Barriers to diabetes management: Patient and provider factors

diabetes research and clinical practice 93 (2011) 1–9

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Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres

Review

Barriers to diabetes management: Patient and provider factors Soohyun Nam a,*, Catherine Chesla b, Nancy A. Stotts c, Lisa Kroon d, Susan L. Janson e a

Johns Hopkins University, School of Nursing, Department of Health Systems and Outcomes, 525 North Wolfe Street, Baltimore, MD 21205-2110, United States b University of California, San Francisco, School of Nursing, Department of Family Health Care Nursing, San Francisco, CA, United States c University of California, San Francisco, School of Nursing, Department of Physiological Nursing, San Francisco, CA, United States d University of California, San Francisco, School of Pharmacy, Department of Clinical Pharmacy, San Francisco, CA, United States e University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, United States

article info

abstract

Article history:

Despite significant advances in diagnosis and treatment, the persistence of inadequate meta-

Received 11 June 2010

bolic control continues. Poor glycemic control may be reflected by both the failure of diabetes

Received in revised form

self-management by patients as well as inadequate intervention strategies by clinicians. The

8 January 2011

purpose of this systematic review is to summarize existing knowledge regarding various

Accepted 3 February 2011

barriers of diabetes management from the perspectives of both patients and clinicians. A search of PubMed, CINAHL, ERIC, and PsycINFO identified 1454 articles in English published

Published on line 5 March 2011

between 1990 and 2009, addressing type 2 diabetes, patient’s barriers, clinician’s barriers, and Keywords:

self-management. Patients’ adherence, attitude, beliefs, and knowledge about diabetes may

Type 2 diabetes

affect diabetes self-management. Culture and language capabilities influence the patient’s

Barriers to diabetes management

health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient’s financial resources, co-morbidities, and social support.

Self-management

Clinician’s attitude, beliefs and knowledge about diabetes also influence diabetes management. Clinicians may further influence the patient’s perception through effective communication skills and by having a well-integrated health care system. Identifying barriers to diabetes management is necessary to improve the quality of diabetes care, including the improvement of metabolic control, and diabetes self-management. Further research that considers these barriers is necessary for developing interventions for individuals with type 2 diabetes. # 2011 Elsevier Ireland Ltd. All rights reserved.

Contents 1. 2.

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Methods . . . . . . . . . . . . . . . . . . . . . Results of review . . . . . . . . . . . . . . 2.1. Patient factors . . . . . . . . . . . 2.2. Health care provider factors Discussion and conclusions . . . . . Acknowledgements . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . .

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2 2 2 4 5 7 7

* Corresponding author. Tel.: +1 410 203 1111; fax: +1 410 203 2685. E-mail addresses: [email protected] (S. Nam), [email protected] (C. Chesla), [email protected] (N.A. Stotts), [email protected] (L. Kroon), [email protected] (S.L. Janson). 0168-8227/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2011.02.002

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diabetes research and clinical practice 93 (2011) 1–9

The prevalence of type 2 diabetes is increasing worldwide. Type 2 diabetes is a chronic disease, associated with serious complications and co-morbidities [1]. Despite recent improvements in glucose control in adults with diabetes [2], <15% of adults with diabetes simultaneously met the goal for three important components of care (i.e., glucose, blood pressure and low-density lipoproteins (LDL) cholesterol) as recently as 2007 [3]. Unsatisfactory medical outcomes reflect contributions not only from the lack of self-management on the part of the patient, but also on the part of the health care provider in failing to initiate or intensify therapy appropriately [4]. For this review, diabetes self-management refers to the various tasks which persons with type 2 diabetes need to perform and engage in on a regular basis, including self-monitoring of blood–glucose, taking medications properly, physical activity, healthy eating, foot examinations at regular intervals, and other self-management activities. Both identifying and understanding barriers to ensure adherence to diabetes standards of care in the patient’s selfmanagement and the clinician interventions are the first steps in improving diabetes care and success in diabetes management.

1.

Methods

We searched the PubMed, CINAHL, ERIC, and PsycINFO for the years January 1, 1990–June 1, 2009 using the key words: type 2 diabetes; diabetes mellitus; barriers; diabetes self-management; treatment guidelines; adherence; and diabetes care. Reference lists of relevant studies were also hand searched for additional sources. The goal of this review was not to perform a meta-analysis. Thus, a search for systematic review included cross-sectional studies; randomized clinical trials (RCTs); observational studies and qualitative studies to address various perspectives and issues on both patient and health care providers’ barriers for diabetes management. Review articles and epidemiological studies were largely excluded; unless they were directly relevant to the themes that were part of this review. Of those 1454 citations; 1353 were excluded based on title and abstract since the subject or outcome of interest were not relevant to type 2 diabetes or patient and health care providers’ barriers to diabetes management. After a detailed evaluation of 101 full text articles; twenty-one studies that did not specifically focus on barriers to diabetes control or self-management were excluded. Finally, a total of 80 studies were included in this review. Appendix 1 (Online supplementary file) provides an overview of the studies chosen for this review and includes information about the study findings.

2.

Results of review

2.1.

