia, jabbing pains, burning pains, and amyotrophia. The intensity of symptoms were registered from 0 to 3, and the sum was stratified in four categories (0 to 3). Amaurosis (in at least one eye), cataract, and amputation were registered as present or absent. Plasma creatinine was measured by a calorimetric method. Leukocytes were counted in the sediment from morning urine sample. Increased count was reg-
TO TREATMENT
TABLE
AND
SOCIAL
SUPPORT
1. CHABACTEFUSTICS
Variable
IN NIDDM
OF THE PATIENTS ._____ (95% CL) n %
Mean
Sex Men
Women 58.8 3.5
Age (YeW Schooling (years)
83
68 132
34 66
52 148
26 74
(53.3-56.4) (3.0-4.0)
Marital status No union Married or free union Years since diagnosis BMI (men) BMI (woman) Systolic blood pressure (mm Hg) Diastolic blood pressure Life style Smoking habit Alcoholism Exercise Cl.,
confidence
interval;
2::: 29.0 132.7
(izi2) (28.3-29.8) (129.8-135.7)
82.5
(80.9-84.1) 49 5 45
BMl,
body-mass
25 2.5 22.5
index.
istered when more than 6 leukocytes field were found.
per high power
Analysis of data. We studied the possible determinants of adherence to diet and to medication, testing as candidate regressors age, years since diagnosis, smoking habit, alcoholism, knowledge on diabetes, and variables related to family structure and function. The multivariate interaction of these factors was tested with stepwise multiple regression analysis with forward inclusion of variables. The influence of categoric variables from family function: communication within the family and control of behavior were analyzed by analysis of variance (ANOVA), and post-hoc analysis for differences between pairs of groups was done with the least-significant difference test. The association of adherence to diet and to medication with variables related to metabolic control and with complications was examined with stepwise multiple regression. Significance was accepted with p < 0.05. RESULTS Table 1 shows the main characteristics of patients under study, in regard to biological characteristics, schooling and marital status. Table 2 shows the characteristics of family structure and function. For the total group, the scores of adherence to diet had a mean value of 17.7 (17.2-18.3, C.I., 95% confidence interval), a 63.3% of the maximum score. The mean score of adherence to medication was 11.0 (10.8-11.2, C.I.), a 91.6% of the maximum score. The scores of social support for the group was 2.80 (2.62-2.98, C.I.). Knowledge on diabetes was 55.3 (54.5-56.1,95% C.I.). Blood glucose levels had mean values of 184.5 (173.3-
84
GARAY-SEVILLA
TABLE
2. FAMILY
1 Dfnb Cony
El’ AL.
STRUCTURE
Variable
Structure Number of children Age of spouse(years) Type of family Nuclear Uniparental Extended Family Function Problem solving in the family Satisfactory Not satisfactory Communication within the family Clear and direct Clear and indirect Masked and direct Masked and indirect Roles in the family Husband or wife Sons and daughters Parents of the patient Brothers Other Affective responsivenes Effusive Others With anguish Others Affective involvement with the spouse Positive Negative Control on behavior in the family Chaotic Laissezfaire Flexible Rigid
Mean
AND
TABLE
FUNCTION
(95% C.I.)
n
3. RESULTS FROM THE STEPWISE REGRESSION ANALYSIS
%
Family
Dependent
7.1 (6.6-7.6) 53.6 (41.6-55.5)
1995; Y:81-86
Variable
P
Partial Correlation
p
Adherence to Diet Significant
101 50.5 25 12.5 74 37
153 76.5 46 23.0
137 40 11 11
68.5 20.0 5.5 5.5
69 34.5 95 47.5 21 10.5 14 7.0 1 0.5 143 57 178 21
71.5 28.5 89.0 11.0
97 45 103 55
36 44 58 34
18 22 39 17
195.6C.I.),HbA1,was11.9(11.5-12.4C.I.).Bloodcreatinine had mean value of 0.94 (0.89-0.99 C.I.). In regards to complications, the scores on neuropathy were as follows: zero was found in 11% of the patients, one in 59.5%, 2 in 29%, and 3 in 5.5%. Cataract was found in 4.5%, amaurosis in 5.01, and amputations in 1.5% of the patients. Table 3 shows the results of the stepwise regression procedure. Higher adherence to diet was associated with more years since diagnosis and with greater social support. Higher adherence to medication was associated with greater social support and older age of the spouse. Adherence to diet and to medication were not different in the groups with diverse types of communication within the family (F = 0.08, p = 0.97, and F = 0.60,
Regressors
0.204 0.186
0.208 0.190
0.003 0.007
0.012 0.036 -0.095 0.065 0.046 0.039 -0.045 - 0.014 - 0.038 -0.083 0.059 0.064
0.012 0.037 -0.099 0.067 0.048 0.040 -0.046 -0.015 -0.039 -0.086 0.062 0.062
0.867 0.604 0.166 0.347 0.503 0.574 0.518 0.837 0.582 0.226 0.388 0.386
0.217 0.168
0.219 0.171
0.002 0.016
-0.132 Age of the patient 0.018 Schooling 0.025 Years since diagnosis Number of children -0.009 Problem solution 0.053 -0.039 Roles in the family Positive affective response 0.008 Negative affective response 0.081 Affective involvement -0.022 -0.040 Alcoholism -0.028 Smoking habit Knowledge of diabetes 0.054 --
-0.107 0.018 0.025 -0.009 0.054 - 0.039 0.008 0.084 -0.023 -0.042 - 0.029 0.055
0.134 0.769 0.726 0.8% 0.449 0.573 0.911 0.240 0.747 0.557 0.686 0.439
Years since diagnosis Social support Nonsignificant
Variables
Age of the patient Schooling Alcoholism Smoking habit Number of children Age of the spouse Problem solution Roles in the family Positive affective response Negative affective response Affective involvement Knowledge of diabetes Adherence to Medication Significant
