Adherence in multimorbidity: mixed methods study of patients with diabetes and end stage renal disease

Abstract

Introduction: Patients with coexisting Diabetes Mellitus and End-Stage Renal Disease (DM-ESRD) represent the fastest growing and most frail subgroup of the ESRD population. Multimorbidity can intensify treatment demands and adversly impact behavioural and emotional outcomes. The study aimed to document prevalence and factors associated with psychological distress and adherence outcomes in DM-ESRD. Methods: A mixed-methods study including interviews (n=61) and a cross-sectional questionnaire survey with DM-ESRD patients (n=221) in Singapore (59±9.8 years; 60.6% male; 54.8% Chinese). Measures included the Hospital Anxiety and Depression Scale, UCLA Loneliness Scale, Beck Hopelessness Inventory and measures of Health Literacy, Illness/Treatment Perceptions, Nutritional Quality-of-Life and Adherence indicators (self report and clinical markers). Results: Interpersonal tension and challenges related to appetite and complexity of diet dominated arratives. Survey data indicated high rates of distress (57%; 53.6%; 52.9%; 62.9% for depression, anxiety, loneliness & hopelessness, respectively) and non adherence (ranging between 19% to 62.9% across aspects of renal and diabetes regime components). Multivariate modelling indicated that Health Literacy dimensions (communication, support, obtaining/appraising information and Nutritional QOL were associated with distress indicators (ps <.05). Negative illness perceptions (treatment burden), low health literacy (provided support, obtaining/appraising information) were associated with low adherence indicators (ps <.05). Conclusion: DM-ESRD patients find diet and health care communication/navigation challenging and experience psychological distress. Carefully tailored interventions are needed to support and empower patients for manage coexisting DM ESRD