2. Factors
Patient Factors
• Adherence
• Attitudes and beliefs
• Knowledge
• Culture/Ethnicity/Language
• Financial resources
• Co-morbidities
• Social support
Health Care Provider Factors
• Beliefs, attitude and knowledge
• Patient- provider interaction and
communication
• Health care system
4. Adherence
• Glycemic control is affected by poor patient to treatment regimens
• Once-daily regimens have higher rates of adherence than twice-daily regimens
• Adherence rates are lower for insulin use than for oral hypoglycemic agents
• Monotherapy regimens has higher adherence rates than those of polytherapy regimens
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.
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
5. Attitudes And Beliefs
• 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
• In recent studies of insulin-naive patients with type 2 diabetes, approximately 33% reported an
unwillingness to take insulin if it were prescribed
• Patients perceive insulin therapy as evidence of personal failure
• Fear of daily insulin injections
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
Polonsky WH, Fisher L, Dowe S, Edelman S. Why do patients resist insulin therapy? Diabetes 2003;52:A417
6. Knowledge
• Relationship between knowledge and health outcomes is inconsistent
• Knowledgeable patients are more likely to perform self-management activities
• Limited knowledge about diabetes, its causes and symptoms affects the diabetes related
complications
7. Culture/Ethnicity/Language/Financial Resources
• Culture influences an individual’s beliefs, attitudes, knowledge, and behaviors, and in turn, can
affect diabetes self-management
• Misconception of insulin being potentially harmful is a common belief among traditional
Mexican Americans
• Cultural factors to consider in diabetes management include food and dietary preference,
lifestyles, traditional and religious beliefs, and beliefs about general health
• Self-management strategies included dietary restrictions and physical activities
• Lack of English proficiency is a primary barrier for many ethnic minorities in the United States
to fully navigate mainstream health services
• Cost of treatment is a significant barrier to diabetes treatment particularly with low
socioeconomic status
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.
Holmstrom IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes. J Adv Nurs 2005;49:146–54.
8. Co-morbidities
• Patients with multiple chronic conditions frequently experience barriers to self
management
• Competing co-morbidities such as back pain, arthritis, asthma, congestive heart failure,
chronic obstructive pulmonary disease acts as barriers
• Up to 33% of people with diabetes suffer an episode of depression during their lifetime
• Depression also has an inverse relationship with social support, with a bi-directional
causal model
• 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
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
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.
10. Beliefs, Attitude and Knowledge
• Physicians’ attitudes toward diabetes management may be more important than their actual
knowledge of the disease
• Clinicians’ beliefs, attitudes, and knowledge influence patients’ adherence to the prescribed
regimen
• Physician’s attitude at the time of diagnosis is critical in patient’s attitudes about the
seriousness of diabetes and subsequent self-management behavior
• Clinician’s lack of knowledge about recent evidence based guidelines may affect the diabetes
care outcome
11. Patient-Provider Interaction And Communication
• Good patient-provider communication predicts better diabetes self-care, better diabetes
outcomes or both
• Many clinicians recognize that they lack effective communication tools and skills in counselling
and shared decision-making
• It may be difficult for clinicians to change their communication style to one that is more
effective, even when supported by special training programs
• 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
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.
chillinger 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.
12. Health Care System
• Over 75% of individuals diagnosed with type 2 diabetes receive diabetes care exclusively from
primary care provider
• Only about one-third of patients with type 2 diabetes correctly follow the health care
provider’s directions for diabetes care
• 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
• In a primary care setting, individualized goals combined with educational and surveillance
support for clinicians may reduce risk factors associated with diabetes-related complications in
patients with type 2 diabetes
Shumaker S, Schron E, Ockene J, McBee W. The handbook of health behavior change. New York: Springer; 2004
