The use of motivational interviews by nurses to promote health behaviors in adolescents: a scoping review protocol

Adolescents - defined as young people between 10 and 19 years of age1 - are, in general, a relatively healthy segment of the population.2 However, the developmental changes that take place during adolescence may affect their subsequent risk for diseases and for a variety of health-related behaviors. In fact, early onset of preventable health problems (e.g. obesity, malnutrition, STDs) and the engagement in health risk behaviors (e.g., sedentary life style, excessive alcohol consumption, unprotected sex) during adolescence, are likely to put them at greater risk for physical and mental health problems at a later stage in life. Moreover, health related problems and health risk behaviors may disrupt adolescents' physical and cognitive development and therefore may affect their ability to think and act in relation to decisions about their health in the future.1 In summary, health-related behaviors in adolescence, apart from their influence on the continuum of "health-disease", they also have the potential to influence future behaviors. In fact, several studies have shown that past behaviors are good predictors of future behaviors .3,4 Thus, promoting healthy practices during adolescence and taking measures to better protect young people from health risks are essential for the prevention of health problems in adulthood.5 According to the World Health Organization, the main problems affecting young people include mental health problems (such as behavioral disorders, eating disorders, suicide, anxiety or depression), the use of substances (illegal substances, alcohol and tobacco), interpersonal violence, nutrition (a proper nutrition consists of healthy eating habits and physical exercise), unintentional injuries (which are a leading cause of death and disability among young people, with road traffic injuries accounting for about 700 deaths per day), sexual and reproductive health (for example, risky sexual behaviors, early pregnancy and childbirth) and HIV (resulting from sexual transmission and drug injection).5,6 On the other hand, the number of children and youth with chronic health conditions has increased dramatically in the past four decades7 as larger numbers of chronically ill children survive beyond the age of 10.8 Despite the lack of data on adolescents' health making it difficult to determine the prevalence of chronic illnesses in this age group9, it is known that one in ten adolescents suffers from a chronic condition worldwide.10 In fact, national population based studies from Western countries show that 20-30% of teenagers have a chronic illness, defined as one that lasts longer than six months.8 The most prevalent chronic illness among adolescents is asthma and the one with the highest incidence is diabetes mellitus, particularly type II.9 Traditionally, healthcare professionals have been mainly investing in health education activities, through the transmission of knowledge with a view to creating habits, customs and behaviors, and promoting healthy lifestyles. However, empowering people does not only consist of giving them the right information11 , i.e. good information is not enough to cause people to make changes.12 The motivation or desire to change unhealthy behaviors and habits depends on many factors, namely intrinsic motivation, control over personal decisions, self-confidence and perception of effectiveness, personal ambivalence, and individualized assistance.12 Many professionals assume that supplying knowledge is sufficient for behavioral changes; however, even very good advice often fails to generate behavioral change. After all, people continue to engage in unhealthy behaviors despite clearly knowing what they should do and how to change. "What is lacking is the motivation to apply that knowledge".13, p.1233 In fact, behavioral change is a complex phenomenon with multiple determinants that also includes motivational variables. It is associated with ambivalent processes expressed in the dilemma between keeping the current status and moving on to new ways of acting. For example, telling adolescents that if they keep on engaging in a certain behavior, they are increasing the risk of developing a long-term condition such as cardiovascular disease, stroke or diabetes is rarely enough to trigger the desired behavioral change; people are more likely to change when they believe that the change is really effective and that they are able to implement it.12 Therefore, it is essential to provide specific training for "healthcare professionals to master motivational techniques, avoid confrontation with the users, and facilitate behavioral changes".14 In this context, motivating patients to make behavioral changes is also an important nursing task where change in lifestyle is a major element of patients' treatment and preventive interventions.15 One of the nurse's goals is to help improve a patient's health or help them to manage existing health conditions. Once nurses are in a position where they have to focus on accomplishing tasks and telling patients what needs to be accomplished16, the role of the nurse is expanding even more into the use of motivational strategies.17 MI is bringing nurses back to therapeutic communication and moving them closer to successful health promotion and disease management, by promoting behavior change and empowering their patients. As the nursing profession evolves, MI is seen as a challenge and the basis of nurse's interactions with individuals, families and communities.16, 17 In the same way, MI may be taken as an essential tool in the provision of nursing care