Regressors
Social support Age of the spouse Nonsignificant
Variables
p = 0.61, respectively). Adherence to diet was no different in diverse groups of family control, (F = 0.67, p = 0.57). Scores on adherence to medication were different among the groups of family control (F = 3.79, p = 0.01). The post-hoc analysis showed that patient with rigid control in their families had lower scores of adherence to medication (10.3 f 0.3) as compared with the groups with Laissez-faire type of control (11.2 f 0.2, p = 0.010) and with flexible control (11.3 f 0.2, p = 0.002) (Figure 1). Scores on social support were different among the groups of control within the family (F = 4.32, p = 0.006). The post-hoc analysis showed that the group with chaotic control had lower scores as compared with that with flexible control (p < 0.001) (Figure 1). In the analysis of association of adherence to diet with variables related to metabolic control and compli-
cations, greater adherence to diet was associated with
ADHERENCE
J Diab Comp 1995; 9:81-86
Li 0
13-j
p < .OOl :
T
CHAOTIC
LAISSEZ-
CONTROL
RIGID
FLEXIBLE
OF BEHAVIOR
1. Scoresof adherence to medication(upperpanel)and socialsupport(lowerpanel)in the groupsof control of behavior within thefamily (chaotic,laissez-faire, rigid andflexible). Differenceamongthe groupswassignificant:F = 3.79, p = 0.01 for adherenceto medicationand F = 4.32, p = 0.006, for social support.Horizontallinesshowsignificantdifferences between pairs of groups,using the least-significant differencetest. FIGURE
lower scores of peripheral neuropathy (p = - 0.190, p = 0.006) and 1ower blood creatinine levels (p = - 0.153, p = 0.028). High scores on adherence to medication were associated with lower blood glucose levels (l3 = -0.178, p = 0.011, and with lower scores of peripheral neuropathy (I3 = -0.153, p = 0.028). DISCUSSION
Adherence to diet and to medication have a pivotal role in the management of patients with NIDDM. Therefore efforts should be made to identify psychological and social factors that influence patients’ adherence to treatment. The group of patients in this study may be considered as a selected one, because of the low acceptance rates for inclusion. It is possible that an acceptant is more concerned about the disease than a nonacceptant, possibly having a higher compliance
TO TREATMENT
AND SOCIAL SUPPORT IN NIDDM
85
to treatment than the average patient. Therefore, results may not be fully extrapolated for the whole population of diabetic persons. In this study, social support appeared as the main determinant of compliance to medication, this finding is in agreement with the observations of Wilson et al.rB They reported that social support was the most consistent and strongest predictor of self-care behavior across the different aspect of management of the disease, such as medication taking and glucose testing, in patients with NIDDM. Ruggiero et a1.6 found that high adherence to insulin administration, was associated with higher scores for social support in women with gestational diabetes. In our study, social support was also associated with higher scores for adherence to diet. Adherence to diet may require stronger support from the patients/relatives, considering that meals are usually shared by all members in a family. This factor may be more significant in traditional societies. Therefore, it is important to examine the influence of the structure and the function of the family on this problem. Our results showed that patient with rigid control in their families had lower scores of adherence to medication. A rigid control of behavior within a family may imply decreased adaptation to change, in particular to deleterious changes such as a chronic disease in one of its members. This factor may favor the denial of the disease. Rigid control may also enhance the development of conflict with the authority, increasing the denial of the disease. The result of such denial is a diminished compliance with treatment. Furthermore, the onset of a permanent disease with a high genetic component, such as NIDDM, in one of the members of the family have a strong impact. It may modify the capability for adaptation of a family that changes the functioning to more rigid forms of control in response to the threats of disintegration of the family.12 Further evidence for the contention that flexible control gives a better environment for compliance to treatment is the fact that this group also had higher scores of social support. In this study, we found that years since diagnosis is the main determinant of compliance to diet, this may indicate that after years of suffering the disease, attitudes of denial are reduced, and patients progressively accept treatment. On the other hand, older ages of the spouse were associated with higher scores on adherence to medication. This suggests that mature partners are more likely to give support to follow medical prescriptions. The influence of these two factors indicate that time may improve the factors associated with acceptance of disease and treatment, and the conditions of the family associated with them. The scores of compliance to treatment were associated with variables related to the control of diabetes
86
GARAY-SEVILLA
ET AL.
