Adherence and Beliefs About Medications, and Illness Perception Among Type 2 Diabetic Patients in Assiut University Hospital
Conditions: Diabetes Mellitus, Type 2, Adherence, Medication
Sponsor: Assiut University

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Medication Adherence, Illness Perception and Beliefs about 
Medications among Patients with Type II Diabetes Mellitus Attending 
Diabetes Clinic in Assiut University Hospital, Egypt 
 
 
Thesis Protocol 
Submitted for the Partial Fulfillment of Master’s Degree in Public Health 
and Community Medicine 
 
By 
Zeinab Galal Eldeen Abdelhamid 
Demonstrator of Public Health and Community Medicine 
Faculty of Medicine, Assiut University 
 
Supervised by 
 
Prof. Dr Hosnia Said Abd El-Megeed 
Professor of Public Health and Community Medicine  
Faculty of Medicine, Assiut University 
  
Dr. Doaa Mazen Abdel-Salam 
Associate professor of Public Health and Community Medicine 
Faculty of Medicine, Assiut University 
  
 
Faculty of Medicine 
Assiut University 
2022 
 
 
 

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Introduction 
Diabetes mellitus (DM) is considered one of the oldest fast-growing public 
health problems. It’s a chronic metabolic disorder characterized mainly by high 
level of glucose level, associated globally with increased morbidity and mortality 
particularly in developing countries [1]. 
DM leads to serious problems in heart, blood vessels, kidney and nerves. 
The World Health Organization (WHO) had anticipated that DM is going to 
become the seventh most significant primary cause of death worldwide by the 
year 2030 [2]. 
Main types of DM include type1 DM where the body stops making insulin, 
and type 2 DM which is more common, usually in adults when the body becomes 
resistant to insulin or doesn't make enough insulin [3]. 
Currently, 463 million persons suffer from diabetes worldwide. In addition, 
55 million in Middle East and North Africa (MENA) Region suffer from diabetes, 
and it is estimated that by 2045 this will rise to 108 million according to the 
International Diabetes Federation (IDF) [4] 
Egypt is considered the ninth leading country in the world for the number of 
type 2 diabetes patients and its prevalence was nearly tripled over the last 2 
decades, reaching 15.2% as nearly 8 million of adults suffer from type 2 DM, 
expecting to be doubled by 2045, urging the global community to recognize DM 
as one of the most important health challenges of the twenty first century [4]. 
Hence comes the importance of self-management in patients with type 2 DM 
in reducing complications from the disease and improving overall health 
outcomes. These important self-management behaviors include taking 
medications regularly, healthy diet, doing physical activities, quitting smoking, 
foot care and self-monitoring blood glucose level [5]. 

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Adherence of patients with type 2 DM to medication is associated with better 
balanced glycemic control (HbA1c <7%), thus helping in reduction of 
microvascular and macrovascular complications [6]. 
Adherence to medication is mainly influenced by several factors such as 
demographic, socioeconomic, cultural, health system related factors, educational 
and personal factors such as patient’s age, complexity of medication, side effects, 
cost, availability, accessibility and whether they’re receiving emotional and social 
support from their families [7]. 
Mental representation of DM affect patients’ coping behavior. Many patients 
lack the understanding of type 2 DM. Perception of the disease is important, it’s 
not just about taking the prescribed medication, it’s about the extent to which the 
patient follows medical instructions [8]. 
Studies have showed that illness perception and beliefs about medication by 
type 2 DM patients is commonly linked with their adherence to medication and in 
return better glycemic control [9]. 
Perception is about everything regarding the illness such as illness identity, 
time line of the disease, consequences, comorbid conditions, number of hospital 
admission, whether it can be controlled or not, and emotional response to being 
diabetic [10]. Beliefs in self-control and self-management over health will affect 
adherence to treatment regimens and glycemic control [9]. 
Perception about illness shapes self-management behavior. If patients have 
strong perception about treatment plan and regimen with personal control, it’ll 
lead to lower level of HbA1c and better health outcome [10]. 
Patients’ beliefs about medication are mainly about the necessity of taking 
the prescribed medication to maintain their health now and in the future, and 
concerns about the possible negative effects of taking the medication such as 

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addiction or long-term adverse effects from regular use. Some patients believe 
that medication helps them, while others believe that multiple harmful effects of 
the treatment may outweigh any positive outcomes. Some of the patients who 
have strong opinions about their medication avoid taking it or, conversely, abuse 
it [11]. 
Patients who are convinced that a specific medication is essential for their 
health are much more likely to adhere to the treatment than those who do not hold 
such a belief [12]. 
We hypothesize that some factors associated with non-adherence to 
medication can be investigated so that interventions can be implemented to 
increase adherence to medication, helping in achieving better glycemic control 
and better health outcomes and reducing complications. 
As data concerning diabetic patients’ adherence are deficient in upper Egypt, 
this study will help in filling the gap on illness perception and beliefs about 
medication, which in turn affects patients’ adherence to medication and thus better 
glycemic control in type 2 DM. 
Rationale  
Data regarding predictors of adherence to diabetes medication is limited in 
Egypt. This study aims to investigate whether illness perception, beliefs about 
medication were associated with adherence to medication and glycemic control 
(HbA1c) in Egyptian patients with type 2 diabetes in Diabetes Clinic in Assiut 
University Hospital. To the best of our knowledge, no previous studies on 
adherence to medication were done in Assiut Governorate. 
 