to adolescents, being itself a workspace with possible therapeutic effects regarding problems, clarification of doubts, and development of skills.18 In fact, MI may be particularly applicable in work with adolescents because of their specific developmental stage. Adolescents attempt to establish their own autonomy and identity while struggling with social interactions and moral issues, which leads to ambivalence.19 Consistent with the developmental challenges during adolescence, "MI explicitly honors autonomy, people's right and irrevocable ability to decide about their own behavior"20 while allowing the person to explore possibilities for change of risky or maladaptive behaviours.19 MI can be defined as a directive, client-centred counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style of interpersonal relationship.21 It is a set of strategies and techniques widely used in clinical practice based on the transtheoretical model of change. The Stages of Change model describes five stages of readiness—precontemplation, contemplation, preparation, action, and maintenance—and provides a framework for understanding behavior change.22 The MI has been widely tested and applied in different areas, such as modification of addictive behaviors, interventions with offenders in the context of justice, eating disorders, promotion of therapeutic adherence among chronic patients, promotion of learning in school settings or intervention with adolescents at risk.18,23 In general, clinical practice has been adopting the perspective of motivation as something relatively immutable, i.e., the adolescent is either motivated for change/treatment and, in these conditions, the professional's role is to help him/her, or the adolescent is not motivated and then change/treatment is not feasible. Alternatively the theoretical model underlying the MI technique postulates that the individual's adherence to change/treatment depends on his/her motivation, which can change throughout the therapeutic intervention. As several studies found positive results for effects of MI24-26 and its use by health professionals is encouraged23,27 nurses may play an important role in patients' process of change. As nurses have a crucial role in clinical contexts, they can facilitate the process of ending risk behaviors and/or adopting positive health behaviors through some motivational techniques, namely with adolescents. A considerable number of systematic reviews about MI already exist pointing to some benefits of its use in the treatment of a broad range of behavioral problems and diseases.13,28,29 Some of the current reviews focus on examining the effectiveness of MI for adolescents with diverse health risks/problems 30-32. However, to date there are no reviews that present and assess the evidence for the use of nurse-led MI in adolescents. Therefore, we have little knowledge of what works for whom (which adolescent subpopulation) under what circumstances (in which setting, for what problem) in relation to motivational interviewing by nurses. There is a clear need for scoping or mapping the use of MI by nurses with adolescents to identify evidence gaps and to inform opportunities for future development in nursing practice. On the other hand, information regarding nurse-led implemented and evaluated interventions, techniques and/or strategies used, contexts of application and adolescents subpopulation groups is dispersed in the literature33-36 which impedes the formulation of precise questions about the effectiveness of those interventions conducted by nurses and therefore the realization of a systematic review. In other words, it is known that different kind of motivational interventions have been implemented in different contexts by nurses, however does not exist a map about all the motivational techniques and/or strategies used. Furthermore the literature does not clarify which is the role of nurses at cross professional motivational intervention implemented programs and finally the outcomes and evaluation of interventions are unclear. Thus, the practical implication of this mapping will be clarifying all these aspects. Without this clarification is not possible to proceed to the realization of a systematic review about the effectiveness of the use of motivational interviews by nurses to promote health behaviors in adolescents, in a particular context and/or health risk behavior; or regarding the effectiveness of certain technique and/or strategy of MI. Consequently, there are important questions about the nature of the evidence in this area that need to be answered before formulating a precise question of effectiveness. This scoping review aims to respond to these questions. An initial search of the JBI Database of Systematic Reviews & Implementation Reports, Cochrane Database of Systematic Reviews, , Database of promoting health effectiveness reviews (DoPHER), The Campbell Library, Medline and CINAHL, has revealed that currently there is no Scoping Review (published or in progress) on the subject. In this context, this scoping review will examine and map the published and unpublished research around the use of MI by nurses implemented and evaluated to promote health behaviors in adolescents; to establish its current extent, range and nature and identify its feasibility, outcomes and gaps in the evidence defining research priorities in this field. This scoping review will be informed by the JBI methodology37 that suggests a five stage methodological framework for conducting scoping reviews which includes: identifying the research question, searching for relevant studies, selecting studies, charting data, collating, summarizing and reporting the results.

