this study was part of a larger study that looked at several outcomes , including diabetes coping behaviors and glycemic control status of t2 dm patients . the study design was cross - sectional and it was conducted at the national centre for diabetes and endocrinology ( ncde ) in tripoli , libya , after being approved by universiti kebangsaan malaysia research and ethics committee and the management at the ncde . the ncde , although a referral center , provides diabetes follow - up , medications , and laboratory services for diabetes outpatients . to find out the minimum sample size required for the large study , the largest sample size obtained was considered , and it was based on the sample size needed to test the difference in the prevalence of poor glycemic control across males and females using the fleiss formula ( 18 ) . the preliminary data used in the calculation included a prevalence of poor glycemic control among males of 45% and among females of 58% ( 19 ) . a sample size of 498 was needed for a margin of precision (  ) of 5% and a power of 80% . to compensate for low response and rejection due to non - eligibility , 30% was added . patients were recruited systematically at the laboratory waiting area between october and december 2013 , whereby every fourth patient was approached at their coming sequence . when the patient was not eligible , the immediate next patient was invited . the eligibility criteria included being libyan , having t2 dm for at least 1 year , being 18 years old or above , having no cognitive impairment that could interfere with communication or comprehending the questions , being able to read and write in arabic , having no visual impairment that interfered with self - reporting , and being willing to participate in the study . those who were placed on a diet plan only , pregnant women , and very ill patients were not eligible . the type of diabetes was self - reported , and it was verified whenever applicable by checking the medical follow - up card of each respondent . however , as not all the follow - up cards showed the type of diabetes , further verification of diabetes type was done at the stage of analysis . those who reported being diagnosed before the age of 40 , placed on insulin at diagnosis , and on insulin at the time of the study ( 20 ) were considered as having type 1 diabetes and were excluded from the analysis . out of the 648 addressed patients , 523 responses were considered in the data analysis , which gave a response rate of 80.7% . 1 . patients were given a briefing about the study , as well as on their participation and withdrawal rights . data collection was based on a self - reported questionnaire , which gathered information about patients sociodemographic characteristics and disease profile , their diabetes illness perceptions based on the revised illness perception questionnaire ( ipq - r ) , and medication adherence based on the eight - item morisky medication adherence scale ( mmas-8 ) . data on age , sex , marital status , education level , employment status , income , duration of diabetes , type of diabetes medication , presence of comorbidity , and the number of other medications were gathered from the information sheet . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item : timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item : treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item :  my diabetes will last a short time ) . timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item :  i have the power to influence my diabetes ) . treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is a valid ( 23 , 24 ) single - dimension measure that comprises eight items ( sample item :  when you travel or leave home , do you sometimes forget to bring along your medications? ) . each item is attached to a yes or no response , except for the last item , which has a five - level likert - type response ( 23 ) . the short construct of the mmas-8 was useful as data were collected in a busy clinical setting ( 25 ) . a score of 8 indicates high adherence , a score of 6 and above but less than 8 indicates moderate adherence , whereas a score below 6 indicates low adherence ( 23 , 24 ) . this version was found to be reliable and valid among libyans with t2 dm ( 26 ) . the internal consistency reliability of the ipq - r and mmas-8 was assessed using cronbach 's alpha . a chi - square test , independent t - test , and the mann whitney u test were used to explore the bivariate associations between medication adherence and sociodemographic characteristics , disease profile , and illness perceptions . all variables that showed bivariate associations with medication adherence at a p - value of 0.25 or less were included in the multiple regression analysis . a two - step hierarchical binary multiple logistic regression was run to test the contribution of illness perceptions on low medication adherence . a p - value less than 0.05 was considered in the interpretation of the significance of the findings . this study was part of a larger study that looked at several outcomes , including diabetes coping behaviors and glycemic control status of t2 dm patients . the study design was cross - sectional and it was conducted at the national centre for diabetes and endocrinology ( ncde ) in tripoli , libya , after being approved by universiti kebangsaan malaysia research and ethics committee and the management at the ncde . the ncde , although a referral center , provides diabetes follow - up , medications , and laboratory services for diabetes outpatients . to find out the minimum sample size required for the large study , the largest sample size obtained was considered , and it was based on the sample size needed to test the difference in the prevalence of poor glycemic control across males and females using the fleiss formula ( 18 ) . the preliminary data used in the calculation included a prevalence of poor glycemic control among males of 45% and among females of 58% ( 19 ) . a sample size of 498 was needed for a margin of precision (  ) of 5% and a power of 80% . to compensate for low response and rejection due to non - eligibility , 30% was added . patients were recruited systematically at the laboratory waiting area between october and december 2013 , whereby every fourth patient was approached at their coming sequence . when the patient was not eligible , the immediate next patient was invited . the eligibility criteria included being libyan , having t2 dm for at least 1 year , being 18 years old or above , having no cognitive impairment that could interfere with communication or comprehending the questions , being able to read and write in arabic , having no visual impairment that interfered with self - reporting , and being willing to participate in the study . those who were placed on a diet plan only , pregnant women , and very ill patients were not eligible . the type of diabetes was self - reported , and it was verified whenever applicable by checking the medical follow - up card of each respondent . however , as not all the follow - up cards showed the type of diabetes , further verification of diabetes type was done at the stage of analysis . those who reported being diagnosed before the age of 40 , placed on insulin at diagnosis , and on insulin at the time of the study ( 20 ) were considered as having type 1 diabetes and were excluded from the analysis . out of the 648 addressed patients , 523 responses were considered in the data analysis , which gave a response rate of 80.7% . 1 . patients were given a briefing about the study , as well as on their participation and withdrawal rights . data collection was based on a self - reported questionnaire , which gathered information about patients sociodemographic characteristics and disease profile , their diabetes illness perceptions based on the revised illness perception questionnaire ( ipq - r ) , and medication adherence based on the eight - item morisky medication adherence scale ( mmas-8 ) . data on age , sex , marital status , education level , employment status , income , duration of diabetes , type of diabetes medication , presence of comorbidity , and the number of other medications were gathered from the information sheet . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item :  my diabetes will last a short time ) . timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item :  i have the power to influence my diabetes ) . treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item :  my diabetes will last a short time ) . timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item :  i have the power to influence my diabetes ) . treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is a valid ( 23 , 24 ) single - dimension measure that comprises eight items ( sample item :  when you travel or leave home , do you sometimes forget to bring along your medications? ) . each item is attached to a yes or no response , except for the last item , which has a five - level likert - type response ( 23 ) . the short construct of the mmas-8 was useful as data were collected in a busy clinical setting ( 25 ) . a score of 8 indicates high adherence , a score of 6 and above but less than 8 indicates moderate adherence , whereas a score below 6 indicates low adherence ( 23 , 24 ) . this version was found to be reliable and valid among libyans with t2 dm ( 26 ) . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item :  my diabetes will last a short time ) . timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item :  i have the power to influence my diabetes ) . treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is related to the number of symptoms the patients have experienced since their diabetes diagnosis and that they attribute to their diabetes . the second section comprises 38 items and measures seven illness perception domains ( timeline acute / chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) . each of the 38 items is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . timeline acute - chronic perception ( six items ) refers to the perception of the illness duration . a high score indicates a strong perception of diabetes as a chronic ( long - term ) illness ( sample item :  my diabetes will last a short time ) . timeline cyclical perception ( four items ) refers to the perception of the pattern of the course of the illness . a high score indicates a strong perception of diabetes course as a cyclical or unstable illness ( sample item :  i go through cycles in which my diabetes gets better and worse ) . consequences perception ( six items ) refers to the perception of the seriousness of the illness and its impact on life . a high score indicates a perception of diabetes as a serious illness with negative impacts on life , social relationships , or economic status ( sample item :  my diabetes is a serious condition ) . personal control perception ( six items ) refers to the patient 's perception of his or her own ability to manage or control the