Patient factors

Adherence: Better adherence to a self-care regimen, a characteristic of active patient self-management, can reduce mortality and disability, improve quality of life, and reduce health care costs [5–7]. Glycemic control is affected by poor

patient adherence to treatment regimens, for example, failure to keep appointments or take medications as recommended [8]. Several studies compared cohorts with different medication adherence regimens. Once-daily regimens had higher rates of adherence than twice-daily regimens (61 vs. 52%) [9]. Monotherapy regimens demonstrated higher adherence rates than those of polytherapy regimens (49 vs. 36%) [10]. Among patients with diabetes, adherence rates were lower for insulin use than for oral hypoglycemic agents (73–86%) [11]. Poor adherence among persons with type 2 diabetes has been attributed to misperceptions regarding the potential seriousness of the disease as well as to differences in patients’ understandings of the disease as well as those of health care providers [12]. Attitudes and beliefs: People with diabetes hold a wide range of attitudes and beliefs about diabetes and its treatment which in turn affects the way they perceive the need for and importance of self-management education. Anderson et al. surveyed 1202 persons with type 2 diabetes, using a revised version of the Diabetes Attitude Scale (DAS) [13]. Findings revealed an association between persons with positive attitudes and adherence outcomes. Similar findings were seen in the study conducted by Farmer et al. [14]. Beliefs about the benefits of medications were positively and strongly associated with the intention to take medications regularly by individuals with type 2 diabetes. Other studies confirm that individuals with positive attitudes toward management of their diabetes are more likely to change their behavior in order to control their blood glucose levels than those with negative attitudes [15–17]. The natural progression of type 2 diabetes suggests that 60% of individuals with the disease will eventually require insulin treatment to optimally control blood glucose levels [18]. Despite the demonstrated efficacy of insulin therapy in achieving and maintaining glycemic control in individuals with type 2 diabetes, many individuals that may benefit from insulin therapy do not receive it, or do not receive it in a timely manner [19]. In recent studies of insulin-naı¨ve patients with type 2 diabetes, approximately 33% reported an unwillingness to take insulin if it were prescribed [20,21]. The reluctance to initiate insulin therapy in a timely manner is based on a variety of factors, primarily patients’ attitudes and beliefs regarding diabetes and treatment [22,23]. Patients perceive insulin therapy as evidence of personal failure and as welldeserved punishment for failing to manage their disease [24]. In addition, patients have a fear of daily insulin injections. Other negative attitudes include the belief that taking insulin means life is more restricted and that taking insulin will not be effective but rather will worsen the disease and in turn produce more severe complications [24]. Common misconceptions about the need for transitioning to insulin therapy may affect a patient’s ability to agree and participate in selfmanagement of type 2 diabetes. Knowledge: The relationship between knowledge and health outcomes is inconsistent. Knowledge does not necessarily lead to risk-reducing behavior: people may engage in unhealthy behaviors despite knowledge of their risks [25]. Heisler et al. examined 843 adults with type 2 diabetes to address whether knowing one’s most recent HbA1c (glycated hemoglobin) test result is associated with a more accurate

diabetes research and clinical practice 93 (2011) 1–9

assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control [26]. Respondents who knew their HbA1c values reported better understanding of diabetes self-management and assessment of their glycemic control as compared to respondents who did not know their HbA1c values. However, knowledge of one’s HbA1c level alone was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve one’s diabetes self-management. Findings from a study of 670 adults with diabetes suggest that knowledgeable patients are more likely to perform selfmanagement activities. However, the patients did not reach metabolic outcome goals, nor did they receive the recommended ambulatory care for individuals with diabetes [27]. Similarly, in an observational study of 284 insulin-treated veterans with stable type 2 diabetes, subjects with higher knowledge scores also perceived fewer barriers to blood glucose monitoring (r = 0.211; p = 0.006). However, performance on the diabetes knowledge test was not related to perceived adherence to self-care, diet, exercise or medication. In the study, multivariate analysis showed that age, years of schooling, duration of treatment, cognitive function, sex and level of depression were independent determinants of the knowledge score [28]. In another study, investigators found that limited knowledge about diabetes and its causes and symptoms affected the prevention of diabetes-related complications [29]. In contrast, Anderson et al. demonstrated that the less individuals knew about diabetes, the less likely they were to develop strong attitudes toward the management of their condition and its self-care, positive or negative [13]. Thus, knowledge itself may not be sufficient for motivating an individual to manage their diabetes. However, knowledge is intermittently but not consistently linked to disease outcomes. Even when individuals adhere to a prescribed diabetes regimen, many report that they do not know why they are performing the self-management strategies, nor do they understand the benefits of performing such actions [30]. Thus, misunderstandings about diabetes and its treatment were both common and numerous, despite regular check-ups and adequate access to care. Culture/Ethnicity/Language: Culture influences an individual’s beliefs, attitudes, knowledge, and behaviors, and in turn, can affect diabetes self-management [30,31]. Fitzgerald et al. examined patients’ attitudes (n = 672) toward diabetes by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for Caucasians and African Americans with type 2 diabetes [32]. Caucasians not using insulin reported the most positive attitude and the least negative attitude toward diabetes care. The reverse was true for Caucasians using insulin: this group reported the least positive attitudes and the most negative attitudes toward diabetes care. In contrast, African Americans had fewer differences in the scores for the attitude scales between insulin users and non-insulin users. The study also showed that in comparison to Caucasians, African Americans reported receiving more support from family and friends. Furthermore, the support they received was interpreted more positively [32]. Lipton and colleagues reported that the misconception of insulin being potentially harmful is a common belief among