CAREGIVING FOR A FAMILY MEMBER WITH HEAD AND NECK CANCER

Objective: To know the perception of informal caregivers regarding the care for a family member with head and neck cancer. Methods: Qualitative study conducted between March and May 2014 in the radiotherapy outpatient center of the Centro de Alta Complexidade em Oncologia – CACON (Oncology High Complexity Center) of the Hospital Universitário de Brasília – HUB (University Hospital of Brasília) using semi-structured interviews with nine caregivers about the experience of caring for family members. Data underwent Content Analysis and four units of meaning were identified: “Representation of cancer in the Family”, “The care as debt, individual reward or reconstruction of family ties”, “Repercussions of cancer on the caregiver’s personal life” and “Social support and network used by caregivers”. Results: Feelings of sadness and surprise at the moment of diagnosis were attributed to cancer, as well as the idea of punishment. The care was seen as personal satisfaction, accomplishment and opportunity for family rapprochement. Work overload and change in routine were altered functions. Religiosity, exchange of experience in the waiting room and institutional support appeared as coping strategies. Conclusion: The experience of caring for family members with head and neck cancer directly interferes in the lives of caregivers. Pointing out the institutional embracement as a strategy within the social network reinforces the importance of integrating the caregivers as a significant part of the health care plan developed by the health team.

With or without you: does partner satisfaction and partner-directed violence influence the presence of a partner on women's Facebook cover profile photographs?

Social network sites (SNSs) provide new opportunities for online self-presentation of millions of users. The cover profile photograph (CPP) along with written information regarding relationship status is a central component of online self-presentation, although their associations with actual romantic relationships are not clear. We investigated relationships between the presence of a current romantic partner on the CPP and the displayed relationship status and partner satisfaction, partner-directed violence and women's intrasexual competition with peers. A total of 28 % of the 158 women with a Facebook profile and being involved in a romantic relationship had their romantic partners on their CPP. As predicted, women with their partners on the CPP were more satisfied with their romantic relationship than others. Furthermore, women who did not have their partner on the CPP tended to conceal or lie in their displayed mating status suggesting that this may be a strategy how to attract another potential mate. The partner-directed violence and intrasexual competition hypotheses were not supported. Overall, the CPP and an honestly displayed relationship status is an expression of relationship satisfaction amongst women.

A Multidimensional Approach to Social Support: the Questionnaire on the Frequency of and Satisfaction with Social Support (QFSSS)

The Questionnaire on the Frequency of and Satisfaction with Social Support (QFSSS) was designed to assess the frequency of and the degree of satisfaction with perceived social support received from different sources in relation to three types of support: emotional, informational, and instrumental. This study tested the reliability of the questionnaire scores and its criterion and structural validity. The data were drawn from survey interviews of 2042 Spanish people. The results show high internal consistency (values of Cronbach's alpha ranged from .763 to .952). The correlational analysis showed significant positive associations between QFSSS scores and measures of subjective well-being and perceived social support, as well as significant negative associations with measures of loneliness (values of Pearson's r correlation ranged from .11 to .97). Confirmatory factor analysis using structural equation modelling verified an internal 4-factor structure that corresponds to the sources of support analysed: partner, family, friends, and community (values ranged from .93 to .95 for the Goodness of Fit Index (GFI); from .95 to .98 for the Comparative Fit Index (CFI); and from .10 to .07 for the Root Mean Square Error of Approximation (RMSEA)). These results confirm the validity of the QFSSS as a versatile tool which is suitable for the multidimensional assessment of social support.

An examination of factors influencing ERP key-user satisfaction: A qualitative case study