 
 

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Objectives of the study 
1- Assess medication adherence among diabetic patients attending Diabetes 
Clinic in Assiut University Hospital.   
2- Identify patients’ beliefs about medication and illness perception. 
3- Link patient’s beliefs about medication and illness perception with                     
medication adherence. 
4- Investigate the correlates of medication adherence, illness perception, and 
beliefs about medication. 
Subjects and methods 
Study Design and setting  
The present study will be cross sectional. This study will be conducted in 
Assiut University Hospital. The target population will include diabetic patients 
attending Diabetes Clinic in Assiut University Hospital. The clinic offers various 
services including clinician consultations, health education, medication 
dispensing, foot, and vision screening. The clinic is also responsible for treating 
and monitoring patients with diabetes. All patients who fulfill the inclusion 
criteria and presented to Diabetes Clinic in Assiut University Hospital will be 
included in the present study 
Sample size estimation  
The sample size was calculated using the Epi info version 7 StatCalc, based 
on the following assumption: prevalence rate of non-adherence among Egyptian 
population (55.5%) [13], level of confidence 95%, precision 5%, and design effect 
1. The calculated sample size was raised to 417 after adding 10% as non-response 
rate. 
 

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Inclusion criteria 
1- Patients who are diagnosed with type 2 DM for at least 1 year according to 
the diagnostic criteria of the 10th revision of the International Classification 
of Diseases (ICD-10). 
2- Patients treated with insulin or oral medication or both for at least 6 months. 
3- Age group:  adult patients (> 18 years old) will be included in the present 
study. 
Exclusion criteria 
1- Newly diagnosed diabetic patients or ill on the day of recruitment, or not 
taking any medications for type2 DM  
2- Patients with type1 DM 
3- Psychiatric patients or on anti-depressant treatment or using psychotropic 
drugs affecting their cognitive ability. 
Data collection tool 
Data will be collected through semi-structured questionnaires which will be 
filled by the researcher herself. The questionnaire will be composed of five parts:  
The first part will inquire about sociodemographic data such as age, sex, 
educational level, occupation, residence, and marital status.  
The second part is about clinical data including BMI, duration of diabetes, type 
and number of prescribed medications, number of comorbid conditions, 
number of diabetes-related complications, and patients’ most recent HbA1c 
levels were taken from medical records. HbA1c levels of ≥ 8% indicate 
suboptimal glycemic control in patients with T2D.  
The third part of the questionnaire is the Arabic version of Morisky Medication 
Adherence Scale (MMAS-8) [14]. It remains one of the most widely used 
mechanisms to assess patient adherence [14]. It consists of 8 questions. 

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Response choices are “yes” or “no” for items 1 through 7 and Item 8 has a 
five-point Likert response scale. Each “no” response is rated as 1 and each 
“yes” response is rated as 0 except for item 5, in which each “yes” response 
is rated as 1 and each “no” response is rated as 0. For Item 8, the code (0-4) 
must be standardized by dividing the result by 4 to calculate a summated 
score [14]. Total scores on the MMAS-8 range from 0 to 8, with scores of 8 
reflecting high adherence, 7 or 6 reflecting medium adherence, and <6 
reflecting low adherence [14].  
The fourth part of the questionnaire is the Brief Illness Perception Questionnaire 
(B-IPQ). B-IPQ is a rapid assessment tool with a Cronbach’s alpha of 0.65 
that measures eight different aspects of illness perception: consequences, 
timeline, personal control, treatment control, identity, concerns, 
understanding, and emotional representation [15]. The B-IPQ is a 9-item 
instrument that measures illness perception from eight different aspects 
using an 11-point Likert scale. A higher score reflects a more threatening 
view of the illness, while a lower score indicates a benign view of the illness 
[15].  
The fifth part of the questionnaire is the Beliefs about medicine which is assessed 
using the Arabic version of the Beliefs about Medicines Questionnaire 
Specific (BMQ-Specific). It includes two subscales, which evaluate patients’ 
perceptions of the necessity of medicine in controlling their illness 
(Necessity-Specific) and concerns about potential adverse effects of 
medicine (Concerns-Specific). Each subscale consists of 5 items and is 
scored on a 5-point Likert scale. High scores on the Necessity-Specific 
subscale indicate that the patient perceives their medicine as necessary, 
whereas high scores on the Concerns-Specific subscale indicate that the 
patient is concerned about potential adverse effects [16]. 
 
 

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Statistical analysis 
 Data entry and analysis will be carried out using SPSS version 24. 
Descriptive statistics will be done in the form of frequencies, mean and SD then 
analytic statistics will be done as chi square, independent sample test and 
correlations tests. Values will be considered significant when P values are equal 
to or less than 0.05.  
Pilot study 
Before starting to collect data, a pilot study will be carried out to fulfill the 
following purposes:  
1- Testing the questionnaire form and detecting any modification required.  
2- Estimation of the time needed to fill the questionnaire.  
3- Detection of the difficulties that may arise and how to deal with them. 
Ethical Considerations 
1- The research proposal will be reviewed and approved by the Ethical 
Committee of Assiut Faculty of Medicine.     
2- Administrative permission will be obtained from the University authority. 
3- Informed written consent will be obtained from subjects before being 
included in the study. 
4- Privacy and confidentiality of the data will be assured. 
 
 
 
 
 

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