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traditional Mexican Americans and probably inhibits participation in insulin treatment [33]. They also reported that in many cases, the emotional barriers and cultural beliefs of Latinos are more important than financial barriers, even among low-income, urban residents. The investigators noted that because family needs are considered most important, adhering to a treatment regimen is viewed as self-indulgent to Latino clients. Cultural factors to consider in diabetes management include food and dietary preference, lifestyles, traditional and religious beliefs, and beliefs about general health. In Chinese culture, the freedom to enjoy food plays a critical role in one’s quality of life [34]. Lai et al. conducted in-depth interviews of 22 Taiwanese individuals with type 2 diabetes to examine their perceptions about their conditions and selfmanagement strategies [35]. Self-management strategies included dietary restrictions and physical activities. Many participants believed that sweating related to a spa bath would decrease drug absorption and avoid the renal toxicity of hypoglycemic agents. To date, no research has been done comparing cultural beliefs in diabetes self-management across different racial ethnic groups. Caban and colleagues conducted a systematic review of research on culturally relevant issues for Hispanics with diabetes [36]. In the review, they demonstrated that the perceived cause of diabetes, perspectives about God, living with diabetes, the use of folk healers, and the use of alternative treatment and fatalism differed by subgroups of Hispanics within United States and level of acculturation. The authors concluded that while clinician and educators would benefit from understanding individual perspectives about diabetes, understanding these perspectives within a larger socio-environmental context is also important because a statement regarding Hispanics’ cultural belief may not be applicable across all Hispanic subgroups. A review of spirituality and diabetes self-management in African Americans conducted by Polzer et al. showed that spirituality is deeply embedded in African American cultural heritage and is intertwined in all aspects of life including beliefs about health and illness [37]. The study suggested that spirituality may enhance self-management of diabetes, as shown in studies of other illnesses such as cancer and HIV, by serving as a source of support when they turn to God [37]. The patient–provider relationship is built through communication and the effective use of language. Lack of English proficiency is a primary barrier for many ethnic minorities in the United States to fully navigate mainstream health services. In particular, Hispanic minority populations have poor access to treatment and services because of language and literacy barriers [38]. Lasater et al. conducted a retrospective cohort study where 183 Hispanic patients with type 2 diabetes were Spanishspeaking (SS) only and control patients were English-speaking (ES) or bilingual [39]. In the study, SS patients were less likely to understand their prescriptions; 22% of SS patients reported no comprehension vs. 3% of ES patients ( p = .001). Although there was not a statistically significant difference between the two groups, a trend was observed that SS patients were less likely than ES patients to be taking insulin (30% vs. 42%, respectively; p = .07) [39]. These findings suggest that language discordance

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diabetes research and clinical practice 93 (2011) 1–9

between clinicians and patients may impact the process of patient education and thus adversely affects glycemic control in Hispanic patients with type 2 diabetes. Financial resources: In addition to culture, cost of treatment may be a significant barrier to diabetes treatment, particularly for patients with a low socioeconomic status and limited to no health insurance coverage. In a diabetes screening program in New Mexico, low annual income and lack of health insurance were identified as primary reasons why patients (n = 118) with newly diagnosed type 2 diabetes did not seek and obtain medical care [40]. Sixty percent of uninsured patients failed to obtain care following diagnosis compared with 6% of those who were insured. In addition, in a 7 year study of Mexican Americans with diabetes (n = 908), inadequate health insurance was significantly associated with inconsistent use of medications, which related to increased likelihood of reporting kidney problems ( p = 0.008), all-cause mortality ( p = 0.003) and diabetes associated death ( p = 0.002) [41]. In one qualitative study, patients (n = 54) reported that they would cut pills in half to reduce medication costs if they could not afford to take medications as prescribed [42]. Other patients reported missing medical appointments due to lack of transportation and lack of funds required to take the bus or a cab. Co-morbidities: People with multiple chronic conditions frequently experience barriers to self-management due to the simultaneous demands of competing co-morbidities, such as back pain, arthritis, asthma, congestive heart failure, chronic obstructive pulmonary disease, fatigue, and depression [42,43]. A study of seniors with multiple morbidities showed the potential barriers to self management that were significantly associated with low levels of physical functioning were high level of morbidity, compound effects of conditions and persistent depressive symptom [44]. Up to 33% of people with diabetes suffer an episode of major depression during their lifetime [45]. Depression rates are twice as high among individuals with diabetes as compared to those without a chronic disease [46,47]. Furthermore, many individuals with type 2 diabetes do not seek professional help to address their depression [42]. Depression interferes with diabetes self-management and glycemic control because it has the potential to alter the perception of disease self-management and is associated with increased morbidity, mortality, functional limitation, and health care costs [48,49]. Depression also has an inverse relationship with social support, with a bi-directional causal model [50,51]. Social support: Numerous studies showed that lack of social support affects perceived barriers to self-care and future mortality and morbidity [43,52]. However, the role of social support in diabetes care has been shown with mixed results [53,54]. Wing and associates conducted a study to test a family oriented approach for obese patients with type 2 diabetes [53]. Spouse participation in weight loss education groups had a negative impact for obese men with type 2 diabetes while obese women with type 2 diabetes attained more weight loss with their spousal support [53]. In a cross-sectional study by Gleeson-Kreig et al., social support was not strongly related to diabetes self-management for Hispanic participants with fairly large networks, composed primarily of family members [54].

