Document Type : Original Article
Authors
- . Nasrin Pourhabibi
- . Roya Sadeghi 1
- . Bahram Mohebbi 2
- . Elham Shakibazadeh 1
- . Mojgan Sanjari 3
- . Azar Tol 4
- . Mehdi Yaseri 5
1 Department of Health Promotion and Education, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Cardiology, Cardiovascular Intervention Research Center, Cardio‑Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Department of Internal Medicine, School of Medicine Endocrinology and Metabolism Research Center Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
4 Department of Health Education and Health Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
5 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Abstract
BACKGROUND: Treatment adherence is one of the behaviors associated with type 2 diabetes that
predicts whether it will be successfully treated or develop complications and become uncontrolled.
This study aimed to determine factors affecting nonadherence to treatment among diabetic patients
with limited health literacy from the perspectives of patients, their families, and healthcare providers.
MATERIALS AND METHODS: This qualitative study with a content analysis approach was conducted
on 84 eligible type 2 diabetes patients with limited health literacy and poor adherence to treatment,
as well as their families and healthcare providers using a purposive sampling method, in Kerman city
in 2021. Interviews were conducted using a semistructured interview guide with a broad, open‑ended
question to provide a general history of the disease separately. The interviewer asked participants
to identify the perceived barriers to treatment nonadherence. Each interview lasted 45–60 min.
MAXQDA version 20 and inductive content analysis were used to code and analyze extracted data.
RESULTS: Four major themes emerged from the patients’ perspectives as “financial problems,”
“individual factors,” “problems related to medication availability,” and “healthcare providers’ poor
practices.” Two major themes were classified from the perspective of patients’ families as “financial
problems” and “Individual factors,” and four major themes were identified from the viewpoint of
healthcare providers including “financial problems,” “individual factors,” “scarcity and medication
availability,” and “poor practice of the healthcare provider.” These mentioned barriers were confirmed
regarding treatment nonadherence among study participants.
CONCLUSION: Study findings revealed different factors of treatment nonadherence among diabetic
patients with limited health literacy. Therefore, these factors should be considered in tailoring
promotive educational and supportive interventions. Considering the importance of adherence to
treatment patients, planning empowerment family‑based interventions focusing on health literacy
improvement seems necessary.
Keywords
- Barati S, Sadeghipour P, Ghaemmaghami Z, Mohebbi B, Baay M,
Alemzadeh‑Ansari MJ, et al. Warning signals of elevated
prediabetes prevalence in the modern Iranian urban population.
Prim Care Diabetes 2021;15:472‑9.
2. Gholamaliei B, Karimi‑Shahanjarini A, Roshanaei G,
Rezapour‑Shahkolaei F. Medication adherence and its related
factors in patients with type II diabetes. J Educ Community Health
2016;2:3‑12.
3. Razavi N, Majlessi F, Mohebbi B, Tol A, Azam A. Assessing the
effect of educational intervention on treatment adherence based
on Aim Model among patients with type 2 diabetes. Iran J Diabetes
Metab 2017;16:173‑82.
4. Mousavizadeh SN, Ashktorab T, Ahmadi F, Zandi M. Evaluation
of barriers to adherence to therapy in patients with diabetes.
J Diabetes Nurs 2016;4:94‑108.
5. Bennich BB, Munch L, Overgaard D, Konradsen H, Knop FK,
Røder M, et al. Experience of family function, family involvement,
and self‑management in adult patients with type 2 diabetes:
A thematic analysis. J Adv Nurs 2020;76:621‑31.
6. Tanharo D, Ghods R, Pourrahimi M, Abdi M, Aghaii S, Vali N.
Adherence to treatment in diabetic patients and its affecting
factors. Pajouhan Sci J 2018;17:37‑44.
7. Hashemi SM, Bouya S. Treatment adherence in diabetic patients:
An important but forgotten issue. J Diabetes Nurs 2018;6:341‑51.
8. Zomahoun HT, Moisan J, Lauzier S, Guillaumie L, Gregoire JP,
Guenette L. Predicting noninsulin antidiabetic drug adherence
sing a theoretical framework based on the theory of planned
behavior in adults with type 2 diabetes: A prospective study.
Medicine (Baltimore) 2016;95:e2954.
9. Traina SB, Mathias SD, Colwell HH, Crosby RD, Abraham C.
The Diabetes intention, attitude, and behavior questionnaire:
evaluation of a brief questionnaire to measure physical
activity, dietary control, maintenance of a healthy weight,
and psychological antecedents. Patient Prefer Adherence
2016;10:213‑22.