and the appearance of complications: Plasma glucose with adherence to medication, peripheral neuropathy with adherence to medication and to diet, and plasma creatinine with adherence to diet. Those findings are consistent with the view that the scales for compliance to treatment were effective to evaluate the care for the disease. We concluded that adherence to medication and diet in NIDDM patients are strongly associated with social support. Some aspects of the family such as the age of the spouse and the control of behavior within the family are also associated with adherence to medication. Years since diagnosis was associated to adherence to diet. Social support and its relationships with the family structure and function may be different in diverse cultures. Therefore, further work about these subjects should be done in different societies. The influence of cultural values on rigid forms of control within a family, denial of disease, and unacceptance of modern medicine should be investigated in future work. It is important for the practicing physicians, and for institutional programs about NIDDM, to consider factors associated with compliance to treatment. Better strategies to improve the social support and family function, are urgently needed in programs oriented to the control of NIDDM, in order to improve patients’ adherence to treatment. REFERENCES Kurtz SM: Adherence to diabetes regimens: Empirical status and clinical applications. Diabetes Educ 1650-56, 1990.
Harris R, Linn MW, Pollack LW, Tewksbury D: The relationship between the health belief model and compliance asa basisfor intervention in diabetesmelhtus. Pediatr Adolesc Endocrinol10:123-132,1982. Harris R, Linn MW, Skyler JS, Sandifer R: Development of diabetes health belief scale. DiabetesEduc 13: 292-297, 1987. Bobrow ES, AvRuskin TW, SilIer J: Mother-daughter interaction and adherenceto diabetesregimen. Diabetes Care8:146-151, 1985.
5. Glasgow RE, Toobert DJ: Socialenvironment and regimen adherenceamong type II diabetic patients. Diabetes Care 11:377-386,1988. 6. Ruggiero L, Spirit0 A, Bond A, Coustan D, McCarvey S: Impact of social support and stresson compliance in woman with gestational diabetes. Diabetes Cure 13: 441-443, 1990. 7. Williams TF, Anderson E, Watkins JD, Coyle V: Dietary errors made at home by patients with diabetes. I Am Diet Assoc 51:19-25, 1967. 8. Cerkoney KAB, Hart LK: The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabefes Care 3:594-598, 1980. 9. Ary DV, Toobert D, Wilson W, Glasgow RE: Patient perspectives on factors contributing to nonadherence to diabetesregimens. Diabetes Care 9:168-172, 1986. 10. Kirkley BG: Behavioral and socialantecedentsof noncompliance with nutritional management of diabetes [Dissertation]. St. Louis, Washington University, 1982. 11. RamseyCN Jr, Lewis JM: Family structure and functioning, in Rake1RE (eds.). Family Practice, 3rd edition. Iowa City, IA, WB Saunders, 1984, pp. 21-40. 12. Authier J, Starr G, Authier K: Impact of illnesson the family, in Rake1RE (eds). Family Practice, 3rd edition. Iowa City, IA, WB Saunders, 1984,pp. 102-117. 13. Anderson BJ, Auslander WF: Researchon diabetes managementand the family: A critique. Diabetes Cure 3:696-702, 1980. 14. Newbrough JR, Simpkins CC, Maurer H: A family development approachto studying factors in the management and control of childhood diabetes. DiabetesCare 88392, 1985. 15. Hansen CL, Henggeler SW: Metabolic control in adolescentswith diabetes:an examination of systemicvariables. Fum Sys Med 2:5-16, 1984. 16. Wishner WJ,O’Brien MD: Diabetesand the family. Med Clin North Am 62:8494X56, 1978. 17. Epstein NB, Bishop DS, Daldwin LM: MCMaster Mode1 of family functioning view of the normal family. 1. Marr Fum Cows 4:19-31, 1978. 18. Wilson W, Ary DV, Biglan A, Glasgow RE, Toobert DJ, Campbell DR: Psychosocialpredictor of self-care behavior (compliance) and glycemic control and noninsulin-dependent diabetes mellitus. Diabetes Care 9: 614-622, 1986.