Therefore, gender and racial differences in social support should be understood along with other contextual factors (e.g. socidemographic factors) and development of alternative support besides family network should be also considered for those without available family members.

2.2.

Health care provider factors

Most of the published literature related to diabetes selfmanagement focuses exclusively on patients, rather than clinicians or patient–clinician interactions. Patients and clinicians differ substantially in their perceptions, knowledge, and attitudes, which may lead to confusion and conflict, and in turn, to poor outcomes [55]. Better understanding of clinician factors is needed to improve diabetes self-management education and quality of diabetes care. The following topics on clinician’s barriers were evaluated: belief, attitude, knowledge, communication, and health system. Beliefs, attitudes, and knowledge: Physicians’ attitudes toward diabetes management may be more important than their actual knowledge of the disease. Puder and Keller mentioned in their reviews that clinicians’ beliefs, attitudes, and knowledge influence patients’ adherence to the prescribed regimen. Many clinicians still consider type 2 diabetes to be a non-serious disease [56]. Dietrich found that physician’s attitude at the time of diagnosis was critical in patient’s attitudes about the seriousness of diabetes and subsequent self-management behavior [57]. Feelings at the time of diagnosis ranged from being scared, shocked, and panicky to being mad and resigned. Dietrich found that if the physician reacted by downplaying the seriousness of the disease, it was perceived as less serious by the patient. Similarly, Hunt and colleagues found that patient attitudes toward insulin therapy were influenced by clinicians’ attitudes, as well as personal experiences and observations [22]. Larme and associate studied the attitudes of primary care providers toward diabetes [58]. They found most providers considered diabetes harder to treat than hypertension ( p = .03) and angina ( p = .03). A majority also rated hyperlipidemia and arthritis as easier to treat than diabetes, but the ratings were not statistically significant [58]. Larme and associates also conducted qualitative analysis to gain an in-depth understanding of provider attitudes. The qualitative analysis revealed that the clinicians actually doubted the efficacy of diabetes treatment and their own abilities to carry it out. This finding suggests that clinician attitude toward treatment efficacy can counteract the diabetes management, during the patient encounter because both clinicians and patients share frustrations toward diabetes. The patient may perceive the inability of either party to achieve a sense of control over the disease and thus the patients’ perception may affect their empowerment in diabetes self-management [58]. The clinician’s lack of knowledge about recent evidencebased guidelines may affect the diabetes care outcome. In particular, physicians are uncertain about when to start insulin and which and how much insulin they should use [59]. The clinician’s lack of knowledge about patients’ psychological well-being has also been reported [60]. In a crosssectional study of 3827 providers and 5104 adults with type 1

diabetes research and clinical practice 93 (2011) 1–9

and 2 diabetes in 13 countries, only 10% of patients reported receiving psychological treatment. Despite awareness that up to 41% of patients with diabetes experience psychological symptoms that affected their ability to self-manage their diabetes, many clinicians reported a lack of confidence in their ability to identify and evaluate psychological problems and to provide support for patients who suffer from these problems [60]. Implications from these studies are that training should be provided to health care providers in order to increase their knowledge of diabetes and influence their beliefs and attitudes toward collaborative self-care diabetes management [58,59]. Additional skill training in recognizing and managing psychological distress is also warranted. Patient–provider interaction and communication: Patients’ disease perceptions are influenced by the types of services they receive and the types of health care professionals they encounter as part of their diabetes care [12]. Good patient– provider communication predicts better diabetes self-care, better diabetes outcomes, or both [61]. Unfortunately, many patients report significant barriers in collaborative diabetes management, which in turn affects adherence [62]. Most clinicians recognize that they lack effective communication tools and skills in counseling and shared decision-making [63] and perceive this lack of skill to be a barrier for effective diabetes treatment [22]. In a study involving 367 patients with types 1 and 2 diabetes in a primary care setting, poor patient– provider communication was associated with poor treatment adherence [64]. Several randomized controlled trials (RCTs) were conducted to test whether clinician-focused interventions improved clinician–patient interaction and communication and patients’ diabetes outcomes [65–67]. Unfortunately, Kinmonth et al. found that clinician training produced some improvement in communication and patient satisfaction but did not significantly change diabetes outcome such as knowledge, HbA1c, BMI (body mass index), and other cardiovascular risk factors in the patients [65]. In contrast, in the other RCTs that tested patient-focused interventions, improvements in patients’ psychosocial factors (i.e., diabetes knowledge, attitude and self-efficacy) and biomedical factors (i.e., HbA1c, BMI and cardiovascular risk factors) were seen [68–70]. It may be difficult for clinicians to change their communication style to one that is more effective, even when supported by special training programs. Furthermore, it may not be feasible for clinicians providing diabetes care in primary care settings to implement in their daily work the most comprehensive type of intervention that addresses patient psychosocial issues and encourages participation in diabetes selfmanagement in addition to medication and metabolic management. Health care system: Over 75% of individuals diagnosed with type 2 diabetes receive diabetes care exclusively from primary care providers [71]. Yet, only about one-third of patients with type 2 diabetes correctly follow the health care provider’s directions for diabetes care [71]. In the current health care system, overstretched primary care providers need to complete many preventive activities, deal with chief complaints, write prescriptions and referrals, and handle other issues within a 10- to 15-min office visit. Thus, it is difficult for

