Open Journal of Psychiatry, 2023, 13, 136-152

https://www.scirp.org/journal/ojpsych
ISSN Online: 2161-7333
ISSN Print: 2161-7325

Adherence in Patients with Type 2

Diabetes and Depression and the Role
of Physician-Patient Relationship:
A Cross-Sectional Study

Nadine Mansour1,2*, Nargis Albert1, Mohamed Khalil3

1
Department of Public Health and Community Medicine, Alkasr Aleini Medical School, Cairo University, Cairo, Egypt
2
Giza Health Directorate, Ministry of Health and Population, Giza, Egypt
3
Department of Psychiatry, Alkasr Aleini Medical School, Cairo University, Cairo, Egypt

How to cite this paper: Mansour, N., Abstract

Albert, N. and Khalil, M. (2023) Adherence
in Patients with Type 2 Diabetes and De- Background: Diabetes mellitus (DM) challenges health and quality of life of
pression and the Role of Physician-Patient patients, families, and communities. Patients with comorbid depression are
Relationship: A Cross-Sectional Study. Open more likely to develop macrovascular and microvascular complications. The
Journal of Psychiatry, 13, 136-152.
aim was to assess glycemic control and adherence in diabetic patients with
https://doi.org/10.4236/ojpsych.2023.133013
comorbid depression. Further, the study evaluated the relationship between
Received: May 8, 2023 adherence and the physician-patient relationship. Methods: The study was
Accepted: July 4, 2023 conducted at Al-Agouza Family Medicine Center (AFMC) between February
Published: July 7, 2023
2018 and March 2020. The included patients were between 35 - 80 years of
Copyright © 2023 by author(s) and age; had type 2 diabetes with hemoglobin A1c (HbA1c) ≥ 6.5%, fasting plas-
Scientific Research Publishing Inc. ma glucose ≥ 126 mg/dl, and scored between 11 - 30 on the Beck Depression
This work is licensed under the Creative Inventory (BDI). Logistic regression, chi-square, and analysis of variance
Commons Attribution International (ANOVA) were used to assess the relationship between depression, adhe-
License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
rence, physician-patient relationship, and other variables. Results: The study
Open Access included 100 eligible patients with a median BDI score of 20 (10 - 30). The
median diabetic panel for patients was FBS 188 (126 - 348) mg/dl, PPS 282.50
(162 - 448) mg/dl, and HbA1c 9.5 (6.6 - 14.0)%. Depression and regular fol-
low-up visits were statistically associated with improvement of diabetes
symptoms (p = 0.019). There was a significant relationship (p < 0.001) be-
tween adherence, regular follow-up visits, and knowledge of DM. Further,
there was a significant relationship between the physician-patient relationship
and DM improvement (p = 0.047). Conclusion: Physician-patient relation-
ship was paramount to improving adherence and positive diabetes care. Our
findings suggest a shift to a physician-patient relationship model with mutual
agreement on medical decisions is highly recommended.

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 N. Mansour et al.

