From Compliance to Adherence in Diabetes Self-Care: Examining the Role of Patient’s Potential for Mindful Non-Adherence and Physician-Patient Communication

Abstract

Purpose

To examine factors that facilitate an understanding of the relationship between two important, and often interchangeably used, concepts in diabetes management: compliance and adherence.

Design

A cross-sectional survey.

Setting

Online data collection.

Subjects

365 respondents at least 18 years of age and currently in treatment for diabetes.

Measures

We measured patients’ compliance, adherence, mindfulness, and perceptions about physician-patient communication, as well as their demographic characteristics.

Analysis

A moderated mediation analysis was conducted to examine the conditioned indirect effect of compliance on adherence.

Results

The direct effect of compliance on adherence was positive and significant (β = .378, SE = .073, P < .05, BootCI [.234, .521]), but the compliance-adherence association was also partially mediated by patient’s potential for mindful non-adherence. A higher level of compliance increased potential for mindful non-adherence (β = .716, SE = .082, P < .05, BootCI [.555, .876]), and, in turn, the increased potential for mindful non-adherence reduced adherence (β = −.107, SE = .045, P < .05, BootCI [–.196, −.018]). This detrimental mediating effect of potential for mindful non-adherence was contingent on the perceived quality of physician-patient communication (index = .076, SE = .038, 95% BootCI [.003, .153]), indicating that the positive perception significantly reduced the negative mediating effect of potential for mindful non-adherence on adherence.

Conclusion

Given that patients with diabetes are involved in a complex self-care, an established partnership and collaboration between patient and doctor is essential to promoting adherence; when the treatment coincides with the patient’s beliefs and needs, mindful non-adherence is less likely to occur.

Keywords

patient adherence compliance physician-patient communication mindful non-adherence diabetes care moderated mediation

Purpose

Diabetes is one of the leading causes of blindness, amputation, end-stage renal disease, cardiovascular disease, and other acute complications.¹ It is also the seventh leading cause of death in the United States, affecting over 30 million people of all ages.² Research shows that 415 million people worldwide live with diabetes, and this number will continue to rise.³ While Type 1 and Type 2 diabetes vary in their etiological, pathophysiological, epidemiological features,^4,5 adherence to doctor-recommended treatments is critical to both Type 1 and Type 2 diabetes patients managing their diabetes and avoiding health complications.¹ Unfortunately, studies have shown that a large number of patients have difficulty with adherence to doctor-recommended treatments,⁶ and non-adherence to recommended treatment regimens has been reported as a major barrier in the management of diabetes patients.^7,8

In light of the importance of this issue, a substantial body of research has been conducted to examine compliance and adherence to medical instructions for patients with a variety of chronic illnesses,⁹ including type 1 and type 2 diabetes.^10-13 However, while the accumulated findings provide some consistent information on specific factors hindering the ability of patients to follow their doctors’ diabetes care recommendations,^14,15 conceptualization of patient adherence used in the literature has been ambiguous or inconsistent. In particular, two closely connected but distinct terms—“compliance” and “adherence”—have been used interchangeably.¹⁶ Although scholars have pointed out that they are different concepts,^17-21 to our knowledge, no research has empirically tested how adherence differs from and/or is connected to compliance and what the implications of differentiating the 2 concepts are for improving patient adherence. The present study aims to address this gap. We first review the conceptual difference between adherence and compliance as two valuable but separate components in the course of diabetes care. Then, we examine the role of 2 other variables, patient’s potential for mindful non-adherence and physician-patient communication, to identify important factors in understanding the path from compliance to adherence.

Compliance and Adherence

Overall, the terms compliance and adherence have been used interchangeably in the literature, despite their conceptual differences.^16,18,22 According to the Oxford English Dictionary, compliance is defined as “the acting in accordance with, or the yielding to a desire, request, condition, direction, etc.” This definition implies an asymmetric power relationship between 2 involved parties, such as the expectation that patients will passively follow orders in a medical context. A conventional definition of compliance—“the extent to which a person’s behavior in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice”²³—demonstrates this view, emphasizing an imbalanced relationship between the patient and the doctor.²⁴ According to Cramer and colleagues,¹⁹ patient compliance is closely related to developing the habit of taking medication in accordance with the physician’s prescription (time, quantity, and frequency). Similarly, compliance has been defined as the extent to which the patient’s behavior matches the prescriber’s recommendations.²⁵ Given that the term “compliance” implies a passive action, some scholars have associated it with the issues surrounding the dominance of medicine where patients surrender all decision-making and control to health care providers.^26,27

Adherence, on the other hand, implies persistence in practice and maintenance of behavior beyond compliance.^28,29 Coming from the Latin word adhaerere, which means “to cling to, keep close, or remain constant,” adherence refers not to the accurate following of rules but rather to the extent to which the individual keeps following the previously accepted rules.¹⁷ Adherence is also distinguished from the passive nature of compliance in that adherence decreases when patients do not perceive any benefit from changing their behavior.^30,31 Thus, “adherence” has been considered a broader term that incorporates factors affecting a patient’s ability and motivation to follow treatment recommendations. This notion of adherence aligns with the modern vision of healthcare, which assumes that the patient participates in the treatment development process, being a “consumer” of medical services rather than a passive obedient participant.³²

While the concept of compliance has been valuable in understanding the complex problems and decision-making processes involved in diabetes care,¹⁶ an examination of how adherence evolves from compliance will further enhance our understanding. Diabetes self-management is complex and at times can be discouraging.³³ Once it is established that the patient is sufficiently familiar with the recommended treatment plan to perform it correctly, it is equally important to ensure that the patient continues performing the accepted self-care plan for an extended period of time. Thus, the main goal of this study is to examine the factors that can lead from compliance to adherence.

