The mediating role of health beliefs in the relationship between depressive symptoms and medication adherence in persons with diabetes

Self-efficacy and self-care behavior of Malaysian patients with type 2 diabetes: a cross sectional survey

This study investigated the association between self-efficacy and self-care behavior to determine the degree of self-efficacy and to examine differences in self-efficacy according to patient variables, including state of health, of Malaysian patients with type 2 diabetes. The sample comprised 388 patients (respondents). We collected the data from December 2010 to February 2011. We found a significant positive relationship between self-efficacy and self-care behavior (r(s) = 0.481, P < 0.001). The degree of self-efficacy was moderately high (mean = 7.570). We found significant differences between self-efficacy and education level (Wilk's Lambda = 0.918, F[12, 1008] = 2.779, P < 0.05), duration of diabetes (Wilk's Lambda = 0.954, F[8, 736] = 2.264, P < 0.05), other chronic conditions (Wilk's Lambda = 0.967, F[4, 383] = 3.304, P < 0.05) and diabetic complications (Wilk's Lambda = 0.963, F[4, 383] = 3.653, P < 0.05). Self-efficacy can be used as a model to understand self-care behavior. Individualized nursing interventions based on self-efficacy theory should be utilized in high risk diabetic patients so as to assist and improve self-care behavior.

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Barriers to diabetes management: patient and provider factors

Despite significant advances in diagnosis and treatment, the persistence of inadequate metabolic control continues. Poor glycemic control may be reflected by both the failure of diabetes self-management by patients as well as inadequate intervention strategies by clinicians. The purpose of this systematic review is to summarize existing knowledge regarding various 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 between 1990 and 2009, addressing type 2 diabetes, patient's barriers, clinician's barriers, and self-management. Patients' adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. Culture and language capabilities influence the patient's health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient's financial resources, co-morbidities, and social support. 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.

Reliability and validity of diabetes specific Health Beliefs Model scales in patients with diabetes and serious mental illness

AIMS

In this study we evaluate the reliability and validity of existing Health Beliefs Model (HBM) scales developed to assess HBM domains in a population of patients with both diabetes and serious mental illness (SMI). While diabetes medication adherence has frequently been evaluated through the lens of the HBM, it is unclear if developed scales are reliable and valid in patients with SMI.

METHODS

We surveyed 152 veterans with diabetes and SMI. Domains of the HBM assessed included perceived benefits, side effects and barriers to diabetes medication taking, perceived susceptibility to and severity of diabetes, diabetes self-efficacy, diabetes locus of control, and perceived diabetes control.

RESULTS

HBM scales showed good internal reliability within a SMI population, with Cronbach alphas ranging between 0.73 and 0.86 for all scales assessed except one. HBM scales also showed associations with self reported diabetes medication adherences in six of the ten domains.

CONCLUSION

Scales assessing diabetes specific domains of the HBM exhibit both reliability and validity in patients with both diabetes and SMI.

How are adherent people more likely to think? A meta-analysis of health beliefs and diabetes self-care

PURPOSE

Diabetes is increasingly prevalent, and nonadherence with diabetes treatment regimens is associated with physical and social costs. Psychological predictors of adherence have been investigated in the literature, including cognitive factors. The present meta-analysis was conducted to investigate the association between beliefs related to diabetes and adherence to diabetes regimens.

METHODS

Studies that measured both (a) beliefs, perceptions, or cognitions about diabetes and (b) the relationship between such cognitive factors and blood glucose levels or other adherence behaviors were included. This research focused on adults with any type of diabetes, reaching a final sample of 48 studies. The effect size r was calculated for all types of beliefs and outcomes.

RESULTS

The types of beliefs most strongly associated with adherence were self-efficacy, perceiving a positive relationship with physician, and beliefs about the personal consequences of adherence. A few limitations of this meta-analysis are that studies were only retrieved through databases and other sources were not searched, only articles in English were included, and only adult participants were included.

CONCLUSIONS

People who are more adherent have a higher level of confidence in their ability to follow medical recommendations, expect more meaningful positive consequences for adherence, and perceive a more positive relationship with their health care provider. Educators and clinicians could use cognitive restructuring techniques to facilitate these types of beliefs and perceptions in people with diabetes.