Several companies are trying to improve their operation efficiency by implementing an enterprise resource planning (ERP) system that makes it possible to control the resources of the company in real time. However, the success of the implementation project is not a foregone conclusion; a significant part of these projects end in a failure, one way or another. Therefore it is important to investigate ERP system implementation more closely in order to increase understanding about factors influencing ERP system success and to improve the probability of a successful ERP implementation project. Consequently, this study was initiated because a manufacturing case company wanted to review the success of their ERP implementation project. To be exact, the case company hoped to gain both information about the success of the project and insight for future implementation improvement. This study investigated ERP success specifically by examining factors that influence ERP key-user satisfaction. User satisfaction is one of the most commonly applied indicators of information system success. The research data was mainly collected by conducting theme interviews. The subjects of the interviews were six key-users of the newly implemented ERP system. The interviewees were closely involved in the implementation project. Furthermore, they act as representative users that utilize the new system in everyday business processes. The collected data was analyzed by thematizing. Both data collection and analysis were guided by a theoretical frame of reference. This frame was based on previous research on the subject. The results of the study aligned with the theoretical framework to large extent. The four principal factors influencing key-user satisfaction were change management, contractor service, key-user’s system knowledge and characteristics of the ERP product itself. One of the most significant contributions of the research is that it confirmed the existence of a connection between change management and ERP key-user satisfaction. Furthermore, it discovered two new sub-factors influencing contractor service related key-user satisfaction. In addition, the research findings indicated that in order to improve the current level of key-user satisfaction, the case company should pay special attention to system functionality improvement and enhancement of the key-users’ knowledge. During similar implementation projects in the future, it would be important to assure the success of change management and contractor service related processes.

An Investigation Into The Perceptions Of Parents And Teachers Regarding The Adjustment To Sixth Grade Across School Configurations

A qualitative study was conducted in a large urban school district in the Mid-Atlantic region of the Unites States to investigate the perceptions of parents and teachers regarding the adjustment to sixth grade across school configurations. The investigation revealed the psychosocial and environmental factors that have an impact on sixth graders according to their grade span configurations. The study was conducted in the large urban school district, referred to as the “County,” which has a history of low and inconsistent achievement of sixth graders across a variety of grade span configurations. Through the analysis of the teacher and parent interviews conducted in two K-6 schools and two 6-8 middle schools, four themes were identified: transitioning, cultural awareness, social adjustment, and preparedness. The four themes emerged from the perceptions and observations of sixth graders, as shared by parents and teachers of sixth graders, according to their grade span configurations. Each of the responses was compared according to the identified grade span configuration K-6 and 6-8. From the data collected, recommendations were provided to the school district in which the study was conducted to better support teachers, parents, and sixth graders. Further research was also recommended of larger samples of sixth grade span configurations to better understand the complex dynamics of the relationships between grade span configurations for sixth graders and student achievement.

The Role of Attachment in a Social Cognitive Model of Social Domain Satisfaction in College Students

The study examined a modified social cognitive model of domain satisfaction (Lent, 2004). In addition to social cognitive variables and trait positive affect, the model included two aspects of adult attachment, attachment anxiety and avoidance. The study extended recent research on well-being and satisfaction in academic, work, and social domains. The adjusted model was tested in a sample of 454 college students, in order to determine the role of adult attachment variables in explaining social satisfaction, above and beyond the direct and indirect effects of trait positive affect. Confirmatory factor analysis found support for 8 correlated factors in the modified model: social domain satisfaction, positive affect, attachment avoidance, attachment anxiety, social support, social self-efficacy, social outcome expectations, and social goal progress. Three alternative structural models were tested to account for the ways in which attachment anxiety and attachment avoidance might relate to social satisfaction. Results of model testing provided support for a model in which attachment avoidance produced only an indirect path to social satisfaction via self-efficacy and social support. Positive affect, avoidance, social support, social self-efficacy, and goal progress each produced significant direct or indirect paths to social domain satisfaction, though attachment anxiety and social outcome expectations did not contribute to the predictive model. Implications of the findings regarding the modified social cognitive model of social domain satisfaction were discussed.

Factors influencing dental appearance satisfaction in adolescents: a cross-sectional study conducted in Southern Brazil

The perception of dental aesthetic appearance may affect social interaction and psychological status, influencing dental needs and the search for treatments. Aim: To investigate the satisfaction with dental appearance and influencing factors among adolescents. Methods: The study was carried out among adolescents aged 14 to 19 years attending a private high school in Brazil. Data on demographic information, the perception of dental appearance, previous aesthetic treatments and wish to perform dental treatments were collected in the school. Data were analyzed using Pearson’s chi-square test or Linear Trend. Multivariate analysis was performed using the Poisson regression. Results: A total of 531 adolescents (Response rate = 98.3%) answered the questionnaire. The prevalence of dissatisfaction with dental appearance was 17.4%. Almost 65% had history of previous orthodontic treatment and 16% performed dental bleaching. Approximately 45% of children wished to undergo orthodontics and 54.8% to bleach their teeth. Dissatisfaction with dental appearance was associated with individuals unsatisfied with dental color (95% IC[1.73;4.32]), those perceiving poor dental alignment (PR3.16 95% IC[2.11;4.72]) and those wishing orthodontic treatment (PR2.9; 95% IC[1.79; 4.70]). Conclusions: The prevalence of dissatisfaction was considerable and was associated with aesthetic concerns such as tooth color, dental alignment and with the wish for orthodontics. In this young population, a large part of adolescents had already performed orthodontic and bleaching treatments and wished to perform those treatments again. Satisfaction with dental appearance could affect the adolescents’ behavior regarding search for dental treatment, thus causing possible overtreatment.

