International Journal of Nutrition, Pharmacology, Neurological Diseases

: 2020  |  Volume : 10  |  Issue : 3  |  Page : 105--111

Factors Associated with Treatment Adherence in Children with Malnutrition in Turkey

Fatih Ozdener1, Feza Kirbiyik2, Ali Evrim Dogan2, Arzu Baygul3, Study Group Factrem4,  
1 Department of Pharmacology, School of Medicine, Bahcesehir University, Istanbul, Turkey
2 Medical Department, Nutricia, Advanced Medical Nutrition, Istanbul, Turkey
3 Department of Biostatistics and Medical Informatics, School of Medicine, Beykent University, Istanbul, Turkey
4 .

Correspondence Address:
MD, PhD Fatih Ozdener
Department of Pharmacology, School of Medicine, Bahcesehir University, Sahrayı Cedit mah. Batman sok. No: 66-68, Yenisahra-Kadıkoy Istanbul


Aims: Malnutrition (MN) is associated with an increased mortality rate in infants and children and is an important comorbidity. Adherence to MN treatment is critical for a successful outcome, as are early diagnosis and administration of an appropriate treatment regimen. This study aimed to identify the factors pediatricians perceive to be associated with adherence to MN treatment in children. Materials and Methods: This mixed-methods study employed both qualitative and quantitative methods. The study included 136 pediatricians from various geographical regions of Turkey. Data were obtained via face-to-face interview, questionnaire, and group discussion. Results: Physicians perceived that among the patients that were diagnosed with MN, 66% underwent enteral nutrition therapy and that the treatment adherence rate was 59%. Patient-related factors associated with adherence to MN treatment were treatment tolerability, the severity of MN, and comorbidities. Nutritional product-related factors associated with treatment adherence were cost and flavor. Family-related factors associated with treatment adherence were parental level of education, economic status, and the level of confidence in the treatment modality. Use of an unflavored pediatric oral nutritional product increased the treatment adherence in patients aged 18–24 months (60% vs. 40%), whereas flavored varieties increased the treatment adherence rate after 2 years of age. Conclusion: The prevalence of MN is high in Turkey and non-adherence to MN treatment is common. Increasing awareness of the factors that contribute to adherence to MN treatment among physicians, the general public, and government are important for improving the rate of adherence to MN treatment.

How to cite this article:
Ozdener F, Kirbiyik F, Dogan AE, Baygul A, Factrem SG. Factors Associated with Treatment Adherence in Children with Malnutrition in Turkey.Int J Nutr Pharmacol Neurol Dis 2020;10:105-111

How to cite this URL:
Ozdener F, Kirbiyik F, Dogan AE, Baygul A, Factrem SG. Factors Associated with Treatment Adherence in Children with Malnutrition in Turkey. Int J Nutr Pharmacol Neurol Dis [serial online] 2020 [cited 2020 Sep 22 ];10:105-111
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Malnutrition (MN) is a global public health problem in both developing and developed countries that presents as undernutrition or obesity.[1] MN is also an important comorbidity associated with an increased mortality rate in infants and children.[2] Moreover, MN as a comorbidity is associated with exacerbation of primary illnesses.[3] Reports show that despite measures aimed at reducing the incidence of MN, undernutrition is not currently declining at the expected rate and obesity continues to increase, keeping the overall level of MN quite high. Globally, it is estimated that among children aged >5 years, 5.9% are overweight and 21.9% are stunted.[4] A recent study reported that the prevalence of MN in Turkey is estimated to be 12.3% among otherwise healthy children at the time of hospital admission.[5]

Following proper assessment of nutritional status, MN treatment can necessitate the use of nutritional products, enteral nutrition (EN),[6] or parenteral nutrition (PN).[7],[8] Although recognized as critical for a successful outcome, treatment adherence, and the factors associated with adherence to MN treatment have not been adequately studied.[9] Treatment adherence has been particularly neglected in children, especially in terms of non-adherence to MN treatment.[10] Non-adherence to treatment is wasteful of time, money, and resources and adversely affects the doctor-patient relationship.[11]

There are multiple determinants of treatment adherence, the majority of which fall into the following well-defined areas: socioeconomic, the healthcare team, system-related factors, condition-related factors, therapy-related factors, and patient-related factors.[12] Unfortunately, one of the obstacles to studying treatment adherence in many developing countries is the fact that patient records are not always complete in rural areas, making it difficult to accurately track adherence to treatment. Moreover, available records are primarily patient-related, and treatment- and family-related records are incomplete or lacking in entirety due to poor record-keeping practices. Research has highlighted the importance of the doctor-patient relationship and patient perceptions of health, but there are only a limited number of studies on physician perceptions of the causes and consequences of treatment non-adherence.[13] As such, the present study aimed to determine the perceptions of the factors associated with MN treatment adherence in pediatricians in Turkey that treat MN in children, based on a questionnaire, face-to-face interview, and group discussion.