The Role of Patient’s Potential for Mindful Non-Adherence

While adhering to management regimes instructed by a doctor in everyday life is a challenging task by nature,³⁴ non-adherence has also been viewed as a result of rational decision-making based on patients’ personal beliefs about the medical advice they receive.^35-37 Donovan and colleagues³⁶ were some of the first to note that doctors and patients could have different perspectives on health and illness. According to them, illness is considered normal to doctors, and they have a clear understanding of appropriate treatment. To patients, illness is considered abnormal, and they have a range of alternative beliefs that are rational on their own terms. When their beliefs conflict with the doctors’ view and the conflicts are unresolved, they may stay confused and dissatisfied.³⁷ Donovan and Blake³⁶ also argued that patients’ choice to ignore advice or alter prescribed doses of medication could be a reasoned decision because they carefully analyze each treatment option offered and make their own decisions based on those analyses. In this case, the process of following doctor’s recommendations is strategic and “mindful” rather than “mindless.”³⁶ Other scholars have also conceptualized (non-)adherence as a multifactor phenomenon that can be the result of a mindful decision process based on patients’ personal beliefs.³⁸ For example, patients do not simply perceive that taking drugs is entirely an action of obeying the doctor’s orders^31,39 Instead, they weigh the costs and benefits of taking particular medications as they perceive them within the context of the constraints of their everyday lives and need.^36,40 Thus, patients’ increasing desire for autonomy can shape a central component of patient’s potential for mindful non-adherence.³⁹

Based on the review of the linkage between compliance and adherence, we first hypothesize that, in general, there is a positive relationship between them (H1). Furthermore, as the literature suggests that patients’ mindful autonomous decision-making process can serve as a filter for medical advice, it is reasonable to posit that patients’ increased mindfulness may lead them to choose to ignore some medical recommendations that they initially complied with. Thus, we hypothesize that patient’s potential for mindful non-adherence will mediate the relationship between compliance and adherence (H2).

The Role of Physician-Patient Communication

The next natural question is under what conditions patients are more likely to make their own mindful decisions that will lead them to continue or discontinue following doctors’ medical recommendations. As reviewed in the previous sections, compliance may be achieved even in the traditional physician-patient interaction setting in which the doctor weighs all risks and benefits, makes a decision, and assumes the patient will follow it. Mindful adherence, on the contrary, may not be achieved without a shared decision-making and cooperation communication process. Indeed, increasing patient empowerment—a self-determination of health and treatment-related goals—through effective physician-patient communication has become an important component of modern healthcare.^32,41 According to the patient-centered care approach introduced to confront the conventional paternalistic view of physician-patient relationship,²⁴ patient’s view of illness, life circumstances, unique needs, and perspectives on recovery should be considered before prescribing a treatment.^42,43 Similarly, a contemporary mutual participation model of physician-patient relationship emphasizes an equal distribution of power, a shared decision-making, and a mutual cooperation between the 2 parties.⁴⁴

Extensive research has shown the effectiveness of these approaches in promoting patient adherence and various positive health outcomes.^41,43,45 For example, collaborative, goal-oriented, communication between health professionals and patients was found to enhance patients’ satisfaction, self-efficacy, and commitment.^41,46-48 Researchers have also reported that patients who play an active role in the communication process by asking questions and sharing opinions tend to understand the treatment regimen better⁴⁹ and are more likely to seek healthcare options.⁴⁶ In particular, scholars point out that chronic illness care decisions are more likely to require an active patient role.⁵⁰ Thus, perceptions about physician-patient communication can be an important factor in understanding the relationship between compliance and adherence through patient’s potential for mindful non-adherence in diabetes care. The role of patient’s potential for mindful non-adherence in explaining the relationship between compliance and adherence may vary according to how satisfactory and positive the patients perceive their interaction with physicians. Thus, we propose that the effect of patient’s potential for mindful non-adherence in intervening the compliance and adherence relationship will be moderated by the quality of physician-patient communication (H3). By examining these hypotheses, the present study aims to facilitate an understanding of the relationship between 2 important, and often interchangeably used, concepts in diabetes management: compliance and adherence. Figure 1 presents the conceptual model and hypothesized paths tested in this study.

Figure 1.

Hypothesized model.