Estímulos, barreiras e experiências na procura de ajuda para a disfunção sexual : estudo com utentes dos cuidados de saúde primários

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Mobility and satisfaction with lower-limb prostheses and orthoses among users in Sierra Leone: A cross-sectional study

Objectives: To investigate patients' mobility and satisfaction with their lower-limb prosthetic or orthotic device and related service delivery in Sierra Leone; to compare groups of patients regarding type and level of assistive device, gender, area of residence, income; and to identify factors associated with satisfaction with the assistive device and service. Methods: A total of 139 patients answered questionnaires, including the Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire (QUEST 2.0). Results: Eighty-six percent of assistive devices were in use, but half needed repair. Thirty-three percent of patients reported pain when using their assistive device. Patients had difficulties or could not walk at all on: uneven ground (65%); hills (75%); and stairs (66%). Patients were quite satisfied with their assistive device and the service (mean 3.7 out of 5 in QUEST), but reported 886 problems. Approximately half of the patients could not access services. In relation to mobility and service delivery, women, orthotic patients and patients using above-knee assistive devices had the poorest results. The general condition of the assistive device and patients' ability to walk on uneven ground were associated with satisfaction with the assistive devices and service. Conclusion: Patients reported high levels of mobility while using their device although they experienced pain and difficulties walking on challenging surfaces. Limitations in the effectiveness of assistive devices and limited access to follow-up services and repairs were issues desired to be addressed.

Developing self-guided scuba dive routes in the Algarve (Portugal) and analysing visitors' perceptions

Scuba diving allows for underwater visitation of cultural and natural resources. Underwater routes can be used as a tool for guided and supervised underwater visits. Two scuba diving routes were implemented in the Algarve (South of Portugal), the "B24" and "Poco" diving sites. The perceptions of scuba divers regarding several aspects of the routes and the existing support infrastructures were studied following a survey carried out through face-to-face interviews from 2008 to 2012. Divers profile and their perceptions were analysed using 246 valid questionnaires. Divers were mainly Portuguese, over 30 years old and with more than 12 years of formal education. Some of the support infrastructures did not achieve a "good" or "acceptable" grade. This should be carefully considered by diving operators and managers, because perceptions tend to circulate throughout the diving tourists. All features of interpretative slates were graded as highly satisfactory. Overall, diver satisfaction increased slightly after route implementation, with an average ranking of "good". These findings support the implementation of underwater routes as a way to promote diving activity, and to increase divers' environmental education and awareness. (C) 2013 Elsevier Ltd. All rights reserved.

Promuovere l'autovalutazione e il miglioramento delle strategie di apprendimento degli studenti internazionali cinesi: una ricerca empirica presso l'Università di Bologna