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primary care providers to devote extensive time to the behavioral, psychosocial, and emotional issues of persons with type 2 diabetes. Research suggests that longer appointment times for patients with chronic diseases, provision of automated reminder systems, and tools such as flow sheets or checklists can improve diabetes care [58,72]. Ziemer and colleagues conducted a 3-year RCT to determine whether receiving computerized reminders that provide patient-specific recommendations at each visit and/or performance improvement feedback every 2 weeks will lead to providers’ intensifying diabetes therapy appropriately and improve diabetes outcomes in a primary care setting as compared to a control group [73]. After 3 years, providers who received computerized reminders alone showed no statistical difference in tendency to intensify therapy as compared to a control group of providers. However, providers who received computerized reminders plus performance improvement feedback and providers who only received performance improvement feedback demonstrated statistically significant improvements in their efforts to intensify diabetes therapy compared to the control group providers, indicating that feedback on performance improved provider behavior and lowered patient’s HbA1c levels. Another RCT assessed the effect of a multifaceted intervention directed at general practitioners (GP) on six year mortality, morbidity, and risk factors of patients with newly diagnosed type 2 diabetes [74]. The multifaceted intervention provided to 484 GPs included regular followup and individualized goals for patients supported by prompting doctors, clinical guidelines, feedback, and continuing medical education. Intervention GPs arranged more followup consultations and became more focused on lowering risk factors through setting goals. The results indicate that in a primary care setting, individualized goals combined with educational and surveillance support for GPs may reduce risk factors associated with diabetes-related complications in patients with type 2 diabetes.

3.

Discussion and conclusions

Effective type 2 diabetes management is widely acknowledged as challenging for both patients and their health care providers. Several patient factors may contribute to type 2 diabetes management: adherence, beliefs, attitudes, knowledge, ethnicity/culture, language ability, financial resources, co-morbidities, and social support. Seven studies found that adherence to self-management are influenced by an individual’s financial resources, beliefs and attitudes about the disease, and effectiveness of the treatment regimen. This in turn positively affected glycemic control [12–17,42]. Knowledge alone, however, does not necessarily lead to good adherence of self-care if other barriers still exist. Poor adherence, as a well-recognized problem can be improved by delivering effective patient–clinician communication. Clinicians should understand the patient’s psychosocial factors as well as other financial barriers by assessing the reason for this lack of adherence to effectively deliver the self-

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diabetes research and clinical practice 93 (2011) 1–9

care message to patients. Furthermore, the recognition of collaborative relationships in the management of chronic illnesses such as diabetes is important. For example, providing a rational for the recommended treatment instead of telling patients what to do can facilitate the patient’s involvement as a primary decision maker for the treatment which in turn, can lead to success in adherence by eliminating patient’s misunderstanding and negative attitudes toward diabetes treatment. Several other strategies to improve adherence are: simplifying treatment regimen (e.g. reducing number of daily doses of medication); the use of simple screening question on adherence at regular clinic visit; tele-monitoring; or regular telephone feedback by a nurse. Greater understanding of health issues related to culture is critical because cultural beliefs and practices may facilitate or deter diabetes management. The relationship between culture and diabetes self-management is complex and varied among not only different ethnic groups but also different gender, age and treatment group (i.e. insulin vs. oral agent). The reviewed studies suggest that bilingual and bicultural clinicians that match a patient’s native language will strengthen the culturally sensitive diabetes care in overcoming cultural and language barriers. In addition, spirituality-focused disease management is beneficial in providing diabetes care to African Americans. In Hispanic and Asian groups, the family role and social support should be fully explored and incorporated into diabetes management. Using bilingual community health workers or peer group support has the potential to deliver effective culturally tailored diabetes interventions for the Hispanic and Asian groups. While differences in culture can explain some of the barriers in diabetes care, more research is needed to better understand the role of the culture in health issues and its mechanism within the larger socio-structural contexts. Co-morbidities are barriers to self-management because of competing treatment regimens. Depression, in particular, is prevalent in individuals with diabetes and decreases one’s perceived ability to self-manage illness. The possibility of a bidirectional relationship between diabetes and depression has been addressed by indicating weight gain and hyperglycemia as side effects of antidepressant use as well as by relationships between social support and depression [50,51,75]. Therefore more attention to patients with both diabetes and depression is needed to assess treatment effects and enhance a support system. Diabetes is a complex disease and the barriers to its management are multifactorial. Better understanding of the mechanism about how the barriers are related to each other and how they work in the context of mediating and moderating effect is warranted. Positive social support, for example, may serve as a mediating/modifying factor to patients’ perceived barriers of self-care, health promotion, and risk reduction. More importantly, predisposing and modifiable barriers should be understood within an overarching framework, rather than classified separately. To overcome predisposing barriers such as race and ethnicity, a tailored approach needs to be used, incorporating individual’s cultural norms and socioeconomic status such as education/health literacy level and insurance status rather than in an overly standardized way. While the problem of health disparity gaps is well documented, intervention programs for ethnic minorities who are most vulnerable to