illness . a high score indicates a high perception of the personal ability to control diabetes ( sample item :  i have the power to influence my diabetes ) . treatment control perception ( five items ) refers to the perception of the effectiveness of treatment in controlling the illness . a high score indicates a high perception of the effectiveness of diabetes treatment in controlling diabetes ( sample item :  my treatment can control my diabetes ) . illness coherence ( five items ) refers to the patient 's perception of his or her own understanding of the illness . a high score indicates a high perception of the personal understanding of diabetes and that diabetes is perceived as a clear or unambiguous illness ( sample item :  i have a clear picture or understanding of my condition ) . a high score refers to more emotional responses to diabetes and indicates that diabetes affects the patient emotionally and makes him or her emotionally distressed ( sample item : the last section of the ipq - r is the cause section , and it comprises 18 disparate items ( causes ) . each item is attached to a five - level ( strongly disagree  strongly agree ) likert - type response . we dichotomized the responses to each cause item into yes and no , where yes indicated those who strongly agreed or agreed on the item as a cause for their diabetes ( 22 ) . only the eight illness perception domains ( identity perception , timeline acute - chronic perception , timeline cyclical perception , consequences perception , personal control perception , treatment control perception , illness coherence , emotional representations ) were defined as independent variables and tested for their contribution to medication adherence , whereas the cause section was only included for description . the scale was translated from english into arabic by two bilingual translators using a forward  backward method . the content validity of the scale was assessed by a group of libyan experts , and two items were added to the other 14 generic symptoms in the identity subscale numbness and paresthesia . then , face validity was pretested on 10 diabetic libyans and the necessary amendments to enhance the clarity were done . it is a valid ( 23 , 24 ) single - dimension measure that comprises eight items ( sample item :  when you travel or leave home , do you sometimes forget to bring along your medications? ) . each item is attached to a yes or no response , except for the last item , which has a five - level likert - type response ( 23 ) . the short construct of the mmas-8 was useful as data were collected in a busy clinical setting ( 25 ) . a score of 8 indicates high adherence , a score of 6 and above but less than 8 indicates moderate adherence , whereas a score below 6 indicates low adherence ( 23 , 24 ) . this version was found to be reliable and valid among libyans with t2 dm ( 26 ) . the internal consistency reliability of the ipq - r and mmas-8 was assessed using cronbach 's alpha . a chi - square test , independent t - test , and the mann whitney u test were used to explore the bivariate associations between medication adherence and sociodemographic characteristics , disease profile , and illness perceptions . all variables that showed bivariate associations with medication adherence at a p - value of 0.25 or less were included in the multiple regression analysis . a two - step hierarchical binary multiple logistic regression was run to test the contribution of illness perceptions on low medication adherence . a p - value less than 0.05 was considered in the interpretation of the significance of the findings . the mean diabetes duration was 9.4 ( sd=7.3 ) years , and the number of other long - term medications ranged from zero to seven . sociodemographic characteristics and disease profile ( n=523 ) ld , libyan dinars ( conversion rate at the time of the study : 1 ld = 1.32 usd ) . table 2 displays the descriptive statistics of diabetes illness perceptions based on the identity and views sections of the ipq - r . all eight illness perception domains displayed a satisfactory internal consistency , with the alpha coefficient ranging from 0.87 for the emotional representations subscale to 0.76 for the consequences perception subscale . respondents showed low diabetes identity perception , indicating that they attributed few of the symptoms they experienced to their diabetes ( mean=4.55 , sd=3.72 ) . they showed a high perception of diabetes timeline as a chronic illness ( mean=22.08 , sd=5.34 ) and a moderate perception of diabetes course as a cyclical ( unstable ) illness ( mean=12.42 , sd=4.80 ) . respondents had a moderately high perception of the treatment controllability of their illness ( mean=19.19 , sd=4.48 ) and their personal control over diabetes ( mean=18.93 , sd=7.06 ) , while demonstrating a moderate diabetes consequences perception ( mean=16.24 , sd=6.05 ) and emotional representations ( mean=16.99 , sd=7.76 ) . diabetes illness perceptions based on the revised illness perception questionnaire ( ipq - r ) scale 
 table 3 shows the descriptive statistics on the perceptions of the cause of diabetes . the five most commonly indicated causes out of the 19 listed items as causes for diabetes were allah 's will / fate ( 86.6% ) ,  hereditary  it runs in my family ( 53.0% ) ,  my emotional state ( 44.4% ) ,  family problems or worries ( 40.0% ) , and  diet or eating habits ( 35.6% ) . diabetes cause perceptions ( n=523 ) the cause section of the ipq - r consists of disparate items . 