Methods

Design and Sample

We recruited participants through the online data-collection service Mechanical Turk (MTurk). MTurk is a website where participants from across the globe can take surveys and receive compensation for their efforts. MTurk samples are more demographically diverse with respect to race, age, educational attainment, income, and other factors and are inexpensive compared to other non-subject pool options such as survey panels.⁵¹ In this study, MTurk’s geographic qualification function was applied to recruit participants only from the United States. To be eligible for participating in this survey research, a person had to be at least 18 years of age and currently in treatment for diabetes. When recruiting rare populations, however, it is essential to use pre-screening measures (e.g., masking qualification criteria) to prevent fraudulent responses.⁵² Thus, we created a short pre-survey with 3 masked questions to determine eligibility. Among the 1852 respondents who participated in the pre-survey, only those who met the eligibility (n = 367) were provided with a link to the main survey hosted on Qualtrics and asked to sign an informed consent. Participants were compensated $.50 for their work. Based on the examination of the quality of responses and outliers in the collected data, those who submitted unfinished questionnaires or unreliable responses, such as unvarying responses across different measurement items including identical responses for reverse-coded items (n = 14), and those who spent less than 3 minutes or over 35 minutes to complete the survey (n = 36) were excluded.

Measures

Compliance

Compliance is operationalized as the extent to which a patient’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health recommendation. A 16-item Diabetes Self-Management Questionnaire (DSMQ) developed by Schmitt and colleagues⁵³ was used to assess recommended self-care activities associated with glycemic control in patients with diabetes. The DSMQ has previously demonstrated efficiency to provide reliable and valid information on diabetes self-management. All items were scored on a four-point scale with anchors 1 applies to me very much) to 4 (does not apply to me). In the present study, the reliability across the items was .84.

Adherence

Adherence is operationalized as persistence in practice and maintenance of diabetes self-care behavior. In this study, 4 items were used to assess patient adherence to recommended treatment. Example items include “I stick to my diabetes treatment schedule even when I don’t feel well” and “I continue with my diabetes treatment even if doing so interferes with my daily activities.” Items were answered on a 5-point scale ranging from 1 (not true at all) to 5 (very true). In the present study, the scale scores had an estimated internal consistency reliability of .79.

Patient’s Potential for Mindful Non-Adherence

Based on the literature that considers non-adherence as a type of mindful decisions led by a patient’s rational analysis of the doctor-recommended diabetes treatment based on the patient’s beliefs,^35,36,38 the 4-item “mindful non-adherence” sub-dimension of the Patient Self-Advocacy Scale (PSAS)³⁵ was used to assess a patient’s mindfulness. The 4 items were specifically developed to measure the potential of a mindful non-adherence in health behaviors, which is a tendency to reject treatments or a willingness to be non-adherent when treatments fail to meet patient expectations. Items were answered on a 5-point Likert scale ranging from 1 (not true at all) to 5 (very true), rating participants’ agreement with statements such as “Sometimes I think I have a better grasp of what I need medically than my doctor does” and “If I am given a treatment by my physician that I don't agree with, I am likely to not take it.” In the present study, the scale scores had an estimated internal consistency reliability of .85.

Physician-Patient Communication

The quality of physician-patient communication is operationalized as a collaborative problem-solving and decision-making process based on ongoing interaction between doctor and patient with respect to the patient’s beliefs. The quality of physician-patient communication was measured with a 15-item Health Care Climate Questionnaire (HCCQ).^31,37 HCCQ was designed to be used by patients to report their perceptions of their doctors and assess how the physician’s support motivates the patient to take personal responsibility for his/her health. Example items include “I feel that my physician provided me with choices and options” and “My physician listens to how I would like to do things.” Items were answered on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), and scores on the 5 items were added together to get a total physician-patient communication score. In the present study, the scale scores had an estimated internal consistency reliability of .92. Correlations, means, and standard deviations for the key variables are presented in Table 1.

Table 1.

Correlations, Means, and Standard Deviations for Study Variables.

Variables	M	SD	1	2	3	4
1. Adherence	3.875	.740	1
2. Compliance	2.939	.658	.281**	1
3. Mindfulness	2.909	.987	–.004	.480**	1
4. Physician-patient communication	3.833	.745	.544**	.260**	.144*	1

Note. ** P < .01 level, *P < .05 level.

Analysis

We first estimated the measurement model by conducting a confirmatory factor analysis (CFA) to assess the validity of the factor structure of each construct measured in this study. A minimum factor loading of .50 was used as a criterion for including items to be a part of a construction. The measurement model was constructed and analyzed in Mplus v.8.⁵⁴ using maximum likelihood estimation. We used the following indices to assess fit: χ², comparative fit index (CFI) with values of .90 indicating adequate fit and values of .95 indicate good fit; root mean square error of approximation (RMSEA), with values of .05 or lower suggesting good model fit and values between .05 and .08 suggesting reasonable fit; and standardized root mean square residual (SRMR) with values of less than .10 indicating good model fit.