Keywords
Depression, Type 2 Diabetes, Adherence, Physician-Patient Relationship

1. Background/Rationale & Objectives

DM challenges health and quality of life of patients, families, and communities.
Type 2 diabetes (T2D) is the most common form of diabetes, affecting more
than 95% of diabetics globally [1]. Currently, around 537 million, or 1 in 10
adults aged between 20 and 79 years are living with diabetes. The diabetic threat
to global health is rapidly escalating with numbers expected to increase to 643
million and 783 million by 2030 and 2045 respectively. In low to middle-income
countries, the ratio of diabetic patients is even higher (3 in 4). Further, diabetes
mortality is on the rise. In 2021, it was the direct cause of 6.7 million deaths be-
fore the age of 70 worldwide estimated at 1 death every 5 seconds [2].
Over time diabetes can have a detrimental effect on the heart, blood vessels,
eyes, kidneys, and nerves. T2D patients are susceptible to short- and long-term
complications. Adults with diabetes have a two- to three-fold increased risk of
heart attacks and strokes compared to their healthy counterparts. The reduced
blood flow and neuropathy increase the chance of developing diabetic foot and
eventual limb amputation. Diabetic retinopathy is attributed to 2.6% of global
blindness and diabetic nephropathy is among the leading causes of kidney fail-
ure [3] [4].
Compared to patients with diabetes alone, patients with comorbid depression
are more likely to develop macrovascular and microvascular complications.
Further, comorbid depression is associated with higher mortality rates [5] [6].
The relation between diabetes and depression is bidirectional. Depression is as-
sociated with poor diabetes control as a result of low medication adherence,
self-care, and adverse mental status. Conversely, depression can develop as a re-
sult of endocrine and neurological abnormalities caused by diabetes and its asso-
ciated complications [6] [7].
The care of diabetes involves adopting a healthy diet and lifestyle and routine
self-care. Adherence is key to favorable clinical outcomes and has been asso-
ciated with reduced hospital admissions, morbidity, and mortality [8]. Accord-
ing to the WHO report, the average adherence to long-term therapy in devel-
oped countries is approximately 50% with lower rates reported for adherence to
lifestyle instructions. This percentage is even lower in developing countries [4].
Between one-third and two-thirds of all medication-related hospitalizations and
half of nursing home admissions in the United States are due to poor medication
adherence [9]. In addition, the direct costs of complications attributable to poor
control of diabetes are 3 - 4 times higher than those of control [4]. Improving
adherence would yield substantial health and economic benefits. Balkrishan et al.
observed that for each 10% increase in adherence among diabetic patients, there

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N. Mansour et al.

has been an 8.6% - 28.9% decrease in total annual healthcare costs [10].
Moreover, improving physician-patient communication has been linked to
greater adherence, better health outcomes, and quality of life [11] [12]. These
days the physician-patient relationship is often superficial and centered on dis-
ease management and health institutions’ interests. As a result, the management
plan is based on unilateral decisions and the provider’s experience. Poor com-
munication is a barrier to effective diabetes treatment. Comprehensive action
should be adopted that focuses on the patients and their diseases alike [13].
Non-adherence challenges patients and healthcare systems. Traditionally, non-
adherence has been attributed to a patient’s failure or refusal to comply with
prescribed medications due to a lack of knowledge or motivation. However, a
new perspective has emerged that adopts a more collaborative approach between
patient and provider that focuses on concordance rather than adherence. This
perspective recognizes a broader set of factors and provides a better under-
standing of the problem [14]. This study aimed to assess glycemic control and
adherence among diabetic patients with comorbid depression. Further, the study
evaluated the relationship between adherence and the physician-patient rela-
tionship and explored possible reasons for poor adherence.

2. Methods
2.1. Study Design, Settings, & Participants
This cross-sectional study was conducted at Al-Agouza Family Medicine Center
(AFMC) between February 2018 and March 2020. The AFMC is a primary
health care center located in Giza, Egypt. Over 1370 family medical records are
currently stored in the AFMC patient registry (database) which has been main-
tained since 2011. The study was reported according to the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE) guideline [15].
Eligible patients were between 35 and 80 years of age; ambulatory; able to give
informed consent; and able to obtain reliable information. Patients were in-
cluded if they met the American Diabetes Association criteria for T2D (HbA1c
≥6.5%, fasting plasma glucose (FPG) ≥126 mg/dL) with diagnosis confirmed by
the participants’ medical clinician [16] and if they scored 11 - 30 on the BDI
scale (Mild mood disturbance to Moderate depression) [17].
Participants were excluded if they had type I diabetes and psychiatric disord-
ers other than depression or personality disorders including schizophrenia, bi-
polar disorder, and substance or alcohol abuse. Depressed patients on treatment
for depression were not included. Suicidal patients and those diagnosed with
major depressive disorder were referred to a psychiatrist.
The study was part of a trial registered on clinicaltrials.gov (NCT04214600)
[18]. The Elkaser Eleni medical school, Cairo University research ethics com-
mittee approved this trial (D-49-2019). It was conducted in accordance with the
Declaration of Helsinki Ethical Guidelines for medical research involving human
subjects.

