Psychosocial Determinants of Treatment Adherence in Patients with Type 2 Diabetes – A Review

Figures & data

Table 1 Summary of the Qualified Studies

No	Author and Year	Study Design	Study Group	Psychosocial Factors Affecting Adherence to Diabetes Treatment	Limitations
1	Rao D et al, 2020^Citation17	A longitudinal study	287 black adult patients with T2DM (56.3% male) aged 52.6±12.03	Physician communication, beliefs about medicines, self-efficacy, depression, illness perception	- Small sample size - No regression models to assess predictors of adherence
2	Saffari M et al, 2019^Citation18	A longitudinal study	793 patients with T2DM (55.0% male) aged 70.21± 15.10 years.	Social support, religiosity, religious coping	- Social support and religious coping were context-based - No assessment of other factors associated with religiosity, (locus of control, spiritual coping, and self-efficacy)
3	Adisa R et al, 2017^Citation19	A prospective cross-sectional study	200 patients with T2DM aged 63.7 ± 12.4 years	Access to family support, monthly income, medicine affordability	- Self-report measure (risk of bias)- No assessment of availability and influence of structural support (knowledge and attitudinal barriers on outcome) - A cross-sectional study design
4	Smalls BL et al, 2015^Citation20	A cross-sectional study	615 adults with T2DM (61.6% male), 53.6% in aged 45–64 years, 53.6 non-Hispanic Black	Social support, social cohension, comorbidities, age 65+, hispanic race, health insurance – medicaid, being employed, food insecurity	- A convenience sample from only the southeastern United States - A cross-sectional study design
5	Tiv et al, 2012^Citation21	A cross-sectional study	3637 patients with T2DM aged 65.0 ±11.1 years (54.4% male)	Family and social support, age 65–84 years, professional activity, financial difficulties, presence of microvascular or macrovascular complications,	- Use of self-report data on medication adherence -Cross sectional study
6	Osborn CY and Egede LE, 2012^Citation22	A cross-sectional study	139 patients with T2DM in mean age 62.7 ±11.9 years (71.9% male), 41.4% African American	Social support, depressive symptoms	- No subgroups analysis (gender, race/ethnicity, health literacy status) - The PHQ-9 used to quantify depressive symptoms (other studies have shown that the tool overestimates the prevalence of major depression in samples of people with diabetes and other comorbidities) - A cross-sectional study design
7	Bouldin ED et al, 2017^Citation23	A cross-sectional study	253 adults age 30–70 with poorly controlled diabetes (45% white, 25% black, and 43% Hispanic)	Caregiver support	- Risk of bias (social desirability) - Using broad definition of having acaregiver (periodic or minimal assistance) -No information about how long the caregiver had provided assistance, what types of support the caregiver provided, the quality of care, or the caregiver’s confidence in promoting self-care - Small number of patients with caregiver - A cross-sectional study design
8	Song Y et al, 2013^Citation24	A descriptive observational study	83 Korean Americans with T2DM in mean age 56.5 ± 7.9 years (57.8% male).	Unmet needs for social support, self-efficacy, age	- Study was conducted on a relatively small and homogeneous sample from one ethnic minority group -Social support assessed by measuring the patients’ perceptions
9	Watkins YJ et al, 2013^Citation25	A cross-sectional study	132 African American adults with T2DM (male 33%), in mean age 52.2±12.8	Spirituality, religion, age, gender, income	-Study focused on African American adults -Self-reported data -No consideration of religious affiliations and associations and the impact they have on health behaviors (smoking, alcohol) - A cross-sectional study design
10	Anderson JR et al, 2016^Citation26	An observational study	117 couples in which one partner was diagnosed with T2DM (male patients 57.3%), mean age of patients 57.44 ± 9.83 years	Dietary adherence: diabetes stress, depressive symptoms Exercise adherence: comorbidities, T2DM duration, depressive symptoms	-The sample was fairly homogenous with respect to race/ethnicity, education, and geographic location-self-report measures
11	Bell RA et al, 2010^Citation27	A cross-sectional study	696 patients with T2DM divided into 2 groups: with depression (n=586, aged 74.1 ± 5.3 years, 64.6% male) and without depression (n=110, aged 74.1 ± 5.9 years, 35.4% male)	Depression	-A cross-sectional study -Self-report measures
12	Zhang Y et al, 2015^Citation28	A cross-sectional study	2538 patients with T2DM (53% male) aged 56.4 ± 10.5 years	Depression	- Patients from metropolitan hospital-based clinics only - No assessment of marital status and income which might have prognostic significance for depression -The PHQ-9 used to quantify depressive symptoms - No formal psychiatric examination to confirm a diagnosis of major depression