Patient adherence to medication requirements for therapy of type 2 diabetes

Type 2 diabetes is a complex, progressive endocrine and metabolical disease that typically requires substantial lifestyle changes and multiple medications to lower blood glucose, reduce cardiovascular risk and address comorbidities. Despite an extensive range of available and effective treatments, < 50% of patients achieve a glycaemical target of HbA(1c) < 7.0% and about two-thirds die of premature cardiovascular disease. Adherence to prescribed therapies is an important factor in the management of type 2 diabetes that is often overlooked. Inadequate adherence to oral antidiabetes agents, defined as collecting < 80% of prescribed medication, is variously estimated to apply to between 36% and 93% of patients. All studies affirm that a significant proportion of type 2 diabetes patients exhibit poor adherence that will contribute to less than desired control. Identified factors that impede adherence include complex dosing regimens, clinical inertia, safety concerns, socioeconomic issues, ethnicity, patient education and beliefs, social support and polypharmacy. This review explores these factors and potential strategies to improve adherence in patients with type 2 diabetes.

Construct Validity of the Holistic Complementary and Alternative Medicines Questionnaire (HCAMQ)-An Investigation Using Modern Psychometric Approaches

The scientific basis of efficacy studies of complementary medicine requires the availability of validated measures. The Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ) is one such measure. This article aimed to examine its construct validity, using a modern psychometric approach. The HCAMQ was completed by 221 patients (mean age 66.8, SD 8.29, 58% females) with chronic stable pain predominantly from a single joint (hip or knee) of mechanical origin, waiting for a hip (40%) or knee (60%) joint replacement, on enrolment in a study investigating the effects of acupuncture and placebo controls. The HCAMQ contains a Holistic Health (HH) Subscale (five items) and a CAM subscale (six items). Validity of the subscales was tested using Cronbach alpha's, factor analysis, Mokken scaling and Rasch analysis, which did not support the original two-factor structure of the scale. A five-item HH subscale and a four-item CAM subscale (worded in a negative direction) fitted the Rasch model and were unidimensional (χ2 = 8.44, P = 0.39, PSI = 0.69 versus χ2 = 17.33, P = 0.03, PSI = 0.77). Two CAM items (worded in the positive direction) had significant misfit. In conclusion, we have shown that the original two-factor structure of the HCAMQ could not be supported but that two valid shortened subscales can be used, one for HH Beliefs (four-item HH), and the other for CAM Beliefs (four-item CAM). It is recommended that consideration is given to rewording the two discarded positively worded CAM questions to enhance construct validity.

Barriers to accessing care in patients with chronic hepatitis C: the impact of depression

BACKGROUND

Patients with hepatitis C viral (HCV) may perceive barriers to accessing speciality care for HCV, and these barriers may be related to depressive symptoms.

AIM

To evaluate the relationship between barriers to care, demographics, and depressive symptoms.

METHODS

A cross-sectional analysis of 126 patients referred for HCV at two speciality HCV clinics. Barriers to care, depressive symptoms and sociodemographics were measured using standardized instruments. A retrospective chart review was conducted to collect clinical outcome data.

RESULTS

Depressive symptoms were reported in 26%. Common barriers included lack of personal financial resources; lack of HCV knowledge in the community; lack of professionals competent in HCV care; stigmatization of HCV; and long distances to clinics offering care. After we controlled for sociodemographics, depression accounted for an additional 7-18% of variability in all barriers (all p values <0.01). Lower depression, marital and employment status were associated with subsequent receipt of HCV treatment in 38% (45/120) of patients; perceived barriers were not.

CONCLUSIONS

Depression is independently associated with perceived barriers to care. Higher depressive scores, but not perceived barriers, were associated with nontreatment. Healthcare providers who diagnose HCV need to be cognizant of numerous perceived barriers to accessing HCV care, and the impact that depression may have on these perceptions and receipt of treatment.

Exploring the relationship between diabetes self-efficacy, depressive symptoms, and glycemic control among men and women with type 2 diabetes

Depression and low self-efficacy are both associated with worse glycemic control in adults with diabetes, but the relationship between these variables is poorly understood. We conducted a cross-sectional study examining associations between depressive symptoms, self-efficacy, and glycemic control among men (n = 64) and women (n = 98) with type 2 diabetes to see if self-efficacy mediates the relationship between depression and glycemic control. Correlational and mediational analyses examined the relationship between these three variables for the sample as a whole and separately by sex. A significant association between depressive symptoms and glycemic control was found for men (0.34, P < 0.01) but not for women (0.05, P = 0.59). Path analysis suggested that, among men, self-efficacy mediates the relationship between depressive symptoms and glycemic control. We conclude that men with depressive symptoms and type 2 diabetes may need tailored interventions that improve their self-efficacy in order to achieve glycemic control.