ABSTRACT We carried out a cross-sectional study to investigate factors associated with adherence to diet and medication in non-insulin-dependent diabetes mellitus (NIDDM) patients. A total of 200 patients not seeking treatment from clubs for diabetics from two hospitals in Leon, Mexico, accepted inclusion. Patients interviewed had a mean age of 58.8 (53.3-56.4, 95% C.I.) years. We evaluated adherence to diet and medication, knowledge on diabetes, social support, family’s structure and functioning (with a modified McMaster model), metabolic control, and complications. Stepwise multiple regression procedure showed that adherence to diet was associated with years since diagnosis @ = 0.003) and with social support fp = 0.007). Adherence to medication was associated with social support (p = 0.002), and the age of the spouse (p = 0.016).
INTRODUCTION dherence to treatment is referred to as the characteristics of the behavior that define the extent to which a patient follows a medical treatment .I For non-insulin-dependent diabetes mellitus (NIDDM), Harris et a12r3 found that
A
Instituto de Investigaciones Medicas. Universidad juato, Ledn, Guanajuato, Mexico. Address reprint requests to: Dr. Juan M. MaIacara, Investigaciones Medicas, Universidad de Guanajuato, 929, Le6n Guanajuato, Mexico. ~oumal of Diabetes and Its Complications 1995; 9:82-f% 0 Elsevier Science Inc., 1995 655 Avenue of the Americas, New York, NY 10010
de GuanaInstituto de 20 de Enero
Adherence to medication was lower in patients from families with rigid control than in the group with Laissez-faire type of control fp = 0.010) or the group with flexible control @ = 0.002). Social support was lower in the group with chaotic control than that in the group with flexible control (p < 0.001). Compliance to diet was associated with peripheral neuropathy and plasma creatinine, and adherence to medication with plasma glucose and peripheral neuropathy. We concluded that (1) adherence to treatment in NIDDM patients is associated with social support; (2) some aspects related to the family, such as the age of the spouse and the control of behavior, were also associated with compliance to treatment; and (3) it is important for the practicing physicians, and for institutional programs, to consider factors associated with adherence to treatment. (Journal of Diabetes and Its Complications 9;2:81-86, 1995.)
compliance to a prescribed diet and exercise was associated with the benefit perceived, and adherence to medication was correlated with the cost perceived. According to Brobrow et al.,4 adherence is associated with less aggressiveness, and open frank discussion about diabetes. Studies carried out for NIDDM5 show that supporting behavior correlated with blood glucose and diet adherence, but the frequency of nonsupporting behavior did not correlate with adherence. Glasgow et al5 investigated factors associated with social environment, and they found that family support was the strongest and most consistent predictor
SSDI
1056~8727/95/$9.50 1056-8727(94)00021-H
82
GARAY-SEVILLA
ET Al..
1 Diab Camp 1995; 9:81-8h
of adherence to treatment in patients with NIDDM. A study in women with gestational diabetes showed significant correlation between diet compliance and social support. Insulin compliance was related to social support but not with minor or major stressorsh In diabetic patients, nonadherence for diet ranged from 35% to 75%,‘,* for the technique of administration of insulin is about 80%,’ and 9390 for thtr combination of proper insulin, foot care, and diet or urine testing regimens.* Some patients justify their nonadherence to treatment on basis of economic factors, interpersonal problems with their spouses and families,9*10and other factors. The interaction of the family structure and function with adherence to treatment in NIDDM patients is insufficiently studied. Family functioning is a set of patterns of interactions among members of a family.” During the course of a chronic disease such as diabetes mellitus, adverse interactions may impose an excessive load on the capability for adaptation of the family. It may have an effect on the course of the disease. Under such circumstances, a family function may change to a rigid control, that may threaten its stability. ‘* Several investigators have proposed that the family system has a role on the initiation, selection of symptoms, clinical course, use of clinical facilities, and the compliance to medical treatment in diverse chronic diseases.12-” This study was done to investigate the adherence to diet and medication in NIDDM patients, and its associations with social support, metabolic control, complications, knowledge on diabetes, and family’s structures and functioning.