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2.2. Sample Size Calculation

It was estimated that 11% of patients in the database AFMC had T2D. A sample
size of 80 participants was calculated based on a sample with a power of 80% and
a 5% significance level. The sample size was estimated by assuming the maximum
variability criterion, with a confidence level of 95% and a precision of 4% [19]. We
recruited 100 participants to allow for an expected dropout rate of 15% - 20%.

2.3. Data Sources & Measurements

A structured questionnaire was used to collect data from the study participants.
The questionnaire was translated into the layman’s Arabic language. It was
tested on ten patients for one month to check for clarity of the questions and
responses. Accordingly, the questionnaire was modified to improve patients’
comprehension. It included:
1) Sociodemographic: age, gender, marital status, education level, and occu-
pation.
2) Diabetes History: age of onset and duration of diabetes, comorbidities,
diabetes side effects, and family history; and type of diabetes medications (insu-
lin or oral hypoglycemic drugs).
3) Diabetes Self-Management Questionnaire (DSMQ): was used to assess
glycemic control, self-care activities, and the physician-patient relationship [20].
Responses to the questions were adjusted based on the pilot testing to “always,
often, sometimes, and never.”
4) Depression Assessment Using BDI [17]: BDI is a 21-question multiple-
choice self-report inventory, used for measuring depression’s severity. A value of
0 to 3 was assigned for each answer and then the total score was compared to a
key to determine the depression’s severity. The standard cut-off scores were as
follows: 1 - 10 Normal; 11 - 16 Mild mood disturbance; 17 - 20 Borderline clini-
cal depression; 21 - 30 Moderate depression; 31 - 40 Severe depression; over 40
Extreme depression. Further, we used the (SCID-5) [21] to diagnose patients
with mood disorders and exclude other psychiatric morbidities.
5) Measure Treatment Adherence (MTA): modified scale was used to assess
diabetes adherence [22] [23]. Several studies have validated the scale [24] [25].
The MTA Scale consisted of six questions and allowed answers from “always” to
“never”, with scores ranging from 1 to 4 points. The highest values indicated the
highest treatment adherence level. Adherence scores were considered as follows:
more than 75%-good adherence; between 50% - 75%-poor/partial adherence;
and less than 50%-non-adherence.
Further, six questions were added to the questionnaire to further explore: 1)
Adherence; “How often do you go to diabetes-related doctors’ appointments?” a)
Twice a month; b) Every month; c) Every two months; d) A few times a year);
“How often do you test your blood glucose?” (a) Every day; b) Every week; c)
Twice a month; d) Every month; e) Every two months; and f) A few times a
year); and “where?” (Home/health facility); 2) Possible reasons for non-adherence

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N. Mansour et al.

and responses were: a) Treatment is ineffective; b) Medication side effects; c)

Treatment is expensive; d) Forgetfulness; e) Others); and 3) Physician-patient
relationship: “Does the doctor talk to you and ease your complaints?” a) Always;
b) Sometimes; d) Never); and 4) “How would you rate your understanding of
diabetes?” (Good or Poor).
The anthropometric measurements of weight in kilograms (kg) and height in
centimeters (cm) were conducted using the UGM-200 health scale while partic-
ipants were wearing light clothes, with bare feet, and looking at the horizon. The
waist circumference (WC) in centimeters was measured on bare skin, mid-distance
between the bottom of the rib cage and the top of the iliac crest using a measur-
ing tape. The body mass index (BMI) was calculated by dividing the weight by
the height squared (BMI = weight in kg/height squared in cm) [26].
Laboratory investigations included FPG, 2-hour post glucose (2-hPG), and
HbA1c to assess diabetes control. Participants arrived at the study center fol-
lowing an overnight fast (≥7.5 hours) and were instructed to take their antihy-
pertensive medications as prescribed. FPG and 2-hPG were drawn from the an-
tecubital vein and further processed.