10. Guenette L, Lauzier S, Guillaumie L, Gregoire G, Gregoire JP,
Moisan J. Patients’ beliefs about adherence to oral antidiabetic
treatment: A qualitative study. Patient Prefer Adherence
2015;9:413‑20.
11. Wu P, Liu N. Association between patients’ beliefs and oral
antidiabetic medication adherence in a Chinese type 2 diabetic
population. Patient Prefer Adherence 2016;10:1161‑7.
12. Guenette L, Breton MC, Guillaumie L, Lauzier S, Gregoire JP,
Moisan J. Psychosocial factors associated with adherence to
non‑insulin antidiabetes treatments. J Diabetes Complications
2016;30:335‑42.
13. Jafarian‑Amirkhizi A, Sarayani A, Gholami K ,
Taghizadeh‑Ghehi M, Heidari K, Jafarzadeh‑Kohneloo A, et al.
Adherence to medications, self‑care activity, and HBA1c status
among patients with type 2 diabetes living in an urban area of
Iran. J Diabetes Metab Disord 2018;17:165‑72.
14. Pourhabibi N, Mohebbi B, Sadeghi R, Shakibazadeh E, Sanjari M,
Tol A, Yaseri M. Determinants of Poor Treatment Adherence
among Patients with Type 2 Diabetes and Limited Health
Literacy: A Scoping Review. J Diabetes Res. 2022;;2022:1‑10. doi:
10.1155/2022/2980250.
15. Khosravi A, Ahmadzadeh K, Arastoopoor S, Tahmasbi R. Health
literacy levels of diabetic patients referred to Shiraz health centers
and its effective factors. Health Inf Manage 2015;12:205.
16. PashakiMS, EghbaliT, Niksima SH, AlbatinehAN, GheshlaghRG.
Health literacy among Iranian patients with type 2 diabetes:
A systematic review and meta‑analysis. Diabetes Metab Syndr
2019;13:1341‑5.
17. AbbasZadeh Bazzi M, Karimiaval M. Relationship between health
literacy and self‑care behaviors in diabetic patients type II referred
to the center of diabetes control and prevention in Zabol. J Health
Lit 2018;3:10‑9.
18. Charoghchian Khorasani E, Peyman N, Sahebkar M, Moghzi M.
Investigating health literacy in patients with type 2 diabets
referring to the health houses of Chenaran in 2016. J North
Khorasan Univ Med Sci 2017;9:183‑91.
19. Brundisini F, Vanstone M, Hulan D, DeJean D, Giacomini M.
Type 2 diabetes patients’ and providers’ differing perspectives
on medication nonadherence: A qualitative meta‑synthesis. BMC
Health Serv Res 2015;15:516.
20. Reisi M, Mostafavi F, Javadzede H, Mahaki B, Sharifirad G,
Tavassoli E. The functional, communicative, and critical health
literacy (FCCHL) scales: Cross‑cultural adaptation and the
psychometric properties of the Iranian version. Iran Red Crescent
Med J 2017;19(1):e29700.
21. Seyed Fatemi N, Rafii F, Hajizadeh E, Modanloo M. Psychometric
properties of the adherence questionnaire in patients with chronic
disease: A mix method study. Koomesh 2018;20:179‑91.
22. Treharne G, Riggs D. Ensuring quality in qualitative research.
Chapter 5. Issues in Qualitative Research. 2015. p. 57‑73.
23. Graneheim UH, Lundman B. Qualitative content analysis in
nursing research: Concepts, procedures and measures to achieve
trustworthiness. Nurse Educ Today 2004;24:105‑12.
24. DehvanF, BaghiV, LotfiA, GH G. Medication adherence inhibitors
and facilitators in type 2 diabetic patients: An Integrative review.
Sci J Nurs Midwifery Paramed Facult 2018;3(1):1‑17.
25. Alwazae M, Al Adel F, Alhumud A, Almutairi A, Alhumidan A,
Elmorshedy H. Barriers for adherence to diabetic retinopathy
screening among Saudi adults. Cureus 2019;11:e6454. doi:
10.7759/cureus. 6454.
26. Rezaei M, Valiee S, Tahan M, Ebtekar F, Ghanei Gheshlagh R.
Barriers of medication adherence in patients with type‑2
diabetes: A pilot qualitative study. Diabetes Metab Syndr Obes
2019;12:589‑99.