MATERIAL
AND METHODS
Reauitment of Patients. A cross-sectional study was carried out with patients not seeking treatment from clubs for diabetes from two hospitals. Invitation was done during their weekly meetings, after explaining the purpose of the study. Twenty visits to groups of people with diabetes were done, and an acceptance rate close to 20% was obtained. A total of 200 patients with NIDDM, 19-85 years old, were included in the study. All of them were residents in the urban zone of the city, who showed adequate physical and mental capacity to answer questions about their disease. The details of the questionnaire were explained to the volunteers. Patients answered it through direct questioning by an investigator. The investigators involved in the study did not have institutional ties with the hospital or treating physician. Questionnaire. The questionnaire had 66 items, and included the following: General D&n. Sex, date of birth (for calculation of age), schooling (in years), marital status in two groups:
married or in free union and nonunited (single, widowers, divorced, or separated), years since diagnosis of NIDDM, weight and height to calculate body-mass index (BMI) (weight/height:, kg/m2), and sitting systolic (SBP) and diastolic blood pressures (DBP). Social Support. Social support was evaluated on the basis of the patient’s perception of the backing they received by their relatives and their friends to comply with treatment for diabetes. The Diabetes Social Support Questionnaire, designed for gestational diabetes6 was modified by us for patittnts with NIDDM. The score ranged from 0 to 3). Life Style. Smoking habit, alcoholism (if alcoholic beverages were periodically consumed), and exercise (if done more than once per week) data were collected as yes or no. Structure of the Family. The family structure was classified as: Uniparental if only one parent was living at home, nuclear if both parents did so, and extended if other relatives such as married sons or daughters, grandparents or uncles were living at home. The number of sons and daughters was also collected.
Function of fhe Fuamily. The family functioning was evaluated with the modified McMaster model,” including six aspects: (1) Problem solving in the family was evaluated in seven categories: identification of problems, communication to the appropriate person, development of alternatives, decision taking, action, monitoring the action, and evaluation, with progressively increased scores for these stages. (2) Communication within the family was rated in four categories (clear and direct, clear and indirect, masked and direct, and masked and indirect). (3) The roles assumed b) each member of the family were explored on six aspects: provision of financial support, confidence, counseling, problem solution, spend time in the family, and provides love. For each item, five categories were considered: husband or wife, a son or daughter, parents of the patient, a brother or sister, or other. Higher scores were given if the roles were assumed by the husband or the wife. (4) Affective responsiveness registered for happy situations with five categories (very effusive, effusive, lukewarm, very lukewarm, and indifference); and adverse situations with five categories (very anguish, anguish, tranquil, very tranquil, and indifference) with higher score for full responses. (5) Affective involvement between the couple, a range of involvement with six scores of progressive empathic involvement. (6) Control of behavior in the family had four categories: rigid (if permissions for members of the family were seldom given), flexible (if permissions were frequently obtained), laissez faire (permissions almost always granted), and chaotic (if no permissions
1 Diab Comp
199.5; 9:81-86
were needed). Each aspect was examined choice questions.
ADHERENCE
by multiple
Knowledge on Diabetes. Knowledge was investigated with 13 questions related to the nature of the NIDDM, its associated factors, procedures to monitor metabolic control, the complications of the disease, and the care needed for control of the disease and its complications. Questions were designed as short statements that the patient answered on a Likert’s scale from 1 to 5: Total disagreement, disagreement, indifferent, agreement, and total agreement. The sum of answers was the score of knowledge. The maximum score was 58. Adherence to Treatment. Adherence to treatment was assessed in regards to prescribed diet and to medication. Adherence to diet was investigated with seven questions concerning uniformity of daily intake of food, acceptance and compliance to prescribed diet, and asking the patient’s interest in keeping an appropriate weight. Adherence to medication included three questions about continuity of intake of medication, self-decided changes of doses or its type. Answers ranged from 1 to 4, with increasing scores for better compliance. Validity of Questionnaire. Validity of the questionnaire was tested in a pilot study applied to 20 patients. Correlation matrices of responses to sets of questions were calculated for each aspect; only significant questions were included in the final questionnaire. For social support, four questions were tested, and three had significant results. For knowledge on diabetes, 13 out of 19 questions were significant. For adherence to treatment, 10 out of 11 questions were significant and therefore included in the final questionnaire. Questions related to family function were also tested with a correlation matrix, and only significant factors were included. After validation of the questionnaire, it was applied to the group of patients under study. The time for response was 30-45 min. Metabolic Control of Diabetes and Complications of Diabetes. Metabolic control was evaluated by a fasting blood glucose (enzymatic GOD-PAP method purchased from Lakeside) and a determination of HbA1, (Sigma, St. Louis, MO) (normal values, 5.5%~8.5%). Peripheral neuropathy was evaluated questioning six symptoms in both legs: paresthesia, hyperesthesia, dysesthesia, jabbing pains, burning pains, and amyotrophia. The intensity of symptoms were registered from 0 to 3, and the sum was stratified in four categories (0 to 3). Amaurosis (in at least one eye), cataract, and amputation were registered as present or absent. Plasma creatinine was measured by a calorimetric method. Leukocytes were counted in the sediment from morning urine sample. Increased count was reg-
TO TREATMENT
TABLE
AND
SOCIAL
SUPPORT
1. CHABACTEFUSTICS
Variable
IN NIDDM
OF THE PATIENTS ._____ (95% CL) n %
Mean
Sex Men
Women 58.8 3.5
Age (YeW Schooling (years)
83
68 132
34 66
52 148
26 74
(53.3-56.4) (3.0-4.0)
Marital status No union Married or free union Years since diagnosis BMI (men) BMI (woman) Systolic blood pressure (mm Hg) Diastolic blood pressure Life style Smoking habit Alcoholism Exercise Cl.,
confidence
interval;
2::: 29.0 132.7
(izi2) (28.3-29.8) (129.8-135.7)
82.5
(80.9-84.1) 49 5 45
BMl,
body-mass
25 2.5 22.5
index.