2.4. Statistical Methods

Data were analyzed using the Statistical Package for Social Science Version 21
(SPSS-V 21). The normal distribution of the data was examined by the Shapi-
ro-Wilk test [27] [28] and parametric tests. Results of p > 0.05 were considered
insignificant, indicating a normal distribution. A parametric Levene’s test was
used to verify the equality of variances in the samples (homogeneity of variance)
(p > 0.05) [29] [30].
Descriptive statistics were computed as medians and interquartile ranges
(IQR) for continuous variables and percentages for qualitative variables. Logistic
regression was conducted to examine the association between depression, regu-
lar follow-up, and improvement in diabetes symptoms. We used the chi-square
test to determine the relationship between 1) adherence to medications and 2)
physician-patient relationship as outcome variables and the independent va-
riables regular follow-up visits, improvement of DM, knowledge about the dis-
ease and management, and adherence to diabetes self-care.
Moreover, a one-way Analysis of Variance (ANOVA) was performed to assess
the effect of adherence on HbA1c, BMI, and WC. Log-10 was used to normalize
HbA1c, BMI, and WC. P-values were reported to three decimal places with
p-values less than 0.001 reported as p < 0.001. We used 2-sided p-values with
alpha ≤ 0.05 significance level.

3. Results
3.1. Sociodemographic, Anthropometric Measurements & Clinical
Investigations
Figure 1 shows the flow diagram of the study participants. Of the 349 diabetic

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 N. Mansour et al.

patients we contacted, 100 met our inclusion criteria and were included in the
study. Around 69% of the patients were females; three-fourths (74%) were be-
tween 45 - 54 years of age. The majority were married 62% and illiterate 42%.
More than half of the patients (60%) were unemployed; around half (48%) were
housewives as shown in Table 1. The median WC and BMI were 107 (81 - 143)
cm and 33.63 (21.11 - 51.26) kg/cm2, respectively. Results of the diabetic panel
were FBS 188 (126 - 348) mg/dl, PPS 282.50 (162 - 448) mg/dl, and HbA1c 9.5
(6.6 - 14.0)%.

Table 1. Sociodemographic characteristics of study participants, n = 100.

Demographics Sub-groups Percent

Male 31
Gender
Female 69

35 - 44 17
45 - 54 37
Age
55 - 64 17
>=65 29

single 2
married 62
Marital status
divorced 12
widowed 24

illiterate 42
read/write 11
primary 9
Education level
preparatory 8
secondary 5
university 25

full time 28
part time 4
per diem 8
Job status
unemployed 7
retired 5
housewife 48

no job 23
unskilled 3
Job type Skilled (Manual) 5
managerial 1
Professional 8

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Figure 1. STROBE flow diagram and sample characteristics.

3.2. Diabetes History & Diabetes Management

The median (IQR) age for developing diabetes was 45 (30 to 69) years, and the
duration of the disease was 10 (1 to 30) years. Most patients (41%) had at least
one comorbidity. The most reported comorbidity was hypertension (53%). The
majority had one to two side effects (31% & 33% respectively) which were tin-
gling and numbness (81%), followed by retinopathy (45%). Around three-fourths
of the sample (73%) had a positive family history of diabetes.
The majority of patients used oral hypoglycemics (69%) and showed incon-
sistent testing of blood glucose (65%) in a health facility (81%) and frequent fol-
low-up visits every other month or less (68%). Diabetes self-care showed variable
results in which 36% of the patients reported excellent vs. 37% reported poor
diabetes self-care. More than half (66%) of patients did not have knowledge of
diabetes or its management.

3.3. Depression in Diabetic Patients

The median (IQR) for the BDI score was 20 (10 - 30). According to the scale,
49% of the participants had moderate depression, 33% had anxiety and mood
disturbances, and only 18% had mild depression. Logistic regression was used to
examine the effect of depression and regular follow-up visits on diabetes symp-
tom improvement likelihood.

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 N. Mansour et al.

A preliminary analysis indicated that the assumption of multicollinearity was

met (tolerance 0.995). Inspection of the standardized residual value revealed
three outliers that were kept in the dataset. The logistic regression model was
statistically significant [χ2 (2, N = 100) = 7.97, p = 0.019)], suggesting that it
could distinguish between no/improvement in diabetes symptoms. The model
explained between 7.7% (Cox & Snell R square) and 11.6% (Nagelkerke R
square) of the variance in the dependent variable and correctly classified 77% of
cases. Depression severity (not follow-up visits frequency) significantly contri-
buted to the model. The depression severity odd ratio suggested that for every
increase in depression score, there were 1.092 times less likely improvements in
diabetes symptoms.