To test hypotheses 1 through 3 (see Figure 1), we used the PROCESS macro developed by Hayes.⁵⁵ PROCESS macro facilitates the implementation of bootstrapping methods and allows for probing the significance of conditional indirect effects at different values of the moderator variable. Model 4 in the PROCESS permits testing the indirect effect of an independent variable (compliance with diabetes treatment recommendations in the present study) on a dependent variable (adherence to diabetes treatment recommendations) through a mediator (patient mindful non-adherence). Model 14 in the PROCESS⁵⁵ permits testing the conditioned indirect effect of an independent variable (compliance with diabetes treatment recommendations in the present study) on a dependent variable (adherence to diabetes treatment recommendations) through a mediator (patient’s potential for mindful non-adherence) for different levels of a moderator (physician-patient communication). Three variables were controlled for in this study: age, gender, and ethnicity. Hayes’s bootstrapping procedure⁵⁵ provides an estimation of both direct effects and conditional indirect effects. PROCESS reports a bootstrap 95%-confidence interval for the indirect effect, which is considered significant if the confidence interval does not include zero. The index of moderated mediation shows whether and to what extent an indirect effect is moderated in a model.⁵⁵

Results

The total number of respondents included in the final analyses were 317 (62% male), with most participants in the age group 25–49 years old (n = 222, 70%), followed by the 18–25 age group (n = 62, 19.6%), 50–65 age group (n = 23, 7.3%), and 65 and older age group (n = 10, 3.2%). Most participants were identified white (n = 199, 62.8%), followed by black or African American (n = 69, 21.8%), Hispanic or Latino (n = 19, 6%), Asian or Pacific Islander (n = 23, 7.3%), Native American (n = 5, 1.6%), and others (n = 2, .6%) (see Table 2).

Table 2.

Study Sample Demographics.

Demographics	n (%)
Gender
Male	196 (62)
Female	121 (38)
Age
18–25	62 (19.6)
25–49	222 (70)
50–65	23 (7.3)
65 and older	10 (3.2)
Ethnicity
White	199 (62.8)
Black/African American	69 (21.8)
Hispanic/Latino	19 (6)
Asian/Pacific Islander	23 (7.3)
Native American	5 (1.6)
Other	2 (.6)

The result of the CFAs with maximum likelihood estimation showed good overall model fit to the data, (χ²[371] = 777.09, P < .05, CFI = .906, RMSEA = .059, 90% confidence interval [CI] = .053, .065, SRMR = .053), indicating that the hypothesized factor structure was reasonable.

The direct effect of compliance on adherence was found to be positive and significant (β = .378, SE = .073, P < .05, BootCI [.234, .521]), indicating that a higher level of compliance leads to a higher level of adherence even after controlling for the influence of patient’s potential for mindful non-adherence. Thus, hypothesis 1 was supported. With regard to hypothesis 2, in addition to the direct effect there was a statistically significant indirect effect of compliance on adherence through mindfulness, indicating a partial mediation (Indirect effect = −.077, SE = 045, P < .05, BootCI [−.177, −.001]) (see Table 3). Specifically, a higher level of compliance was positively related to patient’s potential for mindful non-adherence (β = .716, SE = .082, P < .05, BootCI [.555, .876]), and, in turn, the increased mindfulness was associated with reduced adherence (β = −.107, SE = .045, P < .05, BootCI [−.196, −.018]). Thus, hypothesis 2 was supported.

Table 3.

Indirect Effect of Compliance on Adherence through Patient’s Potential for Mindful Non-adherence.

	Direct Effect of Compliance on Adherence (Hypothesis 1)
Mediator	b	SE	Bootstrap 95% CI
Mindfulness	.378	.073	(.234 .521)
	Indirect effect of compliance on adherence (Hypothesis 2)
Mediator	b	SE	Bootstrap 95% CI
Mindfulness	−.077	.045	(−.177 −.001)

Note. The table reflects values controlled for effects of age, gender, and ethnicity.

Finally, hypothesis 3 examined whether the indirect effect of compliance on adherence through patient’s potential for mindful non-adherence can vary according to (i.e., can be conditioned by) the quality of physician-patient communication. The effects of demographic variables (age, gender, and ethnicity) were controlled. Confidence intervals (95%) were estimated using bootstrapping procedures with 10 000 resamples. Our analysis showed that, even when controlling for participants’ age and gender, patient’s potential for mindful non-adherence did not play a mediating role that weakened the positive linkage between compliance and adherence when patients’ perceptions about the quality of physician-patient communication were positive. As shown in Table 4, the index of moderated mediation was significant (index = .076, SE = .038, 95% BootCI [.003, .153]), indicating that the indirect effect of compliance on adherence through potential for mindful non-adherence is contingent on the quality of physician-patient communication. Specifically, the indirect effect of compliance on adherence through potential for mindful non-adherence was significant for low (b = −.157, SE = .055, 95% BootCI = −.277 to −.062) and middle levels of the quality of physician-patient communication (b = −.104, SE = .039, 95% BootCI = −.193 to −.038), but did not reach its significance when the perceived quality of physician-patient communication was high (b = −.05, SE = .038, 95% BootCI = −.139 to .011). Thus, hypothesis 3 was supported.

Table 4.

Conditioned Indirect Effect of Compliance on Adherence through Mindfulness by Physician-Patient Communication.

	Condition: Quality of Physician-Patient Communication
Mediator		b	SE	Bootstrap 95% CI
Mindfulness	Low	–.157	.055	(–.277 −.062)
	Middle	–.104	.039	(–.193 −.038)
	High	–.052	.038	(–.139 .011)
Index of moderated mediation		.076	.038	(.003 .153)

Note. Values for the quantitative moderator (physician-patient communication) are the mean and plus/minus one SD from mean. The table reflects values controlled for effects of age, gender, and ethnicity.

