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Addressing Barriers
Guidelines
published by the American Association for Diabetes Educators in 2009
suggested that there should be universal access to diabetes
self-management education or
“DSME”.
There have been a number of reports suggesting that clinician-centered care has limitations. Diabetes is a case in point, requiring patient-centered care to achieve successful management of the disease. Lifestyle changes are among the most difficult changes for a patient to make in an effort to control blood sugars. The patient’s perspective should be considered. And this is where a social worker should play a vital role. Lifestyle choices for diet and exercise are very personal decisions. It may take a lot more effort to change eating and activity habits than it is to take on a medication regimen. When patients first hear their diagnosis, it may take a while to sink in and they may actually go through stages of grieving, including denial, anger, bargaining, depression, and acceptance. The acceptance stage may be where the patient is ready to deal with diabetes management, although this may take some time. As with all grief coping, any patient may cycle through these stages many times or return to stages at different times in their life. Because lifestyle is a choice, even if it is a choice to do nothing, patients can become defensive against the clinician’s or educator’s judgment about their lifestyle. Or, their behavior may be motivated by something only vaguely related, as mentioned earlier. The provider should recognize that integrating new diet and exercise regimens, or other changes in lifestyle can be difficult. If the patient doesn’t understand the rationale or doesn’t believe that they can accomplish the recommended changes, he or she may avoid the education and training opportunities offered that can improve adherence. A social worker should work with these patients to develop a working relationship, so that they my open the door to acceptance and adherence. Costs of therapies, including office visits, medications, and laboratory or other evaluations, and therapy complexity can impact adherence to recommendations. Providers will need to understand how these issues are de-motivators to each patient--and work to overcome these barriers. Finally, staff and health care providers should be on the lookout for signs of problems with interpersonal relationships, both in the clinic and in the family setting, that may be barriers to adherence. Lifestyle:
•Acknowledge
patient perspectives and concerns
•Provide
a reason and motivation
•Individualize
strategies and think long-term
•Follow-up
with support from patient network
•Refer
to support
Patient perspectives should be explored and acknowledged. Several recommendations have been made to improve patient adherence to lifestyle recommendations, including education to improve awareness of the rationale for maintaining blood glucose control, and adhering to recommended therapies. Patients can be referred to diabetic educators for education and individualized training on lifestyle changes that may best suited to the patient’s needs and preferences. Support groups and other resources can help to provide the needed encouragement and motivation to maintain positive changes. In general, strategies to improve adherence should align with patient goals and expectations for outcomes. Home-based care can offer the opportunity to assess home resources and hazards as well as to individualize interventions to the patient’s home environment. Medications and Monitoring:
Multiple and complex medication therapies can be very daunting. According to Daly et al, of the patients surveyed, most were not adherent to medications because of cost, forgetting to take them, or interference by depression. Oral medications are now recommended by the American Diabetes Association on diagnosis, rather than waiting for a trial of lifestyle management. In some cases, multiple oral antihyperglycemic medications may be prescribed, and they may have different dosing schedules. There may be additional medications prescribed for co-morbidities, such as hypertension and hyperlipidemia. While each of these is important, it may be difficult for a patient to be motivated when there are no tangible changes they will notice. Finally, adverse events can hamper adherence efforts. Some medications have gastrointestinal effects. But, there is probably most concern about the possibility of hypoglycemia, which is possible with single medications and even more of a concern with intensive therapy with multiple medications. If a patient has problems with adhering to regimens with multiple medications and dosing schedules, it has been recommended to consider combination therapies that reduce pill burden as well as simplify the dosing schedules. A team pharmacist can assist in making recommendations for coordinating and streamlining a schedule of medications that may be required to control co-existing problems, such as hypertension and hyperlipidemia. The American Diabetes Association suggests that patient training in self-management is essential to the success of diabetes control. In one study, follow-up through automated telephone calls and self-care training reduced adherence problems by 21%. Daly et al suggested that patients may not follow through on monitoring blood glucose because of costs, too much of a bother, interference of depression, lack of understanding, dislike for doing it, pain involved in self-monitoring, and a lack of knowledge on how to use the results. Still, if these barriers are overcome, self-monitoring can improve patient efforts to adhere to therapies through direct feedback on how well their efforts are working. According to research by Malanda et al, the emotions and stress involved with diabetes management can be barriers to patient adherence, which may be overcome by self monitoring of glucose levels. |