istered when more than 6 leukocytes field were found.
per high power
Analysis of data. We studied the possible determinants of adherence to diet and to medication, testing as candidate regressors age, years since diagnosis, smoking habit, alcoholism, knowledge on diabetes, and variables related to family structure and function. The multivariate interaction of these factors was tested with stepwise multiple regression analysis with forward inclusion of variables. The influence of categoric variables from family function: communication within the family and control of behavior were analyzed by analysis of variance (ANOVA), and post-hoc analysis for differences between pairs of groups was done with the least-significant difference test. The association of adherence to diet and to medication with variables related to metabolic control and with complications was examined with stepwise multiple regression. Significance was accepted with p < 0.05. RESULTS Table 1 shows the main characteristics of patients under study, in regard to biological characteristics, schooling and marital status. Table 2 shows the characteristics of family structure and function. For the total group, the scores of adherence to diet had a mean value of 17.7 (17.2-18.3, C.I., 95% confidence interval), a 63.3% of the maximum score. The mean score of adherence to medication was 11.0 (10.8-11.2, C.I.), a 91.6% of the maximum score. The scores of social support for the group was 2.80 (2.62-2.98, C.I.). Knowledge on diabetes was 55.3 (54.5-56.1,95% C.I.). Blood glucose levels had mean values of 184.5 (173.3-
84
GARAY-SEVILLA
TABLE
2. FAMILY
1 Dfnb Cony
El’ AL.
STRUCTURE
Variable
Structure Number of children Age of spouse(years) Type of family Nuclear Uniparental Extended Family Function Problem solving in the family Satisfactory Not satisfactory Communication within the family Clear and direct Clear and indirect Masked and direct Masked and indirect Roles in the family Husband or wife Sons and daughters Parents of the patient Brothers Other Affective responsivenes Effusive Others With anguish Others Affective involvement with the spouse Positive Negative Control on behavior in the family Chaotic Laissezfaire Flexible Rigid
Mean
AND
TABLE
FUNCTION
(95% C.I.)
n
3. RESULTS FROM THE STEPWISE REGRESSION ANALYSIS
%
Family
Dependent
7.1 (6.6-7.6) 53.6 (41.6-55.5)
1995; Y:81-86
Variable
P
Partial Correlation
p
Adherence to Diet Significant
101 50.5 25 12.5 74 37
153 76.5 46 23.0
137 40 11 11
68.5 20.0 5.5 5.5
69 34.5 95 47.5 21 10.5 14 7.0 1 0.5 143 57 178 21
71.5 28.5 89.0 11.0
97 45 103 55
36 44 58 34
18 22 39 17
195.6C.I.),HbA1,was11.9(11.5-12.4C.I.).Bloodcreatinine had mean value of 0.94 (0.89-0.99 C.I.). In regards to complications, the scores on neuropathy were as follows: zero was found in 11% of the patients, one in 59.5%, 2 in 29%, and 3 in 5.5%. Cataract was found in 4.5%, amaurosis in 5.01, and amputations in 1.5% of the patients. Table 3 shows the results of the stepwise regression procedure. Higher adherence to diet was associated with more years since diagnosis and with greater social support. Higher adherence to medication was associated with greater social support and older age of the spouse. Adherence to diet and to medication were not different in the groups with diverse types of communication within the family (F = 0.08, p = 0.97, and F = 0.60,
Regressors
0.204 0.186
0.208 0.190
0.003 0.007
0.012 0.036 -0.095 0.065 0.046 0.039 -0.045 - 0.014 - 0.038 -0.083 0.059 0.064
0.012 0.037 -0.099 0.067 0.048 0.040 -0.046 -0.015 -0.039 -0.086 0.062 0.062
0.867 0.604 0.166 0.347 0.503 0.574 0.518 0.837 0.582 0.226 0.388 0.386
0.217 0.168
0.219 0.171
0.002 0.016
-0.132 Age of the patient 0.018 Schooling 0.025 Years since diagnosis Number of children -0.009 Problem solution 0.053 -0.039 Roles in the family Positive affective response 0.008 Negative affective response 0.081 Affective involvement -0.022 -0.040 Alcoholism -0.028 Smoking habit Knowledge of diabetes 0.054 --
-0.107 0.018 0.025 -0.009 0.054 - 0.039 0.008 0.084 -0.023 -0.042 - 0.029 0.055
0.134 0.769 0.726 0.8% 0.449 0.573 0.911 0.240 0.747 0.557 0.686 0.439
Years since diagnosis Social support Nonsignificant
Variables
Age of the patient Schooling Alcoholism Smoking habit Number of children Age of the spouse Problem solution Roles in the family Positive affective response Negative affective response Affective involvement Knowledge of diabetes Adherence to Medication Significant
Regressors
Social support Age of the spouse Nonsignificant
Variables