Discussion

The present study contributes to the extant diabetes research and practice by examining the role of patient’s potential for mindful non-adherence and quality of physician-patient communication as factors that bridge compliance and adherence. The existing literature uniformly emphasizes the crucial role of adherence to treatment recommendations in the complex and longstanding diabetes management process. However, non-adherence to recommended treatment regimens remains as a major barrier in the management of patients with diabetes, and factors that can lead from an initial compliance to persistent adherence to recommended medication regimen and exercise requirements have been underexamined.

To understand how patients’ with diabetes adherence can evolve from compliance, we first focused on the role of patient’s potential for mindful non-adherence. The results indicate that increased patient’s potential for mindful non-adherence could negatively intervene in the positive relationship between compliance and adherence. Specifically, patients with diabetes who perceived good reasons not to follow the advice of their doctor are less likely to adhere to the recommended diabetes treatment. As reviewed earlier, patient’s potential for mindful non-adherence encompasses a patient’s right to choose whether to follow treatment recommendations, making the patient’s autonomous decision-making a main contributor to adherence or non-adherence.^31,35-37 This finding is consistent with the argument that non-adherent health behavior is often strategic and a result of rational decision-making, demonstrating that patient’s potential for mindful non-adherence can serve as a filter for any medical advice patients receive.

To further examine under what conditions patients are more likely to make their mindful decisions to maintain or stop following doctors’ medical recommendations, we focused on the role of physician-patient interaction. Previous research has shown that patients tend to be more satisfied and are more likely to follow the agreed treatment plan when their physician engages in a cooperative communication style.^41,43, Consistent with the literature, we found that physician-patient communication played a significant role in the transition from compliance to adherence in patients with diabetes. Patients with diabetes who felt empowered by their doctor and were involved in a collaborative decision-making process about their treatment reported better adherence to recommended self-care behavior. Moreover, their positive perception of physician-patient communication significantly reduced the negative mediating effect of mindfulness on adherence.

These findings together indicate that even though patient’s potential for mindful non-adherence, based on personal beliefs and autonomy level, can reduce adherence to diabetes self-care, patient-centered care with the emphasis on effective physician-patient communication^32,42,43 can mitigate this tendency and thus improve adherence. Effective physician-patient communication not only focuses on the well-being of the individual but also accounts for the patient’s experience of the illness and personal beliefs in a shared decision-making process.^{35,40,49,56,57} Our finding confirms that an established partnership and collaboration between patient and doctor is essential to promoting adherence in patients with diabetes; when the treatment coincides with the patient’s beliefs and needs, mindful non-adherence is less likely to occur.

Given that patients with chronic illnesses are usually involved in complex self-care and need to persistently follow the recommended medication regimen and exercise requirements, many scholars have pointed out that understanding and promoting passive compliance may not be sufficient to improve positive outcomes in managing a chronic diabetes condition.^18,26,36 Findings from this study provide empirical support regarding how treatment plan following (compliance) can be promoted into persistent self-care (adherence) by overcoming possible barriers of patient autonomous decision-making through a patient-centered approach to healthcare. While it is important to educate patients on following the recommended treatment, it is also crucial to inform doctors about the importance of understanding and responding to patients’ personal beliefs that might contradict effective treatment. Patient-centered care with an emphasis on proper physician-patient communication can help facilitate this process.

It should be noted that the findings and discussions of this study cannot be isolated from the ongoing discussions about the inconsistent conceptualization and operationalization of compliance and adherence. For example, another concept, concordance, has been used as a synonym for compliance or adherence in the literature.^25,58,59 Thus, while the conceptual definitions of variables and their relationships examined in this study were carefully chosen based on the existing literature, we acknowledge that our approach might be only a subset of a larger body of research concerning patient compliance and adherence. Also, a number of different approaches have been used in previous studies to assess patient compliance and adherence, including the use of direct, behavioral measures, such as blood testing.⁶⁰ The present study, by contrast, relies on self-reported responses to measure the two concepts. Moreover, in our study, mindful non-adherence and physician-patient communication was measured solely based on the patients’ perspective and was not observed directly. This decision was on the basis of previous research reporting that patient perception was the most reliable measure of patient-centered communication.⁶¹ However, we cannot rule out the possibility that those self-reported measures involve errors in the survey and statistical estimation processes. For instance, some patients might have reported a higher level of compliance than it is due to self-representation bias, while other participants with a low self-advocacy and autonomy level have under-reported their compliance or adherence behavior. In addition, the current study focuses on examining the role of two variables—patient’s potential for mindful non-adherence and physician-patient communication—to shed light on the path from compliance to adherence in relation to diabetes self-care. It should be noted, however, that there are other significant factors that can produce critical conditions that influence the relationship between compliance and adherence.⁶² For example, our analyses did not differentiate between Type 1 and Type 2 diabetes while they differ in their clinical characteristics and treatment methods.⁵ Relatedly, although we took the influence of age, gender, and ethnicity into account in the analysis, there were only few participants in the age group over the age of 65. This may reflect the known tendency of MTurk recruitment to attract younger population.⁶³ Moreover, other individual- and social-level factors (e.g., income level, education level, type of health insurance, self-regulation, social support, etc.) may also provide critical conditions that influence patient adherence in diabetes management. Lastly, the findings of the present study should be limited to the particular health behavior and individuals examined in this study. Despite the limitations outlined above, this study provides an important opportunity to update the existing diabetes care literature by distinguishing adherence from compliance and providing empirical evidence about the role of patient’s potential for mindful non-adherence and physician-patient communication for understanding their relationship.

