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Compliance, adherence, concordance, empowerment, and self-management: five words to manifest a relational maladjustment in diabetes

Authors Settineri S , Frisone F , Merlo EM, Geraci D , Martino G 

Received 8 November 2018

Accepted for publication 23 January 2019

Published 29 April 2019 Volume 2019:12 Pages 299—314


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Scott Fraser

Salvatore Settineri,1 Fabio Frisone,2 Emanuele Maria Merlo,2 Daniele Geraci,3 Gabriella Martino3

1Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy; 2Department of Cognitive Sciences, Psychology, Educational and Cultural Studies (COSPECS), University of Messina, Messina, Italy; 3Department of Clinical and Experimental Medicine, University of Messina, Italy

Background: The pathological reality of diabetes and the incidents in following the prescribed therapies have been considered and are still a serious and relevant problem in the health sector.
Objective: This review aims at highlighting the importance of clinical psychological phenomena that underlie the notion of therapies.
Methods: The review was conducted through search engines such as PubMed, Medline, Web of Science and Google Scholar. The articles related to compliance, adherence, concordance, empowerment and the self-management of diabetes were included, in order to highlight the possible similarities and differences that these terms bring with them in them management of diabetes.
Results: Starting from 252 initial publications, 101 articles were selected that highlighted the practical implications that each term has compared to the others.
Conclusion: The review can represent a bridge between the medical approach and clinical psychology, in which integration can suggest paths aiming at improving patients’ existential conditions and adaptation.

Keywords: compliance, adherence, concordance, empowerment, self-management, diabetes


The lack of phenomenological knowledge of the health professional of diabetes, both under the aspect of pharmacology and of physical health, often causes health professionals themselves to forget that the drug has aspects that exceed its biochemical efficacy. We cannot ignore the emotional significance that the patient gives to the drug, and the surplus value that the health professional gives to the therapeutic medium. In this review we will deal with the aspects of collaboration between health professionals and patients that can be seen as effective, or the various proposals by many other authors.17

The educational approach is not sufficient enough, since therapy has a stronger meaning than prescriptions, as suggested by literature.8 This concept is limited to what the patient views as having an active role in their own self-management9,10 or “adherence”.1113 These terms derive from the Latin “adhaerentia”, derivative of adhaerēre “to adhere”, is to be attached, supported, and closed. The use of etymologies and metaphors express only a part of the adjustment processes of the subject. There is in fact a lack between clear instructions given to patients and unknown variables not sufficiently understood, together with low empathy.

It is probably better to use the term “self-care”14 to underline a sort of emotional relationship that is something more than an empathic act. The last cited author suggests an approach to this type of relationship, while suggesting seven behaviors. The same psychoanalyst Jung uses this metaphor: «the meeting of two personalities is like the contact between two chemical substances; if there is a reaction, both are transformed».15

The concept of transference and counter-transference has been emphasized by psychoanalysis. Several other orientations have foreseen further concepts, like Winnicott, who specialized in the field of play and Gestalt in the encounter between patient and therapist. All those theoretical fields, impose on phenomenology as a method of describing the dimension of the phenomenon and the attempt to reach therapeutic protocols that must be adopted to every singular patient. The intent of this research is to highlight the need to get in touch with the subjective experience, in order to improve the outcomes of treatment. The clinical approach ensures a greater likelihood of glycemic control, as proven by the fact that many changes in glycemic metabolism are dictated by the same efforts and styles of health care as Hayes et al16 have taken into account. A frequent mistake made by clinicians is to confuse the prescription and general theoretical orientations of psychology with the subjectivity of a lifestyle. Therefore, there is a necessity to distinguish a prescription from the value that the individual patient attributes to it.

The analysis, although apparently complex and long, arises from the need to highlight the trend of past and current clinical approaches in scientific literature.


Search strategy

A review of the scientific literature was conducted in order to analyze the behaviors of adherence to the pharmacological treatments of diabetes. Research strategies have been used through the computer database of PubMed, Medline, Web of Science and Google Scholar; the searched keywords refer to the concepts of Compliance, Adherence, Empowerment, Concordance, and Self-Management.

During this phase, the various domains on which the article is focused on have been identified:

  1. Definitions of the phenomena related to the adherence of pharmacological treatments for diabetes;
  2. Intervention strategies and results obtained;
  3. Analysis of current knowledge referring to the origin of non-adherence.


Based on the keywords searched, 252 articles were found, of which 101 selected on the basis of title and abstract. The 101 articles in the table allow us to observe the similarities and differences that characterize the studies that conceptually prefer a term like compliance rather than empowerment or the others to investigate the therapeutic adherence.