 Materials and Methods

This mixed-methods study included data obtained from 136 pediatricians from various geographic regions of Turkey. Representation of each region was based on the highest annual number of pediatric MN cases. Data were obtained via face-to-face interview, a questionnaire, and group discussion. Both qualitative and quantitative approaches were used to analyze the data. The data presented herein are the result of the pediatricians’ self-reporting via face-to-face interview, a survey questionnaire, and group discussion. ESPEN guidelines for definitions and terminology of clinical nutrition were used as the basis for the questionnaire and interviews[8] Pediatricians were instructed to answer each question based on their observations of the treatment of pediatric MN patients in their respective regions.

The patient flow data presented in [Table 1] were obtained by asking the pediatricians to provide a numerical answer for each question, and then the answers were collectively analyzed with respect to the frequency distribution. The consolidated survey results were discussed collaboratively with the participants, so as to generate an objective consensus. For the factors associated with adherence to MN treatment presented in [Figure 1], the pediatricians were provided a list of known factors for each category and were asked to prioritize them in numerical order (the highest priority being 8 and the lowest priority being 1 [Figure 1]A and B and the highest priority being 6 and the lowest priority being 1 [Figure 1]C). The frequency distribution and mean were calculated and listed in descending order. The answers to open-ended questions [Figure 2], [Figure 3], and [Figure 4] were categorized according to the percent frequency of the responses obtained from the group.{Table 1}{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Statistical analysis was performed using MedCalc Statistical Software v.17.2 The normality of the distribution of continuous variables was determined using the Shapiro-Wilk’s test. Descriptive statistics are presented as mean ± SD for normally distributed variables and median (range) for variables not normally distributed. The chi-square test was used for categorical variables and is expressed as observation count and percentage. The study protocol was approved by the Bahcesehir University Clinical Research Ethics Committee on 20.12.2017 (number 2017-20/01).


Among the factors crucial to the quality management of disease is physician patient workload.[14] Primary among the data this study sought to analyze were patient load and the characteristics of the patients diagnosed as MN by pediatricians [Table 1]. The mean number of pediatric patients examined daily per pediatrician was 62, of which 7% were diagnosed as MN. The most common age at diagnosis of MN was 2.4 years. In 30% of the patients, MN was secondary to a primary disease. In all, 66% of the patients underwent enteral nutrition therapy and the pediatrician perceived rate of adherence to MN treatment was 59%.

Next, this study aimed to obtain data regarding the most important patient, nutritional product-, and family-related factors associated with adherence to MN treatment [Figure 1]. In terms of patient-related factors, treatment tolerability, the severity of MN, and co-morbidities were strongly associated with adherence to treatment [Figure 1]A. Regarding nutritional product-related factors, cost, flavor, and the requirement of a prescription for obtaining the product were associated with adherence to treatment [Figure 1]B. The family-related factors parental level of education, economic status, and confidence in the treatment modality were associated with adherence to treatment [Figure 1]C.

Subsequently, the relationship between nutritional product flavor and adherence to treatment was analyzed [Figure 2]. Use of an unflavored pediatric oral nutritional product increased the rate of adherence to MN treatment in patients aged 18–24 months (60.6% vs. 39.6%), whereas use of a flavored product and a product’s ability to be used in a variety of recipes were both important in patients aged >2 years.

Positive treatment outcomes, especially those observed shortly after MN treatment is initiated can be an important driver of adherence to treatment. Thus, this study analyzed data regarding the most frequent positive outcomes observed by the treating pediatricians. An increase in anthropometric measurement percentiles and improvement in perception and communication were the most readily observable positive outcomes of MN treatment [Figure 3]. Lastly, the pediatricians were asked to provide their recommendations for increasing the MN treatment adherence rate in Turkey [Figure 4]. Educating patient families about MN, reinforcing the importance of routine anthropometric measurement percentile checks, and educating family physicians about MN were the most frequent recommendations for increasing the rate of adherence to MN treatment in Turkey.