So What? (Implications for Health Promotion Practitioners and Researchers)

What is already known on this topic?

Patients with chronic illnesses are usually involved in complex self-care and need to persistently follow the recommended medication regimen and exercise requirements. While adherence to these recommendations is crucial in leading to positive health outcomes during the prolonged diabetes management process, non-adherence to recommended treatment regimens remains as a major barrier.

What does this article add?

Distinguished from the concept of compliance which implies the passive role of patients, the concept of adherence encompasses elements associated with a patient’s ability and motivation to follow treatment recommendations. However, factors that can lead to adherence from compliance have been underexamined. This study contributes to the literature by examining the role of patient’s potential for mindful non-adherence and physician-patient communication as factors in understanding the compliance-adherence relationship.

What are the implications for health promotion practice or research?

Our findings highlight that patients’ mindful and autonomous decision-making can be a barrier in facilitating the flow from compliance to adherence. Equally importantly, however, an established physician-patient partnership based on collaborative communication process is essential to promoting adherence in patients with diabetes, mitigating the occurrence of mindful non-adherence. These findings can help health researchers and practitioners better understand how to lead active, persistent self-care (adherence) from the passive following of treatment recommendations (compliance).

Footnotes

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare that there is no conflict of interest. The study was approved by the Institutional Review Board at the University of Miami. Approval number is 20190622. All participants gave their consent by signing a written consent form.

Author Contributions

KS and ME: conceptualization and design of the study, data collection, data analysis, writing process, content editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kim Soyoon

Malova Ekaterina

References

Harding

Pavkov

Magliano

Shaw

Gregg

. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019;62(1):3-16. doi:10.1007/s00125-018-4711-2.

National Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention, US Department of Health and Human Services. Published online 2020:12–15. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2Fdata%2Fstatistics-report%2Fdiagnosed.html

Ogurtsova

da Rocha Fernandes

Huang

Linnenkamp

Guariguata

Cho

, et al. IDF Diabetes Atlas: global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40-50. doi:10.1016/j.diabres.2017.03.024.

Ozougwu

Obimba

Belonwu

Unakalamba

. The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. J Physiol Pathophysiol. 2013;4(4):46-57.

Liu

Sun

Snetselaar

, et al. Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: population based study. BMJ. 2018;362:k1497. doi:10.1136/bmj.k1497.

Egede

Gebregziabher

Dismuke

Lynch

Axon

Zhao

, et al. Medication nonadherence in diabetes: longitudinal effects on costs and potential cost savings from improvement. Diabetes Care. 2012;35(12):2533-2539. doi:10.2337/dc12-0572.

Han

Sohn

Lee

J-Y

Jang

. Health behaviors and medication adherence in elderly patients. Am J Health Promot. 2017;31(4):278-286. doi:10.4278/ajhp.150205-QUAN-709.

Patel

Gupta

Burns

Mohamed

Cole

Lane

, et al. Biochemical Urine Testing of adherence to cardiovascular medications reveals high rates of nonadherence in people attending their annual review for type 2 diabetes. Diabetes Care. 2019;42(6):1132-1135. doi:10.2337/dc18-1453.

Cheen

MHH

Tan

Wee

Thumboo

. Prevalence of and factors associated with primary medication non‐adherence in chronic disease: A systematic review and meta‐analysis. Int J Clin Pract. 2019;73(6):e13350. doi:10.1111/ijcp.13350.

10.

Atinga

Yarney

Gavu

. Factors influencing long-term medication non-adherence among diabetes and hypertensive patients in Ghana: A qualitative investigation. PLoS One. 2018;13(3):e0193995. doi:10.1371/journal.pone.0193995.

11.

Giugliano

Maiorino

Bellastella

Esposito

. Clinical inertia, reverse clinical inertia, and medication non-adherence in type 2 diabetes. J Endocrinol Invest. 2019;42(5):495-503. doi:10.1007/s40618-018-0951-8.

12.

Murchison

Hark

Pizzi

Dai

Mayro

Storey

, et al. Non-adherence to eye care in people with diabetes. BMJ Open Diabetes Res Care. 2017;5(1):e000333. doi:10.1136/bmjdrc-2016-000333.

13.

Wei

Champman

Chen

, et al. Beliefs about medicines and non-adherence in patients with stroke, diabetes mellitus and rheumatoid arthritis: a cross-sectional study in China. BMJ Open. 2017;7(10):e017293. doi:10.1136/bmjopen-2017-017293.

14.

Capoccia

Odegard

Letassy

. Medication adherence with diabetes medication. Diabetes Educ. 2016;42(1):34-71. doi:10.1177/0145721715619038.

15.