p = 0.61, respectively). Adherence to diet was no different in diverse groups of family control, (F = 0.67, p = 0.57). Scores on adherence to medication were different among the groups of family control (F = 3.79, p = 0.01). The post-hoc analysis showed that patient with rigid control in their families had lower scores of adherence to medication (10.3 f 0.3) as compared with the groups with Laissez-faire type of control (11.2 f 0.2, p = 0.010) and with flexible control (11.3 f 0.2, p = 0.002) (Figure 1). Scores on social support were different among the groups of control within the family (F = 4.32, p = 0.006). The post-hoc analysis showed that the group with chaotic control had lower scores as compared with that with flexible control (p < 0.001) (Figure 1). In the analysis of association of adherence to diet with variables related to metabolic control and compli-
cations, greater adherence to diet was associated with
ADHERENCE
J Diab Comp 1995; 9:81-86
Li 0
13-j
p < .OOl :
T
CHAOTIC
LAISSEZ-
CONTROL
RIGID
FLEXIBLE
OF BEHAVIOR
1. Scoresof adherence to medication(upperpanel)and socialsupport(lowerpanel)in the groupsof control of behavior within thefamily (chaotic,laissez-faire, rigid andflexible). Differenceamongthe groupswassignificant:F = 3.79, p = 0.01 for adherenceto medicationand F = 4.32, p = 0.006, for social support.Horizontallinesshowsignificantdifferences between pairs of groups,using the least-significant differencetest. FIGURE
lower scores of peripheral neuropathy (p = - 0.190, p = 0.006) and 1ower blood creatinine levels (p = - 0.153, p = 0.028). High scores on adherence to medication were associated with lower blood glucose levels (l3 = -0.178, p = 0.011, and with lower scores of peripheral neuropathy (I3 = -0.153, p = 0.028). DISCUSSION
Adherence to diet and to medication have a pivotal role in the management of patients with NIDDM. Therefore efforts should be made to identify psychological and social factors that influence patients’ adherence to treatment. The group of patients in this study may be considered as a selected one, because of the low acceptance rates for inclusion. It is possible that an acceptant is more concerned about the disease than a nonacceptant, possibly having a higher compliance
TO TREATMENT
AND SOCIAL SUPPORT IN NIDDM
85
to treatment than the average patient. Therefore, results may not be fully extrapolated for the whole population of diabetic persons. In this study, social support appeared as the main determinant of compliance to medication, this finding is in agreement with the observations of Wilson et al.rB They reported that social support was the most consistent and strongest predictor of self-care behavior across the different aspect of management of the disease, such as medication taking and glucose testing, in patients with NIDDM. Ruggiero et a1.6 found that high adherence to insulin administration, was associated with higher scores for social support in women with gestational diabetes. In our study, social support was also associated with higher scores for adherence to diet. Adherence to diet may require stronger support from the patients/relatives, considering that meals are usually shared by all members in a family. This factor may be more significant in traditional societies. Therefore, it is important to examine the influence of the structure and the function of the family on this problem. Our results showed that patient with rigid control in their families had lower scores of adherence to medication. A rigid control of behavior within a family may imply decreased adaptation to change, in particular to deleterious changes such as a chronic disease in one of its members. This factor may favor the denial of the disease. Rigid control may also enhance the development of conflict with the authority, increasing the denial of the disease. The result of such denial is a diminished compliance with treatment. Furthermore, the onset of a permanent disease with a high genetic component, such as NIDDM, in one of the members of the family have a strong impact. It may modify the capability for adaptation of a family that changes the functioning to more rigid forms of control in response to the threats of disintegration of the family.12 Further evidence for the contention that flexible control gives a better environment for compliance to treatment is the fact that this group also had higher scores of social support. In this study, we found that years since diagnosis is the main determinant of compliance to diet, this may indicate that after years of suffering the disease, attitudes of denial are reduced, and patients progressively accept treatment. On the other hand, older ages of the spouse were associated with higher scores on adherence to medication. This suggests that mature partners are more likely to give support to follow medical prescriptions. The influence of these two factors indicate that time may improve the factors associated with acceptance of disease and treatment, and the conditions of the family associated with them. The scores of compliance to treatment were associated with variables related to the control of diabetes
86
GARAY-SEVILLA
ET AL.