Variation in patients' and pharmacists' attribution of symptoms and the relationship to patients' concern beliefs in medications

BACKGROUND

The process by which symptoms are identified and characterized is related to adverse drug event reporting. Patient and pharmacist symptom attribution may differ and be related to certain patient characteristics.

OBJECTIVES

(1) To compare attribution of symptoms to a cause for patients and pharmacists; (2) to quantify the association between patients' concern beliefs and patient-pharmacist agreement on patients' symptom attribution to medications; and (3) to identify any associations between patients' propensity to agree with pharmacists' assessments of symptom attribution with various clinical and/or sociodemographic characteristics.

METHODS

An Internet survey of Medicare beneficiaries was administered by Harris Interactive ®. The survey elicited information on health symptoms that subjects experienced and to whom they reported these symptoms. If subjects did not experience symptoms and did not report them, the reasons for not reporting were elicited. A clinical expert panel reported ratings about respondents' (1) likelihood of the symptom experienced being attributed to a medication and (2) probability of the symptom being attributed to the reason the patient stated. Frequencies of unreported symptoms for each reason/category were examined. Chi-square and Fisher's exact test analyses examined the variations between patients' and pharmacists' ratings of symptom attribution to medications and associations between attribution and patient sociodemographic and clinical characteristics, such as the number of medications used. Independent sample t tests examined how attributions were related to concern beliefs.

RESULTS

Most patients thought their symptom(s) were the result of their disease, something other than medications or age. There was no statistically significant difference between patients' and pharmacists' symptom attribution (χ(2)=1.376, P=.24). Individuals whose symptom attributions differed from pharmacists were likely to have stronger concern beliefs in medication (t=-3.03, P<.01).

CONCLUSIONS

Patients' concern about their medications may be related to their symptom attributions. Older adults may not consider these concerns when asked about their symptom attributions.

Relationships among self-management, patient perceptions of care, and health economic outcomes for decision-making and clinical practice in type 2 diabetes

OBJECTIVES

Type 2 diabetes (T2D) treatment involves complex interactions between biological, psychological, and behavioral factors of care, requiring multifaceted efforts in clinical practice and disease management to reduce health and economic burdens. We aimed to quantify correlations among these factors and characterize their level of inclusion in economic analyses that are part of informed medical decision-making.

METHODS

A comprehensive, stepwise systematic literature review was performed on published articles dated 1993 to 2008 using medical subject heading and keyword searches in electronic reference libraries. Data were collected using standardized techniques and were analyzed descriptively.

RESULTS

A total of 97 articles fulfilling all inclusion criteria were reviewed, including 16 on economic models (17% of articles). Most studies were retrospective (41 of 97; 42%) and from managed care perspectives (66%). Oral antidiabetic drugs were a central focus, appearing in 83% of studies. Patient behaviors, particularly medication adherence and persistence in real-world settings, are well researched (n=65) and may influence diabetes outcomes, cardiovascular risk, mortality rates, and treatment-specific resource use (e.g., hospitalizations) and costs (<or=$3400 annually per patient). Nevertheless, they are absent from current economic models.

CONCLUSIONS

Strong correlations exist between patient behaviors, perspectives of care, health outcomes, and costs in T2D. Enhancing their inclusion in pharmacoeconomic modeling, notably the influence on clinical effectiveness of variation in self-management between treatments, should ultimately lead to more accurate estimates of comparative cost-effectiveness, and thereby improve value-based resource allocation and patient access to appropriate therapy.