Nel quadro di alcuni filoni di ricerca inerenti alla promozione delle strategie cognitive, metacognitive e motivazionali degli studenti per una migliore efficacia del loro apprendimento (anche a livello universitario), il contributo presenta l’impianto e gli esiti di una ricerca empirica volta a indagare le percezioni degli studenti internazionali cinesi sulla loro esperienza universitaria in Italia, con un focus sulle eventuali difficoltà nell’adozione di un approccio autonomo e strategico all’apprendimento, e a sperimentare un intervento formativo messo a punto per sostenerli nel miglioramento del loro approccio all’apprendimento attraverso l’uso di procedure sistematiche di autoriflessione, self-recording e autovalutazione supportate dalla ricercatrice. Il disegno della ricerca è un quasi-esperimento a due gruppi con pre-test e post-test. Il campione è costituito da 60 studenti di diversi Dipartimenti dell’Università di Bologna che hanno partecipato volontariamente alla ricerca, di cui 30 hanno preso parte all’intervento. Gli strumenti utilizzati per la misurazione in ingresso e in uscita sono il Questionario sui Processi di Apprendimento e alcune scale del Questionario sulle Strategie di Apprendimento. Agli studenti del gruppo sperimentale è stato somministrato anche un questionario finale di valutazione del percorso formativo. Sono state inoltre effettuate alcune interviste a distanza di tempo come fase di follow up. Gli studenti in entrambi i gruppi affrontano sfide relative all’ambientamento nel contesto universitario italiano, con particolare riferimento a difficoltà linguistiche e di integrazione sociale. I principali fattori influenti sull’efficacia dello studio includono le barriere linguistiche, la gestione del tempo, la consapevolezza e l’uso delle strategie di studio. Nonostante emerga un miglioramento del gruppo sperimentale tra pre e post test, le differenze tra i due gruppi non sono risultate statisticamente significative. Tuttavia, i feedback forniti dagli studenti nel questionario di soddisfazione per il percorso formativo e nelle interviste post-intervento evidenziano percezioni positive sull’utilità del percorso, con benefici relativi al loro approccio allo studio.

The Influence Of The Environment On The Development Of Thyroid Tumors: A New Appraisal.

Most epidemiological studies concerning differentiated thyroid cancers (DTC) indicate an increasing incidence over the last two decades. This increase might be partially explained by the better access to health services worldwide, but clinicopathological analyses do not fully support this hypothesis, indicating that there are carcinogenetic factors behind this noticeable increasing incidence. Although we have undoubtedly understood the biology and molecular pathways underlying thyroid carcinogenesis in a better way, we have made very little progresses in identifying a risk profile for DTC, and our knowledge of risk factors is very similar to what we knew 30-40 years ago. In addition to ionizing radiation exposure, the most documented and established risk factor for DTC, we also investigated the role of other factors, including eating habits, tobacco smoking, living in a volcanic area, xenobiotics, and viruses, which could be involved in thyroid carcinogenesis, thus, contributing to the increase in DTC incidence rates observed.

[factors Associated With Satisfaction With Life Among Elderly Caregivers And Non-caregivers].

This article seeks to investigate associations between satisfaction with life and sociodemographic variables, health conditions, functionality, social involvement and social support among elderly caregivers and non-caregivers, as well as between satisfaction and the intensity of stress in the caregiver group. A sample of 338 caregivers was selected according to two items of the Brazilian version of the Elders Life Stress Inventory. A comparison-group of elderly non-caregivers was selected at random, with a similar gender, age and income profile. Data were derived from self-reported questionnaires and scales. Elderly caregivers with low levels of satisfaction and high levels of stress revealed more symptoms of insomnia, fatigue, diseases and worse IADL performance. Those with greater satisfaction and less stress revealed a good level of social support. Insomnia, depression and fatigue were associated with low satisfaction among caregivers, and with fatigue, depression and low social support among non-caregivers. It was considered relevant that instrumental, psychological and informative support can improve the quality of life and the quality of care provided by elderly caregivers, especially if they are affected by unfavorable health and psychosocial conditions and low satisfaction with life.

Beliefs Related To Adherence To Oral Antidiabetic Treatment According To The Theory Of Planned Behavior.

to identify salient behavioral, normative, control and self-efficacy beliefs related to the behavior of adherence to oral antidiabetic agents, using the Theory of Planned Behavior. cross-sectional, exploratory study with 17 diabetic patients in chronic use of oral antidiabetic medication and in outpatient follow-up. Individual interviews were recorded, transcribed and content-analyzed using pre-established categories. behavioral beliefs concerning advantages and disadvantages of adhering to medication emerged, such as the possibility of avoiding complications from diabetes, preventing or delaying the use of insulin, and a perception of side effects. The children of patients and physicians are seen as important social references who influence medication adherence. The factors that facilitate adherence include access to free-of-cost medication and taking medications associated with temporal markers. On the other hand, a complex therapeutic regimen was considered a factor that hinders adherence. Understanding how to use medication and forgetfulness impact the perception of patients regarding their ability to adhere to oral antidiabetic agents. medication adherence is a complex behavior permeated by behavioral, normative, control and self-efficacy beliefs that should be taken into account when assessing determinants of behavior.