Davies

Gagliardino

Gray

Khunti

Mohan

Hughes

. Real-world factors affecting adherence to insulin therapy in patients with Type 1 or Type 2 diabetes mellitus: a systematic review. Diabet Med. 2013;30(5):512-524. doi:10.1111/dme.12128.

16.

Chatterjee

. From compliance to concordance in diabetes. J Med Ethics. 2006;32(9):507-510. doi:10.1136/jme.2005.012138.

17.

Aronson

. Compliance, concordance, adherence. Br J Clin Pharmacol. 2007;63(4):383-384. doi:10.1111/j.1365-2125.2007.02893.x.

18.

Cohen

. Concept analysis of adherence in the context of cardiovascular risk reduction. Nurs Forum. 2009;44(1):25-36. doi:10.1111/j.1744-6198.2009.00124.x.

19.

Cramer

Roy

Burrell

Fairchild

Fuldeore

Ollendorf

, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11(1):44-47. doi:10.1111/j.1524-4733.2007.00213.x.

20.

De las Cuevas

. Towards a clarification of terminology in medicine taking behavior: compliance, adherence and concordance are related although different terms with different uses. Curr Clin Pharmacol. 2011;6(2):74-77. doi:10.2174/157488411796151110.

21.

Stevenson

. Concordance: what is the relevance for pharmacists? Int J Pharm Pract. 2001;9(2):67-70. https://academic.oup.com/ijpp/article-abstract/9/2/67/6139014.

22.

Hearnshaw

Lindenmeyer

. What do we mean by adherence to treatment and advice for living with diabetes? A review of the literature on definitions and measurements. Diabet Med. 2006;23(7):720-728. doi:10.1111/j.1464-5491.2005.01783.x.

23.

Haynes

Sackett

. Compliance in health care: Johns Hopkins University Press; 1979. Published online.

24.

Håkansson Eklund

Holmström

Kumlin

Kaminsky

Skoglund

Höglander

, et al. “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Educ Counsel. 2019;102(1):3-11. doi:10.1016/j.pec.2018.08.029.

25.

Horne

Weinman

Barber

Elliot

Morgan

Cribb

, et al. Concordance, adherence and compliance in medicine taking. NCCSDO:40-46. https://www.academia.edu/download/48441294/Concordance_Adherence_and_Compliance_in_20160830-5901-19sk9e2.pdf (2005).

26.

Lutfey

Wishner

. Beyond “compliance” is “adherence”. Improving the prospect of diabetes care. Diabetes Care. 1999;22(4):635-639. doi:10.2337/diacare.22.4.635.

27.

Spencer

. Transforming patient compliance research in an era of biomedicalization. J Health Soc Behav. 2018;59(2):170-184. doi:10.1177/002214651875686.

28.

Benner

Glynn

Mogun

Neumann

Weinstein

Avorn

. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288(4):455-461. doi:10.1001/jama.288.4.455.

29.

Treharne

Lyons

Hale

Douglas

KMJ

Kitas

. “Compliance” is futile but is “concordance” between rheumatology patients and health professionals attainable? Rheumatology. 2006;45(1):1-5. doi:10.1093/rheumatology/kei223.

30.

Resnick

. Testing the effect of the WALC intervention on exercise adherence in older adults. J Gerontol Nurs. 2002;28(6):40-49. doi:10.3928/0098-9134-20020601-10.

31.

Williams

Freedman

Deci

. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21(10):1644-1651. doi:10.2337/diacare.21.10.1644.

32.

Timmermans

. The engaged patient: the relevance of patient-physician communication for twenty-first-century health. J Health Soc Behav. 2020;61(3):259-273. doi:10.1177/0022146520943514.

33.

Chiang

Maahs

Garvey

Hood

Laffel

Weinzimer

, et al. Type 1 diabetes in children and adolescents: a position statement by the American diabetes association. Diabetes Care. 2018;41(9):2026-2044. doi:10.2337/dci18-0023.

34.

Broom

Whittaker

. Controlling diabetes, controlling diabetics: moral language in the management of diabetes type 2. Soc Sci Med. 2004;58(11):2371-2382. doi:10.1016/j.socscimed.2003.09.002.

35.

Brashers

Haas

Neidig

. The patient self-advocacy scale: measuring patient involvement in health care decision-making interactions. Health Commun. 1999;11(2):97-121. doi:10.1207/s15327027hc1102_1.

36.

Donovan

Blake

Fleming

. The patient is not a blank sheet: lay beliefs and their relevance to patient education. Rheumatology. 1989;28(1):58-61. doi:10.1093/rheumatology/28.1.58.

37.

Williams

Rodin

Ryan

Grolnick

Deci

. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17(3):269-276. doi:10.1037//0278-6133.17.3.269.

38.

Gentili

Maldonato

Grieco

Santini

. Influence of patients’ representations and beliefs about diabetes and its treatment on their adherence to therapy. Diabetes Nutr Metab. 2001;14(3):140-152. https://www.ncbi.nlm.nih.gov/pubmed/11476361.

39.

Sandman

Granger

Ekman

Munthe

. Adherence, shared decision-making and patient autonomy. Med Healthc Philos. 2012;15(2):115-127. doi:10.1007/s11019-011-9336-x.

40.