Non-adherence to treatment regimens is a common problem in pediatric patients with chronic conditions,[14],[15] yet research on treatment adherence in this patient population is lacking.[9] Studies conducted primarily on pediatric patients with non-gastroenterological diseases show that non-adherence can be as high as 50% in children[15] and 75% in adolescents.[16] Furthermore, the issue of pediatric treatment adherence is more complex than in adults because of developmental constraints, and the influence of family and peers, making it difficult to generalize findings from adult studies to the pediatric population.[15]

The prevalence of MN in Turkey is estimated to be 12.3% among otherwise healthy children at the time of hospital admission.[5] In the present study the pediatrician perceived prevalence of MN was only 7%, which might have been due to their inclusion of the healthy pediatric population presenting to primary healthcare settings rather than inclusion solely of the children admitted to hospital [Table 1]. Furthermore, the perceived rate of treatment adherence was 60%, which is consistent with rates (60%–80% of doses) reported in pediatric patients with chronic conditions.[17] According to the present study’s pediatricians’ perceptions, treatment tolerability is the most significant patient-related factor associated with adherence to MN treatment. Tolerability, in this instance, refers to an imaginary threshold of treatment adherence maintained by the pediatric patient, which is negatively affected by the unwanted effects of the treatment. The capacity to tolerate is inversely correlated to the complexity of the treatment regimen, as this has been proven to be negatively correlated with the primary adherence.[18] When MN is secondary to a pre-existing chronic illness, adherence to MN treatment can be further complicated by the disease-specific multi-drug regimens used for the primary illness. Ethnicity-specific issues, such as parental and professional knowledge and beliefs, healthcare system utilization patterns, and language, have also been identified as barriers or facilitators of chronic disease management.[19],[20] Similarly, the present findings indicate that the severity of MN and confidence in the treatment modality are important factors associated with treatment adherence. Patients’ perceptions of the properties of medicines, as well as a general preference for taking or not taking medicine can be important factors related to treatment non-adherence, as fear of or negative perceptions of medication can be major factor associated with medication non-adherence.[21]

Among the nutritional product-related factors, cost and the reimbursement ratio were perceived to be the most important factors related to MN treatment adherence by the present study’s pediatricians. These factors become especially important in regions of Turkey in which low economic status can be a limiting factor (unpublished observations). Further complicating the problem, these same regions, unfortunately, are those with the highest rates of MN and less than optimal access to the healthcare system. The present findings show that the flavor of nutritional products used to treat MN is at least as important as price to MN treatment adherence. The findings also show that patients aged 18–24 months prefer flavorless nutritional products, whereas those aged >24 months prefer flavored products that can also be used for cooking. This is consistent with the research showing that early-life experiences of dietary flavors transmitted from the maternal diet through breast milk can directly shape the flavor and food preferences of infants and children.[22] Infants fed a nutritional formula that differs in taste from that of breast milk may initially be less tolerant of it; however, with time they can learn to like new flavors and might accept different varieties.

Parental level of education was the most important family-related issue perceived by the present study’s pediatricians to be associated with adherence to MN treatment. Education is a multi-dimensional and complex issue, both at the individual and community level, and is also related to economic status. Nonetheless, low-level education and lack of physician-provided clear instructions related to treatment duration can lead to non-adherence,[23] which might be partly due to a physician’s lack of optimal time spent with each patient or due to physicians’ or parents’ lack of communication skills.[24],[25],[26] The present findings show that an average pediatrician in Turkey examines 60 patients per day for a mean duration of ≥10 min [Table 1], which is clearly less than the optimal time required to deliver the necessary treatment instructions.

Recent research shows that family, social, and psychosocial dysfunction can be important factors in non-adherence to treatment in children with chronic diseases, and that such dysfunction should be clinically addressed early in the course of disease to facilitate a positive outcome.[27] MN not only affects patients physically, but also causes emotional distress and social dysfunction, disrupting a child’s relationships with peers and negatively affecting school performance. As such, according to pediatricians, in addition to improvements in weight and height, improvements in perception, communication, and quality of life are also achieved via MN treatment. Pediatricians in the present study recommended family and physician education, and routine anthropometric measurement percentile checks for improving MN treatment adherence. Despite its importance to public health, MN treatment is not sufficiently covered during medical and postgraduate training. Efforts to close this gap in medical school curricula will certainly be necessary for improving adherence to MN treatment. When face-to-face interventions are not feasible,[28],[29] automated internet-based education is considered to be a cost-effective and practical means of improving treatment adherence among adolescents.[30] Similar interventions can target families of children with MN. Turkey is a country with widespread—almost ubiquitous—cell phone usage and text message reminders, as well as mobile phone applications, could prove invaluable for increasing adherence to treatment for chronic conditions, including MN.