Table 1 Summary table of classification of articles


The meaning of compliance in medicine refers to the ability of an organ to distend in response to applied pressure. In physics, compliance refers to the property of a material undergoing elastic deformation or (of a gas) changing in volume when subjected to an applied force. In therapy, it means to agree with rules or standards. More specifically, the patient and the family’s response to the prescription given.103

In 1997 it was hypothesized that it would be sufficient to reduce the frequency of the doses of the drug to achieve an improvement in compliance; but this practice included risks, as it depended on the therapeutic range of the drug itself.77 Of course, that does not divert from the fact that a better compliance can be achieved by using simpler and less frequent dosage regimens to facilitate the correct intake of drugs.19,30,33,35,39,40,48,51,52,59,61,92,99,102 It is also true that some studies5,10,25,71,72,100,101 have shown that the patient’s motivation to be more compliant with treatment also increases according to the efforts and confidence that the health care provider can transmit in reference to the guidelines to be followed by the patient. The high number of the authors cited underlines the strength of the “trust” element in adhesion to the treatment. Referring to childhood, it has been noted that the complexity related to the treatment of chronic diseases greatly complicates adherence to treatment.44 In order to be able to effectively manage a chronic disease such as diabetes, it seems essential not only to establish a relationship of trust between the health professional and the patient, but also a “friendship”.73 There seems to be a correlation between the quality of an established cooperation and the quality of diabetic treatment. When we talk about the factor of friendship we enter into subjectivity closely linked to the personality of the health professional. The studies on compliance in adolescence6470,88 highlighted that the crucial factor for achieving the best possible treatment depends mainly on the type of relationship that the patient is able to establish with health-care workers, family members and friends. It can be seen from other studies that the importance of the patient-health professional relationship seems to play a decisive role at any age.21,26,38,45,54,57 In light of the above, it seems that in order to achieve an improvement in the patient’s compliance with diabetic care the main solutions are traceable in the possibility of using less painful procedures in taking the required drugs. This is a way of increasing the patient’s knowledge of the chronic disease,29,89,93 while also improving the relationship between the health professional and the patient. Perhaps, the health professional should favor those essential self-care components that Shrivastava summarizes in the seven essential behaviors: healthy eating, being physically active, monitoring blood sugar along with medications, good problem-solving skills, healthy coping skills and risk-reduction behaviors.

Figure 1 The arrow shows the remarkable reduction of HbA1c % in the favourable condition of full compliance, where the patient maintains a passive role.


This term refers to the health professional prescriptions regarding timing, doses, frequency and periods of drugs-consumed.103

From this it is possible to notice how adherence to therapy is defined as the extent to which a person’s behavior in taking medication, following a diet and/or performing changes in lifestyle, corresponds to the recommendations agreed upon by a health professional. Research suggests that adherence to therapeutic recommendations for diabetes treatment is low.96 Producing an effective improvement, could either reduce the risk of complications caused by ineffective treatment or decrease the frustrations of the said health professionals.42

The reasons for non-adherence are multifactorial and difficult to identify. They include age, information, perception and duration of the disease, complexity of the dosage regimen, poly-therapy, cognitive factors, tolerability, clinical inertia, socioeconomic problems, culture, patient education and beliefs, social support and polypharmacy.18,32,43,47,50,82,85,87,97 Those studies also indicate how adherence is implemented through a combination of fixed-dose tablets and less frequent administration regimens, through educational initiatives - with particular attention to the quality of communication between patient and health professional - and through reminders and support systems to help reduce costs. Overall, some results suggest that fixed dose combined tablets and individual dose packaging may improve adherence in a number of settings, but the limitations of available evidence indicate that uncertainty remains about the extent of these benefits.34 Electronic monitoring systems have been useful to improve adherence to individual patients, and could help health professionals to identify patients who need additional support;35 however, even in this case it can be seen how the results obtained cannot completely overcome the problem of adherence.

Figure 2 The arrow shows how adherence improves treatment. Also in this case the patient maintains a passive role.


The term refers to the deep knowledge of the relationship and to the achievability of examining crucial questions regarding the patient’s lifestyle.104

It is important to clarify the dynamics that differentiate the various aspects of the approach to pharmacological therapies in diabetes,20 since the interactive level between clinicians and patients should not be experienced exclusively as an instructive end,21 but as a space for the grouping of skills and support in the decision-making process related to the drug therapy.41 Regarding the terminological transition from compliance to concordance,8 there is a need to overcome the emotion related to rigid orders, to a relationship based on cooperation. It would make the process of taking medicine more stress-free, considering the subject as a decision-maker. The patient’s consideration avoids undergoing orders that place the agents on different levels, and considers both figures of equal breadth.31

Figure 3 Patient active role with cooperation.