13	Carper MM et al, 2014^Citation29	A cross-sectional study	146 patients with T2DM (57.5% male) aged 56.01 ± 9.28 years	Depression, diabetes distress, quality of life (domains: personal relationships, environmental, achievement, psychosocial growth)	- The ratio of participants to measure items (9:1) - High levels of depression severity and diabetes distress of patients - A cross-sectional study design - recruited primarily non-Hispanic White limiting generalizability of the findings to other racial/ethnic groups
14	Sweileh WM et al, 2014^Citation30	A cross-sectional study	294 patients with T2DM (44.2% male), 73.5% ≤65 years,	Depression	- A cross-sectional study design -Self-report measures - No multivariate analysis of factors associated with adherence
15	Zuberi SI et al, 2011^Citation31	A cross-sectional study	286 patients with T2DM (44.8% male) aged 31–60 years	Depression	- A cross-sectional study design - No assessment of educational status and household income - Self-report measures
16	Derakhshan Shahrabad H et al, 2018^Citation32	A prospective observational cohort study	24 females with T2DM (aged 20–40 years) divided into 2 groups: control (n=12) and experimental (n=12) Intervention:12 weeks Lazarus multimodal psychotherapy	Depression, anxiety	-No adherence assessment - No formal psychiatric examination to confirm a diagnosis of depression -Self-reported data - No multivariate analysis of factors associated with adherence
17	Ciebiada M et al, 2017^Citation33	An observational study	55 patients with T2DM (34.5% male) aged 73.7 ± 4.4 years	Depression	- No standardised tool to assess adherence - No formal psychiatric examination to confirm a diagnosis of depression -Self-reported data - No multivariate analysis of factors associated with adherence
18	Górska-Ciebiada M et al, 2017^Citation34	An observational study	82 patients with T2DM and depressive syndrome aged >65 years	Depression	-A single-centre study with a small sample size - Self-reported data - No standardised tool to assess adherence
19	Akpalu J et al, 2018^Citation35	A cross-sectional study	400 patients with T2DM (21.5% male) aged 52.7 ± 8.7 years	-	- A cross-sectional study design - Patients were selected from a specialized tertiary hospital in urban Ghana - No standardised tool to assess adherence
20	Linetzky B et al, 2017^Citation36	A multinational prospective observational cohort study	4341 patients with T2DM in mean age 61.77 ± 11.02 years (50% male)	Diabetes duration, high country income, private insurance status, insulin treatment regimen, communication, diabetes-related distress	- A cross-sectional study design - No standardised tool to assess adherence -Self-reported data
21	Ratanawongsa N et al, 2013^Citation37	A cross-sectional study	9377 patients with T2DM in mean age 59.5±9.8 years (48.3% male)	Communication	- A cross-sectional study design - Risk of recall bias - Only CMG use to assess adherence and does not evaluate early stages of adherence for newly prescribed medications (primary nonadherence) - Limited pharmacy data on insulin use by patients
22	Kirkman MS et al, 2015^Citation38	An observational study	218,384 patients with T2DM (47% male) aged 64.9±4.8 years	TYPE of therapy (new or continuing), age, gender, education, income, geographic region, prescriber specialization, prescription factors (pill burden, prescription drug channel, out of pocket costs)	- No race/ethnicity data - No primary nonadherence (not filling an initial prescription for a medication) assessment - MPR measures only refill behavior and not actual medication taking
23	Xie Z et al, 2020^Citation39	A secondary data analysis of a 24-week randomized controlled trial (RCT)	148 patients with T2DM and hypertension (59.5% male), 52.7% aged ≥64 years	Perceived health status, self-efficacy, older age, gender, living status, diabetes duration	- Self-reported data
24	Mutyambizi C et al, 2020^Citation40	A cross-sectional study	396 patients with T2DM aged 41–60 years (39% male), 35% were African	Older age, being non-African, gender, professional activity, marital status, education	- A cross-sectional study design - The risk of social desirability bias during the face-to-face interviews - Data collected in two hospitals
25	Alfian SD et al, 2019^Citation41	An observational retrospective inception cohort study	6669 patients with T2DM (55.1% Male) aged 63.2+11.3 years	Older age, type of prevention, the prescription of diuretics, beta-blocking agents or calcium channel blockers as initial drug class, gender	- Assessment of non-adherence and non-persistence based on drug dispensing (risk of underestimate true rates, because of not taking all the drugs collected at the pharmacy) - Coexisting hypertension