Bissell

May

Noyce

. From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions. Soc Sci Med. 2004;58(4):851-862. doi:10.1016/s0277-9536(03)00259-4.

41.

Rathert

Wyrwich

Boren

. Patient-centered care and outcomes. Med Care Res Rev. 2013;70(4):351-379. doi:10.1177/1077558712465774.

42.

Constand

MacDermid

Dal Bello-Haas

Law

. Scoping review of patient-centered care approaches in healthcare. BMC Health Serv Res. 2014;14:271. doi:10.1186/1472-6963-14-271.

43.

Robinson

Callister

Berry

Dearing

. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract. 2008;20(12):600-607. doi:10.1111/j.1745-7599.2008.00360.x.

44.

Botelho

. A negotiation model for the doctor-patient relationship. Fam Pract. 1992;9(2):210-218. doi:10.1093/fampra/9.2.210.

45.

van den Berk-Clark

Secrest

Walls

Hallberg

Lustman

Schneider

, et al. Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occurring smoking: a systematic review and meta-analysis. Health Psychol. 2018;37(5):407-416. doi:10.1037/hea0000593.

46.

Green

Johnson

Yarborough

BJH

. Seeking, delaying, and avoiding routine health care services: patient perspectives. Am J Health Promot. 2014;28(5):286-293. doi:10.4278/ajhp.120702-QUAL-318.

47.

Martin

Williams

Haskard

Dimatteo

. The challenge of patient adherence. Therapeut Clin Risk Manag. 2005;1(3):189-199. https://www.ncbi.nlm.nih.gov/pubmed/18360559.

48.

Pirbaglou

Katz

Motamed

Pludwinski

Walker

Ritvo

. Personal health coaching as a type 2 diabetes mellitus self-management strategy: a systematic review and meta-analysis of randomized controlled trials. Am J Health Promot. 2018;32(7):1613-1626. doi:10.1177/0890117118758234.

49.

Joosten

EAG

DeFuentes-Merillas

de Weert

Sensky

van der Staak

CPF

de Jong

CAJ

. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77(4):219-226. doi:10.1159/000126073.

50.

Montori

Gafni

Charles

. A shared treatment decision-making approach between patients with chronic conditions and their clinicians: the case of diabetes. Health Expect. 2006;9(1):25-36. doi:10.1111/j.1369-7625.2006.00359.x.

51.

Paolacci

Chandler

Ipeirotis

. Running experiments on amazon mechanical turk. Judgment Decision. 2010. https://papers.ssrn.com/abstract=1626226. Accessed March 15, 2021.Published online June 24

52.

Chandler

Paolacci

. Lie for a dime. Soc Psycholog Personality Sci. 2017;8(5):500-508. doi:10.1177/1948550617698203.

53.

Schmitt

Gahr

Hermanns

Kulzer

Huber

Haak

. The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcome. 2013;11(1):138. doi:10.1186/1477-7525-11-138.

54.

Muthén

. Mplus user’s guide: statistical analysis with latent variables, user’s guide. Los Angeles: Muthén & Muthén; 2017.

55.

Hayes

. Introduction to mediation, moderation, and conditional process analysis. A regression-based approach. Second Edition. New York, NY: Guilford Publications. https://play.google.com/store/books/details?id=8ZM6DwAAQBAJ (2017).

56.

Katon

Kleinman

. Doctor-patient negotiation and other social science strategies in patient care. In: Eisenberg

Kleinman

, eds. The relevance of social science for medicine. Dordrecht, Netherlands: Springer Netherlands; 1981:253-279.

57.

Vermeire

Hearnshaw

Van Royen

Denekens

. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Therapeut. 2001;26(5):331-342. doi:10.1046/j.1365-2710.2001.00363.x.

58.

Cameron

. Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. J Adv Nurs. 1996;24(2):244-250. doi:10.1046/j.1365-2648.1996.01993.x.

59.

Settineri

Frisone

Merlo

Geraci

Martino

. Compliance, adherence, concordance, empowerment, and self-management: five words to manifest a relational maladjustment in diabetes. J Multidiscip Healthc. 2019;12:299-314. doi:10.2147/JMDH.S193752.

60.

Smalls

Gregory

Zoller

Egede

. Direct and indirect effects of neighborhood factors and self-care on glycemic control in adults with type 2 diabetes. J Diabetes Complicat. 2015;29(2):186-191. doi:10.1016/j.jdiacomp.2014.10.008.

61.

Stewart

. Towards a global definition of patient centred care. BMJ. 2001;322(7284):444-445. https://www.bmj.com/content/322/7284/444.short?casa_token=uusnFv1wDDgAAAAA:cjxtIX4G3MGXXPSvdfxAPC18zMTLH-mSty-eL7OrwFQ1WEe8MU6CGVd9SIAST5aYgSZIoBZTjBmeAenE.

62.

DiMatteo

. Variations in patients’ adherence to medical recommendations. Medical Care. 2004;42(3):200-209. doi:10.1097/01.mlr.0000114908.90348.f9.

63.

Chambers

Nimon

Anthony-McMann

. A primer for conducting survey research using MTurk. Int J Adult Vocat Educ Technol. 2016;7(2):54-73. doi:10.4018/IJAVET.2016040105.