The World Health Organization’s definition of adherence with long-term therapy is based on the definitions of Haynes1 and Rand2 and reads: “the extent to which a person’s behavior — taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.”3
Poor adherence with medication regimens in children and adolescents with chronic health conditions is a recognized problem that hinders the delivery of effective treatments and has a significant impact on the health care outcomes of children.4,5 A study conducted in children and adolescents with juvenile rheumatoid arthritis found the rate of medication adherence to be only 55%.6
The factors governing oral medication adherence among children and adolescents with type 2 diabetes (T2D) have not been studied in depth until recently. The TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth; ClinicalTrials.gov Identifier: NCT00081328) study group, formed by investigators from several institutions across the United States, studied the treatment regimens and clinical course of T2D in pediatric patients (10-17 years). The group recently completed a study that took a closer look at barriers and strategies for oral medication adherence among children with T2D. Study results were published in the February 2018 issue of Diabetes Research and Clinical Practice.7
“We found that global and specific forgetting was highly prevalent and that youth looked to family and their own behavioral skills to improve their adherence,” investigators wrote in their paper. They noted that, “findings are similar to those reported among youth with other serious chronic diseases.”7
Conducted between July 2004 and February 2009, the study enrolled 699 subjects age 10 to 17 years from 15 clinical sites and randomly assigned them to receive metformin alone, metformin plus rosiglitazone, or metformin plus lifestyle intervention for diabetes management. All study participants had been diagnosed with T2D less than 2 years previously and had a body mass index ³85th percentile. Each participant had an adult caregiver who provided support throughout the study.
Barriers and strategies for medication adherence were assessed in participants who were prescribed any glucose-lowering oral medication at 6, 12, or 24 months from baseline (n=611, n=583, and n=525, respectively). Assessments were performed every 2 months during the first year and every 3 months during the second year. Treatment failure, shown by loss of glycemic control, was the primary treatment outcome. Medication adherence was based on pill counts and expressed as the percentage of prescribed drug taken.
The study found that 69.2%, 72.4%, and 78.9% of participants assessed at 6, 12, and 24 months, respectively, missed 1 or more doses within 2 to 3 months since their last visit. The demographic characteristics of study participants who reported missed doses (61.5% female; 13.9 ± 2.0 years; >80% racial/ethnic minorities) were not significantly different from the overall group. Forgetfulness was the most common reason for missed doses. Specifically, “forgets or missed in general” (~40%) and “forgets or misses a particular dose” (~20%) were most commonly reported.
Interestingly, study authors wrote that, “the morning dose posed more of a challenge than the afternoon/evening dose and there was a primary reliance on family support to manage the overall care regimen.”7 Common reasons for missing the morning doses were “late for school or work” or “wakes up late.” The percentage of study participants who reported missing 1 or more doses of medication increased significantly from 70% at the 6-month visit to 78.9% at the 24-month visit (P =.0011).
The association between the total number of barriers and the degree of medication adherence was assessed in a group of 423 participants. Of those who reported 3 or more barriers, 76% were found to have <80% adherence, compared with 51.8% and 28.7% of participants who reported 2 or 1 barrier, respectively. The observed differences in the degree of medication adherence were significant (P <.0001).
Family support (³50%) and pairing the medication regimen with daily routines (>40%) such as meals or tooth brushing were the most common adherence strategies reported by study participants. Significantly higher adherence rates were found in study participants who used the latter strategy (P =.009). Study participants who used “family help only” as the main adherence strategy were, on average, approximately 1 year younger than participants who relied on “routines only” for adherence. A small number of study participants (n=23) who used a “reminder device” as an adherence strategy were found to have 91.3% adherence.
The study found that the behavioral and developmental factors affecting medication adherence strategies in the studied group of patients with T2D were similar to those observed in children with other chronic pediatric conditions. The authors noted that the research on T2D self-management in this age group suggests that multicomponent treatment regimens, ones that include both family communication and individual behavioral strategies, give best results. They further wrote that “a more uniform approach to family communication, self-management, and regimen adherence behaviors for serious pediatric conditions, including type 2 diabetes, may prove to be the most fruitful.”7
- Haynes RB. Determinants of compliance: The disease and the mechanics of treatment. In: Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore MD: Johns Hopkins University Press; 1979: 27.
- Rand CS. Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia. Am J Cardiol. 1993;72:D68-D74.
- World Health Organization. Adherence to long-term therapies: Evidence for action. http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf. 2003.Accessed April 17, 2018.
- Badawy SM, Thompson AA, Kuhns LM. Medication adherence and technology-based interventions for adolescents with chronic health conditions: a few key considerations. JMIR Mhealth Uhealth. 2017;5(12):e202.
- Drotar D. Strategies of adherence promotion in the management of pediatric chronic conditions. J Dev Behav Pediatr. 2013;34(9):716-729.
- Litt IF, Cuskey WR. Compliance with salicylate therapy in adolescents with juvenile rheumatoid arthritis. Am J Dis Child. 1981;135:434-436.
- Venditti EM, Tan K, Chang N, et al for the TODAY Study Group. Barriers and strategies for oral medication adherence among children and adolescents with type 2 diabetes. Diabetes Res Clin Pract. 2018;139:24-31.