Adherence Issues in Diabetes Care

A comprehensive review of treatment adherence in diabetes is beyond the scope of this chapter; however, the tremendous importance of compliance with the complex medical regimen warrants a brief discussion (for additional information on adherence issues, see Delamater 2000 and Chapter 13, "Treat ment Adherence," in this volume). As mentioned previously, diabetes adherence is a multifaceted construct, and children with diabetes face multiple task demands in regard to a complex treatment of a chronic illness. Although low overall adherence levels have been demonstrated in many chronic illnesses (Adams et al. 1997; Epstein and Cluss 1982), adherence levels in diabetes have often been found to be particularly poor (e.g., Johnson et al. 1986; La Greca et al. 1990; Reinehr et al. 2008). A number of types of adherence difficulties have been delineated in the research literature. Poor levels of adherence with young children and adolescents have been shown in self-monitoring of blood glucose (Dela-mater et al. 1989a; Wing et al. 1985) and dietary intake (Delamater et al. 1989b; Maffeis and Pinelli 2008). Insulin administration has also been shown to be an area of concern (Weissberg-Benchell et al. 1995); however, some studies indicate otherwise (Kyngas 2000). Importantly, these studies also demonstrate that although chronological age is often used as a marker for when a child should be given greater responsibility for self-care, many young individuals are not developmentally mature enough to handle the rigors of adhering to a regimen. Furthermore, problems with adherence have been shown to persist well into young adulthood (e.g., Donnelly et al. 2007; Raum et al. 2008; Schmittdiel et al. 2008).

Although many factors have been linked to adherence, much of the extant research has focused on three primary areas, specifically diabetes knowledge, role of family support, and psychosocial factors that influence adherence. Researchers suggest that diabetes adherence knowledge should be continuously revisited (La Greca et al. 1990; Maffeis and Pinelli 2008), and some studies demonstrate that doing so can positively affect regimen adherence (Christensen 1983); however, research results in this area are mixed (Kyngas et al. 2000; Wysocki et al. 2003).

Many studies have found that parental support, involvement, or cohesion is associated with better adherence, whereas parental conflict can have detrimental effects (Anderson et al. 1997; C.L. Davis et al. 2001; Jacobson et al. 1994; Kyngas 2000; Wysocki and Greco 2006). Parental monitoring specific to diabetes (instead of general warmth) has also been shown to have a positive effect on adherence (Ellis et al. 2007).

Finally, studies have indicated that psychosocial factors such as self-esteem, motivation, and auton omy have been linked with better compliance (Kyngas et al. 1996; Litt et al. 1982). On the other hand, externalizing problems in children and adolescents could lead to lower levels of adherence. In a study conducted by Duke et al. (2008), the researchers discovered a pattern in which the externalizing problems (oppositional defiant behavior, conduct problems) of youth were associated with critical parenting, which consequently led to decreased levels of adherence.

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