 table 4 shows the descriptive statistics on diabetes medication adherence based on the mmas-8 . the mean medication adherence score was 6.06 ( sd=1.89 ) , and the prevalence of low medication adherence was 36.1% . medication adherence based on the mmas-8 
  use of the mmas is protected by us copyright laws . a license agreement is available from : donald e. morisky , scd , scm , msph , professor , department of community health sciences , ucla school of public health , 650 charles e. young drive south , los angeles , ca 90095 - 1772 ; dmorisky@ucla.edu . several sociodemographic variables and disease profile  related factors showed statistically significant associations with medication adherence . the frequency of low medication adherers was significantly higher among males than females ( =10.247 , p=0.001 ) . respondents with secondary to high education level reported a significantly higher prevalence of low medication adherers than those with primary education ( =5.628 , p=0.018 ) . a significantly higher frequency of low adherers was also found among employed respondents compared to the unemployed ( =17.921 , p<0.001 ) and among the moderate- to high - income group compared to the low income group ( =3.925 , p=0.048 ) . respondents who had no comorbidity showed a significantly higher prevalence of low medication adherers compared to those who had comorbidity ( =11.466 , p=0.001 ) . in addition , there was a significant difference in the number of other long - term medications between low adherence and moderate - high adherence groups ( z=2.810 , p=0.005 ) . regarding illness perceptions , a significant difference in the mean treatment control perception score ( t=2.366 , p=0.018 ) was found between patients who reported low adherence to their diabetes medications ( mean=18.58 , sd=4.51 ) and those who reported moderate - high adherence ( mean=19.54 , sd=4.44 ) . bivariate association between sociodemographic factors , disease profile , and illness perceptions with medication adherence 
 t statistic ( independent t - test ) ; z statistic ( mann  whitney u test ) . table 6 shows a two - step hierarchical binary logistic regression model . in the first step , all sociodemographic and disease profile  related factors that displayed associations with medication adherence at p0.25 in the bivariate analysis were entered into the model . all illness perceptions that displayed crude associations with medication adherence with p0.25 were entered in the second step . in the first step , the model showed a good fit of the included variables as indicated by the non - significant hosmer lemeshow test ( p=0.160 ) . referring to the block omnibus test , the contribution of the model with these variables to low medication adherence variance compared to the model with the constant alone was significant (  ( df ) = 26.997(8 ) , p=0.001 ) . based on the nagelkerke r 
 , this model contributed to 6.9% of the variance of low medication adherence . in the second step the model showed a good fit of the included variables as indicated by the non - significant hosmer the addition of illness perceptions led to a significant improvement in the model 's level of predictivity as indicated by a significant chi - square increment (  ( df ) = 19.867(5 ) , p=0.001 ) . referring to the nagelkerke r thus , illness perceptions have a unique contribution to medication adherence above and beyond the control variables alone . hierarchical regression model of low medication adherence predictors  , chi - square difference across two subsequent models after adding illness perceptions . the final model showed that two illness perceptions contributed significantly to low medication adherence ; these were treatment control perception and illness identity perception . high treatment control perception contributed slightly yet significantly to medication adherence as a protective factor . the odds of having low adherence to medications decreased with the increase in treatment control perception ( p=0.044 , or=0.95 , 95% ci=0.91_0.99 ) . on the other hand , high identity perception predicted lower medication adherence , as the odds of having low adherence to medications increased with the increase in identity perception ( p=0.008 , or=1.08 , 95% ci=1.02=1.14 ) . two of the control variables also displayed a significant contribution to low medication adherence ; these were sex and employment status . females were 1.5 times less likely than males to be low adherers ( p=0.026 , or=0.59 , 95% ci=0.370.93 ) and unemployed respondents were half as likely as employed respondents to be low adherers ( p=0.008 , or=0.45 , 95% ci=0.250.81 ) . to the best of our knowledge , this study was the first to explore diabetes perceptions as guided by the csm in the libyan context . although this might indicate that females were more willing to participate in the study , it may also reflect the sex profile of diabetes in libya . an early study of the epidemiological pattern of diabetes in benghazi , libya , found that the prevalence of t2 dm was significantly higher among females than males ( 27 ) . the predominance of females over males was also reported in a previous study among diabetics in the same center where our study was conducted ( 28 ) and in other libyan diabetes settings ( 6 , 7 ) . the respondents reported a low identity perception , indicating that they attributed few of the symptoms they had experienced after the diagnosis to their diabetes . regarding personal and treatment control perception domains , the respondents reported a moderately high perception of both their own ability to control their diabetes and the effectiveness of their diabetes treatment . personal control perception is a close concept to self - efficacy , which is also about the confidence of the patients in their personal ability to control their illness . in line with our finding , a previous study among adult diabetics in libya reported a moderate level of self - efficacy ( 7 ) . the respondents perceived diabetes as a chronic illness , and moderately perceived the course of diabetes as unstable or cyclical . the respondents reported moderate coherence perception , which reflects a moderate personal understanding of diabetes . this finding shows that many of them perceived diabetes as an ambiguous illness that they did not understand well . lack of professional information on diabetes , which in turn affects diabetes knowledge , could be one of the reasons . several previous studies in the libyan diabetes context showed a poor level of diabetes knowledge ( 6 , 7 ) . therefore , empowering our patients diabetes knowledge through diabetes educational programs could help in optimizing their diabetes coherence or understanding perception . the respondents perceived that diabetes imposed moderate consequences on their life and health and they displayed moderate negative emotional responses to their illness . the islamic religious influences on the constitution of diabetes perceptions were reflected in the perception of the cause of diabetes , where  allah 's will / fate was the most frequently reported cause for diabetes . we also found that more respondents attributed their diabetes to psychosocial factors like their emotional state and family problems or worries than to their diet or eating habits . for instance , in a study among nepali diabetics , pollution and immunity were frequently reported as the causes of diabetes , whereas emotional state was among the least perceived causes ( 22 ) . furthermore , a study in the united states reported heredity , diet and eating habits , and own behavior as the top three perceived causes for diabetes ( 14 ) . more than one - third of the respondents reported low adherence to their diabetes medications . this is considerable , and it should be taken seriously for its consequences on patients health and its ultimate impacts on the health - care system . our study confirmed the findings of two previous studies in the libyan diabetes context ( 6 , 7 ) . in a large diabetes care center in benghazi , libya , roaeid and kablan ( 6 ) reported that 27.1% of diabetics were not taking their medications regularly . in a more recent study in the same center in benghazi , elkharam et al . ( 7 ) assessed adherence to diabetes management advice using hba1c as a distant adherence measure , and their findings also reflected the problem of low adherence levels . both of these two studies used different adherence measures to that used in this current study . compared to some middle eastern countries , the reported low medication adherence prevalence in this study is lower than that reported in palestine among t2 dm patients , using the same measure ( 42.7% ) ( 29 ) , but higher than that reported in jordan ( 30 ) . 