the ineffective health care due to multiple barriers, is still lacking. Therefore it is important to prioritize in working with the multiple barriers of ethnic minorities using a patientcentered approach: for example, to determine whether utilizing the health care system is more critical than educating health knowledge for those with language barriers. A number of methodological issues, including causality, selection bias, self-report, confounders, and measurement issues limit the studies reviewed for exploring patient factors. Despite these limitations, study findings suggest the multiple intertwined factors that influence diabetes self-management for people with type 2 diabetes can be efficaciously addressed by a patient-centered approach, along with support of patient’s priority. Clinician factors include failing to follow treatment guidelines, beliefs, attitudes and knowledge, patient–clinician interaction and communication, and the health care system. The evidence RCTs bring to support their findings is methodologically strong but flaws in the RCTs include limited generalizeability and external validity. Most RCTs reviewed were conducted in primary care settings and research subjects were physician providers rather than nurse practitioners, dieticians, pharmacist and other diabetes educators who commonly provide diabetes care. The patients in the reviewed RCTs were primarily Caucasian. Therefore inference from these studies may be applied only to physicians who work in primary care settings with a predominantly Caucasian population rather than for underserved ethnic minorities with rates of high mortality and morbidity who disproportionately suffer from diabetes. Future research is clearly needed to investigate the experiences and perceived barriers of clinicians who work with a substantial number of ethnic minorities with diabetes. With an ever increasing demand on the clinicians’ role, providing clinicians with an exhaustive list of individual patient’s risk factors and barriers to diabetes management may not be adequate for improving the quality of care without the support of an efficacious system. Reviewed studies suggest that the appropriate time, resources and training of clinicians, using feedback and incentives for use of evidence-based practices have the potential to improve clinicians’ communication skills and patients’ health outcomes. Moreover, an adequate infrastructure and system change should take place at both the organizational and community level. Identifying various stakeholders and building a collaborative partnership with them will reduce the significant gap between what is known about diabetes care and what is commonly practiced in primary care. We have substantial evidence that both patients and clinicians have multiple barriers for diabetes management. The next logical step would be to address how to translate this evidence into the real world. For ethnic minorities who have poor access to health care due to language barriers and financial resources, providing community-based health education through their native language would be more realistic. This is more conducive rather than recommending a big and urban hospital education center where individuals often feel reluctant and intimidated. More community-based health programs and research addressing the specific need for this growing ethnic minority population are needed to overcome various barriers and in turn, to reduce the health disparity gap.

diabetes research and clinical practice 93 (2011) 1–9

Lastly, diabetes management is an ongoing process for both patients as well as clinicians. Further research should be directed toward focusing not only on the outcomes but also on the process evaluation of how a program has been modified and evolved with prospective. In addressing the sustainability of an effective diabetes program, patient and clinician barriers should be considered, which in turn would reduce the enormous burden of diabetes on our society.

Conflict of interest The authors declare that they have no conflict of interest.

Acknowledgements Acknowledgment of financial and/or other support: California Endowment and American Association of Colleges of Nursing (AACN), Nurse Faculty Program, 2007–2009.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.diabres.2011. 02.002.

references [1] Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782–7. [2] Hoerger TJ, Segel JE, Gregg EW, Saaddine JB. Is glycemic control improving in U.S. adult? Diabetes Care 2008;32:81–6. [3] Minnesota Community Measurement. Minnesota health scores. http://www.mnhealthcare.org/main.cfm [accessed 01.06.09]. [4] Aljasem LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. Diabetes Educ 2001;27:393–404. [5] Gallagher EJ, Viscoli CM, Horwitz RI. The relationship of treatment adherence to the risk of death after myocardial infarction in women. JAMA 1993;270:742–4. [6] Horwitz RI, Horwitz SM. Adherence to treatment and health outcomes. Arch Intern Med 1993;153:1863–8. [7] Horwitz RI, Viscoli CM, Berkman L, Donaldson RM, Horwitz SM, Murray CJ, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990;336:542–5. [8] Nicolucci A, Carinci F, Ciampi A. Stratifying patients at risk of diabetic complications: an integrated look at clinical, socioeconomic, and care-related factors SID-AMD Italian Study Group for the implementation of the St. Vincent declaration. Diabetes Care 1998;21:1439–44. [9] Dezii CM, Kawabata H, Tran M. Effects of once daily and twice-daily dosing on adherence with prescribed glipizide oral therapy for type 2 diabetes. South Med J 2002;95:68–71. [10] Dailey G, Kim MS, Lian JF. Patient compliance and persistence with antihyperglycemic drug regimens: evaluation of a medicaid patient population with type 2 diabetes mellitus. Clin Ther 2001;23:1311–20. [11] Rajagopalan R, Joyce A, Smith D, Ollendorf D, Murray FT. Medication compliance in type 2 diabetes patients: retrospective data analysis. Value Health 2003;6:328.