26	Mahfouz EM and Awadalla HI, 2011^Citation42	A cross-sectional analytic study	206 patients with T2DM (39.8% of male) aged 54±6.3 years	Self-monitoring: older age, education dietary adherence: occupation, duration of diabetes	- A cross-sectional study design - Self-reported data
27	Mendes R et al, 2019^Citation43	A cross-sectional study	94 patients with T2DM in mean age of 75.2 ±6.7 years (46.8% male)	Anxiety, insulin use	- A cross-sectional study design - Self-reported data
28	Akturk U et al, 2018^Citation44	A descriptive observational study	264 patients with T2DM aged 52.33±14.6 years (39.4% male)	Education level, acceptance of illness, professional activity, income, support for care, smoking, comorbidities	- Recruited only the patients registered in the Başharık Family Health Center - Self-reported data
29	Alyami M et al, 2019^Citation45	An observational study	115 Muslim Saudi nationals patients with T2DM, in mean age 56±12.43 years (58% male)	Age, sense of coherence, illness perception – consequences and illness identity	- Participants were recruited from a single diabetes outpatient clinic using convenience sampling - Self-reported data
30	Özkaptan BB et al, 2019^Citation46	A cross-sectional, descriptive study	200 patients with T2DM in mean age 53.87 ± 11.3 years (37.5% male)	Age, BMI, HbA1c, fasting blood glucose, postprandial blood glucose, acceptance of illness	- A cross-sectional study design - Self-reported data - No analysis of the correlation between acceptance of illness and adherence
31	Can S et al, 2020^Citation47	A cross-sectional, study	133 patients with T2DM in mean age 57.3±11.7 years (37.6% male)	Acceptance of illness in domain diet, exercise, foot care and total	- A cross-sectional study design - Self-reported data - No analysis of the correlation between acceptance of illness and adherence - No standardised tool to assess adherence
32	Dhippayom T and Krass I, 2015^Citation48	An observational cross-sectional study	543 T2DM patients (57.6% male) aged 63.0 ± 10.6 years	Age, knowledge of diabetes and treatment, beliefs about medicines - specific-concern, reported having difficulty in paying for medication, insulin use, polypharmacy	- A cross-sectional study design - Self-reported data
33	Graça Pereira M et al, 2019^Citation49	An cross-sectional study	387 Caucasian patients diagnosed with T2DM (58.1% male) in mean age 59.2 years	Bieliefs about medicines (needs), illness perception (concerns, consequences, personal control, treatment control, emotional response)	- A cross-sectional study design - Self-reported data
34	Yoel U et al, 2013^Citation50	An observational cohort study	101 low adherent Bedouin patients with diabetes, hypertension and lipid metabolic disorder aged 49.7 ± 12.0 years (51.5% male) and 99 high adherent patients aged 55.3 ± 12.4 years (36.4% male)	Beliefs about medicines	- Coexisting lipid metabolic disorder and hypertension - Questions about the clinic team were asked to patients at the clinic - Self-reported data - Study focused only on Bedouin - No multivariate analysis of factors associated with adherence
35	Rosland AM et al, 2015^Citation51	A community-based participatory study	108 patients with T2DM divided into 2 groups: intervention (n=56, 25% male, aged 50.2 ±10.2 years) and control (n=52, 32.7% male, aged 56.4 ±12.3 years) Intervention: The six-month intervention included CHW-delivered group diabetes management classes, home visits and accompaniment to physician appointments to model activated participation	Family and friends support, CHW support	- A cross-sectional study design - Study participants were low-income, racial/ethnic minority adults - Assessment of only one type of diabetes social support(positive support from family and friends) - Self-reported data - No standardised tool to assess adherence
36	Rosland AM et al, 2014^Citation52	An cross-sectional study	13,366 patients with T2DM (51% male) aged 59±10 years	Healthful eating and physical activity: social support, emotional support	- A cross-sectional study design - Self-reported data - Analysis of 18 multivariable models and risk of one or more false positive findings

Abbreviations: T2DM, type 2 diabetes mellitus; BMI, body mass index; HbA1c, glycated hemoglobin; CHW, community-based health worker; PHQ-9, Patient Health Questionnaire-9; MPR, Medication Possession Ratio; CMG, Continuous Measure of Medication Gaps.

Figure 1 Study flow chart.

Note: Own elaboration based on the data obtained in the study.

Figure 2 Factors influencing adherence to treatment recommendations by patients with diabetes according to WHO modified by own elaboration.

Note: Figure based on data from World Health Organization⁵³ and supplemented with psychosocial factors not included in the WHO report.

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