Predictors of adherence to diabetes medications: the role of disease and medication beliefs

Despite the effectiveness of drug therapy in diabetes management high rates of poor adherence persist. The purpose of this study was to identify potentially modifiable patient disease and medication beliefs associated with poor medication adherence among people with diabetes. A cohort of patients with diabetes was recruited from an urban primary-care clinic in New York City. Patients were interviewed in English or Spanish about: disease beliefs, medication beliefs, regimen complexity, diabetes knowledge, depression, self-efficacy, and medication adherence (Morisky scale). Logistic regression was used to identify multivariate predictors of poor medication adherence (Morisky > 1). Patients (n = 151) had diabetes for an average of 13 years with a mean HgA1C of 7.6 (SD 1.7). One-in-four (28%) were poor adherers to their diabetes medicines. In multivariate analyses, predictors of poor medication adherence were: believing you have diabetes only when your sugar is high (OR = 7.4;2-27.2), saying there was no need to take medicine when the glucose was normal (OR = 3.5;0.9-13.7), worrying about side-effects of diabetes medicines (OR = 3.3;1.3-8.7), lack of self-confidence in controlling diabetes (OR = 2.8;1.1-7.1), and feeling medicines are hard to take (OR = 14.0;4.4-44.6). Disease and medication beliefs inconsistent with a chronic disease model of diabetes were significant predictors of poor medication adherence. These suboptimal beliefs are potentially modifiable and are logical targets for educational interventions to improve diabetes self-management.

Diabetic patients' medication underuse, illness outcomes, and beliefs about antihyperglycemic and antihypertensive treatments

OBJECTIVE

The purpose of this study was to determine how patients' beliefs about antihyperglycemic and antihypertensive medications relate to medication underuse and health status.

RESEARCH DESIGN AND METHODS

In diabetic patients from an economically distressed region, we assessed perceived necessity and harmfulness for antihyperglycemic (n = 803) and antihypertensive (n = 573) medications, past year's medication underuse, A1C, systolic blood pressure (SBP), and diastolic blood pressure (DBP).

RESULTS

After correction for multiple analyses, multivariate models indicated that perceived need for antihyperglycemic medication was associated with being younger, being prescribed insulin, and being prescribed multiple medications. Concern about antihyperglycemic medications was associated with being younger, African American, dissatisfied with information received about medication, and of low health literacy. For antihypertensives, perceived necessity was associated with having numerous medical comorbidities and being dissatisfied with medication information; concern was associated with being younger, dissatisfied with information received about medication, and of low health literacy. Up to one-half of patients underused at least one of the types of medication; many of these patients attributed this underuse to cost. For both types of medications, concern was significantly associated with both cost-related and non-cost-related underuse, and antihypertensive concern was associated with higher SBP and DBP.

CONCLUSIONS

Even after adjustment for economic factors, patients who are younger, African American, or of low health literacy are especially concerned about medication harmfulness, which is in turn associated with medication underuse and higher blood pressure. To enhance adherence and outcomes, interventions should address patients' underlying concerns about potential adverse treatment effects and focus on both cultural factors and health literacy.

Exploring the impact of depressive symptoms and medication beliefs on medication adherence in hypertension--a primary care study

OBJECTIVE

This study aimed to assess the levels of adherence in a sample of hypertensive patients being cared for in primary care in Northern Ireland and to explore the impact of depressive symptoms and medication beliefs on medication adherence.

METHODS

The study was conducted in 97 community pharmacies across Northern Ireland. A questionnaire containing measures of medication adherence, depressive symptoms and beliefs about medicines was completed by 327 patients receiving antihypertensive medications.

RESULTS

Analysis found that 9.3% of participants were non-adherent with their antihypertensive medication (self-report adherence scale) and 37.9% had scores indicative of depressive symptoms as determined by the Center for Epidemiological Studies Depression Scale (CES-D). In the univariate analysis, concerns about medications had negative effects on both adherence and depressive symptomatology. However, logistic regression analysis revealed that patients over the age of 50 were more likely to be adherent with their medication than those younger than 50. Depressive symptomatology and medication beliefs (concerns) were not significantly related to adherence in the regression analysis.

CONCLUSION

Depressive symptomatology was high in the sample as measured by the CES-D. Age was the only significant predictor of medication adherence in this population.

PRACTICE IMPLICATIONS

Health care professionals should consider the beliefs of the patient about their hypertensive medications and counsel younger patients on adherence.

Association between depression and concurrent Type 2 diabetes outcomes varies by diabetes regimen

AIMS

Although depression has weak associations with several Type 2 diabetes mellitus (DM) outcomes, it is possible that these associations are concentrated within certain patient subgroups that are more vulnerable to their effects. This study tested the hypothesis that depression is related to glycaemic control and diabetes-related quality of life (DQOL) in patients who are prescribed injected insulin, but not those on oral glucose-lowering agents alone.