This term refers to the strengthening and improvement of power.103

103Empowerment can be considered as a process, in which the contact between an authority and another figure generate improvements in the state of health. There are some studies that suggest setting up structured objectives,56 adapted through problem-solving practices and coping strategies.24,62 The term includes several associated meanings, such as patient-centered and collaborative care but a collaborative approach to clinical reality remains transversal.23 Several scientific contributions tend to emphasize the importance of education in empowerment groups.6,55 However, we cannot help but consider the fact that processes of the over-evaluation of empowerment can produce negligence on other important issues related to the treatment of chronic diseases, as suggested in a review by Paterson.78

Figure 4 Patient active role with acquisition of competences.


This term refers to a system of participative management.103

From a review by Norris et al,2 it emerges that educational self-management and cooperation with patients can be more effective than the exclusive intervention of the health professional, for example glycemic, weight and lipid control. The author reports important scientific contributions that clarify the role of major and minor life events related to self-reported compliance, clarifying that educational intervention can be considered as an indicator of improvement in health status,9 even though it is still unclear how to achieve certain clinical results. It is therefore evident that self-management education produces positive effects, as it is also known that the benefit begins to decline from one to three months after the intervention, suggesting the need to implement practices aimed at promoting them.76 Multi-faceted and organizational interventions that would facilitate structured patient reviews are effective in care pathways.10,80,81

Figure 5 Active role of patient with responsibility.


The results related to the adherence in the treatment of diabetes highlight a critical fact, because over time the treatment has had different meanings. The Table 1 contains a large number of articles related to the theme; the various articles have posed the problem. Can these terms be used as synonyms or do they need a distinction? In the first analysis the Figures 15 show how the words (compliance, adherence, concordance, empowerment, self-management) empathize the passive or active role of the patient, the exclusive role of the health worker and the synergy of more professionals. The current research involves the collaboration of various figures related to the clinical field; they agree on the need to implement the knowledge of the phenomena related to the failure of adherence. The review of the literature has highlighted how difficult it is to understand the implications of a clinical fact that interfere with the assumption of therapy. Among the elements that lead to these results it would be useful to consider the unconscious aspects of patients. It is noticed that these aspects are dictated by emotions such as desire expressed differently if the patient has a passive role, as shown in Figures 35. It seems interesting to note how all five terms can currently be used according to: a) health education; b) knowledge of the patient; c) level of emotional maturity of the subject; d) personality type; e) value given by the health professional to cognitive and emotional processes; f) life planning; g) availability to knowledge; h) resilience.

However, it is not possible to respond hastily to some issues. Is it certain that among the terms “compliance”, “adherence”, “concordance”, “empowerment”, “self-management” a term can bring us closer to the patient’s experience? Is it evident that we can confide with the patient’s experience following the guidelines of one approach instead of another? Is it not true that a chronic pathology like diabetes could, in the long run, provoke a deviation in the subjective perception of the Self?

These questions, rather than discouraging health care, should shift attention from the objective processes of care to the comprehension of each patient. This is close to the phenomenological approach introduced by the German phenomenological tradition.105 In this case, one could easily notice how the quality of the therapeutic proposal, which in self-management would seem to be the best because it activates the conscience in terms of responsibility, in a chronic disease that is so widespread like diabetes it would be effective only in terms of ideals. Since therapy is a path rather than a goal, the idea is to propose a symbolic integration inherent in the very word of self-management. The word Self implies the overcoming of the Ego emphasized in compliance and in adherence, the intellectual overcoming of concordance, the mechanical cognitivism of empowerment.


The vast amount of literature, rather than emphasizing the successes and failures of the treatments, should offer a synthesis based on the complexity that every chronic disease poses. We suggest that the undoubted advantages of multi-disciplinary studies have contributed to a lengthening and improvement in the quality of life. We are faced with a complex phenomenology, which is foreseen by a continuum of damage that goes from the biological lesion to the maladjustment of the subject. The concept of care must be preceded by the promotion of quality of life and prevention policies. Based on the research carried out, a comprehensive need is outlined. We must take into account the resistance and the difficulties of including some aspects within patient care pathways. The valorization and the comprehension of the subjective modalities106 of conducting lifestyle would produce knowledge useful to bring the patient closer to clear indications of the medical prescriptions. The unknown aspects of physical and existential damage107 increase the weight of the phenomenon. The possibility of basing future treatments even on existential knowledge in the scientific field is certainly advantageous. The practical implications of this article refer to the inclusion of existential models of knowledge. The figures involved in this article have helped to suggest that the various points of view can be integrated into the field of care for diabetic patients, in order to turn the research experience into a practical support for patients and their subjective differences. This research aims to suggest an open point of view to the consideration of functional models that provide comprehension.

The peculiarity of the clinical psychology contribution suggests that even for chronic diseases such as diabetes, the mere possibility of listening to the patient could be a valid measure to alleviate the loneliness that aggravates every condition of suffering.108


The authors report no conflicts of interest in this research.


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