[12] Lawton J, Peel E, Parry O, Araoz G, Douglas M. Lay perceptions of type 2 diabetes in Scotland: bringing health services back in. Soc Sci Med 2005;60:1423–35. [13] Anderson RM, Donnelly MB, Dedrick RF. Measuring the attitudes of patients towards diabetes and its treatment. Patient Educ Couns 1990;16:231–45. [14] Farmer A, Kinmonth AL, Sutton S. Measuring beliefs about taking hypoglycemic medication among people with Type 2 diabetes. Diabet Med 2006;23:265–70. [15] de Weerdt I, Visser AP, Kok G, van der Veen EA. Determinants of active self-care behavior of insulin treated patients with diabetes: implications for diabetes education. Soc Sci Med 1990;30:605–15. [16] Dunn SM. Rethinking the models and modes of diabetes education. Patient Educ Couns 1990;16:281–6. [17] Masaki Y, Okada S, Ota Z. Importance of attitude evaluation in diabetes patient education. Diabetes Res Clin Pract 1990;8:37–44. [18] Wright A, Burden AC, Paisey RB, Cull CA, Holman RR. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K. prospective diabetes study (UKPDS 57). Diabetes Care 2002;25:330–6. [19] Davidson MB. Early insulin therapy for type 2 diabetic patients: more cost than benefit. Diabetes Care 2005;28:222–4. [20] Polonsky WH, Fisher L, Dowe S, Edelman S. Why do patients resist insulin therapy? Diabetes 2003;52:A417. [21] Larkin ME, Capasso VA, Chen C, Mahoney EK, Hazard B, Cagliero E, et al. Measuring psychological insulin resistance: barriers to insulin use. Diabetes Educ 2008;34:511–7. [22] Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients’ fears and hopes about insulin therapy. The basis of patient reluctance. Diabetes Care 1997;20:292–8. [23] Zambanini A, Newson RB, Maisey M, Feher MD. Injection related anxiety in insulin-treated diabetes. Diabetes Res Clin Pract 1999;46:239–46. [24] Davis SN, Renda SM. Psychological insulin resistance: overcoming barriers to starting insulin therapy. Diabetes Educ 2006;32:146S–52S. [25] Avis NE, McKinlay JB, Smith KW. Is cardiovascular risk factor knowledge sufficient to influence behavior? Am J Prev Med 1990;6:137–44. [26] Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S. The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care 2005;28:816–22. [27] Persell SD, Keating NL, Landrum MB, Landon BE, Avanian JZ, Borbas C, et al. Relationship of diabetes-specific knowledge to self-management activities, ambulatory preventive care, and metabolic outcomes. Prev Med 2004;39:746–52. [28] Murata GH, Shah JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA, et al. Factors affecting diabetes knowledge in type 2 diabetes veterans. Diabetologia 2003;46: 1170–8. [29] Pace AE, Ochoa-Vigo K, Caliri MH, Fernandes AP. Knowledge on diabetes mellitus in the self care process. Rev Lat Am Enfermagem 2006;14:728–34. [30] Holmstrom IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes. J Adv Nurs 2005;49:146–54. [31] Friedman MM. Transcultural family nursing: application to Latino and black families. J Pediatr Nurs 1990;5:214–22. [32] Fitzgerald JT, Gruppen LD, Anderson RM, Funnell MM, Jacober SJ, Grunber G, et al. The influence of treatment modality and ethnicity on attitudes in type 2 diabetes. Diabetes Care 2000;23:313–8.

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diabetes research and clinical practice 93 (2011) 1–9