In conclusion, adherence to MN treatment in children is a complex behavior associated with a variety of patient-, nutritional product-, and family-related factors. Increasing adherence to MN treatment will require the cooperation of healthcare providers, families, and patients. Pediatricians’ perceptions of the barriers to MN treatment adherence are important for developing effective strategies for increasing the rate of adherence to MN treatment.


*FACTREM- Study Group collaborators:

Görkem Astarcıoğlu, Mehmet Gökhan Tekin, Filiz Başarır Karakaş, Hande Namal Türkyılmaz, Fatih Sun, Oya Baltalı, Devran Demir, Caner Aydın, Özlem Karaoğlu, Özlem Büyükocak, Fahri Aydın, Varol Alagöz, Mehmet Enes Coşkun, Hülya Yasemin Uslu, Münevver Tuğba Temel, İsmail Ersan Can, Levent Temel, Beyhan Sarıkaya, Serpil Erdoğan, Enes Turan, Alper Tunga Özbek, Cansu Turan, Merve Korkmaz, Furkan Korkmaz, Cansu Yılmaz, Yezdan Akman, Hakan Erkman, Barış Çakır, Elif Pınar Çakır, Nurşah Keskin, Cem Keskin, Ahmet Şahin, Ümit Ece, İsmet Öncü, Mahmut Gökçe, Mahmut Dönmez, Özlem Kazanasmaz, Halil Kazanasmaz, Salih Güneş, Hasan Doğan, Alper Divarcı, Saadettin Acar, Ali Oruç, Enes Salı, Nihat Çelebi, Türker Borucu, Cemil Kaya, Yusuf Doğan, Ahmet Beytekin, Özlem Uğur, İbrahim Hocanlı, Büşra Çevirgen, Özgür Okumuş, Çiğdem Yanar Ayanoğlu, Feza Aksoy, Manolya Şanlı, Ceyda Kapıcıoğlu, Ebru Şahin, Mehmet Karacı, Mualla Öztürk, Sibel Özümit, Olcay Yasa, Şükrü Karakullukçu, Necla Yüce, Fatma Demir- baş, Sevcan Sarısoy, Gülsüm Figen Günindi, Hülya İnce, Nezih Akgün, Gülfer Akça, Hasan Farabi Aydınol, Atiye Gündüz, Ünal Akça, İsmet Gebeşoğlu, İbrahim Taşkaya, Uğur Sezgin, Filiz Gebeşoğlu, Duygu Gümüş Oğuz, Elvan Bahçeli, Mahmut Aykın, Murat Minici, Yasin Yoldaş, Hüsamettin Yakut, İbrahim Güllük, Ali Akyiğit, Ergin Cucu, Tuğba Güler, Seda Keleş, Ece Kurtul, Belkıs Aygün, Tuğçe Güzelkaş, Sedef Öztürk, Ali İşlek, Halil Keskin, Erkan Akkuş, Ersin Şimşek, Mahmut Caner Us, Kazım Öztarhan, Günsel Kutluk, Tuğçe Uzunhan, Ozan Uzunhan, Bilal Yılmaz, Sultan Yılmaz, Emrah Naiboğlu, Meryem Başaran, Eylem Kıral, Coşkun Yarar, Kürşat Bora Çarman, Emre Kaplan, Ahmet Gündüzöz, Mehmet Arslanoğlu, Yıldız Öntürk, Özlem Özen, Derya Taşkesen, Selda Hekim Yıldırım, Gürkan Bozan, Adnan Eroğlu, Gökalp Başbozkurt, Dilşah Salman, Hakan Tekgüç, Hakan Balta, Özlem Gülümser, Mutlu Karakaş, Serhat Kılıç, Arzu Kutlu, Derya Bozkurt, Ayşin Hanlı Şahin, Belkıs Hatice İnceli, Meliha Sevim Kantekin, Sinan Aslan, Burak Seyrek, Mehveş Anıl, Nuray Arda Devecioğlu, Yonca Atılbaz, Ahmet Köse, Şenay Acar.

Statement of Authorship

Fatih Ozdener contributed to the research design, data collection, data analysis, data interpretation, and writing of the manuscript. Feza Kirbiyik, Ali Evrim Dogan, and Arzu Baygul contributed to the research design, data analysis, data interpretation, and review of the manuscript. FACTREM study group* investigators contributed to the data collection and the data interpretation.

Financial support and sponsorship

This study was supported by Nutricia Advanced Medical Nutrition, Turkey. Feza Kirbiyik and Ali Evrim Dogan are employees of Nutricia Advanced Medical Nutrition, Medical Department, Turkey.

Conflicts of Interest

The authors declare that there is no conflict of interest.


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