3.4. Adherence
Around three-quarters of patients reported good medication adherence (73%).
The median (IQR) for MTA score for adherence was 95.83% (25% to 100%) (9%
were none compliant, 18% were poorly compliant, and 73% were compliant).
The most reported reasons for non-adherence were cost and forgetfulness, both
at 29%. Further, 77% felt better about medications, and more than half (65%)
cited monetary burdens related to the disease.
A Chi-Square Test of Independence was performed to assess the relationship
between adherence and regular follow-up visits, improvement in DM, knowledge
about the disease, and self-care (Table 2). Adherent patients had good know-
ledge about DM (44%) and experienced an improvement in diabetes symptoms
compared to non-adherent patients (62%). However, only 31% of adherent pa-
tients reported regular follow-up visits and the majority reported poor self-care
(36%). There was a significant relationship between adherence and regular fol-
low-up [χ2 (1, N = 100 = 13.609, p < 0.001]; DM improvement [χ2 (1, N = 100) =
9.604, p = 0.002]; and knowledge of DM [χ2 (1, N = 100) = 3.950, p = 0.047]; and
self-care [χ2 (3, N = 100) = 20.963], p < 0.001]. There was no significant statistic-
al relation between sociodemographic variables and MTA score or with adhe-
rence to medications, diet, and exercise using the chi-square test.
A one-way ANOVA was performed to compare the adherence effect on
HbA1c, BMI, and WC. Analysis revealed that there was not a statistically signif-
icant difference in HbA1c between at least two groups [F (between groups 1,
within groups 98) = 0.237, p = 0.627]. However, there was a statistically signifi-
cant difference in BMI and WC between at least two groups [F (between groups
1, within groups 98) = −4.985], p = 0.028] & [F = 4.358], p = 0.039] respectively).

3.5. Physician-Patient Relationship

More than three-fourths of the patients (79%) reported poor physician-patient
relationships despite more than half reported receiving dietary (58%) & lifestyle
(including exercise) (54%) counseling. Around half of the patients did not eat
healthy food (52%) or exercise regularly (46%) to control diabetes.

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Table 2. Analysis for adherence to medications & physician-patient relationship.

Adherence to medications Doctor-patient relationship

Variables P-value Variables P-value
Yes No Always Sometimes Never

Regular follow-up Regular follow-up

visits visits

Always 31 1 Always 8 1 23
<0.001 0.339
Never 42 26 Never 9 3 56

DM outcome DM outcome

Improved 62 15 Improved 17 3 57 0.047

0.002
Not improved 11 12 Not improved 0 1 22

Knowledge Yes No Knowledge

Good 44 22 Good 7 2 57 0.040

0.047
Poor 29 5 Poor 10 2 22

Self-care Yes No Self-care

Always 18 18 Always 7 1 28

Often 6 2 Often 1 1 6
<0.001 0.849
Sometimes 13 6 Sometimes 2 1 16

Never 36 1 Never 7 1 29

Further, we tested the relationship between the physician-patient relationship

and regular follow-up visits, DM improvement, knowledge about the disease,
and self-care (Table 2). Patients with a poor physician-patient relationship were
less likely to have regular follow-up visits (56%). However, 57% of patients re-
ported improvement in diabetes and better knowledge of the disease and its
management. There was a significant relationship between the physician-patient
relationship and DM improvement [χ2 (2, N = 100) = 6.135, p = 0.047]; and
knowledge [χ2 (2, N = 100) = 6.457, p = 0.040]. However, there was an insignifi-
cant relation between the physician-patient relationship and regular follow-up
visits [χ2 (2, N = 100) = 2.164, p = 0.339] and self-care [χ2 (6, N = 100) = 2.671, p
= 0.849]. Moreover, there was an insignificant statistical relation between the
physician-patient relationship and adherence to medications, diet, and exercise
with the chi-square test.