and the appearance of complications: Plasma glucose with adherence to medication, peripheral neuropathy with adherence to medication and to diet, and plasma creatinine with adherence to diet. Those findings are consistent with the view that the scales for compliance to treatment were effective to evaluate the care for the disease. We concluded that adherence to medication and diet in NIDDM patients are strongly associated with social support. Some aspects of the family such as the age of the spouse and the control of behavior within the family are also associated with adherence to medication. Years since diagnosis was associated to adherence to diet. Social support and its relationships with the family structure and function may be different in diverse cultures. Therefore, further work about these subjects should be done in different societies. The influence of cultural values on rigid forms of control within a family, denial of disease, and unacceptance of modern medicine should be investigated in future work. It is important for the practicing physicians, and for institutional programs about NIDDM, to consider factors associated with compliance to treatment. Better strategies to improve the social support and family function, are urgently needed in programs oriented to the control of NIDDM, in order to improve patients’ adherence to treatment. REFERENCES Kurtz SM: Adherence to diabetes regimens: Empirical status and clinical applications. Diabetes Educ 1650-56, 1990.
Harris R, Linn MW, Pollack LW, Tewksbury D: The relationship between the health belief model and compliance asa basisfor intervention in diabetesmelhtus. Pediatr Adolesc Endocrinol10:123-132,1982. Harris R, Linn MW, Skyler JS, Sandifer R: Development of diabetes health belief scale. DiabetesEduc 13: 292-297, 1987. Bobrow ES, AvRuskin TW, SilIer J: Mother-daughter interaction and adherenceto diabetesregimen. Diabetes Care8:146-151, 1985.
5. Glasgow RE, Toobert DJ: Socialenvironment and regimen adherenceamong type II diabetic patients. Diabetes Care 11:377-386,1988. 6. Ruggiero L, Spirit0 A, Bond A, Coustan D, McCarvey S: Impact of social support and stresson compliance in woman with gestational diabetes. Diabetes Cure 13: 441-443, 1990. 7. Williams TF, Anderson E, Watkins JD, Coyle V: Dietary errors made at home by patients with diabetes. I Am Diet Assoc 51:19-25, 1967. 8. Cerkoney KAB, Hart LK: The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabefes Care 3:594-598, 1980. 9. Ary DV, Toobert D, Wilson W, Glasgow RE: Patient perspectives on factors contributing to nonadherence to diabetesregimens. Diabetes Care 9:168-172, 1986. 10. Kirkley BG: Behavioral and socialantecedentsof noncompliance with nutritional management of diabetes [Dissertation]. St. Louis, Washington University, 1982. 11. RamseyCN Jr, Lewis JM: Family structure and functioning, in Rake1RE (eds.). Family Practice, 3rd edition. Iowa City, IA, WB Saunders, 1984, pp. 21-40. 12. Authier J, Starr G, Authier K: Impact of illnesson the family, in Rake1RE (eds). Family Practice, 3rd edition. Iowa City, IA, WB Saunders, 1984,pp. 102-117. 13. Anderson BJ, Auslander WF: Researchon diabetes managementand the family: A critique. Diabetes Cure 3:696-702, 1980. 14. Newbrough JR, Simpkins CC, Maurer H: A family development approachto studying factors in the management and control of childhood diabetes. DiabetesCare 88392, 1985. 15. Hansen CL, Henggeler SW: Metabolic control in adolescentswith diabetes:an examination of systemicvariables. Fum Sys Med 2:5-16, 1984. 16. Wishner WJ,O’Brien MD: Diabetesand the family. Med Clin North Am 62:8494X56, 1978. 17. Epstein NB, Bishop DS, Daldwin LM: MCMaster Mode1 of family functioning view of the normal family. 1. Marr Fum Cows 4:19-31, 1978. 18. Wilson W, Ary DV, Biglan A, Glasgow RE, Toobert DJ, Campbell DR: Psychosocialpredictor of self-care behavior (compliance) and glycemic control and noninsulin-dependent diabetes mellitus. Diabetes Care 9: 614-622, 1986.