METHODS

Participants (103 on insulin, 155 on oral glucose-lowering agents alone) with Type 2 DM were recruited from a large US healthcare system and underwent assessment of glycaemic control (glycated haemoglobin; HbA(1c)), medication adherence and diabetes self-care behaviours, DQOL and depression (none, mild, moderate/severe).

RESULTS

There was a significant regimen x depression interaction on HbA(1c) (P = 0.002), such that depression was associated with HbA(1c) in patients using insulin (beta = 0.35, P < 0.001) but not in patients using oral agents alone (beta = -0.08, P = NS). There was a similar interaction when quality of life was analysed as an outcome (P = 0.002). Neither effect was mediated by regimen adherence.

CONCLUSIONS

The generally weak association between depression and glycaemic control is concentrated among patients who are prescribed insulin. Similarly, the association between depression and illness quality of life is strongest in patients prescribed insulin. Because this is not attributable to depression-related adherence problems, psychophysiological mechanisms unique to this group ought to be carefully investigated. Clinicians might be especially vigilant for depression in Type 2 DM patients who use insulin and consider its potential impact upon their illness course.

Medication taking and diabetes: a systematic review of the literature

PURPOSE

The purpose of this systematic review is to evaluate the evidence of the challenges and barriers to medication taking (adherence) and to summarize the interventions that improve medication taking in type 1 and type 2 diabetes mellitus.

METHODS

PubMed, the Cochrane Collaborative, and the Health and Psychosocial Instruments databases were used to obtain articles identified by using the MeSH headings of diabetes, medication, oral hypoglycemic agents, oral antihyperglycemic agents, oral antidiabetic agents, insulin, adherence, medication taking, compliance, fears, treatment, and electronic monitoring. Only articles published in English between 1990 and May 7, 2007, and including individuals of all ages with type 1 or type 2 diabetes mellitus were included. Retrospective and prospective studies reporting adherence to medications using self-report, pill counts, medication possession ratios, and electronic monitoring devices were included. Database analyses of prescription records from various organizations or countries were included only if adherence to pharmacologic therapy was stated. Surveys and questionnaires assessing medication taking were also included. The data from the selected literature was abstracted independently. The various studies were grouped together based on the type of study conducted. Studies were not included if a specific measure of adherence to medication was not used or stated. The studies are presented in 3 tables according to design.

CONCLUSIONS

Several barriers to medication taking have been suggested for those with diabetes mellitus, although well-controlled trials to confirm and resolve these barriers are limited. Diabetes educators should be aware of the common barriers to medication taking (regimen complexity of more than 1 diabetes mellitus drug or more than 1 dose daily, depression, and remembering doses and refills) and provide screening and support to their patients to resolve barriers if they exist. Further studies are needed to test specific interventions to improve medication taking in diabetes.

Diabetic patients treated with dialysis: complications and quality of life

AIMS/HYPOTHESIS

The aim of this study was to describe the prevalence of complications, health-related quality of life (HRQOL) and the influence of beliefs about control over health in diabetic dialysis patients.

METHODS

Of 53 eligible diabetic patients on chronic dialysis during January 2004 in our clinic, 38 (76%) completed a kidney-specific (Kidney Disease Quality of Life) and a generic (SF-36) questionnaire and were characterised in terms of cardiovascular diseases and diabetic complications. Matched groups of non-diabetic dialysis patients (n = 40) and diabetic patients with a long duration of diabetes and normal kidney function (n = 38) served as controls. Generic HRQOL was compared with matched data from a survey on the Danish general population (n = 2248).

RESULTS

Micro- and macrovascular complications were significantly more frequent in diabetic dialysis patients than in diabetic patients without renal disease. Self-rated physical health was significantly worse (p < 0.01) in diabetic dialysis patients (35 +/- 9 [mean +/- SD]) compared with non-diabetic dialysis patients (41 +/- 10), diabetic patients with normal kidney function (45 +/- 12) and the matched general population (47 +/- 19). The diabetic dialysis patients had similar levels of kidney-specific quality of life and mental health compared with the control groups. Reduced physical health was predicted by the presence of end-stage renal disease, diabetes and short time spent in education. Among the diabetic patients, those who believed more on their own ability to control their diabetes and less on chance reported better mental health and were less likely to be on dialysis.

CONCLUSIONS/INTERPRETATIONS

Diabetic dialysis patients are characterised by a high prevalence of diabetic complications, reduced self-rated physical health but relatively good mental health.