 in this study our findings added to the preexisting research evidence on the role of the csm illness perceptions in guiding the coping behaviors in illness ( 1014 ) . two illness perceptions were found to contribute significantly to medication adherence ; these were identity and treatment control perceptions . the respondents who attributed many of the symptoms they had experienced to their diabetes were more likely to be low adherers to their medications . meanwhile , treatment control perception was a protective factor , as those who reported higher perception of the effectiveness of their treatment were less likely to be low adherers . in line with our findings , it was found that the perceived treatment effectiveness in diabetes control contributed to the use of insulin ( 31 ) . although treatment control perception was identified among the predictors of medication adherence among nepali diabetics , unlike in our study , higher perception of treatment effectiveness was associated with lower medication adherence ( 22 ) . the final model also identified two personal characteristics as predictors of low medication adherence ; these were sex and employment status . this was inconsistent with the findings of some studies where no relationship between sex and adherence level was reported ( 29 , 32 ) . this could be related to some barriers that employed diabetics face , such as the lack of time or access to medications while away from home . consistent with our findings , some other studies found that employment status influenced medication adherence in diabetes ( 22 , 33 ) . several limitations should be considered in the interpretation of the findings from this study , such as the cross - sectional design , which precludes making causal assumptions , and self - reporting of data , which is subject to recall bias as well as over- and under - reporting bias . type 2 diabetic libyans who are unable to read and write should be considered in further research that uses face - to - face interviews . as the study was conducted in a single diabetic center in tripoli , the findings could not be generalized to all libyans with t2 dm . however , the findings could be generalized to the study population , which is libyans with t2 dm who attended the center during the study period . the findings may inform local diabetic care providers about how their patients perceive their diabetes . the current study confirmed the suboptimal level of medication adherence reported by some previous studies in the libyan diabetes context . these findings could be used to develop medication adherence promotion approaches , as in the form of psychoeducational interventions . the findings from this study showed that males and employed patients were more likely to be low adherers ; therefore , they might represent in - need groups for medication adherence promotion . thus , further research is needed to identify what other factors could explain low medication adherence among libyan diabetics . in addition , as our study was conducted at a single center , in the capital city of libya , more research in the libyan diabetes context is warranted to support the generalizability of the findings from our study to all libyans with t2 dm .
backgroundthe surrounding environment influences the constitution of illness perceptions . 
 therefore , local research is needed to examine how libyan diabetes patients perceive diabetes and how their perceptions influence their medication adherence.methodsa cross - sectional study was conducted at the national centre for diabetes and endocrinology in tripoli , libya , between october and december 2013 . 
 a total of 523 patients with type 2 diabetes participated in this study . 
 a self - administered questionnaire was used for data collection ; this included the revised illness perception questionnaire and the eight - item morisky medication adherence scale.resultsthe respondents showed moderately high personal control and treatment control perceptions and a moderate consequences perception . 
 they reported a high perception of diabetes timeline as chronic and a moderate perception of the diabetes course as unstable . 
 the most commonly perceived cause of diabetes was allah 's will . 
 the prevalence of low medication adherence was 36.1% . 
 the identified significant predictors of low medication adherence were the low treatment control perception ( p=0.044 ) , high diabetes identity perception ( p=0.008 ) , being male ( p=0.026 ) , and employed ( p=0.008).conclusiondiabetes illness perceptions of type 2 diabetic libyans play a role in guiding the medication adherence and could be considered in the development of medication adherence promotion plans .