27. Chepulis L, Morison B, Cassim S, Norman K, Keenan R,
Paul R, et al. Barriers to diabetes self‑management in a subset of
New Zealand Adults with type 2 diabetes and poor glycaemic
control. J Diabetes Res 2021;2021:5531146.
28. Shukla R, Gudlavalleti MV, Bandyopadhyay S, Anchala R,
Gudlavalleti AS, Jotheeswaran AT, et al. Perception of care and
barriers to treatment in individuals with diabetic retinopathy
in India: 11‑city 9‑state study. Indian J Endocrinol Metab
2016;20(Suppl 1):S33‑41.
29. Huang YM, Shiyanbola OO. Investigation of barriers
and facilitators to medication adherence in patients with
type 2 diabetes across different health literacy levels: An
explanatory sequential mixed methods study. Front Pharmacol
2021;12:745749.
30. Habte BM, Kebede T, Fenta TG, Boon H. Barriers and facilitators
to adherence to anti‑diabetic medications: Ethiopian patients’
perspectives. Afr J Prim Health Care Fam Med 2017; 17;9(1):e1‑e9.
31. NelsonL, WallstonK, KripalaniS, LeStourgeonLM, WilliamsonSE,
Mayberry LS. Assessing barriers to diabetes medication adherence
using the information‑motivation‑behavioral skills model.
Diabetes Res Clin Pract 2018;142:374‑84.
32. Mostafavi F, Zamani Alavijeh F, Salahshouri A, Mahaki B. The
psychosocial barriers to medication adherence of patients with
type 2 diabetes: A qualitative study. Biopsychosoc Med 2021;15:1.
33. Mukona D MS, Zvinavashe M, Stray‑Pederson B. Barriers
of adherence and possible solutions to nonadherence to
antidiabetic therapy in women with diabetes in pregnancy:
Patients’ perspective. J Diabetes Res 2017;2017:3578075. doi:
10.1155/2017/3578075. - 34. Pamungkas R, Chamroonsawasdi K, Vatanasomboon P,
Charupoonphol P. Barriers to effective diabetes mellitus
self‑management (dmsm) practice for glycemic uncontrolled
type 2 diabetes mellitus (t2dm): A socio cultural context of
Indonesian communities in west Sulawesi. Eur J Investig Health
Psychol Educ 2020;10:250‑61.
35. McBrien KA, Naugler C, Ivers N, Weaver RG, Campbell D,
Desveaux L, et al. Barriers to care in patients with diabetes and
poor glycemic control—A cross‑sectional survey. PLoS One
2017;12:e0176135.
36. Basu S, Garg S. The barriers and challenges toward addressing the
social and cultural factors influencing diabetes self‑management
in Indian populations. J Soc Health Diabetes 2017;5:71‑6.
37. Açıl D, Bahar Z. Perceived barriers to diabetes management at
home: A qualitative study. Turk J Biochem 2019;44:621‑9.
38. Mishalia M, Omera H, Heymann AD. The importance of
measuring self‑efficacy in patients with diabetes. Fam Pract
2011;28:82‑7.
39. Bamari F, Mansuri A, Poodineh Moghadam M, Hormozi T,
Rohi Saadabad M. A survey of family problems in patients with
type II diabetes: A review article. J Diabetes Nurs 2015;3:69‑75.
40. Wilkinson A, Whitehead L, Ritchie L. Factors influencing the
ability to self‑manage diabetes for adults living with type 1 or 2
diabetes. Int J Nurs Stud 2014;51:111–22.
41. Meurs M, Roest AM, Wolffenbuttel BH, Stolk RP, de JP,
Rosmalen JG. Association of depressive and anxiety disorders
with diagnosed versus undiagnosed diabetes: An epidemiological
study of 90,686 participants. Psychosom Med 2016;78:233–41.
42. Chen S, Zhang Q, Dai G, Hu J, Zhu C, Su L, et al. Association
of depression with pre‑diabetes, undiagnosed diabetes, and
previously diagnosed diabetes: A meta‑analysis. Endocrine
2016;53:35–46.
43. Bădescu SV, Tătaru C, Kobylinska L, Georgescu EL, Zahiu DM,
Zăgrean AM, et al. The association between diabetes mellitus and
depression. J Med Life 2016;9:120‑5.
44. Moulton CD, Pickup JC, Ismail K. The link between depression
and diabetes: The search for shared mechanisms. Lancet Diabetes
Endocrinol 2015;3:461–71.