[33] Lipton RB, Losey LM, Giachello A, Mendez J, Girotti MH. Attitudes and issues in treating Latino patients with type 2 diabetes: views of healthcare providers. Diabetes Educ 1998;24:67–71. [34] Yao G, Chung CW, Yu CF, Wang JD. Development and verification of validity and reliability of the WHOQOL-BREF Taiwan version. J Formos Med Assoc 2002;101:342–51. [35] Lai WA, Lew-Ting CY, Chie WC. How diabetic patients think about and manage their illness in Taiwan. Diabet Med 2005;22:286–92. [36] Caban A, Walker EA. A systematic review of research on culturally relevant issues for Hispanic with diabetes. Diabetes Educ 2006;32:584–95. [37] Polzer R, Miles MS. Spirituality and self-management of diabetes in African American. J Holistic Nurs 2005;23: 230–50. [38] Dagogo-Jack S, Funnell M, Davidson J. Barriers to achieving optimal glycemic control in a multi-ethnic society: a US focus. Curr Diabetes Rev 2006;2:285–93. [39] Lasater LM, Davidson AJ, Steiner JF, Mehler PS. Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus. Arch Intern Med 2001;161:77–82. [40] Burge MR, Lucero S, Rassam AG, Shade DS. What are the barriers to medical care for patients with newly diagnosed diabetes mellitus? Diabetes Obes Metab 2000;2:351–4. [41] Kuo YF, Raji MA, Markides KS, Ray LA, Espino DV, Goodwin JS, et al. Inconsistent use of diabetes medications, diabetes complications and mortality in older established population for the epidemiologic study of the elderly. Diabetes Care 2003;26:3054–60. [42] Jerant AF, von Friederichs-Fitzwater MM, Moore M. Patients’ perceived barriers to active self-management of chronic conditions. Patient Educ Couns 2005;57:300–7. [43] Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003;1:15–21. [44] Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality of life outcomes in seniors with multimorbidities. Ann Fam Med 2007;5:395–402. [45] Lustman PJ, Clouse RE, Freedland KE. Management of major depression in adults with diabetes: implications of recent clinical trials. Semin Clin Neuropsychiatry 1998;3:102–14. [46] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24:1069–78. [47] Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997;20:585–90. [48] Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000;23:934–42. [49] Chao J, Nau DP, Aikens JE, Taylor SD. The mediating role of health beliefs in the relationship between depressive symptoms and medication adherence in persons with diabetes. Res Soc Admin Pharm 2005;1:508–25. [50] Friedman LC, Brown AE, Romero C. Depressed mood and social support as predictors of quality of life in women receiving home health care. Qual Life Res 2005;14:1925–9. [51] Vanderhorst RK, McLaren S. Social relationships as predictors of depression and suicidal ideation in older adults. Aging Ment Health 2005;9:517–25. [52] Cohen S. Social relationships health. Am Psychol 2004;59:676–84. [53] Wing RR, Marcus MD, Epstein LH, Jaward A. A ‘familybased’ approach to the treatment of obese type 2 diabetic patients. J Consult Clin Psychol 1991;59:156–62.

[54] Gleeson-Kreig J, Bernal H, Woolley S. The role of social support in the self-management of diabetes mellitus among a Hispanic population. Public Health Nurs 2002;19:215–22. [55] Anderson RM, Fitzgerald JT, Gorenflo DW, Oh MS. A comparison of the diabetes-related attitudes of health care professionals and patients. Patient Educ Couns 1993;21:41–50. [56] Puder JJ, Keller U. Quality of diabetes care: problem of patient or doctor adherence? Swiss Med Wkly 2003;133:530–4. [57] Dietrich UC. Factors influencing the attitudes held by women with type II diabetes: a qualitative study. Patient Educ Couns 1996;29:13–23. [58] Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care 1998;21:1391–6. [59] Brown JB, Harris SB, Webster-Bogaert S, Wetmore S, Faulds C, Stewart M. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Fam Pract 2002;19:344–9. [60] Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: results of the crossnational diabetes attitudes wishes and needs (DAWN) study. Diabet Med 2005;22:1379–85. [61] Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83–90. [62] Schillinger D, Bindman A, Wang F, Stewart A, Piette J. Functional health literacy and the quality of physician– patient communication among diabetes patients. Patient Educ Couns 2004;52:315–23. [63] Wens J, Vermeire E, Royen PV, Sabbe B, Denekens J. GPs’ perspectives of type 2 diabetes patients’ adherence to treatment: a qualitative analysis of barriers and solutions. BMC Fam Pract 2005;6:20. [64] Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient–provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001;158:29–35. [65] Kinmonth AL, Woodcock AJ, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk The Diabetes Care From Diagnosis Research Team. Br Med J 1998;317:1202–8. [66] Pill R, Stott NC, Rollnick SR, Rees MA. A randomized controlled trial of an intervention designed to improve the care given in GP to type 2diabetic patients: patient outcomes and professional ability to change behavior. Fam Pract 1998;15:229–35. [67] Woodcock AJ, Kinmonth AL, Campbell MJ, Griffin SJ, Spiegal N. Diabetes care from diagnosis: effects of training in patient-centered care on beliefs, attitudes and behavior of primary care professionals. Patient Educ Couns 1999;37:65–79. [68] Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment Results of a randomized controlled trial. Diabetes Care 1995;18:943–9. [69] Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care a randomized controlled trial. Med Care 2000;38:218–30. [70] Trento M, Passera P, Tomalino M, Bajardi M, Pomero F, Allione A, et al. Group visits improve metabolic control in type 2 diabetes: a 2-year follow-up. Diabetes Care 2001;24:995–1000.

diabetes research and clinical practice 93 (2011) 1–9

[71] Shumaker S, Schron E, Ockene J, McBee W. The handbook of health behavior change. New York: Springer; 2004. [72] Eytan TA, Goldberg HI. How effective is the computerbased clinical practice guideline? Eff Clin Pract 2001;4: 24–33. [73] Ziemer DC, Doyle JP, Barnes CS, Branch WT, Cook CB, ElKebbi IM, et al. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African

Americans with Diabetes (IPCAAD) 8. Arch Intern Med 2006;166:507–13. [74] Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen PA. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 2001;323:970–5. [75] Lustman PJ, Griffith LS, Clouse RE, Freedland KE, Eisen SA, Rubin EH, et al. Effects of nortriptyline on depression and glycemic control in diabetes: results of a double-blind, placebocontrolled trial. Psychosom Med 1997;59:241–50.

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