Obstacles to adherence in living with type-2 diabetes: An international qualitative study using meta-ethnography (EUROBSTACLE)
Introduction
Low adherence to prescribed medical interventions is an ever-present and complex problem, especially for people with a chronic illness. Low adherence is a growing concern, seriously undermining the benefits of current medical care. Therefore, medical non-adherence has been identified as a major public health problem. The enormous amount of quantitative research, ∼9000 articles, undertaken since 1975 was of variable methodological quality, with no gold standard for the measurement of adherence so that it often was not clear which type of non-adherence was being studied. Many authors did not feel even the need to define ‘adherence’. Often absent in this research was the patient, although the concordance model [1] points at the importance of the patient's agreement and harmony in the doctor–patient relationship. The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Some qualitative studies in the 1990s have identified important issues such as the quality of the health provider–health receiver relationship and the patient's health beliefs in this context [1], [2].
Diabetes requires complicated treatments and lifestyle changes and is, therefore, a useful model of self-management as a necessary component of care [3], [4], [5]. One aspect of effectiveness is the adherence to the prescribed medication, monitoring or lifestyle advice, by people who have diabetes. Evidence indicates that improved adherence to medication and lifestyle advice improves metabolic control: thereby leading to a reduction in the risk of complications, an increase in life expectancy and a reduction of morbidity in people living with type-2 diabetes [6], [7], [8], [9], [10]. Furthermore, successful management of diabetes, including adherence to treatment and advice, can also improve the quality of life for people living with diabetes [11].
According to these findings, qualitative studies using focus groups were conducted in seven European countries to assess health beliefs and obstacles to treatment recommendation adherence. The objective of the meta-ethnography study presented was to make a synthesis of these seven studies.
Our research aimed to answer three questions. First, what are the differences and similarities of the obstacles to adherence for people living with type-2 diabetes in each country? Second, are these obstacles the same in countries with different health-care systems? Third, can the data from parallel, international, multilingual qualitative studies be synthesised to answer the first two questions?
Section snippets
Methods
A first study using focus groups [12] was conducted in Flanders (Belgium) to assess the health beliefs of people living with type-2 diabetes in relation to their illness, their communication with caregivers and the problems encountered in adhering to treatment regimens [13].
The findings were that health beliefs, the quality of the doctor–patient communication, and the quality of the information patients receive are important factors for patient adherence to treatment recommendations. Possible
Results
Thirty-nine focus groups with 246 participants were conducted in seven European countries. The key themes and second-order interpretations of the data from each country are shown in Box 2. The synthesis with key themes and third-order interpretations is presented in Table 3. The resulting key themes were: course of diabetes, information, person and context, body awareness and relationship with the health-care provider.
Discussion
The research questions were answered. The data from seven, parallel, qualitative studies was synthesised successfully to provide these answers. The results of this synthesis of qualitative studies using meta-ethnography show that the obstacles to adhering to treatment recommendations for people living with type-2 diabetes comes to an number of explanatory models: the course of diabetes, information, person and context, body awareness, and the relationship with the health-care provider. These
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgements
The authors thank the Executive and Research Committees of the European General Practice Research Network for encouraging this research project and for funding. The Departments of General Practice of the universities of Antwerp, Ljubljana, Maastricht, Rennes, Tartu, Warwick and Zagreb are thanked for their miscellaneous support.
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