4. Discussion
4.1. Characteristics of Depressed & Diabetic Patients
The study was part of an RCT conducted in a primary healthcare facility in Elgi-
za, Egypt (NCT04214600). It included 100 diabetic patients. The majority of pa-

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 N. Mansour et al.

tients in the study were females. Since they were housewives, they had flexible
schedules. In addition, females tend to seek primary healthcare services more
than men. Similarly, earlier studies suggested higher depression prevalence and
scores among females with T2D than males [31] [32] [33] [34]. The high preva-
lence of depression in women might be attributed to the change in socio-cultural
roles women play nowadays. In addition to the hormonal changes, they expe-
rience which make them more susceptible to stress and psychiatric disorders.
Regarding education levels, about 42% were illiterate, and 11% could read and
write. CAPMAS 2017 reported illiteracy rates in Egypt at 25.2%, which was low-
er than the study results [35]. Further, around half of the patients were unem-
ployed. This percentage was lower than the EDHS 2014 reported rate of unem-
ployment among females (86.4%) [36]. Low education attainment increases
unemployment, leading to low socioeconomic status and stressful life events.
This renders people more vulnerable to psychological stress with diabetes, de-
pression, and other chronic diseases.
The age range of diabetic patients was between 45 - 54 years similar to other
studies [31] [37]. The median (IQR) age for developing diabetes was 45 (30 to
69) years and the duration of the disease was 10 (1 to 30) years. T2D prevalence
increases with age, although it can occur at any age. Nowadays, people develop
diabetes at younger ages than before. Moreover, there is a shift in diabetes diag-
nosis age from 52.0 to 46.0 years [38]. DM duration is a major predictor of de-
pression. When the duration is long, more patients develop depression [39].
Understanding diabetic sociodemographic characteristics is paramount for
healthcare planning, research, and other public health efforts. Knowing the age
distribution, gender, educational attainment, and employment patterns of di-
abetic patients helps in designing culturally relevant public health programs that
are appropriate and accessible to various sociodemographic groups and eco-
nomic levels. Identifying employment patterns of population subgroups may
help improve education systems and vocational training.
The majority of patients had at least one comorbidity. The most common
comorbidity was hypertension. Around one-third of the patients experienced
one or two T2D side effects. The most commonly experienced side effect was
tingling/numbness (peripheral neuropathy) (82%). In a meta-analysis by Engum
et al., there was a positive association between depression and diabetes compli-
cations, both macrovascular and microvascular [40]. Another review showed
that, over a five-year period, patients with major depression and DM had a 36%
higher risk of developing advanced microvascular complications such as neph-
ropathy or blindness. In addition, they had a 25% higher risk of developing ad-
vanced macrovascular complications, such as myocardial infarction and stroke
[41].
Obesity poses a major health challenge because it substantially increases
chronic disease risks. In developing countries, overweight and obesity are on the
rise. Clinical evidence indicates a stronger association of diabetes with central

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N. Mansour et al.

obesity than with general obesity. WC is the most reliable method for measuring
both intra-abdominal fat mass and total fat in the abdomen. High WC mea-
surements have been strongly associated with morbidity and mortality [42] [43].
Our results showed the median WC was 107 (81 - 143) cm and BMI was 33.63
(21.11 - 51.26) kg/cm2. Based on the STEP Survey 2018, Egyptians between 15
and 69 years old had an average BMI of 28.2 ± 0.30 kg/m2 [44].
Diabetes and depression occur together approximately twice as frequently as
would be predicted by chance. Comorbid depression and diabetes were asso-
ciated with poor glycemic control and increased complications. The study par-
ticipants showed poor glycemic control with a median FPG of 188 mg/dl; 2 h PG
282.50 mg/dl; and HbA1c of 9.5%. Similarly, other studies reported HbA1c levels
above 8% and even higher levels among those with depression [45] [46] [47].
The median BDI score was 20 indicating around half of the participants had
moderate depression. Our results suggest that patients with high BDI scores
were less likely to show improvement in diabetes.

4.2. Adherence & Physician-Patient Relationship

Medication adherence is key to controlling DM. According to several studies,
patients with diabetes and depression have a low level of adherence to medica-
tions [48] [49]. The median MTA score in this study was 95.83% indicating good
adherence. The self-reported adherence by the patients was in concordance with
the MTA scale results which were similar to those of Gonzalez et al. [50]. Fur-
ther, our results showed that adherent patients were more knowledgeable about
DM and reported improvement in diabetes symptoms compared to their
non-adherent counterparts. Adherence was significantly related to regular fol-
low-up visits; DM improvement; knowledge; self-care, BMI, and WC. However,
it was insignificantly related to HbA1c. This high adherence rate might be due to
the fact that diabetes care, including follow-up visits and medication dispensing,
was free of charge in the health facility where the study was conducted.
Guidelines on the management of non-communicable diseases recommend
diabetes patients see their primary healthcare physician at least once every four
months. Further, patients with uncontrolled diabetes should have more frequent
visits. The majority of participants reported regular follow-up visits every two
months or less. The study was conducted in an urban center. It is well known
that urban health facilities tend to be better equipped and accessible than rural
facilities.
Family medical centers should strengthen programs focusing on encouraging
regular primary health care (PHC) services. That could be achieved by encour-
aging regular phone calls or electronic follow-up reminder systems or home vis-
its to improve patient outcomes. Such approaches would promote trust between
the healthcare teams and patients, diminish anxiety, and improve patients’ wil-
lingness to visit primary health facilities. Moreover, financial incentives, whether
in the form of allowances or per diem payments could be provided for health-

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 N. Mansour et al.

care personnel involved in ensuring the implementation of the system.

The main factor that could be a potential predictor of adherence was the phy-
sician-patient relationship. Lack of adherence occurs frequently in depressed and
diabetic patients alike. Motivating patients to achieve high adherence is chal-
lenging [51]. The majority of patients reported poor physician-patient relation-
ships. Around half of the patients did not have good control over their diet or
adopt an active lifestyle. Patients who had a poor physician-patient relationship
were less likely to have regular follow-up visits. There was a significant relation-
ship between the physician-patient relationship and DM improvement and
knowledge. However, there was an insignificant relationship between the physi-
cian-patient relationship and regular follow-up visits; self-care; and adherence to
medications, diet, and exercise.
Patient participation concepts emphasize real partnerships between patients
and physicians. The interaction between patients and healthcare professionals
should not be limited to reinforcing treatment instructions. Instead, it should be
in a way where both parties can pool their expertise to achieve mutually agreed
goals. Evidence suggests that involving patients more in consultations can in-
crease treatment adherence [52] [53].
Patients and physicians have different perspectives and interpretations of dis-
eases. The physician’s motivation to achieve optimal medical results may conflict
with the patient’s motivation to lead his own life. A closer relationship where pa-
tients are more engaged with their physicians could reduce frustration. Physi-
cians should have the skills to explore patients’ expectations and translate them
into realistic objectives that fulfill patients’ perspectives. In fact, patients should
be the primary actors in medical decision-making, and healthcare providers
should adopt a supportive role.
The study was conducted in a single urban PHC facility. The reported results
reflect a small segment of the diabetic population, which hinders the external va-
lidity of the study. Further, due to the small sample size, the chi-square assump-
tion was violated (no more than 20% of the expected cells with >5) for some va-
riables including physician-patient relationship and doctor visits, DM improve-
ment, knowledge, and self-care. Further, data were transformed to the normal
distribution to conduct one-way ANOVA, for variables HbA1c, BMI, and waist
circumference using Log10.

5. Conclusion
Our findings suggest a shift to a physician-patient relationship model with mu-
tual agreement on medical decisions. This joint physician-patient interaction
could contribute to more positive diabetes care. As a result, patients will be able
to set their own goals, which will enhance physicians’ consultation depth and
value. In this regard, large-scale studies are recommended to extend the findings
to other rural and urban settings further and include a larger segment of pa-
tients.

DOI: 10.4236/ojpsych.2023.133013 147 Open Journal of Psychiatry

N. Mansour et al.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

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